Textbook of

GYNECOLOGY
 Textbook of
GYNECOLOGY

Sudha Salhan
MBBS (Hons), MD, PGDHM (NIHFW), CIC (IGNOU)
Professor and Head
Department of Obstetrics and Gynecology
Vardhman Mahavir Medical College and Safdarjung Hospital
New Delhi, India

Foreword
Anusuya Dass

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Textbook of Gynecology
First Edition: 2011

ISBN 978-93-5025-369-4
Printed at
Dedicated to
My Patients
 Contributors

Abha Majumdar Durgesh K Dash

Senior Consultant Senior Resident Associate Consultant
Department of Obs and Gyne Department of Obs and Gyne Department of Obs and Gyne
Sir Ganga Ram Hospital VMMC and Safdarjung Hospital Indraprastha Apollo Hospital
New Delhi, India New Delhi, India New Delhi, India
AK Jain GK Rath Kiran Guleria
Consultant Head of the Department Professor
Department of Obs and Gyne Department of Radiotherapy and Department of Obs and Gyne
VMMC and Safdarjung Hospital Oncology, AIIMS University College of Medical Sciences
New Delhi, India New Delhi, India New Delhi, India
Aruna Batra Gouri Ganguli Lalit Kumar
Professor Ex-Professor and Head Department of Oncology
Department of Obs and Gyne Department of Obs and Gyne AIIMS
VMMC and Safdarjung Hospital Medical College, Allahabad New Delhi, India
New Delhi, India Uttar Pradesh, India
Leena
Ashok Khurana H Koratkar Senior Resident
Director Research Assistant, ICMR
Department of Pediatrics
The Ultrasound Lab Maulana Azad Medical College
JIPMER, Pondicherry, India
Defence Colony New Delhi, India
New Delhi, India Mahua
Harsha Gaikwad Senior Resident
Asmita Muthal Rathore Associate Professor
Department of Obs and Gyne
Professor Department of Obs and Gyne
VMMC and Safdarjung Hospital
Department of Obs and Gyne VMMC and Safdarjung Hospital
New Delhi, India
Maulana Azad Medical College New Delhi, India
New Delhi, India Manju Aggarwal
HP Anand
Senior Resident
B Minocha Consultant Department
Ex-Consultant and Unit Incharge Department of Obs and Gyne
Department of Obs and Gyne
Department of Obs and Gyne VMMC and Safdarjung Hospital
VMMC and Safdarjung Hospital
VMMC and Safdarjung Hospital New Delhi, India New Delhi, India
New Delhi, India MD Goswami
Indira Ganeshan
Banashree Das Senior Specialist
Consultant
Consultant IVF Center Department of Obs and Gyne
Department of Obs and Gyne Kapoor Hospital VMMC and Safdarjung Hospital
VMMC and Safdarjung Hospital New Delhi, India New Delhi, India
New Delhi, India
Jyotsana Suri Meenakshi
BD Hasija Specialist Specialist
Consultant Department of Obs and Gyne Anesthesia
Department of Obs and Gyne VMMC and Safdarjung Hospital VMMC and Safdarjung Hospital
VMMC and Safdarjung Hospital New Delhi, India New Delhi, India
New Delhi, India
Kaushiki Meenakshi Bhatt
BG Matapurkar Senior Consultant Senior Resident
Ex-Professor Obs and Gyne Department of Pediatrics
Surgery Max Hospital Kalawati Saran Hospital
Maulana Azad Medical College Gurgaon Lady Hardinge Hospital
New Delhi, India Haryana, India New Delhi, India
 Meetu Salhan Payal Chaudhary Priyanka
Senior Pediatric Resident Research Officer Senior Resident
Department of Pediatrics HRRC Department of Obs and Gyne
VMMC and Safdarjung Hospital VMMC and Safdarjung Hospital VMMC and Safdarjung Hospital
New Delhi, India New Delhi, India New Delhi, India
Moni Tuteja P Chowdhury Puneet Singh Kocher
Senior Resident Research Officer Senior Resident
Maternal and Reprod Health Obs and Gyne Department of Radiology
Department, SGPGI, Lucknow VMMC and Safdarjung Hospital AIIMS
Uttar Pradesh, India New Delhi, India New Delhi, India
Textbook of Gynecology

Monika Gupta Peeyush Pandit

Senior Resident
Pushpa Singh
Consultant Radiology Professor
Department of Obs and Gyne Gulati Imaging Institute Head of the Department
VMMC and Safdarjung Hospital Hauz Khas Obs and Gyne
New Delhi, India New Delhi, India RML Hospital
Monika Madaan New Delhi, India
Pikee Saxena
Associate Professor (Adhoc)
Associate Professor
Lady Hardinge Medical College Rani Jain
Obs and Gyne
New Delhi, India Chief Medical Officer
Lady Hardinge Medical College
Obs and Gyne
Neena Aggarwala New Delhi, India
RML Hospital
Assistant Professor
Pinkee Saxena New Delhi, India
Laparoscopy and Urogynecology
Pelvic Surgery Research Officer
R Bharti
University of Nebraska Department of Obs and Gyne
Specialist
Medical Center VMMC and Safdarjung Hospital
Obs and Gyne
USA New Delhi, India
VMMC and Safdarjung Hospital
Niharika Dhiman PK Julka New Delhi, India
Senior Resident Professor
Department of Radiotherapy and R Kumari
Department of Obs and Gyne
Oncology Specialist
Safdarjung Hospital
AIIMS Department of Obs and Gyne
New Delhi, India
New Delhi, India VMMC and Safdarjung Hospital
Nivedita Sarda New Delhi, India
Consultant PK Verma
Department of Obs and Gyne Consultant Rahul Manchanda
VMMC and Safdarjung Hospital Department of Anesthesia Consultant
New Delhi, India VMCC and Safdarjung Hospital Manchanda Nursing Home
New Delhi, India New Delhi, India
Paramita
PG Student P Muley Raksha Arora
Department of Obs and Gyne Consultant Obs and Gyne Director Professor
VMMC and Safdarjung Hospital Baba Hospital Obs and Gyne
New Delhi, India New Delhi, India MAMC and Hospital
New Delhi, India
Parveen Gulati Poonam Puri
Director Rajesh Rastogi
Consultant
Gulati Imaging Institute Consultant
Department of Skin and BD
Hauz Khas Head of the Department
VMMC and Safdarjung Hospital
New Delhi, India
New Delhi, India Department of Psychiatry
VMMC and Safdarjung Hospital
Pawan Nayyar Pratima Mittal New Delhi, India
Consultant Associate Professor and Consultant
Department of Anesthesia Department of Obs and Gyne Rajesh Uppal
VMMC and Safdarjung Hospital VMMC and Safdarjung Hospital Consultant Radiologist
New Delhi, India New Delhi, India New Delhi, India

viii
Rashmi Sharma Shubha Sagar Trivedi Sunita Malik
Assistant Consultant Head of the Department Professor
Southend Rotunda Department of Obs and Gyne Department of Obs and Gyne
Holy Angels Hospital Lady Hardinge Medical College VMMC and Safdarjung Hospital
New Delhi, India New Delhi, India New Delhi, India
R Sinha Sunita Singal
Shweta Rajani
Consultant Obs and Gyne
Senior Resident NFSG
VMMC and Safdarjung Hospital
Department of Obs and Gyne Department of Obs and Gyne
New Delhi, India
VMMC and Safdarjung Hospital VMMC and Safdarjung Hospital
Rekha Bharti New Delhi, India New Delhi, India

Contributors
Specialist
Department of Obs and Gyne Sindhu Vijay Kumar Sushma Rani
Safdarjung Hospital Assistant Professor Senior Medical Officer
New Delhi, India Physical Medicine and Rehabilitation Department of Obs and Gyne
All India Institute of Physical Medicine VMMC and Safdarjung Hospital
Renuka Sinha New Delhi, India
Consultant and Rehabilitation (AIIPMR)
Department of Obs and Gyne Mumbai, Maharashtra, India Sushma Suri
VMMC and Safdarjung Hospital Professor
SK Sen
New Delhi, India Department of Obs and Gyne
Ex-Senior Specialist
Sabri VMMC and Safdarjung Hospital
Department of Obs and Gyne
Senior Resident New Delhi, India
VMMC and Safdarjung Hospital
Obs and Gyne New Delhi, India Tarun Puri
VMMC and Safdarjung Hospital
Ex-Resident
New Delhi, India Sonia Ghuman
Department of Radiotherapy and
Senior Medical Officer
Sakshi Oncology
CGHS, Chandigarh, India
PG Student AIIMS
VMMC and Safdarjung Hospital Sonia Malik New Delhi, India
New Delhi, India Director
Urvashi Miglani
Sanjay Gupte Southend Rotunda
Senior Medical Officer
Director Holy Angels Hospital Department of Obs and Gyne
Gupte Hospital New Delhi, India RML Hospital
Pune, Maharashtra, India
Sudha Salhan New Delhi, India
SB Khanna Professor and Head
Senior Consultant V Ramesh
Department of Obs and Gyne Head of the Department
Obs and Gyne Oncosurgeon
VMMC and Safdarjung Hospital Department of Skin and BD
Department of Obs and Gyne
New Delhi, India VMMC and Safdarjung Hospital
Indraprastha Apollo Hospital
New Delhi, India Sujata Das New Delhi, India

Sharda Patra Senior Medical Officer Vasantha Muthuswamy

Assistant Professor Department of Obs and Gyne Ex-Senior Deputy Director General
Lady Hardinge Medical College VMMC and Safdarjung Hospital Indian Council of Medical Research
New Delhi, India New Delhi, India New Delhi, India
Shikha Goyal Sujata Mishra Veena Singh
Ex-Resident Associate Professor Chief of Clinical Division
Department of Radiotherapy and Department of Obs and Gyne Institute of Cytology and Preventive
Oncology
Cuttack Medical College Oncology (ICMR), Noida
AIIMS
Odisha, India Uttar Pradesh, India
New Delhi, India
S Prateek Sunesh Kumar Vibhu Mehdirata
Consultant Professor Director Professor
Department of Obs and Gyne Department of Obs and Gyne Dermatology
VMMC and Safdarjung Hospital AIIMS LHMC Hospital
New Delhi, India New Delhi, India New Delhi, India

ix
 Foreword

During the last two decades, there have been tremendous advances in medical sciences, and gynecology has
been no exception. A new textbook by a group of teachers under the expert guidance of Dr Sudha Salhan,
Professor, Consultant and Head of the Department of Obstetrics and Gynecology, Vardhaman Mahavir Medical
College and Safdarjung Hospital, New Delhi, India, is, therefore, welcome. While preparing the text, the
contributors and the editor have utilized their experience received from a large number of students and teachers.
The book has some new features, i.e. counseling, ethics, medicolegal problems and flow charts. I earnestly
hope all these will enhance the utility of this book for the students. All procedures have been explained in as
simple manner as possible.
I am confident that after reading this book, the students will develop special interest in gynecology and
would like to take up postgraduation in the subject.
I wish Dr Sudha Salhan and this book all success.

Dr Anusuya Dass
Former Principal
Lady Hardinge Medical College
New Delhi
India
 Preface

This Textbook of Gynecology has been written with emphasis on recent advances, counseling, medicolegal
aspects and ethics. In this fast mechanized world, the art of talking to the patient is fast disappearing. Therefore,
a chapter on Counseling has been included in this book. We must also be aware of the legislations pertaining
to our subject. With this end in mind, a chapter on the Medicolegal Aspects of Obstetrics has been written.
Other often neglected but important topics are discussed in detail along with chapters on Medical Termination
of Pregnancy (MTP) and Preconception and Prenatal Diagnostic Techniques (PNDT) and Biomedical Waste
Management. Finally, it is important to know about the importance given to maternal health by the Government
of India (e.g. NRHM). This book will update students on the recent endeavors of the government to alleviate
suffering of women by various schemes. Overall, this book will provide a comprehensive and up-to-date
picture of the interesting subject of gynecology.
The contributors of the chapters are seasoned gynecologists dealing with women’s health day in and day
out. I thank them all for sparing time from their busy schedule. I offer special thanks to Mrs Jayshree for the
typing and related work. I thank my postgraduate students for line diagrams. I also thank my family for their
unstinted support.
I also offer special thanks to M/s Jaypee Brothers Medical Publishers (P) Ltd for publishing this book. I
also thank Mr Tarun Duneja (Director–Publishing), Mr KK Raman (Production Manager), Mr Ashutosh
Srivastava (Asst. Editor), Ananda Mohanty (Proof Reader), Mr Ram Murty (Graphic Designer), Mr Pramod
Kumar Rout, Mr Pankaj Kumar Mandal and Mr Rajesh Kumar (DTP Operators) of Jaypee Brothers.

Sudha Salhan
 Contents

SECTION 1: BASICS OF GYNECOLOGY

1. Evolution of Gynecology .......................................................................................................................... 1
Sudha Salhan, Meenakshi Bhatt
• Definition of Gynecology 1
2. Medicolegal Aspects ................................................................................................................................. 3
Sanjay Gupte, Sudha Salhan
• The Legal Context of Professional Liability 3
• Civil Law in Relation to Gynecology and Obstetric Practice 3
• Criminal Law in Relation to Gynecology and Obstetric Practice 4
• MedicoLegal Aspects of MTPs 4
• Medicolegal Aspects of Sterilization 4
• In Gynecology 4
• Medicolegal Aspects of Endoscopic Surgery 4
3. Communication and Counseling in Gynecology .................................................................................... 6
Sudha Salhan, Jyotsana Suri
• Listening and Learning Skills 6
• Building Confidence and Giving Support 8
4. History Taking and Examination in Gynecology ................................................................................... 11
Sudha Salhan, Harsha Gaikwad
• Examination 12
• Gynecological Examination 12
5. Psychiatric Aspects of Gynecology ...................................................................................................... 22
Rajesh Rastogi
• Menstrual Disorders 22
6. Bioethics and Evidence Based Management ....................................................................................... 28
Vasantha Muthuswamy, Sudha Salhan

7. Organizing Studies and Clinical Work ................................................................................................... 32

Meenakshi Bhatt
• Tips for Effective Studying 32
• Tips for Making Good Presentations 33
• Tips for Working Efficiently in the Wards 33

SECTION 2: ANATOMY AND PHYSIOLOGY

8. Surgical Anatomy of Female Genital Tract ............................................................................................ 34
Sudha Salhan
• Blood Supply to the Female Pelvic Organs 43
9. Development of Female Genital Tract ................................................................................................... 46
Sudha Salhan, Paramita, SK Sen

10. Physiology of Menstruation ................................................................................................................... 56

Pikee Saxena, B Minocha
• Definition 56
• The Endocrine Cycle 56
• Ovarian Cycle 57
• Uterine Cycle 58
 SECTION 3: ENDOCRINOLOGY IN GYNECOLOGY
11. Pediatric Gynecology ............................................................................................................................. 61
Sudha Salhan
• Prepubertal Girl Child 61
• Positioning for Examination of a Female Child 62
12. Puberty .................................................................................................................................................... 64
Meenakshi Bhatt, Sudha Salhan
• Definition 64
• History 64
Textbook of Gynecology

13. Adolescent Gynecological Issues ......................................................................................................... 68

Pratima Mittal, Pinkee Saxena, AK Jain
• Gynecological Concerns of Adolescents 68
• Disorders of Pubertal Growth and Maturation 68
• Concerns Regarding Normal Menstruation and Menstrual Hygiene 68
• Menstrual Disorders 70
• Hyperandrogenism 72
• Infections in Adolescents 75
• Pelvic Pain in Adolescents 75
• Genital Tumors in adolescents 76
• Issues related to Sexuality and Sexual Violence 77
• Reproductive Health issues such as Pregnancy, Abortions, Contraception 77
• Miscellaneous Issues 79
• Adolescent Immunization 81
• Pelvic Examination in Adolescents 81
• Approach to an Adolescent Client 81
• Adolescent-friendly Health Services 82
14. Amenorrhea ............................................................................................................................................ 83
Pratima Mittal, Aruna Batra
• Definition of Amenorrhea 83
• Etiology of Amenorrhea 83
• Evaluation of Amenorrhea 84
• Management of Amenorrhea 88
• Specific Disorders Responsible for Amenorrhea 89
15. Androgen Excess in Reproductive Life ................................................................................................ 94
Abha Majumdar

16. Dysmenorrhea and Chronic Pelvic Pain (CPP) ..................................................................................... 98

Sudha Salhan
• Dysmenorrhea 98
• Chronic Pelvic Pain 100
• Gynecological Conditions: The Most Common Causes in 30–70% Cases of CPP 100
• Gynecological Conditions 101
17. Abnormal Uterine Bleeding (AUB) ....................................................................................................... 104
Sudha Salhan, Gouri Ganguli, Sunita Single
• Dysfunctional Uterine Bleeding (DUB) 105
• Ovulatory DUB 105
• Anovulatory DUB 105
• Aims of Investigations 107
• Management 107
• Medical Treatment 107
• Hormonal Therapy in AUB in Reproductive Age Women Aims 107
• Surgical Treatment 108
• Postmenopausal Bleeding (PMB) 108

xvi 18. Premenstrual Syndrome (PMS) ........................................................................................................... 111

Sudha Salhan
19. Endometriosis ...................................................................................................................................... 113
Kiran Guleria, Sudha Salhan
• Pathology 114
• Diagnosis 115
• Prevention of Endometriosis 119
20. Causes of Infertility .............................................................................................................................. 123
Indira Ganeshan, Sonia Malik
• Male partner 123
• Obstruction of Efferent Ducts 124
• Failure to Deposit Sperms in Vagina 124
• Defect in Sperms and Seminal Fluid 124

Contents
• Female Factor 125
• Uterine Factors 127
• Immunology of Infertility 127
• Adoption 137
21. Assisted Reproductive Technology (ART) .......................................................................................... 138
Sonia Malik, Rashmi Sharma
• Other Art Techniques 144
• Complications of IVF 144
22. Menopause ............................................................................................................................................ 147
Sudha Salhan, R Sinha, Sujata Mishra
• Prevention and Treatment of Osteoporosis 154

SECTION 4: DISORDERS OF EARLY PREGNANCY

23. Bleeding in Early Pregnancy ................................................................................................................ 158
Sudha Salhan, Indira Ganeshan, Harsha Gaikwad
• Hydatidiform Mole 163
24. Ectopic Pregnancy (EP) ....................................................................................................................... 164
Sudha Salhan
• Definition 164
• Epidemiology 164
• Fate of Ectopic Pregnancy 167
• Criteria for Medical Treatment 169
25. Trophoblastic Disease .......................................................................................................................... 174
Sudha Salhan, Jyotsana Suri
• Gestational Trophoblastic Disease 174
26. Recurrent Pregnancy Loss .................................................................................................................. 184
Sudha Salhan, Indira Ganeshan, Harsha Gaikwad
• Etiology 184
• Management 186

SECTION 5: ABNORMALITIES AND INJURIES OF GENITAL TRACT

27. Malformations of Female Genital Tract ............................................................................................... 189
Sudha Salhan, Priyanka
• Classification 189
28. Disorders of Sex Development (DSD) ................................................................................................. 194
Leena, Sakshi
• Nomenclature and Classification 194
• Normal Sex Development 194
• Clinical Evaluation 195
• Laboratory Investigations 196
• Management 196
• Some Common Conditions 197 xvii
• Other Syndromes 198
 29. Pelvic Organ Displacements ................................................................................................................ 200
SB Khanna, K Dash, Kaushiki, Sudha Salhan, R Bharti, R Kumari
• Basic Anatomy of Pelvic Floor 200
• Ligament and Facial Support 200
• Pelvic Floor Innervation 200
• Biomechanics of Genital Prolapse 201
• Epidemiology of Pelvic Organ Prolapse 201
• Etiology of Prolapse 203
• Classification of prolapse 203
• Malpas Classification 203
• Pelvic Organ Prolapse Quantification System (POPQ) 203
Textbook of Gynecology

• Management of Pelvic Organ Prolapse 204

• Inversion of Uterus 208
30. Violence Related to Gender and Sexuality .......................................................................................... 212
Sudha Salhan
• Management of a Rape Victim 213
• History 213
• Examination of the Assault Victim 213
• Treatment of Rape Victim 214
• Female Genital Mutilation (FGM) 214
31. Reproductive Morbidity ........................................................................................................................ 216
Sudha Salhan
• Definitions 216
32. Role of Rehabilitation Medicine in Gynecology Practice ................................................................... 218
Sindhu Vijay Kumar
• Rehabilitation of the Patient Undergoing Gynecological Surgery 218
• Cancer Rehabilitation 220
• Urinary Incontinence 220
• Rehabilitation Management of Genital Displacements and Prolapse 222
• Management of Lymphedema 222
• Chest Physiotherapy and Postural Drainage 222
• Pelvic Inflammatory Disease 222

SECTION 6: GENITOURINARY PROBLEMS IN GYNECOLOGY

33. Urinary Tract Infection (UTI) ................................................................................................................. 224
Sudha Salhan

34. Urinary Incontinence in Females ......................................................................................................... 225

Monika Gupta, Aruna Batra, Sudha Salhan
• Stress Urinary Incontinence 226
• Overflow Incontinence 227
• Urge Incontinence 227
• Clinical Presentation 228
• Evaluation 228
• Management 229
• Conservative Management 229
• Behavioral Techniques 229
• Pharmacotherapy 230
• Surgical Treatment 230
• Overactive Bladder (OAB) 231
• Reflex Incontinence 232
• Total Incontinence 232
35. Genital Fistula ....................................................................................................................................... 233
Sudha Salhan
• Gynecologic Causes 233
xviii • Prevention of VVF 236
• Techniques of Repairs 237
 SECTION 7: INFECTIONS OF GENITAL TRACT
36. Reproductive Tract Infections and Sexually Transmitted Diseases (RTIs and STDs) ...................... 240
Sudha Salhan, Poonam Puri, V Ramesh
• Reproductive Tract Infection (RTI) 240
• Symptoms of STDs 241
• Chancroid (Soft Chancre/Soft Sore/Ulcus Molle) 243
• Lymphogranuloma Venereum (LGV) 245
• Gonorrhea 246
• Non-Gonococcal Urethritis 246
• Bacterial Vaginosis 247

Contents
• Trichomoniasis (Trichomonas Vaginalis) 247
• Scabies (Sarcoptes Scabiei) 248
• Crab Louse (Pediculosis Pubis) 248
• AIDS (HIV I and HIV II) 248
• Hepatitis B (Hepatitis B Virus) 248
• Genital Warts 248
• Herpes Progenitalis 249
• Molluscum Contagiosum 250
• HPV Infection 250
• Sequelae and complications of RTI/STI 251
• Prevention of RTI/STI 251
37. Pelvic Inflammatory Disease (PID) ...................................................................................................... 252
Sudha Salhan, Mahua

38. Genital Tuberculosis ............................................................................................................................ 257

Jyotsana Suri, Sudha Salhan

SECTION 8: GENERAL PRINCIPLES OF GYNECOLOGY

39. Screening for Gynecological Cancers ................................................................................................ 262
Veena Singh, Sudha Salhan
• Screening for Cervical Cancer 262
• Colposcopy 266
• Screening for Ovarian Cancer 267
• Screening for Breast Cancer 268
• Endometrial Cancer 269
• Vaginal Cancer 270
• Vulvar Cancer 270
• Tumor Markers in Gynecology 270
40. Chemotherapy and Radiotherapy in Gynecological Malignancies .................................................... 272
Tarun Puri, Shikha Goyal, PK Julka, GK Rath
• Radiation Therapy 272
• Cancer of the Uterine Cervix 273
• Cancer of the Uterine Body 277
• Carcinoma Ovary 278
• Carcinoma Vagina 280
• Carcinoma Vulva 280
• Gestational Trophoblastic Disease 280

SECTION 9: DISEASES OF VAGINA

41. Benign Conditions of the Vagina ......................................................................................................... 283
Sudha Salhan
• Congenital Abnormalities 283
• Infections 284
• Pathological Discharges 285
• Vaginal Burns 291 xix
• Foreign Bodies in the Vagina 292
 • Benign Conditions of Vagina 292
• Miscellaneous Conditions 293
42. Premalignant and Malignant Conditions of the Vagina ...................................................................... 294
Sudha Salhan
• Premalignant Conditions of the Vagina 294
• Vaginal Carcinoma 294

SECTION 10: DISEASES OF CERVIX

43. Benign and Premalignant Conditions of Cervix ................................................................................. 299
Textbook of Gynecology

Sudha Salhan, Harsha Gaikwad, Moni Tuteja

• Benign Conditions of the Cervix 299
• Cervicitis 300
• Non-infectious Cervicitis 302
• Metaplasia, Hyperplasia and Endometriosis 302
• Benign Tumors 303
• Premalignant Lesions of Cervix and their Management 304
• Management of Abnormal Cervical Cytology During Pregnancy 308
• Clinical Response to Neoplasia in Pregnancy 308
• Postpartum Re-evaluation 308
44. Malignant Conditions of the Uterine Cervix ........................................................................................ 310
Sudha Salhan
• Epidemiology of Cancer Cervix 310
• Natural History of Cancer Cervix 311
• Diagnosis of Cervical Cancer 313
• Staging Carcinoma of Cervix (2009) 313
• Spread of Cancer Cervix 315
• Prevention of Cervical Carcinoma 317

SECTION 11: DISEASES OF UTERUS AND FALLOPIAN TUBES

45. Benign and Premalignant Conditions of the Uterus ........................................................................... 320
Shubha Sagar Trivedi, Monika Madaan, Sharda Patra, Sudha Salhan
• Management 324
• Key Points 326
• Other of Benign Conditions of Uterus 327
• Adenomyosis 328
• Premalignant Conditions of Uterus 329
46. Malignant Conditions of Uterus and Fallopian Tubes ........................................................................ 332
Sudha Salhan, Pushpa Singh, Urvashi Miglani
• Malignancies of Uterus 332
• Fallopian Tube Carcinoma 338
• Etiology 338
• Hu ET AL’S Criteria 339
• Role of Imaging in the Diagnosis of Primary Fallopian Tube Carcinoma 339
• Role of Tumor Markers 339
• Role of Chemotherapy 340
• Role of Radiotherapy 340
• Role of Hormonal Agents 340
• Role of Second Look Laparotomy 341

SECTION 12: DISEASES OF OVARY

47. Benign Conditions of Ovary and Fallopian Tubes .............................................................................. 343
Manju Aggarwal, Payal Chaudhary, Sudha Salhan
• Adnexal Mass 343
xx • Physiologic and Functional Ovarian Cysts 343
• Polycystic Ovaries 343
 • Endometriosis 343
• Inflammatory 344
• Benign Neoplasms 344
• Dermoid Cysts (Mature Cystic Teratomas) 344
• Serous Cystadenoma/Mucinous Cystadenoma 345
• Ectopic Pregnancy 346
• Clinical Presentation and Complications 346
• Ovarian Cyst Rupture and Hemorrhage 346
• Ovarian Torsion 346
• Evaluation 347
• Laboratory Studies 347

Contents
• Imaging Studies 347
• Diagnostic Procedures 347
• Management 347
• Premenopausal Women 348
• Premenarchal and Postmenopausal Women 348
• Indications for Surgery of Asymptomatic Menopausal Adnexal Mass 348
• Summary and Suggested Management Protocol 348
• Operative Considerations 348
• Management in Pregnancy 349
• Remnant Ovarian Syndrome 350
• Residual Ovarian Syndrome 350
48. Ovarian Malignancy .............................................................................................................................. 351
Sunesh Kumar, Lalit Kumar
• Epidemiology of Ovarian Cancer 351
• Pathology 352
• Staging of Ovarian Carcinoma (FIGO,1998) 355
• Clinical Features 355
• Surgery 356
• Chemotherapy for Epithelial Ovarian Cancer 357
• Malignant Ovarian Germ Cell Tumors (MOGCT) 360

SECTION 13: DISEASES OF VULVA

49. Dermatoses of Vulva ............................................................................................................................ 365
Vibhu Mehdirata
• The Uniqueness of the Vulvar Dermatoses 365
50. Other Benign Conditions of Vulva ....................................................................................................... 369
Sudha Salhan, Moni Tuteja
• Developmental 369
• Infections 369
• Allergic 369
• Systemic Diseases 369
• Epithelial Disorders 369
• Epithelial Lesions 371
51. Premalignancies and Malignancies of the Vulva ................................................................................ 374
Sudha Salhan, Payal Chaudhary
• Premalignant Conditions of the Vulva 374
• Vulvar Malignancy 374
• Epidemiology and Risk Factors 374
• Clinical Manifestations 375
• Diagnosis 375
• Histologic Types 375
• Mode of Spread 376
• Pretreatment Evaluation 376
• Treatment of Vulvar Squamous Cell Cancer 378
• Prognosis 379
• Treatment of Other Histologies 380 xxi
 SECTION 14: MTP AND CONTRACEPTION
52. The Medical Termination of Pregnancy (MTP) and Safe Abortion ..................................................... 381
Sudha Salhan, Sangeeta Kaul
• Requirement of the Place (MTP Rules 2003) 381
• Safe Abortion 382
• Preoperative work-up 383
• Precautions 383
• Follow-up 384
• How to make induced abortions safe? 384
• Methods of Medical Termination of Pregnancy 384
Textbook of Gynecology

• Manual Vacuum Aspiration (MVA) 384

• Medical Method 389
53. Contraception ....................................................................................................................................... 390
Sudha Salhan
• Definitions 390
• Methods of Contraception 390
• Temporary or Spacing Methods 391
• Permanent Method of Contraception 407
54. The Preconception (PC) and Prenatal Diagnostic Techniques (PNDT)
(Prohibition of Sex Selection) Act ....................................................................................................... 413
Sudha Salhan
• Adverse Child Sex Ratio in India 413

SECTION 15: IMAGING MODALITIES IN GYNECOLOGY

55. Role of X-Ray in Gynecology ............................................................................................................... 416
Puneet Singh Kocher, Sudha Salhan
• Plain Radiograph 416
• Chest Radiographs 418
• Contrast Studies 418
• Barium Enema 423
56. Ultrasound (USG) in Gynecology ........................................................................................................ 424
Rajesh Uppal
57. Color Doppler and 3D Ultrasound in Gynecology .............................................................................. 431
Ashok Khurana
• Technical Considerations 431
• Congenital Uterine Malformations 432
• Focal Endometrial Lesions 436
• Intrauterine Devices 438
• Endometrial Fluid Collections 438
• Endometrial Receptivity 438
• Fibroids 440
• Adenomyosis 443
• Fallopian Tubes 443
• Vascular Disease in the Pelvis 445
• Functional Ovarian Cysts 449
• Polycystic Ovaries 451
• Endometriosis 451
• Dermoid Cysts 454
• Neoplastic Ovarian Lesions 455
• Ultrasound in Urogynecology 457
• Infertility 459
58. Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) in Gynecology ................... 468
Parveen Gulati, Peeyush Pandit, Sudha Salhan
xxii • Computed Tomography (CT) 468
• Magnetic Resonance Imaging (MRI) 469
 • Contraindications 470
• CT in Gynecology 470
• MRI in Gynecology 470
• Congenital Anomalies 470
• Benign Uterine Conditions—Leiomyoma 472
• Leiomyoma 472
• Adnexa 476
• Carcinoma of the Vulva 478
59. Positron Emission Tomography (PET) in Gynecology ....................................................................... 479
Sudha Salhan

Contents
SECTION 16: OPERATION THEATER ACTIVITIES
60. Asepsis and Antisepsis in Operation Theater (OT) ............................................................................ 480
HP Anand, Sudha Salhan
• Need for Asepsis in OT 480
• Prophylactic Antibiotics 485
61. Preoperative Care ................................................................................................................................. 486
Sunita Malik, Pawan Nayyar

62. Intraoperative and Anesthesia Complications During Gynecology Surgery .................................... 490
Sudha Salhan, Sonia Ghuman, Meenakshi, PK Verma
• Hemorrhage 491
• Ureteral Injuries 491
• Bladder Injury 492
• Bowel Injury 492
• Complications during Laparoscopic Surgery 492
• Complications of Anesthesia 493
• Partial Pressure 498
• PH Scale 498
• Acidemia 498
• Alkalemia 498
• Acidosis 498
• Alkalosis 498
• Buffers 498
• Standard Bicarbonate 498
• Actual Bicarbonate 498
• Base Excess 498
• Arterial Blood Gas Sampling: Clinical Considerations 498
• Interpretation of a Blood Gas Sample 499
63. Postoperative Care and Complications .............................................................................................. 501
Renuka Sinha, Sushma Suri, Sudha Salhan
• Postoperative Care 501
• Postoperative Complications 502
64. Sutures and Needles ............................................................................................................................ 506
Nivedita Sarda, Sudha Salhan
• Other Suture Characteristics 506
• Classification of Sutures 507
• Needles 509
• Needle-holder 511
65. Minor Procedures ................................................................................................................................. 512
Sushma Suri, S Prateek, P Chowdhury, Harsha Gaikwad, P Muley, Sabri, HP Anand, Sudha Salhan
• Sedation 512
• Local Anesthesia 512
• Autopapas Screening 514
• Use of Electrical Energy in Gynecological Surgery 524
xxiii
 SECTION 17: MAJOR OPERATIONS
66. Perineal Tears ....................................................................................................................................... 533
Sunita Singhal, Sudha Salhan
• Predisposing Factors 533
• Classification 533
• Repair of First and Second Degree Tears 533
• The Management of Third- and Fourth- Degree Perineal Tears 534
• Technique 534
• Postoperative Management 535
• Consequences of Perineal Trauma 535
Textbook of Gynecology

• Future Deliveries 535

• Delayed Management 535
67. Endoscopy in Gynecology ................................................................................................................... 537
Rahul Manchanda
• Endoscopy 537
• Laparoscopy 537
• History 537
• Instruments 537
• Hysteroscopy 543
• Diagnostic Instruments 543
• Anesthesia 544
• Technique 544
• Indications 544
• Contraindications 545
• Complications 545
• New Developments 546
68. Operations of Ovary ............................................................................................................................. 547
Niharika Dhiman, Sudha Salhan

69. Conservative Surgical Methods of Treatement of Pelvic Organ Prolapse ........................................ 549
Sudha Salhan, Shakti Bhan Khanna, HP Anand, Kiran Bala Dass, Kaushiki
• Vaginal Procedures 549
• Abdominal Methods 555
• Recent Advances in Surgical Management of POP 558
70. Hystercetomy ........................................................................................................................................ 559
Sudha Salhan, Rani Jain, MD Goswami
• Types of Hysterectomy 559
• Complications of Abdominal Hysterectomy 563
• Vaginal Hysterectomy 563
• Preoperative Preparation 563
• Ancillary Procedures for Complicated Cases 569
• Vaginal Hysterectomy in Special Circumstances 570
• Cornual Fibroid 570
• Big Uterus with Multiple Fibroids 570
• Operative Procedure 570
• Postoperative Care 571
• Urologic Issues 571
71. Microsurgery in Gynecology ................................................................................................................ 574
Rekha Bharti, Sudha Salhan
• Definition 574
• Evolution of Microsurgery 574
• Limitations of Microsurgery by Laparotomy 574
• Advantages of Laparoscopic Tubal Anastomosis 574
• Indications of Microsurgery 574
• Contraindications to Tubal Microsurgery 574
xxiv • Equipments for Conventional Microsurgery 575
 • Equipments for Laparoscopic Microsurgery 575
• Surgical Steps in Microsurgery 575
72. Myomectomy ......................................................................................................................................... 577
Sudha Salhan, Shweta Rajani

73. Radical Surgeries in Gynecology ........................................................................................................ 579

Sudha Salhan, Banashree Das, HP Anand
• Radical Hysterectomy 579
• Radical Vulvectomy 582
• Radical Vaginectomy 586

Contents
• Exenteration 588
74. Vault Prolapse ....................................................................................................................................... 589
Banashree Das
• Definition 589
• Incidence 589
• Risk Factors 589
• Management of Vault Prolapse 590
• Operations 590
• Transvaginal Repair 590
• Abdominal Operation for Vault Prolapse 591
75. Vaginoplasty ......................................................................................................................................... 593
BD Hasija, Sudha Salhan

76. Laser in Gynecology ............................................................................................................................ 597

Sunita Malik, Sujata Das

77. Robotic Surgery in Gynecology ........................................................................................................... 600

Neena Aggarwala

SECTION 18: MISCELLANEOUS

78. Breast Diseases .................................................................................................................................... 603
Sunita Singal, Sudha Salhan
• Anatomy of Breast 603
• Changes at Puberty 603
• Role of Hormones 603
• Embryology 604
• Abnormal Conditions of the Breasts 604
• Breast In Pregnancy and Lactation 605
• Abnormal Lactation 605
• Inducted Lactation 606
• Suppression of Lactation 606
• Benign Conditions of Breast 607
79. Drugs Used in Gynecology .................................................................................................................. 610
Sudha Salhan, Pikee Saxena
• Estrogens 610
• Progestins 611
• Oral Contraceptive (OC) 611
• Injectable Preparations 611
• Intrauterine Insert 611
• Emergency Contraception 612
• Anti-estrogens 612
• Antiprogestins 612
• Androgens/Antiandrogens 613
• GnRH Agonists (Analogs) 614
• GnRH Antagonists 614
• Glucocorticoids 614
xxv
 • Ovulation Inducing Agents 614
• Alternative Drugs for HRT in Menopause 615
• Menopausal Osteoporosis 616
• Hyperprolactinemia 617
• Hyperinsulinemia in PCOD 617
• Drugs for Abnormal Uterine Bleeding (AUB) 618
• Drugs Used in Urinary Incontinence 618
• Sildenafil 618
• Prostaglandins (PG) 618
• Vaginal Drugs for Local Infections 618
• Micronutrients and Antioxidants 618
Textbook of Gynecology

• Vaccination 618
80. Basis of Neo-Organo-Histogenesis in vivo: Regeneration of Fallopian Tubes and Uterus ............. 620
BG Matapurkar, H Koratkar
• General Considerations 620
• Desired Metaplasia 620
• Human Utility 623
81. Stem Cells Research, Clonning and Gene Therapy ........................................................................... 626
Ankita Singal, Renuka Sinha, Sudha Salhan
• Stem Cell Research 626
• Gene Therapy and Cloning 629
• An Overview 629
• Basics of Gene Therapy 629
• Gene Therapy: Approaches and Requirements 630
• Diseases Treated with Gene Therapy 631
• Gene Therapy in Gynecological Cancers 632
82. Care of a Terminally Ill Patient: Palliative Care ................................................................................... 634
Sudha Salhan
• Definition 634
83. Biomedical Waste Management and Handling Rules ......................................................................... 635
Sudha Salhan

84. National Rural Health Mission (NRHM) and Reproductive and Child Health II (RCH II) ................... 642
Sudha Salhan

85. Specimen in Gynecology ..................................................................................................................... 645

Renuka Sinha, Sudha Salhan
• Gynecology Specimens 645
• Ovarian Tumors 645
86. Common Instruments in Gynecology .................................................................................................. 648
Asmita Muthal Rathore, Raksha Arora, Sudha Salhan

87. Frequently Asked Questions in Final MBBS ....................................................................................... 656

Meetu Salhan

88. Often Asked Multiple Choice Questions in MD/MS Entrance Examinations ..................................... 658
Durgesh

Index ...................................................................................................................................................... 663

xxvi
 Section 1 Basics of Gynecology

1 Evolution of Gynecology

Sudha Salhan, Meenakshi Bhatt

DEFINITION OF GYNECOLOGY (Fig. 1.4) who gave the concept of germs in France. By all these
It is that branch of medical science, which treats the functions discoveries the era of asepsis and antisepsis dawned making
and diseases peculiar to women (Oxford English Dictionary). surgeries safer.
The pathology of non-pregnant women is the main focus. Gynecology as a specialty in medical sciences was well
Unlike Obstetrics, which is as old as mankind, Gynecology established only by the 1880s. Hysterectomy was first described
is a comparatively recent subject added to medical education. by Soranus in a case of uterovaginal prolapse; he presumably
Previously it was dealt with by general surgeons. This is linked performed amputation of cervix. In the sixteenth century an
with the evolution of knowledge of anatomy, development of Italian, Berengario de Capri wrote about excision of uterine
antisepsis and asepsis, discovery of anesthesia and antibiotics portion in prolapse of uterus. However, Langenbeck (1813) first
and establishment of blood bank services in recent decades, performed planned vaginal hysterectomy. The indication at that
besides others. A few important milestones are described in time was most often cervical carcinoma.
the chapter. Ephraim McDowell of Kentucky (1809) performed the first
Only ancient Egyptian technicians had some knowledge of laparotomy for ovarian tumor without anesthesia. The first
anatomy as they routinely did evisceration of dead bodies for abdominal hysterectomy was attempted by Charles Clay (1843)
mummification. In the thirteenth century, surgeons were at Manchester. Repair of vesicovaginal fistulae was done by
responsible for autopsies to determine the cause of death. James Marion Sims (1840) (Fig. 1.5) on slave women (also
Though the first textbook “Gynecology” was written by without anesthesia) in a lateral position named after him. This
Soranus, a Roman physician (120 AD) but it contained only operation of his played a major role in establishing gynecology
Obstetrics. Vesalius (1543) published the first authentic work as a separate specialty.
on human anatomy. He was a surgeon. Later William Hunter Improvement in anesthesia (after 1846) and antisepsis led
(1918-1983) wrote about the structure of the female pelvis. to better outcome. The abdominal hysterectomies were mostly
Sir James Simpson (1811–1870) (Fig. 1.1) brought out the subtotal.
subject of hospital infection. Semmelweis (1818–1865) was the Rubber gloves were invented by William Stewart Halsted
first to say that infection (puerperal sepsis) is caused by the in 1889–1890 and used by Hunter Robb (1894), a gynecologist,
physician himself. He suggested washing of hands with at Johns Hopkins Hospital. Early post-operative mobility was
chlorinated lime solution before examination, to prevent advocated by Emil Ries (1899); he was a professor of Gynecology
infection. But his idea was not taken kindly by his medical in Chicago.
colleagues. The same fate awaited Oliver Wendell Holmes in Pioneering work was done by Howard Atwood Kelley. He
1842 (Fig. 1.2) when he made the statement that doctors was the head of Obstetrics and Gynecology in the newly opened
themselves were carrying the infection of puerperal infection Johns Hopkins Hospital (1889). He concentrated on Gynecology
to their patients. Joseph Lister (1827–1912) (Fig. 1.3) used and Pathology and trained leading Gynecologists of his time.
carbolic acid for cleaning the instruments, sutures and dressing His stitch (Kelly’s stitch) is still used in urinary incontinence.
for use in the operations. It was Louis Pasteur (1822–1895) Kelly also started radical hysterectomy.

Fig. 1.1: Sir James Simpson Fig. 1.2: Oliver Wendell Holmes Fig 1.3: Joseph Lister
Basics of Gynecology

Fig. 1.4: Louis Pasteur Fig. 1.5: James Fig. 1.6: Robert Edward (L) Fig. 1.7: Subhas
Marion Sims Patrick Steptoe (R) Mukhopadhyay

The concept of early detection of cancer was conceived by 3. Edstrom K and Fernstrom I. The diagnostic possibilities of a
Thomas Stephen Cullen (1900), the successor of Kelly. GN modified hysteroscopic technique. Acta Obstet Gynaecol Scan
Papanicolaou along with H Trant published the findings of 1970;49:327.
detection of uterine cancer by smear. Recognition of cancer in 4. Garceau E. Vaginal hysterectomy as done in France. Am J Obstet
Dis Women Child 1895;31:35.
situ was also started by Cullen in 1912. It was only in 1943 that
5. Goldrath MH, Fuller TA, Segal S. Laser photo-vaporization of
Richardson first carried out total abdominal hysterectomy. endometrium for the treatment of menorrhagia. Am J Obstet
Philipp Bozzini (1805) thought of visualizing the lumen or cavity Gynaecol 1981;140:14.
by an endoscope. The hysteroscope was constructed by 6. Green-Armytage VB. The rise of surgical gynaecology 1800-1950,
Desormeaux (1865). However, after development of physics for in Anonymous Edinburgh, E and S Livingtone Ltd; 367.
Section 1

light source, Robert Neuwirth (1971) started laparoscopic tubal 7. Green-Armytage VB. Vaginal hysterectomy: a new technique and
ligation and removal of adhesions. The design of the endoscopes follow-up of 500 consecutive operations for haemorrhage. J Obstet
has improved and now we have both uterine (hysteroscopic) Gynecol Brit Em 1939;46:848.
and laparoscopic surgeries of any conceivable type. 8. Harriton FH. An introduction to history of medicine, 4th Edn,
Philadelphia PA. WB Saunders & Co;1929.
Transcervical resection of endometrium (TCRE) was
9. Heaney NS. A series of 627 vaginal hysterectomies performed for
introduced in 1981 by Milton Goldrath. During the 1960s, Kurt benign disease with three deaths. Am J Obstet Gynecol 1935;30:269.
Semm, a German gynecologist, created the automatic 10. Kelly HA. Operative Gynecology. New York: Appleton & Co;1898,
insufflator. Later he described a technique for laparoscopic N. Abrams, Inc.
assistance in vaginal hysterectomy in 1984 which was subse- 11. Langenback CJM. Geschichte einer von mir gluklich verichteten
quently called laparoscopically assisted vaginal hysterectomy extirpation der ganger gebarmutter Biblioth Chir Opth Hanover
(LAVH). Harry Reich performed the first laparoscopic 1817;1:557.
hysterectomy (LH) in January, 1988 in Pennsylvania. Lyons 12. Lyons TL. Laparoscopic supracervical hysterectomy. A comparison
of morbidity and mortality results with laparoscopically assisted
developed the minimally invasive laparoscopic supracervical
vaginal hysterectomy. J Reprod Med 1993;38:763.
hysterectomy (LSH) in 1990. 13. Mäkinen J, Johansson J, Tomas C, et al. Morbidity of 10110
Victor Bonney (1930) and Washington Atlee (1845) were the hysterectomies by type of approach: Hum Reprod 2001;16:1473.
pioneers in myomectomies. Laparoscopic myomectomy was 14. McDowell E. Three cases of extirpation of diseased ovaria. Eclectic
frequently preformed since 1991 by Jean-Bernard Dubuisson Repertory, and Analytical Review, Medical and Philosophical
and associates. Uterine artery embolism was initially started 1817;7:242.
by Ravina and coworkers in 1995. Different energy sources (cold, 15. Neuwirth RS, Amin HK. Excision of submucous fibroid with
laser and electric current) are now being experimented with to hysteroscopic control. Am J Obstet Gynaecol 1976;126:95.
destroy a tumor. 16. Overton C, Hargreaves J, Maresh M. A national survey of the
complications of endometrial destruction for menstrual disorders.
The first assisted reproductive technology baby was born
The MIST-LETOE study (Minimally Invasive Surgical Techniques—
under the treatment of Robert Edwards and Patrick Steptoe (Fig. Laser, endothermal or Endorescetion). Br J Obstet Gynecol
1.6). Edwards is awarded Nobel Prize in Physiology and 1997;104:1351.
Medicine in October 2010. The first baby born is Marie Louise 17. Pantaleone D. On endoscopic examination of the cavity of the womb
Brown. In our country also Subhas Mukhopadhyay (Fig. 1.7) (TRL from Italian) Med Press Circ 1869;8:26.
was the first Indian Obstetrician and Gynecologist to perform 18. Reich H, Decaprio J, McGlynn F. Laparoscopic hysterectomy. J
IVF in October 3rd, 1978. The name of the first IVF child is Gynecol Surg 1989;5:213.
Durga barely 67 days after the world’s first IVF baby. Though 19. Ricci JV. The Development of Gynaecologic Surgery and
his work was not recognized. Instruments. Philadelphia: Blakiston, 1949.
20. Richardson EH. Simplified technique for abdominal
In this chapter we followed the evolutions of Gynecology
panhysterectomy. Surg Gynecol obstet 1929;48:428.
over the years. It should be noted that Gynecology is still an 21. Richart RM, Neuwirth Rs, Israngkun C, et al. Female sterilization
evolving discipline and progress is expected to be made by electrocoagulation of tubal ostia using hysteroscopy. Am J Obstet
especially in the fields of cancer therapy, robotic surgery and Gynaecol 1973;117:801.
stem cell therapy. 22. Ségond E. Considerations on the technique, the difficulties and the
dangers of vaginal hysterectomy. Trans Am Gynaecol Soc
BIBLIOGRAPHY 1896;21:133.
1. Burnham W. Extirpation of the uterus and the ovaries for 23. Semm K. Hysterectomy by pelviscopy: an alternative approach
sacromatous disease. Nelson’s Am Lancet 1853;7:147. without colpotomy (CASH). In: Laparoscopic Hysterectomy.
2. Clay C. Observations on ovariotomy, statistical and practical. Also Anonymous. Oxford Blackwell Scientific publication; 1993.p.118.
24. Temkin OT. Soranus’ Gynaecology. Baltimore Johns Hopkins
2 a successful care of entire removal of the uterus and its appendages.
Trans Obstet Soc Lon 1864;5:58. University Press; 1956.
 2 Medicolegal Aspects

Sanjay Gupte, Sudha Salhan

The medical profession is at crossroads in our country. After professional medical liability so outlined. There is even more
doctors were brought under the purview of Consumer to say now. This reassuring picture has ceased to represent the
Protection Act (CPA) by the Supreme Court in 1991, litigations law.
against doctors have increased by leaps and bounds. This has
put the Doctor-Patient relationship under severe strain. Both CIVIL LAW IN RELATION TO GYNECOLOGY
the doctors and the patients have suffered as a consequence. AND OBSTETRIC PRACTICE
There are many reasons for this. Misinterpretation, over The law in relation to medical, gynecology and obstetric
reaction, and ignorance regarding the legalities are prominent practice, in particular, is in the process of evolving slowly in
amongst them. India. When an unexpected obstetric complication occurs,
during the medical practice, the patient most commonly wants
THE LEGAL CONTEXT OF PROFESSIONAL LIABILITY to sue the doctor for ‘negligence.’ This negligence can be civil
In the book ‘The Discipline of Law (1979)’ Lord Denning wrote or/and criminal. Following the decision of the Supreme Court
that ‘an action for negligence against a doctor is for him unto a in IMA vs VP Shanta the doctor is considered as a service
dagger. His professional reputation is as dear to him as his body, provider and the patient as a consumer. Therefore, a suit will
perhaps more so. An action for negligence can wound his lie in the jurisdiction of the consumer forum. The doctor-patient
reputation as severely as a dagger to his body. He was quoting relationship is based on the contract and hence the principles
from his own direction to the jury in the case of Hatche V Black. of Indian Contract Act become applicable, but the courts tend
In that case the plaintiff’s vocal cords were badly damaged to look at it as ‘fiduciary’ contracts, which put more liability on
during an operation, carefully performed, on a toxic thyroid the doctor as they are in a more advantageous position as
gland. The plaintiff’s physician (though not her surgeon) had regards the patient. Medical negligence is a civil wrong and
reassured the plaintiff, prior to the operation, that there was no attracts the provisions of the law of Torts.
risk to her voice. There was, and that risk materialized. She Let us understand the basic concepts of these laws to realize
was under contract to the BBC as a singer and after the operation how the complaints are made and how defense is planned.
she could not broadcast again. Under the Contract Act the consent carries a great value. A
Negligence is defined as failure to act in accordance with good informed consent is an important aspect of the defense.
the standards of reasonable competence at the time. With regards to the law of negligence, it is important that the
Denning LJ, as he then was, continued to guide the jury’s patient should prove these points:
consideration of the doctor’s professional conduct thus: 1. The doctor was legally bound to give the treatment.
‘You must not, therefore, find him negligent simply because 2. That actual damage has been caused to the patient, which
something happens to go wrong: if, for instance, one of the risks can be proved.
inherent in an operation actually takes away the benefits that 3. The doctor’s treatment has been the proximate cause of the
were hoped for, or if in a matter of opinion he makes an error of damage (Causa causans).
judgment. You should only find him guilty of negligence when 4. The treatment of the doctor was below the accepted
he falls short of the standard of a reasonably skillful medical “Standard of Care.”
man, in short, when he is deserving of censure — for negligence.’ The doctor could contest the above stating that:
Some examples of the prosecution in gynecology are: 1. The damage was not due to his treatment.
• During examination, operation/sterilization without 2. The patient was also negligent and had he/she not been
consent. The consent must be both informed and written. negligent the damage could have been mitigated. (The
If patient and attendant do not understand he/she is to be commonest example: Not following the advise of the doctor
explained and signature of a witness is taken. called as ‘contributory negligence’).
• Leaving sponge, etc. inside the abdomen during operation 3. The said complication is “Vis a major” (act of God) and not
• Doing MTP without consent (313 IPC), by non-recognized due to negligence of the doctor.
practitioners, at non-recognized place and beyond 20 weeks. 4. The treatment of the doctor was well within the standard
(Criminal Abortion 312 IPC) established in the field.
• Failure of tubectomy—When it is proven that there was These concepts must be employed in day-to-day obstetric
neglect (e.g. one fallopian tube not tied) 314 IPC killing of and gynecology practice. Meticulous record keeping with this
fetus, 315 IPC killing of mother, 316 causing death of a child. insight of law can do wonders while contesting cases of medical
There was much to say, even in 1954, about the picture of negligence. On 17 February 2009, a Supreme Court Bench
 consisting of Justices Markandey Katju and RM Loda said, A 6. Follow-up instructions not given. Especially in cases of
medical practitioner is not liable to be held negligent simply failure of sterilization.
because things went wrong from a mischance or misadventure
or through an error of judgment in choosing one reasonable INGYNECOLOGY
course of treatment in preference to another. He would be liable 1. Missing the diagnosis especially of a cancer.
only when his conduct fell below the standards of a resonably 2. Undefendable non-standard surgical procedures.
competent practitioner in his field (Dr Martin FD Souza vs Mohd 3. Surgical or anesthesia complication.
Ishfag at Nanavati Hospital Mumbai). While doctors who cause 4. Improper follow-up.
death or agony due to medical negligence should certainly be These are the situations, which lead to medicolegal
penalized keeping in mind that, like all professions, doctors complications.
too can make errors of judgment but if they are punished for
that no doctor can practice his vocation with equanimity. MEDICOLEGAL ASPECTS OF ENDOSCOPIC SURGERY
Basics of Gynecology

Therefore, these cases should be refered to a committee of 1. The surgeon should be adequately trained.
doctors or a committee of doctors specialized in the field where 2. Proper equipment has to be available.
negligence was attributed. Only after the doctor or the 3. Careful case selection is important.
committee reports that there is a prima facie case of medical 4. Detailed communication as regards the procedure and
negligence should a notice be issued to the doctor/hospital informed consent is vital.
concerned. This is necessary to avoid harassment to doctors 5. Standard techniques should be followed.
who may not ultimately be found to be negligent. The police 6. The procedure should be documented.
was warned not to arrest or harass doctors unless the facts 7. Possibility of complication, especially the precaution taken
clearly come within the parameters laid down by the Apex Court should be documented.
in Jacob Methew’s case; otherwise the policemen will themselves 8. Postoperative instructions and follow-up should not be
here to face legal action. If a patient is non-compliant, make a neglected.
record in the case sheet.
To avoid medicolegal problems, proper communication and
Section 1

documentation are the two most important aspects, which need

CRIMINAL LAW IN RELATION TO GYNECOLOGY
to be remembered.
AND OBSTETRIC PRACTICE
To make it easy to remember, I would like to put our
In India, the Indian Penal Code and Criminal Procedure Code guidelines in the following way:
deal with criminal law. Most often when there is a death of a
patient, the relatives are likely to lodge a complaint against a A: Awareness: Be aware, especially in a mishap, may it be a
doctor. The complaint is lodged at the police station under miscarriage or any other adverse outcome of surgery. Think of
section 304 A of Indian Penal Code. the possibility of litigation.
This means that the patient could sue a doctor under: Attendance: Early attendance is vitally important. If a patient
1. The Civil Law. comes to the hospital with pain or bleeding and she is not
2. Consumer Protection Act (CPA). attended to by any doctor early, this is where the problem starts.
3. The Criminal Law. Early attendance to the patient’s complaints in a nursing
4. The complaint can also be made to the respective state home is also important.
medical council, which in turn, can initiate an inquiry
against the doctor. It must be remembered that the patient B: Behavior: Rude behavior of the doctor or staff is an obvious
can complain to all the four authorities and in fact there has cause. But it may not be just behavior. Indifference to the
been an increasing trend of such situations in contemporary patient’s complaint or not listening to patient’s viewpoint can
obstetric and gynecology practice. be the beginning of a problem.
In gynecology, the doctor can be sued in various situations. C: Communication (Chapter 3): By communication we try to
Let’s look at them one by one. It is obviously not possible to inform, instruct and persuade the patient. We also hope to
elaborate all the situations in detail but the following will serve inspire confidence. This can only happen if we are able to explain
as good pointers. to the patient the need for the treatment and how we plan to
impart it and the risk involved. But we also must not forget
MEDICOLEGAL ASPECTS OF MTPs that the communication should be a two-way affair and allowing
1. Unqualified doctors. the patient to communicate can be the crux of prevention of
2. Carrying out MTP at an unrecognized place under MTP medicolegal problems. Unexplained adverse outcome, unmet
Law. expectations and unexpected costs are the main causes of
3. Proper consent not taken—Only the patient’s consent is medicolegal cases and good communication can prevent this.
enough when she is an adult. Consent is very important in gynecology practice. Explanation
4. Minimum investigation not done. of the disease and treatment to the patient is provided by the
5. When complication arises (e.g. perforation) if they are not treating gynecologist. The patient understands and gives
recognized and treated. informed consent. The consent can be implied, oral or written
6. Long term sequelae—infertility, Rh isoimmunization and informed. Written informed consent is preferred. An adult
of 18 years or more of age can give consent if she is in sound
MEDICOLEGAL ASPECTS OF STERILIZATION
mind. In patients below 18 years or of unsound mind the legal
1. Unqualified person. guardian can give the consent. In emergency and in an
2. Unrecognized place. unconscious patient where no attendant is available two doctors
3. Improper consent. can sign and proceed for life-saving procedures.
4. Wrong selection of patient.
5. Complications not recognized and treated. Certificates: Certificates for medicolegal problems. Giving false
4 certificates is a criminal offense. It is important to identify the
person as well as not to get pressurized in changing the facts. G: Goodwill: It is not only important to have goodwill among
There is an example of a doctor who, on the patient’s request, patients and relatives but also among your colleagues and the
mentioned an earlier date on the certificate of elective community at large. Not commenting unnecessarily, adversely,
appendectomy than the actual date. That doctor landed in jail about previous treatment given by a colleague, is a point to be
because the patient had committed murder before getting remembered in this regard.
admitted to his nursing home.
H: Help: One should not hesitate to seek help when needed as
D: Documentation: Documentation or records are a mirror of well as a second opinion wherever deemed fit.
our action in the court of law. Records should be Correct, ‘Help’ also refers to the helping staff of our hospital. Junior
Complete, Contemporary and Chronological and they should doctors, nurses, even ayahs can land a doctor in trouble by
correlate when recorded by various doctors. Made up records inadvertent wrong comments about treatment or by hurting
can easily be made out and can be held as criminal forgery. patient by their behavior.
Good records not only help the treatment of patients but also

Chapter 2
come handy as our defensive shields in a court of Law, e.g. I: Investigations: While treating a patient proper bio-chemistry
noncompliant to advise. as well as other needed investigations should always be carried
out.
E: Ethics, Empathy, Explanation and Equipment: Ethical
There are many cases where courts have held doctors
treatment and empathy towards the ill-patient always holds us
negligent for not resorting to investigations on time, which
steadfast in any medicolegal problem. Do not take percentages
could have helped in diagnosis and treatment.
of profits; do not team up with chemists and laboratories in

Medicolegal Aspects
unethical practices. J: Judgment: While treating a case, and especially so in
When things do not go as per patient’s expectations, it is Obstetrics and Gynecology, careful and considered judgment
important to offer true and correct explanation to the patients. is vital.
This helps them to keep their faith and confidence in us. K: Knowledge: To use proper judgments one needs proper
Having proper equipment like Oxygen Cylinders, Boyle’s updated knowledge. Updating ourselves with the newer and
machine, Pulse oxymeter, etc. in the hospital is proof of our important developments in our field needs no emphasis.
intention towards the duty and care. I think, if followed, these easy to remember guidelines
F: Finances: Many times exorbitant charges or charges which should enable us to avoid medicolegal problems. But finally
patient feels are exorbitant can trigger off medicolegal disputes. one must agree that we also need some…
Hence, reasonable charges and proper explanations are always L: Luck not to land with unforeseen mishaps in the court and
warranted. to keep the image of the medical profession as noble.

5
 3 Communication and
Counseling in Gynecology

Sudha Salhan, Jyotsana Suri

Strong therapeutic knowledge and good communication are LISTENING AND LEARNING SKILLS
the foundations of a good relationship between a doctor and 1. The place must be clean, calm (no noise) and orderly. A
the patient. Communication is defined as a process of passing comfortable environment makes the patient feel at home.
messages, ideas, opinions, attitudes, facts, information and Greet her with a pleasant gesture. Accept her with dignity.
understanding from one person to another. Communication is Respect her as an individual and take her statement as true
the basis of the relationship between a physician and a patient. (trust). Full attention towards the patient is essential. Talk
It is essential in their joint attempt to achieve therapeutic goals. to her by name. Use proper soothing words.
It is indispensable for effective patient care. 2. Managing women’s sickness requires information of
Despite its monumental importance, the role of sensitive and intimate activities. Maintenance of privacy
communication is often ignored. Often it may seem superior to should be ensured before probing into those facts.
achieve therapeutic success by placing greater emphasis on Therefore, it is important to have a private place (e.g. a
physical examination, blood tests, X-rays, sonography, separate room or at least a part of the room separated from
medications and surgeries. However, it is seen that when this the rest of the room by the use of curtains) to make the
is done and the basic tenets of patient and doctor patient or the couple feel free to bring up personal matters
communication are ignored, patient care and the quality of (privacy of place). Personal privacy or confidentiality is
treatment suffer greatly. It is imperative that in our day-to-day ensured by not sharing her/their facts with anyone. This is
interactions with patients, we display respect for their further aided by keeping the records secret (as in MTP/HIV)
autonomy. and by talking in a low tone so that none else overhears
Communication is effective when the patient interprets and sensitive conversations. The patient is reassured that
understands the doctor’s message in the same way as the doctor confidentiality will be maintained unless she desires to
intended. Effective communication in the medical world has reveal the facts to someone.
been shown to be essential to a patient’s satisfaction in addition 3. Asking questions: Questions are asked to know the purpose
to the care he/she receives. The development of trust, the giving of the visit and to know about the patient’s personal health.
of full accurate information and the patient’s compliance, Both closed ended and open questions are required.
depend to a great extent on the health care provider ’s Closed ended questions are those whose answers consist
communication skills. It may be inborn in a few doctors but the of yes or no. They do not give us any extra information
majority must acquire this by active learning. besides what has been asked, e.g. “Do you drink milk in
Counseling is a method of communication. It is a way of your breakfast?” The answer is either yes or no.
working with people in which we try to understand their Open questions are those which encourage a person to
feelings and help them to make decisions. This is a very talk and give more detailed information. This saves us from
important skill as we deal with human beings (patients, their asking too many questions and helps us to learn more in a
relatives, colleagues, seniors, juniors, etc.). Counseling skills shorter time, e.g. “What do you eat for breakfast?”
are useful when we talk to our patients as well as in our daily Closed questions are needed only for obtaining
interactions with our colleagues, our family members and information such as the name, the age, etc. They should be
friends. We, as doctors, should make a sincere effort to be good used as infrequently as possible. Open questions give the
counselors, besides being astute clinicians. patient an opportunity to express her feelings and thoughts
The communication skills will be discussed under two major and thus provide us with a greater number of details. Do
headings: not ask leading questions as far as possible, e.g. “I hope
I. Listening and learning skills you will not bear any more children now, will you?” These
II. Building confidence and giving support can urge the patient to give the answers we desire rather
A patient often can provide the necessary pieces to the than answering truthfully. These questions may even be
diagnostic puzzle, if she is listened to effectively. Sir William judgmental or personally threatening.
Osler once noted that the physician should listen, for the patient Ask one question at a time. Be brief and clear. Ask only
will tell the diagnosis. Poor communication is actually the main those questions which have some sense or purpose. Too
reason for the medicolegal cases, poor adherence to treatment, many questions are not desirable. Be silent in between
adverse advertisement and termination of physician’s care. questions to give the patient time to recollect. Ask additional
Communication can be verbal and nonverbal. questions only if you do not understand the answer to a
 previously asked question. Also keep in mind the following
key points:
4. Speak in a language which is easily understood by the
patient.
5. Do not rush with questions; try to go with the pace of the
patient.
6. Try not to interrupt the narration unnecessarily.
7. Always be honest in your discussion about the disease and
treatment.
8. Voice quality is important.
9. Try to be precise and to the point.
10. Supplementation with written communication like

Chapter 3
pamphlets, notes, etc. will help.
11. Visual communication (in the form of photographs, charts
in the waiting space, microfilms or documentaries showing
the main steps of operative procedures or detailing
precautions which should be taken after delivery or
operations, etc.) is a very effective means of communication.

Communication and Counseling in Gynecology

Using Supportive Non-verbal Communication
Let the patient speak more than you do. Most of our
communication should be non-verbal.
This means that we should show our positive or helpful
attitude through our posture, expression (facial), body language,
movements or other means but without speaking. Non-verbal Fig 3.2: Assist the patient to get up to the table
communication reinforces the verbal messages. It can be carried
out by accepting what the patient is telling us and it can be 4. Take time. Do not show any signs of impatience, e.g. looking
used to encourage her, e.g. by patting on the back. The at the watch or yawning or shifting positions frequently
establishment of rapport and the communication of emotional while the patient is speaking. Make her feel that you have
support through non-verbal communication skills can help to time for her. As far as possible go at the pace of the patients.
cement the physician-patient relationship. Failing to use these She may not reveal the details of her illness and personal
skills interferes with effective patient care. life to a provider who does not take time to show interest in
Some of the helpful forms of non-verbal communication are: her complaints. By inattention valuable clues to the
1. To maintain the head at the same level as the patient; if we diagnosis are missed.
are sitting the patient we are talking to should also be seated 5. Use a smooth and gentle tone of voice during talking. Do
and not standing. Lean forward while listening (Fig. 3.1). not express judgment, disapproval or any other negative
2. Maintain eye-to-eye contact with the patient. Show interest reaction by the tone of your voice.
in what is being said, by nodding, smiling, etc. Do not 6. Offer your hand to the patient to assist her in getting up
wrinkle your brow or raise an eyebrow in a judgmental and down from the examination table (Fig. 3.2).
manner. Listen attentively. Do not do any other maneuvers 7. Try to uncover the patient gradually and only partially, e.g.
when listening to her like playing with a pen or a paper first the chest, then the abdomen and finally the perineal
weight, etc. region (that too by asking her to remove only one side of
3. Remove barriers while talking to the patient or her family. her salvar/trouser). Provide her complete privacy. The
Sitting behind a table, writing notes simultaneously, reading patient should never be uncovered suddenly without
case papers or talking on the phone or mumbling to indicate informing her and without proper privacy.
involvement is some other thinking process can all act as 8. Help her climb down the examination table by giving a hand
barriers and discourage the patient. after completing the examination.
9. Touch appropriately, according to the situation and the local
customs, e.g. patting a newborn baby is appropriate.
However, for a male doctor to pat a young female patient is
inappropriate in a conservative society like ours.

Reflection
Reflection means repeating back or reflecting what the patient
is saying. This helps the patient to realize that we have heard
and understood her and she will, then, impart further
information to us. It is desirable to say it in a slightly different
way, so that it does not sound as if we are imitating her, e.g. if
the patient says, “Doctor, I was awake the whole night due to
headache.” We can reflect on this information by saying “So
you could not sleep last night because of headache?”

Fig. 3.1: Non-verbal communication maintenance of head level, eye- Paraphrasing

to-eye contact, appropriate touching, no barrier in between and paying It is a statement or remark explained in other words or another
full attention. way so as to simplify or clarify. Tell the patient about her 7
 complaint by paraphrasing or telling in your own words. She Response 1
will be reassured that you have understood her concerns. Doctor—“Oh no! There is no weakness whatsoever after
vasectomy.”
Validation This is an inappropriate response, because it is
The patient thinks her situation is unique and is uncomfortable, disagreeing.
thus when we tell her that these feelings are common to a Response 2
particular situation, she feels reassured that her feelings are Doctor—“Yes, weakness after vasectomy operation can be
not exceptional. a problem.”
This is also an inappropriate response because it agrees
Empathizing with the patient mistaken idea.
This means to show the patient that we understand how she Response 3.
feels. Empathy is different from sympathy. Sympathy shows Doctor—“I see that you are worried that your husband
Basics of Gynecology

that we are sorry for a person but from our point of view, will become weak after vasectomy.”
whereas empathy is from the patient’s point of view, e.g. if a This is an appropriate response because it shows
patient says “Doctor, I feel very tired since the time I have acceptance.
become pregnant.” If the doctor says “Yes, I understand how After we have accepted and understood what the patient
you feel I too felt very tired when I was pregnant.” This shows feels, we have to give her information so that her mistaken
sympathy and it brings the attention towards the doctor. If the idea is corrected. This has to be done in a tactful way so
doctor says that it does not sound too critical.
“You are feeling very tired nowadays. It must be very 2. Recognize and praise what a patient is doing right. As
distressing to you.” This shows empathy to the patient. Empathy doctors we are trained to look for problems and correct
is more than just reflecting back what the patient says to us. them. However, as counselors we must look for good
practices followed by the patient and praise her. Praising
Barriers in Effective Communication good practices builds the patient’s confidence besides
Section 1

Use of a language not properly understood by the patient or encouraging her to continue those good practices. For
her relatives should be avoided. Speak in clear words. Use of example, “It is very good that you recognized that this
ambiguous words or phrases is a barrier in the communication bleeding is not normal and came to seek treatment.”
process. Be precise; use of nonessential language prevents 3. Give practical help wherever possible. For example,
effective communication. Do not overburden the patient or her helping a pregnant patient climb the examination table helps
relatives with information. It will unnecessarily confuse them. the patient trust the doctor and builds a rapport between
Noise is also an important communication barrier. Emotional them.
and psychological factors may also interfere with effective 4. Give a little, relevant information. Patients do not want
communication. If the patient is sitting at a distance from the technical details. What they really want to know is what
doctor, communication will be hampered. their problem is, how it happened and what needs to be
Excessive use of judging words such as ‘good,’ ’bad,’ ‘well,’ done to treat it, the chances of cure and any alternative
‘right,’ ‘normal,’ ‘proper,’ ‘wrong,’ etc. should be avoided as treatment available. Physicians must provide this infor-
they suggest a preconceived idea of the doctor for the patient. mation for all patients in simple, clear and non-technical
Note that judging questions are often closed questions. Using language. It is important not to overburden the patient with
open questions helps to avoid using judging words. However, too much information, which may not be relevant for her
some encouragement is always helpful. Further the patient’s right now. Information should be given in a positive way
notion of what is correct or incorrect may be very far from the and not in a critical manner. However, it has been observed
truth. For example, if the doctor asks, “Are you taking your that patients usually want more information and detailed
contraceptive pills properly?” he/she cannot be sure of the disclosures than their physicians routinely provide.
significance of the answer because the patient’s idea of what is 5. Use simple language. Try to speak in the patient’s language.
‘proper’ is not known to the doctor. More appropriately, the Do not use too much of scientific terminology. Speak using
doctor should ask, “How are you taking your contraceptive simple, familiar terms in a soothing manner to explain things
pills?” This question will make the patient reveal exactly how to a patient. This improves communication with the patient.
she takes her pills and hence, provide complete information. She can understand better and can ask questions for
clarification.
BUILDING CONFIDENCE AND GIVING SUPPORT 6. Make one or two suggestions; do not command. When we
1. Accept what the patient thinks or feels. Sometimes, a patient counsel the patient, we suggest what she could do. Herein
may have a wrong idea about her disease or its treatment. It lies the entire basis of counseling that we leave all options
is important not to disagree with her in a blunt manner. This open for the patient and let her decide what she wants to
will make her feel wrong and reduce her confidence. She do in a particular situation, after she has been given all the
may not wish to give any further information after that. relevant information. This leaves her feeling in control of
However, it is equally important not to agree with her the situation and helps her feel confident.
mistaken idea. 7. Summarizing. This skill is used to enable the patient to
So what can be done in such a situation? We should just summarize what is so far discussed in the meeting. This
accept what she feels or says. This means responding in a helps her clarify the issues discussed, including medical or
neutral way; do not agree or disagree. personal information. At the end of this she can let the doctor
Example. know the decision she has made; if she has not reached a
1. Patient—“Doctor, my husband will become weak if he decision an appointment for a second session is given. She
undergoes a vasectomy operation.” is also asked to return for follow up. Our aim is to satisfy

8
 the patient as much as possible. Try to always leave a ray of a normal life as a female (apart from child bearing and
hope. If you cannot cure at least you can care. menstrual function) after undergoing gonadectomy and on
All this can be summarized in the GATHER approach: hormone replacement therapy.
G – Greet the patient. 6. In a patient with bad obstetric history: Patients who have
A – Ask about herself and family. had multiple abortions, congenitally malformed babies and
T – Tell the patient about available options with their poor fetal outcome should be referred to a genetic
respective merits and demerits. counseling clinic in the interval period along with her
H – Help her choose the treatment. spouse. They should be counseled about the risk of poor
E – Explain. fetal outcome in the next pregnancy, after reviewing
R – Schedule a Return visit after treatment to check the case. The interventions which may be required
whether there has been any improvement or if any should be discussed, along with information about their
problems or doubts have arisen. Also carry out a side effects.

Chapter 3
reexamination at this visit. Sometimes a return visit 7. Ectopic pregnancy: Patients who have an ectopic pregnancy
is needed for patient to take a decision regarding her should be counseled for medical treatment only if she fulfills
therapy and show the results of investigations the criteria—as repeated check-ups are required.
advised. 8. Infertility: Infertile couples need very sensitive handling.
Information about their problem should be given in a
Some Counseling Situations in Gynecology positive manner. They should be encouraged to make use
Counseling the patients should be based on current medical of all modern treatment modalities. Discuss all these

Communication and Counseling in Gynecology

knowledge and keeping in mind the patient’s best interest. In modalities with utmost patience. The possibility of adoption
addition, we must give due respect to her own preference. Clear should also be discussed in cases with very poor prognosis.
and ample communication fosters trust, facilitates access to 9. Hysterectomy: Patients who are undergoing hysterectomy
services and improves quality of medical care. must be informed about the cessation of menses and the
Every patient requires counseling from her gynecologist. inability to conceive after the operation. They should be
However, the counseling requirement, that needs to be met in advised to follow-up when called.
a few specific situations are detailed below. 10. Conservative surgery vs hysterectomy in situations such
1. Patients advised hormones, e.g. progesterone or combined as uterine fibroid, Abnormal Uterine Bleeding (AUB), pelvic
oral contraceptives are told to start the tablet on a particular organ prolapse: While counseling these patients the
day of the cycle. The day the menstrual period starts is taken advantages and disadvantages of both options
as the first day of the cycle and accordingly the drugs are should be clearly explained to the patient. The risk of
taken on the fifth or fifteenth days as the gynecologist recurrence of disease after conservative surgery should be
prescribes. informed. The patient should be helped to choose the right
2. Medical termination of pregnancy (MTP): While option for her situation keeping in mind her age, parity,
counseling these patients, stress should be laid on the fact desire for future child bearing, desire for menstrual function
that MTP should not be used as a contraceptive method and current state of health. In some cases of multiple fibroids
and repeated abortions can have a negative impact on the it is important to discuss with the patient undergoing
patient’s reproductive health. She should be able to decide myomectomy that it may be possible that after removing
her preference of a reliable and long-term method of all the fibroids there may be very little useful uterine tissue
contraception after the MTP. The counseling will also help left. In these cases discuss and take consent of hysterectomy
her to decide the method of MTP that she desires (Surgical as well before operation. Similarly, in cases of extensive
or Medical Method). endometriosis the possibility of hysterectomy must be
3. Patients visiting the clinic for contraceptive advise: discussed and consent should be taken for the same. In these
Effective contraception is important in the prevention of two situations assure the patient that all efforts will be made
unwanted pregnancies. Contraception is an issue that to preserve the uterus.
demands a great deal of sensitivity from the physician. 11. Preoperative Counseling: The gynecologist should build a
There is a need to take into account the different cultural rapport with the patient so that a relationship of trust is built.
and religious background of the patients. There should be The aim of preoperative counseling is to help the patient to
no coercion to adopt a particular method of contraception and dispel any fears regarding the surgery.
the patient should be encouraged to choose a method which She should be encouraged to ask any questions about
best suits her situation. The failure rate of the different the surgical procedure, the length of hospital stay and the
methods including ligation should also be discussed. complications that may arise in the postoperative period.
4. Mullerian agenesis: Before the vaginoplasty operation the The risks of the surgical procedure, especially in relation to
patient should be counseled regarding the fact that the the patient’s medical conditions, should also be discussed.
surgery will not enable her to menstruate or to bear a child. Alternative modes of therapy and their results can also
Vaginoplasty will be useful only when the patient is desirous be enumerated to the patient.
of marriage and she should be cautioned that if regular coital 12. Menopause: Menopause is perceived by many as a loss of
function is not performed after vaginoplasty the caliber of youth and it may be a very disturbing experience for the
the neo-vagina may decrease or a stricture may form unless patient. She is often depressed, anxious or irritable due to
the cones are regularly used. hormonal changes as well as due to psychosocial reasons.
5. Testicular feminization: These patients have been reared Good counseling sessions with the gynecologist can help
as females since birth. To inform them bluntly that they are these patients. The doctor, along with prescription of drugs,
genetically male will lead to confusion and identify crisis. can counsel her regarding the importance of her life in the
Instead, they should be gently counseled that they can lead postmenopausal period. Stress should be laid on the

9
 importance of regular exercise, a balanced diet, good sleep • We respect your right to choose your treatment and hence
and hygiene. She should be encouraged to use her time the right to a second opinion.
productively and pursue some hobby for which she may • We respect your right of confidentiality regarding your
have been too busy in her younger days. health issues.
13. Patients with malignancies are counseled for postoperative • We respect your right to competent treatment and hence
chemotherapy or radiotherapy to prevent recurrences. promise to keep ourselves updated.
• We respect your social rights and hence promise to help
Patients’ Rights Charter you in case of gender violence and we promise to act to
Health care is a partnership in which the doctor and the prevent gender discrimination of any kind including
patient have reciprocal obligations. Trust between doctors and prenatal sex determination.
patients is an essential element of healing relationships. We
recognize this sacred relationship and hence would like to BIBLIOGRAPHY
Basics of Gynecology

pronounce that: 1. ACOG Committee opinion No 363. Patient testing: Ethical issues
• We respect you, our patient, as a person and your moral in selection and counseling; 2007.
right to bodily integrity and self determination. 2. Cassell EJ. Talking with patients, Vol.1. The Theory of Doctor-
patient communication. Cambridge, MA: MIT Press; 1985.
• We respect your right to ethical and fair treatment.
3. Friedman HS. Nonverbal communication in medical interaction.
• We respect your right to information as regards your health In: Friedman HS, Dimatteo MR, Eds. Interpersonal Issues in Health
diagnosis and treatment. Care. New York: Academic press; 1982.
• We respect your right to know about the treatment offered, 4. Osler, Sir William. Address to students of the Albany Medical
medication used and treatment options available. College. Albany Med Ann 1899;20:307.
Section 1

10
 4 History Taking and
Examination in Gynecology

Sudha Salhan, Harsha Gaikwad

The history taking and clinical examination should be start of bleeding (menstruation). Is there headache or
thorough and meticulous keeping in mind the patients as a fullness of breast, etc. before start of menses, which is
whole. The most important evidence is always provided by the relieved with the commencement of menstrual flow (pre-
history, which the patient or her relatives can give, if allowed menstrual syndrome). History of vomiting or severe pain
to do so. In gynecology the diagnosis can nearly always be made during period, which render her unfit for day-to-day works
or reduced to one or two possibilities with only history, without (severe dysmenorrhea). Some may complete of midcycle
any physical examination. The examination should in fact pain in lower abdomen on one side (Mittelschmerz) it is
proceed with the provisional diagnosis in mind. Nowadays, due to ovulation and is usually mild and transitory. The
women also come for preventive health check up or screening, date of the first day of the menstrual period should always
e.g. pre pregnancy check up, Papanicolaou test and screening be recorded to exclude pregnancy related complications.
for breast, cervical and ovarian malignancy, etc. The menstrual history can be denoted numerically as 14/3/
A careful history taking is started with the outlines like 26–28, i.e. the age of menarche is 14 the menstrual cycle is
name, age, address, marital status, parity, social status, and chief 26–28 days long and the flow lasts for 3 days. Ask if there
complaints. any history of bleeding in between two cycles? Mostly the
The history should be asked in details. If more than one patients are not sure about cycle size confusing last day of
complaint are encountered then the sequence is put in a last period and first day of this period. In that case ask her
chronological order. The symptoms are to be correlated to one to write on a diary for a few months and show you. History
pathology first before embarking on the diagnosis of multiple of contract bleeding, i.e. bleeding at coitus may point to
pathology. The genital tract is so clearly linked embryologically cancer cervix. Age of menopause in mother or elder sister,
and anatomically to the uniary tract and large bowel that it is if available, is useful.
mandatory to ask for any symptoms related to these organs 2. Obstetric history: It is commonly seen that many
during a routine gynecological history. Similarly, the gynecological problems date back to the earlier childbirth
reproductive endocrine organs have direct link with other or miscarriage. History should be asked about the number
endocrine organs of the body and it is necessary to take note of children she has borne, nature of deliveries, (whether
of endocrine diseases before associating them in the etiology of vaginal or by cesarean section), ages of the children specially
gynecological disorders. The duration and severity of the the last one, any complications during or after any of these
complaint is important. Is it connected or aggravated by pregnancies and deliveries. Also ask for bad obstetric
anything? Is it the same throughout or increasing? history, e.g. abortion, stillbirth, intrauterine growth
It is advisable to ask the patient to describe her main restriction, neonatal death, etc. The codes are G-for gravida
complaint or complaints in her own words. A patience and (total number of pregnancies), P-for para (number of
good listening is necessary in order to make the patient pregnancies beyond period of viability), A-miscarriage or
comfortable during subsequent physical examination. Besides termination of pregnancies (up to 20 weeks) and L- for
chief complaints, the history should also include the following: number of living children. GPAL or GP A-B-C-D. The duration
1. Menstrual history of breastfeeding should be asked. Enquire about years of
2. Obstetric history marriage.
3. Past medical and surgical history 3. Past medical history or surgical history: History should
4. Personal history be asked about relevant medical disorders like
5. Sexual history hypertension, tuberculosis, diabetes mellitus, jaundice,
6. Family history asthma, drug allergy, epilepsy, thyroid problems, psychiatric
7. Social history. illness, etc. Ask for any history of hospital admission and
1. Menstrual history: The patient should be enquired about bleeding tendencies. Is she on any drug? Ask about any
the age at which her first period occurred (menarche) blood transfusion.
whether her cycles are or were regular, i.e., they occur at Tactfully ask for intravenous drugs intake. These are not
regular interval every month. Ask about the duration of only related to the gynecological trouble but their presence
bleeding in days. The amount of blood loss during periods requires care during operative procedure, if indicated. Also
should be ascertained by asking if she passes clots or by enquire about sexually transmitted diseases by asking at
the number of pads she has to use are they fully soaked or least history of excessive vaginal discharge or itching, etc.
not and whether she experiences any pain during periods. History of general, obstetrical or gynecological surgery in
If there is pain whether it starts before, during or after the the past should be asked. The nature of the operation and
 complication, if any, pertaining to surgery and anesthesia. doctor, etc.) with him while examining the patient. The general
Ask whether she had a complicated postoperative period. systemic examination should be done in great detail. Scalp hair
Check with the records, if available. are seen. Look for nutrition and built whether too obese or thin
4. Personal and contraceptive history: Ask about (Pondral index) which may relate to endocrinopathy,
the occupation, any addiction, marital status, contraceptive malignancy or infection. Observe the alertness and intelligence
practice regarding the method used for, e.g. IUCD may be of the patient. See for the development of secondary sex
relevant in patient complaining of menorrhagia or heavy characters. Look for anemia, jaundice, thyroid enlargement, any
flow during periods. Does she sleep well? Ask for urinary lymphadenopathy in the neck (tuberculosis) specifically the left
complaints like pain after micturition (cystitis), supraclavicular lymph nodes (malignancy).
incontinence, etc. Also enquire about vaccination history. Examine the feet for edema. Bilateral edema in presence of
History of taking any drugs for a long time, especially an abdominal tumor suggests pressure symptoms, but
hormones which have a bearing on menstrual cycle, or of unilateral non-pitting edema is suggestive of a malignant
Basics of Gynecology

having addiction or allergy to any drug should always be growth involving the lymphatics. Look for any multiple needle
enquired. Any recent alteration in life, e.g. a new life partner, pricks (IV drug user). Also keep in mind physical abuse and
any shock (death of dear one) change of medication, etc. signs of physical trauma. Try to measure blood pressure of all
Any history of sexual, physical or psychological abuse, if women above 50 years of age.
available should be probed further. Whether she is non- Cardiovascular and respiratory systems must be examined
vegetarian or vegetarian is to be known. Total calories taken for any pathology. Liver, spleen and kidneys should be palpated
in a day is calculated by one day recall method. to exclude abnormal enlargement.
5. Sexual history: In an Indian setting can at least ask for any
problem during sexual intercourse. Any history of Examination of Breasts
dyspareunia? All women regardless of risk, deserve the benefits of routine
6. Family history: Enquire if there is history of similar breast examination for early cancer detection as part of their
complaints in the family (parents, brother, sister, etc.) regular periodic gynecological health survey. Maintain a high
Section 1

especially in cases of hirsutism, colon, breast and genital index of suspicion at all times. Inspect and palpate under good
tract malignancies. Similarly, history of tuberculosis in any illumination with the patient supine and then sitting. Search
of the family members can give clue to the diagnosis of for dissimilarities in the breast, changes in skin characteristics
genital tuberculosis. Hypertension and diabetes may be like inflammation, pigmentation, focal venous engorgement,
there in her parents or siblings. edema, induration, Peaud’ orange (skin), nipple discharge (clear
7. Socioeconomic status: Education status is elicited. Living —Galactorrhea (Fig. 4.1) or blood stained) any other
in own house with basic facilities or on rent. Approximate abnormalities and axillary examination for palpable, matted or
income of the family (Kappu Swami Classification). fixed lymph nodes is also important. Breasts should be palpated
Details of chief complaints of their duration, whether with the flat of fingers in the supine positions and bimanually
increasing or decreasing. When was she perfectly alright? Any in the sitting position (see figures in the Chapter 78 the breast).
past history of similar complaints, outcome of any treatment
taken for the same in the past, if any is elicited. GYNECOLOGICAL EXAMINATION
At the end of history one must make some diagnosis or few Abdominal Examination
differential diagnosis. All the salient points in the history must
be documented with date and time, if provided by the patient. The abdominal examination should be made systematically by
inspection, palpation, percussion and auscultation of all the
EXAMINATION quadrants. The patient is asked to empty the bladder before
The patient should always be examined by her consent. Try to examination (but not before examining a patient of stress
uncover the patient in part with all privacy and dignity. incontinence). In case of chronic retention, catheterization with
Examination is to be done from above downwards so ask her sterile catheter can be done.
to show chest after examination of head, face and neck. After The examiner stands on the right side of the patient and the
examination of the chest. She can cover it. Then we look at the patient lies flat on a comfortable surface, with the thighs slightly
abdomen and finally the perineal region. Ask her to remove flexed and abducted to make the abdominal muscles relaxed.
salvar/trouser from the left leg. Never suddenly uncover the
patient completely without informing her and without proper
privacy, we can use a sheet of cloth to cover that part of the
body which is not examined at that time.
The examination includes
a. General and systemic examination.
b. Gynecological examination, which includes:
1. Abdominal examination
2. Examination of breasts
3. Pelvic examination.
Before examination, the patient must be told about the
procedure. Keep on telling her, especially while examining the
perineum that now you are touching her with hands (separating
the labia) introduction the speculum (show her first, the
speculum), e.g. I will use this instrument for internal
examination taking Pap smear or swabs for culture.
The general and systemic examination: If the gynecologist
12 is a male he must have a female attendant (a nurse, a junior Fig. 4.1: Galactorrhea
Inspection tumors (Figs 4.3 A and B). It is necessary to elicit presence of
Inspect the abdominal skin for any pigmentation, or the fluid in the peritoneal cavity in every cases of pelvic tumor.
discoloration like striae gravidarum, scars of surgery, keloid However, if there is intestinal adhesions or the tumor is
formations, dilated veins, umbilical abnormality like eversion. retroperitoneal, it will be resonant.
See for any lump in the abdomen (Fig. 4.2A), its site in relation Auscultation
to the quadrants of abdomen, its mobility with respiration. The
It helps in hearing the intestinal sounds, which may be absent
abdomen may be distended uniformly and the respiration more
in generalized peritonitis or are exaggerated in intestinal
thoracic in intestinal distention. In pelvic peritonitis the lower
obstruction cases. On a pregnant uterus, uterine Soufflé and
abdomen is only distended with restricted movements on
the fetal heart sounds can be heard.
inspiration with pelvic tumors, which extend into the abdomen
the abdominal wall moves over the tumor during inspiration. Pelvic Examination
Most of the pelvic tumors produce large abdominal swellings

Chapter 4
Pelvic examination includes
which arise from the pelvis and the upper limits are apparent.
1. Inspection of the external genitalia.
In presence of ascites the flanks or the sides of the abdomen are
2. Per speculum examination.
full and center remains flat. While a huge tumor is more
3. Per vaginal examination or bimanual examination.
prominent in the hypogastrium situated either centrally or to
4. Rectovaginal examination.
one side. Always inspect the hernial orifices after making her
5. Per-rectal examination.
cough (Fig. 4.2B) incision hernia. Also observe the abdomen
Before performing the pelvic examination the patient must

History Taking and Examination in Gynecology

when she lifts her head (makes abdominal musles tight). It
be informed about the procedure, she should be asked to empty
differentiates intra-abdominal mass from mass in the abdominal
wall.
Palpation
Light palpation is done with the ulnar border and flat of the
left hand when the examiner is standing on the right side of the
patient. In winter season prewarm the hands before palpation
to prevent involuntary contraction of abdominal muscles when
touched with cold hands. If rigidity of the abdominal wall is
encountered it can be either voluntary or due to peritonitis. If it
is voluntary, the patient can be distracted by asking to open the
mouth or talking to the patient. If a mass is felt in the lower
abdomen then its location, size, mobility, tenderness and
whether the lower border of the mass can be reached by
perabdominal examination or not should be elicited. In pelvic
tumors, the lower border cannot be reached while in ovarian
tumors with a long pedicle, the lower pole can be easily
palpated. In cystic tumors one can elicit a fluid thrill. Whether
a mass is felt or not, routine palpation of liver, spleen, kidneys,
colon, etc. is to be done. Palpate the painful area, shown by the
patient, last of all. Also palpate the inguinal lymph nodes.
Percussion
Pelvic tumors, like uterine fibroid and ovarian cyst, are dull on
percussion, but the flanks are resonant. Dullness in the flanks (A) Ovarian cyst (B) Ascites
and shifting dullness indicate presence of free fluid within the
abdominal cavity (ascities). Such a finding is present in ovarian Figs 4.3A and B: Ascites and ovarian cyst

Figs 4.2A and B: (A) Lipoma of abdominal wall (B) Incision hernia 13
 the bladder, if not done previously, as full urinary bladder may 1. Inspect the vulva from above downwards for any congenital
make the examination difficult and obscure the important abnormality, abnormal hair growth, (pattern of pubic hair)
findings, except in cases of stress urinary incontinence. A female lice and boils (Fig. 50.1) etc. skin lesion, leukoplakia (See
attendant or a nurse should be present by the side of the patient Fig. 49.9A in Chapter 49 ), itching marks, uterovaginal
if the examiner is a male gynecologist. prolapse, (Figs 4.7 A and B) dermatitis or condylomata, etc.
When the patient is a minor or unmarried consent from the (Fig. 4.8). Clitoral growth (Fig. 4.9) swelling over labia
parent or guardian is required and try to keep the mother with (Bartholin gland) (Fig. 4.10). There can be other
you at the time of examination. abnormalities like varicose veins of vulva (Fig. 4.11)
The patient should be examined in a well-lit area in carcinoma valva (Figs 4.12 A and B), vaginal growth
total privacy. The patient is examined commonly in the
dorsal position with knees flexed (Fig. 4.4). Other position
being lithotomy position and the Sim’s position (Figs 4.5
Basics of Gynecology

and 4.6).
The key to an effective gynecological examination is
communication with the patient. Draping, lubrication needs,
speculum size and position of the patient on the examining table
should be explained in advance. The patient should be allowed
to ask us to slow down or stop the examination, at any point
when she wishes. Mirrors may be used effectively to
demonstrate. Minimize exposure be done unless indicated. The
gynecologist is to be direct facing towards the patient’s external
genitalia. Ask her to remove the left leg of salwar/trouser and
panty or cover with a sheet if in saree.
Section 1

Fig. 4.4: Dorsal position

Figs 4.7A and B: Prolapse uterus

Fig. 4.5: Lithotomy position

14 Fig. 4.6: Sim’s position Fig. 4.8: Condylomata

 Chapter 4
Fig. 4.9: Clitoral growth Fig. 4.10: Bartholin cyst

History Taking and Examination in Gynecology

Fig. 4.11: Varicose vein Fig. 4.13: Vaginal growth

Figs 4.12A and B: Cancer of vulva

(Fig. 4.13) carcinoma of vagina (Fig. 4.14), and perineum, is fissure or anal fistula. Perineal area is also inspected for warts,
to be ruled out. Examine the urethra for any discharge vesicles of herpes (Fig. 4.17), mollescus (Fig. 4.18), etc.
redness, prolapsed mucosa look for any other lesion If stress urinary incontinence is to be elicited do it with
(coruncle fig. 50.5 etc.). Look for the hymen. If present its the bladder full, ask her to cough. If urine is seen leaking,
shape is seen any bulging, e.g. in imperforate hymen (Fig. perform Boney’s test. For further examination ask her to
4.15). Ask the patient to cough and see for any urine leakage empty her bladder and come.
or prolapse of tissues like cystocoele, rectocoele or cervical 2. Lesions noted on external genitalia should be stained with
descent or any discharge from the introitus after separating toluidine blue (if available) to highlight areas of increased
the labia with two fingers of left hand. Gartner duct can be nuclear density, colposcopically directed biopsies may be
seen. Also look at the anus for hemorrhoids, (Fig. 4.16) indicated later on. 15
Basics of Gynecology

Fig. 4.14: Vaginal carcinoma Fig. 4.15: Inperforate hymen

Section 1

Fig. 4.16: Hemorrhoid external Fig. 4.17: Herpes

• Local inspection is followed by per speculum examination

of the vagina and cervix. Two types of speculum are
commonly used namely—
a. Sim’s speculum with anterior vaginal wall retractor (Fig.
4.19).
b. Cusco’s bivalve speculum (Fig. 4.20).
• Show the speculum and tell the patient that you will use it
for internal examination. Separate the labia with two fingers
of left hand. Insert (prewarmed in winter) closed Cusco’s
speculum transversely into the vagina till its depth. Then
open the two blades gradually to inspect the cervix (Figs
4.21 A to C). No lubricant or antiseptic solution is used as
they interfere with cytology and culture (if needed).
Similarly, with Sim’s speculum is introduced after the labia
have been manually separated. The speculum to be inserted
directly (Fig. 4.22) in transverse direction. In some cases it
Fig. 4.18: Mollescus

16
Fig. 4.19: Sim speculum Fig. 4.20: Cusco’s speculum
 Chapter 4
Fig. 4.22: Perspeculum examination

is inserted vertically and then rotated in 90 degree. In the

later case do not touch clitoris as it is a very sensitive area.

History Taking and Examination in Gynecology

Can see a vaginal septum (Fig. 4.23) by separating labia
majora.
The cervix is best visualized with Cusco’s speculum.
But the anterior and posterior vaginal walls are not
visualized properly with this speculum. Sim’s speculum is
best for the vaginal walls inspection. Look for color of the
cervix (see Fig. 43.8) as leukoplakia, blue in pregnancy, etc.)
normal cervix (Fig. 4.24A) also sometimes can see more than
one cervix (Fig. 4.24B) and T-zone (Fig. 4.24C) any growth
like endocervical polyp coming out of cervix (Fig. 4.25),
cervical polyp (Fig. 4.26) tuberculosis of cervix (Fig. 4.27)

Figs 4.21A to C: Insertion of speculum Fig. 4.23: Vaginal septum

Figs 4.24A to C: (A) Normal cervix (B) Double cervix (Dr Mary, CMC Ludhiana) (C) Normal SC junction 17
Basics of Gynecology

Fig. 4.25: Endometrial polyp coming out of cervix Fig. 4.26: Cervical polyp
Section 1

Fig. 4.27: Tuberculosis of the cervix Fig. 4.28: Cancer cervix

Fig. 4.29: Nabothian follicle Fig. 4.30: Cervical erosion

cancer of cervix (Fig. 4.28) and nabothian follicle (Fig. 4.29) beneath the speculum blades are also screened for any
erosion (Fig. 4.30) ulcer, discharge (Fig. 4.31), or bleeding pathology.
at or around the cervix as far as possible. Can also look for The Cusco’s speculum is closed and removed gently and
cancer vagina (Fig. 4.32). If needed cervical or Pap smear put into the disinfectant (10% bleach) solution to kill virus
and endocervical smear can be taken simultaneously (Figs of human immunodeficiency disease. After per speculum
4.33 A to D) at this time. Discharge if any can be collected examination per vaginal or bimanual examination is done.
(for direct visualization under microscope) after making wet In unmarried girls it can be deferred until seems essential
smear and for culture and sensitivity on a swab. While the or it can be done under anesthesia. Palpate for any swelling
18 speculum is being removed the areas which were hidden which is evident on inspection.
 Chapter 4
Fig. 4.31: Candidal vaginitis Fig. 4.32: Vaginal cancer

History Taking and Examination in Gynecology

Figs 4.33A to D: (A) Ayre spatula (B) Endocervical brush (C) Pap smear (procedure) (D) Spread

3. Per-vaginal (bimanual) examination: Tell the patient that

you are going to do her internal examination with two
fingers (index and middle fingers of the right hand). Insert
index finger first. The urethra is pressed gently from above
downwards to see for any discharge. With thumb on the
labia, majora and index finger in vagina palpate labia major
for any swelling of Bartholin gland, etc. (Fig. 4.34). The
cervix is then palpated. Feel for the consistency of cervix.
Normally, it is as firm as tip of the nose (it is soft in
pregnancy and irregular in carcinoma). The direction of
cervix will tell the position of the uterus. If the cervix is
pointing forward the uterus is retroverted and it is pointing
backward the uterus is anteverted. Look for its mobility
and elicit any pain during movements. These two fingers
of the right hand are then placed in the posterior fornix of
the vagina. These fingers lift up the uterus. The left hand is
placed externally on the lower abdomen and is brought
behind the uterus. The uterus is then palpated between the
Fig. 4.34: Labial palpation 19
 fingers of the two hands. The left hand should be placed on size, shape position, mobility, consistency, direction
the abdomen well above the level of the symphysis pubis (anteverted or retroverted) also look for any tenderness. In
and the fingers of the left hand should reach as far back as anteverted uterus the fundus is felt anteriorly while in a
possible to feel the uterus (Figs 4.35 A to E). The patient can retroverted uterus the fundus felt facing posteriorly and
be asked to take deep breaths to make the abdominal can easily be felt by the fingers in the vaginal fornix. If there
muscles relax so that the palpation becomes easier. With is severe vaginitis or vaginismus bimanual examination may
both hands in these two positions palpate the uterus for its not be possible (because of severe pain).
Basics of Gynecology
Section 1

Figs 4.35A to E: Pervaginal examination

20 Fig. 4.36: PV PR examination Fig. 4.37: PR examination

 For palpation of the uterine appendages the vaginal fingers well-palpated. The pouch of Douglas can be palpated for
are placed in the lateral fornix and are pushed backwards and the extent of disease in endometriosis ovarian and cervical
upwards. The counter pressure is applied by the abdominal malignancies. In cases of carcinoma of the cervix the
hand placed to one side of the uterus in a backward direction. parametrium and uterosacral ligament and rectal mucosa
A normal fallopian tube cannot be palpated: Normal sized involvment is noted. Put gloves in bleech solution for
ovary, if palpated, is sensitive to manual pressure, patient feels decontamination after completing examination.
a dull pain sensation on palpation. Thus both sided fornices Always wash hands after pelvic examination.
are palpated for any abnormal enlargement of fallopian tubes After completion of the examination write down the
or ovaries or a tubo-ovarian mass, before palpating the pouch findings on outpatient ticket or ward case sheet mentioning
of Douglas. If there is no mass felt in the fornices it means ovaries the date and time of examination. Put a provisional
are not enlarged. The pouch of Douglas can be examined though diagnosis. Write required investigation and give appropriate
the posterior fornix. Feel for any nodularity, mass, tenderness treatment. This is a very important document. Explain to

Chapter 4
or any fullness. Before removing the fingers ask her to contract her about the diagnosis. Call her for a follow-up after a
the muscles of the pelvis and feel for amount of levator muscle reasonable time or whenever the condition worsens.
tightening. On follow-up visit write down the date and time. Ask
4. Vaginorectal (PV PR) examination (Fig. 4.36): In this the whether her condition has improved, is stationary or worsened.
index finger is put in vagina and middle finger in the rectum. Note down the results of investigations done. You can revise
It is required to differentiate rectal growth and their your diagnosis and treatment. Document and give her date for
extension into the vagina and vice versa. follow-up visit. If the patient is admitted in the hospital write

History Taking and Examination in Gynecology

5. Per-rectal (PR) examination (Fig. 4.37): In cases of day to day development in the case sheet.
imperforate hymen, severe vaginitis, unmarried patient or
case of carcinoma of the cervix per rectal examination is BIBLIOGRAPHY
required. Abdominal hand’s assistance is needed. Size of 1. Emanuel A. Friedman “Gynaecological decision making”; 1983.
uterus can be made out though ovaries and tubes are not pp.4-10.

21
 5 Psychiatric Aspects of Gynecology

Rajesh Rastogi

INTRODUCTION Etiology
While any psychological disorder occurs more frequently in The cause of PMS is uncertain. The linkage of PMS symptoms
women than men, there is a small group of these disorders that to biological events (ovulation and menstruation) not
are specific to women. The onset or exacerbation of surprisingly led to the development of biomedical theories of
psychological symptoms is related to the reproductive cycle. etiology that particularly focused on endocrine abnormalities.
The psychiatrist services may play an important role in Despite extensive investigations, researchers have been
assessing and treating the psychological issues that contribute unable to find any relationship to the levels, ratios, or rates of
to or are a consequence of various gynecological conditions. change in progesterone or estrogen.
The main gynecological associations are given below. Evidence indicates that a number of emotional disorders
such as depression and anxiety are caused by changes in
MENSTRUAL DISORDERS central neurotransmitters and neuromodulators such as
Premenstrual Syndrome (PMS) norepinephrine, serotonin, and dopamine.
The most current theory is that, in some women, changes
Menstruation related changes in mood and behavior were
in hormonal levels in the hypothalamic-pituitary-gonadal
described by Hippocrates and recognized in the Bible.
(HPG) axis trigger changes in the 5-hydroxytryptamine (5-HT)
system, resulting in decreased serotonin and the symptoms of
Classification
depression (Severino, 1994). This theory is supported by the
In ICD-10, ‘premenstrual tension syndrome’ is classified with fact that 65% of patients with unipolar mood disorder
‘pain and other condition’ in the section on female genitourinary experience PMS, while PMS patients have been found to have
disorders. In the fourth edition of Diagnostic and Statistical a lifetime prevalence of major depression of 60%. Women who
Manual of Mental Disorders (DSM-IV), ‘premenstrual develop PMS/PMDD tend to have detectible abnormalities in
dysphoric disorder’ is described as a mood disorder but is only serotonin regulation with less serotonin uptake by platelets than
included in the appendix as a research diagnostic category in control subjects during both the follicular and the luteal
requiring further study. phases (severino, 1994). While no evidence has been found that
women’s expectations about their menstrual cycle may be a
Definition and Epidemiology
factor in their experiencing symptoms, as women who have
This term denotes a group of distressing psychological and been mislead into believing they are in the luteal phase of their
physical symptoms starting a few days before and ending cycle experience “premenstrual symptoms” (Schmidt et al.,
shortly after the onset of a menstrual period. 1991).
Premenstrual syndrome (PMS) is a cyclic disorder of women In summary, the etiology of PMS is under investigation. It
of reproductive age that recurs at some point between ovulation is likely that biological and psychosocial factors play a role in
and menstruation. It is characterized by a combination of the development of PMS, but the relative importance of these
affective (e.g., fluid retention, breast tenderness, headache), different variables has not been established.
behavioral (e.g., poor coordination, relationship difficulties) and
cognitive (e.g., poor concentration) symptoms. Community Clinical Features
surveys suggested that premenstrual complaints were reported Symptoms should start in the luteal phase, cause significant
by 20–90% of women in their reproductive years (American impairment in a woman’s functioning, and disappear within
College of Obstetricians and Gynecologists 1989). the first few days of the menses. There must also be at least one
The American Psychiatrist Association has devised a symptom-free week during the woman’s cycle. Of all the
diagnostic category of premenstrual dysphoric disorder symptoms ascribed to PMS, the ones that most often bring
(PMDD) to focus on the cases of PMS in which marked mood women to their physicians for help are those of depression,
disturbance and a clinically significant impairment of anxiety, or irritability. (Parry, 1999).
functioning are the predominant symptoms (American In a study of 240 women identified as suffering from PMS,
Psychiatric Association, 1994). These symptoms must not be the five most prevalent symptoms were depression (56%),
merely a premenstrual exacerbation of an ongoing psychiatric irritability (48%), anxiety (36%), mood lability (26%) and
disorder. Approximately, 1–5% of women meet criteria for headache (23%) (Freeman et al., 1985).
PMDD.
 The common psychological symptoms include anxiety, than women in the general population. Although there is an
irritability, and decreased interest in activities, increased increased incidence of certain psychological symptoms in the
fatigability and difficulty in concentrating. There are changes perimenopausal years (Stewart et al. 1992) possibly related to
in appetite and sleep patterns. The physical symptoms include the combination of fluctuating hormonal level and negative
breast tenderness, abdominal discomfort, and a feeling of anticipation of menopause, in the 6 months following the
distension. cessation of menses, there is actually a decrease in prevalence
of depression and suicide (McKinlay et al., 1987). Studies do
Diagnosis not support the hypothesis that perimenopausal or
Diagnosis of PMS/PMDD requires a detailed history with postmenopausal women are at greater risk of depressive
specific attention to the type, severity, timing, and impact of disorder (Kessler et al. 1993, Schmidt et al., 1996).
the woman’s symptoms as well as information on past In those women who do exhibit depressive symptoms at
psychiatric history and current stressors. Diagnosis is best made menopause a number of factors may contribute (Charney

Chapter 5
by careful history taking, physical examination and prospective and Stewart, 1997). Some of these women appear to have
monitoring of symptom fluctuating during the menstrual cycle. the previously described vulnerability to depression
related to impaired gonadal hormone modulation of the
Treatment serotonergic system. In other women, the symptoms of “depre-
Treatment options for PMS range from lifestyle management ssion” may actually be reactions to the physiologic changes
(diet and exercise) to antidepressants and ovulation accompanying menopause. For example, night sweats due to
suppressors. Given that treatment is largely determined by fluctuating serum estrogen levels can interfere with sleep,

Psychiatric Aspects of Gynecology

symptom profile, it may be necessary to try a number of options leading to symptoms of fatigue, poor concentration, depressed
sequentially to find the most beneficial approach for a given mood and irritability.
individual.
Psychological Factors
General Measures Physician must also pay attention to psychological and cultural
Supportive or general health measures such as education of consideration (Gise, 1997). Women who anticipate menopause
the patient about the nature of this disorder; lifestyle changes as a time of rapid aging and decreased attractiveness may
to avoid or reduce stressful activities in the premenstrual period; become depressed at this time. Some women fear the loss of
a healthy diet, avoiding salty foods, which may exacerbate a the valuable roles postmenopausal. Other psychological
tendency for fluid retention, or caffeine, which may increase stressors include: children leaving home; (empty rest syndrome)
irritability; and a regular exercise routine may be helpful in difficulties in finding new fulfilling roles; loss of a partner; health
relieving distressing symptoms (Riveratovar et al., 1994). problems; responsibilities for aging parents; and the death of
Some studies have shown cognitive behavioral approaches relatives or friends.
and relaxation are of some benefit (Morse et al., 1991; Goodale
et al., 1990) Treatment
Treatment programs must be individualized. Treatment of
Medications symptoms of depression at menopause requires an assessment
Fortunately, research in the last several years has confirmed of the contribution of the different etiologic factors. Often
the benefits of using antidepressant therapy. Studies so far have consultants see depressed women who have been placed on
found that the use of fluoxetine, sertraline, paroxetine, and hormone replacement therapy (HRT) to alleviate their depres-
clomipramine in the usual therapeutic doses for depression has sion. Although HRT may be helpful in relieving hot flashes or
been highly successful at decreasing or eliminating the night sweats, it has not been found to effectively relieve clinical
symptoms of PMS/PMDD (Robinson, 1994). The fluoxetine may depression (Zweifel and O’Brien, 1997). Studies have shown
be given in an intermittent manner starting at day 15 of the efficacy of antidepressant drugs to treat clinical depression
menstrual cycle (the start of the late luteal phase) and associated with menopause.
discontinuing the drug several days after menses commence Exercise, diet and symptomatic treatment are all helpful in
(Steiner et al., 1997). reducing physical discomfort. In psychotherapy the patient
should be encouraged to accept the menopause as a natural life
Menopause event and to develop new activities, interests and gratifications.
Menopause is a natural physiological event. It is usually dated
as having occurred after an absence of menstrual periods for Infertility
six months. Usually, the menses tamper off during a two to five Up to 10% or more of women will experience infertility.
year span, most often between the ages of 48 and 55. Infertility is the inability of a couple to conceive after 1 year
It has erroneously been perceived that symptoms of of coitus without the use of a contraceptive. The causes of
depression and anxiety are more common in menopausal infertility are attributed to disorder in women in 60 percent of
women. Various reasons have been put forward to explain the cases and to disorder in men in 40 percent of cases.
increased reporting of psychological symptoms. Psychosocial
stressors, such as changes in family role and social support, Causes
loss events, physical illness and aging, are associated with the Medical
presentation of affective and menopausal symptoms (Cooke The most common medical causes of infertility are irregular
and Greene 1981). ovulation, endometriosis, and damaged fallopian tubes. In
This is probably so because much of the research has approximately 10% of the cases, no anatomic or physiologic
involved distressed women attending menopause clinics rather cause can be identified.

23
 Psychological an actual loss. Couples who decide not to pursue parenthood
There is no simple relationship between infertility and may develop a renewed sense of love, dedication, and identity
psychological conflicts. The only psychological causes clearly as a pair. Others may need help in exploring the options of
related to infertility include absent or infrequent vaginal husband or donor insemination, invitro fertilization (IVF), and
intercourse, infrequent or absent periods secondary to eating adoption.
disorders, medications such as typical neuroleptics which
inhibit ovulation by increasing serum prolactin levels. Research Pseudocyesis
is ongoing as to whether stress can cause infertility via Pseudocyesis is a rare condition in which a woman believes
influences on the hypothalamic, pituitary, or adrenal hormones that she is pregnant when she is not, and develops symptoms
on the reproductive system (Robinson and Stewart, 1995). and signs of pregnancy.
The common clinical features include the following:
Effects • A firm belief in the pregnancy, usually lasting until the onset
Basics of Gynecology

People who have difficulty conceiving may experience shock, of a false labor at 9 months, after which the disorder usually
disbelief, and a general sense of helplessness, and they develop resolves
an understandable preoccupation with the problem. Until
• Amenorrhea
recently, women were blamed when couples did not have
• Morning sickness and pica
children, and feelings of guilt, depression, and inadequacy
frequently accompanied the perception of being barren. The • Enlargement of the breast and nipples
reaction to the discovery of infertility varies with the individual • Abdominal distension
and the personal, religious, social and cultural importance • Other changes similar to those of early pregnancy.
placed on having a child (Dunkel-Schetter and Stanton, The psychological basis is usually an intense desire for
1991).The inability to have a child can produce severe children, especially in older childless women. In some cases,
psychological stress on one or both partners in a marriage. They however, a guilty fear of pregnancy has been the background
may feel defective and undesirable, have low self-esteem, and cause.
Section 1

become depressed. Some may grieve for the lost infant they The correct diagnosis should be made on ultrasound
cannot have. Self-blame increases the likelihood of examination, revealing that the uterus is too small for pregnancy.
psychological problems. The women may feel guilty and believe
she is being punished for past sins. The woman may feel angry, Treatment
fear abandonment or consider leaving in order to free her These women require psychotherapy. Simply revealing the
partner to find a fertile female. Men, but not women, are at diagnosis is unsatisfactory because the patients may go to
increased risk for psychological distress if they are older and another doctor with the same symptoms, or develop a
do not already have biological children. recurrence. The underlying conflicts must be explored, helping
the patient to face the fact that she is not pregnant. Some patients
Evaluation
may require anxiolytics or antidepressant medication.
A psychiatric evaluation of the couple may be advisable.
Current practice encourages simultaneous investigations of Anorexia Nervosa
factors preventing conception in both men and women, but Anorexia nervosa was described by Marce in 1859 and named
frequently women still initiate an infertility workup. in 1868 by the English physician William Gull, who emphasized
A thorough sexual history of the couple—including such the psychological causes of the condition, the need to restore
factors as frequency of contact, erectile or ejaculatory weight, and the role of family.
dysfunction, and coital position must be obtained. Frequently, There are psychological and somatic reasons for an
conception is less likely simply because the woman rises to void, antagonism between pregnancy and anorexia nervosa,
wash, or even douche immediately after coitus. Coitus with nonetheless, the majority of women with anorexia nervosa
the woman in the superior position is also not conducive to recover, with return of menstruation when their weight reaches
conception because of the lessened retention of semen. about 80 percent of the standard weight. Ovulation can be
Couple should be asked about marital disharmony or induced by clomiphene or human menopausal gonadotropin
emotional conflicts about intimacy, sexual relations, or parenting in those who fail to menstruate.
roles can directly affect endocrine functions and such
physiological processes as erection, ejaculation, and ovulation. Epidemiology
There is no evidence, however, for any simple, causal relation Anorexia nervosa is estimated to occur in about 0.5 to 1 percent
between stress and infertility. of adolescent girls. It occurs 10 to 20 times more often in females
Worries about attractiveness and sexual desirability are than in males. The condition usually begins in adolescence, most
common. Partners may feel ugly or impotent, and episodes of often between the ages of 16 and 17. It generally begins with
sexual dysfunction and loss of desire are reported. ordinary efforts at dieting which then goes out of control.
Treatment Etiology
Whatever the cause of the infertility the burden of treatment Anorexia nervosa appears to result from a combination of
falls mainly on the women. biological, social and psychological factors.
Fertility drugs, or gonadotropin releasing hormone
therapies, have been reported to cause psychiatric side effects. Diagnosis
These drugs include buserelin, gonadorelin, and goserelin. In the fourth edition of Diagnostic and Statistical Manual of
Professional intervention may be necessary to help infertile Mental Disorders (DSM-IV), the diagnostic criteria for anorexia
couples ventilate their feelings and go through the process of nervosa consists of:
mourning for their lost biological functions and the children • Refusal to maintain body weight at or above a minimally
they cannot have. Couples who remain infertile must cope with normal weight for age and height
24
• Intense fear of gaining weight or becoming fat, even though Counseling
underweight It is common practice for counseling to be part of the abortion
• Disturbance in the way in which one’s body weight or shape process. The goal of counseling should be to help the patient
is experienced reach a decision regarding the management of her pregnancy,
• In postmenarchal females, amenorrhea, i.e., the absence of to help her resolve her conflicts, and to help her regain her
at least three consecutive menstrual cycles.( A woman is psychological and social equanimity.
considered to have amenorrhea if her periods occur only Those most at risk for psychiatric illness following the
following hormone therapy, e.g. progesterone adminis- miscarriage are ones with a prior psychiatric illness, marked
tration). ambivalence about the decision, a lack of social supports, or
Obsessive-compulsive behavior, depression and anxiety are who are being pressured into having the miscarriage
the other psychiatric symptoms in anorexia nervosa most (Blumenthal, 1991). Religious factors may be extremely
frequently noted in the literature.

Chapter 5
important to consider, particularly for women associated with
Unfortunately, the term “anorexia,” meaning loss of religious groups that condemn miscarriage as a sin. Women
appetite, is a misnomer, because the loss of appetite is usually who are denied also tend to have poor outcomes (Blumenthal,
rare in the disorder. 1991). Those who lack access to safe and legal miscarriage are
Treatment under enormous stress. They may be forced to stay in abusive
Success largely depends on establishing a good relationship relationships. Children born to women who were denied
with the patient. It should be made clear that achieving an miscarriage may experience psychological problems

Psychiatric Aspects of Gynecology

adequate weight is an essential priority in order to reverse the (Blumenthal, 1991). Alternatively, these women may undergo
physical and psychological effects of starvation. Educating the illegal or unsafe miscarriage, which may lead to permanent
patient and family about the disorder and its treatment is physical or psychological trauma (Stotland, 1991).
important. Successful treatment depends on maintaining a firm
Sterilization
yet supportive approach to the patient, often through a
combination of positive reinforcers (praise) and negative Women can be prevented from bearing children by various
(restriction of exercise and purging behavior). operations on the uterus and fallopian tubes, indication for
Treatment of this complex condition usually involves a which are contraceptive, medical, eugenic and psychiatric.
combination of general measures (weighing daily, keeping input Considerations similar to those for hysterectomy apply to
and output chart, etc.), principles of behavioral and supportive these procedures. Retrospective studies have suggested that
psychotherapy, and medications. sterilization leads to psychiatric disorder, sexual dysfunction,
and frequent regrets after the operation. However, prospective
Miscarriage enquiry has shown that the operation does not lead to significant
Miscarriage is the termination of pregnancy before psychiatric disorder; sexual relationships are more likely to
the time of fetal viability. Abortion may occur spontaneously, improve than worsen, and definite regrets are reported by fewer
or it may be induced. An induced abortion may be legal or than one patient in twenty (Cooper et al. 1982). Regret is more
illegal. common in the following groups of women:
Essentially all patients who miscarry have familial, martial, • Younger women or those with fewer children
social, psychological, and other problems or conflicts that they • Those in whom sterilization was the condition for a
must attempt to resolve or to which they must adjust concerning termination
the miscarriage. The degree of psychological reaction varies • Those under external pressure
widely, depending on the woman’s personality, the situation in • Those sterilized for medical reasons such as inherited
which the pregnancy occurred, the reasons why a contraceptive disorders
was not used, the expected benefits of pregnancy, the degree to • Those sterilized in the course of a psychiatric illness: This
which these expectations are being fulfilled, the responses of often impairs judgment and, after recovery, decisions may
others to her pregnancy, and a host of additional factors. be regretted.

Short-term Psychiatric Effects Hysterectomy

A varying degree of guilt, grief, disappointment, and depression This is one of the most common operations and is performed
is usually present. in about 10 percent of women. It would not be surprising if the
loss of the womb had psychological effects on feminine identity.
Long-term Psychiatric Effects In young women the loss of fertility can be a source of
They are usually minimal and infrequent. Within 3 to 6 months discontent.
the majority of women resolve their conflicts, become secure in Several retrospective studies have indicated an increased
the appropriateness of their decision, and develop a healthy frequency of depressive disorder after hysterectomy. A
adjustment to the situation. An undetermined number of prospective investigation using standardized methods showed
women continue to harbor disappointment, guilt or other that patients who are free from psychiatric symptoms before
undesirable emotional effects. hysterectomy seldom develop them afterwards. Some patients
Miscarriage more commonly alleviates than precipitates with psychiatric symptoms before hysterectomy lose them
emotional distress. Women who are psychologically stable afterwards, but other continue to have symptoms after that
usually handle the miscarriage well. Women who are operation.
psychologically unstable handle the miscarriage in manner no Hysterectomy may also have an effect on libido, but
better and no worse than that in which they handle other crisis this is probably also a myth. On the other hand studies have
in life. Women with severe psychiatric problems handle the shown an increase in the frequency of intercourse, and of
abortion least well. enjoyment.
25
 Cancer Radiotherapy causes nausea, fatigue, and emotional distress.
Over the last three decades increasing attention has been given Chemotherapy often causes malaise and nausea, and anxiety
to the psychiatric aspects of cancer. About half of all cancer about chemotherapy may cause anticipatory nausea before the
patients have psychiatric disorders. The largest group has treatment. The latter may be helped by behavioral treatments
adjustment disorder (68%), with major depressive disorder used for anticipatory anxiety.
(13%) and delirium (8%) being the next most common Counseling and support is also required in infertility,
diagnoses. Most of these disorders are thought to be reactive to menopause, endometriosis and secondary amenorrhea.
the knowledge of having cancer.
Suicide
Psychological Factors in Etiology and Prognosis Although suicidal thoughts and wishes are frequent in people
It is not surprising that cancer patients have emotional reactions with cancer, the actual incidence of suicide is only 1.4 to 1.9
to the disease. Some writers have suggested the opposite times that of the general population. Factors that signal a
Basics of Gynecology

relationship, namely that psychological factors including vulnerability to suicide in patients with cancer are given below.
depression, personality traits the suppression of anger, and • Depression and hopelessness
stressful life events may play a part in the etiology of cancer. • Poorly controlled pain
Overall , the evidence for this idea is not convincing, partly • Feeling of loss of control
because the research on which it is based has severe limitations • Exhaustion
of methodology including reliance on retrospective accounts • Anxiety
and on subjective or non-standardized methods of assessment • Preexisting psychopathology (major psychiatric disorder)
(Levenson and Bernis, 1991). Instead of studying the role of • Family problems
psychological factors in the onset of cancer, other workers have • Threats and history of prior attempts of suicide.
examined the influence of these factors on the course and
outcome of cancer. Greer et al. (1979) reported that the prognosis Psychological Treatments
of breast cancer was better in patients who reacted to their illness Various psychiatric treatments can be helpful for patients with
Section 1

by denial or who had ‘a fighting spirit’ than in patients who cancer, including counseling and social support groups (Breibart
reacted in other ways, but the considerable body of evidence is and Holland, 1993). Recent studies of support group (Spiegel
contradictory. Evidence from subsequent studies is equally 1990; Fawzy, 1993) and cognitive behavioral treatments (Moorey
conflicting, and it remains uncertain whether psychosocial and Greer, 1989) have shown benefits to survival time and
factors significantly affect the course of the condition. immune function.
One possibility is to provide educational programs,
Psychological Consequences of Cancer counseling or group therapy for all cancer patients whether or
The psychological consequences of cancer are similar to those not problems.
of any serious physical illness. Some patients delay seeking Careful follow-up to detect and treat patients with
medical help because they fear or deny symptoms (Facione psychiatric complications is probably more useful than
1993). Knowledge of the diagnosis of cancer may cause shock, counseling given routinely. Antidepressants and cognitive-
anger, and disbelief as well as anxiety and depression. behavioral treatment are useful in selected cases.
Cancer, their psychological reactions include fear of death,
disfigurement, and disability; fear of abandonment and loss of BIBLIOGRAPHY
independence; fear of disruption in relationships, role 1. American College of Obstetricians and Gynecologists Premenstrual
functioning, and financial standing; and denial, anxiety, anger, Syndrome: committee opinion no. 66. ACOG, Washington DC, 1989.
2. American Psychiatric Association. Diagnostic and Statistical
and guilt.
Manual of Mental Disorders. (4th edn). Washington DC. American
The most common associated psychiatric disorder is Psychiatric Press, 1994.
adjustment disorder (Derogatis et al., 1985) the risk of suicide 3. Bluementhal SJ. Psychiatric consequences of abortion: overview of
is increased in the early stages (Harris and Barraclough, 1995). research finding. In NL Scotland (ed) Psychiatric Aspects of
Depressed mood is particularly likely at the time of diagnosis Abortion. Washington DC. American Psychiatric Press; 1991.
and following relapse but is usually transient. Major depression pp.17-37.
occurs throughout the course of cancer affecting 10-20% of 4. Brietbart, W and Holland JC (Eds). Psychiatric aspects of symptom
patients (Noyes and Kathol 1986) and appears to be more management in cancer patients. American Psychiatric Press,
Washington DC, 1993.
frequent in those suffering pain (Spiegel 1994; McDaniel et al.,
5. Charney D and Stewart DE. Psychiatric aspects. In DE Stewart
1995). and GE Robinson (Eds), A Clinician’s Guide to Menopause.
Organic mental disorder may arise from brain metastases Washington DC. American Psychiatric Press; 1997.pp.129-44.
which originate most often from carcinoma of the lung, but 6. Clouston PD, De Angelis LM, and Posner JB. The spectrum of
also from tumors of the breast and alimentary tract, and from neurological disease in patients with systemic cancer. Annals of
melanomas (Clouston et al.,1992). Neurology 1992;31:268-73.
About a quarter of patients undergoing mastectomy or other 7. Cooke DJ. Greene JC. Types of life events in relation to symptoms at
treatments for breast cancer develop depression or anxiety of the climacterium. Journal of Psychosomatic Research 1981;25:5-11.
8. Cooper PJ, Gath D, Rose N, and Fieldsnd R. Psychological sequelae
clinical severity within eighteen months. Effective symptoms
to elective sterilization: a prospective study. British Medical Journal
are especially common after a recurrence, and during 1982; 284:461-3.
radiotherapy and chemotherapy. Other responses to 9. Derogatis LR, et al. Prevalence of psychiatric disorders among
mastectomy are low self-esteem, embarrassment about dis- cancer patients. Journal of the American Medical Association
figurement, and marital and sexual problems (Irvine et al., 1991). 1985;249:751-7.
Several kinds of treatment for cancer may cause 10. Dunkel-Schetter C and Stanton AL. Psychological adjustment to
psychological disorder. Emotional distress is particularly inferlity. In. AL Stanton and C Dunkel-Schetter (Eds). Infertility:
common after mastectomy and mutilating surgery. Perspective from stress and Coping Research. New York:
26 Plenum;1991.pp.197-222.
11. Facione NC. Delay versus help seeking for breast cancer symptoms. 26. Noyes R and Kathol RG. Depression and cancer. Psychiatric
A critical review of the literature on patients and provider delay. Developments 1986;2:77-100.
Social Science and Medicine 1993;36(12):1521-34. 27. Parry, BLA forty-five year old women with premenstrual dysphoric
12. Fawzy FI. Malignant Melanoma: Effects of an early structured disorder. JAMA 1999;281:368-73.
psychiatric intervention, coping and affective state on recurrence 28. Pugh R, Jerath BK, Schmidt WM, Reed RB. Rates of mental disease
and survival 6 years later. Archives of General Psychiatry 1993;50(9): related to child rearing. New England Journal of Medicine
681-9. 1963;22:1224-8.
13. Freeman EW, Sondheimer S, Weinbaum PJ, et al. Evaluating 29. Rivera-Tovar A, Rhodes R, Pearlstein TB, et al. Treatment efficacy.
premenstrual symptoms in medical practice. Obstetrics and In JH Gold and SK Severino (Eds) Premenstrual dysphorias. Myth
Gynaecology 1985;65:500. and Realities. Washington DC. American Psychiatric Press;
14. Gise L. Psychosocial aspects. In. DE Stewart and GE Robinson (Eds.). 1994.pp.99-148.
A Clinician’s Guide to Menopause. Washington DC. American 30. Robinson GE. Place of psycho-active drugs in the treatment of
Psychiatric Press; 1997.pp.29-44. premenstrual syndrome. CNS Drugs 1994;2(6):453-64.

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15. Goodale IL, Donnar AD, Benson H. Alleviation of premenstrual 31. Robinson GE and Stewart DE. Infertility and new reproductive
syndrome with the relaxation response. Obstet and Gynecol technologies. In. JM Oldham and MB Riba (Eds). American
1990;75:649-55. Psychiatric Press, Review of Psychiatry, Washington, DC : American
16. Greer S, Marcus T, and Pettingal KW Psychological response to Psychiatric Press 1995;14:283-306.
breast cancer: effect on outcome. Lancet 1979ii;785-7. 32. Schmidt PF, Neiman LK, Grover GN, et al. Lack of effect of induced
17. Harris EC and Barraclough BM. Suicide as an outcome for medical menses on symptoms in women with premenstrual syndrome. N
disorder. Medicine 1995;73:281-96. Engl J Med 1991;324:11-74.
18. Helmy YA, Hassanin IMA, Elraheem TA, et al. Psychiatric morbidity 33. Schmidt PJ, Roca CA, Rubinow DR. Psychiatric disorders during

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following hysterectomy in Egypt. Int J of Gyn. and Obst 2008;102: the peri-menopause. Bailliere’s Clinical Psychiatry 1996;2(4):710-2.
60-4. 34. Severino SK. A focus on 5-hydroxytryptamine (serotonin) and
19. Irvine D, Brown B, Crooks D, et al. Psychosocial adjustment in psychopathalogy. In. JH Gold and SK Severino (Eds), Premenstrual
women with breast cancer. Cancer 1991;67:1097-117. dysphorias. Myth and Realities. Washington DC. American Psy-
20. Kessler RC, McGonagle KA, Swartz M, et al. Sex and Depression chiatric Press; 1994.pp.67-98.
in the National Comorbidity Survey I: lifetime prevalence, 35. Spiegel D. Can psychotherapy prolong cancer survival?
chronicity and recurrence. Journal of Affective Disorders 1993;29: Psychosomatics 1990;31:361-6.
85-96. 36. Spiegel D. Health caring: Psychosocial support for patient with
21. Levenson J and Bernis C. The role of psychological factors in cancer cancer. Cancer 1994;74:1453-7.
onset and progression. Psychosomatics 1991;32:124-32. 37. Steiner M, Korzekwa M, Lamont J, et al. Intermittent versus
22. McDaniel JS, Musselmann DL, Porter MR, Reed DA and Nemeroff continuous fluoxetine dosing in the treatment of premenstrual
CB Depression in patients with cancer. Archives of General dysphoria: a pilot study. Psychopharmacol Bull 1997;33:771-4.
Psychiatry 1995;52:89-99. 38. Stewart DE, Boydell K, Derzdo C, et al. Psychological distress
23. McKinlay, JB, Mc Kinlay , and Brambilla D. The relative during the menopausal years in women attending a menopause
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depression in mid-aged women. J Health Soc Behav 1987;28: 39. Stotland NL. Psychiatric issues in abortion and the implications of
345-63. recent legal changes for psychiatric practice. In. NL Stotland (Ed).
24. Moorey S. and Greer S. Psychological therapy for patients with Psychiatric Aspects of Abortion. Washington DC. American
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27
 6 Bioethics and Evidence Based Management

Vasantha Muthuswamy, Sudha Salhan

Introduction 4. I will not permit consideration of Religion, Nationality, Race,

‘Ethics’ is a generic term for referring to the moral code of Party Politics or social standing to intervene between my
conduct in a civil society. It not only concerns the rules, customs ‘duty’ and my ‘patient.’
and beliefs of a society but also concerns the scholarly efforts 5. I will practice my profession with conscience and dignity.
to interpret and follow these. According to Oxford dictionary 6. The health of my patient will be my first consideration.
Ethics has been described as “a set of principles of morals, science 7. I will respect the secrets which are confided in me.
of morals, moral principle, rules of conduct of a group, organization 8. I will give to my teachers respect and gratitude which is
or an individual.” Ethics and values have found interesting their due.
expressions in different cultures throughout the evolution of 9. I will maintain by all means in my power the honor and
man and society has been prescribing such codes of conduct noble traditions of the medical profession.
for different professionals. The ethical code of conduct for 10. My colleagues will be my brothers. I make these promises
medical professionals and physicians existed since time solemnly, freely and upon my honor.”
immemorial, the most ancient reference being found in the The above declaration describes the decorum, duties and
Charaka Samhita of Ayurveda (1st–2nd Century AD) which social ethics of physicians and prescribes the standards of
describes the Physician’s duties towards his patients and others conduct appropriate to a good physician. Such a professional
in the profession. However, the most well-known code for decorum surrounded by an aura of scientific knowledge related
medical professionals is the ‘Hippocratic Oath’ (600 AD) of the to health and diseases satisfied the public for centuries that
Greco-Roman period. All these and other such codes have doctors were decent, responsible, competent and trustworthy.
stemmed from the basic concept of ‘Non-maleficence,’ i.e. ‘Do The prestige that this profession enjoys in the eyes of the society
No Harm’ which was the driving principle for all physicians in is related to its contributions to the well-being of the society
their handling of their patients resulting in a fiduciary and the quality of performance by its members in adhering to
relationship between the two. the laid-down principles of doing no harm, relieving pain and
suffering, maintaining confidentiality, being trustworthy and
Professional Code for Physicians fair in their dealings.
Most of the earlier literatures describe the qualities of a good
physician to be gentle, pleasant, comforting, discreet and firm Evolution of Bioethics
‘to benefit the sick and do them no harm,’ keep confidence, to The centuries old Code of ethics for physicians was subjected
refrain from monetary and sexual exploitation of the patients to repeated challenges as various concepts of health and healing
even at the cost of one’s own health and wealth. Thus medical emerged over centuries. The concept of ‘just moral propriety in
ethics is a conglomerate of obligations that are moral and which medicine’ was propounded by Thomas Hobbs in 1651 and that
govern the professional practice. Most of the medical Councils of ‘medical humanism’ by John Gregory in the 18th century.
around the world have thus prescribed the codes for the Thomas Percival came up with the concept of ‘Bioethics’ for
respective countries. The Medical Council of India which is the the first time. As the medicine of the nineteenth century
statutory body established under an Act of Parliament vested absorbed advances in science and technology and learnt to use
with the power of regulating standards of medical education the numerical method of evaluating the results of treatment,
and medical practice, promulgated the Code of Ethics in 1956 knowledge and skill became more measurable. In the decades
to be followed by all the registered medical practitioners in the during and after World War II, medical sciences have advanced
country. Any violation of the code may lead to ‘penalties,’ to a great extent and medical interventions have become
including cancellation of registration. Every medical student increasingly technical, prompting medical ethics to be viewed
on completion of the course is required to take the oath to abide with a new perspective. Public health and health care do not
by the following declaration: just belong to the domain of treating physicians. In the present
1. I solemnly pledge myself to consecrate my life to the service setting of increasing community expectation of health combined
of humanity. with declining public resources, health services face an
2. Even under threat, I will not use my medical knowledge increasing number of complex and difficult problems. These
contrary to the laws of humanity. are wide ranging including, for example, how to deal with new
3. I will maintain the utmost respect for human life from the technologies such as biotechnologies, the allocation of scarce
time of conception. ‘high-tech’ resources, confidentiality and privacy of patients,
assessment of risk and benefit, issues at beginning and end of written by Fyfe to his wife (kept in Churchill Archives Centre
life such as the ‘right to die’ for the elderly, terminally ill and/or at Cambridge University). Fyfe eventually went on to draft the
chronically disabled persons. Such issues are not resolvable by European Convention on Human Rights. Later on Nuremberg
medical science or medical professionals alone and the code on experimentation in human subjects also came into being
approaches to be adopted may have far-reaching implications in 1947.
beyond the context of health care. These are complex, profound Thus a new beginning was made in the moral traditions of
social problems requiring a broad-based multidisciplinary medicine and laid the foundation for the new discipline of
approach. Hence the definition of the newly coined ‘Bioethics’ Biomedical Ethics or Research Ethics as part of Bioethics.
as proposed by Warren Reich in Encyclopedia of Bioethics reads
that ‘Bioethics denotes the systemic study of the moral dimensions – Basic Principles
including moral vision, decisions, conduct and policies – of the life The four cardinal virtues of a health professional are
sciences and health care, employing a variety of ethical methodologies compassion, discernment, trustworthiness and integrity. Truth

Chapter 6
in an inter-disciplinary setting.’ telling and consent seeking have long been part of an indigenous
The new science of bioethics thus born, while inheriting medical tradition based on medical theories that taught that
some of the ideals and values of the old medical ethics knowledge and autonomy had demonstrably beneficial effects
encounters unprecedented new queries and dilemmas with the on most patient’s health. The principle of autonomy implies
emerging medical and scientific progress and requires the that physicians must inform their patients about the nature of
concerted efforts of physicians, legal experts, theologians, the condition and its expected course, about the benefits and
philosophers, social scientists, policy makers and the socially risks of any proposed treatment and of alternative treatments,

Bioethics and Evidence Based Management

aware public at large to provide plausible answers to the queries if available. It is also emphasized that doctors and patients
raised to safeguard the basic human rights. should make joint decisions. Maintaining the confidentiality of
patients’ information is a duty of the physicians. Hence, rights
Biomedical Research Ethics of the patients and the responsibilities of the physicians
The ancient codes of ethics directed the physicians that they constitute the basic principles of ethics of medical practice.
have a moral obligation to attain new knowledge and skill. From The Nuremberg Code has delineated ten basic principles
the beginning of medicine, physicians knew that treatment for medical research that must be observed to satisfy moral,
successful in prior cases might fail in a present case. In desperate ethical and legal concepts. Voluntary consent of the human
moments of illness, previously untried remedies were subjects, experimental results to bring good to the society, prior
attempted, sometimes with unexpected success. However, the experiments with animals, avoidance of unnecessary physical
Hippocratic maxim, “benefit and do no harm” urged physicians and mental suffering, prior assurance that no death or disability
to maintain a constant intent to cure. Medical history hints that will result, the scientific qualification of researchers, evaluation
certain Alexandrian physicians were permitted to perform by subjects rights and researcher’s duty to terminate harmful
venesection on criminals and these experimenters were referred experiments are the major principles of this code which holds
to as “medical murderers” by Roman medical encyclopedist, good till date.
Celsus. Much later in 1865, noted French physiologist and Father The World Medical Association also brought out the
of Experimental medicine, Claude Bernard states that, “It is our Helsinki Declaration in 1964 to guide the treating physicians
duty and right to perform experiments on man whenever it about the norms to be followed in therapeutic as well as non-
can save his life, cure him or gain him some personal benefits. therapeutic research. The necessity of adhering to the principles
The principle of medical and surgical morality, therefore, enunciated in the Nuremberg Code and Helsinki Declaration
consists in never performing on man an experiment which got top priority in various countries in the 1970s and resulted
might be harmful to him to any extent, even though the result in formulation of numerous national and international
may be highly advantageous to science, and to the health of guidelines to protect the individuals participating in any
others.” Thus, one can see that while advocating experiments research from any harm.
on fellow human beings, Bernard’s principle lies within the During the following decades, there was a quantitative
Hippocratic tradition. The enthusiasm for experimentation grew increase in medical research but it was also accompanied by
during the 19th century and early 20th century. The worst qualitative improvement in research methodologies, ethical
“scientific experiments” came to light following the Second review and evaluation of research results. Constitution of
World War at the Doctors’ trial in Nuremberg where Institutional Ethics Committees or Institutional Review Boards
innumerable atrocities committed by Nazi physicians on unin- became a practice and the peer review of research was done
formed prisoners of war in the name of medical research came based on the basic principles enshrined in the Codes and
to light and shocked the entire world. This was followed by guidelines followed by different countries. These principles
proclamation of Nuremberg Code on Experimentation in mainly comprised of the following:
Human Subjects in 1947, marking a new era of code of ethics • Non-Maleficence – Do no harm
for medical research which drew unprecedented attention from • Beneficence – Fruitful result, Do good
public, professionals and policy makers. • Autonomy – Respect for persons
Nuremberg Trial: This was the trial of Nazi Reichsmarschall • Justice – Distributive justice, equitable distribution of risks
Hermann Goering (considered as Hitler’s natural successor), and benefits.
Albert Speer (Hitler ’s minister of armaments and war The purpose of research, its potential benefits to
production) and their accomplish at Nuremberg in 1945–46 (an participants, the anticipated risks and compensations for the
year long trial). The chief conducting the trial was Sir Hartley same, the unexpected consequences and steps proposed to
Shawcross with David Maxwell. Fyfe (previously Solicitor tackle the same, the evaluation of risk benefit ratio are all
General during World War II) as his assistant. Footings of covered under the principles of non-maleficence and
horrors in the concentration camps at Auschwitz were included. beneficence.
It showed infants and small children killed and suffering besides The fundamental moral principle of “respect for persons”
tortoures done to the adults. This can all be read in 205 letters demands voluntary, informed consent from individuals 29
 participating in research and is termed as the ‘Autonomy’ safety and rights of the research participants. Further those
principle. This includes right to privacy and confidentiality and violating the same can be subjected to penal provisions.
obligations to protect the vulnerable groups by obtaining
informed consent from the legal guardians wherever necessary. Bioethics Education
Recruitment of those with diminished autonomy also requires The idea of justice and fairness in human relationships and
special consideration and adequate justification. Hence respect for life in all its forms makes the subject of bioethics
obtaining ‘Informed Consent’ has become the most crucial important in education and research. Teaching of bioethics has
requirement in any clinical research. become an integral part of medical and life sciences curriculum
The principle of Justice demands that the fruits of research in many developed countries since the early 1980s. Standards
are equitably distributed amongst the beneficiaries and the and ideals internal to the profession of medicine and nursing
participants in research. This has gained global importance in should be inculcated in the students of these professions to
view of the growing international collaboration between enable them to act in accordance with the worthy goals and
Basics of Gynecology

developed and developing countries. Selection of subjects, role expectations of health care institutions.
equitable study design and access to post-trial benefits are the Though individuals can act in accordance with principles
hallmarks of this principle. and rules as well as their ideals to protect the rights and
All clinical research involving human subjects should take obligations of patients and research participants, it is essential
the above principles into consideration while planning, to inculcate these with examples and case studies as applicable
conducting and evaluating the research and during utilization to different subjects so that the students are able to appreciate
of the research results. the applications of these principles and know the current
concerns in the global scenario. Hence efforts are on to introduce
Advances in Science and Technology teaching of medical ethics in all curricula of medical and life
The recent advances in science and technology are mind sciences. Till such time, it is necessary for the students to look
boggling. Those that existed solely in the realm of science fiction up relevant websites and consult guidelines and the few
till recent years have become a reality; in their wake they have available textbooks on the subject. Short-term and long-term
Section 1

brought numerous ethical dilemmas. Each of these requires training programs in the area of research ethics are available
careful scrutiny by appropriate scientific and ethics committees for those interested in the topic. Any medical practitioner or
before any research is undertaken. The controversial issues are medical researcher who has undergone such training will be
so many and so complicated that each one of them requires an enriched person and will be capable of protecting the rights
close scrutiny and consensus decisions. Advances in of the society.
biotechnology, genomics, genetic engineering, organ and tissue
transplantation, new reproductive technologies, cloning, Conclusion
medical devices, recombinant products, surgical innovations, Bioethics has emerged as a new discipline in the last two to
life support systems all pose challenges to the conscientious three decades and is gradually growing into a multidisciplinary
researchers and the society has to evolve acceptable solutions specialty. Though it has been a part of medical jurisprudence
to benefit the majority. Constant debates are the need of the till now, the advances in medical science and their ramifications
hour. There is no single solution to any issue and decisions are resulted in this subject becoming a specialization by itself and
taken on case to case basis. a new breed of trained bioethicists are dominating the health
care institutions in the recent years.
Ethical Guidelines Law, Philosophy and Social Sciences are closely linked with
Apart from the Nuremberg Code and the Helsinki Declaration medical decision-making, research with human subjects and
numerous national and international codes and guidelines are the care of the terminally ill patients. Hospital ethics committees
available for the interested professionals and public. In India, and institutional research ethics committees function as
the Medical Council of India issued the Code of Ethics for the conscience-keepers of the society. Bioethical discussions and
professionals in 1956 which was revised in 2002. For research debates inform individuals and the society about the new
ethics, the Indian Council of Medical Research brought out the innovations and the differing values about human life so that
‘Policy statement on ethical considerations for research on appropriate decisions can be taken. Public policies and teachable
human subjects released in 1980 and a revised and detailed curriculum are the needs of the time to enable professionals to
document ‘Ethical guidelines for biomedical research on human carry on with their roles and responsibilities entrusted by the
subjects’ released in 2000. The revised guidelines elaborate on public.
the general principles and delve into details on five specific
areas such as clinical trials, epidemiological research, human Evidence Based Reproductive Medicine (EBRM)
genetics research, organ transplantation and assisted Definition: It is the conscientious, explicit and judicious use of
reproductive technologies. These guidelines are available on current best evidence in making decisions about care of the
the ICMR website: www.icmr.nic.in. individual patients (David Sachett, the God Father of evidence
All institutions conducting medical research are required based medicine). Evidence based medical practice and clinical
to follow these guidelines in letter and spirit and the research research and is graded into 3 categories: Grade I randmomized
proposals are to be approved by a duly constituted Institutional control trials Grade II-1 controlled trials without randomization
Ethics Committee. The roles and responsibilities of the Ethics Grade II-2 Cohort or case control studies. Grade II-3 comparison
Committees and the details of the ethics review procedures are between time/place with or without intervention. Grade III
elaborated in the ICMR ethical guidelines under the Chapter clinical experience.
on ‘Ethics Review Procedures.’ Efforts are on to legislate these EBRM tries to integrate the best literature evidence with
guidelines to make the provisions mandatory for all, so that clinical expertise. The treatment is tailored to individual patient.
ethics committees exist in all institutions and quality ethical It requires a fresh outlook towards apparently well-known
review is undertaken without any fear or favor to protect the problems. This is all for better care of the patients without
30
wasting valuable time on unnecessary procedure and drugs 5. Code of Medical Ethics framed under Section 33 of the Indian
(minimizes redundant procedures). Medical Council Act, 1956, Revised, 2002.
It is an emerging paradigm for medical practice and 6. Code of Medical Ethics, Medical Council of India, Revised, 2002.
7. David Rothman, Strangers at the Bedside, New York, Basic Books,
teachings. More and more randomized controlled trial are
1991.
required in both undergraduate and postgraduate curriculum 8. Ethical Guidelines for Biomedical Research on Human Subjects, Indian
for better patient care. Council of Medical Research, Revised, 2000.
Now virtually no drug enters clinical practice without 9. Helsinki Declaration, World Medical Association, Revised, 2000.
clinical trial of safety and efficacy. Similarly, research is needed 10. Hippocrates, Aphorisms I in WHS Jones (trans) Hippocrates with
for therapeutic surgeries and diagnostic tests. EBRM separates an English translation, Cambridge, Mars Harvard University Press,
facts from fantasy in clinical practice. There is no place for 1959.
preference. It is not ethical to promote certain treatment without 11. International ethical Guidelines for Biomedical Research involving
Human Subjects, WHO CIOMS, 1993.
a proper clinical trial.

Chapter 6
12. Jay Katz. The Silent World of Doctor and Patient, New York, Free
For EBRN constant updating of knowledge and keeping Press, 1984.
up with the many meta-analysis results and research outcomes 13. Jay Kat Z (Ed.) Experimentation with Human Beings, Russell Sage
is essential. All these improve patient care (which is our main Foundation, New York, 1972.
goal). 14. Satyavati GV. Ethical considerations in Biomedical Research, Indian
Paediatrics, 1992.
BIBLIOGRAPHY 15. Thomas Percival, Medical Ethics,London S Russell, 1803.
16. The American Medical Association Code of Ethics, 1847.

Bioethics and Evidence Based Management

1. Albert R Jonsen, The Birth of Bioethics, Oxford University Press,
17. Tom L. Beauchamp and James Childress, Principles of Biomedical
1998.
Ethics, Oxford University Press, Revised Edn. 1994.
2. Andrew C Ivy. The History and ethics of the use human Subjects in
18. Vasantha Muthuswamy, Ganguly NK. Ethical Values in Biomedical
Medical Experiment—Science 1948;108:1.
Research, Building a Vibrant India - Democracy, Development and
3. Beecher HK. Ethics in Clinical Research, New England Journal of
Ethics (Ed.) MM Luther, Tata McGraw Hill Publishing Company
Medicine, 1966.
Limited, 2002.
4. Belmont Report, The National Commission for the Protection of
19. Warren T Reich, The Encyclopedias of Bioethics, Revised Edn, 1995.
Human Subjects, DHHS, US, 1979.

31
 7 Organizing Studies and Clinical Work

Meenakshi Bhatt

Medical and nursing students are no strangers to heavy books 5. Study aggressively: Do not drift from one page to the next in
and numerous subjects. However, studying and time a daze. Give the text your full concentration. In addition, set a
management skills become especially important when it timer and refer to it often so that you are forced to finish your
becomes necessary to divide time between the textbooks and reading on time.
the laboratories and clinics. This chapter is being included to 6. Take notes: You may like to take notes in a notebook (a
provide help in this essential aspect of medical training. It is notebook set aside for this very purpose; not any scrap of
divided into three sections: paper that meets the eye) or within the textbook itself. Tiny
1. Tips for effective studying flow chart/diagrams/lists can be made in the margins or on
2. Tips for making good presentations stick-on papers. These will be very helpful at the time of
3. Tips for working efficiently in the wards. revision.
7. Discuss: This is an invaluable part of learning. As you try
TIPS FOR EFFECTIVE STUDYING to explain concepts to your friends/juniors, you will find
1. At the outset decide why you want to study. Formulate in that they become clearer to you, too. Other students can
your mind the questions that you want to be answered at give you a whole new perspective on a topic. Often, it is not
the end of your reading session. May be you have seen a what you read but what you hear your friends teaching you
patient with that condition recently and want some doubts that you remember during the examination.
clarified. Whatever be the reason, study with a constant 8. Often you may need to refer to more than one book for a
lookout for answers to those questions. This is far more topic. You must decide early on which book will serve as
productive than passively ploughing through paragraph your main course book. Make it a habit of making notes
after paragraph. from a reference book into the main book or a special
2. Set a clear goal: The goal should be specific in terms of the notebook while/ soon after you are done reading. This timely
time to be spent and the material to be studied and should effort will come in very useful. Otherwise, in a week you
preferably be written down. Different kinds of books require will remember precious little of what you read from the
different reading speeds: Some are concise and packed with reference book and there may never be enough time for
information. These need the reader to pay attention to every you to go back to it again.
word. Others are written in a more explanatory style and While studying, visualize yourself preparing the day before
can be read faster. Thus, the number of pages which can be the examination. Then organize your notes in such a way
read and understood in a given period of time will vary from that you are able to access all the vital information on that
book to book. It is helpful to do a trial run and record the crucial day with the minimum of fuss.
average reading speed. This will aid in the setting of an 9. Approach a chapter from many angles: You are not duti-
achievable target. bound to start reading from the beginning and till the end.
The study duration should be in keeping with your stamina and Instead, you can start reading from the end of the chapter
past study habits. If you find yourself fidgeting after 30 minutes as this is the most neglected part. You can choose to read
of deep study, it is futile to set up time slots of one hour. Thus, it is only a part of the chapter in the middle, e.g. instead of
important to honestly recognize one’s capacity and set targets reading all about malaria in one go, you can read only the
accordingly. pathogenesis on one day and read the rest on another.
3. Assess your previous knowledge of the topic before you 10. Approach a topic from many angles: If reading a whole
start reading about it. You will often be surprised at how new subject, begin with the smallest book on the subject.
much you already know and that in itself is a great morale This way you get an idea of the basic concepts. Then, you
booster. In addition, you will know exactly where you are can go on to greater details.
lacking. While reading highlight the parts that you were Instead of reading only a regular course book which
misinformed or uninformed about. often gets boring, read a book in question and answer format
4. Before taking the final plunge, flip through the chapter and or a book of differential diagnosis. For example, when
see the headings and subheadings. Read the summary and reading about cervical cancer, supplement the usual
the key points; go through the graphs, pictures and flow textbook by reading an approach to postmenopausal
charts. This way, you will get a quick overview and will bleeding. This way, not only do you get to know the salient
know what to expect. Most fresh medical students are ill- points about carcinoma of the cervix, but also read about
equipped to forming a holistic picture of a topic, since MCQ other relevant conditions, e.g. DUB. What is more important
(Multiple choice question) based examinations force them is that you get to apply knowledge and learn to think like a
to train themselves to see mainly the details. doctor rather than like a student.
 However, time is limited and while reading such and why. Read your books and understand the subject. Then
alternative resources, remember to note essential points. You use the internet to seek answers to specific questions or
will never get the time to get back to those books again. obtain much needed pictures/diagrams. Even then, use only
11. Use several reading techniques: The time, when the only reputed websites, e.g. CDC, WHO and quote them in your
reading you could accomplish was on your desk in the presentation. Not all the information on the internet is reliable.
comfort of your room, is long gone. You must train yourself 4. Give a list of topics you will discuss at the beginning of
to read in all kinds of circumstances. In the wards or before the presentation. It adds clarity and keeps the audience
a class, while you wait for your teacher to arrive; in the bus interested.
on the long commute to and from home; in the fifteen spare 5. Use only key words and sentences on the slide/
minutes you get between classes. Always carry a book with transparency. If the presentation is too wordy the audience
you to make long waiting times productive. In these less may spend all their time reading it and miss what the
than conducive situations you may not read much but let speaker is saying.

Chapter 7
that not deter you from reading something. Just flip through 6. Use pictures, graphs, flowcharts liberally to explain your
the pages or go through the index and read whatever new point better and to keep the audience awake!
catches your eye. 7. Use large letters and colors with good visibility.
12. Read about the patients you see in the clinic: Even if you 8. Talk to your friends/ colleagues to find out what they want
do not have time to read everything about each case when to know by the end of the presentation. Keep in mind these
you return to your room, read at least the clinical features ideas while preparing your material.
and the treatment. 9. Get the opinion of a good friend/senior on the finished

Organizing Studies and Clinical Work

13. Do pointed reading: If you have a doubt in your mind about product.
a certain topic, it is not your moral duty to read the entire 10. Practice speaking and time the presentation yourself.
chapter. This is true even if you don’t know the chapter
well. Find out what you had set out to find. Then, whenever TIPS FOR WORKING EFFICIENTLY IN THE WARDS
time permits (immediately or at a later date) read the chapter 1. Ask your seniors for advice. They have probably worked
in its entirety. out all the shortcuts needed to get things done fast.
2. Prepare ahead If a large amount of sampling needs to be
TIPS FOR MAKING GOOD PRESENTATIONS done in the morning, prepare for it the previous evening.
Sooner or later you will have to make presentations on certain 3. Keep important materials handy Keep in your bag prefilled
topics in font of you fellow students and your teachers. Here investigation forms and other important papers (e.g. blood
are a few pointers to help you do your best. requisition forms, X-ray forms). This prevents many panic
1. Start preparing well in time: Once you read about the topic, attacks on busy days.
you need time to mull over it and absorb it. You need time 4. Be punctual It will decrease your stress level and that of
to prepare the presentation and to get it checked by a senior/ your seniors!
teacher and make the necessary corrections. Also keep some 5. Maintain cordial relations with your colleagues and the
time for the unexpected guest, bout of diarrhea or a power ward staff. It is basic courtesy and it also ensures that they
cut! will pitch in on a heavy day or when you are in a tight spot.
2. Before you hit the books, pause and try to recall what you We need all the help we can get.
know about the subject and what more would you like to 6. Keep a list of important phone numbers within easy reach
know. (e.g. X-ray room, laboratory). It will save you needless visits
3. Do not rush to the nearest internet café to carry out an to every corner of the hospital.
exhaustive search on the topic. The net is the greatest waster 7. Tackle paperwork aggressively. It is essential and letting it
of time man has devised. It is also an invaluable source of sit around will not make it disappear or make the work any
information if you know what to search for, from where easier.

33
 Section 2 Anatomy and Physiology

8 Surgical Anatomy of Female Genital Tract

Sudha Salhan

INTRODUCTION opening, the openings of various glandular and vascular structures

It is important to know any deviation from normal in anatomy and the perineum.
or histology, as it forms the basis of most of the gynecological Mons pubis (Mons veneris) is the area over the symphysis
diseases. Since the urethra, urinary bladder, ureter, pelvic colon, pubis. It contains fatty and connective tissue. At puberty it bears
rectum and anus are closely associated with female genital hair-forming escutcheon. The shape of escutcheon is triangular
organs, any alteration in their function or structure during with base at mons pubis and apex below on the outer surfaces
childbirth or disease will influence the gynecological of both labia majora.
procedures, and vice versa when gynecological conditions
Labia majora are two fat filled folds of skin extending from the
encroach them and pose difficulties in treatment and surgeries.
mons pubis backwards on either side of vaginal opening. They
No two women are alike in respect of anatomy. Variation is
are approximately 7–8 cm in width and 1–1.5 cm thick. They
the rule. For convenience we can divide the female genital
taper posteriorly and unite to form the posterior commissure
organs into external and internal. and merge into the perineal body. The lateral sides are hairy
a. Female External Genital Organs (Pudenda) after the puberty. They are the counterparts of the male scrotum.
• Vulva Each labium majus is covered by stratified squamous
– Mons pubis/Veneris epithelium.
– Labia majora In its substance there are many sebaceous glands, sweat
– Labia minora (Nympha) glands, elastic fibers, adipose tissues and plexuses of veins but
– Bartholin’s glands (Greater vestibular glands) no muscle cells. The subcutaneous tissue of labia majora is
– Clitoris similar in composition to the abdominal wall. The superficial
– Vestibule tissue of this region, where fat predominates, has been called
– Vestibule bulb Camper’s fascia as it is on the abdomen.
– Hymen In the deeper layers there is less fat and more interlacing
– Vaginal enterance fibrous tissue; this layer is called Colles’s fascia and is similar
– External urethral opening to Scarpa’s fascia of the abdomen.
– Opening of various glandular and vascular structures.
– Perineum
• Vagina
b. Internal Genital Organs
• Uterus
• Supports
• Fallopian tubes
• Ovaries
c. Associated Structures
• Urethra and
– Urinary bladder
– Sphincteric structures
• Ureter
• Pelvic colon
• Rectum and Anus
d. Blood Supply of Female Pelvic Organs
e. Nerve Supply of Pelvis
f. Lymphatic Drainage of Female Pelvis Associated Structures
Female external genital organs (Fig. 8.1): It includes the following
exterior genital organs. Vulva or Pudenda include whatever is
visible on external examination. It comprises mons veneris, labia
majora, labia minora, Bartholin glands, clitoris, vestibule and
vestibular bulb, vaginal entrance, hymen, external urethral Fig. 8.1: Female external genitalia
 Some of the sebaceous glands are large and are called
apocrine glands; their secretions when modified by local
bacteria give a characteristic odor. The connective tissue is very
loose and hence becomes edematous easily.
The terminal part of round ligaments of the uterus and the
obliterated processes vaginalis (canal of Nuck) are present in
labia majora.
Before puberty there are no hair on the outer surface of labia
majora and mons. At and after the puberty hair growth starts
and fat appears. At this time of life the labia majora cover the
vaginal orifice. In children, and postmenopausal women the
amount of fat is very less hence the vaginal orifice remains

Chapter 8
uncovered.
Applied anatomy
1. Since stratified squamous epithelium covers the region, the
mons pubis and the labia majora are vulnerable to ordinary
skin diseases like boils, (Fig. 50.1) sebaceous cysts and new
growths like hidradenoma (of apocrine glands), etc.

Surgical Anatomy of Female Genital Tract

2. The round ligament can give rise to leiomyomas in this
region and the obliterated processes vaginalis can become Fig. 8.2: Bartholin’s glands and vestibular bulb
a dilated embryonic remnant in the adult.
Labia minora (nymphae) They are on each side of vaginal
opening and on the inner side of the labia majora as two moist above the external urethral opening. It is attached to the under
folds of thin soft skin. These labia minora correspond to the surface of the symphysis pubis by the subcutaneous suspensory
floor of the penile urethra in males. They split towards the mons ligament. It is divided into a glans (only the glands and prepuce
side into two folds, the anterior folds joining to form the prepuce are visible), body (corpus) and two crura. The glans has spindle
and the posterior folds forming the frenulum of the clitoris. shaped cells, covered by squamous epithelium. The two crura
Posteriorly, towards the perineum, both the labia majora join to (corpora cavernosa with smooth muscle fibers) arise from the
form the fourchette. Fossa navicularis is a small hollow between interior surface of the ischiopubic rami; they are long and
the fourchette and the hymen. narrow and are firmly attached to the pubic bone, continuing
Labia minora are covered by stratified squamous epithelium dorsally to lie on the inferior aspect of the pubic rami. The
with no hair follicles or adipose tissue. The stroma contains ischiocavernosus muscles originate at the ischial tuberosities
sebaceous follicles, a few sweat glands, many blood vessels and and the free surface of the crura, to insert into the upper crura
some smooth muscle fibers. The skin is loosely attached to the and body of the clitoris and fuse just below pubic arch to form
underlying tissues. the corpus or body. The body can be palpated against the
Labia minora are hardly visible before the puberty. But in symphysis pubis.
multiparous women they may project prominently. Applied anatomy
Applied anatomy 1. The blood vessels of the clitoris have connections with the
1. The fourchette is a sharp fold of skin that is injured during vestibular bulb and may suffer injury during parturition.
delivery and occasionally during the first intercourse. Causing perfuse bleeding.
2. Smooth muscle fibers enable the labia to become turgid 2. It is an erectile organ.
during the sexual excitement.
Vestibule (a Latin term meaning a hall next to the entrance) On
3. Since the skin is loosely attached to the underlying tissues
separating the labia this area is seen in front of the vaginal
it allows easy dissection in the vulvectomy operation.
opening. It is bounded anteriorly by the clitoris and posteriorly
Bartholin glands (greater vestibular glands). These lie one on by the fourchette, openings of the urethra, the vagina, the ducts
either side of vaginal orifice posterolaterally (at the junction of of Bartholin’s glands and ducts of paraurethral (Skene’s) glands.
middle and post third) (Fig. 8.2). They correspond to the
Cowper’s glands or bulbourethral glands in males. They are
oval (pea shaped) and about 0.5–1 cm in diameter and when
normal, cannot be palpated. The ducts are 1.5–2 cm long and
open just outside the lateral margin of the vagina. Each Bartholin
gland is a compound racemose gland and its acini are lined by
low columnar epithelium. Multilayered columnar cells line the
duct (Fig. 8.3). Its function is to secrete a colorless mucoid
secretion with a characteristic odor, mainly in response to sexual
excitation.
Applied anatomy
1. Bartholin’s glands may be infected with gonorrhea or other
bacterial infections when they may form a Bartholin’s gland
abscess. It is the duct which gets distended in Bartholin cyst.
Clitoris is the female counterpart of the penis, but unlike in
male, it is separate from the urethra. It lies below the mons Fig. 8.3: Bartholian cyst–40x Dr Chandok
pubis hidden by the two folds of labia minora and is located Pathology Department, ESI Hospital 35
 External urethral meatus is anterior to the vaginal orifice and
posterior to the clitoris. The Skene’s ducts open into the sides
of the urethral openings. The fossa navicularis is in the posterior
part of the vestibule in nulliparous women. On either side of
the urethral opening are small depressions called paraurethral
pouches with adjacent, barely perceptible, urethral labia.
Two vestibular bulbs are counterparts of corpora spongiosa of
males. They lie under the lining of the vestibule on either side.
They are an elongated aggregation of veins above 3–4 cm long,
1–2 cm wide and 0.5–1 cm thick close to the ischiopubic rami.
Applied anatomy
Anatomy and Physiology

1. During parturition the vestibular bulbs are usually pushed

up beneath the pubic arch. They are liable to injury and
rupture causing hemorrhage or hematoma.
The hymen is a thin incomplete membrane covered on both
surfaces by squamous epithelium. It lies at the entrance of the
vaginal opening. It has a few openings for the drainage of
menstrual blood. It varies in shape and can be annular,
crescentic, septate or cribriform.
Applied anatomy
1. The hymen is mostly torn during the first act of coitus. In
imperforate hymen it remains intact and prevents flow of
menstrual blod (see Fig. 4.15).
2. Injury may also be caused by operations, digital interference
or insertion of menstrual tampons.
Section 2

3. The type of tear will give more information about its cause,
e.g. during parturition the injury is greater and the remains
of the hymen are a few tags around the vaginal opening
called carunculae myrtiformes.
Figs 8.4A and B: (A) Normal vagina-10x Dr Rath, Dept of Anatomy
The vaginal entrance lies at the posterior end of the vestibule
VMMC (B) H/P of Vagina (Dr A Gupta, Sikkim, Manipal Institute of
and is of different shapes. Medical Sciences)
The vagina is a tubular structure containing both fibrous and
muscular tissue. It lets the uterus communicate externally to
the vulva. It is directed upwards and posteriorly from the vulva
forming an angle of 60–70° to the horizontal.
Anteriorly the vagina is separated from bladder and urethra
by connective tissue condensation called the vesicovaginal fascia
or septum. Posteriorly, it is separated from lower portion of
rectum by the connective tissue condensation called the recto-
vaginal fascia or septum.
The upper fourth of the vagina is separated from the rectum
by the rectouterine pouch or cul-de-sac of Douglas. The vagina
pierces the triangular ligament and the pelvic diaphragm 1 cm
and 2.5 cm respectively from its lower end. The upper end of
the vagina (the vault) is blind except where it is perforated by
the cervix and has the external os projecting through its upper
anterior wall. The vault of the vagina is divided into four
Fig. 8.5: Normal rugae of vagina
fornices by the cervix. The posterior fornix is the deepest (7–10
cm) and is called the Pouch of Douglas (POD). The anterior
fornix is shallow (6–8 cm). There are two lateral fornices on is a thin fibromuscular coat of inner circular and outer
either side of cervix. The introitus (opening) of vagina is longitudinal layer of smooth muscle. It is believed by some that
functionally closed by the labia, which are in contact with each they are arranged in a crisscross manner. There is also rich
other. vascular connective tissue with a few small lymphoid nodules.
The anterior and posterior walls of the vagina are lying close This connective tissue is the controversial perivaginal
together normally, obliterate the cavity of the vagina. The vagina endopelvic fascia. No glands are present in the vagina.
has a diameter of 4–5 cm at its lower end and 8–10 cm at its Embryonic remnant (Gartner’s cysts) lined by columnar or
upper end. The vagina is covered by non-cornified stratified cuboidal epithelium can be seen in the vagina (see Fig. 9.5).
squamous epithelium (Figs 8.4A and B). But it can become They lie on the side of vagina (Fig. 8.6).
cornified (Fig. 29.16) once it is exposed to air, as in procidentia. The vagina is kept moist by small amounts of uterine
Prominent longitudinal ridges project into the vaginal lumen. secretion.
There are also many transverse ridges called rugae (Fig. 8.5) The upper part of the vagina is formed from the Mullerian
making a corrugated surface. Below the vaginal covering there ducts and the lower portion is formed from the urogenital sinus.
36
 7. The vagina absorbs water, electrolyte and substances of low
molecular weight. This is important in clinical practice as it
enables administration of drugs like estrogen, progesterone,
prostaglandin, and antibiotics, etc. pervaginally.
8. The vaginal inlet and the tissue around it are richly supplied
by blood vessels and so it bleeds profusely if injured by an
accident or at operation.
Perineal body lies between the vagina and the anus. It is also called
the central tendon of the perineum, as it is the central point into
which many muscles get inserted. It supports the lower part of
the vagina. The perineal body is attached to the inferior public
rami and ischial tuberosities through the perineal membrane and

Chapter 8
superficial transverse perineal muscles. It receives the insertion of
bulbocavernous muscle and of some fibers of the pelvic diaphragm
Fig. 8.6: Female internal genital organs (levator ani). Posteriorly there is indirect attachment to coccyx by
the insertion of the external anal sphincter.
The superficial cells of the vaginal mucosa are rich in Applied anatomy
glycogen hence the vagina stains deep brown with iodine. This 1. The perineal body may be torn during parturition

Surgical Anatomy of Female Genital Tract

property is seen in mucosa of infants due to estrogen of the External anal opening may also be injured. Hence, after
mother. This is also seen even after menopause (though much delivery examine carefully to see and repair any injury there
less in amount). and then. This prevents further damage.
Muscles are mostly involuntary but there may be a few
voluntary fibers contributed by the levator ani at the sites of Female Internal Genital Organs (Fig. 8.7)
their insertion. The fascial sheets fuse with the fascia covering Uterus
the levator ani muscles, the triangular ligament and perineal The uterus is an inverted pear-shaped hollow muscular organ.
body. It is situated in the abdomen with the bladder in front and
At birth, because of maternal estrogen, Doderlein’s bacilli are rectum posteriorly. It is divided into fundus (part above the
present in the vagina of the female newborn and the pH is acidic. insertion of fallopian tubes at the cornua) the body, and the
After a few weeks of birth the pH rises to 7 and the epithelium cervix. The isthmus is the part between the body of the uterus
atrophies. At puberty, due to formation of estrogen, the pH is acidic and the cervix. The uterus is flattened from before backwards,
again and Doderlein’s bacilli increase markedly. With repeated more so on the anterior wall. The measurements vary but the
childbirth and distension of the vagina the rugae disappear. At nulliparous organ is approximately 8–9 cm in length, 6 cm across
menopause the vagina shrinks and the epithelium atrophies. and 4 cm from before backward. The walls are 1–2 cm thick.
The functions of the vagina are: The normal length of the cavity is 7 cm (7–8 cm). It can be
1. Acts as excretory channel of the uterus (secretions and measured during operations by uterine sound. (Fig. in chapter
menstrual blood) of instruments).
2. It is the organ of copulation and. The cavity is shaped like an inverted triangle. It
3. It is part of the birth canal. communicates with the vagina through the cervix and with the
peritoneal cavity via the fallopian tubes. It is lined by
Applied anatomy
endometrium.
1. Through the thin walls of the fornices the internal pelvic
The uterus is covered partially by peritoneum. The whole
organs can be felt. (by pervaginal examination)
of the fundus, the anterior wall as low as the isthmus and the
2. Via the POD, after holding the posterior lip of the cervix by
the vulsellum, one can gain access to the peritoneal cavity
by culdocentesis (Fig. in ch 65). If culdocentesis yields
altered blood an ectopic pregnancy is suspected. In the case
of pelvic abscesses pus is aspirated via the same route and
then colpotomy (Fig. in ch 65) (opening of vagina) is done
to drain the pus colpotomy is also done for vaginal tubal
ligation.
3. The length and width of the vagina varies considerably in
different women. But anatomical shortness or narrowness
does not cause any difficulty in normal functions, as the
vagina is distensible due to the tone and contractions of the
surrounding muscles.
4. After childbirth small tags can get buried during healing or
repair of vaginal lacerations and form vaginal inclusion cysts.
5. During pregnancy the vaginal discharge, which is acidic, is
more profuse and also contains exfoliated epithelial cells
and bacteria.
6. Doderlein’s bacilli or lactobacillus are more numerous in
the pregnant vagina then otherwise; they act on the glycogen
within the exfoliated vaginal cells and form lactic acid. This
acidity is very important, as it is a natural resistance to Fig. 8.7: Sagittal section of genitourinary system
infection during the reproductive age. (Internal pelvic organs) 37
 posterior wall as low as the attachment of vagina to the cervix
are intimately covered with peritoneum (see Fig. 8.7). The sides
of the uterus, between the attachment of the two leaves of the
broad ligament, the whole of the cervix except the posterior
aspect of its supravaginal part are not covered with peritoneum.
The main walls have thick involuntary muscles (myometrium)
running obliquely in a crisscross spiral fashion (Fig. 8.8). The
more superficial muscle fibers however, are arranged
longitudinally and are continuous with muscle fibers of the
fallopian tubes and the vagina. Fibrous and elastic tissues are
mixed with the muscles. There is no submucosa, thus the glands
of the lining endothelium sometimes dip into the fibromuscular
Anatomy and Physiology

tissue.
The lining of the uterus (the endometrium) has glands and
a specialized stroma.
Applied anatomy
1. Thick involuntary muscles (myometrium) running
obliquely in a crisscross spiral fashion helps in preventing
postpartum hemorrhage (PPH) (Fig. 8.9).
2. The superficial portion of the endometrium undergoes cyclic
changes with the menstrual cycle. Fig. 8.9: Criss-cross spiral fashion uterine muscle

Cervix is divided into two portions: the portio vaginalis, which

protrudes into vagina and the portio supravaginalis, which lies
above the vagina.
The substance of the cervical wall consists of dense fibrous
Section 2

connective tissue with only some smooth muscles connecting

the myometrium with the muscles of the vagina. They are
circularly arranged and into these tissues are attached the
cardinal and the uterosacral ligaments and pubocervical fascia.

Histopathology
The portiovaginalis is covered by non-keratinizing stratified
squamous epithelium (Fig. 8.10). The cervical canal (2.5 cm) is
lined by a columnar epithelium, which secretes mucus and is
thrown into V-shaped folds giving it a characteristic appearance
— plicae palmatae or arbor vitae. Endocervix has cylindrical
columnar epithelium (Fig. 8.11). Fig. 8.10: Ectocervix, Dr Yadav RML Hospital
The internal os marks the upper border of the cervix and at
the lower border is the external os. Near the external os is the
transitional zone (T-zone) (Figs 8.12 A to C) where the change
from cylindrical columnar epithelium to squamous epithelium
occurs (squamo-column junction).
The level of transitional zone in relation to the external os
varies depending on the age and hormone levels. It may be up
to 1 cm in width.

Fig. 8.11: Endocervix

The longitudinal axis of the uterus is approximately at right

angle to the vagina and normally lies tilted forward; this is
termed anteversion. The uterus is also flexed forwards on itself
at the isthmus; this is anteflexion. In around one fifth of women
this tilt is backwards causing retroversion and retroflexion.
Anteriorly: The uterus is related to the bladder and is
separated by the uterovesical pouch of peritoneum. Posteriorly
is the POD with coils of intestines, sigmoid colon, and upper
38 Fig. 8.8: Muscles of the myometrium rectum. Laterally: Are the broad ligament and its contents. The
uterine artery and the ureter are of special importance as they
are very close at the supravaginal portion of the cervix.
At birth the cervix is twice the length of the body of the
uterus. At puberty the ratio reverses. After menopause the
uterus atrophies, the mucosa is thinned, glands disappear and
muscles are reduced. The cervical lips disappear and the
external os becomes flush with the vaginal vault obliterating
the fornices.
Applied anatomy
1. The transitional zone is an active area of cellular transition;
it is here that the cervix is most susceptible to malignant
transformation when acted on by carcinogens.

Chapter 8
2. Usually retroversion of the uterus does not cause any
significant pathology.
Fallopian tubes: Are paired tubular structures about
7–12 cm in length. Each fallopian tube is divided into 4 distinct
parts. At the cornua, the interstitial portion starts, and then is
the narrow isthmus. Next is the ampulla, the most spacious

Surgical Anatomy of Female Genital Tract

with convoluted mucosa. Laterally is the fimbrial end with
petal-like projections providing a wide surface for ovum pick-
up. One fimbria is long and reaches up to the ovary—the fimbria
ovarica.
The serosal layer consists of the peritoneum with underlying
areolar tissue. The muscle layers are the outer longitudinal and
the inner circular muscle fibers. They are fairly thick at the
isthmus and thin at the ampulla. The mucous membrane is
thrown into folds or plicae especially at the infundibular area.
It consists of columnar epithelium, most of the cells bearing
cilia, which together with the peristaltic action help in sperm
and ovum transport. The epithelium also contains secretory cells
as well as a third group of intercalary cells of uncertain function.
Histopathology (Fig. 8.13).
Ovaries are two in number. They are solid, grayish pink
almond-shaped in young adults and approximately 3 cm × 1.5
cm × 1 cm in volume. Before childbirth each ovary is longitudinal
in disposition; after childbirth there are many variations. It is
not covered by peritoneum. It is attached to the uterine cornua
by the ovarian ligament and to the hilum of the broad ligament
by the mesovarium. The latter transmit the vessels and nerves.
Laterally it is attached to the suspensory ligament of the ovary
with folds of peritoneum, which become continuous with that
over the psoas major.
Each ovary can be divided into the medulla and the cortex.
The medulla is the central vascular part containing loose Figs 8.12A to C: (A) TZ Junction (B) H/P of cervix T zone (Dr A Gupta,
connective tissue having many elastic fibers and non-striated Sikkim, Manipal Institute of Medical Sciences) (C) Squamocolumnar
muscle cells. The outer thicker cortex contains a network of junction
reticular fibers and fusiform cells. A single layer of cuboidal
cells called the germinal epithelium covers the outer surface.
Below it is the tunica albuginea, an ill-defined layer of
condensed connective tissue. Primordial follicles are present
in the cortex but some are seen in the medulla. They in turn
develop into graffian follicles (Fig. 8.14), corpus luteum (Figs
8.15A and B) and finally atretic follicles (corpus albicans) (Fig.
8.16).
The ovary is related anteriorly to the fallopian tubes, the
superior portion of the bladder and uterovesical pouch and
posteriorly to POD. Superiorly are the bowels and omentum
and inferiorly are the broad ligaments with their contents.
Laterally the ovary is related to the parietal peritoneum and
the pelvic sidewalls.
In fetal life the ovaries are situated in the lumbar region
near the kidney. They gradually descend into the pelvis (Fig.
9.9). Each ovary is packed with primordial follicles. The ovaries Fig. 8.13: H/P of Fallopian Tube (Dr A Gupta, Sikkim,
grow in size till puberty by increasing the stroma. With puberty Manipal Institute of Medical Sciences) 39
Anatomy and Physiology

Fig. 8.14: Graffian follicle (Ovary) Dr Yadav, RML Hospital Fig. 8.16: Corpus albican + stroma (ovary)
Dr Yadav, RML Hospital

along side the uterus to the internal cervical os as Gartner’s

duct.
2. Blood supply of the ovary is from the ovarian vessels and
anastemosis with uterine vessels.
The Ureter: There are two ureters connecting the kidney with
the urinary bladder. The approximate length is 25–30 cm, with
a diameter of about 4–6 mm. They are equally divided into
Section 2

abdominal and pelvic parts. There are slight constrictions at three

points at the renal pelvis (upper isthmus) as they cross the brim
of the lesser pelvis(lower isthmus) and also when they enter
the bladder (intramural). Each ureter is about 3 mm thick and
has 3 layers—the outer fibrous coat becoming continuous with
the bladder wall, a second non-striated muscular layer with
outer circular and inner longitudinal layer, and near the bladder
a third layer of muscles-outer longitudinal layer (as in the
urinary bladder). It is lined by transitional epithelium
(Histology Fig. 8.17).
The ureter can be recognized by its peristalsis. In its
abdominal part it is retroperitoneal traveling along the
anteromedial aspect of psoas major and is crossed by ovarian
vessels.
At the level of the sacroiliac joints the ureter enters the pelvis
and crosses the bifurcation of the common iliac artery (pelvic
position). On further descent it passes posterolaterally in the
pelvis and travels in front of internal iliac artery and its anterior
division, medial to the obturator vessels and nerves. In the true
pelvis it reaches medially and forwards on the lateral side of
the uterosacral ligament at the level of the ischial spine.
Traversing the base of the broad ligament it is about 2 cm lateral

Figs 8.15A and B: (A) Histopathology of corpus luteum (B) Corpus

luteal cyst -40x Courtesy by Dr Chandok, Pathology Department, ESI
Hospital

some primordial follicles develop each month into graffian

follicles. After menopause the ovary atrophies and is small and
shriveled. The fully involuted ovary of old age contains
practically no germinal elements.
Applied anatomy
1. The mesonephric ducts and tubules are always present as
vestigial structures. The epoophoron are a series of parallel
blind tubes in the mesosalpinx. Sometimes between the
epoophoron and the uterus are a few rudimentary tubes—
the paroophoron (Figs 8.6 and 9.4B). They may get filled
with fluid forming paraovarian cysts. The caudal part of
40 the mesonephric duct is well developed in some, running Fig. 8.17: Ureter histology (Dr Yadav, RML Hospital)
to the cervix in the ureteric canal of the cardinal ligament and The Urinary bladder: It is a muscular organ capable of altering
at this point the uterine vessels cross it superiorly from lateral its size and shape depending upon the amount of urine. This
to the medial side. At this site it is anterolateral to the upper reservoir of urine is a retroperitoneal viscus lying behind the
part of the vagina. Slightly medially it enters obliquely into the pubis symphysis. It is a tetrahedron when empty with a fundus,
urinary bladder at the trigone (Fig. 8.18). a triangular base and a superior and two inferior lateral surfaces.
Applied anatomy The latter meets to form the rounded border joining the superior
1. Operative trauma to the ureter can be of the following types: surface at the apex. Meeting of the base inferiolateral surfaces
• Crush injury due to a wrongly applied clamp. at the urethral orifice and the inferior forms bladder neck. This
• Transection is the urethral orifice. Normal bladder capacity is 300–600 ml,
• Ligation but in patients with retention of urine several liters can be
• Kinking and resultant obstruction accumulated. The bladder becomes more rounded as it fills and
• Ischemia because of devascularization due to Extensive in extreme cases can reach upto umbilicus.

Chapter 8
dissection (e.g. in Wertheim’s hysterectomy) There are 3 layers of the bladder wall. Outermost is the
• Segmental resection peritoneum, covering only the fundus. The second layer is
• Injury by a laparoscope. the detrusor muscle; it is nonstriated and has three layers—
2. The ureter can be injured at the following points during the middle circular, and the outer and inner longitudinal.
operations Innermost lies the mucous membrane (Fig. 8.19).
• Adjacent to the cervix in the ureteric canal, where it is The peritoneal covering extends from the anterior abdominal
wall to the fundus of the bladder (see Fig. 8.7). This peritoneum

Surgical Anatomy of Female Genital Tract

crossed over by the uterine vessels, the ureter may be
injured or accidentally ligated while ligating these vessels is displaced anteriorly upwards on filling of the bladder making
• Beyond the uterine vessels as it enters the cardinal it bereft of peritoneum anteriorly. This is utilized in suprapubic
ligament on its way to enter the bladder catheterization of full bladder without entering the peritoneal
• In the part of the ureter which enters the bladder wall cavity. Below the reflection of the peritoneum anteriorly is the
(intramural) Cave of Ritizius filled with loose cellular tissue. Posteriorly the
• Near the pelvic brim where it is near the ovarian vessels base of bladder is separated from the upper vagina by
during broad ligament fibroid operation. pubocervical fascia below the supravaginal portion of the cervix.
• At or below the infundibulopelvic ligament Here uterovesical pouch containing coils of intestines.
• Along the course of the ureter on the lateral pelvic wall The mucous membrane is transitional epithelium. There are
just above the uterosacral ligament no glands in the bladder. The mucous membrane is loosely
• During dissection of lymph nodes in Wertheim attached to the underlying muscular wall and hence forms rugae
operation as it is just lateral to Inferior Vena Cava when empty. The trigone is an inverted triangular area bounded
• A high suture near the cervix in the pelvic floor repair above by two ureteral openings and below by urethral opening;
occasionally injures the ureter here the mucous membrane is firmly attached to the underlying
• Blind hemostatic suturing in vault bleeding is muscles, hence it appears smooth.
dangerous. The interureteric ridge is slightly curved. The ureteric
Most such ureteral injuries occur in the lower third of the openings are about 2.5 cm apart.
ureter. The chances of damage are greater when any tumor, Applied anatomy
like a fibroid or an ovarian cyst, distorts the pelvic anatomy or 1. The mucous membrane’s transitional epithelium responds
the course of the ureter deviates due to a malignant tumor or to ovarian hormones. Therefore, menopausal women are more
broad ligament pathology. prone to cystitis.
2. Ureters open at an oblique angle through slit-like openings,
this prevents reflex of urine when the bladder contracts for
voiding.
3. During abdominal hysterectomy the bladder may be injured
3–4 cm above the trigone and it can be easily repaired.
4. While performing anterior colporrhaphy or vaginal
hysterectomy the bladder can be damaged, more so if

Fig. 8.18: Route of ureter Fig. 8.19: Urinary bladder (Dr Yadav, RML Hospital) 41
 previous repair was done. If this damage goes unnoticed, The anal canal passes downwards and backwards and is about
vesicovaginal fistula (VVF) forms. 3 cm long. Laterally there is fat in the ischiorectal fossa, which
The urethra runs anteroinferiorly from the internal meatus of support (otherwise slit like empty cavity) when distended.
the urinary bladder. It lies behind the symphysis pubis in close Anteriorly is perineal body and lower vagina and posterior
relation to the anterior vaginal wall. Its length is approximately relation is anococcygeal body.
1 cm and it is 6 mm in diameter. After crossing the perineal The sphincteric muscles are voluntary. External sphincter
membrane it ends at the vestibule. The external urinary meatus is of 3 layers of striated muscles, levator ani muscles also
is below the clitoris. Skene’s tubules draining the paraurethral surrounding the anal canal and are important in the control of
glands (homologous to the male prostrate) open into the lower defecation. The internal sphincter is involuntary and is the
urethra. thickened circular muscles of the gut wall around the anal canal
Near the bladder the urethra is lined by transitional just above the anorectal junction. Posterolaterally are piriformis,
epithelium, which later converts into non-keratinizing stratified coccygeus and levator ani muscles, third, fourth and fifth sacral
Anatomy and Physiology

squamous epithelium by the time it reaches the external urethral and coccygeal nerves. Anteriorly can feel uterus, adnexa, upper
meatus. The muscle layers are the inner longitudinal and the vagina and pouch of Douglas. Laterally is ischiorectal fossa (on
outer circular, which are continuous with those of the urinary per rectal examination).
bladder. Applied anatomy
The urethra is anteriorly related to the symphysis pubis with 1. While doing per rectal examination we can feel lower 3
some loose cellular tissue in between. Posteriorly it is near the sacral vertebrae, the coccyx, medical sacral and superior
anterior vaginal wall and Skene’s tubules. Laterally it is in rectal vessels.
relation to the urogenital diaphragm, bulbospongiosus muscle 2. Laterally we also feel for the cardinal ligaments for
and the vestibular bulb. involvement in the staging of carcinoma of the cervix.
Near its lower end, before crossing the perineal membrane Tissue layer fused to the undersurface of the muscularis of
it is encircled by voluntary muscles fibers—arising from the the posterior vaginal wall to form the anterior border of the
inferior pubic ramus to form the so called external sphincter; rectovaginal space. It varies in size, strength and consistency in
this allows the voluntary arrest of urine flow. different individuals. It is a fixation point for the upper border
of the perineal body and is very important clinically.
Section 2

Applied anatomy
1. The urethra is kept closed by the tone and elasticity of its
Anatomical Pelvic Support
muscles, except during micturition.
2. The decussating arrangement of vesical muscle fibers at the Varying degree of support to the birth canal is given by at least
urethrovesical junction acts as an internal sphincter and nine different anatomical systems:
helps maintain continence. 1. The bony pelvis
2. Pelvic peritoneum-broad ligaments
The sigmoid colon (Pelvic colon) starts at the pelvic brim as a
3. Subperitoneal connective tissue reticulum including
continuation of descending colon on the left side. Its loop is
• Round ligament
about 40 cm in length and it lies behind the broad ligament in
• Ovarian ligament
the lesser pelvis. It is totally covered with peritoneum and has
4. Fascial ligaments: Transverse cervical (Cardinal) or
a sigmoid mesocolon. At the level of the third sacral vertebra it
Mackenrodt ligament
continues as rectum.
• Uterosacral ligament
Its mucous membrane consists of non-ciliated columnar
• Pubocervical fascia
epithelium and is thrown into irregular folds. The muscle layers
5. The paravaginal attachments of the vaginal sulci to the arcus
are the inner circular and the outer longitudinal with three taenia
tendineus
coli bands. As the taenia are shorter they give the sacculated
6. The urogenital diaphragm including pubo-urethro-vaginal
appearance to the pelvic colon. There are also appendices
ligament.
epiploicae.
7. Pelvic diaphragm particularly the pubococcygeus
Inferiorly the sigmoid colon is in relation with the uterus
component of levator plate.
and urinary bladder and on the left side is the rectum. On the
8. The fascia of Denonvilliers (rectovaginal septum)
right side above are coils of ileum. Posteriorly there are the left
9. The perineum including the perineal body.
ureter, the left internal iliac vessels, piriformis muscle and the
All of them in combination provide the support.
sacral plexus. Laterally are the left ovary, left external iliac
vessels and the obturator nerve. Bony Pelvis is the ultimate fixed attachment of the pelvis soft
tissues. It is inflexible, firm and strong and thus resists sudden
The Rectum is 10–12 cm in length and lies on the concavity of
strain and stress. This response is both age and hormone related.
the sacrum and coccyx forming an anterior-posterior curve
Hence any deviation from normal due to trauma or any
called the concavity of the sacral flexure. The lower end is the
congenital abnormality may fail to provide adequate support
ampulla bulging into the posterior vaginal wall, then continue
to the soft tissue.
as the anal canal. The peritoneum covers it on the front of upper
and middle third and the sides of the upper third only. Broad ligaments are the peritoneal covering along with blood
The lining is of mucus-secreting columnar epithelium. When vessels and lymphatics. They provide support to the uterus and
empty, the lining is thrown into transverse folds. Horizontal the cervix.
folds are always present and are more pronounced during The round ligament provides accessory support to maintain
distension. There is absence of sacculations, appendices anteversion and anteflexion of the uterus.
epiploicae and mesentry that helps to differentiate it from the
Ovarian ligament a fibromuscular cord, together with the round
sigmoid colon. Taenia coli fuse 5 cm above the rectum and form
ligament, is the homologue of the gubernaculum of the testis of
one anterior and one posterior band, which descend in the rectal
the male.
wall.
42
Fascial ligaments consist principally of blood vessels (largely Coccygeus muscle forms the posterior part of the pelvic floor
veins), nerves, lymphatic channel, and areolar connective tissue. arising from the ischial spine and inserting into the lower
It is denser lateral to the cervix and the vagina and contains sacrum and the upper coccyx. It lies in the same plane as
many smooth muscles. It lies above the levator ani muscles and iliococcygeus. Sacrospinous ligament is the tendon or
has two parts. Mackenrodt (cardinal, or transverse cervical) aponeurosis of the coccygeus muscles.
ligament attaches to the uterus at the level of the internal os Pelvic peritoneum also provides some supporting.
and to the lateral vaginal fornices and being extensive and Rectovaginal septum: The fascia of Denonvilliers is a distinct
strong has an important supportive function. It passes lateral fibromuscular elastic.
to the pelvic wall. Its posterior reflection- the uterosacral
ligament—passes posteriorly around the lateral margin of the Applied anatomy
rectum and is attached to the periosteum of the fourth sacral 1. If a tear at this attachment occurs it may result in
verterba. It also assists in anterversion. These two ligments constipation. The laceration in the midline and occurs in

Chapter 8
provide the major support to the uterus. Pubocervical fascia is excessive stretching during labor.
inserted in the body of the pubis. The anterior reflexion is weak
BLOOD SUPPLY TO THE FEMALE
and support bladder base and anterior vaginal wall. It is called
PELVIC ORGANS (TABLE 8.1)
pubocervical ligament.
Abdominal aorta lies to the left of midline in front of the
Urogenital diaphragm: It is divided into two layers— the vertebral column from the T12 downwards with the inferior
superficial and the deep. vena cava on its right side. From its lower part arises the ovarian,

Surgical Anatomy of Female Genital Tract

The superficial layer contains three muscles— the inferior mesenteric, and superior rectal arteries anteriorly
1. Bulbospongiosus muscle (called sphincter vaginae as it and the middle sacral and the lumbar artery posteriorly. At
surrounds the vaginal opening) is attached atteriorly to the L4 level it divides into the right and left common iliac
corpora cavernosa of the clitoris). arteries.
2. Ischiocavernosus (cavering crura of the clitoris). Ovarian branch: Arises from abdominal aorta below the renal
3. the superficial transverse perineal muscles. arteries. The right ovarian artery crosses the inferior vena cava
The deep layer contains the deep transverse perinei muscle and the abdominal part of right ureter and enters the
originating from inner side of ischial ramus and attaching at infundibulopelvic ligament. The left ovarian artery may arise
the perineal body and urethra. These two layers of muscles and from left renal artery. It crosses the left ureter and the bifurcation
their fascial covering constitute the urogenital diaphragm. of the left common iliac artery before entering the infundi-
The urethra is suspended from the pubic bone by bilaterally bulopelvic ligament. Each artery then sends branches to the
symmetrical anterior, posterior and intermediate puboure- ovary through the mesovarium; branches also supply the ureter
throvaginal ligaments. The anterior and posterior ligaments are and fallopian tube. One tributary reaches the cornua of the
formed by reflections of the inferior and superior fascial layers of uterus and freely anastomoses with the uterine branches to
the urogenital diaphgram. The intermediate ligament is the fusion produce a continuous arterial arch.
of these fascial layers. These ligaments contain dense collagen,
smooth and striated muscles and elastic fibers. The striated Ovarian vein: Drain into the pampiniform plexus of veins in
muscles may be a pubourethrovaginal continuation of some fibers the broad ligament and may become varicose. The left vein
of pubococcygeus. Smooth muscles have numerous nerve fibers.
Hence, most of the pelvic supporting ligaments have contractile Table 8.1: Arterial supply of pelvic organs
elements under neural control. The urogenital diaphragm is
Organ Artery Origin
almost horizontal when the woman is standing. The urogenital
diaphragm is fixed to the perineal body; this contributes to the Ovary Ovarian Aorta
support of the urethra and vesicourethral junction decreasing the Vein L-Renal Uterine Internal iliac
R-IVC
tendency of these structures to rotate around the attachment of
Fallopian Ovarian Aorta
the pubourethrovaginal ligament to the pubis. tube Uterine internal iliac
Arcus Tendinei are two in number one on each side of the pelvis. Ovarian Aorta
Levator ani’s arcus tendineus runs from the back of the pubis Vagina Vaginal Internal iliac
to the ischial spine. Medially is the arcus tendineus of the Uterine
Internal pudendal
endopelvic connective tissue. The former provides a soft tissue
Middle rectal
attachment for the connective tissue bundle of fibers attached Vulva Internal pudendal Internal iliac
to the anterior vaginal sulcus. External pudendal Femoral
Pelvic diaphragm: Is formed by the levator ani muscle along with Ureter Renal Aorta
Ovarian Aorta
its superior and inferior fascial coverings. It is derived from the fourth
Uterine Internal iliac
sacral myotome. It was used to wag the tail in animals. In the upright Superior vesical Internal iliac
human being, it mostly supports the pelvic organs and helps in Inferior vesical Internal iliac
bladder and rectal continence. Bladder Superior vesical Internal iliac
It originates from the pelvic surface of the pubic bone, Inferior vesical Internal iliac
the ischial spines and the arcus tendinae. Converging in the Urethra Inferior vesical Internal iliac
midline, it can be divided into the puborectalis (most medial, Internal pudendal Internal iliac
encircling and supporting and forming additional sphincters Sigmoid colon Left colic Inferior mesenteric
Rectum Superior rectal Inferior mesenteric
to the rectum and the vagina), the pubococcygeus (the most
Middle rectal Internal iliac
important and strongest part stretching from pubis to the coccyx) Inferior rectal Internal pudendal
and iliococcygeus (the posterior-most, getting attached to the (internal iliac)
coccyx).
43
 drains into the left renal vein and right vein discharges into ovarian artery. The uterine branches goes circumferentially
inferior vena cava like respective arteries. around the myometrium providing coiled radial branches
Inferior mesenteric branch: Originated from the abdominal ending as basal arteries to supply the endometrium.
aorta. It descends in front of the aorta and then deviates to the The internal pudendal artery—one of the two terminal
left. En route it crosses the left common iliac artery median to branches of internal iliac artery traverses the pudendal canal
the left ureter and then into the mesentry of the sigmoid colon. with the pudendal nerve and divides into branches. Its rectal
It can be injured during para-aortic lymph node dissection. branch supplies skin and muscles of anus and anastomoses with
Along the way it gives a left colic branch supplying the left half the superior and middle rectal arteries, the perineal branch
of the transverse colon and the descending colon and then supplies the perineum and small tributaries (posterior labial
continues as the superior rectal artery nourishing the upper arteries) supply the labia, vestibular bulbs and the vagina. It
rectum and anastomosing with the middle and the inferior ractal terminates as the dorsal artery of the clitoris. The inferior gluteal
branches. artery is the larger terminal branch of the internal iliac artery. It
Anatomy and Physiology

Middle sacral artery is a branch of abdominal aorta. supplies buttock and back of thigh.
The two common iliac arteries have length of about 4-5 cm
Nerve Supply to Pelvis (Table 8.2)
divide into the internal and external iliac branches in front of
the corresponding sacroiliac joint behind the ureter. The artery It is both autonomic and somatic.
on the right is slightly longer, running in front, the left artery Autonomic nerve supply: Only the ovaries and fallopian tubes
passes partly lateral and partly in front of the corresponding are supplied directly by the nerves from the preaortic plexus
vein. It has no branch. traveling along the ovarian vessels. The pelvic plexuses supply
Two external iliac arteries run on the medial border of the all other internal pelvic organs.
psoas major and reach behind the midpoint of the inguinal
ligament to continue as the femoral artery lateral to the femoral Autonomous Nerve Supply
vein and median to femoral nerve (VAN from medial to lateral). Both sympathetic and parasympathetic innervations are seen.
Round ligament and ovarian vessels cross in front of the artery Sympathetic branches from the lower part of lumbar
on both sides. sympathetic trunk join the aortic plexus and ganglia, over the
It has two main branches. The inferior epigastric artery runs bifurfcation of aortra. They form superior hypogastric plexus.
Section 2

obliquely along the deep inguinal ring; after going through the This divides into right and left inferior hypogastric plexus near
transverse fascia it runs up the rectus abdominis muscle supply rectum and redivides into anterior columnar (innervating of
branches to the muscles and the skin above. It finally bladder and urethra) and posterior column (innervating uterus,
anastomoses with the superior epigastic artery above the level cervix, vagina, sigmoid colon and rectum).
of the umbilicus. The second branch is the deep circumflex Parasympathetic nerves are from the second, third and fourth
artery, which supplies the transverse abdominal and internal sacral nerves. These preganglionic fibers go to the pelvic plexus
oblique muscles. and parasympathetic ganglion which are located close to the
The continuation of external iliac artery is the femoral artery wall of the viscera to be supplied.
which gives superficial epigastric artery, superficial circumflex
iliac artery, inguinal arteries and the external pudendal artery, Somatic nerves: Anterior primary rami of the first three lumbar
which supplies the skin of the vulva and anastomoses with the and part of the fourth lumbar nerve with some fibers of 12th
internal pudendal artery. thoracic (subcostal) nerve form the lumbar plexus. This plexus
lies on the surface of the psoas major and its major branches
Internal iliac (Hypogastric) artery: Divides into the anterior supply the pelvic organs.
and posterior divisions at the greater sciatic foramen. (Its total The iliohypogastric nerve supplies the buttocks. The
length is around 4 cm. Its length is 8 cm in the fetus but after ilioinguinal nerve innervates the skin of the mons and
delivery the abdominal 4 cm forms the lateral umbilical surrounding vulva. Both arise from the first lumbar nerve. From
ligament). The ureter is anterior and the internal iliac vein is the first and the second lumbar nerves arise the genitofemoral
behind the artery. The posterior division has 3 branches nerve; its genital branch supplies the skin of the labia majus.
iliolumbar, lateral sacral and superior gluteal. They all supply The lateral cutaneous nerve originates from second and third
muscles of the buttocks. lumbar nerve and supplies the thigh. The femoral nerve, arises
The anterior division has seven branches in addition to
parietal branches. The superior vesical supplies the upper part
of bladder. The obturator branch gives the iliac, vesical and
pelvic branches. The vaginal artery (analog to the inferior vesical Table 8.2: Nerve supply
artery of the male) supplies the upper vagina, the base of the Nerve Spinal segment Innervation
bladder and the rectum. After anastomosing with branches of
Ilioinguinal L1 Sensory-Mons, Labia majora
the uterine artery it forms two median longitudinal azygos
Genitofemoral L1,L2 Sensory-anterior vulva
arteries of the vagina one in front and one behind. The middle (genital branch)
rectal artery gives blood supply to the lower rectal muscles and Posterior S2,S3 Sensory-vulva,
anastomoses with the superior rectal (from inferior mesenteric femoral perineum
artery) and the inferior rectal (from the internal iliac artery) cutaneous
arteries. Pudendal S2,S3, S4 Sensory-perianal skin vulva
The uterine artery is 2 cm from cervix and it crosses the and perineum, clitoris,
ureter and runs (tortuously, to accommodate increased uterine urethra, vaginal vestibule
motor-ext.
size in pregnancy) to the margin of the uterus between the layers
anal sphincter, perineal
of broad ligament and gives branches. These supply the cervix, muscles, urogenital
and the body of uterus, part of urinary bladder and one branch diaphragm.
44 goes to the vaginal artery. At the end it anastomoses with the
from the second, third and fourth lumbar nerve; it is the largest Table 8.3: Lymphatic drainage
branch of the lumbar plexus. The obturator nerve also originates
from the second, third, and fourth lumbar nerves. They both Nodes Primary afferent connections
supply muscles of the hip. The lumbosacral trunks arise from Aortic/para-aortic Ovary, fallopian tube, uterine
fourth and fifth lumbar nerves. The anterior rami of the first corpus (upper) drainage from
three sacral nerves join this trunk and form the sacral plexus in common iliac nodes
front of pyriformis muscles. The major branch is the sciatic Common iliac Drainage from external and internal
nerve. The second branch is the pudendal nerve formed by iliac nodes.
second, third and fourth sacral nerves. At the ischial spine it re- External iliac Upper vagina cervix, uterine corpus
(upper) drainage from inguinal
enters the pelvis through the lesser sciatic foramen with the
nodes.
internal pudendal artery laterally. It lies in the pudendal canal Internal iliac
on the lateral wall of the ischiorectal fossa. A pudendal block Lateral sacral

Chapter 8
is given using a local anesthetic at the point where the nerve Superior gluteal
curls around the ischial spine. The nerve gives three terminal Inferior gluteal
branches. The inferior rectal nerve supplies motor and sensory Obturator
fibers to the external anal sphincter and anal canal and the skin Vesical
around the anus. The perineal nerve divides into the medial Rectal
Parauterine
and lateral posterior labial and supplies the skin of the labia
Inguinal
majora and muscular branches to the anal sphincter and the

Surgical Anatomy of Female Genital Tract

Superficial Vulva, lower vagina, (rare:
levator ani, bulbospongiosus, corpus spongiosum and the DEEP uterus, tube ovary)
urethra. The third branch is the dorsal nerve of the clitoris passing
through the pudendal canal and supplying the crura of the clitoris
The external iliac lymph nodes lie on the corresponding vessels
and the surrounding tissue.
and form the lateral median and anterior groups. They receive
Lymphatic Drainage of the Female Pelvis (Table 8.3) lymphatics from the cervix, the upper vagina, the bladder, and
the lower abdominal wall and from the inguinal lymph nodes.
The main lymph nodes are placed along the blood vessels. They The inferior epigastric and circumflex iliac nodes are also
are important in radical surgeries of the female reproductive members of this group. The internal iliac nodes placed around
malignancies. the internal iliac vessels drain all the pelvic viscera. The
The superficial femoral (inguinal) nodes form a chain just obturator lymph node in the obturator and the sacral lymph
below the inguinal ligament. The lateral nodes receive nodes (on median and lateral sacral vessels) are members of
lymphatics from the gluteal region and the anterior abdominal internal iliac group.
wall. The medial nodes drain the vulva and perineum, the lower The common iliac lymph nodes are situated on either side of
vagina, the lower anal canal and from the uterus as the lymph the aorta. They receive efferents from the external iliac and the
vessels travelling with the round ligament reach the anterior internal iliac lymph nodes.
abdominal wall. The lymphatics of both sides of the vulva Besides those organs which receive blood supply directly
anastomose freely hence the importance of removing the whole from aorta drain their lymph directly to the para-aortic lymph
of the vulva in cases of malignant disease. nodes, viz. ovary, fallopian tubes, upper ureter and in view of
The deep (inguinal) lymph nodes lie on the median side of arterial anastomoses, uterine fundus. Their efferents together
the femoral vein. Efferents from the nodes of cloquet drain the form the lumbar trunk on both sides; the lumbar trunks
clitoris and some the superficial femoral nodes. Efferents from terminate at the cisterna chyli at the base of the neck.
both the superficial and the deep inguinal lymph nodes drain Primary lymph node groups providing drainage to genital
to the external iliac group in the pelvis. structures.

45
 9 Development of Female Genital Tract

Sudha Salhan, Paramita, SK Sen

The female genitalia consists of: (i) external genitalia (vulva) • The posterior wall of the body cavity, on either side of
which can be visualized from outside (Fig. 9.1) and (ii) internal mesentery, is made up of intraembryonic mesoderm
genitalia (fallopian tubes, uterus, cervix, vaginal canal and (intermediate cell mass).
ovaries) which can only be visualized by use of instruments From the inner cell mass (2 weeks after fertilization)
such as vaginal speculum, laparoscope and hysteroscope and develops the epiblast. It becomes 3 layered. The first layer is
by investigative tools such as ultrasonography and MRI (Refer endoderm forming primitive gut folding at 4 weeks and
chapter 8). differentiates into foregut, midgut and hindgut by 5 weeks.
• By 21st day, after fertilization, the primitive gut is formed From hindgut develops cloaca and at 6 weeks which form
from the endoderm of the embryo. urogenital sinus. This urogenital sinus forms (at 9–12 weeks)
• By 30th day, the gut, complete with its mesentery, is formed. the external genitalia. The urinary bladder develops from it by
The mesentery attaches the gut to the posterior wall of the 10 weeks; and in females, this urogenital sinus forms the lower
body cavity. third of vagina. The second layer is ectoderm — which will
• The body cavity is lined by coelomic epithelium. form skin of external genitalia.
The third layer of gesticulation stage is mesoderm, which
forms proximal mesoderm, intermediate mesoderm and lateral
plate mesoderm at 4 weeks of gestation. Intermediate mesoderm
becomes urogenital ridge (Figs 9.2 A and B).
All organs of genitourinary system, excepting the urinary
bladder, urethra and external genitalia, develop from the
urogenital ridge. The urogenital ridge forms pronephros,
mesonephros, gonads, mesonephric ducts and paramesonephric
ducts. The medial aspect of urogenital ridge develop (Figs 9.3A
and B) into indifferent gonads (6 weeks) and testes or ovaries
(8–10 weeks). Pronephros which regresses by 4 weeks. Then
mesonephros ( olffian ducts) develops between 4 and 8
weeks. Finally metanephros forming the functional kidney by
10–13 weeks. Mesonephric ducts develop in males to form male
rete testis (Figs 9.4A and B).
In female, Wolffian duct (mesonephric duct) system becomes a
vestigial structure. The middle tubules of mesonephros form
Fig. 9.1: The vulva epoophoron and caudal tubules form paroophoron. The Wolffian

Figs 9.2A and B: (A) Formation of urogenital ridge (B) The urogenital ridge
 Chapter 9
Fig. 9.5: Gartner cyst seen in vagina

Development of Female Genital Tract

Figs 9.3A and B: Development of paramesonephric duct and its
relation to mesonephric duct

Fig. 9.6: Showing relation of urinary tract and genital tract

become ovary or testis). Hormonal control is the most important

factor. The active role in differentiation of male gonad is
initiated at 6–7 weeks. The chromosome froms its distal short
arm has the location of a gene called sex-determining region
Figs 9.4A and B: Structures derived from mesonephric duct (SR ). This gene produces testes-determining factor. Two more
(A) in male (B) female genes SO 9 and DA I are also important in activation of sex
in male forms. The chromosome produces testosterone and
duct persists as vestigial tube. But can form artner’s duct (Fig. 9.5) anti- Mullerian hormone (AMH) or Mullerian-inhibiting
at different sites in the course of Wolffian duct passing along the substance or Mullerian-inhibiting factor. Hence, the
uterus and vagina. development of male sex organs (testes) is an active event. But
Paramesonephric ducts (Mullerian ducts) are formed by 8 female sex organ (ovaries) is developed by the default process.
weeks. They develop into fallopian tubes and uterus and form When there is no chromosomes, no SR , no testosterone and
upper part of vagina around 9–16 weeks. no AMH, then ovaries developed at 8–10 weeks (about 2 weeks
The external genitalia develop from urogenital sinus, the later than the testicular development time) (Flow chart 9.1).
anterior part of primitive cloaca. The internal genitalia are • By the 5th week, the coelomic epithelium proli-ferates and
developed from the Mullerian ducts (paramesonephric duct). forms medial thickenings, the urogenital ridges together
Ovaries develop from medial aspect of urogenital ridge. with the underlying mesenchyme on either side of the
The development of female genital tract and that of urinary mesenteric root near the developing kidney.
tract occur in close proximity and simultaneously. Hence, • The ovaries develop from the, medial aspect of the
developmental anomaly of genital tract is very often associated urogenital ridges (Fig. 9.7).
with anomalies of urinary system (Fig. 9.6). This has got • Cephalic ends of the ridges, finally, atrophy and form the
appreciable clinical importance (e.g., ectopic pelvic kidney with infundibulopelvic ligament, the middle portion continues
Mullerian agenesis). to grow as the ovary and the caudal end develops into
ovarian ligament.
Development of Ovary • Around the 25th day, the germ cells appear. These originate
The gonadal ridge develops at 5–6 weeks of gestation on either from the primitive hind gut. These cells will eventually form
side of midline. To begin with, it is potential bigonadal (can the gonads. 47
 Flow chart 9.1: Prepotential gonad differentiation
Anatomy and Physiology
Section 2

• The germ cells then migrate from the gut to the root of the
mesentery.

In males In females
Cells of germinal epithe- Sex cord becomes broken
lium proliferate and form up into small masses
solid sex cords Cells of each mass
Seminiferous tubules surround one primordial
formed by canalization of germ cell or oocyte to form
sex cord primordial follicle

• At this stage, the primitive gonad consists of mesoderm

(coelomic epithelium plus mesenchyme) covered by
coelomic epithelium.
• The coelomic epithelium from the surface grows down into
the genital ridge forming sex cords which enclose each germ
cell.
• The germ cells and most of the sex cord cells remain in the
superficial part, the future cortex of the ovary.
• Subsequently, the cords loose connection with surface
epithelium and form small groups of cells each with its germ
cells, forming primitive follicle.
• Some of the sex cord cells grow into the medulla. These
tend to regress and form rudimentary tubules termed as
rete testis.

Fig. 9.7: Development of testis and ovary

The early stages of development of ovary and testis are

exactly the same.
• Cells of ovary and testis from which germ cells are formed
and believed to be segregated early in the life of embryo.
• They differentiate in the wall of yolk sac which migrate from
the yolk sac to the region of developing gonad along dorsal
mesentery by ameboid movement between 20 and 30 days Fig. 9.8: Migration of primordial germ cells from yolk sac
(Fig. 9.8). to developing gonad
48
• As the ovary grows, it projects increasingly into the
peritoneal (coelomic) cavity, thus forming a mesentery
(mesovarium).
Initially, the ovary develops at the lumbar region. Finally, it
is brought down to its permanent position at the level of above
the pelvic brim at birth by a fibromuscular cord called
gubernaculum (Fig. 9.9 and Flow chart 9.2). This attaches the
ovary to the labia through the ventral abdominal wall. The
gubernaculum pulls the ovary medially, so that its longitudinal
axis finally becomes horizontal. The gubernaculum, during its
course from the ovary, gets attached to the Mullerian duct on
either side and is represented in the adult as follows:

Chapter 9
a. The portion between the ovary and the Mullerian
attachment forms the ovarian ligament.
b. The portion between the Mullerian attachment and the groin
forms the round ligament of the uterus.
Fig. 9.9: Descent of ovary
Development of the Uterus and the Fallopian Tubes

Development of Female Genital Tract

• At 35–36 days, when the embryo reaches size of 10 mm, a
longitudinal groove appears, bilaterally, on the dorsal aspect anteroposteriorly at about its middle. The narrow portion
of the coelomic cavity, lateral to the Wolffian (mensonephric) is the site for the future cervix. Still lower down, the lumen
ridge from invagination of coelomic epithelium. widens and again narrows towards its lower end where
• Later on, the groove becomes sealed off to form a tube, the the canalization of the ducts has not occurred yet (Figs 9.11
paramesonephric or Mullerian duct, from which most of the A and B).
female genital tract develops (Fig. 9.2). • Surrounding the fused paramesonephric ducts, there is
• The tube (duct) is open at its upper end, com-municating condensation of mesoderm which is very much thicker in
with the future peritoneal cavity. This opening ultimately the upper fused portion corresponding to the future body
becomes the fimbrial end of the fallopian tube. of the uterus and the cervix.
• The Mullerian duct, thus formed, grows in a caudal – The uterine cavity is developed from the upper parts
direction from either side, extraperitoneally. of the fused paramesonephric ducts and its muscular
• They also bend medially and anteriorly, cross the Wolffian wall is formed from the cond-ensed mesoderm
duct and finally fuse in front of the hind gut in the midline surrounding it.
during the 8th week (Fig. 9.10) – The upper end of the canal remains bicornuate in the
• The lower end of the fused tubes form a solid tip, which early stages up to the 3rd month, and the fundus is
develops burrowing properties. It ends at the roof of the developed later.
urogenital sinus forming an elevation called the Mullerian – At a later stage, there is further fusion of the upper ends
tubercle.’ of the paramesonephric ducts with considerable
• Initially, there is a septum separating the lumina of the two thickening of the uterine wall. By this upward fusion
paramesonephric ducts. Later on, the septum disappears and thickening of the surrounding mesoderm, the
and a single cavity (uterovaginal canal) is formed. The fusion fundus assumes its convexity. The primitive muscle cells
first occurs in the middle, corresponding to the site of the are arranged irregularly around blood vessels and the
future external os of cervix; and from there extends upwards muscle fibers are formed in the 5th month. The
and downwards. The lumen is transverse in the upper part fibromuscular tissue is formed from the condensed
and then becomes smaller and is very much narrowed mesoderm.

Flow chart 9.2: Descent of gonads

49
 the cervix is separated from the vagina by the formation
of rudimentary anterior and posterior fornices. Part of
the cervix (portio vaginalis) thus comes to lie in the
vaginal canal.
– The muscle cells are very irregularly arranged and thus
the muscle fibers, which appear later in the
development, do not show any pattern of arrangement.
– The cervical glands begin to appear at about the same
time as the formation of the epithelial shelves.
– By 10th week, cervix can be differentiated from the
uterine body.
Anatomy and Physiology

Fallopian Tube
Fig. 9.10: Development of uterus and fallopian tubes • The upper unfused parts of both Mullerian ducts retain their
identity and form the fallopian tubes.
– At the cranial end of the ducts, fimbriae begin to appear
towards the end of the second month (Fig. 9.12).
– Condensation of the mesoderm, in the process of the
development of the fundus, encloses the adjacent
portion of the caudal end of unfused Mullerian duct
and thus a small part of the fallopian tube (interstitial)
is situated within the uterine wall.
– Muscular layer of the fallopian tubes is formed from
the surrounding mesoderm. The circular muscular coat
appears early and the formation of longitudinal
muscular coat, occurs later on.
Section 2

– The lumen of the tube is lined by a single layer of

columnar cells, mucosal folds begin to appear in the

Figs 9.11A and B: Formation of uterus and follopian tube

– The development of the folds of mucous membrane and

of the uterine glands occurs at about the 6th month. The
glands in the region of the fundus appear still later and
continue to develop till after birth.
• Cervix: It is developed from the caudal end of the fused
paramesonephric ducts.
– A shelf-like growth of cells lining the paramesonephric
ducts into the surrounding mesoderm occurs and thus, Fig. 9.12: Development of fallopian tubes

Figs 9.13A and B: Formation of vagina (a) Solid caudal tip of Mullerian duct projects into urogenital sinus (b) Solid envaginations from urogenital
sinus (c) Proliferation of endodermal cells to form solid vaginal plate (d) Canalization begins from caudal end (11 wk) (B) Development of
50 female internal genital organ in relation to urinary system
 4th month and become very numerous in the 5th month External genital organ develops almost simultaneously with
(Figs 9.13 A and B). development of internal genital organs.
Development of vagina: The development of vagina is The part of hindgut caudal to the attachment of the allantoic
complex. diverticulum is called the cloaca.
– Vagina is formed from vaginal plate by 4th month. Cloaca shows subdivision broad ventral part—primitive
Bilateral invaginations from the urogenital sinus urogenital sinus—(UGS system) and a narrow dorsal part—
(sinovaginal bulbs) grow upwards lower end. These primitive rectum—rectum anal canal. These two parts are
along with the Mullerian tube’s form vaginal plate. segregated by formation of urorectal septum (Fig. 9.14).
– Canalization occurs starting from caudal end by 11 Urorectal septum consisting of mesoderm grows down
weeks. Vaginal plate is completely canalized by 20 between the allantois and the hind gut during the 5th week.
weeks. This urorectal septum grows towards cloacal membrane and
Hymen is derived from junction of sinovaginal bulbs and eventually fuses with it to form primitive perineal body (Fig.

Chapter 9
urogenital sinus. 9.15A).
Vagina is lined by endoderm of sinovaginal bulbs • Eventually, the urorectal septum fuses with the cloacal
Muscle wall derived from mesoderm of Mullerian ducts. membrane dividing the cloaca, in the coronal plane, into
The central cells disintegrate and the peripheral cells persist two compartments: (i) urogenital sinus ventrally and (ii)
as hymen (Flow charts 9.3 and 9.4). anorectal canal dorsally (Fig. 9.15B).
• Simultaneously, the cloacal membrane also gets divided into
Development of External Genitalia of Female (i) urogenital membrane anteriorly and (ii) anal membrane

Development of Female Genital Tract

Initially, the external genitalia are in an undifferentiated stage. posteriorly (Fig. 9.15C).
Male and female external genitalia can be distinguished by 12th • During this time, the developing uterus grows down and
week of fetal age. makes contact with the urogenital sinus. The developing
• The external genitalia develop in the area bound above by uterus and vagina further push downwards and cause an
the body stalk and below by the tail of the embryo. elongation and narrowing of the upper part of the urogenital
• At an early stage, the hind gut and various urogenital ducts sinus. This will form the future urethra.
open into a common cloaca. This is covered below by a • At the end of the 7th week, the urogenital membrane breaks
membrane known as cloacal membrane having outer down so that the urogenital sinus opens to the surface. This
ectodermal and inner endodermal layers. will form the vestibule. The roof of the urogenital sinus is

Flow chart 9.3: Development of male urogenital system

51
 Flow chart 9.4: Development of female urogenital system
Anatomy and Physiology
Section 2

thus exposed with attached mesonephric and Mullerian a. At the cephalic end, a midline swelling grows, the
ducts. genital tubercle, this will become the clitoris (Figs 9.16A
• Subsequently, the anal membrane also breaks down to open and B).
into the anal pit by 8th week, thus forming the anus. b. Posterior to the genital tubercle and on either side of
• During the 5th week, five mesodermal elevations or swellings the urogenital membrane, a pair of swelling known as
appear on the surface of the embryo around the urogenital sinus, urethral folds or inner genital folds. This will form labia
ventral to the urogenital membrane: minora (labia minus).
c. Lateral to each of the labia folds, another pair of swelling
appears. This is termed labial swelling or outer genital
swelling. This will form labia majora (labia majus).
These labia swellings sweep backwards, approach each
other at their posterior ends, in the midline and, finally,
fuse and form the posterior commissure.
In female, absence of androgen keeps the labio-scrotal
swelling separate.
• The vestibule is formed on breaking down of the urogenital
membrane.
• Certain small but clinically important glands are formed in
and around the urogenital sinus.
a. In the embryo epithelial buds arise from the urethra
and also from the epithelium of the urogenital sinus.
Fig 9.14: Development of female internal genital
(In the male, these two sets of buds grow together and
52 organ in relation to urinary system
 Chapter 9
Development of Female Genital Tract
Figs 9.15A to C: Formation of urorectal septum

Bartholin’s glands. Their ducts open at the vaginal orifice

at the junction of hymen and labia minus near its
posterior end.
c. Similar multiple smaller glands also arise in the anterior
portion of the vestibule from budding of its epithelium.
These are lesser vestibular glands.
Till 7th week, exterior of both sexes looks the same. After 7
weeks, in male, testes secrete androgen (testosterone). Androgen
acts on external genitalia and labioscrotal swelling unites to
form scrotum and urogenital fold and phallus form the penis
and urethera (Fig. 9.17).
The development of female genital tract is summarized in
Table 9.1.
Fate of paramesonephric duct in male and female (Figs 9.18
A and B). In males regresses and remnants form appendix of
testis and prostatic utricle.
Fate of Mesonephric duct in Males
1. Ureteric bud (Figs 9.19 A and B)
2. Trigone of bladder
3. Posterior wall of part of prostatic urethra
4. Epididymis
5. Seminal vesicles
6. Ductus deferens
7. Ejaculatory ducts
8. Mesodermal part of prostate
9. Appendix of epididymis.
Development of Kidney
Development of kidney is from two sources nephrons-derived
Figs 9.16A and B: Formation of female external genitalia from metanephros. Collective part is derived from ureteric bud
(from lower part of mesonephric duct (Fig. 9.6).
give rise to the glands of the prostate). They remain
separate in the female. The urethral buds form the Development of Urinary Bladder
urethral glands and the urogenital buds give rise to It is derived from cranial part of primitive urogenital sinus (i.e.
paraurethral glands of Skenes. The ducts of the latter vesicourethral canal).
open into the vestibule on either side of the urethra. The urethra developed from part of vesicourethral canal
b. Two other small glands arise by budding from the (Figs 9.20 and 9.21) and from urogenital sinus.
posterior part of the vestibule, on either side of the
vaginal introitus. These are the greater vestibular or
The summary of female genital tract is given in Table 9.1 53
and Flow chart 9.5.
Anatomy and Physiology

Figs 9.19A and B: (A) Mesonephric duct, early stage; (B) Rate of
Fig. 9.17: Differentiation of female and male external genitalia mesonephric duct in the male, before descent of the testis

Table .1: Shows comparative parts of genital tracts

Section 2

Structures Genital tubercle ale Penis Female Clitoris

Urogenital folds Ventral part of penis Labia minora
Labioscrotal swelling Scrotum Labia majora
Urogenital sinus • Urinary bladder • Urinary bladder
• Urethra • Urethral and paraurethral gland
• Prostate • Vagina (lower 1/5th )
• Prostatic utricle • Bartholin gland
• Bulbo urethral gland
Mesonephric duct • Ureteric bud • Ureteric bud
• Epididymis • Epoophoron
• Ductus deferens • Paraoophoron
• Seminal (vesicle) • Gartner’s duct.
• Ejaculatory duct
• Mesodermal part of prostate
• Appendix of epididymis
Para mesonephric duct • Appendix of testis • Fallopian tube
• Prostatic utricle • Uterus
• Cervix
• Vagina (upper 3/5th )

54 Figs 9.18A and B: Fate of paramesonephric duct in female and male

 Chapter 9
Fig. 9.20: Development of urinary bladder Fig. 9.21: Development of urethra

Flow chart 9.5: Summary of development of female genital tract

Development of Female Genital Tract

BIBLIOGRAPHY 2. Speroff, Fritz MA. Normal and abnormal sexual development. In

1. Mathew M Garrey, ADT Govan, CH Hodge, Robin Callander. Clinical Gynaecologic Endocrinology and Infertility, Seventh
Gynaecology Illustrated. Churchill Livingstone, Edinburgh, Edition. Lippincott Williams Wilkins; 2006.p.319.
London and New ork, 1st Edn, 1972.

55
 10 Physiology of Menstruation

Pikee Saxena, B Minocha

DEFINITION downregulates the secretion of FSH. Estrogen levels peak

Menstruation is the monthly bleeding from the uterus which towards the end of the follicular phase of the menstrual cycle.
comes out through the vagina for 4–7 days every 28–32 days At this critical moment, estrogen exerts positive feedback on
during the reproductive life of a woman, with an average loss LH, generating a dramatic preovulatory LH surge.
of about 20–60 ml of blood. It has been observed that This LH surge is re uired for ovulation. Under the
about two-thirds of adult women have menstrual cycle lasting influence of LH, the primary oocyte enters the final stage of the
from 21–35 days. The normal menstrual cycle is a tightly first meiotic division and divides into a secondary oocyte and
coordinated cycle of stimulatory and inhibitory effects that the first polar body.
result in the release of a single mature oocyte from a pool of After ovulation, the empty follicle is termed corpus luteum,
hundreds of thousands of primordial oocytes. A variety of (Fig. 8.15A) which produces high levels of progesterone with
factors contribute to the regulation of this process including smaller amounts of estrogen secretion. High progesterone levels
hormones and paracrine and autocrine factors that are still being exert negative feedback on GnRH and subsequently GnRH
identified. pulse frequency decreases. This leads to a fall in FSH and LH
For better understanding, physiology of menstruation, levels. In the absence of fertilization, corpus luteum
which is regulated by complex neurohormonal pathways, can degenerates to form corpus albicans (Fig. 8.16) resulting in a
be divided into endocrine, ovarian and uterine cycles. decline in both estrogen and progesterone levels. This fall in
the estrogen and progesterone concentration is accompanied
THE ENDOCRINE CYCLE by menstruation.
The female menstrual cycle is determined by a complex After withdrawal bleeding, the early events of the follicular
interaction of hormones. The predominant hormones involved phase are initiated by a rise in FSH levels at the first day of the
in the menstrual cycle are gonadotropin-releasing hormone cycle which occurs due to a decrease in progesterone and
(GnRH), gonadotropin hormones viz. follicle-stimulating estrogen levels at the end of the previous cycle and the
hormone (FSH) and luteinizing hormone (LH), estrogen, and subsequent removal of inhibition of FSH by these ovarian
progesterone. hormones.
GnRh is secreted in pulses by the hypothalamus. FSH and The rhythm of the menstrual cycle depends on the
LH (gonadotropins) are secreted by the anterior lobe of the hypothalamic-pituitary-ovarian axis, whereas the amount of
pituitary gland, and estrogen and progestin are secreted at the blood loss is dependent on the condition of the uterus.
level of the ovary. GnRh stimulates the release of LH and FSH
from the anterior pituitary, which in turn, stimulate release of Hormonal Regulation
estrogen and progestin at the level of the ovary. Hypothalamus
LH induces androgen synthesis by theca cells. This Gonadotropin-releasing hormone (GnRH), a neurohormone, is
androgen is transferred into granulosa cells; and under the a decapeptide secreted by the peptidergic neurons in the median
influence of FSH, this androgen is converted into estrogens by eminence and arcuate nucleus in the hypothalamus and
activation of aromatase and p450 enzymes. In patients with delivered to the anterior pituitary by the portal vessels. As
excessive androgen production, normal follicular growth is mentioned above, it is secreted in a pulsatile manner.
inhibited and the result is polycystic ovarian syndrome
characterized by irregular cycles, hyperandrogenism and Pituitary
infertility. LH stimulates proliferation, differentiation, and The gonadotropins, FSH and LH are produced by the anterior
release of follicular theca cells; and increases LH receptors on pituitary cells. Anterior pituitary has two types of secretory cells,
granulosa cells. acidophilic and basophilic cells (based on hematoxylin and eosin
FSH facilitates the development of 1 2 follicles every stains). Gonadotropins are secreted by the basophilic cells. Both
month (Fig. 8.14). FSH secretion is the highest and the most the gonadotropins are glycoproteins.
critical during the first week of follicular stage of menstrual
Ovary
cycle.
It stimulates estradiol secretion by upregulating secretion Ovarian function occurs in a cyclical manner and has two
of androgens by the theca externa and by inducing the phases—the follicular proliferative phase and the secretory
aromatase enzyme receptors on granulosa cells. FSH further luteal phase. Sex hormones like estrogen, progesterone, some
induces expression of FSH receptors by follicles. As estradiol amount of androgens and peptides like inhibin and activin
levels increase under the influence of FSH, estradiol are released from the ovary and are responsible for normal
menstruation.
 or columnar granulosa cells. ona pellucida is a thick layer
composed of glycoproteins and acid proteoglycans which is
present between the oocyte and granulosa cells.
As the follicle develops from a primordial follicle into a
primary unilaminar follicle, the primary oocyte completes its
growth. At this stage of development, the stromal cells
surrounding the follicle, also become more prominent. For an
oocyte to grow properly, it must be surrounded by a layer of
granulosa cells. ap junctions are present between the oocyte
and surrounding granulosa cells. Transportation of amino acids,
nucleotides, and lipid precursors into the oocyte takes place
Uterus from these gap junctions. Growth factors such as kit-ligand and

Chapter 10
The uterine cycle has two phases—the proliferative phase and the GDF-9 are also required for oocyte growth.
secretory phase. This cycle is dependent on the ovarian hormones. Once oocyte growth is completed, the granulosa cells
proliferate to form multiple layers. The follicle at this stage is
OVARIAN CYCLE known as a primary multilaminar follicle. This step of follicular
At birth, there are about 2 million primordial follicles in the development is dependent upon FSH. FSH induces proliferation
ovary; and by puberty, these decrease to about 300,000 in of granulosa cells and increases the number of FSH receptors
number due to spontaneous degeneration of follicles. In the on each granulosa cell, thus accentuating its own effects. The

Physiology of Menstruation
reproductive life, about 400 follicles ovulate; and by menopause, theca cells surrounding the follicle differentiate into two
the ovary will have dense stromal tissue with only afew follicles layers—the theca interna and the theca externa. It is currently
remaining. held that LH drives differentiation of theca cells.
The primary multilaminar follicle develops further to form
Follicular Phase the raafian follicle (Fig. 10.1). The Graafian follicle is
Folliculogenesis characterized by a large, fluid-filled antrum, and an eccentric
After the onset of puberty, between 15 and 20 primordial follicles oocyte. The granulosa cells can also be divided into two
develop into primary follicles with each ovarian cycle. The groups—the zona granulosa which is a thin layer along the
follicular phase of the menstrual cycle starts from the first day periphery of the follicle and the corona radiata which surrounds
of menstruation until ovulation. The primary goal during the the oocyte. The oocyte undergoes the first meiotic division,
follicular phase is to develop a viable follicle capable of giving rise to a secondary oocyte and the first polar body. The
undergoing ovulation. In the beginning, the primary follicle secondary oocyte is now arrested in metaphase of the second
consists of a primary oocyte surrounded by a layer of cuboidal meiotic division and remains like that until fertilization.

Fig. 10.1: Follicular Place of ovulation 57

 As mentioned earlier, the first meiotic division appears to Late Follicular Phase
be initiated by LH acting on granulosa cells, although the exact There is a gradual rise in LH; and this increased level along
mechanism of action is not known. It has been postulated that with the local estrogen production in the follicle, influence the
high cAMP levels inhibit meiosis of the oocyte. In the absence granulosa cells to produce some progesterone. Sufficient
of LH, cAMP is transported from the granulosa cells into the estrogen level induces an LH surge which itself causes a drop
oocyte. It is theorized that LH blocks cAMP transport into the in estrogen level. The peak estrogen level is seen 48 hours before
oocyte, thus removing inhibition of meiosis and allowing ovulation and LH peak occurs about 24–36 hours before
meiosis to proceed. Oocytes also undergo cytoplasmic ovulation. With one follicle becoming dominant, atresia starts
maturation, a series of changes in protein synthesis and in the rest of the unsuccessful primordial follicles.
structure which prepares the oocytes for embryogenesis in the With the LH surge, progesterone level continues to rise and
event of fertilization. The Graafian follicle represents the final this has a negative feedback on FSH, though inhibin which has
stage of follicular development before ovulation. a negative feedback on FSH, has no such effect on LH. The fall
Anatomy and Physiology

LH surge is re uired for ovulation: Shortly before in FSH brings about a reduction in the level of inhibin and a
ovulation, the follicle swells and develops a stigma (weak- rise in the peptide activin of preovulatory follicle (Graafian
projected point) at the periphery of the ovary. At ovulation, the follicle).
stigma ruptures, releasing the secondary oocyte and corona
radiata into the peritoneal cavity to be taken up by the fallopian Ovulation
tube. The zona granulosa and theca cells remain in the ovary There is a perforation in the weak elevated follicular wall and a
and develop into the corpus luteum. The corpus luteum slow release of oocyte occurs along with the follicular fluid.
produces progesterone and, in the event of fertilization,
Luteal Phase
provides the required progesterone until the placenta is
functional. With the release of oocyte, the follicle is now known as corpus
In the absence of fertilization, the life span of corpus luteum luteum (Latin: ellow body). It derives its name from a yellow
is 14 days. If fertilization and subsequent implantation of pigment, which starts collecting in the preovulatory stage.
blastocyst does not occur, the corpus luteum undergoes Luteal phase starts from ovulation and lasts for 14 days. In this
apoptosis; and after several months, becomes the corpus phase, the progesterone level rises as androgen production
Section 2

albicans, a white scar. occurs in the theca cells of the unsuccessful follicle, which are
Under normal circumstances, one follicle evolves into the nearing atresia; and these androgens get aromatized by the
dominant follicle, destined for ovulation, while the remaining granulosa cells in the follicles to progesterone. Some amount
follicles undergo atresia. It is currently not known how the of inhibin is also released. Rise in progesterone and estrogen
dominant follicle is selected; yet, it has been observed that the brings about the secretory phase of the endometrium. Corpus
dominant follicle always expresses an abundance of FSH luteum (CL) remains mature from 19 to 26 days. The mechanism
receptors. of degeneration of CL is not known till now. This results in fall
of progesterone and estrogen and menstruation takes place. Fall
Folliculogenesis in these two hormones and also of inhibin results in a positive
Early Follicular Phase feedback mechanism and triggers the hypothalamus to release
GnRH for the follicular phase of the next menstrual cycle.
The folliculogenesis starts as menstruation is ceasing and the
level of both the gonadotropins (FSH and LH) is low. FSH UTERINE CYCLE
controls follicular differentiation and growth.
Cyclical changes in the endometrium prepare the endometrium
The primordial follicle consists of an oocyte and a single-
for implantation, in case of fertilization. However, menstruation
layered spindle-shaped cells known as granulosa cells. As
starts in the absence of fertilization. The endometrium is divided
follicles mature, the size of the oocyte increases and the shape
into two layers. The upper functionalis layer undergoes
of the ganulosa cells change to cuboids. With the multiplication
changes throughout the menstrual cycle and is shed during
of cuboidal granulosa cells, the primordial follicle becomes a
menstruation, while the lower basalis layer remains constant
primary follicle. In the primary follicle, the granulosa cells are
during the menstrual cycle; and froms it regenerates the
separated by a basement membrane from the stromal cells
functionalis layer each month. The uterine endometrial cycle
which differentiate into theca cells. As the follicle grows, a fluid-
can be divided into three phases—proliferative, secretory and
filled cavity appears inside which contains two peptides—
menstrual phases.
inhibin and activin.
The proliferation starts from the end of menstruation until
Both FSH and local estrogen influence the proliferation of
ovulation. Increasing levels of estrogen induce the proliferation
granulosa cells, which increase the estrogen production. This
of functionalis from stem cells of basalis. There is proliferation
brings about the proli-ferative change in the endometrium.
of endometrial glands and stromal connective tissue.
By the fifth day, the FSH level reaches its peak and selection
Endometrial glands are elongated with narrow lumens and their
of dominant follicle is decided by day 5 to 7. By day 7, the
epithelial cells contain some glycogen. Glycogen, however, is
estrogen level starts rising. The rise in FSH causes a rise in
not secreted during the follicular phase. Spiral arteries elongate
inhibin and this by itself suppresses the FSH. This rise in
and span the length of endometrium (Figs 10.2 and 10.3).
estrogen and inhibin production helps in growth and
The secretory phase begins (Fig. 10.4) at ovulation and lasts
maturation of the dominant follicle.
(Figs 10.5 and 10.6) until the menstrual phase of next cycle. At
Midfollicular Phase the beginning of luteal phase, progesterone induces the
endometrial glands to secrete glycogen, mucus, and other
In this phase, the increased level of estrogen and inhibin brings
substances. These glands become tortuous and have large
about negative feedback on pituitary FSH and a positive
lumens due to increased secretory activity. The spiral arteries
feedback on pituitary LH.
extend into the superficial layer of endometrium.
58
 Chapter 10
Fig. 10.2: Proliferative endometrium (Dr Yadav, RML Hospital) Fig. 10.5: Late secretory endometrium (Dr Yadav, RML Hospital)

Physiology of Menstruation
Fig. 10.3: Proliferative endometrium (Dr Yadav, RML Hospital) Fig. 10.6: Late secretory endometrium (Dr Yadav, RML Hospital)

progesterone levels decrease, the endometrium undergoes

involution.

Uterine Endometrial Cycle (Timing in Table 10.1)

a. Proliferative or follicular phase: Estradiol (from the ovarian
follicles) causes proliferative change in the uterine
endometrium (day 7–14). All the endometrial tissues
become thick.
b. Secretory or luteal phase: Progesterone (from the corpus
luteum) causes secretory changes in the endometrium (day
15–26) to receive fertilized ovum for embedding.
The overview of the menstrual cycle is given in (Fig. 10.7).

Ovulation and Fertilization

Timing of ovulation is very important for successful conception.
Fig. 10.4: Early secretory endometrium (Dr Yadav, RML Hospital)
The fertile period starts about 4–5 days before ovulation, and
ends about 24–48 hours after it. This is because the lifespan of a
In the absence of fertilization by the day 23 of the menstrual sperm is approximately 3–4 days, and of the egg is viable for
cycle, the corpus luteum begins to degenerate and consequently
ovarian hormone levels decrease.
The menstrual phase begins as the spiral arteries rupture Table 1 .1: Showing events at different parts of the cycle
secondary to ischemia, releasing blood into the uterine cavity,
and the apoptosed endometrium is sloughed off. This usually ime interval of events
lasts for 3 to 5 days. During this period, the functionalis layer Events Days
of endometrium is completely shed. Arterial and venous blood, Estrogen secretion 7 – 14
remnants of endometrial stroma and glands, are present in the Onset of LH surge 12 – 15
menstrual flow. Bleeding occurs as capillary bleeding and Estrogen peak 11 – 14
venous hemorrhage and is caused by withdrawl of estrogen LH peak 12 – 15
and progesterone support to endometrium. As estrogen and Progesterone rise 15 – 26
59
 Ovulation calendar can be used to depict the most favorable
days for conception. It performs all the necessary calculations
automatically by taking into account the time of ovulation, the
lifespan of the egg and sperm. The days of fertile period are
highlighted automatically. These software packages are
available free on internet.
The sperm has to travel through the vagina, the cervix and
then across the length of uterus before reaching the fallopian
tube. Once there, the successful sperm swims towards the oocyte
in order to fertilize it. The sperm usually fertilizes the egg in
the ampullary region of fallopian tube.
Ovulation can be determined by
Anatomy and Physiology

• Basal body temperature It can be used to assess timing of

ovulation as rise in temperature occurs in luteal phase by
0.7– 0.8° due to rise in progesterone levels.
• ervical mucus Rising serum estradiol concen-trations
results in gradual thickening of the uterine endometrium
and an increase in the amount and stringiness
(Spinnbarkeit) of the cervical mucus (See Fig. 53.3). Many
women are able to detect this change in mucus character.
Studies of cervical mucus samples during the menstrual
cycle demonstrate a late follicular-phase peak in the mucin
protein MUC5B that may be important for sperm transit to
the uterus.
• L surge There is a close relation of follicular rupture and
oocyte release to the LH surge. As a result, measurements
Section 2

of serum or urine LH can be used to estimate the time of

ovulation in infertile women. Nowadays, do-it-yourself kits
Fig. 10.7: Overview of menstrual cycle
are available to know the LH surge in urine examination.
• Serial ultrasound monitoring of the developing follicle also
determines the time of ovulation.
24–48 hours after being released. Maximum fertility is reached
during the period of 24 hours before ovulation and 24 hours BIBLIOGRAPHY
afterwards. To increase chances of conception, intercourse
1. Granot, Dekel N. The ovarian gay junction protein cennexin 43:
should occur during this fertile window.’ At ovulation, the regulation by gonadotropins. Trends Endocrinol Metab 2002;13:310.
fimbriae at the end of the fallopian tube move over the ovary to 2. Greisen S, ladet T, Ovesen P. Effects of androstenedione, insulin
receive the released egg. (But sometimes ovulation can be and LH on steroidogenesis in human granulosa. Luteal cells. Hum
induced by coitus). Reprod 2001;16:2061.

60
 Section 3 Endocrinology in Gynecology

11 Pediatric Gynecology

Sudha Salhan

The period from newborn to puberty encompasses pediatric normal. All these are due to maternal estrogen. This effect,
gynecology. Though these patients are infrequent, they form too, will decrease with time.
an important group needing special care. Some findings in the 3. Hymen: It may be congested or bulging. The mucus
newborn baby may be due to maternal hormones circulating in produced (under the effect of mother’s estrogen) cannot
her blood. As the child grows, there are fewer visits to the come out because of thick or imperforate hymen. If the
gynecologist till slightly before menarche. The obstetrician mucocele is causing retention of urine or stool, the
needs to be extra sensitive to this group. Proper communication Obstruction can be removed by making operating on the
skills and extreme gentleness are warranted. imperforate hymen or thick transverse vaginal septum
At delivery, the external genitalia of the baby under anesthesia. Otherwise, it will resolve by itself in due
(Fig. 11.1) must be examined in detail by the Obstetrician who course of time.
delivered her mother. Examine the labia and look for any 4. Vaginal bleeding: Spotting or bleeding may be seen for a
bleeding from the vagina. Hymen may be sieve-like, few days to a week after delivery.
imperforate, or may be bulging (mucocele). Inform the mother The fetal endometrium is stimulated by maternal
and other relatives about these being normal, to allay their estrogen. Once the estrogen effect disappears (after birth),
anxiety. The Obstetrician must exclude vaginal agenesis, when the endometrium is shed and may be noticed as spotting or
examining, carefully. In case of suspicion, pass a thermometer vaginal bleeding. It will subside by itself and needs no
or small catheter very gently and look for the potency of vagina. treatment. The cervix looks red due to protuding columnar
If there is any doubt, (as in ambiguous external genitalia) a team epithelium through the external os. There is no anteversion
of doctors (Pediatricians and Gynecologists) will examine this and anteflexion of uterus. Ovaries are not palpable per
social and potential medical emergency (see the chapter 28 on abdominally.
Disordes of Sex Development).
Examples of effects of maternal hormones in the newborn PREPUBERTAL GIRL CHILD
and infants which bring them to the Gynecologist. Breasts are flat with the nipple in the center. Vulva—the mons
1. Breasts: They may be bigger vis-a-vis the body of the girl has no hair. Labia majora and minora are thin with no hair are
child. There may be a discharge seen (watery) from the there on the labia majora. They are not able to cover the introitus,
nipple (witch’s milk). This is due to hormones of the mother hence infection can easily travel up. They usually appear
circulating in the infant’s blood. Repeated expression and hyperemic. The clitoris is small. Smegma around the prepuce
touching of the breasts must be strongly discouraged. They may look like candidial patches.
will spontaneously decrease in size and the discharge will The vagina is lined by a single layer of thin columnar
stop within the first few weeks of her life. epithelium with a few rugae. There are no Doderlein’s bacilli
2. Labial anomaly: Labia majora are bigger than expected and and the pH is alkaline. The uterus is small in size and the cervix
labia minora are thickened; the clitoris may be larger than is at the top of the vault of the vagina. Fornices are not
developed. The ovaries are small with a few follicles developing.
These prepubertal girls come to the gynecologist with the
following complaints:
Vaginal discharge: This may be merely vulval infection which
is mostly non-specific. It may be caused by pinworms (Enterobius
vermicularis) traveling up from the anus and causing itching
and secondary infection Escherichia coli from the rectum may
also be the cause. The labia are thin and infection can easily
occur and go into the vagina as the introitus is open. If the
infection persists, it becomes vulvovaginitis. Other organisms
seen are Streptococcus pneumoniae, Hemophilus influenzae,
Chlamydia trachomatis, etc. Any sexual abuse must be ruled out.
Symptoms are pruritis and burning during micturition, mostly
narrated by the mother (though older children can give their
own history of illness). They may complain of watery or
mucopurulent discharge. Repeated urinary tract infection may
Fig. 11.1: External genitalia of a newborn female child coexist. An ectopic ureter in vagina, perineum or distal urethra
 can be rarely seen. Examination is to be done after building a
rapport with the patient and should be extremely gentle. Carry
out a general examination to ascertain normal growth and
exclude any congenital abnormality preferably under sedation/
anesthesia.
Pelvic examination: Positioning of the girl will depend on her
age. An infant can be examined by placing her on the abdomen
of her mother (Fig. 11.2).

POSITIONING FOR EXAMINATION OF A FEMALE CHILD

A toddler and up to 3–4 years (very young girl) can be seen by
Endocrinology in Gynecology

positioning her on her mother’s lap (Fig. 11.2). She will support
the child’s leg. Blowing by the child (as if filling a balloon), i.e.
Valsalva maneuver will show the lower part of the vagina.
Sometimes kneechest position will help to see the vulva (Fig.
11.3). A light source will show a portion of the vagina. Some
Fig. 11.4: Thudichum speculum
children will lie like adults on the edge of the examination table.
Nasal thudichum speculum (Fig. 11.4) can be used to inspect
the vagina of a small girl. If after all this, the examination is not
complete and a per-rectal or a more detailed vaginal
examination is thought to be necessary, it should be done under
anesthesia only. To diagnose parasitic worm infestation, one
can apply adhesive tape on the perianal region (Graham
technique) or the underwear overnight and then send it for
parasitological examination.
Allergy to the synthetic material of the underwear may be
the cause; hence, examination of the underwear is also required.
Section 3

Fig. 11.5: Labial agglutination

Management: The need for cleanliness is stressed. Cleaning

of the perineum from before backwards is advised (after
defecation). The mother should be advised that only loose-
fitting cotton undergarments should be used. Smear
examination and culture of the discharge can be taken. A saline
soaked sterile cotton swab should be used. For treatment of
pinworm, pyrantel pamoate is prescribed. Cleaning the vulva
by a non-irritant lactic acid-containing solution will prevent
itching. Local and systemic therapy is prescribed according to
the organism isolated in the smear and culture of the discharge.
Antibiotic may be needed if these measures fail to provide
desired effect within a week.
Fig. 11.2: Position of baby on her mother’s abdomen Labial agglutination is seen in early childhood (up to 6
years of age) (Fig. 11.5). There is non-specific infection of the
labia with discharge making them come together and form
adhesions. The problem is usually noticed by the mother. The
adhesions are mostly separated easily. Advice on vulval hygiene
is given. A short course of local estrogen cream may be
prescribed.
Vaginal bleeding after the first month of life is to be
carefully investigated. Foreign body in vagina is a frequent
cause. Trauma due to fall or sexual abuse is to be kept in mind.
Malignancy of the genital tract is a rare cause. Precocious
puberty is also included in the differential diagnosis.
Examination both general and local is done in the OPD or
emergency department, but per-rectal and, if required, per
vaginal examination is to be done under anesthesia only.
Some dermatological conditions (see chapters 50 and 51),
62 Fig. 11.3: Knee chest position like warts, etc. may be seen.
 Different injuries from various foreign bodies (seeds, treatment. Sarcoma botryoides is seen in vagina in children.
erasers) to falls and sexual assaults are seen. In African countries, Treatment is excision followed by chemotherapy. Other tumors
female genital mutation is commonly seen. (For examination of the genital tract are very rare in children.
of rape victim, you are referred to chapter 30). Look for vulval
and vaginal injuries and, if needed, repair them under BIBLIOGRAPHY
anesthesia. 1. Farrington PF. Paediatric vulvo-vaginitis. Clin Obstel Gynecol
1997;40:135.
Neoplasms: Ovarian tumors are uncommon in children. But 2. Henen M, Mckenna J, Busby G, et al. The histology and management
immature teratoma and endometrial sinus tumor does occur in of ovarian cysts found in children and adolescents. Brit J Obst Gyne
girls less than 10 years of age. One of my patients present with 2009;117:181.
the first symptom of not being able to tie her school belt. 3. Kass-Woff JH, Wilson EE. Pediatric gynaecology: Assessment
Ultrasound examination and tumor markers like a-fetoprotein strategies and common problems. Semin Reprod Med 2003;21:329.
4. Strickland JL. Ovarian cysts in neonates: Children and adolescents.

Chapter 11
(AFP), Ca-125, hCG, etc. will help in the diagnosis. Surgical
removal followed by radiotherapy and/or chemotherapy is the Curr Opin Obstet Gynecol 2002;14:459.

Pediatric Gynecology

63
 12 Puberty

Meenakshi Bhatt, Sudha Salhan

DEFINITION increasingly responsive to GnRH (gonadotropin-releasing

Puberty is defined as ‘The period during which adolescents hormone). Pulsatile release of FSH and LH starts occurring
reach sexual maturity and become capable of reproduction.’ during sleep. Serum LH amplitude rises at least one year before
Adolescence is variously defined as ‘The state or process of the onset of puberty. Amplification occurs in the hypothalamic-
growing up’ or as ‘The period in a person’s life when they are pituitary-gonadal axis with progress of puberty.
developing into an adult.’ The hormonal control of the pubertal growth spurt is
complex one. Growth hormone (GH) has a prominent role and
HISTORY it acts through the stimulation of insulin line growth factor-1
Puberty occurs earlier now than in the past as reflected by the (IGF-1) (previously also known as somatomedin C).
age of menarche. The average age of menarche in industrialized Gonadal steroids act in more than one way:
European countries has decreased by 2–3 months/decade over 1. They induce an increase in GH secretion and thereby an
the past 150 years. However, this trend has slowed or ceased in increase in IGF-1 production.
the developed world since the 1940s. This change is probably 2. They have a direct effect on cartilage and bone, because
the result of improved socioeconomic status of resident and they stimulate the local production of IGF-1 and other
the health benefits of urbanization. factors. They promote both the growth and maturation of
The Harvard Longitudinal Studies of Childhood Health and chondrocytes, osteoblasts and other constituents of bone.
Development revealed that girls had earlier menarche if they Maturation leads to fusion of epiphysis and cessation of
were taller and consumed more animal protein than vegetable longitudinal growth.
protein. Moderate obesity (up to 30% above normal weight for In both genders, estrogen (not androgen) is the critical
age) is associated with an earlier menarche as opposed to hormone in the pubertal growth spurt, skeletal maturation and
pathological obesity which actually delays it. achievement of peak bone mass and its maintenance in the adult.
Several studies have revealed that when socio-economic and This effect is exerted through the anabolic effect that this
environmental factors lead to good nutrition, general health hormone has on the osteoblasts and through its apoptotic effect
and infant care, the age of onset of puberty in normal children on osteoclasts. The thickening of cortical bone and the greater
is determined largely by genetic factors. bone strength in boys is, probably, due to the direct effect of
testosterone which increases periosteal bone deposition. The
Sexual Maturity Rating Stages trigger for these changes may be neuronal development during
Somatic and physiologic changes occur in a fixed predictable middle childhood.
sequence. The sequence being thelarche (estrogen effect), Table 12.1: Classification of sexual maturity
pubarche, (androgenic effect maximum growth velocity (growth rating in girls
hormone) and menarche. This enables the division of the process
of development of secondary sexual characters into stages. SMR Pubic hair (Fig. 12.1) Breasts changes in thelarche
stage (mean age 8 years) (Fig. 12.2)
These stages, as described by Tanner, are mentioned in Table
12.1. The completion of stages takes 4–5 years. 1 Preadolescent Preadolescent
The sexual maturity rating (SMR) stages often occur at 2 Sparse, lightly Breast and papilla
different times in all sectors. For example, SMR2 genital pigmented, straight, elevated as small mound;
development usually predates SMR2 pubic hair development. medial border of diameter of areola
labia increased
3 Darker, beginning Breast and areola enlarged,
Hormonal Changes
to curl, increased no contour
During childhood the hypothalamus is suppressed. With the onset amount
of puberty the negative feedback on hypothalamus is gradually 4 Curly, coarse, Areola and papilla from
released. The GnRh (gonadotropin-releasing hormone) from it abundant, but less secondary mound
acts on anterior pituitary to secrete gonadotropins, viz. than in adult
follicular-stimulating hormone (FHS) and lueitinizing hormone 5 Adult feminine tri- Mature, nipple projects,
angle, spread to areola part of general
(LH).
medial surface of breast contour
FSH and LH rise during middle childhood itself. However, thighs
pubertal changes begin only when the pituitary becomes
 Increased GH secretion coincides with the onset of breast Menstrual Changes
development in girls and reaches its peak at Tanner stage 3–4. Menarche (first menstrual period) usually occurs
It occurs earlier in girls than in boys. Similarly, plasma levels of 2–2.5 years after the appearance of breast buds. The median
IGF-1 also peak earlier in girls than in boys. age is 12 years and the SMR stage at this time is usually 3–4. In
The development of breast and its modified apocrine glands 30% of girls, menarche occurs by SMR3. By 10.5–14.5 years, this
is mainly controlled by estrogen, while the growth of pubic percentage rises to 95%. Besides environmental and diet, other
and axillary hair is under the control of androgens (from the factors which determine the age of menarche is race, birth order,
ovary and the adrenal cortex). etc. Anovulatory cycles are very common for the first 2 years
after menarche.
Development of Secondary Sexual Characteristics
and Internal Genitalia (Figs 12.1 and 12.2) Growth
In girls, breast buds appear between 8 and 12 years of age. This The peak velocity of growth acceleration is achieved during

Chapter 12
is the first obviously discernible sign of puberty. However, SMR 3–4. It is interesting to note that this growth is not
increase in height velocity is actually the first sign of puberty symmetric. The limbs grow first and then growth occurs more
in girls, though it is not as obvious. The final changes in the proximally, viz. in the trunk. This accounts for the awkward
development of the breast and pubic hair occur by 17–18 years appearance that teenagers have. And, due to this fact, a rapid
in ~95% of females. increase in shoe size is a harbinger of the pubertal growth spurt.
Vaginal pH decreases as girls approach menarche because The growth spurt reaches its maximum velocity at around
of the increased lactic acid produced by lactobacilli (Doderlein’s 11.5 years in girls (~8.3 cm/yr) and then stops at 16 years. Weight

Puberty
bacilli). Stratification of the lining cells of the vagina occurs a and strength gain follow the growth spurt by several months.
few months before menarche; this too is a result of the action of In a study conducted in the United Kingdom, it was found
estrogen. Vaginal lubrication increases. Physiologic leukorrhea that girls grew a mean of 25 cm between takeoff and cessation
appears at this time. It consists of a clear vaginal discharge (Table of growth.
12.2). Girls reach peak height velocity ~1.3 years before menarche.
The uterus changes from its initial tubular shape to the Therefore, the growth potential is limited once menarche is
mature bulbous structure. Both its length and volume increase, reached. Most girls gain only an additional 2.5 cm following
the former around two-fold and the later almost ten-fold. The menarche.
uterus and cervix ratio 1:3 at birth changes to 3:1 at puberty. It In addition to growth in limbs and trunk, there is an increase
achieves its adult configuration even before menarche. The in size of various organs. The optic globe elongated and the
ovaries also increase in volume, more so in tall girls. They may result is frequent myopia. Widening of hips in girls also occurs,
also appear multicystic on ultrasound even in normal girls. This and is hormonally determined. In addition to hip enlargement,
may be a cause of confusion for an inexperienced observer. there is widening of the pelvic inlet in girls. The latter is
predominantly due to growth of the os acetabuli.
There is doubling of heart size and vital capacity of the
lungs. The pituitary gland enlarges more in females than in
males. However, the brain reaches 95% of the adult size even
before the onset of puberty. Changes in relation of the parts of
the face also occur. The maxilla, brow, frontal sinuses, middle
and posterior cranial fossae increase in size. There is
enlargement of thyroid (thyrotropin effect) and skin
pigmentation (melanocyte-stimulating hormone effect).
Fig. 12.1: Showing staging of pubarche (Pubic hair changes) Lymphoid tissue growth reaches its peak at 12 years of age.
Subsequently, there is a decline.
The majority of adolescents are afflicted with acne, albeit
of varying degrees of severity.

Cognition
Teenagers gradually mature from the concrete thinking of
childhood to the logical thinking of adulthood. However, in
times of stress, the young teenager may revert to his/her
childhood ways of thinking.
Fig. 12.2: Showing stages of thelarche (changes in the breasts) Areas of the brain, which are responsible for prioritizing and
strategizing (dorsolateral prefrontal cortex and superior temporal
gyrus), develop during adolescence.
Cognitive development occurs earlier in girls than in boys.
Table 12.2: Vaginal changes in puberty In addition, there is plenty of individual variation. Also,
Childhood Puberty cognitive and physical developments do not always go hand in
hand. Mature looking teenagers may suffer due to this, as they
Epithelium Thin, few Stratified, several would be expected to behave like adults even though they may
layers Layered have not yet achieved that cognitive maturity. On the other hand,
Glycogen in cells Minimal Abundant
physical maturity correlates well with sexual maturity.
Doderlein’s bacilli Absent Present
(convert glycogen Adolescents, especially early and middle adolescents, are
to lactic acid) more interested in their peers than in their family and this
pH Alkaline Acidic (4–5) determines their dressing sense and their behavior.
65
 Middle adolescents start understanding the moral and legal Medroxyprogesterone acetate (MPA, 10 mg tablets): 30 mg is
repercussions of their actions and start analyzing their actions. given orally in divided doses to suppress menstruation and
They also start spending time in contemplation of their future breast changes. However, it cannot alter the skeletal growth
plans. rate.
Since most of the growth is completed by late adolescence, Cyproterone acetate: It has an agonistic effect on the
a more stable body image is formed. Gradually, the peer group progesterone receptors and is given orally in the dose of 70–
no longer remains all-important. In addition, the teenager’s 100 mg / m2 / day from the 5th to 15th day of the menstrual
thinking becomes less self-centered. cycle.
Role of Counselors GnRh agonists: It acts by suppressing the hypo-
Parents need help and education to differentiate abnormal from thalamopituitary ovarian axis and thus decreases estrogen
normal and adolescents need reassurance that their bodily secretion. It arrests both pubertal velocity and growth velocity.
Endocrinology in Gynecology

changes are normal. It may be given daily as a nasal spray or injected monthly in
Parents also need to adapt their responses and disciplinary the form of a depot preparation.
measures to their growing child who is also undergoing Premature thelarche: It is the isolated development of the breast
cognitive change and who is himself/herself under immense prior to 8 years of age. There is no acceleration of somatic growth
stress. or bone maturation. There is no estrogenic effect in vaginal
cytology. No treatment is required.
Precocious Puberty
Definition: Precocious puberty is defined as the development of Premature pubarche: It is the isolated development of the pubic
secondary sexual characteristics prior to 8 years of age and/or onset and/or axillary hair prior to 8 years of age without signs of
of menstruation prior to 10 years of age. precocious puberty. It is due to unusual sensitivity of the end
organs to the low levels of circulating hormones or due to
Types: ovarian or adrenal pathology.
1. GnRh dependent 2. GnRh independent
Complete Ovary Suggested Investigation
Granulosa cell tumor Hormone estimation: Serum testosterone, 17 OH progesterone,
Constitutional Theca cell tumor dehydro-epiandrostenedione to rule out adrenal hyperplasia.
Primary hypo- Leydig cell tumor
Section 3

thyroidism (juvenile) CT scan: To detect adrenal tumor.

Intracranial pathology Chorionic epithelioma Sonography: To exclude ovarian enlargement.
(trauma, tumor, infection) Premature menarche: It is an isolated event of cyclic vaginal
Incomplete McCune–Albright bleeding in the absence of other signs of secondary sexual
syndrome development. It may be due to undue sensitivity of the uterine
Premature thelarche Adrenal: Hyperplasia, endometrium to the low levels of circulating estrogen. Other
tumor causes of vaginal bleeding such as trauma or foreign body
Premature pubarche Liver: Hepatoblastoma should be excluded.
Premature menarche Iatrogenic: Estrogen or
androgen intake Prognosis
Etiopathology The overall outcome of precocious puberty is influenced by the
etiological factor. Most of the causes are amenable to treatment
Constitutional: This is the most common disorder of puberty and timely intervention.
caused due to early release of GnRh. This results in premature
activation of the hypothalamic-pituitary-ovarian axis. Delayed Puberty
The pubertal changes occur in an orderly sequence. The Definition: The term delayed puberty is used when the
menstrual cycle is usually ovulatory and bone maturation is secondary sex characters do not develop by 13–14 years or
accelerated resulting in early closure of the epiphysis and short menarche is not attained prior to 16 years.
stature.
Etiology: It may be due to hormonal or anatomical causes.
Diagnosis: History of early menarche in mother or sister is
Hormonal Anatomical
suggestive. There is no detectable pathological cause and the
Hypergonadotropic Mullerian dysgenesis
changes occur sequentially.
hypogonadism (Aplasia of uterus)
The basic investigations include: Gonadal dysgenesis, Transverse vaginal septum
X-ray: Of wrist/hand for bone age (as growth acceleration is 46 XO
one of the earliest indications). Pure gonadal dysgenesis Imperforate hymen
46XX, XY
X-ray of skull to exclude intracranial pathology. CT scan or MRI Ovarian failure 46 XX
of the brain too can be done.
Hypogonadotropic hypogonadism
Hormone: Serum HCG, FSH, LH; Thyroid profile (TSH, T4);
Constitutional delay
Serum estradiol, 17 OH progesterone, testosterone,
Chronic illness, malnutrition
dehydroepiandrostenedione (DHEA).
Primary hypothyroidism
Treatment: The treatment aims to normalize the raised Hypothalamic dysfunction
hormonal levels and to arrest the untimely sexual maturation. Hypopituitary defect
The drugs used include: Isolated gonadotropin deficiency
66
 (Kallmann’s syndrome) Management
Intracranial lesions/tumors/congenital defect The treatment of delayed puberty is similar to the management
Craniopharyngioma of primary amenorrhea. It requires certain basic investigations
Pituitary adenoma and assurance. The absence of menses in the presence of normal
Empty sella turcica growth and secondary sexual characteristics is suggestive of
Investigations for delayed puberty developmental anatomical defects like absence of uterus or
General examination: Seconday sexual characteristics record of vagina. This can be confirmed by pelvic sonogram or
height and weight laparoscopic evaluation of the pelvis. The absence of any
Karyotyping: XO; XY obvious defect suggests constitutional delay and warrants
Hormone estimation: FSH; TSH; T4; Prolactin patience and observation of the girl and counseling.
X-ray: Pituitary BIBLIOGRAPHY

Chapter 12
CT; MRI: Pituitary 1. Cambridge Advanced Learning Dictionary
Ultrasonography: Streak or polycystic ovaries 2. Merriam-Webster Online Dictionary
3. Oxford English Dictionary
Aplasia of uterus
4. Tanner JM. Growth at Adolescence, 2nd edn, Oxford, England,
Diagnostic laparoscopy. Blackwell Scientific Publication, 1962.

Puberty

67
 13 Adolescent Gynecological Issues

Pratima Mittal, Pinkee Saxena, AK Jain

INTRODUCTION 9. Reproductive health issues as pregnancy, abortions,

Adolescence is a period of transition from childhood to contraception
adulthood. It corresponds to teenage years (10–19 years, WHO 10. Miscellaneous issues: Adolescent immunization, nutrition,
definition). Adolescents constitute about 20–25% of our body image issues, etc.
population. There are about 230 million adolescents in India.
Adolescence is, possibly, a key factor in determining the future DISORDERS OF PUBERTAL GROWTH AND MATURATION
health of an individual and thus of a country.
Early Puberty
Adolescence is a period of change and change induces fears,
stress and strain. Risk-taking behavior is the hallmark of Early puberty may be a variation of normal development or
adolescent behavior as it is a period of confusion, exploration may be pathological. Precocious Puberty is development of
and experimentation. Adolescents often face constraints in secondary sexual characters as breast enlargement, etc. before
seeking health services due to misperception about their own 8 years of age and menarche before 10 years of age (discussed
needs, fear of disclosure and provider’s negative attitudes. in chapter 12).
Understanding, friendliness and personal touch are the
Delayed Puberty
expectations of adolescents from their treating physician, who
should tackle them with respect, honesty and confidentiality Delayed puberty is suspected when there is absence of pubertal
along with social and psychological support. development at 2 standard deviations (SD) above the mean age
Adolescent girls, who make 10% of the total population and of puberty for that population. Further investigations are
20% of the female population, have a wide spectrum of required in the absence of thelarche by 13 years and absence of
gynecological problems. These problems of adolescents occupy menarche at 16 years of age or if more than 5 years have elapsed
a special space in the spectrum of gynecological disorders of between first sign of puberty and completion of genital growth
all ages. This is because of the physical nature of the problems and menarche. Delay can be physiological or due to some
which are so unique, special, and specific for the age group, organic cause (discussed in chapter 12).
and also because of the associated psychological factors, which
CONCERNS REGARDING NORMAL MENSTRUATION
are very important in the growth and psychosocial remodeling
AND MENSTRUAL HYGIENE
of someone in the transition between childhood and
womanhood. Adolescent girls are often shy and embarrassed Surekha (name changed) a 12-year-old girl was playing with her
to discuss important yet personal aspects of life as menstruation, friends in school. Suddenly, she felt her underpants were feeling wet.
sex, sexually transmitted infections, pregnancy, etc. To achieve As she looked down at her dress, it was all soaked with blood. Other
a healthy reproductive life in the future, these adolescents boys and girls around her were staring. Scared and not knowing what
should be encouraged to visit a health care professional for their was happening to her, she started crying. Ranjeeta, a senior class
problems. student, who was passing by, saw her condition and took her to the
school health center, where she was given a sanitary pad. Surekha had
GYNECOLOGICAL CONCERNS OF ADOLESCENTS many fears and questions but did not know whom to ask. Here are
Gynecological issues of adolescents concentrate on problems some tips for the heath care provider, who can help Surekha by telling
mostly in association with emerging sexual and reproductive her about normal menstruation.
health. These can be: Menstruation is an essential part of growing up. It is an
1. Disorders of pubertal growth and maturation. important landmark in a girl’s life, yet most girls are told about
2. Concerns regarding normal menstruation and menstrual this only when they actually begin their periods. Some girls are
even made to feel that they are “dirty” and impure during this
hygiene
time. Adolescent boys, who just do not have any knowledge of
3. Menstrual disorders: dysmenorrhea, menorrhagia, irregular
menstruation, often get alarmed on seeing adolescent girls
periods, premenstrual syndrome clothes stained with blood as seen in Surekha’s case.
4. Hyperandrogenism : PCOS, hirsutism
5. Infections: RTI, STI, HIV and AIDS, genital tuberculosis Counseling on Menstrual Issues
6. Pelvic pain It is important to talk about this normal body function since a
7. Genital tract tumors significant number of adolescent girls have concerns related to
8. Issues related to sexuality and sexual violence the menstrual cycle, most of which require only reassurance or
counseling. It is the duty of parents, teachers or health care Tampons are inserted into the vagina. Both are made of
provider to tell the adolescent boys and girls about these cotton or another absorbent material. Pads or tampons
physiological events and prepare the girls mentally and should be changed frequently (every few hours). Tampons
psychologically for menarche. All their questions must be are discouraged during adolescence since the hymen may
answered and not swept aside. Besides maintenance of personal not allow easy insertion, vaginal walls may go into spasm
hygiene during this period, she should be told about the sexual and it may not accommodate the regular size tampon
changes that can be anticipated and how to discourage the male without pain; and if one forgets to remove it, it may cause
members in her immediate environment (such as friends, infection and even toxic shock syndrome. Clean, dry, old cotton
cousins, uncles, etc.) from exploiting her. cloth, which is reusable after wash, can be used for absorbing
The facts, to be explained to adolescents in school/ menstrual flow.
community sessions, should highlight that: • Keeping a menstrual calendar diary: The girl records the
• Menstruation is a natural body function. Menstruation marks dates of menstruation. Besides being a good habit will also

Chapter 13
the onset of sexual maturity in girls. It signals that one is help in reassuring the girl that everything is alright. Iron is
capable of bearing a child. Menstruation is a sign that the prescribed to prevent anemia and dietary advice is given.
girl’s reproductive system is functioning healthy and well. • There are certain myths related to menstruation and these
• The right age for menarche (onset of menstruation) has a must be clarified (Table 13.1).
wide range of normalcy. Onset of menstruation before 10
years or the absence of menstruation after 16 years in a girl Menstrual Hygiene
is a sign of abnormality. Geeta (name changed) a 13-year old girl has itching in the genital

Adolescent Gynecological Issues

• Menstruation is the periodic shedding of blood and tissue region and discharge. She was told by her mother not to take bath
from the female reproductive organ called the uterus. during menses.
Explain the physiology of menstruation in simple words. The problem Geeta is facing is self-created as she is
• Explain that normal periods usually last for about 5 days compromising on personal and menstrual hygiene. It is
(average 3–7 days) with a gap of 21–45 days (usual 28 days important to keep the genital area clean and dry during periods
± 2 days) in between the periods, but may be longer or and even otherwise.
shorter in exceptional cases. A girl loses 50–80 ml blood on • To maintain menstrual hygiene, girls can use cloth or
an average during a period. This is equal to 4–6 table spoons. sanitary pads. If using a cloth, clean cotton cloth should be
If she soaks more than 3–4 pads/day in the initial 2–3 days, used to soak the menstrual blood. Cotton has a good
it may be considered excessive bleeding. The flow is usually absorbing capacity. A synthetic cloth should not be used as
heavier at the beginning of the period (first and second day) it may not absorb well and may cause skin irritation.
and becomes light at the end. Sanitary pads can be used along with the undergarments.
Menarche (median age): 12.43 years • The cloth or pads should be changed frequently—3–4 times
Mean cycle interval: 32.2 days in the first a day or whenever one feels wet.
gynecologic year • The cloth and undergarments should be properly washed
Menstrual cycle interval Typically 21–45 days with soap and water and dried in the sun. Sunlight kills all
Menstrual flow length 7 days bacteria. After every period, the washed and dried cloth
Menstrual product use 3–4 pads/tampons per day should be stored in a clean bag, in a clean place till the next
period.
• There are no external signs that indicate that whether a
• If pads are used, they should be wrapped in a paper bag
woman is menstruating.
and disposed. These should neither be flushed in the toilet
• During the first one or two years after menarche, most cycles
nor be thrown in the open.
are anovulatory and periods are irregular. This means that
• The girl should take a bath every day during menstruation.
at one time, there may be a gap of 3 weeks and the next
• Lack of menstrual and personal hygiene may cause vaginal
time may be 5 weeks. Later, usually after a year or so, they
discharge, burning during urination and genital itching in
settle down into a regular pattern. This should not be of
girls.
much concern unless the girl is sexually active in which
• The urinary opening and anus are situated quite close to
case she may be at risk of pregnancy.
the vaginal opening; hence, care must be taken to wash these
• Women use various products to absorb menstrual flow.
parts after passing urine.
Sanitary napkins (pads) are worn inside the underwear.

Table 13.1: Myths in adolescent period

Some Myths Facts
Periods are some kind of disease. Periods are normal and natural for women. It happens to every girl.
Menstrual blood is impure. Menstrual blood is a mixture of blood and tissues of one’s own body.
It is wrong to have a bath and wash one’s hair One should be more careful during these days so that
during periods. one remains clean and dry.
It is bad to eat pickles during these days. It is okay to eat all kinds of food including pickles during periods.
One should not enter the kitchen during periods. As long as one is clean and is not having pain, one can do whatever
one wants to do.
Our bodies emit a bad odor during periods. Bad odor at times during periods may be due to lack of personal
hygiene.
One should eat separately from the family members. One is perfectly normal during these days and isolation is not
required.
Girls should not play outdoor games on the days One can play and even exercise on these days, but
they have their periods. undue pressure on the abdomen should be avoided.
69
 • After passing stools, care should be taken to wash from front dysmenorrhea is due to ovulation only and does not have
to back and not otherwise, to prevent infection. Adequate any other cause. The goal of treatment is to relieve pain.
amount of water should be used for cleaning. ii. Analgesics can be given safely for relief of pain. It is
important to highlight that these drugs are taken for a short
MENSTRUAL DISORDERS period and these do not cause addiction.
Menstrual disorders are the most common gynecological
problem in adolescent girls (75% all over the world). These range Irregular Menstrual Cycles in Adolescents
from amenorrhea to menorrhagia. By 15 years of age, 98% of Whenever there is ovulation, the cycles are usually regular. After
females will have had menarche; and, if menarche is not reached the onset of menarche, about 45% adolescent girls have no
by 16 years of age, it should be investigated. Periods in the first ovulation for 1–2 years. This leads to irregular cycles, which is
few years after menarche may be irregular due to anovulatory a cause for concern for the young girl and her parents as well.
cycles that result from an immature hypothalamic-pituitary- Irregular cycles are of three types:
Endocrinology in Gynecology

ovarian axis. This does not indicate any abnormality. The a. Oligomenorrhea (scanty periods) or amenorrhea (no
adolescent girl needs reassurance to be able to adjust to the periods)
periodicity. She needs to be told that it will normalize in the b. Polymenorrhea
course of a few years. Emotional stress because of the cycles c. Menorrhagia.
itself or otherwise needs to be addressed. The cycles are more
Oligomenorrhea or Amenorrhea
likely to be longer than a month; but, in a few cases, they may
even be shorter or with no fixed pattern. Although most The amount of bleeding varies and is different from one girl to
adolescents will develop normal, regular menstrual cycles, a another. Even a lesser menstrual flow is normal, especially if it
significant number may require gynecologic follow-up for is regular in occurrence and is not associated with any other
persistent abnormal vaginal bleeding. problem. Reassuring the girl about her fertility is important.
Infrequent ovulation is a common and physiological finding
Common Menstrual Disorders in Adolescents shortly after the menarche and it leads to oligomenorrhea.
1. Dysmenorrhea Within one year of menarche, this type of oligomenorrhea is a
2. Irregular menstrual cycles normal phenomenon; but with the history of previous normal
a. Oligomenorrhea or ammenorrhea regular cycles, it is an abnormal condition and requires a
b. Polymenorrhea detailed evaluation for the same.
Section 3

c. Menorrhagia A number of medical conditions can cause irregular or

3. Premenstrual syndrome. missed menses in adolescents. Although secondary amenorrhea
has been defined as the absence of menses for 6 months, it is
Dysmenorrhea valuable to begin evaluation of secondary amenorrhea after the
Dysmenorrhea is defined as difficult menstrual flow or painful absence of menses for 90 days in adolescents. The number one
menstruation. About 50—75% young girls complain of this. This cause of a skipped period is pregnancy. Regardless of whether
is one of the leading, if not the greatest, single cause of lost there is a history of sexual contact or not, pregnancy should be
school days. In addition, the adolescents with dysmenorrhea ruled out. Management is given in the abnormal uterine bleeding.
receive lower grades and have more school adjustment Polymenorrhea
problems. The majority of these cases are not due to disease
Polymenorrhea is the less common complaint in this age group.
and the physical examination is normal. Dysmenorrhea has been
Usually, it is caused by luteal phase dysfunction. Treat with
reported to be significantly increased among mothers and sisters
progesterone support in the luteal phase. Oral contraceptive
of women with the condition. The optimal management of this
pills are also used to regularize the cycles.
symptom depends on an understanding of the underlying
cause. Menorrhagia
Dysmenorrhea is classified as primary (spasmodic) or Menorrhagia in adolescents is usually referred as puberty
secondary (congestive). menorrhagia. It refers to bleeding that is excessive or occurs
The degree of disability due to dysmenorrhea can be: outside the normal cyclic menstruation. The normal menstrual
• Mild (49%): If pain occurs only on the first day of the cycle is defined as having a mean interval of 24–35 days, with a
menstruation, has little or no associated systemic symptoms mean duration of 5 +/– 2 days. The amount of blood loss ranges
and does not inhibit the daily activities of the adolescent. from 30 to 80 cc. Blood loss greater than 80 cc or subjective
• Moderate (37%): During the 1st 2–3 days of the menses impression of heavy flow (i.e., more than 6 full pads or
frequently accompanied by diarrhea, headache, and tampons), and duration of bleeding greater than 7 days, is
fatigue. Some restrictions in the daily routine may be considered abnormal. In adolescents, during the first one or
necessary during the period of peak discomfort although two years, after menarche, approximately 55–82% of menstrual
absenteeism from school is not frequent. cycles are anovulatory and anovulation is the most common
• Severe (14%): Intense spasmodic pain before onset of flow cause for menorrhagia in adolescents. This kind of menorrhagia
and lasts 2–7 days, associated with GI symptoms. Severely is classified as dysfunctional uterine bleeding (DUB) and is
impinges on the adolescent’s ability to carry out her normal recurrent till regular ovulation and cycles are established.
activities. Anemia may develop with menorrhagia of long duration and
The pathogenesis and evaluation of dysmenorrhea are it varies from mild to severe.
discussed in detail in chapter 16, but it is important to
understand that: Causes of Menorrhagia in Adolescents
i. Explanation and reassurance is the backbone of therapy in a. Dysfunctional uterine bleeding (DUB)
the adolescent girl with dysmenorrhea. However, b. Psychological disorders, especially seen in anorexia nervosa.
investigations are required to confirm that the Body fat percentage of 17% is required for initiation of
70
 menses, and approximately 22% is needed for regular bruising, actively bleeding gums or epistaxis, and for
ovulatory cycles. abdominal masses. Any signs of systemic illness should be
c. Endocrine disorders: Hypothyroidism, hyperprolactinemia noted.
(pituitary tumor), Cushing’s syndrome, Addison’s disease, iii. Genital examination: An external genital examina-tion is
congenital adrenal hyperplasia, and polycystic ovarian always indicated. Tanner staging, clitoral size, hymenal
syndrome (PCOS). characteristics, and any signs of infection or trauma should
d. Coagulation disorders: Abnormal uterine bleeding can be be investigated. An internal examination should be
the initial presentation of a blood dyscrasia. These females performed only if there is a history of sexual activity. A
are most likely to present with regular but heavy menses. bimanual examination should be performed to assess for
If bleeding is excessive and presents at the time of menarche, abdominal, adnexal or ovarian motion tenderness and the
an underlying coagulopathy should be ruled out. Therefore, presence of any lower abdominal or pelvic mass. Any signs
it is important to elicit history of bleeding from any other of trauma or instrumentation may be seen on per speculum

Chapter 13
site or easy bruisability. examination. A cervical swab should be obtained for
e. Genital tuberculosis: In developing countries like ours, detection of Neisseria gonorrheae and Chlamydia trachomatis.
tuberculosis (TB) is common. The spread of TB from a An ultrasound may be performed on an adolescent when
primary focus to genital organs takes place at a very early bimanual examination is not possible.
stage of the disease in a subtle manner without causing any iv. Breast: Tanner staging and presence/absence of galactorrhea
menstrual problems in the beginning. The clinical picture should be noted.
is presented a few years later. In 50% of girls, menstruation
Investigations

Adolescent Gynecological Issues

is normal, while 40% girls may have menorrhagia and 10%
will show secondary ammenorrhea after a period of Every adolescent, who presents with abnormal uterine bleeding,
oligomenorrhea. should have:
f. Systemic illness: Any illness that causes excessive weight • Hemoglobin or hematocrit with platelets to determine if
loss, poor nutritional status or emotional distress can cause the patient is anemic.
anovulation. • A beta-human chorionic gonadotropin test should be done
g. Infection: Pelvic inflammatory disease (PID), vaginitis, to rule out pregnancy.
cervicitis • If a history or an examination is pointing towards a bleeding
h. Excessive exercise disorder, a Prothrombin time (PT) and Partial
i. Pregnancy-related disorders: Any type of abortion, ectopic thromboplastin time (PTT) should be sent. These studies
pregnancy may be normal in a patient with von Willebrand’s disease
j. Structural abnormalities: Vaginal, cervical, ovarian, when there is active bleeding (can send for a vWF screen).
endometrial. This may include foreign bodies, trauma • A serum prolactin level should be sent if galactor-rhea was
(including sexual assault) and endometriosis. present on history or examination (Figs 4.1 and 14.3).
• If there are any signs of PCOS, serum FSH, LH and
Evaluation of a Case of Menorrhagia in an Adolescent testosterone levels should be obtained.
History: It is important to obtain the history of: • Thyroid status should be assessed because in many cases,
• Patients’ age at menarche. there may not be evidence of thyroid disease on
• Length and interval of menses (using a menstrual calendar examination.
is often helpful). • Ultrasound can be helpful in patients for diagnosing any
• Amount of daily pads or tampons used during menses. uterine or pelvic pathology or pregnancy-related
• Character of bleeding (clotted blood vs. profuse bleeding complications.
that may be more likely associated with a blood dyscrasia).
Treatment
• A detailed sexual history should be obtained.
• Whether pain is associated with menses (severe pain with The management of abnormal vaginal bleeding is determined
menses may be associated with ectopic pregnancy, missed by the underlying etiology and by the severity of the bleeding.
abortion, STDs, trauma, gynecological tumors). The goals of controlling abnormal bleeding include preventing
• A detailed nutritional history, any change in weight, or complications, such as anemia, as well as restoring regular
emotional stress should be elicited. cyclical bleeding. Underlying systemic, endocrine disorders or
• A history of easy bruising or prolonged bleeding after minor bleeding disorders are addressed, and patients may require
cuts or dental work, and epistaxis should be asked. referral to appropriate specialists for further evaluation and
• History should also include whether there has been any management if one of these conditions is identified.
vision changes or headaches. i. In the young adolescent who is not anemic (light-to-
• Any signs or symptoms of systemic illness should be moderate flow, Hb >12 gm/dl): A conservative approach is
questioned. preferred if the physical examination is normal. A menstrual
• Family history of bleeding disorders, infertility, menstrual calendar should be kept by the patient and a follow-up visit
disorders, gynecological cancers, thyroid disease, and in 3 months should be scheduled.
PCOS. If the irregular menses are extremely bothersome or
affecting her daily activities, hormonal treatment can be
Physical Exam considered, but this is usually not necessary. Reassurance,
i. Vital signs: Changes in pulse rate and blood pressure will that their menses will over time become regular is the key
be evident if the patient is hypovolemic as a result of with this sort of patient. Iron, multivitamin tablets and anti-
excessive or prolonged blood loss. inflammatory drugs during periods may be prescribed.
ii. Physical examination: It should focus on visual field testing ii. For the adolescent who is anemic (moderate flow, Hb
and fundoscopic examination, if there is a history of visual 10–12 gm/dl): Hormonal and iron treatment should be
changes. Assess for thyroid abnormalities, signs of PCOS, initiated. Hormonal treatment, consisting of combined oral
71
 contraceptive pills (OCPs) (e.g., monophasic with 30 to 35 excess with clinical manifestations of irregular cycles, hirsutism,
µg of ethinyl estradiol) is started as one pill twice daily for acne and obesity. It was first described by Stein and Leventhal
1 to 5 days, until the bleeding stops. Once the bleeding stops, in 1935. The disorder is thought to have a genetic etiology, but
OCPs are continued with a new pack, one pill daily, for the severity and course are determined by the patient’s lifestyle
3 to 6 months. Progesterone therapy is useful. Iron specially body mass index (BMI). Health care professionals are
supplementation (e.g., ferrous sulfate 325 mg twice daily) is now realizing that adolescent females are presenting with PCOS
prescribed for 6 months to replenish iron stores. Nonsteroidal and the associated health concerns of menstrual irregularities,
anti-inflammatory drugs (NSAIDs) may be helpful. obesity, type 2 diabetes mellitus and evidence of hyper-
iii. For the adolescent who is anemic (heavy flow, Hb 8–10 androgenism (hirsutism and acne) with increasing prevalence.
gm/dl): Hemodynamically stable. This patient can be PCOS often manifests around the time of menarche as
managed in the same way as as under “moderate flow” if irregular and often lengthened menstrual cycles. Unfortunately,
the family can assist with the management plan and follow- PCOS often goes unrecognized and undiagnosed at this time
Endocrinology in Gynecology

up. If bleeding persists, dose of OCP can be increased to 3 because having irregular periods in adolescence is usually
or 4 times a day for a few days until the bleeding slows, considered normal by many relatives or health care
then taper to two, then one pill daily; the patient may require professionals. These girls often will not receive a diagnosis until
an antiemetic prior to each pill to help prevent nausea. much later, perhaps, at the time, when they seek treatment for
Progesterone therapy is better in anovular cycles. Once infertility.
bleeding stops, continue daily pills for 6 months. May give The main concerns in caring for the adolescents with PCOS
progesterone therapy. are two-fold. The first involves cyclic control of irregular
iv. For the adolescent who is severly anemic (heavy flow; Hb menstruation cycles. The second issue involves the avoidance
<7 gm/dl): Hemodynamically unstable. The patient should of the long-term sequelae that are associated with obesity,
be admitted to the hospital. Blood transfusion should be insulin resistance, glucose intolerance, and type 2 diabetes.
considered depending on the degree and persistence of These conditions can result in subsequent lipid abnormalities
bleeding, as well as on severity of hemodynamic instability. and hypertension that are significant risk factors in the
OCP with 30–50 µg of ethinyl estradiol every 6 hours should development of cardiovascular disease. Early intervention
be started until bleeding slows, then administration of pills through lifestyle modification and the use of various
is tapered to one pill a day over the next 7 days (e.g., one medications is essential to prevent the medical co-morbidities
pill every 6 hours for 2 days, then every 8 hours for 2 days, associated with PCOS.
Section 3

every 12 hours for 2 days, then once daily). Anti-emetic

Diagnosis
agents are advocated with the high doses of OCPs. If
bleeding does not slow after the first 2 doses of the OCP, To establish the diagnosis of PCOS, two of the three criteria is
conjugated estrogens can be initiated intramuscularly or required to be present (Rotterdam Consensus Workshop 2003):
intravenously at a dose of 25 mg every 6 hours to a • Oligomenorrhea/amenorrhea
maximum of 6 doses. If bleeding still persists, dilatation • Polycystic ovaries on ultrasound
and curettage may be considered as a last resort. • Clinical or biochemical signs of hyperandrogenism.
Progesterone therapy is very useful in anovular puberty The National Institute of Health Consensus Conference has
menorrhagia. established definite probable criteria for PCOS, including
menstrual abnormalities, androgen excess and excluding
Premenstrual Syndrome adrenal hyperplasia and other causes of hyperandrogenism.
Some girls feel uncomfortable a few days before their menstrual Insulin resistance, elevated LH to FSH ratio, and ultra-
bleeding begins. They may have one or more of a group of sonographic signs were defined as possible criteria.
symptoms known as premenstrual syndrome (PMS). It is a Mechanism of PCOS
recurrent luteal phase condition (7–10 days before onset of
• Women with PCOS tend to be insulin resistant with
menses) characterized by physical, psychological and
accompanying hyperinsulinemia. To overcome insulin
behavioral changes of sufficient severity to result in
resistance, the body secretes more insulin, thus causing a
deterioration of interpersonal relationships and normal activity.
hyperinsulinemic state. These are all predictive of type 2
It typically disappears within the first 2 days of menstrual cycle.
diabetes. Increased circulating levels of testosterone are
The most frequently encountered somatic symptom is headache
noted in women with PCOS because high levels of insulin
(39%), the most frequent psychological one—irritability (46%).
decrease circulating levels of sex hormone-binding
(This is discussed in chapter 18).
globulin (SHBG). This, in turn, leads to increasing levels
HYPERANDROGENISM of free testosterone and a worsening of the signs of
hyperandrogenism.
Mild symptoms of hyperandrogenism, such as acne and
• There is non-specific hyperandrogenemia due to
hyperseborrhea, are frequent in adolescent girls and are often
exaggerated androgen response to ACTH. The
associated with irregular menses. In most instances, these
hyperandrogenism occurs primarily because of an
symptoms are transient and only reflect immaturity of the
overproduction of testosterone from ovarian thecal cells and
hypothalamic-pituitary-ovary axis during the first year. In some
the adrenal gland. Hyperandrogenism manifests in females
patients, these manifestations can persist and even worsen and
as hirsutism, acne, frontal and temporal balding, deepening
hirsutism may appear, thus revealing an adrenal or ovarian
voice, increased muscle mass, decreased breast size, and in
disorder. The most common cause is polycystic ovarian
severe cases, virilization involving clitoromegaly.
syndrome (PCOS).
Evaluation of a Patient of PCOS
Polycystic Ovarian Syndrome When a young patient presents with hirsutism and irregular
Polycystic ovarian syndrome (PCOS) is a complex endocrine periods, the health care provider should always be alerted to
72 disorder characterized by chronic anovulation and androgen the possibility of PCOS.
Clinical Presentation
• Hyperandrogenism (acne, hirsutism, alopecia—not
virilization)
• Menstrual disturbance
• Infertility
• Obesity
• Acanthosis nigricans.
History
• Menstrual history should focus on age at menarche, length
of time between periods, quantity of menstrual flow, and
presence of dysmenorrhea. Girls with PCOS often begin

Chapter 13
menstruating with menstrual cycles that are fairly regular.
After a few years, the menstrual cycles will become quite
irregular or not occur at all. The menstrual flow in girls
with PCOS tends to be heavier and is associated with Fig. 13.1: USG photo of PCOS
significant cramping.
• Development of secondary sexual characteristics—
adolescent girls diagnosed with PCOS had a history of
ii. Biochemical tests: Most authorities agree that testing should

Adolescent Gynecological Issues

precocious pubarche. Precocious pubarche is defined as the
appearance of pubic hair prior to age of eight years. rule out other etiologies of amenorrhea (such as
• Weight gain (Growth charts): Often, adolescents have had hypothyroidism, hyperprolactinemia, and pregnancy).
no prior history of obesity as a child, but gain a significant Exclude other causes of hyperandrogenism (such as
amount of weight at an accelerated rate following menarche. congenital adrenal hyperplasia [CAH], as well as adrenal
• Development of acne, hirsutism, balding, and voice and ovarian tumors) and detect the presence of insulin
changes—manifestations of hyperandrogenism. resistance, glucose intolerance, and lipid abnormalities.
• Family history of PCOS and diabetes. PCOS tends to cluster • If fasting blood glucose levels are elevated, the next step
in families and to follow the trend of first degree relatives, is to order a 2-hour 75 g glucose test to confirm glucose
especially mothers and sisters of girls diagnosed with the intolerance or type 2 diabetes
condition. Normal Impaired Diabetes
• Social history—to focus on current diet and exercise patterns.
• Patterns of alcohol consumption and tobacco use—as Fasting (mg/dl) <110 110–126 >126
metformin may be one of the medications to be prescribed. 2-hr value (mg/dl) <140 140–199 >200
Alcohol must be avoided when on metformin because
excessive alcohol intake is associated with an increased • Fasting insulin levels (Normal <30 mU/l)
incidence of lactic acidosis. • Fasting blood sugar: Insulin ratio (>4.5)
• Total and free testosterone (Normal total testosterone
Physical Examination
20–80 ng/dl)
• Measurement of body mass index (BMI). If the BMI indicates • DHEAS (Normal <350 mg/dl)
that the patient is obese, measure-ment of waist-to-hip ratio • LH raised (2–10 IU/l) Measured on day 2–3 or on any
is done to determine if the obesity is central/android. An day if amenorrheic
obtained value of greater than 0.72 indicates this type of • FSH (Normal 2–8 IU/l)
obesity. • Decreased SHBG (Normal 16–119 nmol/l)
• Notice signs of hyperandrogenism—presence of hirsutism, • Free androgen index (FAI) T × 100/SHBG (Normal <5)
acne, loss of hair, deepening voice, and clitoromegaly. Acne • Serum prolactin increased (Normal <20 ng/ml) Measure
alone does not indicate PCOS, but it is certainly a sign to if oligo/amenorrheic
look out for as part of the constellation of signs with which • Thyroid-stimulating hormone.
an adolescent may present. • Lipid profile: Low-density lipoprotein and high-density
• Presence of signs of insulin resistance—presence of lipoprotein cholesterol levels.
Acanthosis nigricans and an increased BMI with the presence
of central/android obesity indicate insulin resistance. Treatment
Acanthosis nigricans is a brown darkening of the skin at the Goals of treating PCOS are to treat current troubling signs and
nape of the neck that will spread laterally to the upper thorax symptoms (hirsutism, acne, weight, and menstrual irregularity
and shoulders. This darkened, velvety-appearing skin can issues) and prevent the long-term health problems commonly
also be noted in the axillary and intertriginous areas. seen in women with PCOS treatment depends on:
Investigations: Ultrasound and laboratory data are of key • Managing weight
importance to confirming the diagnosis, although the history • Reducing hyperinsulinemia
and the outward signs seen on physical examination can lead • Treating anovulation and regularizing cycles
to the diagnosis of PCOS. • Antagonizing androgens to treat hirsutism and acne
i. Ultrasound: Diagnosis is on the basis of the following • Prevention of endometrial hyperplasia
criteria (Fig. 13.1). • Preventing long-term effect of PCOS
• Presence of 12 or more cysts of 2–9 mm in subcapsular The cornerstones of management are lifestyle modification
region. and medications.
• Ovarian volume equal to or more than 12 cm i. Weight loss: It is a very good therapy along with changes
• Bright echogenic stroma. in lifestyle and must be initiated as part of the treatment 73
 plan (alone or along with drug therapy) for all patients of • Educating the adolescent can make her more
PCOS. The aim is weight loss of 5–10% and BMI of <27. knowledgeable about the disease and available
a. Diet: Diet modification is advocated. Foods treatment options. The adolescent will then
recommended are of low glycemic index, limiting feel empowered to make informed health care
simple carbohydrates complex carbohydrates and foods decisions on her own. Education can occur through
high in polyunsaturated fatty acids (PUFA) are advised. verbal exchanges, written materials, and/or access to
b. Exercise: Moderate physical activity, 30–60 minutes per Internet-based information contained on websites.
day, should be the goal of all patients with PCOS.
Aerobic exercise through walking, jogging, swimming, Hirsutism
or biking should be encouraged. Hirsutism is defined as the presence of hair in androgen-
ii. Medications dependent sites in which hair does not normally appear in
a. Treatment of hyperinsulinemia: Metformin, rosiglita- women. It is preceded by acne, chronic anovulation and
Endocrinology in Gynecology

zone or pioglitazone may be given. Metformin is an virilization. Hirsutism results from androgenic effects on the
insulin-sensitizing agent and may also be used in these pilosebaceous unit of skin and is commonly associated with
cases for the treatment of insulin resistance as it acne and oily skin. The sites where abnormal hair appear are
increases insulin sensitivity leading to improvement in sideburns, upper lip, chin, chest or intermammary region,
ovarian function. It also lowers LH, free testosterone infraumbilical region, inner thigh and lower back in midline.
levels, PAI-I (Plasminogen activator inhibitor-1) and Most common causes of hirsutism are idiopathic and PCOS.
endothelin I levels in overweight women with polycystic Other causes include congenital adrenal hyperplasia, Cushing’s
ovaries. Metformin induces regular cycles, improves syndrome, ovarian or adrenal neoplasias, drugs like anabolic
ovulation, decrease hirsutism, hyperandrogenemia steroids and androgens and hyperprolactinemia (Discussed in
enhances the effectiveness of fertility drugs, and detail in chapter 15). Obesity and hypothyroidism are
decreases BMI and insulin resistance. aggravators of hirsutism.
Metformin is prescribed in doses of 1,500 to 2,000 mg Treatment aims at:
daily in treating patients with PCOS. Common i. Treating the etiology if any
gastrointestinal side effects (nausea, vomiting, diarrhea, ii. Treatment of hyperandrogenism. This consists of drugs with
and flatulence) can be avoided if the medication is antiandrogenic action.
1. Oral contraceptives: They suppress ovarian androgen
started at lower doses and titrated upwards slowly.
Section 3

production and increase sex hormone-binding globulin,

b. Prevention of endometrial hyperplasia and
thereby reducing free testosterone. OC pills containing
regularization of cycles:
2 mg cyproterone acetate and 35 µg ethinyl estradiol and
• Monthly medroxyprogesterone in a dose of 5–10
those containing desogesterol or drospirenone are
mg/day or norethindrone in a dose of 5–15 mg for
recommended.
10–14 days each month should be given. This avoids
2. Cyproterone acetate: It antagonizes the androgen receptors
abnormal endometrial proliferation but does not
in the skin and acts as a weak progestogen that inhibits
suppress the ovarian androgen produc-tion. It
gonadotropin secretion thereby decreasing androgen
regulates the menstrual cycle.
production. Dose is 50–100 mg from day 5–15 along with
• Low-dose oral contraceptive pills (OCPs):
cyclic estrogen to regularize menstruation as OC pill.
Advantages are contraception, prevention of
3. Spironolactone: It is an oral aldosterone antagonist with
endometrial hyperplasia, regularization of cycles
antiandrogenic properties. It increases metabolic clearance
and treatment of hirsutism. Oral contraceptive pills
of testosterone and reduces cutaneous 5-alfa reductase activity.
containing estradiol and progestogen desogestrel or
Dose 100–200 mg/day.
drospirenone (which is lipid friendly and has no
4. Flutamide: It is a non-steroidal antiandrogen at the receptor
androgenic effect) are used. Drospirenone is an
level given in a dose of 250 mg twice a day.
analog of spironolactone, a known antiandrogenic
5. Finasteride: It is a type II 5-alpha reductase inhibitor. It is
agent, which is effective in improving acne, has a
given in a dose of 5 mg/day.
negative influence on fasting insulin concentrations
6. GnRh agonists: They can be given in a depot preparation
and triglycerides.
with the goal of reducing serum testosterone to 40 ng/dl for
• Metformin also induces regular cycles in 68–95%
patients resistant to the above therapy.
patients treated for 4–6 months.
iii. Dealing with unwanted body hair: Treatment of hirsutism
c. Treatment of hyperandrogenism: Treatment consists
is done by cosmetic methods like electrolysis, waxing,
of drugs with antiandrogenic action discussed in the
bleaching, laser therapy, etc. Electrolysis and laser ablation
treatment of hirsutism (chapter 15).
therapy are the only two methods that claim to be
d. Surgical wedge resection or laparoscopic drilling of
permanent hair removal techniques but are expensive and
the ovaries. It has also been advocated for the treatment
painful procedures. It is also important to refer patients to
of PCOS. Spontaneous ovulation occurs in 70–90% and
reputable technicians who perform these procedures to
hyperandrogenemia is reduced.
reduce the incidence of complications that are often
e. Psychosocial support
associated with these methods of hair removal (scarring
• Offering psychosocial support by building positive,
with electrolysis and hypo-pigmentation with laser ablation
supportive relationships with adolescents
therapy). Plucking and waxing are inexpensive methods
diagnosed with PCOS, will allow them to express
that can be performed in the privacy of one’s home or
their feelings and concerns regarding the disease.
through salon services but are by no means a permanent
Positive communication can greatly impact one’s
solution to hirsutism. Shaving is yet another option, but
body image and self-esteem.
many women find this very undesirable.
74
INFECTIONS IN ADOLESCENTS (donovanosis), lymphogranuloma venereum, molluscum
Reproductive tract infections (RTIs) include all infections of contagiosum, pubic lice, scabies, trichomoniasis.
the reproductive tract, including those not caused by sexual
contact. It includes: Presenting Features
a. Sexually transmitted infections (STIs) Protecting the adolescents from STDs can be done by advising
b. Endogenous infections caused by overgrowth of organisms them to follow ABC strategy.
that are usually present in the genital tract of healthy a. Abstinence
females, e.g bacterial vaginosis, vulvovaginal candidiasis. b. Be faithful
They present as abnormal vaginal discharge. c. Use condom.
c. Iatrogenic infections which are associated with medical The best way to prevent adolescents from contracting an
procedures like induced abortion. STI is to advise them to abstain from any type of sexual
intercourse. However, if they decide to become sexually active,

Chapter 13
Sexually Transmitted Infections or are currently sexually active, there are several precautionary
Adolescents, particularly those who are sexually active, are at measures to follow:
a higher risk of acquiring STDs. The most crucial factors of STD • Have a mutually monogamous sexual relationship with an
risk in adolescents are sexual behavior, specific social factors uninfected partner
and lack of sexual education. • Use (consistently and correctly) a male condom
• Use sterile needles if injecting intravenous drugs
Risk Factors for Increased Susceptibility of Adolescents for STIs • Decrease susceptibility to HIV infections by preventing and

Adolescent Gynecological Issues

• Age at first sexual intercourse: It is seen that early sexual controlling other STDs
debut is associated with an increasing number of lifetime • Delay having sexual relationships as long as possible—the
sexual partners which consequently also increases the risk younger the persons are when they begin to have sex for
of acquiring STDs. the first time, the more susceptible they become to
• Use of contraception: Inconsistent use of contraceptives is developing an STD
seen among adolescents. More than 50% adolescents do not • Have regular check-ups for STDs
use any contraception at their first sexual intercourse. • Learn the symptoms of STDs and seek medical help as soon
• Sexual experimentation: Adolescence is a period of intense as possible if any symptoms develop
sexual experimentation that includes both anal intercourse • Avoid having sexual intercourse during menstruation
and homosexuality. Moreover, girls have the tendency to • Avoid anal intercourse
have sex with older and more experienced partners, who • Avoid douching
are more likely to carry infections. Before 20 years of age, If an adolescent is diagnosed with an STD, he/she should:
the lining of the vagina and exocervix are single layer, which • Begin treatment immediately, take the full course of
is unable to stand the trauma of sexual act and give a strong medications, and follow physician’s advice
barrier to infection. These linings are multilayered (stratified • Notify all recent sexual partners and urge them to get
squamous) in an adult women to give a formidable medical check-ups
protection. • Avoid sexual activity while under treatment for an STI
• Physiological immaturity: During adolescence, there is a • Have a follow-up test to be sure the STI has been
characteristic instability of the hypothalamic-pituitary- successfully treated.
ovarian axis which results in deficiency of progesterone;
hence, less cervical mucus that is, in turn, linked to increased Endogenous Infections
vulnerability of the genital tract to infection. The Endogenous infections commonly present as vaginal discharge
physiological risk of increased susceptibility to infections which is one of the most common gynecologic problems
among adolescent girls is due to the presence of greater encountered in the adolescent population.
cervical ectopy which makes the cervix more susceptible to Vaginal discharge, may be fairly non-specific and may have
gonorrhea, chlamydia and Human Papilloma Virus (HPV). many causes. In the prepubertal age group, discharge is
• Social reasons: generally associated with vulvovaginitis. In the postpubertal
– Poor or unemployed adolescents or adolescents in age group, discharge may be physiologic, or may be associated
socially discriminated ethnic and minority groups are with cervicitis or vaginitis. In each group, gonorrhea and sexual
reported to have earlier first sexual intercourse, more abuse must be ruled out. It is discussed in appropriate chapter.
number of lifetime sexual partners and more intercourse Genital tuberculosis is a common chronic infection in our
without protection. country and can present as menorrhagia (in early phases),
– Adolescents use more alcohol and drugs prior to or amenorrhea and infertility. This is dealt with in chapter 38.
during sex and because of this they may escalate into
high-risk behavior without using any appropriate PELVIC PAIN IN ADOLESCENTS
protection. Pelvic pain is a common problem in adolescents and treating it
– Adolescents have little or no knowledge of STDs and is a challenge for the clinicians. Causes of pelvic pain include
their sequelae and little contact with health care workers. conditions like pelvic inflammatory diseases, pregnancy and
Common types of STDs include: (Discussed in detail in pregnancy-related problems, endometriosis, Mittelschemerz
Chapter 36 RTI/STI/HIV). Common causative organisms are (ovulation pain), adnexal torsion, Mullerian anomalies and
human immunodeficiency virus (HIV), human papillomavirus pelvic adhesions. Urological diseases, gastrointestinal ailments,
(HPV), Chlamydial infections, gonorrhea, genital herpes, musculoskeletal abnormalities and psychosocial problems are
syphilis etc. other causes of pelvic pain. Proper detailed history and
Other diseases that may be sexually transmitted include: assessment of psychological factors help in diagnosing the
Chancroid, cytomegalovirus infections, granuloma inguinale etiology. Ultrasonography besides identifying the pathology
75
 helps in assuring the patient that everything is normal, if no Both these tumors, frequently, produce estrogen and present
pathology is detected. Endometriosis should be kept as a with precocious puberty or irregular menstruation.
possibility if the patient does not respond to analgesics and no Fibroma: These account for 0.5–25 of all ovarian tumors in
organic pathology is identified. infancy and childhood. If the size is greater than 10 cm, the
patient may present with ascites and pleural effusion.
Endometriosis Gonadoblastoma: These consist of both germ cell and sex cord
When seen in adolescents, it presents as cyclical or acyclical stromal elements. They are rounded, smooth, or bossed in
pelvic pain. Dysmenorrhea, irregular menses, dyspareunia, appearance and grayish-pink on the cut surface. One-third is
abdominal pain and nausea, constipation and diarrhea are other bilateral. They are seen in patients with gonadal dysgenesis.
symptoms.
Pelvic examination is often unremarkable. Adenexal masses Malignant Ovarian Neoplasms
may or may not be present. CA-125 levels may be elevated and Most common malignant tumors in adolescent age group are
Endocrinology in Gynecology

ultrasound or MRI may reveal endometriotic lesions in the germ cell tumors. Non-germ cell tumors include tumors derived
abdomen. Diagnostic laparoscopy will help in diagnosis and from malignant epithelial elements (adenocarcinomas,
more often in treatment. cystadenocarcinomas, endometrioid tumors), malignant sex
Medical treatment consists of hormonal suppres-sion by oral cord stromal tumors, malignant counterparts of fibromas and
contraceptives, danazol, DMPA or GnRH agonists. Surgical metastatic tumors.
treatment includes laparoscopic fulguration of implants with Dysgerminoma: It is the most common malignant tumor
removal of endometrioma and lysis of adhesions. accounting for 30–40% of ovarian malignancies of germ cell
origin. These are usually unilateral but may be bilateral in 10%
GENITAL TUMORS IN ADOLESCENTS of cases. The average size is around 15 cm. These are firm or
Genital tract tumors in adolescent girls pose a special challenge solid, rubbery smooth or lobulated. The cut surface shows a
because the need to preserve genital tissue and reproductive homogeneous pinkish gray or yellowish appearance with areas
function has to be balanced against the need of complete excision of necrosis. Histopathology shows presence of polyhedral cells
of tumor. Vaginal, vulval and cervical tumors are rare in with clear cystoplasm.
adolescents; however, ovarian masses may be encountered. Endodermal sinus tumors: This is one of the most malignant
Most of the neoplasms in this age group are benign, but a yolk sac tumors of ovary and occurs almost exclusively in children
significant few can turn out to be malignant. and teenagers. It is confined to one ovary, although rupture and
Section 3

ascites are common. It produces alpha fetoprotein. The tumor is

Ovarian Masses (Given in detail in chapter 49) smooth and glistening and the cut surface shows cystic and solid
Functional ovarian cysts are very frequent in adolescents due areas.
to a higher incidence of anovulatory cycles in this age group.
Ovarian neoplasms account for approximately 1% of all Clinical Presentation of Ovarian Masses in Adolescents
malignant tumors in girls aged 17 years or below. Ninety-two Ovarian neoplasms in adolescent girls are usually asymptomatic
percent of these girls have germ cell tumors, whereas epithelial and may be detected as an incidental finding at laparotomy
tumors are uncommon in this age group. done for some other reason. Most of the patients have vague
Non-specific ovarian enlargement may be seen as abdominal discomfort. Recurrent abdominal pain is seen in
functional ovarian cysts or endometriomas. approximately half of the patients. Torsion may occur in as many
Functional cysts may present as follicular cysts, corpus luteal as 35–40% of neoplasms in adolescents. Occasionally, hormone-
cyst, theca lutein cysts. These are due to higher incidence of producing ovarian tumors in young girls may present as
anovulatory cycles and due to abnormal gonadotropin precocious puberty, abnormal vaginal bleeding or virilization.
secretion. The cysts are usually benign and range from 3–10 cm Tumors as dygerminoma, which destroy ovarian tissue, may
in size and usually resolve spontaneously by 4–8 weeks. Surgery present as amenorrhea. Rapidly growing endodermal sinus
may be required if there are signs of torsion. tumor may have a short clinical history of fever, pain and lump
Endometrioma presents with severe dysmenorrhea, chronic in the abdomen.
pelvic pain, menstrual symptoms or urinary symptoms. CA-
125 may be elevated. Diagnosis is made by ultrasonography Investigations
and laparoscopy. Surgery in this group is excision and/or Ultrasound, CT scan and MRI are the main modalities for
ablation of the implant along with hormonal suppression. diagnosis of these tumors and for providing information
Benign tumors may present as mature cystic teratomas regarding the size, location, spread and consistency of the tumor.
(Dermoid) or sex cord tumors (thecomas, fibromas and They also suggest if it is a benign or malignant tumor. Plain X-
gonadoblastomas) or benign epithelial tumors. ray of abdomen and pelvis is useful in visualizing the
Benign teratoma: These are usually unilateral tumors calcification seen in teratomas.
measuring approximately 10 cm. Cut surface of the tumor has Tumor markers are also useful in detection and monitoring.
glary fatty fluid; and at one place, there is usually a papilla, CA-125 is elevated in epithelial tumors, alpha fetoprotein (AFP)
where hair and sebaceous material, and at times, a tooth or and human chorionic gonadotropin (hCG) are elevated in
cartilage may be seen. Histopathology shows all three elements. endodermal sinus tumor and choriocarcinoma. Placental
Malignant change occurs in 1–2% of cases. alkaline phosphatase and lactate dehydrogenase (LDH) are
Ganulosa/Theca cells tumor: Granulosa cell tumor is usually elevated in dysgerminoma.
unilateral. In 5% of cases, it is seen bilaterally. It is capsulated
with a smooth or lobular surface. The cut surface is cystic with Management
areas of hemorrhage. All granulosa cell tumors should be Functional ovarian cysts, which are less than 6 cm in size, can
considered to be potentially malignant. The thecoma are usually be observed or oral contraceptives can be used for regression
bilateral. It is firm and rubbery in consistency. The cut surface of these cysts. Cystectomy is done when the cyst persists or
76 shows a yellowish substance separated by gray fibrous tissue. increases in size. Benign ovarian neoplasms should be managed
by conservative surgery. Cystectomy with preservation of age of socially sanctioned sexual relations. Both these factors
ovarian tissue is the treatment of choice. Salpingo- result in initiation of sexual activity.
oophorectomy is reserved for cases with torsion or infarction. • Modern culture and media: Adolescents today are growing
Once the diagnosis of ovarian tumor is made, laparotomy up in a modern culture in which peers, TV and movies, music,
must be undertaken without delay in view of the possibility and magazines transmit subtle or obvious messages that
that the tumor may be malignant. Careful inspection of the unmarried sexual relationships (specifically those involving
tumor provides a clear idea of its benign or malignant nature. teenagers) are common, accepted, and even expected.
If the tumor is smooth walled, unilateral, clearly cystic • Sexual violence: There is an increased incidence of sexual
throughout without any adhesions or papilliferous structures, violence in our society among very young children and older
it is probably benign. teenagers. Almost always the perpetrator is someone they
Bilateral cystic tumors may be benign or malignant. A very know and trust—a relative, family friend or caretaker.
careful inspection including bisection of the tumor to inspect Sexual coercion and rapes figure prominently in the lower

Chapter 13
its internal surface will be required to decide what is to be done. socioeconomic strata. Pregnancies are not the only result,
It is important to remember that simple teratomas are sometimes sexual abuse violates the body and the mind, kills the
bilateral. innocence of the child with serious physical and
A solid tumor may be benign or malignant. A psychological consequences.
uniform solid fibromatous looking growth is likely to be a • Socioeconomic factors often force young girls into being
fibroma or more rarely a benign thecoma. In some instances, sexually exploited and into prostitution, which is
the clinical signs of malignancy may be evident with the tumor compounded by their inability to negotiate condom use

Adolescent Gynecological Issues

obviously spreading to nearby organs, peritoneum or the leading to adolescent pregnancy and sexually transmitted
omentum. Whenever there is doubt about the nature of the infections.
tumor, salpingo-oophorectomy must be performed along with • Lack of access to health care facilities: Contraceptive and
frozen section biopsy of the tumor. If the tumor is found to be abortion services are not easily approachable and are not
malignant on histopathology, chemotherapy is advocated. adolescent friendly. This leads to risky pregnancy and
Combination chemotherapy is usually given with Vincristine, unsafe abortion.
Actinomycin D and Cyclophosphamide (VAC). Issues in sexuality for adolescents are:
Dysgerminomas should be managed with postoperative • How to talk about sex?
radiotherapy as they are extremely radiosensitive. • How to make the right choices?
• How not to get affected by disease?
ISSUES RELATED TO SEXUALITY AND SEXUAL VIOLENCE • How to avoid becoming pregnant?
A substantial proportion of young people is sexually active, in • How to stay healthy?
most countries. Why teenagers have sex, and do so without These problems are due to lack of factual information, little
effective methods of contraception? This is a topic of debate. or no guidance and little or no access to health care. Proper
Suggested reasons include: conseling, by a sensitive and adolescent-friendly health care
• Ignorance regarding sexuality and reproduction: provider, can guide the adolescents.
Adolescents become sexually mature (and fertile) Sexually healthy adolescents:
approximately 4–5 years before they reach emotional • Take care of their reproductive health through check-ups
maturity. Sex and sexuality are issues that confuse and • Avoid manipulative relationships
sometimes stress adolescents. This often stems from an • Identify one’s own values and act in accordance with them
unawareness of the issue, misinformation and peer pressure. • Take responsibility for one’s own actions
• Gender imbalances in relationships between adolescents, • Communicate effectively with family and friends
often increases the risks faced by young females. Unlike • Negotiate sexual limits
females, young males are widely perceived to need • Accept refusals for sex
premarital sexual experience and a variety of partners. The • If indulging in sexual intercourse, protect against unwanted
need to conform to these double standards may result in pregnancy and sexually transmitted diseases
reluctance among young girls to report sexual experience. • Seek information and resources about sexuality as needed.
This fear may also inhibit sexually active female adolescents It is well-established that sexually active adolescents are
from seeking contraceptive services. The fear of losing her physiologically at greater risk for STIs than older adults. There
partner or incurring his anger appears to be an important is also risk of teenage pregnancy ending in abortion (Septic)
factor inhibiting young females from exercising choice in and other problems associated with teenage pregnancy.
the timing of sexual activity or negotiating the use of Sexual abuse occurs when a child is engaged in sexual
condoms or other contraceptives. activities that the child cannot comprehend, for which the child
• Behavioral characteristics of adolescents: Morbidity is unprepared and cannot give consent and/or that violates the
pattern in adolescents is heavily influenced by many law and social taboos of society. The sexual activity may include
psychological factors such as impulsiveness and inability any form of orogenital, genital or anal contact or non-touching
to accept the fact that any untoward event can happen to abuse such as exhibitionism or child pornography. How to
them. This inability to perceive future consequences of handle a victim of sexual abuse is discussed in chapter 30.
current behavior is called cognitive immaturity The process
of juvenile experimentation, adventurous nature and poor REPRODUCTIVE HEALTH ISSUES SUCH AS PREGNANCY,
negotiation skills predisposes unmarried girls to sexual ABORTIONS, CONTRACEPTION
activity and unwanted pregnancy. Pregnancy carries significant physical and psychosocial risks
• Increased interval between age at menarche and marriage: for adolescents. Through counseling and treatment, health care
The age of menarche has declined, especially in urban areas. providers should aim to prevent unplanned adolescent
A growing number of adolescent girls go for higher pregnancy. When pregnancies occur, the risks can be reduced
education; and as a result, marry late, thereby delaying the through early diagnosis, by offering a complete range of 77
 therapeutic options and by fully supporting the decisions made approach is the exclusive use of condoms. However, to ensure
by these young people. The health care provider’s role includes maximum contraceptive efficacy, condom use also requires a
medical care and counseling, referral to appropriate services willingness and ability to use emergency contraception in the
and advocacy. event of condom slippage, breakage or failure to use.
Alternatively, adolescents and adults can practice “dual method
Pregnancy Prevention use,” which involves always using a condom plus another
The health care providers have an important role in preventing method that has a lower contraceptive typical-use failure rate,
unplanned adolescent pregnancies. They should discuss e.g. oral contraceptive pill (OCP). Although there is no reported
decision-making with their adolescent patients from a young experience of the use of intrauterine devices (IUDs).
age and apply this to the issues of sexuality, individual choice, • DMPA may affect bone growth so should not be used in
peer pressure, safe sex and contraception in a manner young adolescents.
appropriate to the adolescent’s development. This is particularly Adolescents who have been subjected to sexual coercion
Endocrinology in Gynecology

important for adolescents with a developmental delay, disability and abuse will require special care and support. Emergency
or chronic condition. Adolescents of both sexes, who are likely contraception pill (ECP) is part of a package of services that
to engage in early sexual activity, should be counseled in should be made available in such circumstances. Levonorgestrel
methods of contraception. The discussion should include (1.5 mg as single dose.) within 120 hours of sexual exposure is
information about the emergency contraceptive pill. advocated for prevention of pregnancy. The earlier the
Adolescents at risk of unprotected intercourse include those: ECPs are taken, the more effective they are. No serious
• experiencing social and family difficulties medical complication has been reported. Emergency
• whose mothers were adolescent mothers contraception should not be used as a routine birth control
• undergoing early puberty method, because it is actually less effective at preventing
• who have been sexually abused pregnancies than most types of birth control and the cumulative
• with frequent school absenteeism or lacking vocational goals dose may be harmful.
• with siblings who were pregnant during adolescence
• who use tobacco, alcohol and other substances Adolescent Who Plans to Terminate the Pregnancy
• who live in group homes, detention centers or are street- The adolescent who has decided to terminate the pregnancy
involved. needs:
• Information about the specific details of the procedures
Section 3

Methods of Contraception
available
In general, with the exception of male and female sterilization, • Anticipatory guidance about common emotional responses,
all methods that are appropriate for healthy adults are also such as grief, guilt, relief and anger
potentially appropriate for healthy, post-pubertal adolescents. • Referral to appropriate medical and surgical services
Once puberty has been achieved, methods that are • Appointments for follow-up that include a review of any
physiologically safe for adults are also physiologically safe for complications, such as excessive bleeding, fever, cramps
adolescents. However, as with adults, informed contraceptive after the first 48 hour, abnormal discharge, physical and
decision-making entails consideration of more than just medical emotional concerns, and contraceptive follow-up.
safety. Before discussing contraceptive options, adolescents
must be given the opportunity to express their needs and to Termination of Pregnancy
decide freely whether they want to protect against pregnancy Safe/Unsafe Abortion
or need to protect against STI/HIV. Once a decision is made for Termination of unwanted pregnancy through induced abortion
protection, sexually active adolescents should be presented with generally presents a greater risk to the health and life of all
options that, if used consistently and correctly, will prevent adolescent girls than to an adult woman. Abortion done in a
pregnancy and prevent sexually transmissible diseases. place recognized for termination of pregnancy by a trained
Counseling dialogue between the adolescent and members health professional is usually safe (Discussed in MTP Act).
of the health care team should be structured to assist the The methods of MTP are also discussed in the chapter 53.
adolescent in making a decision that is informed, voluntary and Unsafe abortions are more common among adolescents as
appropriate to the adolescent’s particular circumstances. they are easier to access, in terms of convenience of location
When selecting a method, each adolescent should consider and confidentiality (of prime importance in the case of
the nature of his/her sexual relationship(s), sexual behaviors unmarried girls or those who have been coerced or raped). Apart
engaged in, frequency of intercourse, risk of STIs/HIV, efficacy from the women who die due to postabortion complications,
of the method, ability to comply with use, ability to tolerate there are many more that survive but have to live with chronic
side effects, services available, cost, convenience, religious health problems, and in many cases infertility.
beliefs, attitude of partner(s), and additional personal factors
that may influence the decision and method compliance. When Adolescent Who Plans to Continue the Pregnancy
sexual activity is infrequent or if multiple partners are likely, Prenatal care should be initiated as early as possible to optimize
condoms may be a priority option. Emergency contraceptive maternal and fetal health and well-being. The patient should
pills are an option in the event of condom breakage, slippage, look for a practitioner who is comfortable in addressing social
or other causes of unprotected intercourse. Adolescents who and health issues, such as relationships, smoking, alcohol and
engage in frequent intercourse may opt for methods that are other substance abuse, sexually transmitted infections, nutrition
not coitally related to protect against pregnancy, but will still and breastfeeding, and who will provide anticipatory guidance.
require routine condom use for STI/HIV prevention. Access to adolescent-focused prenatal, postnatal and pediatric
services may improve outcomes for both the adolescent and
Dual Protection and Dual Method Use her infant. The health care provider should:
There are two approaches (other than abstinence) to • Refer the adolescent to an appropriate institution for safe
78 simultaneous protection against pregnancy and STIs. One abortion/delivery
• Encourage her to continue her education to enhance the and habits. Perception of these changes as normal or abnormal
potential for positive maternal and child outcomes, and depends upon comparison of perception of their own body with
decrease social isolation and depression the ‘model’ images. This may lead to changes in behavior of
• Encourage, if appropriate, the presence of the baby’s father adolescents in order to achieve the self-perceived model image.
in the follow-up and discussions about future parenting At times, the attempt to acquire the ‘model’ image becomes
roles and responsibilities pathological and manifest as psychosomatic disorders (eating
• In the case of young women, who choose adoption, refer disorders such as bulimia and anorexia nervosa). Such
them to an adoption service that provides counseling and adolescents need professional help and treatment.
support Body image is defined as “the way one pictures one’s body
• Provide contraceptive counseling to help delay future and competency” or “the picture of an individual has of his or
pregnancies (35% of adolescents who deliver will have her body, what it looks like in the mirror, and what he or she
another pregnancy within the following two years) thinks it looks like to others.”

Chapter 13
• Advocate for high-quality subsidized child care programs Thus, the body image is self-perception of one’s body,
that are flexible in meeting the needs of adolescent parents. personality, and capacities. This self-perception is built on the
information and impressions received by a person since early
MISCELLANEOUS ISSUES
childhood till date from family, friends, community, and
Nutrition for Adolescents projected by the media. This information guides a person in
The Indian Council of Medical Research (ICMR) has provided finding an ‘ideal role model’ for himself/herself. This role model
Recommended Dietary Allowance (RDA) for Indians (Tables may be a real person or even an imaginary one and comparisons

Adolescent Gynecological Issues

13.2 and 13.3). with this role model induce a positive or negative image of one’s
own body. This is reflected in adolescent self-esteem issues. Self-
Body Image Issues esteem is the most important determinant of body image.
Adolescence is a period of changes. These are not limited to As these dimensions may change over time, the body image
physical changes but extend to changes in thinking, attitude also changes over a period of time. Parents, peers and media

Table 13.2: Recommended dietary allowances for Indians

Age group Sex Energy Protein Fat Calcium Iron
Years kcal/day gram/day gram/day mg/day mg/day
10–12 Boys 2190 54 22 600 34
Girls 1970 57 22 600 19
13–15 Boys 2450 70 22 600 41
Girls 2060 65 22 600 28
16–18 Boys 2640 78 22 500 50
Girls 2060 68 22 500 30

Table 13.3: Giving diet chart for girls

Menu 10–14 yrs 15-19 yrs
Breakfast
Milk 1 glass 1 glass
Bread/Porridge 2 pieces/½ small bowl 2 pieces/1 small bowl
Egg/Paneer 1 egg/½ small bowl 1 egg/½ small bowl
Mid Morning Meal
Parantha 1 parantha 2 parantha
(Onion, paneer, potato
or other vegetables)
Vegetables ½ small bowl ¾ small bowl
Fruits 1 1
Lunch
Chapati (or Rice) 2/1 small plate 2–3/1½ small plate
Dal ¾ small bowl 1 small bowl
Salad ½ plate ½ plate
Curd ½ small bowl 1 small bowl
Afternoon Tea
Snack, Upma, Poha, burger/pizza 1 small plate or 40–50 gm 1 plate or 50–75 gm
Sandwich, cutlet
Milk/Milk shake 1 glass 1 glass
Dinner
Chapati (or Rice) 2/1 small plate 2–3/1–2 small plate
Vegetable ¾ small bowl 1 small bowl
Paneer/Non-veg ½ small bowl ¾ small bowl
Dessert ¾ small bowl 1 small bowl
79
 are other important determinants. Parental values do influence adolescent sees an advertisement again and again, so also
the adolescents; but in this age group, peers assume a higher messages on healthy lifestyles and habits need to be told and
importance. Peer norms and acceptability by peers is most re-told.
important in an adolescent’s life. What friends say or think The challenge is to make positive messages attractive,
determines the ideal body image. Another major role is played credible and interesting to the adolescent so that she or he
by print media (newspapers, magazines and books) and remembers and may be passes on the messages to others.
electronic media (television, Internet). To promote sale of their They can be motivated to take up the cause of good health
products, some companies promote their own idea of ‘Ideal because it protects them and gives them a chance to work hard
Body’ or ideal figure endorsed by celebrities. This also influences and enjoy life.
the young minds to a major extent, e.g. thin tall body with fair Changing adolescents’ role models from negative to positive
complexion is projected as ideal and beautiful for girls. Such (from smokers or eve-teasers to sports persons or achievers)
projections may lead to a positive feeling in some girls who have long-term gains—into a balanced adulthood. It can also
Endocrinology in Gynecology

indeed are tall or fair complexioned; but a negative body image help overcome overwhelming body image concerns.
in those who do not possess these qualities, sometimes with
dangerous consequences. Short Stature in Adolescence
Image concerns in girls are: Short stature is a major cause of concern in adolescents and
• Being overweight their parents. There are chances that with age, height will
• Breast size (small or large) increase. It is important to understand that height differs from
• Complexion person to person. However, in no way should it stand in the
• Body hairs, acne blemishes way of leading a normal life. One should always think positively
• Wearing spectacles and focus on qualities and aptitudes. It depends a lot on the
• Being tall/short in height. height of one’s biological parents and many other factors, e.g.
Desire to become thinner tops the list of body image nutrition.
concern of girls followed by the size of their breast. These they To estimate the maximum achievable height of an
think to have impact on their overall looks, beauty and adolescent, it is important to find the midparental height
attractiveness. More and more girls are dieting, joining slimming {(height in centimeter of father + height in centimeter of mother)/
centers to look thin, even if their weight is normal for their age 2; add 6.5 for boys and subtract 6.5 for girls}
and height. Looking thin is ‘in’ and breast size is important for This is the target height for that adolescent and it is plotted
Section 3

attractiveness and a slim and trim image. on a growth chart at column of 18 or more years. If the
Some adolescents with such concerns may seek guidance adolescent is well below this percentile line, then she/he needs
by directly defining their problems as height, overweight, acne, evaluation for short stature.
etc., but most of the adolescents have indirect presentations The importance of nutrition cannot be overlooked.
as: Meanwhile, adolescents should have adequate exercise
• Poor scholastic performance (recent change in performance) including cycling, swimming, running, high jump, long jump
• Excessive tiredness and other such sports activities that help to stretch the body.
• Sleep disturbances Stretching exercises help gain a little height by muscular
• Withdrawal from family and friends stretching of lower limbs.
• Eating disorders
• Excessive shyness Pimples/Acne
• Bullying and delinquency. To some degree, acne is unavoidable during adolescence.
In such situations, adolescents should be asked: Explanation to adolescents that acne is the result of the
• Are you comfortable with size and shape of your body/body acceleration in the production of hormones, androgens, that
parts? Do you often talk about it? occurs in puberty, satisfy the anxiety. Acne is the clogging of
• Are you dieting or diet often? the pores in the skin.
• Do you feel guilty after eating certain foods? They can be guided by telling them regarding the
• Do you feel inferior to other people who as you think have precautions of not touching the face often and frequently
good body size and shape or feel superior to people you washing the face.
think have poor body image? Common myths such as consumption of oily foods or
• Do you not feel like making friends? exposure to sunlight increases these pimples or stress causes
If the answer to any of these is yes, then a thorough workup acne, should be clarified.
is needed to determine the underlying body image issues. A good healthy diet, plenty of water and exercise will help
Adolescents should be told that: the skin look its best. If left untreated, acne may cause a recurrent
• Change is normal, learn to deal with it! discomfort and pain and will ultimately cause scar marks on the
• Real beauty is inside, so develop your inner self. Accept face or other parts of the body. However, acne may be a cause for
what cannot be changed and develop inner happiness. stress in many adolescents.
• Knowledge regarding normal changes occurring
during adolescence and simply knowing the definition of Breast Size
what is normal and what is abnormal helps in clearing Many teenagers worry about their breasts not developing early
misperceptions. enough or at the same pace as their friends. For them,
An adolescent is a consumer—of media and of consumer developing (or lack of it) becomes a source of anxiety and stress.
goods. Therefore, developing critical skills that will help decode For other girls, seeing their breasts budding make them feel
messages from advertisements, influences of peers/role-models embarrassed and uncomfortable about their own body.
who smoke, bunk classes regularly or experiment with sex and Similarly, size of the breast (too small or too big according to
80 alcohol is important. Again, reiteration is the key. Just as an their perception) becomes a source of concern for adolescents.
Counseling that the function of breasts is not dependent on APPROACH TO AN ADOLESCENT CLIENT
size and highlighting the fact that a girl’s inner strength and It is important to identify the problem of an adolescent, helping
actions are more important than the appearance can make them them to make decisions and giving them confidence to put their
confident. decisions into practice. Adolescent counseling is based on the
following principles:
ADOLESCENT IMMUNIZATION • Help the client to identify the problem and make decisions
Proposed immunization schedule for adolescents by Indian for himself or herself
Association of Pediatrics (IAP) • The client (not you as service provider) has the right to
choose his or her own action
Diphtheria, Pertussis, - Tdap Booster dose in • Accurate information is provided
Tetanus previously immunized-Three • Is strictly confidential
doses of Tdap in previously • Takes into account psychosocial, financial and spiritual

Chapter 13
unimmunized or partially needs of the client.
unimmunized
MMR - Single booster dose in all the Attitude of health personnel and interviewing strategy should
adolescents focus on that he/she should be normal:
- Two doses at 4 weeks if • While maintaining a professional manner
• Be relaxed, open, flexible, honest and straight forward
previously unimmunized
• Appear unhurried even if time is limited
Hepatitis B Full course in previously
• Explain confidentiality

Adolescent Gynecological Issues

unimmunized child
• Explain your process
Vaccination against varicella, Hepatitis A and HPV are not • Adolescent’s visit to the clinic gives an opportunity to the
recommended for universal use. health care personnel to offer a psychosocial screening
As certain strains of HPV have been found to cause most examination.
cases of cervical cancer, research efforts have focused on • A psychosocial assessment tool has been developed to assess
developing a vaccine against HPV. Two HPV vaccines are issues of home, education, activities, drugs, sexuality,
currently in the market: Gardasil and Cervarix. These are suicide or depression, and safety (HEADSSS).
administered as a series of three injections over a six-month • This assessment tool provides an entry to discuss the major
period. The vaccine should be given to girls before they become psychosocial issues of adolescents (Although these
sexually active. questions are personal, teens are reported to prefer to
discuss these issues with physicians).
PELVIC EXAMINATION IN ADOLESCENTS • Assurance of confidentiality increases the number of
adolescents who will discuss sensitive informa-tion about
Age of First Pelvic Examination sexuality, substance misuse, and mental health and those
There is no “perfect” time for the adolescent patients to have who are willing to seek future health care. For this reason,
their first pelvic examination. The decision to perform a pelvic administering written questionnaires in the waiting room
examination should be based on the age of the patient, her is avoided.
history and presenting symptoms and considerations of the In offices or clinic settings, with a variety of patients of
additional value a pelvic examination will add in making a different ages, scheduling times when only teens will be seen
diagnosis. The American College of Obstetricians and may be helpful. Teens feel more comfortable having other teens
Gynecologists (ACOG) and the American Cancer Society in the visiting area. This also provides an opportunity to play
recommend that female adolescents have their first pelvic educational videotapes, have different devices or materials out
examination and Pap test within 3 years of the onset of vaginal for display, or provide educational brochures that may be
intercourse or no later than 21 years of age. However, appropriate for younger age groups. Placing sensitive
throughout early middle and late adolescence at the time of information in individual examination rooms rather than the
the periodic preventative care visits and health visits, health waiting room gives teens the opportunity to take or read it
care professionals should provide developmentally appropriate unobserved by other teens.
information, counseling, and anticipatory guidance on
reproduction, STIs, pregnancy prevention, and other women’s Points to Watch for in the HEADSSS Assessment
health issues. H home
E education/employment/eating/exercise
Indications for Pelvic Examination in Adolescents
A activities/peers
After obtaining a thorough health history from the adolescent,
D drugs/cigarettes/alcohol
the health care provider must address the questions: ‘Is a pelvic
examination indicated? Can the pelvic examination be safely S sex/sexuality/(abuse)
deferred or is it absolutely indicated?’ In the non-sexually active S suicide/depression screening/other symptoms
adolescent, a pelvic examination is rarely indicated. Young age S safety/spirituality
is a risk factor for STIs, and sexually active female adolescents If the adolescent has run away from home or spent long
have the highest incidence of STIs of any sexually active periods of time in the home alone, more attention needs to be
population. The greatest STI risk occurs in sexually active female directed to issues related to drug misuse, sexuality, and
adolescents aged <15 years, residents in detention facilities, and depression. A sudden, unexplained drop in grades or frequent
injection drug users. absences should lead to further exploration of sexuality, drug
Counseling, small size of speculum and gentle patient misuse, family problems, or depression. School failure should
handling will give the patient confidence and she will cooperate be explored as a possible early indication of other risk behaviors
with the examining doctor. in high school students. Questions about friends, the use of free
81
 time, and attendance at parties can provide indirect information reorganizing the existing public health system in order to meet
about sexual activity, drug misuse, and mental health. the service needs of adolescents. Steps are being taken to ensure
improved service delivery for adolescents during routine hours
ADOLESCENT-FRIENDLY HEALTH SERVICES
as well as in the dedicated clinics on fixed days and timings at
Services are adolescent-friendly if they have policies and the Sub-center, Primary Health Center, Community Health
attributes that attract adolescents to the facility or program, Center and District Hospitals and also through the outreach
provide a comfortable and appropriate setting for serving activities. A core package of services would include preventive,
adolescents, meet their needs, and are able to retain them for promotive, curative and counseling services for adolescents.
follow-up and repeat visits. Characteristics of an adolescent- Thus, India is aiming for healthy adolescents and a healthy
friendly service are: nation.
• Welcoming facility
• Privacy and confidentiality is maintained BIBLIOGRAPHY
Endocrinology in Gynecology

• Service at a convenient place and at convenient time

1. Deligeoroglou E, Tsimaris P. Menstrual disturbances in puberty.
• Services are free or at least affordable
Best Pract Res Clin. Obstet Gynaecol 2010; 24(2):157.
• Staff treats adolescents with respect and do not judge them 2. Evanthia DK. PCOS in adolescents. Best Pract Res. Clin. Obstet
• A range of services are available and adolescents are not Gynaecol 2010;24(2):173.
asked to come back or referred elsewhere. 3. Molina RC and Zamorono JS. Family planning and adolescent
• These services provide promotional screening—clinicial and pregnancy. Best Pract Res Clin Obstet Gynaecol 2010;24(2):209.
preventive services and have: 4. Orientation Programme for Medical Officers to provide
– Adolescent-friendly policies and procedures Adolescent–friendly Reproductive and Sexual Health Services
– Adolescent-friendly health care providers and support Handouts published by IEC Division, Govt. of India May 2 Ministry
of Health and Family Welfare.
staff
5. Parul Kotdawala, Vinita Salvi and Usha R Krishna, Adolescent Girl
– Have adolescents and community involvement. –Update, FOGSI Publication 2004. published by Jaypee Brothers,
The Government of India has positioned Adolescent Delhi.
Reproductive and Sexual Health (ARSH) Strategy as one of the 6. United Kingdom National Guideline on the Management of
key technical strategies in RCH II Program under the National Sexually Transmitted Infections and Related Conditions in Children
Rural Health Mission (NRHM). This strategy focuses on and Young People (2009).
Section 3

82
 14 Amenorrhea

Pratima Mittal, Aruna Batra

• Definition • When pituitary fails to provide appropriate gonadotropin

• Etiologic factors stimulation to the ovary, resulting in inadequate production
• Evaluation of estradiol or failure of ovulation and progesterone
• Management production. (Compartment III)
• Specific disorders for amenorrhea. • When hypothalamus fails to provide stimulus to pituitary
for production of gonadotropins. (Compartment IV)
DEFINITION OF AMENORRHEA Disorder of each compartment requires specific diagnostic
Amenorrhea is defined as the absence or cessation of menstrual evaluation and management.
flow. Amenorrhea is not a diagnosis or a disease, but rather a
symptom and is a manifestation of various pathophysiological ETIOLOGY OF AMENORRHEA
disorders. Amenorrhea can be physiological or due to some underlying
Any patient fulfilling the following criteria should be pathology. Physiological amenorrhea is seen either at extremes
evaluated as having clinical problem of amenorrhea: of age as at puberty or menopause or in pregnancy and lactation.
• Absence of menses by the age of 14 years with the absence Amenorrhea at puberty is due to inadequate production of
of growth or development of secondary sexual characteristics gonadotropins to stimulate the ovarian follicles for effective
(e.g. breast development). steroidogenesis. Depletion of ovarian follicles at menopause is
• Absence of menses by the age of 16 years with normal responsible for amenorrhea.
development of secondary sexual characteristics (one year During pregnancy, amenorrhea is due to negative feedback
beyond family history of menarche or two years after on production of gonadotropins by increased levels of estrogens
complete sexual maturation). and chorionic gonadotropin from the trophoblasts. High levels
• In a woman who has been normally menstruating, the of prolactin inhibit ovarian response to gonadotropins during
absence of periods for a length of time equivalent to a total lactation.
of at least three of the previous cycle intervals or 6 months Pathological amenorrhea can be either real or
of amenorrhea. concealed. In concealed amenorrhea, (cryptomenorrhea), there
Establishing the etiology of amenorrhea is essential for safe is periodic shedding of endometrium and bleeding; but
and effective management. A basic understanding of the normal menstrual blood fails to come out from the genital tract due to
menstrual cycle, puberty and hormonal changes are key factors obstruction in the passage (imperforate hymen on vaginal
for recognition and treatment of menstrual dysfunction. septum). Amenorrhea is labeled as primary if the woman has
never menstruated and secondary if the woman was having
Physiology of Menstruation (Ref. Chapter 10 for detail) periods but has stopped now.
Basic principles of menstruation are:
• Coordinated hypothalamic-pituitary-ovarian axis. Flow chart 14.1: Regulation of menstrual cycle
• Normal female chromosomal pattern (presence of ovarian
follicles thus production of estradiol)
• Active support by thyroid and adrenal glands.
• Responsive endometrium and anatomical patency of the
genital tract.
These basic principles underlying the physiology of
menstrual function permit formulation of several discrete
compartmental systems (Flow chart 14.1) on which proper
menstruation depends. Amenorrhea occurs:
• When hypothalamus, pituitary and ovaries are functioning
normally, but either the uterus is absent or the endometrium
is unresponsive to the hormones or there is an obstruction
to the cervical/vaginal outflow tract (Compartment I)
• When ovaries fail to produce adequate amounts of estradiol
despite normal and appropriate gonadotropin stimulation
by the hypothalamus and pituitary. (Compartment II)
 The most common cause of amenorrhea in the • Virilizing adrenal/ovarian tumors
reproductive age is pregnancy. • Granulosa-theca tumors ovary.
Etiologies of primary and secondary amenorrhea overlap
leaving very few unique to primary amenorrhea and few unique EVALUATION OF AMENORRHEA
to secondary amenorrhea. Most patients with primary The differential diagnosis of amenorrhea is broad and can range
amenorrhea have one of three conditions: gonadal failure, from genetic abnormalities to endocrine disorders and can be
congenital agenesis of the uterus/vagina, or constitutional delay. due to psychological, environmental, and structural anomalies.
Most nonpregnant women with secondary amenorrhea will To facilitate prompt and accurate diagnostic work up, obtaining
prove to have chronic anovulation, hypothyroidism, a thorough history and carrying out a detailed physical
hyperprolactinemia, or weight loss and anorexia. Etiology of examination is essential.
amenorrhea can be established keeping the symptomatology A good history can reveal the etiologic diagnosis in up to
in mind and can be classified according to the level at which 85 of cases of amenorrhea. History should include:
Endocrinology in Gynecology

the defect is present. • History of childhood growth and development, including

height and weight charts
Compartment I (Uterine/Outflow Tract) • Age at thelarche axillary and pubic hair development and
• Asherman’s syndrome: Secondary to uterine/cervical menarche
surgery or secondary to infections (TB, PID). • Appearance of external genitalia and ambiguity at birth
• Mullerian abnormalities: Transverse blockage as • Age at menarche and menstrual history of the patient’s
imperforate hymen, transverse septum of vagina. mother and sisters
• Mullerian agenesis: Uterovaginal agenesis, Mayer- • History of genetic abnormalities/genetic disorders/
Rokitansky-Kuster-Hauser (MRKH) syndrome, vaginal endocrinopathies in the family
agenesis. • Past history of any chronic illness, trauma, surgery, and
• Androgen insensitivity syndrome: (previously called medications
testicular feminization) female with enzyme deficiency. • History of tuberculosis, diabetes and thyroid disorders
• History of abnormal loss or gain of weight in a short span
Compartment II (Ovarian Failure) of time
• Chromosomal abnormalities: Turner’s 45 O/mosaic/partial • History of vigorous exercise
deletions • Sexual history should be obtained in a confidential manner
Section 3

– Pure gonadal dysgenesis (Perrault/Swyer) • Information regarding substance abuse, home/school

– Gonadal agenesis situations and psychosocial issues should be saught for
• Premature ovarian failure • Any history of galactorrhea (milky discharge from the
• Resistant ovary syndrome (Savage syndrome) breasts) is important and indicates the need for a prolactin
• Effect of radiotherapy/chemotherapy/infections/ hormone level to rule out hyperprolactinemia
autoimmune/galactosemia. • History of hot flashes, breast atrophy and decreased libido
• Ovarian failure due to menopause, surgical removal of along with amenorrhea indicates premature ovarian failure
ovaries. • Certain medications such as phenothiazines (used for
• Polycystic ovary syndrome psychiatric disorders) and some narcotics can cause
• Enzymatic block as 17 hydroxylase deficiency. amenorrhea, usually in association with an elevated
prolactin and galactorrhea
Compartment III (Pituitary) • History of severe postpartum hemorrhage (PPH)
• Hormone-secreting tumors as pituitary adenomas suggests pituitary insufficiency from infarction (Sheehan’s
• Hyperprolactinemia syndrome)
• Hypothyroidism • History of amenorrhea following D C (dilation and
• Tuberculosis, sarcoid granulomas, dermoid cyst of the curettage) leads to suspicion of intrauterine adhesions
pituitary (Asherman’s syndrome), particularly if the procedure was
• Infarction (Sheehan’s syndrome) pregnancy related
• Surgical or radiological ablation • History of uterine surgery such as metroplasty,
• Empty sella syndrome. myomectomy or cesarean section and conization is
important
Compartment IV (Hypothalamic) • On discontinuation of oral contraceptives, some women will
• Constitutional delay (physiological) not have periods for up to several months. However,
• Weight loss, anorexia nervosa, bulimia amenorrhea of greater than 6 months duration after oral
• Vigorous exercise contraceptive use is not related to the pill use and to be
• Emotional stress: Anxiety, pseudocyesis investigated.
• Hormonal contraception A comprehensive review of symptoms should include
• Chronic renal, liver, lung disease, chronic infections, vasomotor symptoms, hot flushes, virilizing changes,
diabetes mellitus, Addison’s disease galactorrhea, headache, fatigue, palpitations, nervousness,
• Genetic Kallmann’s syndrome hearing loss, and visual changes.
• Organic disease/Injury to midbrain: tumors (cranio-
pharyngiomas, gliomas), infiltrative lesions, trauma, Physical Examination
irradiation. Physical examination begins with vital signs, including height
Other endocrine dysfunctions/tumors can also cause and weight and with sexual maturity ratings. In the physical
amenorrhea as observed in: examination, special attention should be given to the following
• Congenital adrenal hypeplasia (CAH) Cushing’s syndrome findings:
84
• General examination
– Cachexia, bradycardia, hypotension, and hypothermia
(anorexia nervosa)
– Fundus changes, visual field impairment, and cranial
nerve signs (Pituitary tumor)
– Acne, acanthosis nigricans, and obesity polycystic
ovary syndrome (PCOS)
– Webbed neck, increased carrying angle, and lack of
breast development (Gonadal dysgenesis—Turner’s
syndrome) (Figs 14.1 and 14.2)
• Breast examination
– Sexual maturity rating (SMR) of breast development

Chapter 14
(Chapter 12)
– Presence of galactorrhea (Hyperprolactinemia) (Fig.
14.3)

Fig. 14.3: Galactorrhea

Amenorrhea
– Underdeveloped breasts with sparse pubic hair
(delayed puberty)
– Undeveloped breasts with normal growth of pubic hair
(Gonadal dysgenesis—Turner’s syndrome)
• Examination of pubic hair and external genitalia:
– Pubic hair distribution and excess facial hair
(Hyperandrogenism/PCOS)
– Absent or sparse axillary and pubic hair, with normal
breast development (Androgen insensitivity syndrome),
without breast development (Delayed puberty)
– Clitoromegaly and virilization (Adrenal or ovarian
tumors )
– Genital anomalies as presence of testis, ambiguous
genitalia.
• aginal per rectal examination
– Distension or bulging of the external vagina
(Imperforate hymen) (Fig. 14.4)
– Shortened/absent vagina without uterus and normal
pubic hair (Vaginal agenesis (Rokitansky-Hauser
syndrome)
– Shortened/absent vagina with uterus and absent pubic
hair (Androgen insensitivity syndrome) (Figs 14.5 A and B)
– Assessment should be done of the vaginal canal for any
transverse septum.

Fig. 14.1: Turner’s syndrome

Fig. 14.2: Turner syndrome karyotype 45XO Fig. 14.4: Imperforate hymen 85
 – Constitutional delay
– Hypothalamic-pituitary lesions/dysfunction.
• Uterus absent
– female with enzymatic deficiency.
Normal Secondary Sexual Characteristics
• Anatomical
– Mullerian abnormalities
– Androgen insensitivity syndrome
– Unresponsive/absent endometrium.
• Non-anatomical
– Premature ovarian failure
Endocrinology in Gynecology

– Immature HTH-pituitary-ovarian axis.

Features of Virilization Present
• 46
– CAH (late onset)/Cushing’s syndrome
– Polycystic ovarian syndrome
– Virilizing ovarian/adrenal tumor
– True hermaphrodite (46 /46 ).
• 46
– 5 reductase deficiency
– Absent anti Mullerian factor.
Some patients will not demonstrate any obvious etiology
for their amenorrhea on history and physical examination.
Before initiating the work up of an amenorrheic patient, it is
important to rule out pregnancy as the cause of amenorrhea,
after ruling out pregnancy a pelvic ultrasound for presence of
uterus and ovaries is advocated. A patient of amenorrhea is
Section 3

then exposed to a combined therapeutic and laboratory

dissection in a logical manner using a step-wise approach (Flow
chart 14.2):
Step 1: The initial step in the work up of the amenorrheic patient
after excluding pregnancy begins with measurement of S
prolactin levels and a progestational challenge test.
• Patients with hypothyroidism should be identified and
Figs 14.5A and B: Non-canalized vagina
treated with thyroxin (Fig. 14.6). This simple treatment is
rewarded with a prompt return of ovulatory cycles. A
significant number of patients with amenorrhea also have
galactorrhea, unilateral or bilateral, persistent or
– Look for evidence of estrogen effect on the vaginal intermittent. It is an important clinical physical sign. A few
mucosa and vaginal secretions. The presence of mucus patients with amenorrhea and galactorrhea will have
suggests that estradiol is currently being produced by hypothyroidism which is not clinically apparent.
the ovaries. Lack of mucus and a dry pale vagina suggest • If prolactin levels are elevated more than 100 ng/ml, MRI of
that no estradiol is currently being produced. head is advocated. If head MRI findings are abnormal, the
– Cervix should be assessed for its potency (rule out cause is pituitary tumor or a brain lesion disrupting the
cervical stenosis). In some cases, there may be cervical pituitary stalk. If the MRI is normal, the cause may be
atresia. medication specifically antipsychiatric, dopamine
– Uterus: If the uterus is enlarged, pregnancy must be antagonist medications which lead to a decrease in
excluded. prolactin-inhibiting factor and a subsequent increase in
– Evidence of any ovarian tumor/adnexal mass is to be serum prolactin levels.
located for. • The purpose of progesterone challenge is to assess the levels
History and physical examination should give information of endogenous estrogens and the competence of outflow
regarding psychological dysfunction or emotional stress, family tract. Progesterone challenge test is carried out either by
history of apparent genetic anomalies, signs of a physical oral administration of medroxy progesterone acetate (MPA)
problem with a focus on nutritional status, abnormal growth 10 mg daily/micronized progesterone 300 mg daily for 5
and development, presence of a normal reproductive tract and days or administrating an intramuscular injection of
evidence of central nervous system (CNS) disease. According to progesterone in oil (200 mg). Within 2–7 days after the
history and examination, patients can be divided in three categories conclusion of progestational medications, the patient will
sexually infantile, normal secondary sex characters and evidence either bleed or not bleed.
of associated virilization etiology of amenorrhea will be different. – Positive withdrawal bleed establishes the facts that:
Sexually Infantile – There is a patent vaginal outflow tract
– Uterus is present which has estrogen (endogenous)
• Uterus present
primed endometrium.
– Gonadal dysgenesis
86
 Flow chart 14.2: Evaluation of amenorrhea

Chapter 14
Amenorrhea

– Minimal ovarian, pituitary, CNS functions present. • Negative withdrawal denotes end organ defect as Asherman’s
Positive withdrawal bleed establishes the diagnosis of syndrome/TB endometritis
anovulation and no further diagnostic evaluation is needed. • Positive withdrawal bleed is a sign of hypoestrogenism and
– Negative withdrawal: Suggests either outflow one should proceed to Step 3.
obstruction or hypogonadism and advocates one to Step 3: The step involves an assay of the levels of gonadotropins
proceed to Step 2 (FS and L ). In order to produce estrogen, ovaries containing
Step 2: Second step is Estrogen Progesterone hallenge est. a normal follicular apparatus and sufficient pituitary
Here, orally active estrogen is administered in quantity and gonadotropins to stimulate this apparatus are required. This
duration certain to stimulate endometrial proliferation step is designated to determine which of these two crucial
and withdrawal bleeding provided that a completely reactive components (gonadotropins or follicular activity) is functioning
uterus and patent outflow tract exists. An appropriate dose improperly. There should be a delay of at least 2 weeks following
is 1.25 mg conjugated estrogen or 2 mg estradiol daily for 21 step 2; as step 2 involves administration of exogenous estrogens
days. The terminal addition of an orally active progestational and endogenous levels of gonadotropins may be altered. These
agent Medroxy Progesterone Acetate (MPA) 10 mg daily for assays will distinguish compartment 2 defects from
the last five days is necessary to achieve withdrawal. In this compartments 3 and 4 defects.
way, capacity of compartment 1 is challenged by exogenous • High levels of FSH 20 and LH 40 IU/ml denotes ovarian
estrogen. failure All patients under the age of 30 years must have
87
 MANAGEMENT OF AMENORRHEA
Appropriate management of amenorrhea depends upon correct
diagnosis, presenting symptom and whether or not pregnancy
is desired.

Objectives of Treatment
• Initiation of menstruation and reproductive potential, in
whom it is possible.
• Appropriate medical and surgical management for
adequate physical development and coital relations.
• Detection and management of any life-threatening
conditions
Endocrinology in Gynecology

• Prevention of osteoporosis.
Accurate diagnosis is the key to management. Treatment
modalities consist of counseling, hormone replacement, surgery
and ovulation induction.
1. Detailed counseling and reassurance should alleviate
anxiety. One should keep in mind that phenotypic
appearance is far more important than either gonadal or
chromosomal identification.
Counseling regarding diet, exercise, etc., should be done.
Psychological factors, if identified, should be handled
carefully. Psychiatric counseling is indicated in severe cases
of anorexia nervosa, etc.
2. Treatment of specific disorder identified, should be
undertaken as in:
• Hypothyroidism: Thyroxine
• TB endometritis: Anti-tubercular treatment
Section 3

• Hyperprolactinemia: Bromocryptine, Carbagolin

• PCO with hirsutism: Cyclic progestin, anti-androgens
• CAH: Corticosteroids.
3. Attempts to restore ovulatory function and create a normal
cyclic hormonal pattern should be aimed at, if this is not
Fig. 14.6: Features of hypothyroidism and hyperthyroidism possible HRT (estrogen and progesterone) is given to hypo-
estrogenic amenorrheic women (to prevent osteoporosis;
atherosclerosis).
4. Periodic progestogen should be taken by amenorrheic women
with normal endogenous estrogen levels (to avoid endometrial
karyotype determination to rule out Turner’s syndrome/
cancer) 10 mg medroxyprogesterone daily for the first 10 days
mosaicism or presence of chromosome. Patients with
of the month.
normal karyotype and high gonadotropins denote
5. When development of secondary sex characteristics is the
premature ovarian failure and etiology can be either
initial goal, estrogens are given daily with dosage increases
iatrogenic or following radiotherapy, chemotherapy
at three-month interval (e.g., conjugated estrogen 0.30 mg,
intrauterine exposure to active or passive smoking or
0.625 mg, 1.25 mg). Once vaginal bleeding occurs,
surgical removal of ovaries or an autoimmune disorder.
progesterone is added each month in combination with
• Low or normal levels of FSH point towards pituitary NS
estrogen to the last 10 days of medications and the patient
failure (Hypogonadotropic) one should proceed to step 4.
takes no medication in the last week. This leaves last week
Step : In this step, imaging evaluation of the sella turcica for signs of each month for withdrawal bleeding, if uterus is present.
of abnormal change is done. If the gondotropin assay is Estradiol valerate 1–2 mg can also be used. The treatment
abnormally low or below normal range, one final localization should start after maximum potential linear growth has
is required to distinguish between a primary (Compartment reached. Hormonal treatment is indicated for the entire life
III) or CNS-hypothalamic (Compartment 4) cause for the of the patients to prevent development of osteoporosis.
amenorrhea. 6. chromosome if present gonadectomy is indicated.
• Imaging evaluation of the sella turcica can diagnose an 7. Surgery is indicated for:
occult craniopharyngioma, or an expanding pituitary tumor. • Ambiguous genitalia
• When coned down view of sella turcica is normal, nRH • Vaginal agenesis
stimulation test can be done for establishing diagnosis of • Uterine anomalies
hypothalmic amenorrhea. • Obstructive collection as imperforate hymen
At this point, the specific anatomic locus of the defect can • Hysteroscopic lysis of adhesions for Asherman’s syndrome
be defined. The clinician can now undertake steps to elucidate • Neurosurgery for craniopharyngioma, pituitary tumor
the specific disorder leading to amenorrhea. Management will causing Cushing’s disease
depend upon the etiology identified according to the above- 8. Pituitary dwarfism has to be treated with human growth
mentioned step-wise approach. hormone (HGH).

88
SPECIFIC DISORDERS RESPONSIBLE FOR AMENORRHEA Diagnosis is by presenting features as cyclic intermittent
Compartment Defects (Uterine/Outflow tract disorders) abdominal pain and urinary frequency. Vaginal/rectal
examination reveals a mass.
Asherman’s syndrome: In this syndrome, there is no response
Treatment is surgery. The septum is excised and edges of
to E P Therapy (Step 2 of diagnostic approach). This is a
the upper and lower vagina are mobilized to permit anastomosis
condition where secondary amenorrhea follows destruction of
(advancement of vaginal flap) (Fig. 41.3).
endometrium. The condition, generally is the result of:
• Overzealous postpartum/postabortal curettage. Impairment Mullerian agenesis:
of endometrium. Uterovaginal agenesis: Lack of Mullerian development—
• Infections, e.g. tuberculosis (Meyer-Rokitansky-Kuster-Hauser syndrome) is a common
• Following uterine surgery including cesarean section, cause of primary amenorrhea. Exact cause of Mullerian agenesis
myomectomy or metroplasty. is unknown however likely causes are mutation of the gene for

Chapter 14
Patients with Asherman’s syndrome can also present besides anti-Mullerian hormone or the gene for anti-Mullerian hormone
amenorrhea with other problems as miscarriages, receptor leading to unwanted exposure to anti-Mullerian
dysmenorrhea or oligomenorrhea. hormone activity.
Diagnosis is by hysterosalpingogram (HSG) or hysteroscopy. As there is similarity of this syndrome to some type of male
A typical pattern of multiple synechiae is seen on hysterogram. pseudohermaphrodite, it is worthwhile to demonstrate the
Hysteroscopy is more accurate as it detects minimal adhesions normal female karyotype.
that are not apparent on hysteroscopy. Diagnostic features are:

Amenorrhea
Treatment aims at lysis of adhesions (synechiolysis). In the past, • Amenorrhea and normal secondary sex characteristics
it was treated with dilatation and curettage. Hysteroscopic lysis • Presence of normal axillary and pubic hair.
of adhesions by cutting, cautery or laser yields better results • Phenotype female and karyotype female (46 )
than the blind dilatation and curettage. IUCD (without copper) • Normal ovarian function including ovulation
or Foley’s catheter (filled with 3 ml fluid and removed after 7 • There is absence of vagina (seen in Fig 14.4) and either
days) is placed in uterine cavity to prevent further formation of absence or severe hypoplasia of uterus
adhesions. Following lysis, for endometrial growth, the patient • Associated renal and skeletal abnormalities may be present.
is treated with high doses of estrogen therapy. Recommended Treatment: Resumption of menstruation and fertility potential
therapy is conjugated estrogen 2.5 mg daily for three weeks is not possible. Creation of vagina can be done for sexual function.
with medroxy progesterone acetate 10 mg added during third Vagina can be created either nonsurgically by progressive
week. Usually, menstrual flow is established after two/three dilatation (Frank’s method) or surgically. In vaginoplasty, an
cycles of therapy. adequate space is created between bladder and rectum and a
Tuberculosis is a common cause in India. Treatment of vaginal mold covered with a split-thickness skin graft is inserted
tuberculosis should be done and prognosis should be explained in this newly created space (See vaginoplasty chapter 75).
to the patient (Discussed in Chapter 38 of Genital Tuberculosis) b. Vaginal agenesis: Vaginal atresia with functioning uterus is
Mullerian abnormalities: In primary amenorrhea, continuity rare and may be associated with absent cervix. Cyclic abdominal
of the Mullerian tube should be assessed. Any disruption in pain may be the presenting symptom. Surgery to construct the
the continuity as imperforate hymen, transverse vaginal septum, cervix has not been successful and hysterectomy is usually
absent cervix, absent uterus can lead to amenorrhea. Most of required. Endometriosis is a common finding.
these anomalies can be detected either by examination or by . Androgen insensitivity syndrome: It is due to a defect in
ultrasonography. androgen receptors that causes resistance to the action of
Imperforate hymen: In this condition, there is cryptomenorrhea, testosterone during embryogenesis and in postnatal life.
i.e. menstruation is occurring, but it is not revealed outside. Previously, this syndrome was called testicular feminization
Menstrual blood is collected in vagina and at times in uterine syndrome as there is a blind vaginal canal and absent uterus
cavity also. with the individual having testes and an karyotype. The patient
The condition is typically observed in 14–16-year-old girls, is a genetic and gonadal male with failure of virilization and is
who have normal secondary sex characters. called a male pseudo-hermaphrodite. Diagnostic features are:
• Normal growth and development, height may be more than
Diagnosis is mainly by history and examination. Important
normal
features are: • Breast development present
• Cyclic intermittent abdominal pain • Pubic or axillary hair absent or deficient
• Difficulty in micturition • Blind vagina and absent uterus
• Lower abdominal swelling • Presence of testis
• Bulging bluish membrane at the introitus as seen in Fig. 14.3. • Inguinal hernia may be present
Treatment is surgery. A cruciate incision is made in the bulging • Genotype male (46 )
bluish membrane at the introitus, to facilitate drainage. The four • Phenotype female
ends are stitched laterally to prevent fusion. • Normal or slightly elevated male blood testosterone levels.
Transverse septum of vagina: There is an obstruction in the Treatment: Incidence of neoplasia in these male gonads is high.
vagina by a septum and menstrual blood is collected in the After puberty, male gonads should be removed to prevent
vagina and in uterine cavity. Septum may be at three levels— malignancy (can be removed laparoscopically). Patients are then
lower third, middle or upper third of vagina. Usually, there is put on HRT for feminine development. These patients are
failure of canalization of the distal third of the vagina. completely female in their gender identity and this should be

89
 reinforced rather than challenged. Therapy in the form of Turner mosaic: In this condition, there is absence of the
appropriate psychological counseling of patient and parents is chromosomes in some cells. Functional cortical (ovarian) tissue
strongly recommended. can be found within the gonad leading to some degree of female
It is important to differentiate between Mullerian agenesis development. In mosaicism, proportion of each cell line
and androgen insensitivity syndrome as the management of determines the manifestation of the condition. Thus, higher the
both the conditions is different. percentage of 45 cells, the more likely is the presence of
Differential diagnosis of a phenotypic female with features of Turner’s syndrome. Presence of some normal 46
secondary sexual characters and no uterus. cells means that there is possibility of ovarian differentiation
and the associated development of secondary sexual characters
Features ullerian agenesis Androgen and on occasions even menses and reproduction. The
insensitivity menopause is early as the functioning follicles undergo an
Hereditary Sporadic -linked accelerated rate of atresia.
Endocrinology in Gynecology

pattern recessive
Gonad Ovary Testes onadal agenesis: There is failure of development of
Chromosome 46 46 gonads. No definite cause for this absent development
S. Testosterone Low Male can be identified. Viral and metabolic influences in early
FSH Normal Increased gestation or genetic mutations may be responsible for this entity.
Breast Well-developed Well-developed There is hypergonadotropic hypogonadism. In the absence
Pubic and Normal Absent
axillary hairs of gonadal function development in female, surgical removal
Other Renal/skeletal None of gonadal streak is necessary to avoid the possibility of
abnormalities neoplasia.

Compartment II Defects: Ovarian Disorders Premature Ovarian Failure

Primary gonadal failure and the resulting impaired secretion About 10 cases of secondary amenorrhea are due to premature
of gonadal steroids is manifested by elevated levels of FSH and ovarian failure, i.e., menopause before the age of 40. Etiology
LH that result from decreased negative feedback. Both of this entity is unknown in most of the cases, probably a genetic
chromosomes must be present and active in oocytes to avoid cause. The disorder can be either due to Turner’s syndrome
accelerated loss of follicles. A karyotype should be performed (mosaic) or due to an autoimmune disorder. Destruction of
on all patients with elevated gonadotropins. Problems in follicles may be either due to infections like mumps, tuberculosis
Section 3

gonadal development can present with either primary or or due to a physical insult as radiation or chemotherapy.
secondary amenorrhea. The most common cause of primary Diagnosis is done by hormone assays.
amenorrhea is streak gonads due to abnormal development of Serum estradiol 50 pg/ml and FSH 40 IU/ml on repeated
gonads, i.e., gonadal dysgenesis. occasions.

Chromosomal Anomalies Treatment

onadal dysgenesis: It refers to abnormal development of Fertility potential is remote high dose estrogen or HMG therapy
gonads. There are several forms of gonadal dysgenesis. Pure may result in ovulation (few cases reported). Rarely
gonadal dysgenesis (PGD) has been used to describe conditions spontaneous ovulation is seen (resistant ovaries). IVF with
with normal sets of sex chromosomes (e.g., 46, or 46, ) donor’s oocyte is advocated. Sometimes immunotherapy may
but may have defects of a specific gene on a chromosome. reverse autoimmue ovarian failure.
Gonadal dysgenesis can be the result of missing, all or part of To prevent autoimmune disorders corticosteroids may be
the second sex chromosome as seen in Turner’s syndrome (e.g., helpful. HRT is prescribed to prevent postmenopausal health
45, ) and its variants. It can also be mixed gonadal dysgenesis hazards.
having a mixture of cell lines, some containing a chromosome Resistant Ovary Syndrome
(e.g., 46, /45, ). Mixed gonadal dysgenesis indicates testicular
This is a very rare condition where elevated levels of
tissue on one side and a streak gonad on the other side.
gonadotropins are observed in the presence of apparently
Turner’s syndrome: Ovarian development is normal till 20 normal ovarian tissue.
weeks and oocytes are formed in ovaries until this stage. There is absence of FSH receptors in the ovarian follicles so
Thereafter, there is failure of the oocyte to undergo further they are unable to respond to FSH.
maturation. The ovary in most individuals at this stage consists There is very low chance of achieving pregnancy even with
of stroma so is unable to produce estrogens. high doses of exogenous gonadotropins.
Diagnostic features (Fig. 14.4) of Turner’s syndrome are: Diagnosis can be confirmed only by ovarian biopsy.
• Sexual infantilism and short stature. Polycystic Ovarian Syndrome (PCOS)
• Associated abnormalities: Webbed neck, coarctation of the
Other than pregnancy, PCOS is the most common cause of
aorta, high-arched pallate, cubitus valgus, broad shield-like
secondary amenorrhea. It is a metabolic syndrome. Here, the
chest with widely spaced nipples, low hairline on the neck,
body becomes resistant to insulin, leading to the release of more
short metacarpal bones and renal anomalies prominent ears
and more insulin to compensate (hyperinsulinemia). The ovaries
and loose skin folds in the neck.
of PCOS women seem to be particularly sensitive to high blood
• High FSH and LH levels
levels of insulin and respond by overproducing androgens such
• Bilateral streaked gonads.
as testosterone. This disrupts the feedback loop between the
• Karyotype—80 45, 0, 20 mosaic forms (46 /45 0).
ovaries and the pituitary gland, and the pituitary gland
Treatment: Hormone replacement therapy (HRT) to prevent produces too much LH (luteinizing hormone), leading to
osteoporosis.

90
overproduction of androgens. The immature follicles in the -ray sella turcica (coned down and lateral view) and CT
ovaries then fail to convert the excess androgens to estrogen, scan may reveal space occupying lesion (macroade-nomas). MRI
which inhibits the development of the follicle. Ovulation doesn’t can detect even microadenomas.
take place because the egg couldn’t develop properly, and the Though hyperprolactinemia is a normal finding in the
immature egg, instead of being released from the ovary, postpartum period leading to amenorrhea, there can be
becomes a tiny cyst that starts producing its own supply of hyperprolactinemia and amenorrhea, due to:
androgens, which interferes with next month’s developing • Hypothyroidism, an easily treated disorder
follicle. • Drugs ( usually with prolactin levels of less than 100 ng/
Diagnostic features are: ml) like:
• Menstrual periods that are infrequent, irregular or absent— Dopamine receptor antagonists (e.g., phenothiazines,
signs of anovulation butyrophenones, thioxanthenes, risperidone, metoclopramide,
• Features of hyperandrogenism as acne, hirsutism—hair sulpiride, pimozide), dopamine-depleting agents (e.g.,

Chapter 14
growth in the beard area, upper lip, sideburns, chest, the methyldopa, reserpine) and others (e.g., isoniazid, danazol,
area around nipples or the lower abdomen along the midline tricyclic antidepressants, monoamine antihypertensives,
• Ultrasound features of polycystic ovaries. verapamil, estrogens, antiandrogens, cyproheptadine,
If any of these two are present, the patient is diagnosed as opiates, H2-blockers cimetidine , cocaine).
PCOS. Treatment: Direct treatment is geared toward resolving
Treatment depends on the needs of the patient and for hyperprolactinemic symptoms or reducing tumor size.
preventing long-term health problems. Nutritional counseling • Patients on medications causing hyperpro-lactinemia

Amenorrhea
that addresses obesity and dyslipidemia is an important aspect should have them stopped if possible.
of medical management. Weight loss may help to decrease • Patients with hypothyroidism should be given thyroid
insulin resistance and also may decrease adverse long-term hormone.
cardiovascular effects. • Patients with hyperprolactinemia and no symptoms
Oral contraceptives for menstrual control, insulin- (idiopathic or microprolactinoma) can be monitored without
sensitizing medications (metformin) for lowering insulin levels, treatment.
androgen-lowering drugs for hyperandrogenism are advocated. • The dopamine agonist, bromocriptine (lysergic acid
Laparoscopic ovarian drilling can be performed. Ovulation derivative), lowers the prolactin level in 70–100 of patients.
induction can be done for patients wanting pregnancy. Dose of 1.25 mg orally at bedtime is started for the first
week and then increased gradually, to minimize the side
Effect of Radiation and Chemotherapy
effects. Maximum dose per day is 7.5 mg.
The effect of radiation is dependent on age and -ray dose. • Cabergoline (ergot-derived dopamine agonist), probably,
High numbers of oocytes in young age are responsible for causes fewer adverse effects than bromocriptine. Dose is
the resistance to castration. Risk of sterilization is 60–70 0.25 mg once or twice a week. Therapy should be continued
on exposure of ovaries to 500–800 rads, in the age group of for approxi-mately 12–24 months (depending on the degree
15–40 years. Exposure of more than 800 rads increases the risk of symptoms or tumor size) and then withdrawn if prolactin
to 100 . levels have become normal.
As far as chemotherapy is concerned, alkylating agents are • Surgical therapy or radiation therapy is rarely required.
very toxic to ovaries. Other chemotherapeutic agents also have • If imaging discovers a microadenoma of 10 mm in
the potential for ovarian damage but to a lesser extent. an asymptomatic woman (non-functional adenomas),
no treatment is required. Follow-up imaging is
Compartment III Defects: Disorders of Anterior Pituitary required after a year or two to see if there is any increase in
A consideration of hypothalamic-pituitary axis must focus on size.
the problems of the pituitary tumors. Pituitary tumors cause
increased dopamine turnover in the hypothalamus and reduced Thyroid Disorders
GnRH release. The most common is craniopharyngioma. Thyroid-stimulating hormone, which is elevated in
Prolactin-secreting pituitary adenoma leading to hyper- hypothyroidism, stimulates prolactin secretion, which, in turn,
prolactinemia is rare in childhood and more commonly occurs affects increased dopamine turnover in the hypothalamus and
after development of secondary sexual characters. reduced GnRH release and amenorrhea. Diagnosis is done by
Pituitary adenomas are divided into two groups: (i) micro- assay of thyroid hormones and thyroid-stimulating hormone.
adenomas (more common in premenopausal women), which Treat-ment is replacement with thyroxin. Hyperthyroidism can
are smaller than 10 mm and (ii) macroadenomas (more common also produce amenorrhea by affecting levels of thyroid-
in men and postmenopausal women), which are 10 mm or stimulating hormones and affecting hypothalamic-pituitary
larger. axis.
Presenting features are usually galactorrhea, secondary Empty Sella Syndrome
amenorrhea and infertility. There may be headache with
In this condition, there is congenital incompleteness of the seller
disturbed vision.
diaphragm that allows an extension of the subarachnoid space
Diagnosis is by estimating prolactin levels. In most
into the pituitary fossa. The pituitary gland is separated from
laboratories, a serum prolactin concentration above
hypothalamus and is flattened leading to pituitary
15–20 ng/ml (15–20 mcg/l SI units) is considered abnormal in
malfunctioning. The condition is benign and does not progress
women of reproductive age. A prolactinoma is likely if the
to pituitary failure.
prolactin level is 250 ng/ml and less likely if the level is 100
reatment Symptomatic and supportive treatment of
ng/ml.
endocrine dysfunction associated with pituitary malfunction,

91
 is advocated. In some cases, surgery may be needed. • Low estradiol leads to increased risk of osteoporosis.
Patients with anorexia nervosa often display other
Sheehan’s Syndrome
personality traits such as a desire for perfection, academic
The syndrome is characterized by the inability of the pituitary success, lack of age-appropriate sexual activity, and a denial of
gland to secrete gonadotropins, because of pituitary necrosis hunger in the face of starvation. Psychiatric characteristics
following massive obstetric hemorrhage. Diagnosis is reached include excessive dependency needs, developmental
by history and decreased estrogen, decreased gonadotropins, immaturity, social isolation, obsessive-compulsive behavior,
decreased thyroid hormones and other pituitary deficiencies. and constriction of affect. Many patients also have co-morbid
Treatment is replacement of deficient hormones. mood disorders, with depression and dysthymic disorder being
most prevalent.
Compartment IV: Central Nervous System Disorders
Hypothalamic disorders are caused by abnormal gonadotropin- Treatment: Increase body weight by proper counseling.
Endocrinology in Gynecology

releasing hormone pulsatility, resulting in impaired Psychiatrist referral may be needed. If hypogonadotropism
gonadotropin levels, particularly LH, and subsequently low persists, ovulation induction with gonadotropins is indicated
estrogen levels. (Chapter 5).

Constitutional Delay Exercise-associated Amenorrhea

This is one of the most common causes (20 ) of primary Some physically active females, particularly adolescents, may
amenorrhea. Amenorrhea is a result of delay in physical develop an energy deficit when the calories they utilize exceed
development, due to delayed reactivation of the GnRH pulse their calorie intake. This deficit may be unintentional, resulting
generator resulting in delay in growth spurt, sexual maturation from inadequate replenishment of the calorie demands of
and bone development. training, or may be intentional—a conscious attempt to lose
weight or body fat in the interest of improved appearance or
Diagnostic features are: athletic performance. This is common in women who participate
• Understature and delayed bone age (diagnosed by -ray- in sports (e.g., competitive athletes, ballet dancers). Eating
wrist joint) disorders have a higher prevalence in female athletes than non-
• Positive family history of delayed menarche athletes. Female Athlete Triad describes a relationship of eating
• Low levels of FSH, LH and estradiol. disorder, osteoporosis and amenorrhea.
Diagnosis is by exclusion and follow up is all that is required
Treatment: Increased dietary intake or cessation of strenuous
Section 3

and prognosis is good. No drug therapy is required only

exercise usually corrects amenorrhea; but if hypogona-
reassurance helps the patient by reducing her anxiety.
dotrophism persists, ovulation induction with gonadotropins
Weight-related Amenorrhea is indicated.
Both low body weight and obesity can affect menstrual function The female athlete who has restrictive eating patterns
and fertility. Amenorrhea in an obese patient is usually due to because she is unaware of her energy needs may require only
anovulation. Neurotransmitter abnormalities may influence nutritional counseling.
hypothalamic dysfunction in acute weight loss, but the exact The female athlete who purposefully engages in disordered
mechanism remains to be determined. Disturbances in central eating behaviors is often best treated using a multidisciplinary
dopaminergic and opioid activity have been described in acute team approach: with a physician who monitors her medical
weight loss and both these substances are known to modulate status and ability to participate safely in sports, a nutritionist
GnRH-mediated LH release. The condition is reversible in most who provides appropriate nutritional guidance, and a mental
cases. Normal periods are established when they reach health professional who addresses any psychological issues.
appropriate weight for height or when stress responsible is Amenorrheic athletes should be encouraged to increase their
eliminated. calcium intake to at least 1,500 mg daily. If intake of dietary
sources of calcium is inadequate, calcium supplements may be
Anorexia nervosa: It is a psychiatric disorder with severe
recommended.
physiologic consequences, characterized by the inability or
refusal to maintain a minimally normal weight. Patients have a Contraception-related Amenorrhea
profoundly disturbed body image as well as an intense fear of When a woman takes hormonal contraceptives for a sufficient
weight gain despite being moderately to severely underweight. length of time, the negative feedback to the pituitary gland may
The disorder may be further divided into two subtypes: persist even after the pills are stopped. This prevents ovulation
(i) restricting, in which severe limitation of food intake is the and causes amenorrhea. After stopping the hormonal
primary means to weight loss, and (ii) binge-eating/purging contraceptives, usually menstruation is established in majority
type (bulimia nervosa) in which there are periods of food intake of cases after a varying period. Fertility rate is normal following
that are compensated by self-induced vomiting, laxative or discontinuation of drug.
diuretic abuse, and/or excessive exercise. Diagnostic criteria
for anorexia nervosa includes: Treatment in case of contraception-related amenor-rhea: The
• Refusal to maintain body weight at or above a minimally first treatment is expectant management, i.e. waiting for a
normal weight for age and height (usually less than spontaneous remission of the amenorrhea and a spontaneous
85 of ideal body weight). A body mass index (BMI) occurrence of periods. The time limit is usually six months; but
17 kg/m if the woman is anxious to get her periods, active treatment
• Intense fear of gaining weight or becoming fat may be started after waiting for only three months. The standard
• Disturbance in the way one’s body weight or shape is treatment of contraceptive-related amenorrhea is by stimulating
experienced, with denial of current low body weight the pituitary to produce FSH and LH. This is done by the drug
• Mean age of onset is 13–14 years (range 10–21 years) clomiphene citrate.

92
Kallmann Syndrome Amenorrhea is a clinical problem with diverse etiologies.
It is a rare disorder where hypothalamus lacks the ability to Thorough history, physical examination, and laboratory workup
produce pulsatile GnRH. Insufficient pulsatile secretion of with a simple logical approach can identify the cause of
GnRH leads to deficiency of FSH and LH. amenorrhea in most patients. Reassurance and a rational
Diagnostic features are: explanation of state of affairs will help reduce anxiety. Follow
• Anosmia (Inability to smell) up, appropriate to various conditions, is an important part of
• Lack of sexual maturation and amenorrhea management.
• Incomplete agenesis of olfactory bulbs and anatomical
defects in hypothalamus. BIBLIOGRAPHY
Treatment is GnRH stimulation. This leads to normal 1. Angus MT, Tason AA, Rabecca D, et al. The management of
release of gonadotropins. intrauterine synechiae. Curr. Opin. Obstet Gynecol 2009;21:335.
Other endocrine dysfunctions tumors which can also cause

Chapter 14
2. ohn Bonnar, William Dunlop, Editrors. What is new in polycystic
amenorrhea as observed in congenital adrenal hyperplasia ovary syndrome in Recent advances in Obstetrics and Gynecology
(CAH)/Cushing’s syndrome, virilizing adrenal/ovarian No. 23 Chap 10 p 147.
tumors—granulosa-theca cell tumors are discussed in 3. Leon Speroff, Marc A. Fritz. Clinical Gynecologic Endocrinology
chapters on Hyperandrogenism and Ovarian Tumors (chapters and Infertility. 7th edn, Lippincott Williams Wilkins , 2005.
4. Shirish N Daftary, Ameet Palki. Reproductive Endocrinology and
15 and 48).
Infertility. BI Publications, 2009.

Amenorrhea

93
 15 Androgen Excess in Reproductive Life

Abha Majumdar

Androgens are present in females in early fetal life when adrenal 3. DHEA produced 10% from ovary and 90% from adrenal
gland secretes significant quantities of dehydroepiandrosterone dehydroepiandrosterone sulfate.
sulphate (DHEAS). In the middle of the first decade, at about 6 4. DHEAS produced 100% from adrenal only.
to 7 years of age, these begin to rise again. This phase is termed 5. Dihydrotestosterone (DHT) is formed by peripheral
as “adrenarche” and is clinically manifested by the appearance conversion of T and A by the action of 5 alpha reductase.
of pubic and axillary hair. In normal girls, the androgen levels The principal circulating androgens are testosterone and
continue to rise throughout the second decade and are its principal metabolite dihydrotestosterone (DHT),
maintained at relatively steady levels until the menopause. androstenedione, dehydroepiandrosterone sulfate (DHEAS).
These contribute in maintenance of body fat and weight, libido All are C19 steroids derived from the conversion of cholesterol
and normal functioning of the reproductive system in terms of in either the ovaries or the adrenal. DHT is the most biologically
ovulation. On the other hand, excess of androgens, either by potent, followed by testosterone. Androstenedione, DHEA and
overproduction or reduced clearance may hamper reproductive DHEAS are comparatively weak androgens, with minimal effect
performance. on skin and hair growth under normal circumstances. DHT is
derived exclusively from peripheral conversion of circulating
Androgens are Produced in Females in Three testosterone and androstenedione in target tissues, in a reaction
Compartments (Fig. 15.1) catalyzed by enzyme 5 alpha reductase.
1. Ovary—ovarian stroma and theca cells.
2. Adrenal—zona fasciculata and reticularis.
3. Periphery and liver—periphery includes skin, fat,
pilosebaceous units and blood.

Type of Androgens Present in Females (Fig. 15.2)

1. Testosterone (T) produced 25% from ovary and 25% from
adrenal and 50% by conversion of androstenedione (A) and
dehydroepiandrosterone (DHEA) in extraglandular tissue
(blood, skin, liver).
2. Androstenedione produced 50% from ovary and 50% from
adrenal. Fig. 15.1: Three compartments of androgen production

Fig. 15.2: Types of androgens present in females

Estimation of Androgens polycystic ovarian morphology on USG and menstrual
Until recently, adrenal androgen secretion has been assessed by irregularity and at the other end of spectrum with symptoms
measurement of urinary 17-ketosteroid secretion, which such as obesity, hirsutism, acne, menstrual cycle disturbance
comprise mainly of DHEA, DHEAS, androstenedione and and infertility. Metabolic disturbances such as elevated
breakdown products of testosterone (T). serum concentrations of luteinizing hormone (LH),
Developments of radioimmune assays now estimate all testosterone, insulin and prolactin are common and may
these in blood. have profound implications for the long-term health of
Total T = SHBG (sex hormone-binding globulin) + free T women with PCOD.
In females, the normal index is 1%, which means the ratio PCOS appears to be a familial condition and a number
of free to total testosterone is 1: 100. Methods of measuring free of genes have been implicated. It has its origins during
T are cumbersome, while measure-ment of total T and SHBG is adolescence.
much easier, therefore, these are undertaken to determine free

Chapter 15
Effect of androgen excess on ovulation/reproductive performance
T levels. in PCOS:
Both testosterone and DHT circulate partly in free state and The ovarian follicle, from the stage of the preantral follicle starts
partly bound to either albumin or to a beta-globulin called sex producing androgens from choles-terol precursors, in the theca
hormone-binding globulin (SHBG). In case of testosterone, 80% interna by the action of the pituitary LH. This physiologic level
is bound to SHBG, 19% weakly bound to albumin and 1% is of the androgens, produced by the follicular cohort, functions
unbound in free state. In hyperandrogenic women, percentage as the substrate for estrogen synthesis (mainly estradiol) by
of free testosterone is increased to about 2%; and in men, the the ovarian granulosa cell layer. Theca cell layer is separated

Androgen Excess in Reproductive Life

level of free testosterone is about 3%. from the granulosa cell layer by lamina basalis or basal
Estrogens increase SHBG levels, whereas androgens and membrane. These androgens seep into the granulosa cells from
insulin lowers them. Normal testosterone levels may be the theca cell layer across the basal membrane. Pituitary FSH
associated with suppressed SHBG levels thus indicating an promotes aromatase enzyme activity in the granulosa
elevated free T level, which is the active component of the total compartment, which, in turn, promotes conversion of
testosterone. androgens into estrogen. Thus, a synchronized pattern of LH
and FSH action in the period of folliculogenesis promotes
Androgen Excess Manifest in Two Ways increased estrogen production and an optimal estrogenic micro-
1. Ovulatory disorders extending to chronic anovulation and environment in the follicle. This is referred to as two cells two-
amenorrhea. gonadotropin theory (Fig. 15.3).
2. External manifestations such as hirsutism, acne vulgaris, However, if the theca androgen production is excessive,
virilization and sometimes also as acanthosis nigricans. as observed in thecal hyperplasia of PCOD syndrome, and
FSH levels are low due to peripheral estrogen negative
Effect of Androgen Excess on Ovary feedback on pituitary, then this leads to sub-optimal
Morphology aromatase activity. This ultimately creates an androgenic
micro-environment with suppressed aromatase action,
reduced estrogen production and finally follicular atresia,
arrest of oocyte growth and maturation. In addition, it also
compromises the oocyte and endometrial quality.
Sources of excess androgen in PCOD
1. Hypothalamic-pituitary-ovarian axis: Increase in LH pulse
frequency and amplitude stimulates theca cells of ovary to
produce more androgens.
2. Ovary: It is not only as a result of LH hypersecretion that
Function thecal androgen production increases; but an intrinsic
Follicular microenvironment is androgenic and hence there is
arrest of follicular growth.
The disorders leading to androgen excess in reproductive
age group females are:
1. Polycystic ovarian syndrome (PCOS) (90% of cases)
2. Congenital adrenal hyperplasia (2–5%)
3. Cushing’s syndrome
4. Masculinizing tumors of ovary
5. Androgen secreting adrenal tumors
6. Hyperprolactinemia
7. Acromegaly
8. Iatrogenic virilization.
Idiopathic hirsutism has not been included in the causes
even though it is a manifestation of androgen excess in female
because it can be associated with absolutely normal ovulatory
function and, therefore, normal reproductive performance.
1. Polycystic ovarian syndrome (PCOS): This constitutes more
than 90% of cases with androgen excess in reproductive
females. This syndrome is a heterogeneous disorder, which
may present at one end of spectrum with findings of Fig. 15.3: Effect of androgen on ovulation 95
 abnormality in ovarian theca cells and stroma also exists. Treatment of CAH is by reducing ACTH levels by substituting
There is abnormal steroidogenesis by polycystic ovarian cortisol in the form of dexamethasone, in the dose of 0.5 mg/
theca cells due to upregulation of cytochrome P450. day, which reduces hyper-androgenism. This reverts the
3. Hypothalamic-pituitary-adrenal axis: Another pituitary reproductive function to normal, facilitating normal ovulation
hormone has been found to speci-fically control the and conception.
synthesis of androgenic steroids, known as cortical Pathogenesis of anovulation in hyperandrogenemia:
androgen-stimulating hormone (CASH) or adrenal Pathogenesis of anovulation is increased androgen load from
androgen-stimulating hormone (AASH). This is seen to adrenals or ovaries (tumors or other pathological conditions),
increase in 15% of cases, which specifically increases the which increase peripheral conversion into estrone which, in
secretion of DHEA and DHEAS. turn, suppresses pituitary FSH. This leads to lack of aromatase
Management is directed into two aspects: activity in granulosa cells and androgen excess in the intra-
Endocrinology in Gynecology

a. Correction of metabolic disturbance follicular environment, eventually leading to follicular atresia.

b. Induction of ovulation Stimulation of ovarian stromal hyperplasia adjacent to the
c. Treatment of hirsutism. tumor and induction of the histologic changes of polycystic
Extensive counseling is required to tell the cause and ovary disease in the contralateral ovary are two mechanisms
consequences and life style changes. reported by which nonfunctioning ovarian tumors also can
a. Correction of metabolic disturbance: This involves correcting cause increased androgen secretion.
hormonal or biochemical disturbances, such as of LH 3. Cushing’s syndrome: This is due to overproduction of
hypersecretion, hyperinsulinemia, ovarian or adrenal cortisol by the adrenal and may occur due to the following
androgen preponderance, or hyperprolactinemia. conditions:
LH hypersecretion can be suppressed with the use of 2 a. Sixty percent cases are due to the excessive pituitary
to 3 cycles pretreatment with oral contraceptive pills (OCP). secretion of ACTH (Cushing’s disease). Cushing’s disease
GnRh analogs can be used in gonadotropin-stimulated cycle has a predilection for younger women (age 20–30 years)
for the same, before undertaking ovulation induction. and is 8 times more common in women.
Hyperinsulinemia is managed by treatment with insulin b. Primary adrenal disease: Adenoma /carcinoma accounts for
sensitizers for 2–3 months such as metformin or pioglitazone 25% of cases.
before induction of ovulation. Ovarian androgen excess is c. Ectopic secretion of ACTH, which is very rare, and occurs
managed by cyproterone containing oral contraceptive pills
Section 3

in the remaining cases. This is ten times more commonly

(OCPs) for 2–3 cycles and adrenal androgen excess by a seen in men than women.
small dose of steroid such as dexamethasone 0.5 mg every Androgen excess in Cushing’s syndrome is caused by
night. About 5% cases of PCOS have simultaneous hyper- increased production of adrenal androgens that
prolactinemia and may require treatment with bromo- accompanies increased production of cortisol. Onset is not
criptine or cabergoline. at menarche unlike PCO and late onset congenital adrenal
b. Induction of ovulation: It can be done by anti-estrogens such hyperplasia (CAH). In addition to frank hirsutism, which
as clomiphene citrate, letrozole, tamoxifen, or by is a result of excessive production of adrenal androgen,
gonadotropins with or without GnRh agonist or antagonist. increase growth in lanugo hair may occur due to increased
c. Treatment of hirsutism: See in chapter 13. cortisol levels. Other common findings include obesity
2. Congenital adrenal hyperplasia (CAH): The most frequent (85%), menstrual /ovulatory disorders (75%) and acne (35%).
enzyme deficiency noted is 21-hydroxylase in CAH and the
condition is inherited as autosomal recessive mode. In Diagnosis: Cortisol levels of less than 5 microgram/dl after 1
females, CAH, when present in its most severe forms, is mg dexamethasone administered at 11 pm the night before the
now almost always detected at birth, when the presence of test, together with the 24 hours urinary cortisol less than 110
ambiguous genitalia makes one suspect the diagnosis. There micrograms excludes Cushing’s syndrome.
are a few cases, however, in which this enzymatic defect is Treatment is directed in treating the cause and suppressing
mild and may become apparent only after puberty, when androgen and cortisol levels.
hirsutism, irregular bleeding, or amenorrhea and
4. Virilizing ovarian tumors: Most androgen-secreting
virilization (including clitoromegaly) may appear. Such an
ovarian neoplasms are benign, present in women under 30
entity is often referred to as acquired, delayed-onset, or
years of age and are rare. Hirsutism and amenorrhea are
attenuated adrenal hyperplasia and is thought to affect 5%
typical presenting complaints of reproductive age women
of women with hirsutism.
with a virilizing ovarian tumor. These women commonly
The underlying enzyme defect leads to low levels of
have a history of cyclical menses until the abrupt cessation
cortisol which stimulates ACTH release, which further leads
of menses and the first appearance of hirsutism,
to stimulation of adrenal glucocorticoid precursors and
simultaneously. The rate of progression of androgenic signs
accumulation of adrenal androgens.
is proportional to the amount of testosterone secreted by
Diagnosis: 17 Ü-hydroxy progesterone, which is a steroid these tumors. The currently accepted classification has been
substrate, spills over to the androgen pathway and causes simplified and divides the tumors into two groups: sex cord
increased production of adrenal androgen. Diagnosis is based stromal cell tumors, (formerly known as androblastomas,
on the short synacthen test in which 17 Ü-hydroxy progesterone arrhenoblastomas or gynandroblastomas,) and adrenal-like
and cortisol levels are measured before, and after the tumors of the ovary which include luteomas, hyper-
administration of a single dose of 250 mg intravenously of nephromas and adrenal rest like tumors. The latter are
ACTH. The diagnosis is made if serum 17 Ü-hydroxy associated with cushingoid-like features in 50% cases. At
progesterone rises to greater than 10 ng/ml in 30 minutes. all ages, women with a virilizing ovarian tumor have

96
 endometrial hyperplasia or adenocarcinoma more follicular selection and growth. The available drugs for
frequently than do women without such a tumor. Increased treatment of hyperprolactinemia are bromocriptine and
aromatization of androgens to estrogens accounts for cabergoline.
increased estrogen in these women. Aromatization of 7. Acromegaly arises from excessive secretion of growth
androgens occurs in extraglandular sites and involves hormone from a pituitary adenoma and may occasionally
predominantly the formation of estrone from present with hirsutism. Accompanying headache, carpal
androstenedione secreted by the tumor. tunnel syndrome and increase in size of skull, supraorbital
Diagnosis: Serum testosterone is usually >5 nmol/l, which is ridges, spade-shaped hands and vertebral enlargements
twice the upper limit of the normal range (0.5–2.5 nmol/l). often with kyphosis are common presenting features.
Virilization, together with serum testosterone in the male range Diagnosis: Growth hormone (GH) measurement during
(>10 nmol/l) are particularly ominous signs. Adrenal-like standard glucose tolerance test, which in normal cases is

Chapter 15
ovarian tumors can also present with elevated DHEAS levels associated with complete suppre-ssion of serum GH, skull X-
(>20 nmol/l). Imaging by ultrasound, CT or MRI of both adrenals ray and if required CT or MRI of the pituitary, are helpful in
and ovaries are required. establishing a diagnosis.
Treatment: Unilateral oophorectomy or salpingo-oophorectomy 8. Iatrogenic virilization is rare and the source of androgen or
is the treatment of choice. the offending hormone has to be removed. Common drugs
5. Androgen-secreting adrenal tumor: Pure virilizing adrenal causing androgen excess are danazol, testosterone, and
neoplasms are rare. Adrenal tumors are divided into the glucocorticoids.

Androgen Excess in Reproductive Life

benign adenoma and the malignant adenocarcinoma.
Typically, these are small, impalpable and, in half the BIBLIOGRAPHY
reported cases occur in premenopausal women. 1. Abraham GE, Chakmakjian ZH, Buster JE, Marshall JR. Ovarian
and adrenal contributions to peripheral androgens in hirsute
Diagnosis: Nonetheless, in patients who are virilized or who women. Obstetrics and gynecology 1975;46:169-73.
have a total testosterone greater than 150 to 200 ng/dl, adrenal 2. Carole Gilling-Smith, Stephen Franks. Hirsutism and virilisation.
tumors should always be ruled out by CT or MRI scan. Serum Gynecology: Shaw RW, Soutter WP, Stanton SL; 1997.pp.343-57.
DHEAS level of greater than 700 mg/dl is suggestive of adrenal 3. Conway GS, Honour JW, Jacobs HS. Heterogeneity
tumor, but it is important to know that normal DHEAS levels of polycystic ovarian syndrome: Clinical, endocrine and ultrasound
features in 556 patients. Clinical endocrinology 1989;30:459-70.
do not rule it out.
4. Fox R. Polycystic ovarian disease and insulin resistance:
6. Hyperprolactinemia: Prolactin affects androgen synthesis pathophysiology and wider health issues. Progress in Obstetrics
in three ways: and Gynecology. John Studd vol 1994;11:351-70.
1. Stimulates production of adrenal androgen DHEAS. In 5. Gabrilove JL, Seman AT, Sabet R, Mitty HA, Nicolas CL. Virilising
hyperprolactinemic women, either dexamethasone or adrenal adenoma with studies on steroid content of adrenal venous
effluent and a review of the literature. Endo Rev; 1981.pp.2-462.
bromocriptine reverses the androgen abnormalities,
6. Hague WM, Adams J, Ridda C. et al. The prevalence of polycystic
suggesting that a synergistic effect exists between prolactin ovaries in patients with congenital adrenal hyperplasia and their
and ACTH. close relatives. Clinical endocrinology 1990;33:501-10.
2. Depresses SHBG due to direct effect on liver production of 7. James Aiman. Virilising Ovarian Tumours. Clinical Obstetrics and
this globulin. Gynecology 1991;34(4):835-43.
3. Hypoestrogenism, which is associated with hyper- 8. Randall BB. Adrenal dysfunction and Hirsutism. Clinical Obstetrics
prolactinemia, also reduces the SHBG levels. and Gynecology 1991;34(4):827-34.
9. Rogerio AL. Hirsutism in polycystic ovary syndrome: Current
However, there is a protective effect against hirsutism
concepts. Clinical Obstetrics and Gynaecology; 1991;34-4:817-26.
by decrease in the 5 alpha reductase activity in hyper- 10. Rosenfield RL, Ehrlich EN, Clearly RE. Adrenal and ovarian
prolactinemic women. Treatment is to reduce prolactin contributions to the elevated free plasma androgen levels in hirsute
levels with or without adding gonadotropins to promote women. Journal of clinical endocrinology 1972;34:92-8.

97
 16 Dysmenorrhea and Chronic Pelvic Pain (CPP)

Sudha Salhan

DYSMENORRHEA Decline of progesterone levels in the late luteal phase tiggers

Definition lytic enzymatic action, resulting in a release of phospholipids
Dysmenorrhea means ‘difficult menstruation,’ but the term is with the generation of arachidonic acid and activation of the
used to mean painful menstruation. cycloxygenase pathway.
Symptoms
Types of Dysmenorrhea • Pain begins a few hours or just after the onset of menstrual
Dysmenorrhea is of two types: period and may last up to 48–72 hours.
a. Primary/idiopathic/true: • Suprapubic cramping, lumbosacral backache, pain radiating
The pain is of uterine origin and directly linked to down to anterior aspect of thigh
menstruation but with no visible pelvic pathology. Pain • Colicky in nature
usually occurs on the first day (spasmodic dysmenorrhea). • The symptoms improve with abdominal massage,
b. Secondary dysmenorrhea: Pain which is associated with counterpressure or movement of body unlike abdomen pain
uterine/pelvic pathology and may continue throughout the due to chemical/infectious peritonitis. These mild symptoms
flow/congestive, i.e. worse premenstrually and relieved may be present in about half of the cases. But they may be
during flow. severe in about 14–20% of cases leading to vomiting and
inability to perform daily routines.
Types of Pains
Signs
1. Congestive: • Normal vital signs
• Premenstrual pain situated either in the back or lower • No abdominal tenderness
abdomen, occurring three to five days before the onset • Normal pelvic organs.
of menstruation and always relieved by menstrual flow.
• Association with constipation and flatulent distension Diagnosis: Rule out underlying pelvic disease first.
of the upper colon. Hemoglobin, ESR, and urine examination to be done. Do an
2. Spasmodic: ultrasound to exclude any pelvic pathology.
• Pain develops on the first day of the menstrual period, Treatment: (Flow chart 16.1) Reassurance, after complete
lasts for a relatively short time, is intermittent and physical examination and investigation, will go a long way in
spasmodic curing the patient.
• Association with faintness, collapse, nausea/vomiting • To relieve pain, we use prostaglandin synthetase inhibitors.
• Severe attack followed by similar but lesser pain in lower Mefenamic acid 500 mg taken just before or after onset of
abdomen and pubic region and on the anteromedial area pains and then continuously every 6–8 hours to prevent
of perineum reformation of prostaglandin byproducts.
• Pain persists not more than 12 hours. • Oral contraceptive pills (OCPs): They are the drug of choice
3. Membranous in patients with no contraindication to OCPs/desires
• Familial contraception. OCPs decrease endometrial proliferation and
• Recurs after pregnancy create an endocrine milieu similar to the early proliferative
• Dysmenorrhea is accompanied by passage of phase when prostaglandin levels are lowest.
membranes, which takes the form of cast of the uterine • Acupuncture/transcutaneous electric nerve stimulation
cavity (TENS).
• Worse prognosis. • Calcium channel blockers, e.g. nifedipine in patients with
intractable dysmenorrhea.
Primary Dymenorrhea • Dietary addition of omego-3 fatty acid helps.
Causes: It is considered to be due to high endometrial Surgery for primary dysmenorrhea
prostaglandin F2 production which is a potent myometrial Considered only when pain is so severe to be incapacitating,
stimulant and vasoconstrictor. Response to prostaglandin and when medical treatment has failed.
synthetase inhibitors proves this theory. The posterior pituitary 1. Laparoscopy: Diagnostic laparoscopy if the patient has
hormone vasopressin may be the cause as it is involved with received adequate medical therapy over 4–6 cycles but no
myometrial hypersensitivity, reduced uterine blood flow and satisfactory response. This is done to rule out pelvic lesions.
hence pain. This may be related to prostaglandin F2 synthesis. 2. Dilatation of cervix: The objective is to stretch the
Psychological and behavior factors may be responsible. fibromuscular tissue at the level of the internal os of the
 Flow chart 16.1: Treatment of dysmenorrhea

Chapter 16
Dysmenorrhea and Chronic Pelvic Pain (CPP)
cervix to render it hypotonic. Dilatation is carried out slowly • Adenomyosis
and continued up to Hagar dilator number 10. • Pelvic congestion syndrome
3. Injection of Lee: Franken–Hauser plexus with anesthestic • Endometriosis.
agents. Causes of unilateral dysmenorrhea
4. Presacral neurectomy: The objective is to eliminate motor • Ovarian dysmenorrhea
impulses responsible for uterine spasm, to increase • Bicornuate uterus
vascularity of uterus and to interrupt the sensory pain • Unilateral location of pelvic endometriosis
pathways from uterus. This is rarely require. • Small fibroid polyp near one cornua
• Ovarian veins syndrome
Secondary Dysmenorrhea
• Colonic/cecal spasm.
• Usually occurs years after the onset of menarche.
Etiology: Excess prostaglandin production or hypertonic Diagnosis of secondary dysmenorrhea
uterine contractions secondary to cervical obstruction, • Laparoscopy aided by hysteroscopy to ascertain the cause
intrauterine mass or presence of foreign body. A definitive • Ultrasound, MRI, hysterosalpingography (HSG) for
cause can be found. The most common causes are: demonstration of congenital uterine anomalies.
• Imperforate hymen Treatment: Directed to the underlying condition.
• Transverse vaginal septum • NSAIDs and OCPs are less useful than in primary
• Cervical stenosis dysmenorrhea.
• Uterine anomalies • NSAIDS for treatment of pain.
• Intrauterine synechiae
• Endometrial polyps Differential Diagnosis
• Intrauterine devices 1. Primary dysmenorrhea
• Uterine leiomyomas 2. Noncyclic pelvic pain: 99
 • Adhesions Etiology: Multiple factors may be responsible for this clinical
• Endometriosis entity.
• Salpingo-oophoritis They can be gynecological and non-gynecological causes.
• Ovarian remnant syndrome Gynecological conditions commonly seen are:
• Pelvic congestion syndrome 1. Endometriosis and adenomyosis
• Ovarian neoplasms 2. Persistent or recurrent pelvic inflammatory disease (PID)
• Pelvic relaxation. and chronic tubo-ovarian abscess, hydrosalpinx and
tuberculosis
CHRONIC PELVIC PAIN 3. Pelvic adhesions
Definition 4. Ovarian pathology—ovarian remnant syndrome and
residual ovary syndrome
Chronic pelvic pain (CPP) is a nonspecific, non-menstrual pain
5. Pelvic congestion syndrome
Endocrinology in Gynecology

of 6 or more months’ duration that may or may not be relieved

6. Chronic ectopic pregnancy
by analgesics. It is localized to the anatomical pelvis and is
7. Leiomyomata
severe enough to cause functional disability and requires
8. Pudendal neuralgia
medical or surgical treatment. It is a very disabling entity
9. Vulvodynia
causing physical, marital and social repercussions.
10. Vulvar vestibulitis syndrome
Pelvic Organs: Nerve Supply 11. Mittelschmerz
12. Intrauterine pregnancy
Pain perception depends on the individual’s genetic make up
13. Torsion of ovarian cyst
and psychological state of mind at that particular time.
14. Pelvic malignancies.
Both sympathetic and parasympathetic autonomic nervous
Non-gynecological conditions frequently encountered are
systems represent pelvic innervation. Sympathetic nerves are
as follows:
mostly involved in afferents going to thoracolumbar
1. Gastrointestinal condition:
distribution (T10 T11T12 and L1 level of spinal cord) from
a. Irritable bowel syndrome
uterus, fallopian tubes and upper vagina through the uterosacral
b. Chronic appendicitis
ligament forming uterine inferior plexus. All afferents join at
c. Diverticular disease (Meckel’s)
the level of rectum and vagina to form hypogastric plexus. To a
d. Regional enteritis and diverticulitis (fever, abdominal
small extent, the parasympathetic fibers also carry pain
Section 3

pain, and tenderness)

sensation from the upper vagina, lower uterine segment and
e. Mesenteric vascular disease and chronic constipation.
cervix to S2–S3 roots. From the perineum and anus, they go via
2. Urinary condition:
the pudendal nerve to S2 and S4. Both sympathetic and a. Interstitial cystitis
parasympathetic fibers supply the bladder, rectum, perineum b. Urethral syndrome, (dysuria, urgency, frequency, no
and anus. Distal fallopian tubes and ovaries have their own night urine or history of trauma), tender, rope-like
nerve supply by T9 and T10. urethra
Pain can be somatic, splanchnic or referred. c. Calculi in kidney and urinary bladder.
Somatic pain originates from external genitals and vagina. 3. Musculoskeletal and orthopedic conditions:
This pain is localized. a. Myofascial pain
In splanchnic pain, a particular organ gets irritated by b. Ergonomic impairment
pulling, stretching or distension. Pain is not exactly localized. c. Exaggerated lumbar lordotic curve
Referred pain: The impulses arising in an organ by the above d. Anterior pelvic tilt (rotated innominates)
methods goes to the spinal cord and comes back by efferents to e. Scoliosis
some other part of the body/dermatome supplied by the same f. Posture alteration (poor posture)
nerve roots. The pain from bladder trigone may be referred to g. Disc disease, osteitis pubis
vagina, ovarian pains, mimics, ureteral pain, etc. h. Pelvic floor somatic dysfunction (myalgias)
i. Herpes zoster
Incidence 4. Psychologic: Depression
Chronic pelvic pain (CPP) is not a disease but a complex 5. Surgical:
multidimensional syndrome. Its frequency can be estimated a. Chronic appendicitis
by the following statement: b. Hernias
• About 38–80% women with unresolved CPP visit c. Nerve entanglement—ilioinguinal/iliohy-pogastric, Lt
gynecology outpatient department. lateral femoral cutaneous, L2–3 (myalgia geniofemoral)
• About 15–40% laparoscopy performed for CPP d. Muscle entrapment.
• About 10–18% hysterectomies performed for CPP. GYNECOLOGICAL CONDITIONS: THE MOST
More than 9 million women in the USA suffer from this COMMON CAUSES IN 30–70% CASES OF CPP
ailment.
Thirty percent cases have their origin in the urinary bladder. History Taking
Reproductive system etiology is seen in 30–70% cases of CPP. A single clear cause may not be elicited. A detailed history is
The amount of disability caused by CPP is not estimated, essential. Find out the progress of pain. Characteristic of pain:
but it may cause a loss of up to 2 million dollars annually in the Sharp, localized (dermal or musculoskeletal) or vague and
USA. diffuse (visceral pain). Is it acute or chronic in onset? Any
As we can see, CPP has many causes. Therefore, long follow relieving or aggravating factor, any radiation to back, etc.
up is required to investigate the factors causing anxiety in the should be inquired about. Treatment taken, (surgery and
patient. This long duration and poor response to treatment often medicine) so far and its effect on pain should be asked. The
100 leads to frequent change of doctors. patient’s and her family member’s attitude about her pain are
also important to know. Any history of bleeding, discharge or If a diagnosis is reached, its treatment will relieve the
dyspareunia should also be elicited. patient. Otherwise, assurance, analgesics, and psychotherapy
Other questions to be asked are: may help.
• History of menstruation, bladder and bowel movement in
GYNECOLOGICAL CONDITIONS
relation to pain.
• Any blood in urine or stool 1. Endometriosis and adenomyosis itself is not sufficient to
• Psychologic depression and history of sexual and substance cause pelvic pain. Fifty percent of endometriosis patients
abuse in childhood. do not have pain. Neurogenic inflammation with all its
• Anxiety disorders, job-related anxiety, etc. complexity is a mechanism for pain in endometriosis and
• What is the social support and coping mechanism. adenomyosis.
• Any history of sleep disturbance, low energy, less appetite In endometriosis of the retrovaginal space, mast cells
are found in peritoneal and ovarian endometriosis. Details

Chapter 16
(seen in depression).
are given in the respective chapters.
Examination 2. Persistent or recurrent pelvic inflammatory disease (PID)
The gait of the patient will point to orthopedic conditions. Any is mostly treated by medication to both the partners.
lordosis or scoliosis may help in finding the cause. Chlamydia is the most common causative organism. Surgery
After raising head and legs, do one finger examina-tion of may be required in pyosalpinx, hydrosalpinx, etc.
the abdomen to find the trigger point in case of myofascial pain. 3. Pelvic adhesions: Some patients are more prone to develop
Ask the patient to cough and look at hernial sites. Examine the pelvic adhesions than others. The cause may be previous

Dysmenorrhea and Chronic Pelvic Pain (CPP)

clitoris, urethra, Skene’s glands and Bartholin’s glands. Put two surgery or infections. Here, pain also is mostly neurological.
fingers in the vagina and palpate the vagina (side walls for Like endometriosis, adhesions may be an incidental,
obturator hernia), cervix, pelvic floor muscles (pubococcygeus, asymptomatic finding in some patients. If laparoscopy is
done under local anesthesia and mapping of pain is done
levator ani, coccygeus, obturator internus). Now, put one hand
by verbal analog pain scale (VAPS), we will find out whether
on the abdomen (bimanual) and see for position of uterus
pain is due to adhesions or not. If it is due to adhesions, then
(retroverted), tenderness and irregular growth in the pouch of
only adhesiolysis will help. Laparoscopic uterosacral nerve
Douglas (because of prolapsed ovaries, endometriosis, or pelvic
ablation is tried by some. Empirical treatment is not beneficial.
inflammatory disease). Look for any localized tenderness on
4. Ovarian remnant syndrome: This is seen after partial
examination, especially at the site of the uterosacral ligament
removal of an ovary in a case of endometriosis or pelvic
and the lateral fornices. For endometriosis, examine her again
inflammatory disease. It occurs due to development of
during the menstrual period. Finding mobility of uterus and
follicles. Normal levels of FSH and LH clinch the diagnosis.
adenexa may help.
Removal of the remaining ovarian tissue is the treatment. In
Investigations residual ovary syndrome, the ovary (one or both) when left
during hysterectomy leads to chronic pelvic pain and
Rule out treatable causes first. Routine blood, urine and stool
dyspareunia. Ovaries are tender to palpation on pelvic
examinations are done. Wet smear of cervical discharge may
examination. Removal of the left out ovary/ovaries is required.
help to diagnose trichomonas infection. Other investigations
5. Pelvic congestion syndrome: The patient complains of a
are done according to the leads obtained by history and
dull pain. The cause may be ovarian malfunction. Diagnosis
examination.
is by history. The characteristic pain is more so while
Ultrasonography may give hard markers like pelvic masses
standing and doing work and it increases over the day.
(ovarian cyst), uterine fibromyoma and small pelvic masses (less
Venography of the pelvis shows dilated vessels in the
than 4 cm diameter).
follicular phase. These dilated veins can be visualized at
CT or MRI may be needed in some cases.
laparoscopy. Medical management by medroxyprogesterone
Neurological and psychological assessments may be
acetate 30-50 mg daily for 6 months causes ovarian
required.
suppression. In intractable case, oophorectomy may be
Laparoscopy required. Chronic constipation may cause pelvic congestion;
It is the gold standard for differential diagnosis of CPP. this may be relieved by change of dietary habits.
Endometriosis, pelvic congestion syndrome, pelvic 6. Chronic ectopic pregnancy, if diagnosed, needs surgery for
inflammatory disease, ovarian cysts, adhesion, etc. can be its removal.
detected giving soft markers. It can also help diagnose 7. Leiomyoma, if causing symptoms, needs ablation.
appendicitis. Done under local anesthesia, laparoscopy can pin- 8. Pudendal neuralgia occurs due to many impairments. The
point the site of pain in some cases. main are pelvic floor dysfunction (causing less sitting
tolerance), connective tissue restriction or subcutaneous
Treatment: While treating chronic pelvic pain, a few basic panniculosis (leading to urgency and frequency of
principles are considered: urination), myofascial trigger point (pain during and after
1. Consider the multiple factors involved in the etiology. passing urine), muscle hypermobility (there is pain during
2. Both body and mind (mood depression, etc.) may be and after passing stool), depression and sexual dysfunction.
affected. Myofascial dysfunction is to be identified and treated early
3. Treatment schedule may take time to show its effect. to give good results by connective tissue manipulation by a
4. Temporary relief with analgesia may be needed besides physical therapist for 6–8 weeks. Then, a pelvic rehabitation
eitology specific treatment. program is started by an occupational therapist. There may
5. Multitherapy rather than monotherapy is more effective. be pudendal nerve entrapment that needs neural
6. Psychological support of both the patient and the family is mobilization by surgery (decompression) and neuro-
needed. muscular reduction.
101
 9. Vulvodynia literally means pain in the vulva. It includes Etiology is unknown but is contributed by many factors
vulval pain of any origin. It includes chronic vulvar itching, viz. visceral hypersensitivity, emotional trauma (especially
burning, stinging and/or stabbing pain in the area around during childhood), enteric nervous system dysfunction
the opening of vulva, cause physical, sexual and (serotonin, acetylcholine and cytokine imbalance) cellular
psychological distress. Women of any age can have this immune dysfunction, etc.
problem. It can be cyclic vulvovaginitis, vulval vestibulitis Treatment: To be individualized. Adding fibers to make
syndrome, dysesthetic vulvodynia or vular dermatosis. The bulky stools (psyllium) may not influence pain.
pain is in the area between the labia majora and the hymenal Laxatives in constipation phase may not relieve pain.
ring, anteriorly frenulum of clitoris posteriorly from the Antispasmodics like dicyclomine hyoscine and
fourchette to the vaginal introitus. The urethra, Skene’s propantheline lessen bowel mobility/spasm.
glands, Bartholin’s glands and the area of the major Anti-diarrheal agents: In diarrheal phase, Loperamide,
vestibular glands are included. On examination, nothing etc.
Endocrinology in Gynecology

positive may be forth-coming. Testing lightly with a cotton Selective serotonin reuptake inhibitors (SSRI’s)
tip applicator may localize the area. Sometimes, red spots antidepressant like—paroxetine may help.
in an ‘o’ shaped area in the posterior fourchette between 5 GnRh analog (Leuprolide) in cases which worsen during
o’clock and 7 o’clock area is seen. menstrual period.
Cyclic vulvovaginitis is the most common type. It is Tegaserod: A serotonin 5HT4 agonist may be helpful in
probably caused by hypersensitivity reaction to Candida IBS with constipation.
antigen. Boric acid suppositories twice a day for four weeks Colonic pacing: A cardiac pacemaker is inserted into a
followed by once a day for 4 days during the menstrual subcutaneous pouch and leads are placed at the colosigmoid
period only may help. Lanoline or Vitamin E oil or junction. Pacing is performed after each meal.
petroleum jelly may be applied around the vulva during Alternative therapy like counseling by expert
this treatment. Lactobacillus suppositories may help. psychologists may help. Hypnosis is sometimes useful.
Gentian violet or iodine douching are other treatment Stress reduction is important and physical activities and
options. Use of calcium citrate 1000 mg in divided doses exercises are advised.
per day help in vulvar vestibulitis syndrome. 2. Interstitial cystisis: It is more common than believed. No
Dysesthetic vulvodynia is common in older women. history showing a connection with the bladder may be
Tricyclic antidepressants may help. Biopsy of vulvar forthcoming. To begin with, the patient has mild and
Section 3

dermatosis may find the cause as psoriasis, seborrheic intermittent frequency and pain. This is followed by a
dermatitis, tinea curis, etc. Physical therapy like manual moderate phase. In mid-phase, they pass urine 10–15 times
therapy for releasing muscle spasm may help. Trigger point in a day with nocturea. They have dyspareunia and
therapy and pelvic floor strengthening and relaxation may premenstrual symptom may flare up. In these cases, sensory
be useful. Provide support and empathy to the patient. nerves of the bladder for pain and urgency are activated
Support from the husband is also required. Analgesics can and upregulated. Pain travels by vesical neurons to the
be used. Transcutaneous electric nerve stimulation (TENS) spinal cord and may be referred to any part of the vulva,
can be used. vagina, lower abdomen, back and pelvis. The etiology may
10. Vulvar vestibulitis syndrome (VVS): Dyspareunia and lie in potassium metabolism—a urinary level 140 mEq/l and
hypersensitivity of vulval skin may be due to infection or above may injure tissues and depolarize nerves and muscles.
trauma. Recurrent yeast infection (27% cases), adolescent Intravesical potassium sensitivity testing is being tried.
trauma during sexual act, injury during delivery, laser A routine urological history with times of voiding for
therapy, etc. are cited causes. Elevated tissue levels of at least 2 days is to be recorded by the patient at home. A
inflammatory cytokines are found (Foster Hasday 1997). hypoestrogen state may be a factor.
Ketoconazole is tried for fungal infection. Treatment: Correct hypoestrogenism. Recovery takes
Anti-inflammatory drugs, systemic drugs and time. Pentosan polysulfate 200 mg, BD × 6–12 months is
administration of anti-inflammatory cytokine interleukin helpful.
10(IL-10) may be helpful. Medication is restarted if symptoms reappear. Tricyclics
Ketamine and other N-Methyl D aspartic acid (NMDA) (amitriptyline) help to inhibit sensory nerve urgency and
receptor inhibitors are useful. pain.
11. Mittelschmerz: It is a periodic pain at midcycle due to Intravesical instillation of Heparin, 2 ml/20,000 unit in
irritation of peritoneum by follicular fluid at the time of its 25 ml of saline twice a week for 4 months and then once a
rupture. It is a self-limiting disease. week may improve the condition.
12. Malignancies in the pelvis may cause pain due to Pyridium, polycitrate (10 mg BD) or polycitrate crystals
entanglement of nerves, congestion or inflammatory (1 packet BD) may be useful.
response. Bladder drill and SSRI antidepressants may help.
Anticholinergic treatment with oxybutynin and
Non-Gynecologic Conditions Tolterodine tartarate can also be tried.
The more often detected conditions are described below: Hydroxyzine, as an antiallergic, in case of mast cell
1. Irritable bowel syndrome (IBS) overactivity, gives good results.
Definition: At least 12 weeks of abdominal discomfort/pain Dietary modification includes finding the foods causing
in the past year with 2 of the 3 following features: flare up and avoiding them. The patient must avoid
• Pain relieved following defecation aggravating foods for at least 2 weeks. Then, she should
• Onset of pain associated with change in stool frequency use them less frequently. She should also avoid artificial
(constipation/diarrhea) sweet-eners, grapes, beans, spicy foods, etc.
• Onset of pain associated with change in stool Calcium glycerophosphate may cause relief in cases of
102 appearance. high acid content.
3. Myofascial pain is due to a trigger point in the muscles 2. Carter J. Hernias in pelvic pain: Diagnosis and treatment Edited
and its fascia. The patient is asked to make the rectus muscle by Howard FM, Perry CP, Carter JE, et al Lippincott Williams &
contract by lifting the head and feet from the bed. Pass a Wilkins 2000:389-92.
3. Foster DC, Hasdey JD. Elevated tissue levels of inflammatory
finger gradually on the abdominal wall and localize the
cytokines : Interleukin I beta and tumor necrosis factor alpha in
trigger point. It can be treated by acupuncture, injection of vulvar vestibulitis. Obstet Gynaecol 1997;89:219-5.
local anesthesia and stretching exercise. Transcutaneous 4. Gunter J: Chronic pelvic pain: an integrated approach to diagnosis
electric nerve stimulation (TENS) may also help. and treatment. Obstet Gynaecol Survey 2003;58(5):615.
4. Obturator hernia as a cause of chronic pelvic pain may be 5. Hanno PM: Analysis of long term Elmiron therapy in interstitial
seen. It is a protrusion of preperitoneal fat or bowel urology 1997;49 (suppl 5A):93-99.
protrudes through the obturator canal. It occurs in patients 6. Howard F. American college of obstetrician and gy ACOG Practice
with weakness of the pelvic floor, multiparity, old age, after bulletin 2005 obstet gynecol 2004;103: 589-605.
7. Kempusaj D, et al. Increased numbers of activated mast cells in
weight reduction, due to raised intra-abdominal pressure,

Chapter 16
endometriosis lesions positive for corticotropin releasing hormone
etc. Obturator nerve being both motor and sensory, may and urocortin. Am J Reprod immunol 2004;52(4):267-75.
cause the pain when compressed by hernia by extension, 8. Mc Kay M. Subsets of Vulvodynia: J Reprod, Med 1988;33:695.
abduction and internal rotation of the thigh. On per vaginal 9. Mc Kay M. Subsets of vulvodynia: a multifactorial clinical problem.
examination, one may feel a slight bulge with or without Arch Dermatol; 1989.p.125.
tenderness on one side. 10. Parsons CL. Stein PC, Bidair M. et al. Abnormal sensitivity to
Treatment is surgery. intravesical potassium in interstitial cystitis and radiation cystitis.
5. Lumbar spine disorders and hip disorders may also Neurol Urody 1994;13:515.

Dysmenorrhea and Chronic Pelvic Pain (CPP)

11. Parsons CL, Benson G, Childs SJ, et al. A quantitatively controlled
contribute to pelvic pain. Exclude all serious causes. The
method to prospectively study interstitial cystitis and which
treatment is interferential therapy. In this, two different demonstrate the efficacy of pentosanpolysulfate. J urol 1993;150:845-
electric currents, one at skin of the vulva and another at 8.
pelvic floor cause relief. Interferential therapy can be 12. Rabben T, Skjelbred P, Oye I. Prolonged anlagsic effect of ketamine
considered a deeper form of TENS. The current perfuses to on NMDA receptor inhibitor in patients with chronic pain. J pharm
a greater depth and affects a greater area than other forms Exp Theap 1999;289:1060-6.
of electrical therapy. 13. Sant GT. Theohas TC: The role of mast cells in interstitial cystitis.
6. Psychological depression: In psychological depression Urol Clin North Am 1994;21:41-53.
14. Shafik A EL Sibai O, Shafik A, et al. Colonic pacing in the treatment
listen to the patient and then discuss appropriate treatment
of patients with irritable bowel syndrome. technique and results.
with the patient and her partner and other family members. Front Biosci 2003; 8:101-5
Help them to cope with her illness. 15. Wesselmann U. Neurogenic inflammation and chronic pelvic pain:
Hence, we see that CPP is a multifactorial ailment and Implications for understanding stress, pain and cognition. Brain
needs a detailed history and examination keeping all Behav immun 2003;17(2):69 85.
causative agents in mind. 16. Whitmore K. Complementary and Alternative therapies for
interstitial cystitis. Rev Urol 2002;4(1):28-35.
BIBLIOGRAPHY 17. Xiong T, Diniels J, Middleton L, et al. Meta-analysis using individual
1. Bologna R, Gomel sky A, Lukban JC. The efficacy of calcium patient data from randomized trials to assess the effectiveness of
glycerophosphate in prevention of food related Flares in Interstitial laparoscopic uterosacral nerve ablation in the treatment of chronic
cystitis. Urology 2001;57(1):119. pelvic pain. A proposed protocol. Brit J Ob Gyn 2007;114:1580.

103
 17 Abnormal Uterine Bleeding (AUB)

Sudha Salhan, Gouri Ganguli, Sunita Single

Definition iii. Metrorrhagia is an irregular acyclical bleeding from the

The term abnormal uterine bleeding includes all types of uterus (in practice, however, any irregular bleeding from
abnormal patterns of bleeding except amenorrhea. Any uterine any part of the genital tract is included in metrorrhagia).
bleeding which is a deviation from the normal regular, Causes:
predictable menstrual cycle with average and predictable • Dysfunctional uterine bleeding
amount and duration of bleeding is abnormal uterine bleeding. • Submucous fibroid
A normal menstrual cycle has a frequency of 21–35 days with • Uterine polyp (fibroid polyp or endometrial polyp)
bleeding for 2–7 days. Blood loss averages 35–80 ml. • Endometrial carcinoma
• Carcinoma of the cervix
Abnormal Menstrual Patterns • Mucous polyps of cervix.
Some specific types of abnormal uterine bleeding are as follows: • Vascular erosion of cervix—pregnancy
i. Menorrhagia is cyclical bleeding at normal and regular – Tubercular cervix
intervals, which is excessive (more than 80 ml/cycle) in • Cervical endometriosis
amount or duration (>5 days) or both. In some cases, • Urethral caruncle
bleeding may be so severe and relentless that daily activities • Ovular bleeding (Mittelschmerz) occurs at midcycle (mostly
become interrupted. Nine to thirty percent of women in the spotting)
reproductive age group have menorrhagia. • Breakthrough bleeding during OCP use
Causes include: • IUCD in utero
Pelvic • Decubitus ulcer in prolapsed uterus.
• Fibroid uterus In these cases, malignancy is to be excluded prior to any
• Adenomyosis definitive treatment.
• Tubo-ovarian mass iv. Oligomenorrhea—menstrual bleeding occurring more than
• Early tubercular endometriosis 35 days apart and which remains constant at that frequency.
• Arteriovenous fistula (Fig. 17.1) Causes:
• IUCD in utero • Preceding the onset of menopause (perimenopausal)
• Endometriosis • Premature ovarian failure
• Granulosa cell tumor. • Pituitary failure
Systemic • Polycystic ovarian disease
• Liver dysfunction (coagulopathy) v. Hypomenorrhea is menstrual bleeding that is unduly scanty
• Renal disease in amount (lasts for <2 days).
• Chronic heart failure (CHF)
• Severe hypertension
• Hypothyroidism
• Hyperthyroidism.
Blood dyscrasias
• Von Willebrand’s disease (VWD)
• Idiopathic thrombocytopenic purpura
• Hemophilia
• Leukemia
• Aplastic anemia
ii. Polymenorrhea is cyclical bleeding which occurs at too
frequent intervals (less than 21 days) but which is normal
in amount.
Causes:
• Dysfunctional uterine bleeding
• PID
• Ovarian endometriosis. Fig. 17.1: AV Fistula color Doppler (Courtesy: Dr Uppal)
 Causes: Table 17.1: Differences between anovulatory
Local Systemic and ovulatory bleeding
1. Uterine synechiae 1. OCP use or use of
progesterone only Anovulatory Bleeding Ovulatory Bleeding
contraception a. Usually presents at a. Usually occurs well
2. Endometrial 2. Perimenopausal near the start/end of within the reproductive
tuberculosis the reproduction period. period.
3. Malnutrition b. Bleeding is acyclical as b. Bleeding is usually
it depends on unpre- cyclical and regular &
4. Anorexia nervosa
dictable breakthrough variable in duration/
vi. Polymenorrhagia is cyclical bleeding which is both from estrogen influence. amount.
excessive and too frequent. c. Bleeding may be so c. Bleeding is usually not so
severe as to threaten life. severe.

Chapter 17
Causes:
• Pelvic infection d. Mainly estrogen d. Progesterone
withdrawal bleeding. withdrawal bleeding.
• Stressful situations
e. Bleeding is always e. Bleeding is usually associated
• Anovulation. painless. with pain
vii. Menometrorrhagia—heavy blood loss at irregular intervals. and PMS
viii. Other causes: f. Tense, emotional, f. Usually normal psyche
• Implantation bleeding: nervous psyche.
1. Threatened abortion g. Not due to pregnancy g. May be due pregnancy

Abnormal Uterine Bleeding

2. Inevitable abortion related complications. related complications.
3. Incomplete abortion. h. Not seen h. Mittelschemeritz can be seen
i. Not present i. Cervical mucus changes
• Gestational trophoblastic disease
present
• Uterine anomalies—uterus didelphys, uterus bicornis j. Monophasic tempera- j. Biphasic temperature
• Pelvic peritonitis ture curve curve
• Salpingo–oophoritis
• Pelvic cellulitis
OVULATORY DUB
• Tamoxifen therapy
• Exogenous estrogen administration 1. IRREGULAR RIPENING
• Coagulation defects • Poor formation and inadequate function of corpus
• Emotional nervous upsets. luteum so that secretion of progesterone is insufficient
ix. Postmenopausal bleeding to support endometrial growth.
It should be noted that while recording the history, the exact • Slight bleeding/ spotting for a few days prior to the start
details of the menstrual cycle should be described instead of menstrual bleeding.
of simply using the terms from (i) to (vii).
• Less than 3 ng/ml of pregnanediol in urine in the luteal
DYSFUNCTIONAL UTERINE BLEEDING (DUB) phase.
• Less than 3 ng/ml of plasma progesterone levels in the
All forms of abnormal uterine bleeding for which no organic
cause (benign or malignant growths) can be found is known as luteal phase.
dysfunctional uterine bleeding (DUB). This is a diagnosis of • Endometrium on histopathology shows patchy areas
exclusion. of secretory changes amidst proliferative endometrium.
Incidence: Approximate incidence of 10%. 2. IRREGULAR SHEDDING
• Incomplete and slow degeneration of corpus luteum
Classification
(Halban’s disease).
1. According to the cause: • Slight bleeding continues intermittently for several days
Primary DUB: Due to dysfunction in the endo-metrium or
after the proper flow, though menstrual bleeding is on
in hypothalamo-pituitary-ovarian (HPO) axis.
Secondary DUB: Due to some undetected pathology time.
outside endometrium/HPO axis. It could be due to clotting • Patchy progestational appearances persist in the
dysfunctions or systemic disorders. endometrium along with proliferative endometrium.
Iatrogenic DUB: Secondary to IUCD/OCPs anticoagulant • It may be due to incomplete withdrawal of LH or
use. variation in endometrial receptor sensitivity to estrogen
2. According to ovulatory status (clinical) (Table 17.1) and progesterone influence.
• Pregnanediol is found in the urine during the menstrual
Ovulatory (10%) Anovulatory (90%) (low levels of phase.
progesterone) 3. IUCD INSERTION
1. Irregular ripening 1. Threshold bleeding of pub-erty • IUCD may induce structural changes in the endometrial
menorrhagia. vessels which may increase bleeding.
2. Irregular shedding 2. Metropathia hemorrhagica • May respond to NSAID treatment or might need
(cystic glandular hyper-plasia) removal of IUCD.
3. IUCD Insertion 3. Premenopausal dysfunc-tional
uterine bleeding. ANOVULATORY DUB
4. Following sterili-
1. Puberty Menorrhagia (Flow chart 17.1): Puberty
zation operation
menorrhagia is a threshold bleeding of adolescence caused
5. Polymenorrhea
by excess/unopposed estrogen and absence of progesterone
105
 Flow chart 17.1: Puberty menorrhagia painless along with slight symmetrical enlargement of the
uterus associated with a small ovarian cyst, that represents
a cystic (anovulatory) graafian follicle seldom more than 5
cm. Differentiation from miscarriage episodes and ectopic
pregnancy is important.

Histological Changes in Uterus/Ovaries

1. Myohyperplasia of the uterine musculature.
2. The endometrium is thick hemorrhagic, polypoidal as cystic
glandular hyperplasia (glands—cystic dilatation with large
cysts—Swiss cheese pattern).
3. Absence of secretory hypertrophy (no cork screw glands).
Endocrinology in Gynecology

4. Superficial areas of necrosis in endometrium as seen on the

first day of menstruation.
5. Ovaries show a cyst with cystic ripening follicle (signs of
luteinization, <5 cm in size) caused by inhibition of ovulation
and corpus luteum formation.

Diagnosis and Evaluation

A meticulous history is revealing. Finding the amount of
bleeding is very important. It can be assessed on a scale of 100
which include the number of pads soaked (amount of soaking
superficial-1 or fully soaked-10), days of bleeding, passing clots
(small clot-1, big clots-10). Pictorial blood assessment chart
(PBAC) by Higham and team. This scoring is also to be
corretated with anemia.
Age and Reproductive Period
Section 3

1. <20 years : Most likely functional dis-turbance like

puberty, me norrhagia, chances of
spontaneous cure.
2. 20–45 years : Pregnancy-related compli cations.
PID
IUCD induced
Hormonal treatment
Organic cause (fibroid, endo-metritis).
3. >45 years : Functional disorders like metro-
in anovulatory cycles. It is in the form of excessive or normal pathia, tumors
but continuous bleeding lasting for many days leading to (benign/malignant)
secondary features like anemia. Pelvic, rectal or ultrasound 4. Postmenopausal : Local organic cause such as genital
examination do not show any abnormality as the
carcinoma must be ruled out.
abnormality is mainly functional. Therapy consists in
correcting the basic hormonal defect by administration of Clinical Examination
progesterone/oral contraceptives and regularizing the 1. Time and mode of onset/relation to menstruation/painful
normal hormonal milieu over a few cycles to control and or painless/proceeded by ammenorrhea, and exact details
regularize menstrual bleeding. of duration, amount and frequency of bleeding is noted.
2. Metropathia hemorrhagica: This is premenopausal 2. Menstrual chart may be very useful (if there is no urgency
menorrhagia caused by anovulation leading to unopposed of treatment). Is the cycle regular or irregular? The patient
estrogen and deficiency of progesterone increase in the latter is asked to maintain a menstrual calendar for 3 months.
part of the menstrual cycle. The disturbance lies in the One advantage of this is that it helps the doctor judge
rhythmic gonadotropic secretion or unresponsiveness of whether the patient is confusing the bleeding free period
follicles or follicular depletion in ovaries. After a variable with the length of the cycle. She is asked to mark the day
period of unopposed estrogen influence on the the period starts and then marks when it stops. She is also
endometrium, the estrogen level falls resulting in asked to note the number of pads per day. Thus, we come
endometrial shedding with heavy bleeding. Uterine muscles to know the exact length of the cycle and the amount of
undergo myohyperplasia under estrogenic influence flow, any accompanying pain should be duly recorded.
leading to symmetrical enlargement of the uterus up to 8 3. Background environment and marital status.
weeks. The endometrium becomes thick, congested and 4. History of bleeding diathesis (nasal bleed, bleeding
often polypoidal (known as cystic glandular hyperplasia). tendency after trauma, bruising, etc.).
The typical presentation is a woman of above 40 years of
age complaining of a single or many episodes of prolonged On Examination
menstruation occurring continuously for days leading to 1. Slight enlargement of uterus may be present.
anemia that may be preceded by a period of short 2. The ovary may contain a cyst (follicle).
amenorrhea (in about 50% cases). Bleeding is usually not 3. It should be ruled out that no other major abnormality is
too severe and consists of bright red colored blood, is forthcoming on examination/history.
106
 Also, enquire about any metabolic hormonal disorders (e.g. 4. To work out definite therapy protocol keeping in view the
thyroid ailment) or coagulation disorder. Any history of patient’s reproductive aims and general conditions besides
treatment for the same is elicited. the pathology.
Investigations MANAGEMENT
1. Hb%—indicates degree of blood loss (a rough guide to the It is to be individualized depends on the age of the patient,
amount of bleeding and hematological status of patient). severity of the bleeding and need to retain fertility. General
2. Platelet count, BT, CT or full coagulation profile if needed— measures like reassurance and counseling is to be used.
to rule out any coagulation/bleeding disorder.
3. If PCOS is suspected, serum prolactin, FSH, LH may be MEDICAL TREATMENT
assayed.
Progesterone Treatment
4. In menorrhagia, do thyroid function tests.

Chapter 17
5. Urine test hCG—to rule out pregnancy. 1. Oral norethisterone/medroxyprogesterone acetate 5 mg tds
6. D&C/endometrial biopsy for genital tuberculosis may be till bleeding stops (within 7 days) which is then followed
done. for next 20 days and then stopped leading to withdrawal
7. Culture of menstrual blood/menstrual blood PCR for genital bleeding.
tuberculosis may be carried out. 2. Next cycle is started on day 5 and continued for 21 days
8. For evaluation of bleeding disorders, do von Willebrand’s and is similarly continued for 2–3 cycles.
factor (VWF) assay, platelet count, factor VIII assay and 3. If on initial hormonal therapy bleeding fails to stop, then
therapeutic endometrial curettage is done and the curetted

Abnormal Uterine Bleeding

other coagulation assays.
9. Chronic renal and hepatic disorders to be excluded. material is sent for histopathological study.

Ultrasound Examination HORMONAL THERAPY IN AUB IN

1. It is important to exclude organic causes of abnormal REPRODUCTIVE AGE WOMEN AIMS
uterine bleeding such as fibroid, endometriotic lesions, 1. To stop bleeding
adenomyosis, etc. 2. To regulate the cycle.
2. Endometrial hyperplasia is seen in cases of dysfunctional Methods
uterine bleeding specially due to excess unopposed estrogen
1. Norethisterone (5 mg) thrice daily till bleeding stops,
stimulation. continue till 20 days, then stopping the drug. Withdrawal
3. Associated ovarian cysts/lesions may be seen. bleeding occurs which is followed by progestogen (5 mg)
Diagnostic/Therapeutic uterine curettage is done and send from day 5 to 26 × 3 cycles—9–12 months (in endometrial
the endometrium so obtained for histopathological examination hyperplasia). Followed by diagnostic endometrial curettage.
(in formalin) and for tuberculosis (in normal saline). This 2. Cyclic progestogen (norethisterone 4 mg) from
procedure is done. 5th–26th day of cycle for 3 cycles (in anovular bleeding). In
cases of excessive bleeding.
1. To exclude organic lesions in endometrium:
3. Natural micronized progesterone 200 mg daily for 12 days
And to diagnose from 14th day of the cycle.
– Incomplete abortion 4. Combined oral pills (19-norethisterone–estrogen) given
– Endometrial carcinoma from 5th–26th day of cycle × 3 cycles. Serves as a
– Tubercular endometritis. contraceptive and helps in resumption of cycle take place.
2. To determine the functional state of endometrium 5. In excessive bleeding, can give isolated estrogen (equine
(secretory/proliferative). conjugated estrogen) 2.5 mg QID (for hemostasis). The
3. To diagnose cystic glandular hyperplasia. bleeding stops in 2–3 days followed by 2.5 mg Od × 21 days.
4. To achieve incidental therapeutic gain (removing the Parenteral therapy in similar doses may be given.
endometrium stops further bleeding). 6. Progesterone containing IUCD reduces bleeding by 50%
with added contraception effect.
In Refractory/Recurrent Cases
1. Hysterosalpingography: To exclude fibroid polyp or Other Agents
congenital malformation of the uterus. Saline 1. Prostaglandin synthetase inhibitors: Nonsteroid anti-
sonohysterography gives contour of the cavity and shows inflammatory drugs (NSAIDS) mefenamic and ibuprofen.
intrauterine lesions. i. Mefenamic acid (500 mg tds) or ibuprofen effective in
2. Laparoscopy: To see pelvic pathology, such as endome- women >35 years with a 50% reduction in bleeding.
triosis, PID, ovarian tumors, especially if DUB is associated (Inhibit conversion of arachadonic acid to prostaglandin
with pelvic pain. and reduce vasodilatation.)
3. Hysteroscopy: Evaluation of endometrial lesion and to take 2. Antifibrinolytic agents (useful in IUD–induced DUB):
concomitant biopsy from suspected lesions, to diagnose Fibrinolytic activity is greater in the endometrium of women
submucous fibroid, often missed by blind curettage. with AUB. Hence, antifibrins-lysic agents are helpful. They
are also helpful in cases of AUB due to IUCD.
AIMS OF INVESTIGATIONS i. Tranexamic acid. The dose of the latter is 500 mg–1 gm
1. To confirm the menstrual abnormality as stated by the QID during bleeding phase (4—5 days).
patient. ii. Ethamsylate—reduces capillary fragility; and causes
2. To exclude organic pelvic pathology. platelet aggregation used from 5 days before and up to
3. To identify possible etiology. 10 days after menstruation. Reduces bleeding by 50%.
107
 iii. Flavonoidic fraction (for phlebotonic effect). Diosmin
improve capillary integrity, (increase capillary resistent
suppress PGE 3 secretion and improve lymphatic
drainage.
3. GnRH analogs: To be used for 3 months only (to prevent
osteoporosis).
i. Subtherapeutic doses : Blood loss is decreased.
ii. Therapeutic doses: Produce amenorrhea.
4. Danazol: In patients with recurrent symptoms and in
waiting for hysterectomy (200–400 mg daily in divided
doses) suppresses estrogen and progesterone receptors in
the endometrium leading to its atrophy and less blood loss.
Endocrinology in Gynecology

5. Ormeloxifene a selective estrogen receptor modulator

(SERM). It blocks cyclic estrogen receptors and cause their
prolong depletion without affection of hypothalamus-
pituitary ovarian action. It prevents proliferation of
endometrium. It is mostly used in perimenopausal AUB
60 mg twice weekly is taken orally for 12 weeks and
subsequently 60 mg once a week is the dose.
6. GnRh antagonists are also being tried. Fig. 17.2: Transcervical resection
7. Clomiphene citrate: Useful in anovulatory AUB especially
in women desirous of pregnancy.
8. Testosterone

Uterine Curettage
1. Done as a diagnostic tool specially if the bleeding is acyclical.
2. As a therapeutic technique it works as hemostat in a number
of cases but only in the current cycle.
Section 3

Time Schedule for Uterine Curettage

• Cyclic bleeding–menorrhagia - premenstrual (25–27 day)
– Irregular shedding – Postmenstrual (5–6 days)
– Irregular ripening – Soon after menstruation
• Acyclic – Soon after the period starts
• Continuous – Anytime as a therapeutic measure to remove
the endometrium and stop bleeding.

SURGICAL TREATMENT
Endometrial Ablation Fig. 17.3: Uterine balloon therapy
Exclude malignancy before this operation.
Counseling before surgery is essential as sometimes • Combined oral contraceptive pills – 43%
recurrence can occur. They are first generation (Transcervical • Levonorgestrel releasing intrauterine system (LNG-IUS) –
resection) (Fig. 17.2) and second generation (Thermachoice 74–97%
Balloon) (Fig. 17.3) and microwave endometrial ablation (Refer • Danazol – 50–80%
chapter 65 for detail). • Oral progestogens for 21 days – 30–90%
• Ethamsylate – 13%
Indication • Flavonoidic fraction – 10%
1. Family is complete • GnRH analogues – >90%.
2. Age more than 40 years-patient more satisfied with results The summary treatment is given in Flow charts 17.2 to 17.4.
as uterus is preserved
POSTMENOPAUSAL BLEEDING (PMB)
3. Blood loss more than 80 ml
4. Any uterine pathology ruled out. By definition, postmenopausal bleeding is a bleeding that occurs
It is a permanent method of endometrial destruction to following the confirmed diagnosis of menopause (amenorrhea,
variable length. which is at least 6–12 months form the end of a woman’s last
menstrual cycle). This should not be confused with infrequent or
Hysterectomy irregular periods occurring around the time of menopause. The
1. Failure of conservative treatment. bleeding can be in the form of spotting or it can be heavy, and it
2. Blood loss impairs health of the patient. may or may not include clots. It is possible that mucus may
3. Family is completed. accompany any occurrence of bleeding, and the discharges may
4. Age approaching 40. often vary in length, frequency, and intensity. There are no
preventive measures that can be taken to treat postmenopausal
Efficacy of Drug Treatment for Women with DUB bleeding. This symptom must always be taken seriously.
Postmenopausal bleeding may be caused by any of the
• NSAIDS—20–50%
108 • Tranexamic acid—47–60%
following:
 Flow chart 17.2: AUB in reproductive age: (20–40 years.) Flow chart 17.4: AUB management

Chapter 17
Abnormal Uterine Bleeding
• Cancer of the uterus, cervix, vagina, vulva.
• Foreign body in the vagina, e.g. forgotten pessary, etc.
Endometrial or vaginal atrophy is the most common cause
of PMB but more sinister causes of the bleeding such as
carcinoma must first be ruled out. Patients at risk for
endometrial cancer are those who are obese, diabetic and/or
Flow chart 17.3: AUB unresponsive
hypertensive, nulliparous, or using exogenous estrogens
(including tamoxifen) or those who experience late menopause

Assessment
Abnormal postmenopausal bleeding should always be taken
seriously and investigated, no matter how minimal or
insignificant it may appear. Initial assessment should include a
complete history with assessment of risk factors as well as
medication history covering use of estrogen, tamoxifen or
anticoagulants. It is also important to enquire about any non-
prescription medication such as phytoestrogens.

Examination
Clinical examination should include abdominal examination,
looking for abdominal masses. On examination of the vulva
look for neoplasms of the vulva. A speculum examination
should be performed to allow assessment of atrophic vaginitis
and to rule out tumors of the cervix, vagina, or cervical polyps.
A pap smear should be taken. The finding of atrophic vaginitis
or an endocervical polyp should not be accepted as the
explanation of the bleeding without further assessment of the
endometrial cavity. Bimanual examination should be performed
to assess uterine size, mobility and position before performing
endometrial biopsy. Cervical or vaginal masses that were not
seen on speculum examination my be palpated, as well as
detection of adnexal masses is done. Rectovaginal examination
allows detection of nodularity in the cul de sac.

• Hormone (estrogen) therapy Biopsy

• Atrophy of the vagina or uterus The gold standard for diagnosis of any malignancy is tissue
• Uterine or cervical polyps biopsy. Endometrial office biopsy or aspiration can be easily
• Endometrial hyperplasia or polyps performed in most patients. Histopathological examination of
• Submucous fibroids any abnormality of the genital tract is mandatory.
• Other causes include
– Vaginal trauma Ultrasound
– Urethral caruncle Transvaginal ultrasound is recommended as a preliminary
– Medical causes (e.g. anticoagulant therapy) noninvasive technique for assessing the endometrium in women 109
 with PMB. It cannot give a definitive answer as to the presence progesterone treatment and definitive treatment in the
or absence of malignancy, although it can be helpful in the postmenopausal woman should be hysterectomy with or
assessment of uterine polyps hyperplasia of the endometrium. without oophorectomy because of the risk of concomitant and
Endometrial thickness more than 5 mm is to be considered future malignancy. Those patients medically unfit for surgery
seriously. Vascularity is important. can be treated with high dose progesterone but need to be
Atrophic vaginitis/endometritis. The diagnosis of atrophic reassessed frequently (3 monthly) with endometrial sampling
vaginitis is made when speculum examination reveals a thin, to ensure reversal of changes. Hyerplasia without atypia can
friable vaginal wall that may bleed upon opening the speculum. be treated with progesterone, with an expected response rate
Women with atrophic endometritis usually have been of 80%. Carcinoma of cervix, vagina and vulva is to be treated
postmenopausal for over 10 years. There is often minimal tissue accordingly (Chapters 41, 42 and 52).
or just mucus and blood on endometrial biopsy. Treatment is
topical or systemic estrogens. The addition of progesterone is Endometrial Carcinoma
Endocrinology in Gynecology

needed if using systemic estrogens with an intact uterus. Over 90% of women with endometrial carcinoma present with
postmenopausal vaginal bleeding. Rarely abnormal endo-
Cervical Polyps metrial cells are seen on a routine Pap smear in asymptomatic
Endocervical polyps are more common than ectocervical polyps. postmenopausal women.
They appear as red protrusions from the external cervical os.
They can usually be easily removed in the office by grasping Treatment
with sponge forceps and twisting off their pedicle. Send the Treatment of endometrial carcinoma is almost always surgical.
tissue obtained for histopathological examination. Staging is carried out at the same time and allows accurate
assessment of the extent of disease (chapter 46).
Endometrial Polyps Foreign body is to be removed. Tamoxifen (used for breast
The incidence of endometrial polyps varies with age, reaching cancer) and estrogen therapy is to be stopped.
a peak in the fifth decade of life. Because they are estrogen
sensitive, their incidence declines after menopause. They are BIBLIOGRAPHY
also associated with tamoxifen use and are the most common 1. ACOG committee opinion. Von Willibrand’s disease in
abnormality seen with patients using tamoxifen. Rarely gynaecologic practice Int J Gynecol Obstet 2002;26:336.
endometrial polyps may undergo malignant change into a 2. Bayer SR, Decherney AH: Clincial manifestations and treatment of
Section 3

DUB. JAMA 1993;269:1823.

carcinoma or sarcoma. Hysteroscopy can identify endometrial
3. Casablance. Management of AUB Obst Gyne. Clin North Am
polyps by direct visualization. Saline infusion sonograms have 2008;35(2):219.
been used to identify polyps that show up as filling defects. 4. Chandra BS, Kumari SS, Shankar, BT, et al. Ormeloxifene in a SERM
Pelvic ultrasound usually does not reveal endometrial polyps for treatment of dyfunctional menorrhagia. J Obstet Gyn. Ind
unless they are particularly large. Treatment is removal during 2004;1:56.
hysteroscopy. The specimen should always be sent for 5. Karsidag YK, Buyakhayrak EE, Kars M, et al. Transvaginal
pathological assessment. sonography, sonohysterography and hysteroscopy for investigation
of focal intrauterine lesions in women with recurrent PMB after
Endometrial Hyperplasia Drc Arch Gynecol Obstet 2010; 2001(4):637.
6. Kingman CEC, Kadir RA, Lec Ca, et al. The use of LNGIUS for
Endometrial hyperplasia covers a range of pathological changes treatment of menorrhagia in women with inherited bleeding
in the uterine glands and stroma. Hyperplasia can be simple or disorders. Br J Obstet Gynecol. 2005;111:1425.
complex with or without atypia. The presence of atypia on 7. Rosenfeld J: Treatment of menorrhagia due to DUB. Am Fam
hystopathology is the most worrisome feature as approximately Physician 1996;53:165.
20% of those with atypical hyperplasia will have concomitant 8. Shrrat GM: Choice of treatment for menorrhagia Lancet 1999;
endometrial carcinoma and a further 25–30% will develop 353:2175.
endometrial malignancy within 2 years, if the condition is left 9. Wellington K, Wagstoff AJ. Tranexamic acid: a review of its use in
the management of menorrhagia. Drugs 2003;63:1417.
untreated. Hyperplasia with atypia responds less well to

110
 18 Premenstrual Syndrome (PMS)

Sudha Salhan

Definition Women with PMS are reported to have suffered greater

It is a cyclical constellation of symptoms occurring in the second traumatic life stress. History of abuse and depression may be
half of the menstrual cycle (secretory or luteal phase) to such a elicited. Allopregnanolone response to stress predict
degree that a patient’s work is affected. This is followed by a premenstrual symptoms severity only in women with prior
period of time free of symptoms. These symptoms should have depression.
occurred for at least 4–6 previous menstrual cycles.
It is a very common symptom in women in the reproductive Symptoms of PMS
age group. Psychiatrists call it premenstrual dystrophic disorder The symptoms occur a week to 10 days before the start of the
(PMDD). menstrual blood loss. The severity varies from slight discomfort
to interference with normal activities at work or home and
Etiology relationships with others. There are a variety of symptoms (over
The etiology is complex and not well-understood. A few 200). The symptoms include bloating, gain in weight, nostalgia,
theories are forthcoming about the cause. backache and headache. Tiredness, lethargy and fatigue may
be there. There is a change of appetite and craving for sweet or
Hormonal deficiency was thought to be the cause, but there is
salty food. Both insomnia and hypersomnia are mentioned.
not much evidence in its favor.
Psychological symptoms like decreased interest in day-to-
Prostaglandins suppress vascular response to angiotensin II. day activity, anger or irritability, anxiety or tension, depression,
A breakdown of this leads to renal, cerebral and vascular mood swings, crying without reason, etc. are reported. Even
changes in premenstrual syndrome (PMS). criminal behavior or suicide tendency is seen.
Hyperinsulinism can be the cause of nervousness, anxiety and Diagnosis: In the World Health Organisation (WHO)
irritability. International Classification of Diseases 10th edition (ICD-10),
Cyclical nostalgia may be a direct effect of prolactin. PMS is classified under in gynecological disorders. The two
main points are a must for diagnosis: (i) association with the
Pyridoxine is a coenzyme in the metabolism of serotonin and menstrual cycle and (ii) cyclicity and timing.
dopamine (mood and behavior regulator). Its deficiency leads The American College of Obstetricians and Gynecologists
to serotonin deficiency causing symptoms of PMS. This theory (ACOG) diagnostic criteria require that at least one of the six
is supported by the response of symptoms of PMS to selective effective symptoms (depression, irritability, anger outbursts,
serotonin reuptake inhibitors (SSRIs). anxiety, confusion, social withdrawal) and one of the four
Hormones secreted by the adrenal and other sympathetic somatic symptoms (breast tenderness, abdominal bloating,
ganglia may affect sodium balance and may cause PMS headache, swelling of extremities) should be there during 5 days
symptoms. The same is true with renal angiotensin aldosterone before the start of menses, at each of three previous menstrual
activity. cycles and relieved within 4 days of the onset of bleeding. Petta
Some women may be more sensitive than others to changing and Associates (2010) encountered nervousness/anxiety (76.4%),
hormone levels during the menstrual cycles. mood swings/crying (55.7%) pain, swelling and tenderness of
Deficiency of mangnesium and calcium may be linked to breasts (37.3%), and cramps (45.4%) in these patients.
PMS symptoms. Psychiatrists call it PMDD and it is designated as a
Endorphin (Endogenous opiate peptides) are controlled, to depressive disorder not otherwise specified.
some extent, by progesterone or both estrogen and Take the history of the last menstrual period. Any stress at
progesterone. They increase in the 14–20th day of the cycle. home or the workplace should be asked for. History of abuse is
Biogenic amines and catecholamines are present in the first half to be asked. Also, enquire for symptoms during the last cycle
of the cycle. Their low level in second half is incriminated in and the complaint therein (ask her to note and then tell).
PMS symptoms. Gamma-amino butyric acid (GABA) is also Different types of record protocols are developed (e.g. PRISM
under research for causing PMS. Its transmitter system is calendar) to record day-to-day symptoms to be shown after
inhibitory to the central nervous system (CNS). Its receptor one month.
sensitivity is a crucial factor. There is a complex interaction between Examination: No specific physical findings are there to establish
the serotonin and GABA system and neuroactive steroids. the diagnosis.
 Rule out other causes of PMS symptoms. Look for anemia Vitamin B6 up to 100 mg day is helpful. Same is true for
and its cause, if present, which may be causing restlessness and Vitamin E supplement.
weakness. See for hypothyroidism. Also, elicits signs of Acupuncture and acupressure may help dysmenorrhea, in
intracranial pathology. some. Evening primrose oil seems to be of no help. Ginger
Breasts are hard and tender to touch. There may be bloating extract is helpful in some cases of mastalgia. Some has shown
of abdomen. relief with gamma linoleic acid with vitamin E.
A pelvic examination is essential to rule out any pelvic Vaginal temperature feedbacks (12-week sessions) is shown
pathology, viz. endometriosis (causing premenstrual congestive by some to reduce physiological and affective system.
dysmenorrhea) or any other abnormality. Chaste tree extract does improve the condition in some.
Laboratory test: No specific laboratory tests for PMS are there Relaxation of muscles by training (for 3 months twice a
at present. Do blood test for the diagnosis of anemia (if present, week) helps some cases of PMS. Massage and spinal
Endocrinology in Gynecology

look for its causes), carry out thyroid function tests, urine routine manipulation has shown good results by a few researchers. Qil
test and stool on three consequent days for ova, parasite and therapy, an oriental complementary therapy, has been observed
cysts. to have good effect by a few clinicians.
Management: Detailed interaction and reassurance of the Surgery is the last approach in desperate cases (ACOG option
patient of PMS goes a long way in removing the anxiety of 153). When all other therapeutic approaches have failed after
having a morbid condition requiring radical treatment. By filling sufficient trial, oophorectomy with or without hysterectomy is
the PRISM calendar, she will herself become aware of the considered after explaining the advantages and disadvantages.
regularity of the symptoms. Involvement of family members SSRIs are effective in most cases of moderate-to-severe PMS
will help her in difficult days, because they will understand and may be tried as the first line option. In a case, where
and react accordingly. contraceptive is also needed, a drospirenone containing oral
Dietary intervention: Though evidence for direct involvement contraceptive pill be useful.
of diet in PMS is lacking, it has been seen that change of diet Use of gonadotropin-releasing hormone (GnRH) analogs
habits help. Avoidance of salt, caffeine, alcohol and chocolates is suited for short-term relief. Menstrual migraine can be
is useful. mitigated by:
Omega-3-fatty acids can be included in the diet. Eating • Nonsteroidal anti-inflammatory drugs.
smaller meals at frequent intervals is advised. Using milk and • Long half-life triptans (naratriptan and frova triptan)
Section 3

milk products are useful as calcium supplement. Magnesium • Estrogen supplementation and even oral contraceptives in
and potassium in seasonal fruits is required. Refined oils are women requiring contraception are helpful. It suppresses
preferred. Avoidance of maida and white rice is recommended. ovulation and hormonal fluctuation.
Change in lifestyle by taking brisk walk for 20 minutes per
BIBLIOGRAPHY
day is beneficial in many PMS patients. Relaxation exercises
1. American college of obstetrician and gynecologists. PMS ACOG
and yoga may help.
committee opinion no. 153 April 1995.
2. American college of obstetricians Gynecologists (ACOG) PMS.
Medicinal Intervention Washington DC ACOG 2000.
The use of medicine is to reduce the symptoms of PMS and 3. Girdler SS, Sherwood A, Hinderliter AI, et al. Biological correlates
enhance quality of life. The symptom-wise treatment is initiated. of abuse in women with premenstrual dysphoric disorder and
Prostaglandin synthetase inhibitors (mefenamic acid 500 mg healthy controls. Psychosom Med 2003;63:849.
TDS) or oral contraceptives are used for dysmenorrhea and 4. Jang HS, Lee MS: Effect of qi therapy (external qigong) on PMS-a
menorrhagia. Diuretics, pyridoxine or progesterones do not randomized placebo controlled study. J Altern Complement Med
2004;10:456.
have any effect on mastalgia. Danazol in low doses in the last
5. Klatzkin RR, Marrow AI, Light KC, et al . Histories of depression,
half of the cycle (100–200 mg/day) can help. Mild anxiolytics allopregnanolone responses to stress and PMS in women. Biol
like alprazole can be used in cases having anxiety. Psychol 2006;71:2.
Estrogen tablets may be given in the last week of the cycle. 6. Lombaridi 1, Luisi S, Quirici B, et al: Adrenal response to
Gonadotropin-releasing hormone (GnRH) agonist with estrogen adrenocartiocotrophic hormone stimulation in patients with PMS.
add back (to prevent menopausal symptoms) is helpful. Gynaecol Endocrinol 2004;18:79.
Sumatriptan orally or by intramuscular (IM) route may be 7. Petta CA, Osis DMJ, Pandua K Sol, et al. Premenstrual syndrome
useful. as reported by Brazilian women. Int. J. Gyn. Obst 2010;108:1,40.
8. Reid RL. Premenstrual syndrome and menstrual related disorders
Depression can be controlled by selective serotonin reuptake
in : Falcone T, Hurd WW, eds. Clinical reproductive medicine and
inhibitors (SSRIs), e.g. fluoxetine and by selective serotonin surgery. City: Mosby 2007.
norepinephrine reuptake inhibitors (SNRIs), e.g. venlafaxine. 9. Van Zak DB. Bio feedback treatment of premenstrual and
They increase serotonin activity and also enhance the synthesis premenstrual effective syndromes. In J Psychosom 1994;41:53
of allopregnanolone by directly stimulating the activity of the 10. Yonkers KA., Brown C, Pearlatein TB, et al. Efficacy of a new low
final enzymes in the biosynthetic pathway. These drugs do dose oral CC with drospirenone in PMDD. Obstet Gynaecol
reduce PMS symptoms. A long-term use is indicated to prevent 2005;106:492.
relapse.

112
 19 Endometriosis

Kiran Guleria, Sudha Salhan

Definition The Implantation Theory

Endometriosis is defined as the presence of endometrial like This theory is based on Sampson’s pioneering work in 1920s
tissue (glands and stroma) outside the uterine lininig. The that endometriosis results from transport of viable endometrial
endometriotic implants which have endometrial glands cells that implant and grow on pelvic peritoneum and
surrounded by stroma respond variably to cyclical hormone surrounding structures especially dependent portions of the
stimulation. It is a chronic and recurrent disease. These vary pelvis—the ovaries, cul-de-sac, uterosacral ligaments, posterior
from minimal lesions on an intact pelvic organ to extensive part of the uterus and posterior aspect of the broad ligaments.
disease including large ovarian endometrioma and massive Women with obstructive genital outflow tract, longer duration
adhesions distorting tubo-ovarian anatomy and involving the of periods and short menstrual length are at higher risk of
bowel, bladder and ureters causing substantial morbidity. endometriosis. Women with endometriosis have more volumes
Hence this disease has a unique benign proliferative growth of refluxed mestrual blood and endometrial tisues than women
process with a tendency to invade the surrounding normal without this disorder. Endometrium of these women is believed
tissues. They are at a higher risk of ovarian, breast and other to be abnormal, predisposed to successful establishment of
cancers and autoimmune and atopic disorders. ectopic disease. It proposes five basic necessary processes to its
development viz. adhesion, invasion, recruitment, angiogenesis
Incidence and Prevalence and proliferation.
It occurs in about 7–15 of women in the reproductive age Endometrium shed during menstruation can be grown at
group. Endometriosis is a disease of reproductive age but has extragenital sites. This explains the occurrence of scar endo-
also been reported in adolescents specially with obstructive metriosis following classical cesarean section, hysterectomy,
uterine abnormalities (e.g. noncanalization of cervix) and myomectomy and episiotomy. However, this theory does not
postmenopausal women receiving hormone replacement. It explain the pathogenesis of endometriosis at distant sites like
afflicts women of all ethnic and social groups. It’s prevalence in lungs, vulva, skin and gut and in non-menstrual women (absent
women with infertility (25–30 ) pelvic pain (40–70 ) and in uterine or tumors syndrome).
asymptomatic women (detected at the time of tubal ligation) is
3–43 . The incidence appears to be rising due to improvement Induction Theory
in diagnostic modalities. There is a substantial toll in the form It proposes that an undefined endogenous biochemical factor
of personal relationships, time off work, surgery, drugs, etc. can induce undifferentiated peritoneal cells to change into
which may be quite expensive. endometrial tissue. Though documented in rabbits, it has not
been substantiated in women and primates.
Etiology
Ectopic endometrium has some differences from entropic Hematogenous and Lymphatic Spread Theory
(normally placed) endometrium. They are anomalies in Halban’s theory suggested that menstrual fragments carry
structure, proliferation, immune component, adhesion endometrial cells through the vascular or lymphatic channels
molecules, proteolytic enzymes and their inhibitors, steroid and to distant sites like umbilicus, ureters, bowel wall, lung, pleura,
cytokine production and responsiveness, gene expression and endocardium, skin, etc.
protein production. The percentage of apoptosis is greatly
reduced in endometriosis. Coelomic Metaplasia Theory
Endometriosis is an estrogen dependent condition but the The peritoneum is induced to undergo metaplasia into
exact etiology is not clear. Various theories have been proposed endometrium by some stimulus (e.g. menstrual fluid, cyclinic
to explain the histogenesis of this disease. ovarian hormones irritants, etc.) (Ivanoff and Meyer theory).
1. Implantation theory (Retrograde flow)
2. The induction theory Genetic Factors
3. Hematological and lymphatic spread The risk of endometriosis is 7–9 higher if a first-degree relative
4. Coelomic metaplasia theory is affected by endometriosis (e.g. mother or sister). An incidence
5. Genetic theory of 75 has been noted in monozygotic twins. There also exists
an association between endometriosis and systemic lupus
6. Immunogenic theory
erythematosus, dysplastic nevi and a history of melanoma.
7. Inflammation theory
There is an association of estrogen receptor gene polymorphism
8. Environmental basis. with endometriosis. The endometriotic tissue may also show
 aneuploidy and loss of heterozygosity. HLA –B7 allele may have
a role.
There is abnormality in detoxification enzyme and tumor
suppression gene is also seen to be involved. apanese race is
more proved to be having the disease.

Immunologic Factors
Altered hormonal and cellular immunity may play a role in its
development.
The immune system may be altered in women with
endometriosis and the disease can be caused by the decreased
clearance of peritoneal fluid endometrial cells. Lack of adequate
Endocrinology in Gynecology

immune surveillance is considered.This may be attributed to

the decreased natural killer (NK) activity or suppression of T-
lymphocytes or reduced macrophage activity. Hence, a
deficiency in cellular immunity decreased macrophagocytic
activity by endo protein similar to haptoglobin encourage the Fig. 19.1: Sites of endometriosis
menstrual tissue to implant and grow on the peritoneum.
Secretion of matrix metalloproteinases (MMPs) is increased PATHOLOGY
enhancing the penetrating power of basal membrane and
stroma. (Nikos et al 2010). Gross
The gross pathology is characterized by variability. Initially in
Inflammation Theory mild endometriosis a number of reddish-blue (raspberry) (Fig.
A state of subclinical peritoneal inflammation exists in these 19.3) or brown fibrin–like spots will be present on ovaries and
women. There is increased peritoneal fluid volume, /or peritoneal surfaces and the adnexa is free of adhesions. In
macrophages, inflammatory cytokines, growth factors and
angiogenesis promoting substances. These increased peritoneal
macrophages also increase sperm phagocytes and reduce sperm
Section 3

motility thus impairing fertility. There is also an increased

secretion of tumor necrosis factor (TNF- ). A positive feedback
system exists between local inflammation and estrogen-driven
local growth of ectopic endometrium.

Environmental Factors
There may be a potential link between environmental pollution
and infertility. Dioxin exposure has been implicated in
development of endometriosis in primates. Whole body proton
irradiation in Rhesus monkeys have a higher frequency of
endometriosis than control. Estrogen-like compounds, toxic
chemicals, life-style and reproductive health role on
development of endometriosis is under study. Estradiol
synthesis is increased and inactivation enzymes are decreased
leading to high local concentration.
(A) Before operation (B) Operated tissue
Progesterone resistance of endometriotic implants are also
Figs 19.2A and B: Scar endometriosis
seen. Presence of inhibitory isoform, A and absence of
sitmulating isoform, B, provides an explanation to progesterone
resistance in these implants.
Most probably a combination of the above factor may be at
work.

Sites of Endometriosis (Fig. 19.1)

Endometriosis is found mainly dispersed in the lower
pelvis below the umbilicus. The most frequent pelvic locations
are the ovaries, cul-de-sac, uterine ligaments (uterosacral
and round), pelvic peritoneum specially bladder and sigmoid
colon, and rectovaginal septum. Other sites include the
umbilicus, laparoscopy/laparotomy (Figs 19.2A and B) or
episiotomy scars, hernial sites, liver, appendix, small intestines,
rectum, urethra, vulva, vagina, cervix, lymph nodes, extremities,
pleural cavity and lungs, rarely pericardium, brain and eyes.
This multiplicity and widespread distribution of these sites
makes it difficult to accept any one theory for the histogenesis
of this disease. Fig. 19.3: Ovarian endometriosis (Gross)

114
progressive disease the older implants coalesce and get burnt metriotic implants consist of endometrial glands and stroma
out (powder burn implants) leaving a scarred, retracted area with or without hemosiderin laden macrophages. Endometrial
of hite opaque endometriosis and only pocket defects on stroma may be more characteristic of endometriosis than
the peritoneal surface with peritubal and peri-ovarian adhesions endometrial glands. A wide range of patterns may occur—from
and fixation. In clinically suspected but non-pigmented histologically to functionally normal endometrium to
endometriosis, 25 of patients demonstrated microscopic foci endometrial stromal cell nodule where hemorrhage and
of endometriosis on grossly normal peritoneum. Lesions are pigmentladen macrophages may be the only microscopic clues.
usually multiple. These lesions may have different degrees of proliferative or
Significant ovarian involvement results in formation of secretory glandular activity, vascularization and mitotic activity.
single or multiple, unilateral or bilateral endometrial cyst called Deep endometriosis is characterized by proliferative glands
endometriomas ( chocolate cysts). These cysts even when and stroma in dense fibrous and smooth muscle tissue.
small have a strong tendency to rupture with an escape of Endometriomas may lack endometrial glands and stroma

Chapter 19
menstrual blood and subsequent ovarian adhesions to and have a broad zone of large phagocytic cells laden with
surrounding structures, like the posterior surface of the uterus hemosiderin. Malignant change in endometriomas is rare and
and the broad ligament. If cysts do not rupture early, large always histologically low grade (adenocarcinoma) and this
endometriomas form with thicker walls and few surrounding malignant transformation is usually not demonstrable.
adhesions.
When uterine ligaments, especially the uterosacral ligament, DIAGNOSIS
are involved, the endometriotic nodules can be palpated on The patient may be completely asymptomatic. But if present,

Endometriosis
bimanual or rectovaginal examinations. the symptoms of endometriosis can be variable. Dysmenorrhea,
Deep endometriosis includes rectovaginal and infiltrative dyspareunia and dyschezia (difficult or painful defecation) may
lesions ( 5–6 mm into the retroperitoneum) involving vital be present as symptom complex or individually, however, the
structures like bowel, ureters and bladder. Pelvic pain is the degree and extent of spread of endometriosis bears no constant
common symptom. Occasionally, invasion and penetration relationship to presence or absence of subjective discomfort.
occurs in sigmoid causing luminal constriction and rectal
bleeding or skin lesion (Fig. 19.1). Pain
Microscopic During the menstrual cycle the ectopic endometrium
(endometriosis) also responds to ovarian hormones in the same
Histological confirmation of endometrial tissue, preferably way as the normally situated endometrium. Its size increaes as
both in glands and stroma, is essential in diagnosis of menstruation bleeding occurs—leading to increased pressure
endometriosis (Figs 19.4A and B). Microscopically, endo- in the area of endometriosis causing varying degree of pain.
Once this blood starts organizing there can be inflammation
fibrosis and adhesion and even pain.
Over 50 of patients complain of dysmenorrhea which is
usually of secondary variety and begins after years of pain free
menses. It usually starts before onset of bleeding and continues
throughout the period. In adolescents with dysmenorrhea,
endometriosis is the important cause to be ruled out.
Lower back pain, pelvic pain, dyspareunia (due to
involvement of cul-de-sac, and uterosacral ligaments) and
dyschezia (from bladder and ureteral involvement) may be
present. There can be loin pain, pain on micturition and pain
on exercise. The possible mechanisms of pain are local
peritoneal inflammation, deep infiltration, tissue damage,
adhesions and fibrosis and collection of shed menstrual blood
in implants. But there is no correlation between degree of pelvic
pain and severity of endometriosis.

Subfertility
It is well-established that a relation exists between endometriosis
and infertility. There are many factors contributing to
subfertility.
1. In more severe cases fertility is compromised as a
consequence of the anatomical distortion of pelvis caused
by adhesions or endometriotic ovarian cysts or both.
2. These adhesions block tubo-ovarian motility and prevent
normal tubo-ovarian closeness and hence ovum pick up.
3. Besides, there is ovulatory dysfunction and luteal
insufficiency.
4. There is destruction of ovarian and tubal tissues but tubal
closure is not seen.
Figs 19.4A and B: Endometriosis histopathology 5. Tubal mobility may be affected.

115
 6. Decreased sperm mobility and increased uterine Clinical Examination
contractility. • Abdominal examination may reveal a cystic swelling, which
7. The embryo implantation may also be abnormal (luteinized is often fixed, and slightly tender, i.e. chocolate cyst.
unruptured follicle LUFs syndrome). • The vulva, vagina and cervix should be inspected for bluish
8. Foliculogenesis is also altered, e.g. smaller follicle size, etc. or black puckered spots.
Ovarian reserve is poorer. • Per vaginal examination may reveal fixed retroverted uterus,
9. Altered immunity and intraperitoneal inflammation uterosacral and pouch of Douglas nodularity, lateral or
increased macrophage activity may influence sperm cervical displacement due to uterosacral scarring. There
function and transport. may be painful swelling of rectovaginal septum and
10. There are also increased peritoneal fluid prostaglandins (F2 unilateral ovarian swelling.
and E2) and there may be the cause of decrease of fertility • In many women no clinical abnormality is detected on
by anovulation, luteal phase defect and LUFs. examination.
Endocrinology in Gynecology

11. There may be galactorrhea or hyperprolactinemia by • The clinical examination may have false negative results,
directly stimulating the afferent thoracic nerve which hence diagnosis should be confirmed by histology and
decreases gonadotropins and increase prolactin level and imaging.
defective ovulation.
12. Dyspareunia—Particularly on deep penetration when Diagnostic Difficulty
uterosacrals are involved. The varied clinical symptoms and signs of endometriosis lead
13. Poorer pregnancy overcome, high rate of pregnancy loss, to diagnostic difficulties. In a survey of women with a proven
preterm delivery, IUGR, preeclampsia, etc. diagnosis, over half gave a history that there was nothing wrong
14. Increased free radicals in the endometrium could lead to and 32 saw other specialists before being referred to a gyne-
low embryo viability during implantation. This abnormality cologist. This causes a delay in starting the effective treatment
is molecular rather than histological. (See flow chart 20.1). and cause disillusionment in the patients.
However, the association with minimal or mild endometriosis
remains controversial. In fertile normal women with normal also, Differential Diagnosis
endometriosis is reported to be minimal or mild in 80 and • Chronic pelvic inflammatory disease (PID) produces similar
moderate or severe in 20 . signs and symptoms. Laparoscopy helps to differentiate
About 30–40 women with endometriosis suffer from endometriosis from PID. Also hormonal therapy produces
Section 3

infertility. The monthly fecundity rate (MFR) is reduced (4–11 ) relief in endometriosis and PID responds to antibiotic
in mild disease as compared to normal (20 ). therapy.
• Uterine myoma with degeneration and associated PID can
Spontaneous Miscarriage produce the same symptoms and signs. Ultrasound and
A few uncontrolled, retrospective studies suggested an laparoscopy can help differentiate these conditions.
association between spontaneous miscarriage and • Ovarian malignancy with metastatic nodules in pouch of
endometriosis, but controlled prospective studies have not Douglas can produce a picture similar to endometriosis.
shown any such associations. However, the symptoms of cancer are not the same as that
of endometriosis and the history is of very short duration
Menstrual Symptoms in cancers.
Menorrhagia occurs in adenomyosis and irregular bleeding • Recto-sigmoid involvement will cause symptoms similar
occurs in cervical-vaginal lesions. Polymenorrhea occurs if to rectal carcinoma. Sigmoidoscopy and biopsy will help
ovaries are involved. establish the diagnosis.
• Chronic pelvic pain.
Endocrine Abnormalities
Endometriosis has been associated with anovulation, abnormal Investigations
follicular development, luteinized unruptured follicle Laparoscopy For definitive diagnosis, endoscopic visualization
syndrome, galactorrhea and hyperprolactinemia. of the pelvis is a must, before institution of therapy. It is the
gold standard in diagnosis of endometriosis. Laparoscopy
Dyspareunia provides a panoramic view and also operative options via
This occurs particularly on deep penetration when uterosacral fulguration or laser at the same sitting.
ligaments are involved. Double puncture laparoscopy should be utilized so that a
careful, systematic, complete pelvic inspection can be carried
Other Symptoms out. The palpating probe should be run over uterosacral
Endometriosis of intestinal tract (colon and rectum) is the most ligaments and the pelvic peritoneum to detect subperitoneal
common extra-pelvic site and may cause abdominal pain and implants. Each ovary should be lifted to visualize its
backache, abdominal distension, cyclical rectal bleeding, undersurface and the adjoining broad ligament and the
constipation and obstruction. Ureteral involvements can lead posterior surface of the uterus. The appendix and serosa of
to obstruction, cyclical pain, dysuria and hematuria. Pulmonary bowel in the pelvis should be carefully inspected for
endometriosis can manifest as pneumothorax, hemothorax or endometriotic implants. Specimen can be obtained. Two or more
hemoptysis during menses. Umbilical and scar (Figs 19.2 A and following findings are needed to clinch the diagnosis;
B) endometriosis should be suspected when a palpable mass endometrial epithelium, endometrial glands, endometrial
with cyclical pain and distension appears in the umbilical area. stroma and hemosiderin-laden macrophages.
In addition patients may present with non-specific symptoms Characteristic findings are typical powder-burn lesions;
of fatigue, general malaise and sleep disturbance. black, dark reddish brown or bluish nodules or the small

116
hemorrhagic cysts surrounded by fibrosis. Other descriptions CA-125 has a limited diagnostic accuracy in diagnosing the
of endometriotic implants can be (1) red implants (petechiae, early stage of endometriosis and is found to increase in
vesicular hemorrhagic, red flame like) (2) serous or clear moderate to severe disease (13 to 95 U/ml). The other markers
implants (3) white opaque or yellow brown discoloration of which can help are IL-6 and peritoneal fluid TNF-alpha levels.
peritoneum. Histological confirmation of laparoscopic CA-125 is useful to predict the recurrence of endometriosis after
impression should be done. therapy.
Ovarian endometriosis is diagnosed by careful inspection
of both ovaries on all sides, which may be limited by adhesions. Classification
Large ovarian endometriotic (chocolate) cysts are usually The most recent and widely accepted classification is that of
located on the anterior surface of the ovary and contain thick The American Fertility Society (AFS), now renamed The
dark-brown viscous chocolate fluid (containing hemosiderin). American Society for Reproductive Medicine (ASRM). The
The removal of this cyst for histological examination is necessary classification originally described in 1979 was revised in 1985.

Chapter 19
for diagnosis under the revised endometriosis classification of It has four categories : stage 1 (minimal), stage 2 (mild), stage 3
the American Society for Reproductive Medicine. If that is not (moderate) and stage 4(severe), based on the degree of
possible then the following criteria should be fulfilled for an involvement of the peritoneum, ovaries and tubes, the extent
ovarian endometriosis cyst: diameter less than 12 cm, adhesion of adnexal adhesions and the degree of obliteration of the cul-
to pelvic side wall or broad ligament, endometriosis on the de-sac. The morphology of peritoneal and ovarian implants is
surface of the ovary and thick chocolate-like content. Presence categorized as red (red, red-pink and clear lesions), white
of ovarian endometriosis is a marker for extensive pelvic and (white, yellow-brown, peritoneal defects) and black (black and

Endometriosis
peritoneal disease (Figs 19.5 A to C). blue lesions). Points are assigned based on dimensional spread
Laparoscopy has a disadvantage of being invasive and it in three categories: 1 cm, 1–3 cm and 3 cm.
may also cause delay in diagnosis and treatment in symptomatic
teenagers and young women. The visual inspection of the pelvis
has a limitation in the diagnosis of retroperitoneal lesions.
Imaging odalities: Radiological, transvaginal or transrectal
ultrasonograpy (for ovarian endometrioma and rectovaginal
endometriosis) can be used. Small lesions are often missed.
There may be focal fluid lesion with hemorrhage; variably
echoic cystic areas may be seen which may be fixed or mobile.
These cysts can be aspirated under ultrasound guidance.
Computed tomography (CT) and Magnetic Resonance Imaging
(MRI) can be used to provide additional information. High
resolution sonography can improve the diagnosis of
retroperitoneal pelvic endometriosis and lesions involving
pelvic organs. (Moen and Associates 1993). Doppler flow studies
enhance the accuracy of diagnosis by finding pericystic blood
flow especially in the hilar region with resistance index above
Stage I (Minimal)
0.45.
Site Size Score
Serum ar ers CA- 125 is the principal serum marker used in
Peritoneum 1–3 cms 2
the diagnosis and management of late-stage endometriosis. The Ovary
search for body fluid markers of early stage disease has included Superficial 1 cm 1
serum, peritoneal fluid (PF), and/or tissue levels of secretory Flimsy 1/3rd 1
proteins, cell adhesion molecules, cytokines, antiendometrial adhesion
antibodies, tumor necrosis factor, vascular endothelial growth Total points 4
factors (VEGF’s), aromatase P-450 expression, cytokinin and 1–5
hormone receptors.

Figs 19.5A to C: Ovarian endometriosis at different stages

117
Endocrinology in Gynecology

Stage II (Mild) Stage IV (Moderate)

Site Size Score Site Size Score

Peritoneum 3 cm 6 Peritoneum 3 cm 4
(deep) (superficial)
Rt ovary Rt tube
Superficial 1 cm 1 Flimsy 1/3rd 1
Flimsy 1/3rd 1 adhesions
adhesion Rt ovary
Lt ovary Flimsy 1/3rd 1
Superficial 1 cm 1 adhesions
Total points 6–15 9 Lt tube
Dense 1/3rd 16
adhension
Lt ovary
Deep 1cm 4
Dense 1/3rd 4
Section 3

adhesions
Total points 30 40

Stage III (Moderate)

Site Size Score
Peritoneum 3 cm 6
(deep)
Cu-de-sac
Partial obliteration 4
Lt ovary
Superficial 1-3 cm 16 Stage V (Severe)
Total points 26
Site Size Score
16–40 Peritoneum 3 cm 4
(superficial)
Lt ovary
Deep 1–3 cm 32
This system reflects the extent of endometriotic disease but
Dense 1/3rd 8
has considerable intra-observer and interobserver variability
adhesion
(Moore et al 2000). It also fails to address a very important factor,
Lt tube
i.e. the depth of invasion. However, it is the only internationally
Dense 1/3rd 8
accepted system and it is the best currently available tool to
adhesions
record the general spread of active disease and adhesions. This
Total points 52
uniformity in classification has helped categorize and analyze
the success and failure of various therapeutic modalities in terms Point assignment changed to 16 if one side is involved.
of pain relief, enhancement of fertility, etc. Point assignment doubled
118
 anti-inflammatory agents may help. In cases of perimenopausal
patients expectant management will tide over the painful period
till menopause ensues and endometriosis is cured by itself
(ovarian hormone poduction is stopped.) Adjunct therapy for
pain relief in category one patient by apanese-style acupuncture
may help.
Symptomatic treatment can be medical or surgical.

Medical Treatment
Hormonal suppression of endometriosis is indicated in
1. Category two patients (see above)
2. Endometriosis and symptoms still exist or recur after

Chapter 19
operative laparoscopy.
Stage VI (Severe)
The ectopic endometriosis responds to steroid hormones
in the same way as intrauterine endometrium. These exogenous
Site Size Score hormones suppress the hypothalamic-pituitary-ovarian axis
Peritoneum deep 3 cm 6 and cause menstrual cessation or may act directly on implants
Cul-de-sac
to inhibit growth and aid resolution. The following drugs are
Complete 40
Obliteration
used:

Endometriosis
Rt ovary
Deep 1–3 cm 16 Progestins
Dense 1/3rd 4 Progestins act by causing initial decidualization
Adhesions (pseudopregnancy) and then atrophy of the endometrium.
Lt tube Progestin—only therapy has proponents as the first choice
Dense 2/3rd 16 treatment for endometriosis because they are as effective as
adhesion
Danazol or GnRH analogues and cost less and have fewer side
Lt ovary
Deep 1–3 cm 16
effects.
Dense 2/3rd 16 Oral medroxy progesterone acetate (MPA) is effective in
Adhesion relieving pain, starting at 30 mg/day (10 mg three times a day)
Total points 114 and its dose can be increased depending upon the clinical
response and bleeding pattern. Irregular bleeding can occur in
30 patients; other side effects are nausea, breast tenderness,
fluid retention, weight gain, reduced libido and depression. The
pain relief is significant (50–70 ) during therapy and pregnancy
PREVENTION OF ENDOMETRIOSIS rate following therapy is 40–50 . Other progestins such as
Prevention is possible in a very few cases. Patients with history Norethindrone, Desogestrel and Lynestrenol can also be given
of endometriosis are advised to complete the family early. orally.
Avoiding tubal patency procedures in the immediate Intramuscular depot medroxy progesterone acetate
postmenstrual phase, classical cesareans and classical (DMPA) can be considered an alternative to GnRH-analogues
hysterotomies are to be reduced. Low dose oral contraceptives in deep seated rectovaginal, bowel and pelvic wall
and aerobic exercise may reduce the incidence of endometriosis. endometriosis. It is administered initially as 10 mg/week for
one month, then 100 mg fortnightly for one month and then
Treatment of Endometriosis 100 mg monthly for 10 months. Alternately, intramuscular
DMPA (150 mg) may be given every three months for pain relief
The therapeutic approach to endometriosis must be
and symptomatic relief, but should be avoided in infertile women
individualized depending upon the patient’s age, current
because it takes a long time for ovulation to resume after stopping
reproductive status and desires, the severity and extent of
treatment.
disease and the response to previous medical treatment or
Norethindrone acetate—5 mg daily for two weeks then
conservative surgery. Counseling in several aspects is very
increase by 2.5 mg per day till 15 mg per day can be given.
important. The course of endometriosis cannot be predicted
hence long-term prognosis cannot be given. Levonorgestrel—releasing intrauterine system ( irena) for 12
Patients can be divided into three categories for the purpose months can reduce dysmenorrhea, pelvic pain, dyspareunia,
of treatment. (1) Endometriosis in infertile patient (2) Endo- and cause significant reduction in recto-vaginal endometriotic
metriosis in the symptomatic patient who wishes to preserve nodule volume.
her reproductive function but needs no treatment for immediate
fertility. (3) Symptomatic patient with extensive endometriosis Oral Contraceptives
and no desire for reproductive function. The continuous administration of any low dose monophasic pill
The principal objectives of treatment are : with a high progestin-estrogen ratio containing 20–35 micro
• Relieve the symptoms (e.g. pain) grams of ethinylestradiol daily for 6 to 12 months can be
• Enhance fertility (if the patient desires) effective in suppressing symptomatic endometriosis (cause
• Eliminate the disease pseudo pregnancy). If breakthrough bleeding occurs, the dose
• Delay recurrence of the disease. can be doubled or tripled. The contraindications to oral
contraceptives should be ruled out before initiating therapy.
Expectant Management The side effects and risk of thromboembolism may limit their
In mild cases observation will give the patient time to complete prolonged use. The patient should be informed that this therapy
her family. If there is only dysmenorrhea then non-steroidal is suppressive rather than curative and the pregnancy rate
119
 following the treatment is about 30 . Combined pill with new Add bac therapy—12.5 mg norethindrone or 0.625 mg of
fourth-generation progestin is 3–6 months’ pill and suits the conjugated equine estrogen with 5 mg/day of medroxypro-
needs of endometriotic women. gesterone acetate to prevent osteoporosis.
Aromatase inhibitors They inhibit the conversion of androgen
Danazol
to estrogen. Letrozole (2.5 mg daily) anastrozole (1 mg daily) is
It is an isoxazol derivative of 17- ethinyl testosterone which under trial.
causes anovulation by attenuating the mid-cycle surge of LH GnRh antagonist—correlix S/C injection once a week for 8
and FSH secretion, inhibiting numerous enzymes in the
weeks.
steroidogenic pathway, preventing growth of endometrial tissue
due to androgen effect and increasing serum free testosterone Other Drugs
concentration. The recommended dose for treatment of
Future studies will focus on selective estrogen receptor
endometriosis is 400-800 mg/day for 6 months. However, this
Endocrinology in Gynecology

modulators (SERMS)- Raloxifene ormeloxifene next generation

causes lot of androgenic side-effects such as hirsutism, mood
of progesterone receptors antagonists mifipristone 100 mg/day
changes, deepening of voice that might be irreversible. Adverse
for 3 months. Selective progesterone—receptor modulators
effects on serum lipids and liver damage that might be
( 867) antiangiogenic agent, (PPAR gamma) ligands, etc.
irreversible and life-threatening limits the use of oral danazol.
The cost of danazol is more than oral contraceptives and Effect of Medical Therapy
progesterones.
Medical therapy is highly effective in relieving pain associated
Progesterone Antagonists with endometriosis, postoperative persistent pain and pain due
to recurrent disease. Conception, however, is impossible or
Progesterone antagonists and progesterone receptor modulators
contraindicated during medical treatment and hence this
suppress endometrium by their antiproliferative effects on
method is not recommended in treating sub-fertility in mild to
endometrium, without the risk for hypoestrogenism or bone
moderate endometriosis.
loss that occurs with GnRH treatment. The clinical effectiveness
Preoperative benefits of medical treatment are that
of these drugs, however, remains to be proved. (Selek and
hormonal suppression reduces the size of ovarian endometriosis
Coworkers 2000).
and facilitates surgical resection of residual disease. Posto-
Mifepristone(RU486)and Onapristone can reduce pelvic
perative advantage of medical treatment is that it increases pain-
pain and induce regression of lesions.
free interval after conservative surgery for symptomatic
Section 3

Gestrinone endometriosis and delays recurrence of endometriosis.

It is a 19-noretestosterone derivative with antiprogestogenic Surgical Treatment
properties. It suppresses FSH and LH that causes a decline in
Surgical treatment aims to remove or destroy visible or palpable
the concentrations of estrogen and progesterone receptors
endometriosis, enhance fertility and decrease pain.
(25crit), a 50 decline in serum estradiol and a decrease in serum
It is indicated in category 1 and 3 patients, i.e.
sex hormone –binding globulin concentration. Ovulation is not
(1) Women with endometriosis where preservation of
inhibited. Gestrinone is administered orally in a dose of 2.5 mg
reproductive function is desired (conservative surgery)
twice a week. Amenorrhea occurs in 50–100 of women and is
(2) Women with moderate to severe endometriosis who have
dose-dependent. The side effects are nausea, muscle cramps,
completed their families (radical surgery). Medical treatment
weight gain, acne, seborrhea, etc. Pregnancy is contraindicated
before surgery may reduce the size and severity of the disease
on gestrinone.
and thus improve the outcome of surgery.
nRH agonists ( nRHa): They are analogues of the 10 amino
acid peptide hormone GnRH. Laparoscopy
These bind to pituitary GnRH receptors and after a brief Laparoscopy is used both for diagnosis and treatment (excise
initial stimulation period of FSH (Follicle Stimulating or coagulate all visible endometriotic lesions and adhesiolysis)
Hormone) and LH (Luteinizing Hormone) release, their where infertility co-exists with minimal, mild and some forms
continued receptor blocking causes pituitary desensitization of moderate endometriosis. In moderate to severe
and downregulation resulting in low FSH and LH levels. It endometriosis, the goal of surgery is to excise/coagulate all
results in a reversible pseudomenopause condition; the peritoneal lesions, ovarian cysts, recto-vaginal implants and
eventual hypoestrogenic state results in endometrial atrophy restore normal anatomy as far as possible. Surgery is carried
and amenorrhea. GnRHa are inactive orally and can be given out with electrocautery, laser or CUSA (cavitational ultrasonic
as once-a-month depot intramuscular 3.75 mg (Leuprorelin), surgical aspirator) for ablation/excision.
once-a-month subcutaneous 3.6 mg (Goserelin) or daily
intranasal (Nafarelin 200–400 mg twice a day or Buserelin Laparotomy
300–400 mg thrice a day) for 3 to 6 months. The daily therapy Laparotomy is reserved for patients with advanced disease in
has variable absorption rates and suffers from lack of whom fertility conservation is not necessary and where surgeon
compliance. is not expert laparoscopist. A definitive or radial surgery in the
The maximum therapeutic benefit is achieved at estradiol form of total abdominal hysterectomy is the therapeutic choice
levels of 30–45 pg/ml resulting in various side effects like hot and bilateral salpingo-oophorectomy should be performed if
flushes, vaginal dryness, reduced libido, depression, reduced either ovaries are involved or other endometriotic areas remain.
bone density and osteoporosis. Hence supplemental oral Excision of remaining adhesions is done. If ovaries must be
calcium and daily add-back low dose estrogen/progestin preserved, e.g. in a young patient or is the patient desires, and
treatment should be given if a GnRHa is utilized for more than residual endometriosis is present, postoperative hormonal
six months. suppression should be used for 3–6 months. After hysterectomy
120
and bilateral salpingo-oophorectomy in young patients estrogen of medical therapy in infertility and there is a clear advantage
replacement is required after three months. of treating visible lesions by operative laparoscopy.
The use of perioperative hormonal suppression is In moderate to severe endometriosis, pregnancy is a rare
controversial as this therapy has no proven benefits. event in untreated patients. Conservative surgery is utilized to
Uterosacral nerve ablation can be done by both laparoscopy normalize anatomy as far as possible and enhance fertility.
and laparotomy. Lee-Frankenhauser sensory nerve plexus and Significant pregnancy rates are reported with this intervention.
parasympathic ganglia in the uterosacral ligaments carry pain
sensation from the uterus, cervix and other pelvic structures. Assisted Reproductive Technology
Their interruption may alleviate pain. The role of super-ovulation plus intrauterine insemination
Presacral Neurectomy disrupts the hypogastric plexus and remains unproven but IVF (in vitro fertilization) definitely has
relieves chronic pelvic pain and dysmenorrhea. This operation a high success rate and an absolute benefit.
can be done through laparoscope or through open surgery.

Chapter 19
Results of Surgical Treatment CONCLUSION
Laparoscopic management causes pain relief in 60–80 patients. Endometriosis remains a difficult clinical entity. Once the
A cumulative intrauterine pregnancy rate of diagnosis is made, it is important to focus on the illness rather
24–48 has been reported in patients of infertility undergoing than the disease, i.e. treat the underlying symptom which may
surgery and the highest pregnancy rates are seen during the be infertility or pain or both. First line treatment for pain is
first 6–12 months. medical. Surgery is reserved for failed medical treatment or
patients with severe disease. In infertility, surgery and assisted

Endometriosis
Infertility and Endometriosis reproduction is the treatment of choice in moderate and severe
disease but in milder cases the appropriate management is
It is well-established that a relation exists between endometriosis
uncertain.
and infertility.
Schematic representation of management of endometriosis
In minimal or mild cases, the most appropriate management
is given in (Flow charts 19.1 A and B).
is unclear. It is now universally accepted that there is no place

Flow charts 19.1A and B: Schematic representation of management of endometriosis

121
 BIBLIOGRAPHY 18. Mahmood TA, Templeton A. Prevalence and genesis of
endometriosis. Hum. Reprod 1991;6:544-9.
1. Admir A, Schima D, Klaus D, et al. Apoptosis in endometriosis. 19. Martin DC, Hubert GD, vander waag R, et al. Laparoscopic
Gyneol and Obst Invest 2009;68:217. appearance of peritoneal endometriosis. Fertil. Steril 1989;51:63-7.
2. Bedaiwy MA, Falcone T. Laboratory testing for endometriosis. Clin 20. Marcoux S, Maheux R, Berube S. Laparoscopic surgery in infertile
Chim Acta 2004;340(1-2):41-5. women with minimal and mild endometriosis. N Engl Med
3. Brosens I, Puttemans P, Campo R, Gordts S, Bronsens . Non- 1997;337:217-22.
invasive methods of diagnosis of endometriosis. Curr. Opinion 21. Matorras R, Rodriguez F, Gutierrez de Teran G, et al. Endometriosis
Obstet. Gynecol 2003;15(6):519-22. and spontaneous abortion rate: a cohort study in infertile women.
4. Bulun SE, ertour K, Takayama K, et al. Molecular basis for treating Eur Obstet Gynecol Reprod. Biol 1998;77:101-05.
endometriosis with aromatase inhibitors. Hum. Reprod. Update 22. Moen MH. Endometriosis in women at interval sterilization. Acta
2000;6:413-8. Obstet Gynecol. Scand 1987; 66:451-4.
5. Cahill D , Hull MGR. Pituitary ovarian dysfunction and 23. Moen MH, Magnum P. The familial risk of endometriosis. Acta
endometriosis. Hum Reprod Update 2000;6:56-66.
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Obstet. Gynecol Scand 1993;72:560-4.

6. Cornille F , Oosterlynck D, Lauweryns M, et al. Deeply infiltrating 24. Moen MH, Halvorsen TB. Histological confirmation of
pelvic endometriosis: histology and clinical significance. Fertil. endometriosis in different peritoneal lesions. Acta Obstet Gynecol
Steril 1990;53:978-83. Scand 1992;71:337-42.
7. Cramer DW, Wilson E, Stillman R , et al. The relation of 25. Moore , Kennedy S, Prentice A. modern combined oral
endometriosis to menstrual characteristics, smoking and exercise. contraceptives for pain associated with endometriosis. Cochrane
AMA 1986;355:1904-8. Database Syst Rev 2000; (2):CD001019.
8. Georgiou I, Syrrou M, Bouba I, et al. Association of estrogen 26. Nikos FV, Konstantinous PE and Stylianos F. Endometriosis, NF
receptor gene polymorphisms with endometriosis. Fertil. Steril and the risk of Gynecological malignancies, including ovarian and
1999;72:164-6. breast cancer. Best Prac. Res. Clin. Obstet Gynecol 2010;24(1):39.
9. Haney AF. Endometriosis: pathogenesis and pathophysio-logy In: 27. Prentice A, Deary A , Goldbeek-Wood S, Farquhar C, Smith SK.
Wilson EA (Ed). Endometriosis. New ork: AR Liss; 1987.pp.23-51. Gonadotropin releasing hormone analogues for pain associated
10. Henderson AF, Studd WW. The role of definitive surgery and with endometriosis. Cochrane database Syst Rev
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In: Thomas E, Rock , (Eds). Modern approaches to endometriosis. 28. Revised American Fertility Society classification. 1985 Fertil.Steril
Carnforth: Kluwer Academics; 1991.pp.275-90. 1985;43:351-2.
11. Hornstein MD, Gleason RE, Orav , et al. The reproducibility of 29. Rodriguez- Escudero FT, Neyro L, Corcostengui B, Bento A:Does
the revised American Fertility Society classification of minimal endometriosis reduce fecundity Fertil. Steril 1998;50:
endometriosis. Fertil. Steril 1993;59:1015-21. 522-4.
Section 3

12. enkins S, Olive DL, Haney AG. Endometriosis: pathogenetic 30. Selak V, Farquhar C, Prentice A, Singla A. Danazol for pain
implications of the anatomic distribution. Obstet Gynecol associated with endometriosis. Cochrane database Syst Rev
1986;67:355-8. 2000;(2):CD000068.
13. uhas , Boss L, Lattrich C, et al. Severe endometriosis. Laparoscopic 31. Vercellini P, Vendola N, Bocciolone L, et al. Reliability of visual
rectal resection. Arch Gynecol Obstet 2010;281(4):157. diagnosis of endometriosis. Fertil. Steril 1991;56:1198-200.
14. Kishon B, Poindexter AN, Fast . Endometriosis in multiparous 32. Vercellini P, Cortesi I, Crosignani PG. Progestins for symptomatic
women. Reprod Med; 1989.pp.215-7. endometriosis, a critical analysis of the evidence. Fertil. Steril
15. Koninckx PR, Meuleman C, Demeyere S, et al. Suggestive evidence 1997;68:333-41.
that pelvic endometriosis is a progressive disease, whereas deeply 33. Waller KG, Lindsay P, Curtis P, et al. The prevalence of
infiltrating endometriosis is associated with pelvic pain. Fertil Steril endometriosis in women with infertile partners. Eur. Obstet Gyn
1991;55:759-65. Reprod Biol 1993;48:135-9.
16. Lin S , Lee RKK, Hwu M, et al. Reproducibility of the revised 34. Walter A , Hentz G, Magtibay PM, et al. Endometriosis: correlation
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17. Liu DT , Hitchcock A. Endometriosis: its association with 35. Waynee PM, Kerr CE, Schayer RN, et al. apanese–Style
retrograde menstruation, dysmenorrhoea and tubal pathology. Br acupuncture for endometriosis–related pelvic pain in adolescents
Obstet Gynaecol 1986;93:859-62. and young women. Pediatr Adolesc Gynecol 2008;21(5):247.

122
 20 Causes of Infertility

Indira Ganeshan, Sonia Malik

Introduction Male factors Female factors

Infertility affects one in six couples. There are about 60–80 million Defective spermatogenesis Vaginal factor
infertile couples worldwide. Obstruction of efferent duct Cervical factor
Some patients spontaneously achieve pregnancy, but others, system
at some stage, experience difficulty in achieving conception and Failure to deposit sperm Endometrial factor
need some kind of assistance to become pregnant. There is about high in the vagina
3–5% probability of achieving pregnancy in one menstrual cycle, Errors in the seminal fluids Tubal factor
this is called fecundability. Fecundity is the probability that a Immunological factor Ovarian factor
Endocrine factors
single cycle will result in a live birth.
Immunological factor
It is estimated that one out of 100 couples with female
partner’s age less than 35 years, 80–85% will achieve pregnancy
within the first year of unprotected intercourse, 90% MALE PARTNER
will conceive within 18 months, and about 95% will conceive Male Factors
within two years. The remaining 5% rarely achieve 1. Defective spermatogenesis
pregnancy without some form of assistance. So infertility may 2. Obstruction of efferent duct system
be defined as an inability to achieve pregnancy within 2 years 3. Failure to deposit sperm high in the vagina
of having unprotected intercourse, though some clinicians 4. Errors in the seminal fluid
prefer this time limit to be 1 year. The time limit before visiting 5. Immunological cause.
the doctor for the women who are over the age of 35 years is
about 6 months of contraceptive free intercourse when it has Endocrinology of Spermatogenesis
not resulted in a pregnancy. This difference in the time limit is The hypothalamus is the integrative center of the reproductive
owing to the declining egg quality with increasing age of the axis. The hypothalamus releases GnRH in a pulsatile manner
woman. and this pulsatile nature appears to be essential for the
In some couples, the fertility is impaired to some extent but production and release of luteinizing hormone (LH) and follicle-
not completely. These patients may conceive in the third year stimulating hormone (FSH) in an episodic manner. LH binds
or subsequently without any assistance. As there is a delay, these to specific receptors on the Leydig’s cells within the testes. This
patients are called subfertile. While, sterility is an absolute state leads to secretion of testosterone. Though the spermatogenesis
of inability to conceive. and sperm maturation needs a high androgenic environment
The cause of infertility could be in the male partner, or just in provided by high levels of testosterone, testosterone is a primary
the female partner; but in some couples, both partners may be inhibitor of LH secretion. FSH binds to Sertoli’s cell and
infertile or subfertile or each could be individually fertile but as a stimulates secretion of androgen-binding protein (ABP) and
couple may need assistance to achieve pregnancy. The causes could inhibin B. After the initial stimulation of LH and FSH, the
be immunological or genetic; this is called combined infertility. constant exposure to GnRH results in inhibition of their release.
In unexplained infertility, the fertility evaluation shows no
abnormality. These patients are likely to have problems which are Defective Spermatogenesis
not diagnosed by the available current investigations. Congenital Causes
Types of Infertility Undescended testes: Most male infants are born with both testes
already in the scrotum; but in some infants, more often in
Primary infertility: It denotes those patients who have never
premature babies, one or both the testes might be undescended
conceived.
or somewhere along the line of descent to the scrotum. The
Secondary infertility: It indicates previous pregnancy but failure descent might happen after delivery; but in some cases, it does
to conceive subsequently. not occur. When the undescended testes is diagnosed in
The causes of infertility can be divided into: adolescence, the function is severely affected.
• Male factor—35% Some genetic abnormalities like Klinefelter’s syndrome
• Female factor—40% (47XXY) can lead to incomplete development of the testes; the
• Unexplained—10–15% other chromosomal abnormalities could lead to nonfunctioning
• Both male and female factors—10–15% testes or functioning testes with poor quality sperm production.
 Exposure to active or passive smoking in intrauterine life (upto Impotence is an inability to maintain an erection for
55%) is also a cause an dramatic reduction in germ cells in the intercourse to take place.
developing fetus. Thus adversely affecting the fertility in later The ejaculatory failures could be because of psychogenic,
life. endocrinal, surgeries involving abdo-minal or pelvic region. The
problem can vary from inability to ejaculate at the time of
Acquired Causes intercourse to retrograde ejaculation into the urinary bladder, so
Optimum production of spermatozoa takes place when the testes there is no sperm deposition in the female genital tract to achieve
is in slightly cooler place than rest of the body, as in the scrotum. fertilization.
In some cases, the temperature of the testes is increased like in Premature ejaculation. Here ejaculation takes place within
varicocele, big hydrocele, tight undergarments, working in hot a short time after sexual arousal. This can only result in infertility
if the ejaculation takes place outside the vagina.
atmosphere, etc. thus adversely affecting spermatogenesis.
Some of the drugs causing impotence and ejaculatory
Endocrinology in Gynecology

Any kind of trauma to the testes like accident, postoperative

dysfunctions:
or torsion may adversely affect spermatogenesis.
Antihypertensives
Infections • Methyldopa
Some infections like mumps, influenza, tuberculosis (TB), • Propranolol
gonorrhea, filariasis, syphilis, brucellosis and Chlamydia • Spironolactone
infections, etc. can cause testicular damage which might not be • Thiazide diuretics
reversible. • Prazosine hydrochloride
• Hydralazine
Endocrinologic Factors • Clonidine.
In these cases, there is a disturbance in the secretion of Sedatives and antidepressants
gonadotropins directly or indirectly thus affecting • Amitriptyline
spermatogenesis. The problem might be in GnRH due to defects • Chlorpromazine
of the hypothalamus, hyperprolactinemia, thyrotoxicosis, and • Diazepam
diabetes mellitus. Other examples are syndromes like • Imipramine
Kallmann’s syndrome, Lawrence Moon-Biedl or Frohlich’s • MAO inhibitors
Section 3

syndrome. • Thioridazine.

Toxins Others
• Clofibrate
Some drugs like cimetidine, spironolactone, colchi-cine, • Cimetidine
hormones, and anabolic steroids can cause depression of sperm • Digoxin
production. Radiation, cytotoxic drugs like alkylating agents— • Ketoconazole
cyclophosphamide, busulphan, chlorambucil, etc. can directly • Alcohol
and irreversibly affect the spermatogenesis in the testes. • Cocaine
OBSTRUCTION OF EFFERENT DUCTS • Heroin
• Nicotine.
Congenital Causes
The vas deferens and/or seminal vesicles fail to develop in some Immunologic Cause
patients like those suffering from cystic fibrosis or carriers of The couples may have circulating antibodies against
cystic fibrosis genes. Here, the spermatogenesis in the testes is spermatozoa, in the semen and/or blood. These antibodies are
normal, but the sperms cannot be transported to the ejaculatory produced when there is damage to the testes or infections of
duct and urethra, so the ejaculate shows azoospermia. the testes and surrounding tissues. IgG antisperm antibodies
are found in the serum, while IgA are found in cervical mucus;
Acquired Causes both classes of antibodies are found in seminal fluid. These
Surgical trauma like herniorraphy or vasectomy or infections antibodies bind to the spermatozoa and immobilize them or
like gonorrhoea and tuberculosis, etc. are the causes. Here again, can cause clumping or agglutination of spermatozoa. Usually,
the production of spermatozoa is normal and because of antisperm antibodies cause subfertility rather than frank
obstruction, the ejaculate will show azoospermia. infertility.
This topic is discussed in detail in the section on
FAILURE TO DEPOSIT SPERMS IN VAGINA immunology of infertility, later in the chapter.
1. Infrequent sexual intercourse
2. Wrong timing of intercourse DEFECT IN SPERMS AND SEMINAL FLUID
3. Impotence, erectile dysfunction Interpreting Semen Analysis (Table 20.1)
4. Premature ejaculation
An unusually high or small volume of ejaculate, high viscosity,
5. Failure of ejaculation
infections of the seminal vesicle or prostate may decrease the
6. Retrograde ejaculation (can occur even in normal men)
fertility potential.
7. Abnormality of penis as hypospadias, phimosis
Low fructose and high prostaglandins also decrease the
8. Psychosexual causes.
sperm function.
Some of the couples could be having delay in conception
The various terms used to describe the altered semen
because they might not be having regular intercourse during
parameters:
the fertile period, thereby not ensuring the availability of enough
1. Oligozoospermia when the concentration of spermatozoa is
spermatozoa in the genital tract to fertilize the egg at the time
124 of ovulation.
less than 20 million sperms/ml of the ejaculate. The chance
 Table 20.1: Normal semen values as suggested pick up and impaired tubal motility. The unhealthy or damaged
by WHO (1999) mucosa might also prevent migration of blastocyst and this may
again predispose to ectopic pregnancy.
Volume 2 ml or more In patients, who have a block in the fimbrial end of the tube,
pH 7.2–7.8 the secretion may accumulate inside the fallopian tube causing
Sperm concentration 20 million/ml or more a dilatation of the tube to cause hydrosalpinx.
Total sperm count 40 million per ejaculate The functions of the fallopian tubes are compromised by
Motility 50% or more progressive for-ward various surgeries that are performed on the nearby
motility (Grade ‘a’ and ‘b’) or 25% or abdominopelvic region or endometriosis, where the resulting
more with rapid linear progression adhesions, distort the anatomy of tubes. The scarring can cause
(Grade ‘a’) within 60 minutes of
twisting of the tubes thereby causing a partial block.
ejaculation

Chapter 20
Morphology 30% or more normal forms
Living sperms 75% or more
Ovarian Factors
White blood cells <1 million/ml The ovarian factor contributes up to 15–25% of cases of infertility.
Total fructose >13 mol/ejaculate Anovulation can occur in any of the following conditions
MAR test (Mixed <50% spermatozoa with affecting HPO axis.
Agglutination adherent particles immuno-
Reaction) bead test fewer than 50 % motile WHO Classification for Ovulatory Disorder
spermatozoa with beads bound The WHO classification of ovulatory disorder helps to ensure

Causes of Infertility
that appropriate treatment is given to a specific patient.

of natural conception appears to fall significantly when the Group I: Hypothalamic Pituitary Failure
sperm concentration is less than 5 million per ml. The patient is usually amenorrheic with no evidence of
2. Asthenozoospermia less than 50% spermatozoa in the semen endogenous estrogen production and low serum FSH levels. The
sample with forward motility patient has normal serum prolactin level and negative
3. Necrozoospermia all the spermatozoa in the sample are dead. progesterone challenge test. There is no detectable space-
4. Globozoospermia none of the spermatozoa in sample has occupying lesion in the hypothalamic pituitary region
acrosomal cap. (hypothalamic amenorrhea, Kallmann syndrome).
5. Teratozoospermia the proportion of spermatozoa with normal
Group II: Hypothalamic Pituitary Dysfunction
shape (morphology) is less than 30%.
6. Azoospermia means absence of sperms in the semen sample. Serum gonadotropins and prolactin levels are in the normal
7. Aspermia denotes no semen sample was ejaculated at range, with evidence of endogenous estrogen production. The
orgasm—absence of ejaculate. patient has positive progesterone challenge test, e.g. PCOD.
Any of these abnormalities may be present either singularly Group III: Ovarian Failure
or in combination. The patient is amenorrheic with elevated FSH level and low or no
evidence of ovarian estrogen. Prolactin level is normal.
FEMALE FACTOR
1. Tubal and peritoneal — 25–35% Group IV: Congenital or Acquired Genital Tract Disorders
2. Ovulatory — 15–25% These patients present with amenorrhea do not respond with
3. Uterine — 10% withdrawal bleeding to repeated course of estrogen due to
4. Cervical — 5% congenital or acquired anatomical disorders of genital tract.
5. Endometriosis — 1–10%
6. Unexplained — 15% Group V: Hyperprolactinemic Infertile Women with Space-Oc-
cupying Lesions in the Hypothalamic-Pituitary Region
Tubal Factors Women here present with a variety of menstrual cycle
The fallopian tubes can also be referred to as oviduct, salpinges disturbances like luteal phase defect (LPD), anovulation,
or uterine tubes. The fallopian tube has a vital role in the amenorrhea with elevated prolactin levels with space-
procreation as the process of fertilization takes place here. occupying lesion in the hypothalamopituitary region.
The extruded follicle is picked up by the fimbrial end of the Group VI: Hyperprolactinemic Infertile Women with No Detect-
tube and the spermatozoas ascend via the uterine end. If there able Space-Occupying Lesion in the Hypothalamic-Pituitary
is an obstruction to the meeting of spermoocyte, the fertilization Region
does not take place. As the fallopian tubes open into peritoneal
The presentation is the same as in the previous group except
cavity on one end, on the other side via uterus, there is a direct
that there is no evidence of a space-occupying lesion.
access to the lower genital tract. Any infection from vagina can
ascend and infect the tubes causing pelvic inflammatory disease Group VII : Amenorrheic Women with Non-Elevated Prolactin
(PID) leading to a tubal damage and block and with recurrent Levels and Evidence of a Space-Occupying Lesion in the
attacks this probability is increased, if not addressed at the Hypothalamopituitary Region
earliest. It has been seen by Cebesay et al 2010 that if there is The patient presents with low endogenous estrogen production,
hydatid of Morgagni, (Fig. 47.3) they may disturb tubal motility normal or low prolactin and FSH levels.
with pick up and transport of the ovum.
In patients, who have partial blocks, the sperm being smaller Ovarian Failure
in dimension to oocyte crosses the obstruction and fertilizes All human females are born with a reserve of oocytes that they
the oocyte. But the fertilized embryo is not able to travel back would require in their reproductive period. Oocytes are already
to the uterus for implantation there, resulting in an ectopic present by the fifth month of intrauterine life. The number starts
pregnancy. Impaired tubal function will include defective ovum decreasing by a mechanism of atresia without being ovulated 125
 thereafter. A woman enters her perimenopause–menopause undergoes luteinization under the action of LH. In these cases,
approximately at around 50 years. Some females have functional normal production of progesterone and normal duration of
deficit in their ovaries and they fail to function normally after the luteal phase of cycle can be observed. LUF is seen in 10%
the age of 40 years and this is called premature ovarian failure. of menstrual cycles of normal fertile women. LUF can be
Here, the serum FSH level starts increasing and the ovaries associated with unexplained infertility, endometriosis, pelvic
become resistant to the effect of the stimulation by these adhesions and the use of nonsteroidal anti-inflammatory
hormones due to exhaustion of oocytes in the ovaries. drugs.
Symptoms and Indices of Ovarian Aging Polycystic Ovarian Disease
1. Gradual shortening of the menstrual cycle This is discussed in detail in a separate chapter.
2. Rising FSH
3. Low inhibin B levels Endometriosis
Endocrinology in Gynecology

4. Low anti-Mullerian hormone (AMH) Endometriosis also contributes to female infertility in

5. Decrease in total antral follicles and a decreasing ovarian 20-30% of cases. The various ways in which endometriosis
volume in USG picture. affects fertility are given on page 166 and in (Flow chart 20.1).
Causes of Ovarian Failure
Hyperprolactinemia
Pituitary causes like Sheehan’s syndrome and tumors like Prolactin is secreted by the anterior pituitary gland, and it can
prolactinomas. be physiologically raised in pregnancy and lactation to facilitate
Endocrinal disorders: Thyroid dysfunction—hypothyroidism or breast development and milk production. But a pathological
hyperthyroidism, adrenal hyperplasia, diabetes mellitus, rise of prolactin is incompatible with fertility as it is generally
polycystic ovarian disease (PCOD), autoimmune disorders. associated with ovarian dysfunction, luteal phase defect,
anovulation and menstrual irregularities.
Premature ovarian failure resulting from genetic or acquired causes.
Genetic causes may be Turner ’s syndrome, gonadal Causes of Hyperprolactinemia
dysgenesis (46XX) (46XY), trisomies (13, 18), X chromosome 1. Physiological:
deletions and translocations. • Pregnancy
Iatrogenic causes like radiations and chemotherapy, etc. directly • Puerperium.
Section 3

affect the ovaries. 2. Idiopathic:

3. Pituitary tumors:
Metabolic causes like galactosemia and 17- hydroxylase
• Microadenoma
deficiency, etc.
• Macroadenoma.
Drug induced: Drugs like psychotropic agents affect the 4. Drug induced
functioning of the hypothalamus. 5. Dopamine receptor blocking agents or dopamine depleting
Resistant ovary syndrome/Savage syndrome is either the absence agents:
of FSH receptors or is a postreceptor defect. • Phenothiazines
• Butyrophenones
Luteinized Unruptured Follicle Syndrome (Trapped Ovum) • Metoclopromide
Luteinized unruptured follicle (LUF) syndrome is defined as • Reserpine
a failure of ovulation, in which, despite the absence of follicular • Methyldopa.
rupture and release of the oocyte, the unruptured follicle 6. Hypothyroidism

Flow chart 20.1: Endometriosis and infertility

126
7. Hypothalamic diseases Anatomical Factors
8. Chronic renal failure. Congenitally elongated cervix, pinhole cervical os, or severe
The raised prolactin interferes with cyclicity of the gonadotropin cervical stenosis, second degree or greater uterine prolapse,
secretion and affects the positive feedback to the hypothalam- acutely anteverted uterus, polyp occluding the cervical canal,
opituitary axis. A sustained rise should call for further evaluation traumatic injury to the cervix due to infections, amputations,
with X-ray of the sella turcica and CT scan to rule out any space- conization, cautery, and dilation or parturition tears which heal
occupying lesions. Neurological and ophthamological examinations with cicatrization, are the main causes for cervical anatomic
are required. Frequently, pituitary adenomas produce more than factors of infertility.
one hormone.
Hyperprolactinemia related to hypothyroidism can be Physiological Causes
corrected by treating with thyroxin. 1. Failure of spermatozoa to penetrate the cervical mucus in
cases of scanty mucus resulting from amputation, conization,

Chapter 20
UTERINE FACTORS cauterization, excessive mucus or too viscous mucus. Low
The endometrium must be sufficiently receptive for effective pH of the cervical mucus and purulent discharge from the
nidation and growth of the fertilized ovum. The possible factors cervix also prevent the sperm penetration.
that can affect a successful implantation and pregnancy till term 2. Immunological factors like antisperm antibodies cause
can be uterine hypoplasia, congenital malformations (Mullerian immobilization of the sperms in the vagina and cervical
anomalies), space-occupying lesions like fibroids, polyps, canal.
uterine synechiae, endometritis (tubercular) and forgotten
Vaginal Factors

Causes of Infertility
intrauterine contraceptive devices.
Factors which prevent proper coitus and impregnation of semen
Luteal Phase Defect (LPD) into the posterior vaginal fornix of the female will result in
The luteal phase of the menstrual cycle starts from ovulation infertility. Various reasons are:
and extends up to menstruation. This phase can last anywhere • Congenital defects of vagina like vaginal atresia, transverse
between 12 and 14 days. A luteal phase which is less than vaginal septum or vaginal tumors.
10 days produces an unfavorable milieu for implantation • Vaginitis resulting from various infections like
of embryo. If an egg is released and fertilized, the resulting trichomoniasis, candidiasis, mixed infection or other
blastocyst would find the endometrium unreceptive sexually transmitted diseases. Chemicals and burns also
for implantation. In here, the endometrial developments contribute to the same.
are out of sync with the rest of the hormone cycle, and the
Weight-BMI
uterine lining lags behind the hormonal cycle. Causes would
include poor follicle production, premature failure of the corpus Maintaining ideal body weight is important in attaining
luteum, failure of the uterine lining to respond (drug-induced pregnancy. In an underweight person or in female athlete, the
ovulation, hyperprolactinemia, hypothyroidism, pelvic proportion of fat to muscle mass is disturbed and the fat content
endometriosis, older women and dysfunctional uterine bleeding). influences the ovarian function. The secretion of FSH and LH
is affected and this leads to anovulation and at times to
Asherman’s Syndrome ammenorrhea or irregular periods.
Asherman’s syndrome is an iatrogenic problem, where there is In patients, who have BMI more than 25, and especially the
damage to the uterine wall leading to the formation of synechiae. ones who have BMI around 30 should try to lose weight to achieve
This happens as a result of excessive curettage during medical near ideal BMI as this will make their cycles regular, they start
termination of pregnancy or in the case of miscarriage or ovulating. Reducing weight also prevents the complications in
incomplete miscarriage, resulting in damage to the endometrium. pregnancy and delivery.
This leads to scarring of the uterus on healing. The extent of the
IMMUNOLOGY OF INFERTILITY
damage can vary from flimsy adhesions to dense bands between
the uterine walls to complete obliteration of the cavity. Immunology and Male Infertility
Immune-mediated male infertility is an autoimmune disease.
Fibroid Uterus Spermatozoa are first produced at puberty and are isolated from
Fibroid is a smooth muscle tumor of the uterus. Though the the systemic circulation. Sperm production occurs well after
association of uterine fibroid with infertility is unclear and the development of immunological tolerance to self-antigens;
controversial, but the following are a few reasons that interfere therefore, sperm-specific components are viewed as foreign by
with fertility in these patients: the immune system. Immunization with sperm elicits a highly
• Fibroids may block the fallopian tubes unilaterally or reproducible immune response that can impair fertility. The
bilaterally. incidence of sperm autoimmunity in infertile couples is 9–36%
• Distortion of the serosal surface of the uterus thereby in contrast to 0.9–4% in the fertile population. The incidence of
distorting the anatomical position of fallopian tubes. detection of sperm antibodies in the infertile male is 8–21% and
• Multiple large fibroids distort the cavity and make the in the female 6–23%. Immunological cause may contribute to
environment hostile. 5–15% of the male infertility factors.
• Cervical fibroid may prevent the transport of sperm. Antisperm antibodies (ASA) can be defined as
• Submucous fibroid will alter the blood flow to the immunoglobulins of the IgG, IgA and/or IgM isotype that are
endometrium resulting in failure to implant or causing directed against various aspects of the spermatozoa (head, tail,
miscarriage in a few cases. midpiece or any combination thereof). Immunoglobulin M is
too large a molecule to cross into the semen. Immunologic
Cervical Factors infertility is probable if more than 50% sperms are bound to
Cervical factors may be either anatomical or physiological, IgG or IgA antibodies. ASA is suspected if more than 10%
which prevent the sperms from ascending to the uterine cavity. spermatozoa are antibody bound. These immunoglobulins can 127
 be found in both males and females and in serum, semen and Adaptive Immune Response
cervical mucus. T helper cells:
The sperm antibodies in men are polyclonal, that is directed • TH1: Interferon gamma to increase cell-mediated immune
at more than one sperm antigen. The possible effects of response and inhibit the humoral immune response.
immunologic reaction to fertility are: • TH2: Interleukin 4 to increase humoral immune response
1. Disordered spermatogenesis resulting in oligospermia and and inhibit the cell-mediated immune response.
azoospermia. Is highly specific and MHC dependent.
2. Binding of antibodies to post-testicular spermatozoa thus
inhibiting their effective transport in the male reproductive Treatment
tract. Corticosteroid therapy
3. Autoagglutination of ejaculated spermatozoa. Most treatments for immunologic infertility have been
4. Sperm cytotoxicity mediated by sperm antibodies. disappointing because of poor results, adverse effects or high
Endocrinology in Gynecology

5. Direct immobilizing effect of sperm antibodies on cost. The most common form of immunosuppressive therapy
spermatozoa in the female tract. Enhancement of phagocytic for ASA has been corticosteroid therapy. Unfortunately, it has
clearance of spermatozoa by macrophages. resulted in improvement of the pregnancy rate in only one of
6. Inadequate spermatozoal traverse of cervical mucus. three controlled double blind studies. Lengthy treatment
7. Disorders of sperm capacitation and acrosome reaction. required for possible effect leads to corticosteroid side effect in
8. Blockage of sperm–ovum interaction approximately 60% of patients. Problems like mood changes,
9. Induction of sperm immunity in the female fluid retention and dyspepsia are common; but some
10. Postfertilization reproductive failure and occult miscarriage. complications, such as GI bleeding and aseptic necrosis of the
hip joint, are quite serious.
Risk Factors for Development of ASA
1. Obstructive azoospermia, e.g. vasectomy Assisted Reproduction Technologies
2. Varicocele Intrauterine insemination (IUI) affords some increase in
3. Epididymitis, prostatitis pregnancy rates over no treatment, but this increase may be
4. Primary testicular failure modest. The reported average success rate for IUI in couples
5. Testicular trauma with male factor antisperm antibodies is 20%. Increased ovarian
6. Idiopathic infertility hyperstimulation may yield better results. Pregnancies with
Section 3

7. Spermatocele. gamete intrafallopian transfer (GIFT) have been achieved in

couples who failed washed sperm IUI and steroid therapy.
Indications for ASA Testing in Infertile Men
Intracellular sperm insemination (ICSI) is the current accepted
1. Abnormal semen analysis (ASA): advanced ART treatment in men with high level of ASA. In one
a. Clumping/Agglutination study, where ASA binding approached 80%, the mean
b. Low motility fertilization rate, embryo development and pregnancy rate were
c. Poor sperm viability comparable to another cohort of ICSI cases without
d. Shaking in place motility. immunologic infertility. ICSI should be the primary choice for
2. Abnormal postcoital test: patients with high immunologic infertility.
a. Low number of sperms in mucus
b. Poor motility Immunology and Female Infertility
c. Shaking in place motility. Autoimmune factors: There are four different autoimmune problems
3. Failed fertilization in IVF that can cause infertility. A woman may have one or more of these
4. Unexplained infertility underlying problems: antiphospholipid antibodies (APLA);
5. Abnormal sperm penetration assay. antithyroid antibodies, antinuclear antibodies and lupus-like
Tests anticoagulant. Thirty percent of women with “unexplained”
There are seven major tests available for ASA testing. infertility will test positive for an autoimmune problem.
1. Agglutination tests Alloimmune factors: Women with alloimmune problems lose
2. Sperm immobilization test (Isojima) their pregnancies in miscarriage or have implantation failure.
3. Cytotoxic tests Either her immune system does not recognize the pregnancy,
4. Immunofluorescence tests or she develops an abnormal immunologic response to the
5. Mixed antiglobulin reaction (MAR) pregnancy.
6. Radioimmunoassay (RIA) and enzyme-linked immunos-
Management
orbent assay (ELISA)
7. Immunobead binding. • Reduce antibody-antigen effects so that trophoblastic
invasion is proper.
Cellular and Humoral Components of Innate and • Correct the TH1:TH2 imbalance.
Adaptive Immunity • Maintain proper vascular perfusion of the placenta and to
Component Innate Adaptive immunity
the fetus.
• Prevent complications inherent to the drugs/regimens used.
Cellular Monocytes/macro- T and B cells
phages, granulocytes, Treatment
NK cells, mast cells, • Low dose aspirin
T cells.
• Steroids
Humoral Complement, acute Antibodies.
plasma proteins, man-
• Heparin on its low-molecular weight fractions
nose binding lectin, • Intravenous immunoglobulins
128 clotting cascade • Lymphocyte immune therapy.
Low Dose Aspirin and unexplained recurrent miscarriage. A patient with high NK
Mode of action: It acts on thromboxane A-2 , decreasing its level cell activity will respond very well to intravenous
and thereby correcting the altered thromboxane: prostacycline immunoglobulin (IVIG) therapy. Some authors do not agree
ratio. with IVIG therapy.
Dosage: Given in doses from 50–80 mg/day. Conclusion: The immune system plays a definite role in
achieving and maintaining a pregnancy. It is important to
Side effects: Nausea, vomiting, gastritis.
understand and recognize these factors in order to treat patients
Steroids of infertility.
Drug of choice: Prednisolone or hydrocortisone since 80–90% is
Evaluation of the Infertile Couple
metabolized by the placenta.
What is the right time to seek help for infertility? Some clinicians
Mode of action: Acts by decreasing antibody formation and

Chapter 20
believe that a couple should start basic investigations after 12
increasing platelet formation by the bone marrow. Response months of unprotected intercourse, while others believe that a
takes place in 3–8 weeks. couple could avoid investigations for 12–18 months. Generally,
Dosage: 10–40 mg/kg body weight. one should take into consideration the woman’s age, any history
Side effects: Hypertension, weight gain, gestational diabetes, or signs suggestive of underlying cause for infertility like erectile
osteoporosis, infections, postpartum infections. dysfunction, irregular periods, endocrine disorders. Early
diagnosis will only ensure the couple has more time available
APLA Heparin and Its Low-Molecular Weight Fractions for treatment before advancing age of the female partner

Causes of Infertility
The drug of choice is low-molecular weight heparin (LMWH) becomes an additional problem.
since chances of bleeding are negligible. It is recommended that both partners are evaluated together,
and diagnosing a problem in one partner should not stop the
Dosage: Varies according to the fraction used.
basic investigations the other partner.
Side effects: Minimal bleeding, osteoporosis. The evaluation will start with taking a good history of both
partners. This questionnaire should probe all aspects of each
Intravenous Immunoglobulins partner. The next step is physical examination, followed by
Mode of action: Prolongs the clearing time of circulating immune routine infertility investigations and finally by specific
complexes (IgG-coated platelets) by binding to the macro- investigations and diagnostic procedures.
phages.
Evaluation of Male Partner
Dosage: 0.5 gm/kg body weight repeated every three weeks.
Husband’s evaluation is done simultaneously with the wife.
Side effects: Hypotension, nausea and headache, life-threatening Usually, in a busy fertility clinic, the husband is usually asked to
anaphylaxis in IgA deficient patients. get a semen analysis, but we should start with a detailed history.
Success rate: 70–82% in some studies. However, cost is Clinical history should include:
prohibitive. History of high-grade fever within past 6 months
History of mumps, any injury or torsion to the testis.
Lymphocyte Immune Therapy History of undescended testis
Mode of action: It decreases the levels of proinflammatory History of recurrent urinary tract infection
cytokines, e.g. IL2, TNFa and helps to restore the TH1: TH2 Has his any of the partner ever been pregnant
balance in favor of TH2 for pregnancy maintenance. Its role is Any previous investigation of infertility
being researched. Any previous treatment of infertility.
Personal History
Autoimmune Treatment
History of alcohol intake
Treatments for autoimmune risk factors include preconception Smoking history
administration of low-molecular weight heparin (LMWH), Drug/substance abuse history
aspirin and prednisone. LMWH is used to treat women with History of sauna/tight underwear or tight clothes.
APLA syndrome and to combat microthrombi. Prednisolone
(10–40 mg. per day) is given to decrease autoantibody levels, Medical history: To find out any long-standing treatment, drug
provide blood-thinning and anti-inflammatory reactions, and intake, chronic respiratory tract disease, tuberculosis or any
reduce the risk of clotting. IV immunoglobulin (IVIG) may be neurologic problem.
given in addition to this. Any endocrinologic problems like diabetes or thyroid
disorder, etc.
Alloimmune Treatment History of sexually transmitted disease
Immunization with her husband’s white blood cells results in History of any swelling in local genitalia.
about a 10% increase in the chance of live birth (to 60%) over Surgical history
the live birth rate without treatment. The risk of complications Any history of surgery in the testis
for these women, such as intrauterine growth restriction (IUGR), Any history of surgery in the pelvic region
preterm birth and birth defects, are generally diminished with Any history of surgery for hernia
treatment. IVIG is also an effective, though more costly Sexual history
treatment for women with low LAD levels. Research shows History of urethral strictures, hypospadias, phimosis
that there is a 28% increased live birth rate among women in History of any erectile dysfunction (ED).
this category who received IVIG, compared to women given a History of ejaculatory problems. Is ejaculation normal,
placebo. IVIG is also recommended for treatment of elevated retrograde ejaculation, premature ejaculation or anejaculation
circulating natural killer (CD56+) cells, circulating embryotoxins is to be ruled out?
129
 Frequency of intercourse • Serum prolactin
History of any epididymitis • Serum testosterone.
History of use of any lubricants. Serum FSH level estimation has a limited role in evaluation
Occupational history: An enquiry into occupation and the related of male factor. An FSH level more than twice normal indicates
occupational hazard working near a furnace, etc. testicular failure. It is usual to find normal serum FSH if sperm
count is more than 5 million per ml.
Physical Examination In patients, who have hypoandrogenization or erectile
General observation of the appearance, signs of virilization such dysfunction performing hormone assays will give some
as deepening of the voice, facial and body hair distribution. information and a blood sugar and lipid profile will help the
Height, weight clinician to rule out any organic cause.
Pulse rate and blood pressure
Ultrasound of Scrotum
Chest and cardiovascular examination
Endocrinology in Gynecology

Any abdominal scar, swelling or hernia. Ultrasound as a routine is of little value in the diagnosis or
treatment. It can be performed if varicocele is suspected.
Local Examination
Any abnormalities of penis, testes or epididymis X-ray of Sella Turcica
Look for any hernia, hydrocele, varicocele veins. MRI of head: In patients with hyperprolactinemia to rule out
Any scar or swelling on the groin
micro- or macroadenoma.
Examination of the prostate, seminal vesicle by P/R
examination. Karyotyping: Screening for abnormalities in the structure or a
number of the sex chromosomes and autosomes, e.g. Y
Investigations chromosome microdeletions.
Semen Analysis Testicular biopsy: A routine diagnostic testicular biopsy is not
recommended.
Semen analysis is the first and basic test that is performed for
A diagnostic testicular biopsy is indicated to distinguish
the male in an infertile couple.
between obstructive and non-obstructive azoospermia.
The semen sample is collected by masturbation after 4 days
Testicular biopsies may also be done to find out the presence of
of abstinence. The sample is collected in a sterile, non-toxic focal area of spermatogenesis prior to planning of ICSI
plastic container. The patient is not allowed to use any jelly or procedure. Therapeutic testicular biopsy is generally done for
lubricants. The sample should be collected in laboratory sperm retrieval for ICSI procedure.
Section 3

premises or transported to the laboratory in 30 minutes. Care

to be taken to keep the sample warm. Evaluation of the Female Partner
The details of semen analysis is to be reported (Table 20.1). The problem can lie anywhere in the vagina, cervix, uterus,
Evaluation of Azoospermia tubes, and ovaries or in the HPO axis.
Clinical history should start with demographic data,
In a patient of azoospermia, pseudoejaculation should be ruled
followed by a detailed history.
out. Some men are not able to produce semen sample.
Occasionally, the patient might collect urethral secretion and Menstrual History
little urine, which can be mistaken for azoospermia. Multiple 1. Age of menarche
semen sample should be done before labeling as azoospermia 2. Number of days of menstrual flow
(at least 3). 3. Amount of flow
If there is a history of high grade fever, the semen sample 4. Regularity of menstrual cycle
should be repeated after 3 months. The azoo-spermia sample 5. Dysmenorrhea
should be centrifuged and a resulting pellet should be 6. Intermenstrual/premenstrual spotting
examined; if no sperm is present but sperm precursors are 7. Last menstrual period.
found, it rules out an obstructive cause of azoospermia, and a
testicular failure is indicated. Obstetrical History
Fructose is produced in the seminal vesicles and enters 1. Length of marriage and cohabitation
through the ejaculatory duct. In patients with congenitally 2. Number and outcome of previous pregnancies, if any
absent vas deferens, the seminal vesicles fail to develop and 3. Number of living children, if any
semen sample consists only of prostatic secretions. 4. Any complication in the last pregnancy, delivery or abortion,
In the obstruction to the vas or epididymis, the sample will if any.
be positive for fructose.
Gynecologic and Sexual History
Hormone Assay 1. Family planning method used
• Serum FSH 2. History of STD, PID, vaginal discharge
• Serum LH 3. Previous investigations for infertility
4. History of ulcer in the genitalia
5. Any postcoital bleeding
LMWH Generic Name Dose Trade Name 6. Frequency of intercourse
• Dalteparin 2500 IU/0.2 ml Fragmin 7. Any dyspareunia
5000 IU/0.2 ml 8. Knowledge about the fertile period
• Nadroparin 3075 IU/0.3 ml Fraxiparine 9. Any history of ejaculation taking place outside the vagina.
4100 IU/0.4 ml
• Enoxaparin 20 mg/0.2 ml Clexane Medical History
40 mg/0.4 ml 1. History of tuberculosis, diabetes mellitus, thyroid disorder
130 • LMWH sodium
salt
3200 IU/0.3 ml
6400 IU/0.6 ml
Fluxum 2. Any long-term medical treatment taken
3. History of galactorrhea.
Surgical History 3. Uterine
Any history of surgeries like appendectomy, ovarian cystectomy, 4. Tubal
myomectomy or any other pelvic or abdominal surgery. 5. Ovarian factor
6. Endometriosis
Drug history: Drug /substance abuse/ smoking history.
7. Unexplained.
Professional and working environment of the patient.
General Physical Examination Vagina
General observation of the woman. See her state of health to assess There does not appear to be many vaginal conditions that cause
if there are any features suggestive of the cause of infertility. infertility per se. There may be a tough segment (septum) that
resists intercourse. These patients might need surgical incision
Height, weight, BMI are taken.
of the septum/hymen. The other problem is vaginismus, which
weight (kg) is a condition in which there is involuntary contraction of the

Chapter 20
BMI is calculated by = 2 vaginal muscles on an attempt of penetration of vagina. There
height (m)
could be organic causes to vaginismus like a lesion in the pelvic
Ideal BMI 20–25 kg/m2 organs, endometriosis or vaginal infections; but, mostly, it is
Underweight = <19.9 kg/m2 psychological in nature. These patients require to be evaluated
Normal = 20–24.9 kg/ m2 by counselors.
Overweight = 25–29.9 kg/ m2
Cervical Factor
Obese = >30 kg/ m2

Causes of Infertility
• Pulse rate, blood pressure, chest, and cardiovascular 1. Cervical mucus factor, low pH, local-antisperm antibodies,
systems are evaluated impenetrable mucus.
• Assessment of secondary sexual characteristics, body hair 2. Loss of mucus due to amputation of cervix or cervical
distribution, facial hair, breast size and developmental diathermy
grading is performed. 3. Faulty direction of the cervix such as found in retroversion.
• Look for any galactorrhea Evaluation of cervical factor and sperm cervical mucus
• Per abdomen examination for any mass, lump, scar from interaction are considered to be important steps in the infertility
previous surgery or any tenderness. investigations.
• Local genital examination and per vaginal examination to During coitus, semen is deposited in the posterior fornix
rule out any infections. and cervix. The semen coagulated immediately after ejaculation
and traps most sperms, until the liquefaction. The sperms are
Routine Blood Investigations rapidly destroyed by vaginal acidity, their entrapment in the
1. Complete hemogram to rule out anemia, any infections coagulum until liquefaction is a protective method of nature.
2. Blood sugar fasting and postprandial The secretion of cervix coats the upper part of the vagina and
3. VDRL, HIV, HBsAg, HCV cervix and causes an increase in the pH.
4. Kidney and liver function tests can be done as they give us Investigation for sperm mucus interaction
a baseline level. 1. Postcoital test
5. Blood group for Rh and ABO typing is done. 2. Slide test
3. Sperm cervical mucus contact test
Endocrine Tests 4. Capillary tube test.
1. Thyroid profile
2. Serum prolactin Cervical Mucus Penetration and Postcoital Test (Sim–
3. If a patient is suspected to be PCOS, other tests like serum Huhner Test)
testosterone, DHEA and cortisol levels can be performed. The periovulatory cervical mucus is clear, copious, and can be
4. A day 2, 3 or 4 serum levels of FSH, LH and serum estradiol. stretched over a few centimeters. This mucus production is
Investigations for patients with bad obstetric history are as because of the action of estrogen, and is maximum during
follows: ovulation.
• Antinuclear antibodies Postcoital test (PCT) has been employed to assess sperm
• Anticardiolipin antibodies survival in cervical mucus.
• Antiphospholipid antibodies Timing: PCT should be performed as closely as possible to
• TORCH IgG and IgM ovulation (midcycle) when estronized cervical mucus is most
Ultrasonography is a very useful and noninvasive test, which receptive to sperm.
gives us reliable information—regarding the status inside the USG evaluation of follicular size and release is commonly
abdomen and rules out any organomegaly, masses and free fluid. used.
A transvaginal ultrasonography with 3–4 D view will give Standard test of PCT is performed approximately 6–12 hours
us the accurate size of uterus, and ovaries. It helps to rule out after intercourse, if the initial standard test yields poor results
any septum, severe adhesions (Ashermann’s) abnormal shape a second test is planned 1–3 hours of coitus which is called
of uterine cavity, fibroids and polyps. The evaluation of “Early Test;” and if infertility persists, a “Delayed Test” is
endometrial thickness, echo pattern, and vascularity can be performed at longer interval 18–24 hours.
done. Antral follicular count followed by evaluation for any
Technique of PCT: A nonlubricated speculum is inserted into the
ovarian/endometriotic cysts.
vagina and a sample from posterior vaginal fornix pool is
aspirated with syringe, or pipette. Different syringes are used
Specific Evaluation of Female Factors
to collect sample from exocervix and endocervical canal.
1. Vaginal The mucus is stretched into a thread which can be up to or
2. Cervical more than 5 cm, this is termed as spinnbarkeit (Fig. 53.3). The 131
 volume of the mucus is then measured; this is followed by corpus luteum starts secreting progesterone. This rise in
microscopic examination to look for adequate number of alive temperature lasts for about 10 days, and falls to normal if the
and motile spermatozoa in the mucus, other cells like white patient is not pregnant.
blood cells. Ferning pattern and pH are also determined. The
most important characteristic is pH as sperm lose motility at a Cervical Mucus
pH of less than 6. The periovulatory mucus is copious, clear, and is very
Interpretation: The presence of progressively motile sperms per stretchable under the effect of estrogen at the time of ovulation.
HPF is a useful criterion. Absence of sperm in PCT may be This mucus will last for two to three days and then will change
caused by problems with deposition, azoospermia or efficient into scanty whitish under the effect of progesterone on cervical
phagocytosis. Antisperm antibodies can cause sperm with glands. Again, this is an indirect evidence and does not actually
shaking motion or agglutination. One negative PCT must be give the time of ovulation.
Endocrinology in Gynecology

repeated.
Ultrasonography
Vaginal pool sample: Spermatozoa are usually destroyed in the
vagina within 2–4 hours. The purpose of examining the vaginal Pelvic ultrasonography is a non-invasive test for documenting
pool sample is to ensure that semen has been actually deposited the ovulation. This is an indirect test again, the patient is
in the vagina. PCT lacks standardization, a definition of monitored from day 9 or day 10 of period, where a growing
normality is lacking and has unknown reproducibility; so follicle is visualized and the growth monitored, after the follicle
nowadays, PCT is not considered a valid test for infertility. size reach 20–22 mm with the collapse of follicle, which was
rounded and regular; and sometimes, with the appearance of
Cervical stenosis: It is a condition in which the cervix becomes
free fluid in POD, one can assume the extrusion of follicle. This
narrowed/constricted. Although there is no accepted diagnosis
is the most common modality used nowadays.
in the literature, the inability to pass a fine probe or endocervcial
brush, are acceptable diagnostic tests. Cervical stenosis may Day 21 Progesterone Assay
follow a cone biopsy or laser surgery. An assessment of serum progesterone on day 21 in a
Indications of treatment of cervical stenosis: 28-day cycle would reveal an elevation of progesterone to
1. Amenorrhea, dysmenorrhea, hematometra, pyometra 30 nmol/l, which gives us a confirmation that the patient
2. Inability to view and sample endometrium had ovulated and the corpus luteum was secreting
3. Inability to perform HSG
Section 3

progesterone. It should be confirmed that these patients

4. Infertility should not be taking progesterone supplements. The time
5. Dilatation to facilitate IUI or embryo transfer in an IVF should be adjusted in those clients who have longer cycles and
Contraindication: Active infection of cervix or vagina. should be done approximately 7 days prior to this onset of
The uterine factor/tuboperitoneal causes are as follows: menstrual flow.
1. Fibroids
2. Endometritis Endometrial Biopsy
3. Asherman’s syndrome Endometral biopsy is an invasive test for confirming ovulation.
4. Bilateral tubal block due to infection, adhesions, sterilization A few pieces of endometrium are taken premenstrually. A
procedure histopathological examination will reveal secretory changes
5. Pelvic adhesions under the effect of progesterone in patients who have ovulated.
6. Endometriosis. The second disadvantage is a possibility of disturbing a
pregnancy that might have ensued.
Diagnostic Tests for Evaluation of Ovarian Function
Causes of Anovulation LH Surge
• Hypogonadotropic hypogonadism The LH level can be monitored by taking multiple blood samples
• Ovarian failure in a patient and the LH surge and LH peak can be documented
• Polycystic ovarian syndrome to predict the time of ovulation, but this is an inconvenient test.
• Weight loss The urinary excretion of LH can be checked by the kits and
• Hyperprolactinemia. ovulation will happen 36 hours after the surge.

Tests for Ovulation Fallopian Tube

Methods for evaluation of ovulation are: Evaluation of uterine cavity and tubes:
1. Basal body temperature monitoring to assess the rise in 1. Rubin’s test
temperature 2. Ultrasonography (USG)
2. Changes in cervical mucus 3. Hysterosalpingography (HSG)
3. Endometrial biopsy to look for secretory changes
4. Hysterosalpingo-contrast sonography (HyCoSy)/
4. Ultrasonic visualization of the collapse of mature follicle
sonohysterography
with free fluid in POD
5. Hysteroscopy
5. Ultrasonic assessment of the endometrial, thickness, pattern,
volume and blood flow 6. Laparoscopy
6. Serum progesterone on day 21 of period (menstrual cycle) 7. Transvaginal hydrolaparoscopy.
7. LH surge detection in serum or urine. Rubin’s test: This test is very inaccurate and has no place in the
evaluation of an infertile patient now. It involves passing carbon
Basal Body Temperature Monitoring
dioxide gas through the cervix and listening with a stethoscope
Under the effect of progesterone, the body temperature rises for the sound of gas bubbling through the open ends of the fallopian
132 slightly by about 0.5 degree celsius. Following ovulation, the tubes and into the pelvis.
Hysterosalpingography Laparoscopy and Dye Test
Hysterosalpingography (HSG) is performed after semen Laparoscopy and dye tests are useful day care procedures to
examination of the husband is normal and occurrence of evaluate the tubal patency and give us an opportunity to
ovulation is confirmed. HSG has been the time honored, visualize the external aspect of tubes and uterus and also see
inexpensive and a simple modality for uterine evaluations. It any peritubal adhesions, cysts or endometriosis and blue fluid.
has remained the primary procedure for assessment of tubal
patency and shape of the uterine cavity. It is also useful in Evaluation of Ovarian Reserve
diagnosing synechiae like in Asherman’s syndrome. Ovarian reserve is an aggregate of the quantity and quality of
Timing: HSG should be carried out optimally within 10 days oocytes. These parameters start declining long before the actual
of the menstrual period when there is no risk of disruption of menopause. The declining ovarian reserve can vary, but in the
pregnancy. The patient should have completed her menstrual majority, the decline starts around the age of 35 and a steep fall
is seen after the age of 39 years.

Chapter 20
flow, so that menstrual tissue or fluid is not carried either into
the tube or peritoneal cavity. It is important to carry out the Symptoms and Indices of Ovarian Aging
procedure before the oocyte has resumed meiosis (12 day/28). 1. Gradual shortening of the menstrual cycle
The oocyte undergoing meiosis is radiosensitive. As X-ray 2. Raising FSH
opaque dye is used, it is preferable to use a water-based dye as 3. Low inhibin B levels
the chance of granulomatous inflammation is less and tolerance 4. Low anti-Mullerian hormone (AMH)
is better (Fig. 20.1). 5. Decrease in total antral follicles and decreasing ovarian
Ultrasound contrast hysterosalpingography (or

Causes of Infertility
volume.
hysterosalpingo-contrast sonography) (HyCoSy) A basal hormone level of serum FSH, LH, estradiol and
The HyCoSy is a relatively new test of tubal patency that is inhibin B performed on day 3 of the menstrual cycle will give
like HSG but does not expose the patient to X-ray radiation. An us an idea of the reproductive potential in that particular cycle.
ultrasound contrast medium which contains galactose In older women, as the follicular phase is shortened, the
microparticles is used. The procedure and method is similar to day 3 FSH level will appear normal, but a baseline estradiol
conventional HSG, but a vaginal probe is utilized for and inhibin B level starts rising above the basal level.
visualization of the flow into the uterus and then fallopian tubes. Interpretation of day 3 FSH
The USG examination before the contrast is injected helps in Less than 9 IU/l is reassuring; these patients respond well
evaluation of any fibroid or cyst in pelvis and adhesion, which to ovarian stimulation and can result in pregnancy and live
might have been missed in HSG. HyCoSy provides a good birth.
alternative to HSG. Between 9 and 10 IU/l; fair response is expected, but can
Availability of 3D and 4D ultrasound pictures can be used vary widely and there may be decrease in chance of live birth.
to reconstruct three-dimensional imaging techniques and thus Between 10 and 12 IU/l; a reduced response to ovarian
facilitate the diagnosis of any existing uterine pathology. With stimulation.
the use of Doppler, the sensitivity is further increased.
Disadvantage: It takes longer than HSG for the procedure to Tests for Evaluation of Ovarian Reserve
be performed. Only one fallopian tube is visualized at a time. 1. Gonadotropin assay
HyCoSy requires trained personnel and radiologists so it might 2. Ultrasound assessment ovarian volume
not be as widely accepted. 3. Antral follicle count

Fig. 20.1: Hysterosalpingography (HSG)

133
 4. Clomiphene citrate challenge test antifilarial therapy. Antibiotics are given for accessory gland
5. GnRH agonist stimulation test (GAST) infection. Empirical therapy with anti-oxidant and vitamin E,
6. Inhibin B assay and multivitamins can be given for 3 months in men with OAS.
7. AMH assay. Too much time should not be wasted in empirical therapy and
the age of wife should always be kept in mind while treating
Clomiphene Citrate Challenge Test
the husband.
Clomiphene citrate challenge test (CCCT) is a dynamic test to
evaluate pituitary for the production of FSH in challenge to Treatment of Specific Causes Erectile Dysfunction (ED)
clomiphene citrate, a partial estrogen receptor antagonist. This In older men, erectile dysfunction usually has an organic cause
blocks the negative feedback of estrogen on the HPO axis, like injury to the nerve, smooth muscles, fibrous tissues, or
leaving regulation of FSH release to inhibin B. impaired blood flow. Diseases such as diabetes mellitus renal
disease, chronic alcoholism, atherosclerosis, vascular disease,
Method: On day 2 or day 3 of the period, an ultrasound of pelvis
Endocrinology in Gynecology

and neurologic disease account for a large percentage of patients

is done to rule out any cysts. And a blood sample for serum
with erectile dysfunction. The other reason for ED can be
FSH and E2 is collected.
iatrogenic, related to medicines that these men are taking like
From day 5, patients are given clomiphene citrate 100 mg
antihypertensive drugs, some antihistamines, antidepressants,
tablet once a day for 5 days.
tranquilizers, cimetidine, etc. The third category of the causes
On day 10 or 11, testing of serum FSH is performed. We
is psychological factors such as stress, anxiety, guilt, depression,
can even do an ultrasound to determine for number and size of
low self-esteem, and fear of sexual failure.
follicles that have been recruited. This will give us added
Treatment should start with life-style modification like
information.
quitting smoking, losing excess weight, increasing physical
Interpretations: If there occurs any elevation in day 3 and 10, activity, cutting back on any drugs with harmful side effects
serum FSH more than 10 or if the sum of both is more than 26 may help some men regain sexual function. Psychotherapy and
IU/l, then it is an abnormal CCCT. behavior modifications will also benefit these men.
Clomiphene citrate increases the sensitivity of ovarian
reserve, but a normal test tells you nothing, it is not an assurance Drug Therapy
of the fertility potential. The test is not very sensitive, but has a Oral: Oral medicines improve the response to sexual
specific predictive value. stimulation. They do not trigger an automatic erection.
An abnormal CCCT gives us the following information: Phosphodiesterase (PDE) inhibitors, e.g. sildenafil have to be
Section 3

• The response to injectable gonadotropins will be poor taken an hour before sexual activity. These drugs work by
• The patient may have a higher cancellation rates in in vitro enhancing the effects of nitric oxide, a chemical that relaxes
fertilization (IVF) smooth muscles in the penis during sexual stimulation and
• Will have fewer eggs retrieved in IVF allows increased blood flow. This group of drug is
• Pregnancy rates are lower following IUI/IVF contraindicated in men who take nitrate-based drugs such as
• Have higher miscarriage rates nitroglycerin for heart problems.
• Increased risk for chromosomally abnormal embryos. Injectable drugs
Antral Follicle Count Drugs, such as papaverine hydrochloride, phento-lamine, and
Antral follicular count and ovarian volume is performed soon alprostadil can be injected into the penis. This causes widening
after the cessation of menstrual flow, by a transvaginal scan. of blood vessels causing it to become engorged with blood.
Antral follicle and volume of ovaries are decreased in the women With a system for inserting a pellet of alprostadil into the
with poor ovarian reserve. Evaluation of PCOS is done as urethra, erection will begin within 8 to 10 minutes and may
prescribed in amenorrhea (chapter 14). last 30 to 60 minutes. The most common side effects are aching
in the penis, testicles and area between the penis and rectum,
Treatment of Infertile Couple warmth or burning sensation in the urethra, redness from
Treatment of an infertile couple should be holistic in nature; increased blood flow to the penis, and minor urethral bleeding
once the basic tests are done and the diagnosis clinched, this or spotting.
would give us the line of treatment which the patient would Mechanical Vacuum Devices
benefit from. The treatment can be medical, surgical and Mechanical vacuum devices cause erection by creating a partial
psychological therapy. Infertility and fertility therapy can be vacuum, which draws blood into the penis, engorging and
extremely stressful for the patients. Apart from the stress of the expanding it.
investigation and treatment, the patient has to go through social
and family pressures. A couple should have adequate and Surgical Therapy
trained counseling to help them cope with the pressure of Implanted devices, known as prostheses, can restore erection
investigation and infertility treatment. This counseling session
of the stressed out patient not only helps the patient to have a Ejaculatory Dysfunctions
focused and positive outlook to the whole process; it also • Premature ejaculation
prevents the drop out rates. • Delayed ejaculation
• Retrograde ejaculation
Treatment of the Male Partner • Anejaculation/anorgasmia.
The treatment of the male partner is usually done by an The etiologies of these ejaculatory dysfunctions are
andrologist, but the gynecologists should also be aware of the numerous and multifactorial; psychogenic, congenital,
basic concepts. anatomic, neurogenic, infectious, endocrinological and
The treatment would depend on the cause. As filarial iatrogenic factors secondary to medications.
infection is very rampant in parts of our country causing chronic Premature ejaculation, if it does not take place outside
134 epididymo orchitis, these patients would benefit from vagina will not result in infertility. Retrograde ejaculation is
caused by diabetes, antihypertensive medication, and mood of vas aplasia. The treatment is surgical sperm retrieval like
elevator drugs or by urethral/prostate surgery. percutaneous epididymal sperm aspiration (PESA) using
The condition can be partial or complete and diagnosis is insulin syringe and a fine needle. The obtained epididymal fluid
made by urine analysis obtained soon after ejaculation, which contains sperms which can be used for intracytoplasmic sperm
will reveal a large number of sperms. injection (ICSI).
Treatment is to stop or substitute the offending drug. In
Ejaculatory Duct Obstruction
postsurgical cases, such as postgenitourinary surgery or in
Ejaculatory duct obstruction can be congenital or acquired. A
diabetes, the condition is usually irreversible but some
diagnostic PESA can be done to confirm the presence of sperm
improvement might be seen with imipramine or pseude-
and this can be cryopreserved and used for ICSI cycle Or PESA
ophedrine-like drugs.
can be done with ICSI cycle itself.
Untreated retrograde ejaculation with no neurologic
Surgical correction or anastomosis can be performed,
problem will require the patient to go through a process of IUI

Chapter 20
vasoepididymal or vasovasal in selected cases of obstructive
to achieve pregnancy. The patient is put on urine alkalizers 2
azoospermia is successful.
days prior to the procedure of IUI, once the urinary pH reaches
7.5, the patient is asked to masturbate followed by collection of Testicular Failure
urine in beaker. This is sent to the laboratory for washing and Testicular failure following high fever, chemotherapy or
examination to confirm the motility of sperms; and if there is radiation can be reversible.
no motility, then to discard the sample. Next catheterize and In cases of irreversible testicular failure, the patients might
empty the bladder, followed by a wash with soda bicarbonate have small pockets of spermatogenesis in the testis, so ejaculate

Causes of Infertility
and then instill 30 ml sperm wash medium and remove the may show a few motile sperms as it is a total collection from all
catheter. Ask the patient to masturbate and then void into a the seminferous tubules in both testes, which can be used for
beaker. The sample is processed and checked for viable sperm ICSI. A multiple needle aspiration biopsies or single seminferous
and then used to perform IUI. tubule biopsy can be done and material scanned under
microscope for any sperm and that can be used for ICSI
Antisperm Antibodies in Men
procedure.
The treatment of antisperm antibody in cases of infertility is
disappointing. Treatment of the Female Partner
IUI, with or without the use of fertility medications, has Treatment of the female partner is a more difficult, expensive,
been used for the treatment of antisperm antibodies. It is extensive, time-consuming process. The first step in
believed to work by delivering the sperm directly into the uterus the treatment of an infertile couple is finding out if the
and providing easier access to fallopian tubes, thus bypassing couple is aware of the fertile period. Treatment starts with
the cervical mucus. In vitro fertilization (IVF) appears to be the explaining to the patient about the fertile period followed by
most effective treatment for antisperm antibodies, especially lifestyle modification, achieving ideal body weight and stress
when antibody level is very high. reduction. This would be followed by control of any endocrine
Varicocele disturbance like diabetes, hyperprolactinemia or thyroid
The treatment of varicocele is very controversial. Varicocele is disorder.
a common finding among fertile men. The surgical option is Hyperprolactinemia
only considered in couples who are infertile with abnormal The treatment starts with identifying the cause and the extent
semen parameters, with no other apparent reason. of disturbance (galactorrhea, amenorrhea, infertility). The drug-
Hypogonadotropic Hypogonadism induced hyperprolactinemia can be reversed by stopping or
Once the diagnosis is made, the treatment includes hormone substitution of the causative drug. Treatment of causative
replacement therapy. The hormone replacement can be by the problems like with hypothyroidism will restore normal
use of a subcutaneous continuous infusion pump which delivers prolactin level.
the required dose at the set interval. The second method could Medical management is by two drugs, namely Bromocriptine and
be replacement with human chorionic gonadotropins (hCG) or Cabergolin; they are dopamine agonist.
human menopausal gonadotropins (hMG) at the required dose Bromocriptine is started at the dose of 1.25 mg or half tablet
weekly (twice or thrice). The duration of treatment is usually of standard available strength of 2.5 mg, taken with meal at
long. night and slowly escalated to 2.5 mg till the normal levels are
achieved. Bromocriptine is not well-tolerated by patients
Azoospermia
because of side effects. Alternatively, Bromocriptine tablets can
Once the diagnosis of azoospermia is made, after ruling out be used intravaginally and this has better tolerance. It may take
pseudoejaculation, an effort should be made to check if there 6–10 weeks for the control of the prolactin levels, then the dose
are any sperm precursor cells that are found in the sample. If should be reduced to lower maintenance dose. Bromocriptine
the sperm precursors are found, it rules out an obstructive cause seems to be safe in pregnancy, in spite of that it is recommended
of azoospermia and confirms the pathology to be testicular that the therapy be discontinued when the women conceive.
failure. Side effects of low dose Bromocriptine:
The next attempt is to find out vas aplasia or ejaculatory duct • Nausea
obstruction in fructose positive patients. Obstructive • Vomiting
azoospermia or primary testicular failure present as fructose • Constipation
negative. • Headache
Vas aplasia: This diagnosis is made clinically. Spermatogenesis • Dizziness
in these patients is normal and azoospermia is only because of • Postural hypotension
the inability of the semen to come out during ejaculation because • Drowsiness. 135
 Cabergolin Side effects of CC
Cabergolin, an ergot derivative, is a potent dopamine receptor 1. Visual disturbance
agonist. It also acts on dopamine receptors in lactophilic cells 2. Ovarian hyperstimulation
in hypothalamus to suppress prolactin production in the 3. Hot flushes
pituitary gland. The main advantage of cabergolin is the lower 4. Abdominal discomfort
side effect and flexibility of weekly or biweekly dosage. The 5. Nausea
starting dose is 0.25 mg twice a week and after the normalization 6. Vomiting
of prolactin level, the dose can be lowered to maintanence dose. 7. Depression
Side effect is the same as bromocriptine. 8. Insomnia
9. Breast tenderness
Surgical Treatment
10. Weight gain
Surgical treatment is restricted for patients who have 11. Rash
Endocrinology in Gynecology

macroadenoma, a transphenoidal resection is done. These 12. Dizziness and hair loss.
usually are patients who do not respond to medical
management as the cure rate with surgery is only approxi CC is contraindicated in:
mately 20–40% in macroadenomas and recurrence rate is very 1. Liver disorder
high. 2. Ovarian cyst
3. Endometrial cancer
Radiation Treatment 4. Uterine bleeding.
Not very popular, as it leads to destruction of pituitary gland
Letrozole
and leads to panhypopituitarism and diabetes insipidus.
Ovarian induction in patients with anovulatory cycles. Aromatase inhibitors are primarily used in the management of
postmenopausal breast cancer. Their use in ovulation induction
Insulin Sensitizers is because of their ability to inhibit androgen to estrogen
1. Metformin conversion, thus lowering the estradiol levels. The low level of
2. Traglitazone (now banned) estradiol causes the reduction in negative feedback and thus
3. Rosiglitazone (only in patients not wanting a pregnancy) increases pituitary gonadotropin output, leading to ovulation
4. Pioglitazone (under trial). induction, when the follicles start developing and subsequent
estradiol level starts increasing.
Section 3

Medical Methods for Augmentation of Ovulation

Dosage 2.5 to 5 mg once a day for 5 days. It has a very short
1. Metformin
half-life so unlike CC does not cause luteal phase problems and
2. Clomiphene citrate (CC)
is well-tolerated.
3. Letoval
4. Gonadotropin-releasing hormone Gonadotropin-releasing Hormone
5. Gonadotropins Increased doses of gonadotropin-releasing hormone (GnRH)
6. Pure FSH may be used effectively for ovulation induction in some patients
7. HMG. with GnRH receptor mutations. Pulsatile administration of
Metformin is a biguanide, available in strength of 500 or 850 mg, GnRH by the subcutaneous pump as administered in
recommended dose is around 1500–2000 mg in divided doses. hypogonadotropic hypogonadism patient, helps in
Metformin has been shown to reverse the endocrine folliculogenesis and with administration of hCG causes the
abnormalities seen with PCOS within 2 or 3 months. They can release of oocyte for achieving pregnancy. A higher dose of
result in diminished facial and body hair growth, regulations GnRH is required for normal luteal phase dynamics than for
of menstrual flow, weight loss and spontaneous ovulation. normal follicular phase function.
Treatment with rosiglitazone can only be given in patients Gonadotropins in PCOS
who are not trying for pregnancy. It is a well-tolerated
For patients who have PCOS, who are not responsive to weight
alternative for overweight PCOS patients. it helps in improving
loss, metformin, CC, Letrozole or ovarian drilling. The next step
menstrual cycle, hyper-androgenism, and insulin resistance in
would be injectable gonadotropins. The critical component in
hyper-insulinemic patients.
such preparation is FSH (recombinant FSH or highly purified
Clomiphene Citrate (CC) Mechanism of Action urinary FSH and never hMG as it has LH and FSH). The regimen
Clomiphene citrate (CC) is an estrogen receptor modulator. It for induction of ovulation in PCOS patient has to take into
binds to the hypothalamus, thus preventing the usual negative account the age, weight and any past history of
feedback of estrogen on GnRH during the follicular phase. This hyperstimulation of ovaries. The protocol for stimulation will
results in increased FSH stimulation to the ovary from pituitary. also depend on whether the patient is scheduled for natural
Major problem with CC is that it can bind to the estrogen cycle/IUI/IVF/ICSI.
receptor for an extended period of 6–8 weeks and depletes If the patient is for natural cycle or IUI, the patient is started
estrogen receptor in estrogen-dependent tissues like cervix and on CC (50 mg) or Letrozole (2.5–5 mg) from day 2, once a day
endometrium, which affects the endometrial development, and for 5 days and ultrasound is performed on day 7 to assess the
causes decreased cervical mucus production. number and size of the recruited follicle, and addition of
The CC is a very popular agent for the induction of ovulation gonadotropins can be done from daily or alternate day
and has been in use for around 40 years. A total of 50 gm is the depending on the response.
starting dose to be started on day 2 or day 3 for better Pure FSH injection can be given daily from day 2, starting
recruitment of follicles. This is followed by follicular study using with half ampoule of 75 unit (37) with serial monitoring with
ultrasonography from Day 9, till collapse of follicle to suggest transvaginal USG. The dose is adjusted according to ultrasound
ovulation. If the response is poor, the dose can be increased in or serum estradiol level (step up protocol) depending on the
136 subsequent cycle. A maximum of 4–6 cycle is recommended. response and when follicular size reaches 18 mm, ovulation
trigger can be given with injection hCG followed by a timed 10. Cervical factor infertility
contact or IUI. While stimulating patients of PCOD, one has to 11. Mild endometriosis
watch out for development of ovarian hyperstimulation 12. Cryopreserved.
syndrome (OHSS).
Prerequisite of IUI
Hypogonadotropic Hypogonadism 1. Age <39 years
The treatment of hypogonadotropic hypogonadism is 2. At least one patent fallopian tube with good tubo-ovarian
hormone replacement therapy. This can be done in pulsatile relationship.
continuous manner using a subcutaneous GnRH pump, which 3. Patient capable of ovulating (spontaneous or induced).
can be programmed to deliver different volumes of drug at 4. Sperm count >10 million/ml prewash or postwash, there
various interval. The pulsatile administration of GnRH makes should be at least 5 million motile sperms.
the pituitary to produce FSH and LH. This acts on the ovaries 5. Easy access to the uterine cavity via negotiable cervical

Chapter 20
to produce follicular development and monitoring is done by canal.
USG.
Steps of IUI
Or we can give daily injections of FSH for stimulating the
ovaries to produce the follicle, which is monitored by ultrasound 1. Patient selection and work up
and estradiol level. 2. Ovarian stimulation and monitoring
The use of pulsatile GnRH is highly effective and a large 3. Timing the procedure (best is between 36 and 40 hours
percentage of females with hypogonadotropic hypogonadism postinjection hCG)
4. Semen wash

Causes of Infertility
ovulate and subsequently get pregnant if there is no male factor.
5. Insemination
Surgical Method for Ovulation Induction Ovarian Drilling 6. Luteal support.
In PCOS patients, who are resistant to injectable gonadotropin
Luteal Support
treatment, laparoscopic ovarian drilling is next step. It involves
the use of unipolar cautery for making 2–4 holes per ovary. 1. Oral progesterone 10 mg twice a day after ovulation
The benefits of drilling are: 2. Micronized progesterone 100 mg BD vaginally (Best option)
1. Marked decrease in androstenedione 3. Injection progesterone 25–50 mg daily
2. Decrease in testosterone levels 4. Vaginal progesterone gels.
3. Increase in spontaneous ovulation and pregnancy rates
4. Decrease in spontaneous miscarriage ADOPTION
5. Fall in multiple pregnancy risk. Adoption should always be kept as a very good option in
infertile couples. Unfortunately, this is not so in India, while in
Artificial Insemination of Semen (Intrauterine Insemination IUI)
foreign countries, many people adopt children, giving them
In cases who fail to conceive even after induction of ovulation, chances to live happily.
insemination of semen into the uterus is tried. Definition: It is a lawful assumption of parental rights and
Insemination can be performed using husband’s semen responsibilities of another human being usually a child under
known as artificial insemination husband (AIH) or from donor 18 years of age.
known as artificial insemination donor AID. It also gives better lives to those children who are adopted.
Insemination can be: In foreign countries adoption is rampant. The famous couples
1. Intravaginal insemination (Actor Angelina Jolie, Brad Pitt, Madonna) adopted many
2. Pericervical insemination children besides their biological children. In our country also
3. Intracervical insemination miss universe and actress Sushmita Sen has adopted two
4. Intrauterine insemination children. In India, a central authority, Central Adoption
5. Intratubal insemination Resource Agency, is set up to look into all adoption related
6. Direct intraperitoneal insemination. matters. It is an autonomous body of the Ministry of Women
The route of insemination is generally dependent on and Child Development. The ministry has launched CARINGS
indication for performing the procedure. But most common (Child Adoption Rsource Information and Guidance System).
route is intrauterine insemination. This is a web based management information system. It
provides preadoption information to parents, registration of
Indication for AIH:
parents, status tracking by parents, facilitates expeditions and
1. Mild male factor infertility
smooth adpotion, ensures transparency in the adoption process,
2. Hypospadias
create a network of stakeholders for improved synergy,
3. Impotence
maintains a National Database to enable effective policy making
4. Sexual dysfunction
and research.
5. Retrograde ejaculation
6. Paraplegics BIBLIOGRAPHY
7. Dyspareunia
1. Cebesoy FB, Kutlar I, Dikensoy F, et al. Morgagni hydatid. A new
8. Anatomic disorder factor in infertility. Arch Gynecol Obstet 2010;281(6):1015.
9. Unexplained infertility 2. www.adoptionindia.nic.in

137
 21 Assisted Reproductive Technology (ART)

Sonia Malik, Rashmi Sharma

Introduction complications. Any ART procedure should be preceded by

Normal fertility has been defined as achieving a pregnancy traditional fertility workup and at this stage, it should be
within 2 years by regular unprotected sexual intercourse. decided whether ART should be instituted, postponed for other
However, many define infertility as not being able to get treatment modalities or refused to the couple. Once the patient
pregnant even after 1 year of unprotected intercourse. has been selected to undergo ART treatment, thorough testing
Prevalence of infertility is approximately 13–14 of married of the patient should be undertaken as outlined in Table 21.2 to
couples and has increased in recent times due to late marriage, correct any problems which may lead to IVF failure. At this
delay in childbearing, increased incidence of STD and MTPs stage, it should also be decided whether specific procedures
leading to PID. Thus, many couples require assisted such as egg, sperm or embryo donation are required.
reproductive technology (ART) to help them realize their The process of IVF involves (1) ovarian stimulation, (2) egg
dreams of having a child. ART is defined as all fertility retrieval, (3) fertilization (4) embryo culture followed by (5)
treatments in which both eggs and sperms are handled (CDC- embryo transfer. Involved in standard IVF protocol. Ovarian
1992 fertility clinic success rate and certification act). This stimulation oocyte retrieval, fertilization embryo selection and
generally means IVF-ET. They do not include treatment in which embryo transfer.
only sperms are handled (i.e. IUI) or procedures in which a
Ovarian Stimulation (Flow charts 21.1 and 21.2)
woman takes medicines only to stimulate egg production
(chapter 20). Most IVF centers use some form of ovarian stimulation in order
The first IVF pregnancy was achieved in 1978 by Patrick to produce multiple oocytes, enabling better selection of
Steptoe and Robert Edwards in UK amidst intense controversy embryos and multiple embryo transfer. Initially, clomiphene
over safety and morality of the procedure. Though Nobel Prize citrate was used for this purpose. This was followed by
is given in 2010. Since then, many million babies have been introduction of gonadotropins (FSH and LH), resulting in
born with these techniques worldwide. IVF is a technique in improved oocyte yield, but these cycles were complicated by
which egg cells are fertilized by sperm outside the woman’s premature LH surge due to high estradiol levels from multiple
womb (in vitro). developing follicles. Introduction of gonadotropin-releasing
hormone agonists (GnRHa) to block intrinsic FSH and LH
Indications of IVF secretion from the pituitary proved beneficial by drastically
The IVF was initially developed to overcome infertility due to reducing cycle cancellations due to spontaneous premature LH
problems of the fallopian tube but it turned out to be successful surge to less than 1 . The recently introduced GnRH
in many other infertility situations as well thus broadening the antagonists have also been used to prevent premature LH surge.
indications of IVF as outlined in Table 21.1.
GnRH Agonist Protocols
Though this technique is helpful in many conditions, the
cost of IVF is prohibitive thus making it the last choice when GnRH agonists are synthetically modeled after the natural
other less expensive treatments have failed. GnRH decapeptide with specific amino acid substitutions
typically in positions 6 and 10. These substitutions inhibit rapid
Evaluation and Preparation of Couple
Proper evaluation of the infertile couple before IVF is very
Table 21.2: Routine tests before proceeding for IVF
important for the success of IVF and prevention of
• Baseline hormones to test for ovarian reserve (Table 21.3)
• Semen analysis
Table 21.1: Indications of IVF
• Semen culture and sensitivity
• Severe tubal damage • Strict sperm morphology
• Male factor infertility (oligoasthenoteratozoospermia, obstructive • Vaginal swab culture and sensitivity
azoospermia, retrograde ejaculation, anejaculation) • HIV, HbsAg and VDRL of both husband and wife
• Unexplained infertility • Evaluation of the uterine cavity by transvaginal USG and
• Ovulatory dysfunctions Hysteroscopy if required (rule out endometrial polyp, submucous
• Premature ovarian failure (third party reproduction) myoma, uterine septum)
• Uterine factor (third party reproduction) • Clipping of hydrosalpinx if visible on USG (as presence of
• Endometriosis hydrosalpinx is known to reduce pregnancy rate significantly)
• Immunological infertility • Trial transfer
 Flow chart 21.1: Assisted reproductive technology flow chart

Chapter 21
Assisted Reproductive Technology
Flow chart 21.2: Important steps involved in a
standard IVF protocol Table 21.3: Markers of poor ovarian reserve
• Advanced age.
• High D-3 FSH ( 10 IU/ml).
• Low antral follicle count.
• Low anti Mullerian hormone (0.4 ng/ml)
• Low inhibin –B on D-3.
• Exaggerated FSH: LH ratio.
• High D-3 estradiol
• Short follicular phase.
• Premature luteinization.

5. Goserelin
6. Deslorelin.
riptorelin is an agonist with only a single substitution at position
6. All agonists have been used for IVF.
There are basically three protocols of GnRHa admini-
stration:
1. Long protocol
2. Short protocol
3. Ultrashort protocol.

Long Protocol (Fig. 21.1)

In the long protocol, GnRHa is started in the mid-luteal phase
(day 21) of the previous cycle followed by gonadotropin
stimulation from day 3 of the next cycle after confirmation of
full pituitary suppression as indicated ultrasonographically by
endometrial thickness of 5 mm and no ovarian cysts or
endocrinologically by serum estradiol levels of 50 pg/ml,
progesterone 1 pg/ml and LH 5 IU/l. GnRHa is continued
degradation of the substance prolonging half-life. Agonists with along with gonadotropins until the day of hCG trigger. This is
two substitutions include: the most commonly used protocol worldwide for IVF.
1. Leuprolide
2. Buserelin Short and Ultrashort Protocols
3. Nafarelin The short and ultrashort protocols have been designed to utilize
4. Histrelin the initial flare-up effect of the GnRHa on pituitary. In both, 139
Endocrinology in Gynecology

Fig. 21.1: GnRH agonist protocol

GnRHa is simultaneously started along with HMG or FSH from useful in decision making for coasting or cycle cancellation in
D-2 of menstrual cycle. In the short protocol, GnRHa is then patients prone for severe OHSS.
continued until the day of hCG trigger; while in ultrashort
Ovulation Trigger
protocol, GnRHa is given only for 3 days. These are especially
of use in poor responders and the short protocol has the added Ovulation trigger is given when at least 2 or more follicles have
advantage of preventing premature LH surge. reached 18 mm or more in diameter, hCG is given in a dose of
5,000–10,000 IU and oocyte retrieval is timed 34–36 hours later.
GnRH Antagonist Protocol In antagonist cycles, a small dose of GnRH agonist can be used
The GnRH antagonists are competitive GnRH receptor blockers as ovulation trigger in place of hCG to prevent OHSS as
leading to instant suppression of pituitary gonadotropin explained earlier.
secretions; so unlike GnRH agonists, these are not associated
with initial flare effect and require administration only for short Oocyte Retrieval (Figs 21.2A to D)
Section 3

period of time. The amount of exogenous gonadotropin In the initial phases of IVF, oocytes were retrieved by
requirement and consequently cost decreases as intrinsic laparoscopic follicular aspiration. With advances in ultrasound
gonadotropins are also available in the initial part of the cycle. technology and development of transvaginal USG probes, it
They can be used either as a single dose of 3 mg on D-7 of was realized that transvaginal US -guided needle aspiration
stimulation or daily dose of (0.25 mg) subcutaneously and as a of follicles provided a safer and less invasive approach for
flexible or fixed regime. In fixed protocol, GnRH antagonist is oocyte retrieval. Adoption of TV US -guided oocyte retrieval
started on D-6 of stimulation irrespective of follicle size; while has enabled us to perform oocyte retrieval as a day care
in flexible protocol, GnRH antagonist to be started when the procedure, as it can be performed only under light sedation or
maximum follicle size reaches 14 mm. No controlled studies short GA. If the number of follicles is low or oocyte recovery
are available comparing single dose or multiple dose or poor, follicles may be flushed with culture media to assist
comparing fixed or flexible approach. recovery of all eggs present (follicular flushing).
The degree of pituitary blockade with antagonists is dose
related so at the dose of 0.25 mg daily, there are free GnRH Fertilization: Laboratory Techniques
receptors available. These free GnRH receptors are responsive As soon as the follicles are aspirated, the aspirate is handed
to stimulation with GnRH agonist utilizing flare effect leading over to the embryologist in the laboratory. The follicular aspirate
to internal LH secretion sufficient for triggering ovulation. This is then scanned immediately on a heated microscope stage for
regime allows the use of GnRH agonist in place of hCG as a oocyte identification followed by transfer of oocytes into culture
trigger and is especially useful in preventing severe ovarian media after dissecting them free of blood clots and granulosa
hyperstimulation syndrome (OHSS ) in high-risk patients. cells if necessary. Each oocyte is then assessed for maturity and
Though the initial studies suggested that pregnancy rates are a quality and optimal time is decided upon for insemination. Each
little less in antagonist protocols, later studies, with increasing oocyte is routinely inseminated with a concentration of 50,000–
clinical experience, have reported comparable pregnancy rates. 100,000 normal motile spermatozoa per ml in microdroplet/oil
Food and Drug Administration (FDA) approved antagonist system. These are then kept in an incubator maintaining stable
preparations: pH and temperature throughout.
1. etrorelix
2. Ganirelix Confirmation of Fertilization on D-1
3. Abarelix This is a critical stage in the development of embryos, since it
helps to distinguish between normal and abnormal embryos. At
Follicular Monitoring approximately 18 hours following insemination, oocytes are
Once gonadotropin administration has begun follicular growth dissected gently in order to examine them for the presence of two
is monitored by repeated transvaginal ultrasonography and pronuclei before these unite during syngamy. Normally, fertilized
estradiol measurement if required. Frequent estradiol eggs should have two pronuclei, two polar bodies, clear cytoplasm
monitoring though still used in many countries has not been and intact regular zona pellucida. Those zygotes with two
found to provide additional information. (NICE) approximately pronuclei are cultured separately from multipronucleate zygotes
150–200 pg/ml of serum E2 is expected per mature follicle. (indicating abnormal fertilization) so that there is no possibility of
abnormal embryos being selected for transfer as after cleavage
140 Serum E2 estimation ( 3,000–4,000 pg/ml on the day of hCG) is
 Chapter 21
Assisted Reproductive Technology
Figs 21.2A to D: Oocyte retrieval

these are indistinguishable. Fertilization rates of approximately Intracytoplasmic Sperm Injection (Fig. 21.5)
60 per egg collected are expected although failure of fertilization The process involves the injection of a single sperm within the
may occur due to previously unrecognized oocyte or sperm ooplasm of the oocyte. Following the first intracytoplasmic
abnormality. sperm injection (ICSI) birth in 1992, thousands of babies have
been born around the world. ICSI is the only option for
Embryo Selection
On day 2, embryos are carefully evaluated to select the ones
with the highest implantation potential. Embryos are graded
morphologically by the number of blastomeres, size, shape,
symmetry and cytoplasmic appearance of blastomeres and
presence and degree of cytoplasmic fragmentation (Fig. 21.3).
Now there is emerging evidence that grading can be done
even at the pronuclei stage—according to distribution and size of
nucleoli within each nucleus and equality between two nuclei.
ygotes showing inequality between sizes, numbers and
distribution of nuclide have fewer chances of blastocyst formation
and implantation (Fig. 21.4).
Gamete Micromanipulation Techniques
Gamete micromanipulation techniques have been introduced
to improve fertilization capability. These include ICSI,
partial zona dissection, zona drilling and subzonal sperm
injection. Out of these, ICSI has proved to be most clinically
successful. Fig. 21.3: 2PN - Fertilization stage
141
 Embryonic Micromanipulation Techniques
The two important embryonic micromanipulation techniques
are assisted hatching (AH)and pre-implantation genetic
diagnosis (PGD).
Assisted Hatching (AH)
In vitro culture conditions and/or advancing maternal age may
lead to hardening of zona leading to hatching difficulties.
Assisted hatching (AH) was developed to overcome this
inability of blastocyst to escape from the zona pellucida. Various
methods employed for assisted hatching are mechanical (partial
zona dissection, P D), chemical (acid tyrode solution) or
Endocrinology in Gynecology

through LASER. In the last decade, several retrospective and

prospective studies, assessing AH in different clinical situations
have given extremely variable results, leaving the embryologist
with the question of whether to hatch or not to hatch. The main
indications for AH have been repeated IVF failure, 35 maternal
age, high basal FSH and thick zona. Many studies have reported
increased PR/IR with AH in poor prognosis patients; but a
Cochrane review in 2006 concluded that despite significantly
Fig. 21.4: Progress of fertilization
improved odds of clinical pregnancy, there is insufficient
evidence to determine any effect of AH on low birth rate.
Preimplantation Genetic Diagnosis
Preimplantation genetic diagnosis (PGD) was considered a good
alternative to prenatal diagnosis but its applications have been
slow mainly due to hindrances in single cell diagnostic
techniques. PGD is indicated in couples with inheritable genetic
Section 3

conditions or sex-linked disorders. Its use has now increased

to couples with repeated miscarriage and repeated IVF failures
to exclude embryos with aneuploidy. Either polymerase chain
reaction (PCR) or fluorescent in situ hybridization (FISH) is
utilized to analyze genetic material obtained from embryo.
Genetic material for PGD can be obtained by either polar body
biopsy, blastomere biopsy from 6–10 cell cleavage stage embryo
or trophoectoderm biopsy from late stage blastocyst. Currently,
blastomere biopsy from 6 to 10 cell embryo is the most preferred
Fig. 21.5: ICSI in progress method (Fig. 21.6).
Cryopreservation Techniques
treatment of severe male infertility. Sperms for ICSI can be A successful embryo cryopreservation program plays an
obtained from ejaculate even when only a few are present or important role in maximizing the cumulative pregnancy rate
through surgical retrieval from the epididymis percutaneous from a single oocyte retrieval. It was in 1983, that the first human
epididymal sperm aspiration (PESA) or testis testicular sperm pregnancy resulted from frozen and thawed embryo. Significant
aspiration (TESA) in azoospermic men. Various indications for advances have since been made in the techniques of oocyte and
ICSI are outlined in Table 21.4. embryo freezing. There are basically two methods to

Table 21. : Indications for ICSI

Ejaculated sperm
Oligozoospermia ( 20 million/ml).
Asthenozoospermia ( 40 progressive motility)
Teratozoospermia ( 15 Normal forms according to
strict Kruger’s criteria)
Antisperm antibodies
Repeated fertilization failure following conventional IVF
Ejaculatory disorders
Sometimes if only very few oocytes are available (to ensure
fertilization)
Epididymal or testicular sperm
Congential bilateral absence of vas deferens.
Obstruction of both ejaculatory ducts
Failed vasovasostomy
Failed epididymovasostomy.
142 Fig. 21.6: Blastomere biopsy
cryopreserve oocytes and embryos; slow rate freezing and Table 21. : Optimization of embryo transfer techni ue
vitrification. In slow rate freezing, extracellular ice formation
• Mock ET
drives cellular dehydration through an equilibrium process.
• USG-guided ET
Vitrification is a non-equilibrium approach where very high • Mid-cavity placement of embryo (1 cm below the fundus)
concentrations of cryoprotectant are used that solidify without • Soft transfer catheter
forming ice crystals. Vitrified solids contain normal molecular • Avoiding manipulation of cervix and fundus to minimize uterine
and ionic distributions of original liquid state. In a way, vitrified contractions
solids are extremely viscous supercooled liquids in molecular • Removing cervical mucus to prevent trapping of embryos
stasis. It is a form of rapid cooling. Slow freezing is a labor- • Using progesterone/NSAID to reduce uterine contractions
intensive process; while vitrification is done very fast hence
the coming era is likely to see vitrification in clinical use. one study showing approximately 30 IVF failures to be
associated with poor ET technique. Embryo transfer technique

Chapter 21
Embryo Transfer (Table 21.5) can be optimized by incorporating simple measures in the
Routinely embryo transfer (ET) is carried out on D-2 or 3 routine protocol as outlined in.
(cleavage stage embryos). Recently, it has been suggested that
with the use of sequential stage-specific media, D-5 blastocyst Luteal Phase Support
transfer will help in selecting embryos with the best Although in natural cycles the ovary produces progesterone
implantation potential enabling us to decrease the number of after ovulation, there is evidence of premature luteolyis with
embryos to be transferred to one without compromising the ovarian stimulation. Hence, luteal phase is supplemented with

Assisted Reproductive Technology

pregnancy rates. But delaying transfer up till D-5 may at times single or combined agents consisting of hCG, progesterone and
be associated with a risk of having no embryos left for transfer estrogen. The hCG 5,000 IU is given intramuscularly on day
if these fail to develop further in laboratory conditions. A 3, 6 and 9 following embryo transfer, but is contraindicated in
Cochrane review in 2005 concluded that blastocyst transfer patients prone for OHSS. Both progesterone or hCG as luteal
cannot be routinely justified as cleavage stage and blastocyst phase support give comparable pregnancy rates. Various routes
transfer leads to similar pregnancy rates with more ET of administration of progesterone are oral, vaginal (8 gel,
cancellations in blastocyst stage. As regarding the number of progesterone pessaries 200 mg TDS) or intramuscular (50–100
embryos to be transferred, all over the world, efforts are being mg daily). Oral progesterone leads to decreased pregnancy rates
made to decrease the number of embryos transferred to one (in with increased first trimester losses in comparison to both
order to reduce the incidence of multiple pregnancies) without vaginal and intramuscular progesterone supplementation as
affecting the success rate. the majority of drug is removed during first pass metabolism
in liver. Studies comparing intramuscular and vaginal
Embryo Transfer Technique (Figs 21.7A to D) administration of progesterone have given varied results. The
The placement of the embryos into the endometrial cavity has use of adjuvants like aspirin, steroids, sildenafil and low
long been recognized as one of the most important steps with molecular weight heparins in implantation failures is still

A B

C D
Figs 21.7A to D: Embryo transfer technique. (A) ET catheter loading; (B) U/S guided placement of embryos;
(C) Cook ET catheter; (D) Wallace ET catheter 143
 debatable and not advocated. However, recently, the use of
estrogen and recombinant LH during the luteal phase appears
to be promising.

OTHER ART TECHNIQUES

Gamete Intrafallopian Transfer
The gamete intrafallopian transfer (GIFT) was developed in 1989
for women with unexplained infertility. During this procedure,
the patient undergoes controlled ovarian hyperstimulation. The
oocytes are retrieved transvaginally under ultrasono-graphic
guidance, and 3–4 oocytes are placed via laparoscopy into one
Endocrinology in Gynecology

of the fallopian tubes along with sperms the fertilization takes

place in vivo inside the fallopian tube. Limitations of GIFT are
that fertilization cannot be confirmed and embryos are not
available for quality assessment. Also, at least one healthy tube
is required.

Zygote Intrafallopian Transfer (ZIFT)

Fig. 21.8: Twin pregnancy
In zygote intrafallopian transfer ( IFT) embryos at 2 PN stage
are transferred via laparoscopy into the fallopian tube. The only
benefit of IFT versus traditional IVF is for women who are Ectopic and Heterotopic Pregnancies
thought to have poor embryo quality due to in vitro culture About 5.5 of all IVF pregnancies are ectopic, and the risk of
conditions. heterotopic pregnancy (embryo both inside and outside the
With the development of good culture media, the success rates uterus) is approximately 1 as compared to the estimated 1/
for IVF are now comparable to, if not better than GIFT or IFT. 30,000 incidence in spontaneous gestations. A high index of
suspicion coupled with early sonography is, therefore,
COMPLICATIONS OF IVF warranted in all pregnancies resulting from IVF.
The inherent component of IVF is supraphysiological ovarian
Section 3

response and transfer of more than one embryo leading to Ovarian Hyperstimulation Syndrome (OHSS)
iatrogenic complications of multiple pregnancy, ectopic and (Figs 21.9A and B and Table 21.6)
heterotopic pregnancy and ovarian hyperstimulation syndrome. Ovarian hyperstimulation syndrome (OHSS) is considered to
be the most serious complication of ovulation induction. It can
Multiple Pregnancy (Fig. 21.8) vary from being a mild illness to a severe life-threatening
Multiple pregnancy remains the most frequent complication of disorder requiring hospitalization and occasionally resulting
IVF and multiple embryo transfer. Multifetal pregnancies are in death of the patient. OHSS can occur as soon as a few days
often complicated by preterm delivery leading to increased after receiving hCG ( early OHSS’) or later ( late OHSS’). Late
perinatal mortality and morbidity. These are also associated OHSS is more likely to be severe and to last longer than early
with significant maternal complications like PIH, PPH and OHSS. OHSS is characterized by a varied spectrum of clinical
gestational diabetes, etc. and laboratory manifestations including multicystic ovarian
Many European countries have legislation to limit the enlargement, massive extravascular fluid accumulation,
number of embryos to be replaced reflecting lower multiple combined with intravascular fluid depletion, hemoconcentration
pregnancy rates in European countries 26.3 European Society and electrolyte disturbances. The pivotal event in the
for Human Reproduction and Embryology (ESHRE) as development of OHSS is the disruption of capillary integrity
compared to the USA (39 –2000 US Registry). that results in leakage of intravascular fluid and proteins into

A B

144 Figs 21.9A and B: Severely hyperstimulated ovaries. (A) Normal image; (B) 3D image
 Table 21. : Classification of severity of OHSS
Bleeding and Infection
Occasionally transvaginal follicular aspiration can lead to
Grade Symptoms
infection and significant bleeding requiring hospitalization,
Mild OHSS Abdominal bloating though the reported incidence is low. Very rarely, ovarian torsion
Mild abdominal pain and rupture are also reported.
Ovarian size usually 8 cm
Moderate OHSS Moderate abdominal pain Birth Defects
Nausea vomiting
Ultrasound evidence of ascites Infants delivered after IVF appear to be at increased risk for
Ovarian size usually 8–12 cm congenital malformations compared with spontaneously
Severe OHSS Clinical ascites (occasionally hydrothorax) conceived children.
Oliguria
Hemoconcentration (hematocrit 45 ) Future Aspects

Chapter 21
Hypoproteinemia Tremendous advances have been made in the field of ART
Ovarian size usually 12 cm during the last 30 years, but still pregnancy rates have improved
Critical OHSS Tense ascites or large hydrothorax
only marginally. One of the grey areas in our understanding of
Hematocrit 55
White cell count 25,000/ml reproduction is embryo-endometrium interaction. Intense
Oligo/anuria research at the molecular, genetic and proteomic level is
Thromboembolism underway to define the markers for endometrial receptivity and
Acute respiratory distress syndrome to unravel the mysteries of the secret cross-talk between the

Assisted Reproductive Technology

Ovarian size may not correlate with severity of OHSS in cases of embryo and endometrium. While induction of ovulation, milder
assisted reproduction because of the effect of follicular aspiration. or softer stimulation protocols are being evaluated in an effort
to decrease the cost of the cycle, stimulation time with more
patient comfort and decreased side effects like OHSS and
the third space. The cause of OHSS is unknown, but it is thought
multiple pregnancy. In an effort to improve the oocyte potential
to be mediated by vasoactive cytokines vascular endothelial
from older woman, ooplasm and nuclear transfer are being tried.
growth factor (VEGF) secreted in excess by hyperstimulated
Haploidization of somatic cells with their consequent use as
ovaries.
egg or sperm is being researched in an effort to avoid ovum or
OHSS is classified into the following categories according
sperm donation potentially giving many patients hope for
to the severity of the condition.
having their own genetic child. Currently, there is a lot of
Mild forms of OHSS are common, affecting up to 33 of in
emphasis on fertility preservation techniques in the form of
vitro fertilization (IVF) cycles while 3–8 of IVF cycles are
ovarian tissue freezing followed by autologous transplantation
complicated by moderate or severe OHSS.
or in vitro maturation of follicles. Ovarian tissue cryopreserva-
Patients who are prone for development of OHSS are as
tion should perhaps be offered to all young women who are
given in Table 21.7.
likely to lose their ovarian functions either because of cancer
Various options that have been suggested to prevent OHSS
treatment or genetic causes.
in patients thought to be at risk of severe OHSS are outlined in
Reproductive medicine has undergone a transformation
Table 21.8.
with the advent of ART. Better understanding of the process of
Management reproduction has led to discoveries in other fields of medicine
as well thus helping millions of people even beyond infertility.
The OHSS is a self-resolving condition and the main aim of
management is correction and maintenance of intravascular BIBLIOGRAPHY
volume, renal function and prevention of thrombotic events.
1. AI-Inany H, Aboulghar M. GnRH antagonist in assisted
Thrombo-embolism is a potentially life-threatening reproduction: a Cochrane review. Hum Reprod 2002;17:872-85.
complication of OHSS, which is reported to happen in 0.7 to 2. Blake, et al.Cleavage stage versus blastocyst stage embryo transfer
10 of OHSS patients. Prophylactic measures in the form of in assisted conception. Cochrane database system review
intermittent pneumatic compression device and heparin 2005;19(4):CD0022118.
therapy must be considered for all patients admitted with OHSS. 3. Buitendigk SE. Children after in vitro fertilization. An overview of
the literature. Int Technol Assess Health Care 1999;15:52-65.
4. Cohen . Embryo replacement technology. San Francisco 31 Annual
Table 21. : Patients prone for developing OHSS Postgraduate Course, ASRM, 1998.
5. Cohen , Elsner C, Kort H, et al. Impairment of the hatching process
• oung age ( 35 years) following IVF in the human and improvement of implantation by
• Lean habitus assisted hatching using micromanipulation. Hum Reprod 1990;5:7-13.
• PCOS 6. Cohen , Alikani M, Trowbridge , Rosenwaks . Implantation
• High E2 response ( 4,000 to 6,000 pg/ml on the day of hCG trigger.) enhancement by selective assisted hatching using zona drilling of
• Multiple ( 35) small and intermediate size follicles human embryos with poor prognosis. Hum Reprod 1993;8:599-603.
7. Daya Salim. Is there a benefit of low dose aspirin in assisted
reproduction Current opinion in obstetrics and gynaecology
Table 21.8: Prevention of OHSS 2006;18(3):313-8.
8. Delvigne A. Rozenberg S. Epidemiology and Prevention of ovarian
• Withholding hCG with cycle cancellation.
hyperstimulation syndrome (OHSS): a review. Hum Reprod,
• Using GnRHa as ovulation trigger in case of antagonist cycles.
Apdate 2002;8:559-77.
• Withholding gonadotropins and deferring hCG administration until
9. Delvigne A. Review of clinical course and treatment of ovarian
E2 levels drop (coasting).
hyper stimulation symdrome (OHSS). Hum Reprod Update
• Deferring embryo transfer with cryopreservation of all embryos.
2003;9:77-96.
• Administering intravenous human albumin or I/V hydroxylethyl
10. Dimitry ES, Subek-Sharpe R, Mills M, Margara R, Winston R. Nine
starch at the time of ovum pick up
cases of heterotopic pregnancies in 4 years of in vitro fertilization.
• Providing luteal support with progesterone instead of hCG
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 11. ESHRE PGD Consortium. Hum Reprod 2002;20:35-48. fertilization: a prospective randomized study. Fertil Steril
12. Farhi , Weissman A, Steinfeld , Shorer M, Nahum H, Levran D. 1999;71:614-8.
Estradiol supplementation during the luteal phase may improve 18. Ludwig M, Katalinic A, Diedrich K. Use of GnRH antagonists in
the pregnancy rate in patients undergoing in vitro fertilization- ovarian stimulation for assisted reproductive technologies
embryo transfer cycles. Fertil Steril 2000;73:761-6. compared to the long protocol. Meta-analysis. Arch Gynecol Obstet
13. Friedler S, Raziel A, Schachte M, Strassburger D, Bukovsky I, Ron- 2001;265:175-82.
El R. Luteal support with micro-nized progesterone following in 19. Lynette Scott, Ruben Alvero, Mark Leondire, Bradly Miller. The
vitro fertilization using a downregulation protocol with morphology of human pronuclear embryos is positively related to
gonadotropin releasing hormone agonist: a comparative study blast cyst development and implantation. Human reproduction
between vaginal and oral administration. Hum Reprod 2000;15(11):2394-403.
1999;14(8):1944-8. 20. Nygen KG, Andersen AN. Assisted reproductive technology in
14. Humaidan P, Bredkjaer HE, Bungum L, et al. GnRH agonist Europe, 1998. Results generated from Europian registers, by
(Buserelin) or hCG for ovulation induction in GnRH antagonist ESHRE. Human Reproduction 2001;16(11):2459-71.
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IVF/ICSI cycles: a prospective randomized study. Hum Reprod 21. Fertility: Assessment and treatment of people with fertility
2005;20:1213-20. problems. 2004 Clinical guidelines. National Collaborating Centre
15. Itskovitz , Kol S, Mannaerts B. Use a single bolus of GnRH agonist for Women’s and Children’s Health, National Institute for Clinical
Triptorelin to trigger ovulation after GnRH antagonist ganirelix Excellence, RCOG Press, 2004.
treatment in women undergoing ovarian stimulation for assisted 22. Penzias AS. Luteal phase support. Fertil Steril 2002; 77(2):
reproduction, with special reference to the prevention of ovarian 318-23.
hyperstimulation syndrome: preliminary report. Hum Reprod 23. Society for Assisted reproductive technology and American
2000;15:1965-8. Society for Reproductive Medicine. 1997 results generated from
16. eif MMW,Edi-osagie ECO,Farquhar C,Hooper L,Blake D, Mckinlay the American Society for Reproductive Medicine/Society for
P. Assisted hatching on assisted conception. Cochrane database Assisted Repro-ductive Technology Registry. Fertil Steril
system review 2003,issue 4. 2000;74:641-53.
17. Licciardi FL, Kwiatkowski A, Noyes NL, Berkeley AS, Krey LL, 24. Steptoe PC, Edwards RG. Birth after reimplantation of a human
Grifo A. Oral versus intramuscular progesterone for in vitro embryo. Lancet 1978;2:366.
Section 3

146
 22 Menopause

Sudha Salhan, R Sinha, Sujata Mishra

Definition estrogen and progesterone production. The ovarian stroma is

Menopause is defined as a time of cessation of ovarian function unaffected, so androgen production by the stroma is spared.
resulting in permanent amenorrhea. It is a retrospective The effects of menopause are related to estrogen deficiency.
diagnosis.
Hormonal Changes
Introduction Estrogen
Every woman faces menopause and many dread its approach Estradiol levels drastically decrease at menopause. There is 66%
fearing the onset of uncomfortable physical side effects and loss reduction in estrogen. It may remain low at 10–20 pg/ml level
of their youth. As longevity increases, we see more and more in blood.
cases needing treatment. Estrones account for most of the circulating estrogen in
menopause. The level is 30–40 pg/ml.
Menopause
Estrogen present is mainly from the peripheral
Menopause has come from the Greek word menos meaning aromatization of circulating androstenedione. It occurs in liver,
menstruation and pause meaning stop of the menstruation, i.e., kidney, hypothalamus and fat. After menopause, 85%
cessation of period. androstenedione comes from the adrenal gland.
The term menopause and climacteric are commonly used
interchangeably although strictly speaking, menopause occurs Androgen
when spontaneous menstruation ceases for 6 months to 1 year Postmenopausal ovary produces more testosterone than the
at approximate age of 45 years or above. premenopausal ovary.
This relative increase in testosterone to estrogen ratio
Climacteric explains the slight virilization in some older women. Some
Climacteric is a transitional phase of weaning off of ovarian hirsutism may be seen. Androgen may enhance early plaque
activity before menopause and may continue for 2–5 years. formation causing increased risk of cardiovascular disease after
5 years’ postmenopause.
Demography
Gonadotropins
About 60 million women in India are above the age of 55 years.
Due to increase in life expectancy, women spend one third of Gonadotropins increase as a result of the absence of negative
their life in the postmenopausal age. Age of menopause ranges feedback of ovarian steroids and are hence elevated in
from 45–50 years. Average age is 47 years. Maximum age is up menopause both in blood and urine.
to 55 years. Below 40 years, it is called premature menopause. FSH: Increases markedly, reflecting fall in estrogen.
The premature menopause can be iatrogenic, in cases of LH: Rises moderately.
hysterectomy with oophorectomy (surgery) or radiotherapy,
chemotherapy and pathological (early ovarian failure, etc.). Metabolic Changes
It is found that, there is no relationship between the age of Estrogen influences carbohydrate metabolism in liver. There
menarche, socioeconomic status and age of menopause. is increased insulin resistance.
Smoking results in earlier age of menopause. Family history of Estrogen also affects lipid metabolism, bile production,
late menopause also plays a role. The menopause is a time for protein production. With the decrease of estrogen, there is an
new development and greater freedom and women should look increase in cholesterol and low density lipoprotein and a
forward to it with confidence. decrease in high density lipoprotein (HDL).
It results in more atherogenic lipid profile and increased
Physiology glucose and insulin level. These changes make the
The cause of menopause is burning out of the ovaries (ovarian postmenopausal women more vulnerable to cardiovascular
follicles). Throughout life, about 450 primordial follicles grow disease and metabolic syndrome.
and ovulate and thousands of ova degenerate. The depletion of
Anatomical Changes
the ovarian follicles is secondary to apoptosis or programmed
cell death. It leads to no or very little response of ovary to Obesity and loss of skeletal muscle occurs due to increase in
pituitary hormones FSH and LH, which results in cessation of leptin level.
 enital organs undergo atrophy and retrogression. Genitourinary Symptoms
Ovaries shrink, their surfaces become grooved, furrowed, An atrophic vagina causes dryness, pruritus vulvae, bleeding,
size decreases to 2 × 1.5 × 1 cm, tunica albuginea thickens. Any dyspareunia, loss of libido and hypoactive sexual desire
ovary palpable on per vaginal examination in this period of disorder (HSDD)
time is considered abnormal and must be taken seriously. Urge incontinence, stress incontinence, dysuria and
Fallopian tube’s atrophy occurs and cilia disappear. Uterus frequency of micturition and recurrent urinary tract infections
reduces in size. may be seen.
Endometrium is thinned out, cervix becomes smaller, Connective tissue and collagen loss may cause thinning of
fornices become shallow or disappear. skin and genitourinary prolapse Disturbing hair loss or thinning
Vagina becomes narrowed, pale, thin and dry. Vulva can occur. Increase in allergies may be seen. Changes in fingernails
atrophies, dyspareunia occurs. Labia majora and minora (softer, crack or break easily) are seen. The odor of the body
become pale, dry and shrink. Pubic hair become less and become changes. Breast tenderness may be there. The muscles and joints
Endocrinology in Gynecology

gray. Development of urethral caruncle can be seen. Pelvic may become tender to touch. Gums may also become tender.
cellular tissue and ligaments become lax and loose. Hence, more
tendency for prolapse uterus is seen. Increased fat deposition Somatic and Non-specific Symptoms
around breasts, hips and abdomen is there. Skin wrinkles and Excessive fatigue, headache, apprehension, mood swings and
becomes rough and fragile and can become hypo- or irritability. Anxiety, nervousness, depres-sion, forgetfulness,
hyperpigmented. Nails become brittle. Hence, a woman gets insomnia, poor concentration, loss of self-esteem and sudden
an overall altered body image. Estrogen has a positive effect on bouts of bleeding and pseudocyesis (false pregnancy) can occur.
collagen and loss of collagen leads to skin wrinkles and prolapse Female sexual disfunction (FSD) may be seen. It is supposed to
of the uterus. be due to androgen lack. A combination of estrogen testosterone
Estrogen inhibits osteoclastic activity, i.e. decreasing the rate helps significantly.
of bone resorption. Its deficiency thus leads to more osteoclastic
activity. It is 3% of bone mass loss every year for 5 years and Late Sequelae
later on 1–2% per year. Osteoporosis is the most common chronic, They are an important cause of morbidity in old age in females.
but silent illness in women in postmenopausal status. Postmenopausal woman may present with arthritis,
Effect of Brain: There is a fall in 2-hydroxylated estradiol, fractures, strokes, osteoporosis, cardiovascular accidents,
which has neuroprotective action against ischemic brain injury. Alzheimer’s disease, colonic cancer, and reproductive organ
Section 3

Depression occurs in women due to increased level of FSH cancer and tooth decay.
and cortisol and serotonin deficiency.
Diagnosis of Menopause
Symptomatology of Menopause Clinical diagnosis is made from the following:
One third of women approaching menopause have no History of the patients—amenorrhea of 6 months to 1 year
symptoms. One third have mild symptoms requiring only Complaints of vasomotor instability
dietary adjustment and one third may have moderate to severe Genitourinary symptoms
symptoms requiring clinical attention. The following are the Somatic/non-specific symptoms
main symptoms: Hirsutism.
Menstrual Symptoms Investigations
In the perimenopausal period, cessation of menstruation occurs To confirm the diagnosis of menopause, the following
by three ways: investigations are very important:
• Abrupt cessation of menses is rare. 1. Serum FSH level >30 IU/L
• Most women note a gradual tapering in amount of flow, 2. Serum estradiol levels will be decreased to < 20 pgm/ml.
e.g. the bleeding used to be for five days. It gradually Estradiol levels may be used to monitor estrogen therapy.
reduces to three days or two days. Investigations which are mandatory for routine care of a
• There can be an increase in the interval between two cycles. menopausal woman are as follows:
The period was regular, i.e. used to come every month. Now, 1. Hb%, fasting and postprandial blood sugar, liver function
it is coming after 2 or 3 months. tests, kidney functions test, ECG, lipid profile, pelvis USG,
Fertility is reduced; however, patients still need to be especially for endometrial thickness and ovarian size.
counseled regarding contraception. 2. Cervical Pap smear should be done.
Vasomotor symptoms (hot flushes and night sweats) 3. Endometrial biopsy is mandatory in patients having
It is the most common and troublesome symptom of postmenopausal bleeding to rule out hyperplasia or
menopause. But the intensity differs from patient to patient. endometrial carcinoma. It is also indicated when
The classic symptoms are hot flushes which occur in 70– endometrial thickness (ET) is >5 mm on ultrasound.
85% of women, 80% of them experience for one year, some up 4. Bilateral mammography: It plays an important role in
to five years. The symptoms are described as a sensation of forming the baseline and follow-up imaging modality for
intense warmth in the upper body that spreads to the face and assessment of breast disease in menopausal women
neck, may be preceded by palpitation, perspiration and lasts especially who are on HRT.
for a few seconds. It starts 1–2 years before menopause 5. Bone mineral densitometry (BMD) is advocated by the
(perimenopausal period). ACOG committee as follows:
The cause of hot flushes is not known. Probably, it occurs • BMD testing is recommended to all post-menopausal
due to the hypothalamic alterations brought about by declining women aged up to 65 years or older.
estrogen levels. These hot flushes are common at night. Then, • BMD testing is recommended to postmeno-pausal
they may cause sleep disturbances also. women younger than 65 years who have one or more
risk factors for osteoporosis.
148
 • BMD testing should be performed in all • If symptoms return after stopping HRT, women may wish
postmenopausal women who presented with fracture to consider restarting it and, provided they are fully
to confirm the diagnosis of osteoporosis and to informed of the risks. It should not be withheld. ‘Short-
determine the disease severity. duration’ HRT is considered for up to five years for relief of
• Dual energy X-ray absorptiometry (DEXA) is the gold symptoms in women in their early 50s. If symptoms persist
standard for diagnosing osteoporosis. longer, HRT should be phased out slowly.
6. Other methods are quantitative computerized tomography • HRT can be used in premature menopause (younger than
and ultrasound. The management of physiological 40 years), unless contraindicated until the age of normal
menopause is different from the management of premature menopause, when the therapy should be reviewed.
menopause. Certain guidelines have been issued by RCOG • HRT can be used as ‘add-back’ therapy when GnRH
in 2005 for the hormone therapy for menopausal women. agonists are administered to avoid menopausal symptoms.
• Local estrogen replacement may be required for the long

Chapter 22
Management of Postmenopausal Women term to reverse the symptoms of urogenital atrophy and
Management of menopause should be such that a woman can appears to be more effective than systemic therapy.
say that “For me no pause.” The management besides gyne- • Low-dose vaginal estrogens can also be used in the women
cology involves many departments including psychiatry, medi- with recurrent urinary tract infection once underlying
cine, orthopedic, rehabilitation, etc. pathology has been excluded.
Establishment of a menopausal care clinic is recommended • There is no evidence that local vaginal estrogen treatment
in all tertiary care hospitals and district hospitals. The objectives is associated with significant risks.

Menopause
of this clinic are: • Irritative urinary symptoms such as urgency, urge
1. Maintenance of health of postmenopausal women incontinence, frequency and nocturia may be improved by
2. Detection of any malignancy like cervical, breast, etc. estrogens. Stress incontinence cannot be treated effectively
3. Prevention of cardiovascular disease by estrogens alone; they are a beneficial adjunct to surgery.
4. Prevention of osteoporosis. • Women who undergo surgical menopause (bilateral
During the initial visit, a detailed history with general oophorectomy) may benefit from testosterone replacement
physical examination is done and baseline investigations, as in addition to estrogen specifically to improve libido. The
mentioned above, are carried out to assess the woman’s health. place of testosterone in the treatment of ovary-intact women
with low libido requires further evaluation. Testosterone
Life-style modification replacement may be associated with adverse clinical and
Menopausal women spend one third of their life after metabolic side effects and long-term consequences are
menopause amounting to almost 30 years. unknown.
Due to changes in the menopausal age, there is drastic As the major consequences of menopause are due to
change in life-style. Hence, management of menopause should estrogen deficiency, estrogen therapy is the treatment of choice.
start before the menopause occurs. In women with intact uterus, combined estrogen/progestin is
• Ideally menopause should be taken as an oppor-tunity to preferred as unopposed estrogen therapy may cause
take up new interests and activities. endometrial hyperplasia. In women without a uterus, estrogen
• The approach of a gynecologist towards a menopausal therapy (ET) can be given.
patient should be holistic.
• Primary intervention should always include and commence Premature menopause These women have a higher incidence of
with lifestyle modification by a multi-disciplinary approach. osteoporosis, coronary heart disease, stroke, and depression.
Avoid trigger factors for vasometer unstability viz cafferine, HRT is given till the age of 50 years.
alcohol, hot and spicy foods and drinks, smoking and stress. Posthysterectomy and Oophorectomy When the ovaries are
• Counseling of postmenopausal patient is most important, removed, ovarian androgens are also absent and so it may lead
health education, awareness about symptoms and their to female androgen deficiency syndrome. It manifests as loss
interpretation must be explained to the women. Assurance of libido, energy, self-confidence and feeling of depression along
of a good start of life and allaying various fears is important. with headache. Such patients are best treated by estradiol and
A positive attitude for life is inculcated. Relaxation, massage, testosterone implants or patches.
acupressure, and reiki helps.
Active participation of the patient in making changes in Different routes of administration
her life-style like weight bearing exercises, daily walk for 30 • Oral estrogen—subjected to first pass effect of liver, alters
minutes, and a suitable natural diet with intake of fresh clotting factors, improves lipid profile.
vegetables and fruits is to be encouraged. New creative hobbies • Transdermal—no first pass effect of liver, risk of
are important in dealing with ‘Empty Nest Syndrome.’ Smoking thromboembolism is eliminated, reduces triglycerides. It
and alcohol intake is discouraged. contains low dose 17 -estradiol gel. The dose is 3 to 4 mg.
Aroma therapy with essential oils of clary. Sage, lemon, The patch releases 50 micrograms/day. It does not seem to
jasmine, etc. help in overcoming emotional ups and downs and increase the risk of stroke (Christal an Coworkers 2010).
case of hot, flushes—Yoga and Meditation also helps. Bladder Transdermal route is better than oral route for the following
training is a simple and effective treatment. reasons:
1. It allows estrogen to be absorbed directly through the skin
Hormonal Therapy into the bloodstream without first passing through the liver.
RCOG Guidelines (2005) 2. It provides consistent level of estrogen essential for the
• HRT is effective for symptomatic relief of menopausal management of vasomotor symptoms, which result from
symptoms and its use is justified when symptoms adversely fluctuating levels of estrogen.
affect quality of life. 3. Oral estrogen leads to accumulation of supraphysiological
• Lowest effective dose for a particular woman for the dose of estrogen in the liver sinusoids after absorption from
shortest period necessary is recommended and treatment the GIT. It causes increased synthesis of hepatic proteins 149
must be reappraised at least annually. involved in hemostasis.
 • Estrogen gel—or local application. Other Drugs
• Vaginal cream 1–2 gm. Daily/10 days/1 month/3 months. ibolone Tibolone has tissue-specific action, synthetic deriva-
• Implants 25–50 mg. Effective for 6 months but minor tive of 19-nortestosterone weak estrogenic and androgenic.
operation is required every 6 months. It is a suitable means
after hysterectomy. Available in tablets of 2.5 mg orally daily.
• It is uterine friendly (prevents endometrial proliferation).
ontraindications of There is no need to add progestogen therapy. No need to
1. Undiagnosed abnormal genital bleeding do standard endometrial surveillance.
2. Known, suspected, or history of breast cancer • Decreases vasomotor symptoms
3. Known or suspected estrogen-dependent neoplasia • Mood elevator
4. Active deep vein thrombosis, pulmonary embolism or • Cardiac friendly—decreases triglycerides and 1+ DL
history of these conditions No effect on LDL and lipoproteins, -AT3 plasminogens and
Endocrinology in Gynecology

5. Active or recent arterial thromboembolic disease platelet count.

6. Liver dysfunction or disease • Bone friendly—decreases bone resorption
7. Known or suspected pregnancy • Breast friendly (no stimulation). It reduces tissue level of
8. Recent mitral insufficiency (MI). estrogen in breast tissue by inhibiting sulfatase activity. It
reduces breast tenderness, decreases mammographic density.
elative ontraindications of
• It is a safe hormonal treatment for postmenopausal women
• Migraine, headache, thrombophlebitis
with residual endometriosis.
• Acute endometriosis, gallbladder diseases
• In postmenopausal women with uterine myoma it avoids
• Poorly controlled hypertension
volume increase of the uterus and myoma.
• Acute intermittent porphyria.
Side effects of Tibolone
Benefits of • Weight gain
• Relief of vasomotor symptoms and improving quality of • Greasy skin
life • Edema, increased hair growth
• Improvement in sexual function • Gastrointestinal upset
• Risk of osteoporosis decreases • Vaginal bleeding
• Cardioprotective effect is still controversial • Abdominal pain.
• Skin texture improves
Section 3

• HRT does not pose additional risk of breast cancer when Selective estrogen receptor modulator (SE ) A compound with
both estrogen agonist and antagonist activity may be termed
used for less than 10 years
“selective estrogen receptor modulator” or SE . It is also
• There is no effective alternative to HRT
called “Tissue-specific estrogen” (Table 22.1).
• HRT has come to be used on a population basis. This means
Raloxifene hydrochloride: It is a benzothiophene
that HRT should be used in all women without contra-
compound. It has antagonistic activity on some tissue and
indications, and not simply as treatment for high-risk groups.
agonist activity in others.
asomotor Symptoms • It is bone friendly
Low-dose estradiol preparations either by an oral route, by gel • It decreases the risk of fracture of vertebrae and hip bone
or by patch for 3 months or longer can be given for the duration by 50%
of symptoms. The initial dose is low and can be increased if • It is cardioprotective in the long term; it decreases LDL and
symptoms persist. To counteract endometrial hyperplasia, increases HDL
progestogens are added for the first 7 days of each calendar • It has low risk of carcinoma of endometrium
month. (Nonethisterone 5 mg or MPA 5 mg). It is better than • It is breast friendly; decreases the risk of carcinoma by 62%.
giving continuous progestogens; there is a risk of PMS type Side effects of Raloxifene
symptoms, breast cancer, etc. Other options for vasomotor • Venous thrombosis
symptoms are isoflavones (act by estrogen pathway) and black • Hot flushes
cohosh (act by nonestrogenic, serotonergic pathway). Deep • Retinopathy.
breathing exercise at that time is helpful. Escitalopram, a selective Contraindications
serotonin reuptake inhibitor reduces frequency and severity of • Venous thrombosis, hepatic dysfunction, vasomotor
hot flushes in menopausal women (Freeman and Coworker 2011). symptoms
• Dose: 60 mg daily with calcium.
Pelvic Atrophy
Low-dose estradiol should be prescribed with appropriate
progestogen for as long as it takes to eradicate symptoms. Local
vaginal estradiol or estriol gels or pessaries can be used. Proge-
stogen is not needed in local therapy. For bladder symptoms, a
higher dose may be needed for a longer duration regardless of
the route of administration, oral, transdermal or local.
Perimenopausal depression It may be associated with a history of
postpartum depression, premenstrual dysphoric disorders. The
treatment is by high-dose transdermal estrogen (100–200µg)
along with oral progestogen for the first 7 days of each month.
Alternative Medicines
• Black cohosh
• Vitamin E.
150
 Table 22.1: Clinical profile of estrogen, Common sites of fracture are vertebrae, distal radius and
raloxifene and ideal SERM femoral neck.
Risk factors for osteoporosis:
Estrogen aloxifene Phyto Ideal
1. The increase in osteoporosis is partly due to an increase in
estrogen SE
the elderly population, but all of it is not due to this fact
Bone + + ± + alone.
Breast + – – – 2. Other contributory factors include dietary factors, decrease
Uterus + – – – in diary products like milk, etc.
CHD risk + + – – 3. An earlier and greater loss of bone because of the impact of
VTE risk + + ± – smoking.
Menopausal + – + + 4. Age, race, small body frame, early menopause, multiparity,
symptoms prolonged periods of lactation with inadequate calcium,

Chapter 22
Urogenital + – + + family history of osteoporosis.
atrophy 5. Lifestyle—smoking, excessive alcohol use, sedentary
Cognitive + ? + + lifestyle.
function 6. Associated medical conditions—hyperthyroidism,
hyperparathyroidism, chronic renal disease
Specific indications 7. Drugs—systemic corticosteroids, heparin and anti-
• Women having risk of breast carcinoma convulsants.

Menopause
• Risk of osteoporosis The skeleton consists of two types of bones:
• Women who cannot tolerate HRT. Cortical bone constitutes 80% of the total bone, while 20%
Ormeloxifene, another SERM is taken as 60 mg twice a week is cancellous (spongy or trabecular) bone. The trabecular bone
for first 12 weeks and then once a week. structure consists of active osteoblasts, inactive osteoblasts and
Phytoestrogens osteoclasts. Cortical bone is in the shaft of long bones and outer
1. Isoflavones: layer of virtually all bones. Cancellous bone is in the bones of
a. Genistein (soy, lentils, garbanzo, i.e. Bengal gram, axial skeleton and in the ends of long bone. Skeletal mass
legumes, beans) gradually increases during growth and is at its maximum
b. Daidzein. between 18 and 35 years of age. It is known as peak adult bone
2. Lignans (cereals, flax seed, fruits) mass which is 25–30% higher in males. Bone remodeling occurs
3. Coumestans (red clover bean, sprout sunflower seed). throughout life. It consists of regeneration, degradation and
They are strongly estrogenic, nonsteroidal plant product. repair, allowing damaged bone to be replaced by new bone.
They are also called natural SERMS. They are given in doses of Bone consists of a large collagenous matrix which is
40–60 mg daily, and are beneficial to prevent CVA impregnated with mineral salts and populated by cells. The
(cerebrovascular accident), osteoporosis and menopausal matrix is composed of type I collagen lying in a
symptoms. They may have positive effect on cognitive mucopolysaccharide ground substance. There are also small
performance an mood (Casini and Coworkers, 2006). amount of non-collagenous protein mainly in the form of
However, well-designed studies are awaited to clarify their proteoglycans and the bone-specific proteins osteocalcin and
different roles. Sources of phytoestrogen are soyabean, lentils, GLA protein, whose function is unknown. GLA protein is
kidney beans. Other sources are wheat, barely, rice, oat, cherry, produced only by osteoblasts and its concentration in the blood
pears, apple, carrot, garlic and onion. Isoflavone supple- is to some extent a measure of osteoblastic activity. The
mentation relieve menopausal symptoms only in women with unmineralized matrix is known as osteoid (Fig. 22.1).
the ability to produce equol. Bone minerals which occupy almost half the bone volume,
Phytoestrogen such as genistein and daidzein, soya possess consist mainly of calcium and phosphorus in the form of
mixed estrogen agonist and antagonist properties. Though crystalline hydroxyapatite. It is laid down in osteoid at the
conclusion requires further large randomized trials. calcification front. In mature bone, the proportion of calcium
It has been seen by El-Sedeek and colleagues (2010) that and phosphorus is constant and the molecule is firmly bound
plasma orexin-A levels in plasma, if higher, it increases basal to collagen.
sympathetic activity, releases catecholamine releases Bone cells are of four kinds:
modulation of vasopressin system and stimulating renal and • Osteoblasts
adrenal orexin receptors. It causes hypertension and also affects • Ostocytes
plasma lipoprotein profile and insulin glucose homeostasis. It • Osteoclasts
is easily reversed by HRT. • Lining cells.
Osteoblasts At the end of a bone remodeling cycle, the osteoblasts
Osteoporosis either remain on the newly formed surface as a quiscent lining
Osteoporosis can be as a systemic skeletal disease characterized cell or become enveloped in the matrix to a resting osteocyte.
by low bone mass and microarchitectural deterioration of bone Hence, osteocytes are regarded as spent osteoblasts.
tissue, with a consequent increase in bone fragility and Osteoclasts communicate with each other and with the
susceptibility to fracture. This is a major global public health surface lining cells by slender cytoplasmic processes. Their
problem. More than 20 million individuals are suffering from function is obscure; but under the influence of parathyroid
osteoporosis in the USA. hormone (PTH), they may participate in bone resorption
One in three women will sustain a vertebral fracture after (osteocytic osteoclysis) and calcium transport.
age 65 years. One of three women will sustain hip fracture It has also been suggested that they are sensitive to
(associated with 5–30% mortality rate). Trabecular bones are mechanical stimuli and communicate information and changes
affected earlier than cortical bones. in stress to osteoblasts.
151
 After closure of epiphyses and cessation of longitudinal sometimes lower in protein content compared to non-vegetarian
growth, there is a period of consolidation with a decrease in diets. Lastly, the most common and least understood form of
cortical porosity. Peak adult bone mass is reached at about the metabolic bone disease in patients with gastrointestinal disease
age of 30–35 years for cortical bone and earlier for trabecular is low turnover osteoporosis which presents usually with
bone. Rate of bone formation and resorption are relatively low compression fractures of vertebral bodies.
and approximately equal. This normal balance between bone Protein and micronutrient deficiencies are thought to
formation and bone resorption maintains skeletal mass. contribute to this disease. Therefore, it is conceivable that
However, the rate of remodeling differs not only between nutritional deficiencies may result in a similar disease in the
cortical and trabecular bone but also in individual bones or absence of GI pathology. Clinical and subclinical protein
portions of bones (Fig. 22.1). malnutrition continue to be a major public health problem in
India, hence its role in osteoporosis. The degree of bone loss
esorption precedes formation and is probably more intense, but
has been correlated with dietary folate, cobalamin, boron,
Endocrinology in Gynecology

it does not last as long as formation. As a consequence, there

Vitamin K in longitudinal and cross-sectional studies. A
are more sites of active formation than of resorption. Bone
significant correlation has also been observed between the
turnover is high when many units are active and low when a
degree of bone loss and dietary zinc.
few are active. The bone remodeling process keeps the s eleton
young by a process of new bone replacing old bone. Unless the Calcium and osteoporosis: Of all the non-genetic factors, the
formation compensates for resorption, the bone mass decreases. role of nutritional factors has been controversial and a matter of
Trabecular bone resorption and formation occur 4–8 times as debate internationally. But there appears to be a consensus that:
fast as cortical bone. 1. Menopausal women are generally calcium deficient.
Beyond the age of 40 years, resorption begins to exceed 2. Osteoporotic women give a history of lower calcium intake
formation by 0.3–0.5% per year in both sexes. In women around than do non-osteoporotic controls.
menopause, accelerated loss of cortical bone is superimposed 3. The administration of calcium to calcium deficient females
on the age-related loss. Loss of trabecular bone begins at an can decrease the rate of bone loss and propensity of
earlier age in both sexes but is probably greater in women. Up fractures.
to 5% of trabecular bone loss per year and 1–1.5% of cortical Studies that involve women beyond early stages of the
bone mass loss occurs after menopause. postmenopausal period definitely indicate a positive impact of
Bone loss that occurs in the 1st 15 years after menopause is calcium supplementation.
attributable to estrogen deficiency rather than aging. After that, Calcium absorption decreases with age and becomes
Section 3

it continues as age-related loss and menopause-related bone significantly impaired after menopause. A positive calcium
loss results in 40–50% reduction in trabecular bones (spine, distal balance is mandatory to achieve adequate prevention against
radius) and 30% reduction in cortical bone. osteoporosis. Calcium balance is also a function of calcium
The risk of fracture from osteoporosis depends upon bone excretion. Even though Indian diet is low in calcium content, it
mass at skeletal maturity and bone mass at menopause and also has a lower protein content and, therefore, there occurs
rate of bone loss with age. low endogenous acid production which may reduce urinary
alterations in calcium homeostasis (and probably in bone mass).
Pathogenesis of osteoporosis The mechanism responsible for This is due to alteration in endogenous acid production and
enhanced bone loss with menopause has not been completely net acid excretion due to the oxidation of the amino acids.
defined. The following hypotheses are important for High salt in the Indian diet is likely to increase urinary
consideration. calcium excretion. Caffeine intake increases urinary and calcium
There is evidence from both human and animal studies that secretion and excessive consumption of caffeine-containing
protein malnutrition may be a risk factor for osteoporosis. drinks like tea may predispose to osteoporosis.
Firstly, osteoporosis is a feature of kwashiorkor. Secondly,
osteoblastic activity and bone formation are markedly Vitamin D and Osteoporosis
depressed in Rhesus monkeys given a special diet containing Vitamin D is synthesized in the skin in response to sunlight as
negligible amounts of proteins for 6–8 weeks. Thirdly, vitamin D 3 (cholecalciferol) or obtained through the diet as
vegetarian diets may predispose to low bone mass as they are vitamin D2 (ergocalciferol).

152 Fig. 22.1: Showing normal and osteoporosis changes in bone matrix
 Daily requirement is 400–800 IU/day and regular exposure As we all know, development of osteoporosis depends upon
to sunlight for 15–30 min/day produces similar amount. the peak bone mass achieved between 30 and 35 years of life.
Factors responsible for peak bone mass are discussed below,
Action of Vitamin D besides the ones already discussed earlier.
1, 25 (OH)2 vitamin D3 has three different primary target organs:
enetic factors influence bone mass. In identical twins, as much
1. Increased calcium absorption from gut increases stimulation
as 80% of age-specific variation in bone mass can be accounted
of osteoblastic activity.
for on a genetic basis. Presence of a specific polymorphism in
2. Decreases parathyroid hormone concentration.
vitamin D receptors (VDR) correlates with bone mineral density
3. Increases bone density at femoral neck and vertebra
with a particular population. Specifically, homozygous ‘bb’
reducing fracture risk by 50%.
genotype is associated with higher lumbar and femoral bone
Hormones and Osteoporosis mineral density than in Bb and BB genotype. Other gene loci

Chapter 22
also probably influence bone and strength.
In 1882, it was recognized that fracture of forearm and hip was
more common in women than in men over the age of 50 years. ace: Bone mass and risk of osteoporosis varies with race.
In 1941, Albright first postulated that a reduction in gonadal American Whites and Orientals have lower peak bone mass
function leads to osteoporosis and demonstrated that treatment than Blacks. Hence, they lose bone at a faster rate than American
with stilbestrol could reverse the negative calcium balance in a Blacks leading to osteoporosis. The lower incidence of
postmenopausal osteoporotic woman. He also suggested that osteoporosis and hip fracture in Black men and women has
postmenopausal osteoporosis may be a disease of protein been attributed to a higher bone mineral content in Blacks than in

Menopause
metabolism. It is demonstrated that increase in osteoclastic Whites despite the fact that bone formation is lower in Blacks.
activity is responsible for osteoporosis. The precise mechanism Osteoporotic fractures occur 10–20 years earlier in Indian men and
whereby diminished ovarian function leads to a decrease in women probably due to decreased bone mass at an earlier age.
osteoblast activity remains unclear. However, a growing body ereditary factors: Family history of osteoporosis is a
of knowledge indicates complex interaction at molecular level. predisposing factor.
1. Increase absorption of calcium probably secondary to
estrogen-induced enhancement of the availability of 1,25- Other factors: Females have more osteoporosis than males. Other
(OH)2D. risk factors which are non-genetic are that underweight women
2. Decreased renal excretion of calcium probably due to or women with a small build may be at a greater risk because
improved renal function. of reduced peripheral conversion of adrenal androgens to
3. Direct role of estrogen receptors in osteoblasts is an estrogen in lipid tissue.
important factor. Undernourishment also leads to osteoporosis as low calcium
4. Many estrogen-dependent growth factors and cytokines are diet takers will have low peak bone mass. High protein diet
involved and estrogen modulates the production of increases calcium excretion by the kidney as it is rich in acids
remodeling. Bone resorption cytokines IL-1, IL-6 and locally which may contribute to dissolution of bone as the body
produced cytokines appear to mediate the enhanced attempts to buffer the extra acid.
osteoclast-mediated bone resorption seen in estrogen Sedentary lifestyle increases bone loss. Exercise may have
deficiency. Peripheral blood monocytes from a patient with beneficial effect in maintaining bone mass. Excessive alcohol
osteoporosis secrete more IL-1. and caffeine consumption and smoking are known to decrease
Interleukin-1 and other cytokines such as TNF stimulate bone loss.
production of interleukin-6 by osteoblasts and IL-6 is probably Nulliparity is a high risk factor. It is possible that during
the most important cytokine in the recruitment of osteoclasts. pregnancy, some age-related bone loss is arrested so that those
In postmenopausal osteoporosis, these are all suppressed by women who had repeated pregnancy will have greater bone
estrogen treatment. mass at the time of menopause.
Estrogen also modulates the production of bone stimulating Prolonged use of corticosteroids and heparin and excessive
factors such as insulin-like growth factor- . thyroid replacement therapy predispose to osteoporosis.
Estrogen promotes synthesis of calcitonin (which inhibits Patients who are kept at complete bedrest and astronauts
bone resorption). It is a peptide hormone released by at microgravity can lose approximately 1% of their bone mass
perifollicular cell of the thyroid glands. each month because immobilization increases bone resorption,
Estrogen increases vitamin D receptors in osteoblasts and while bone formation remains normal or is decreased. A
this may be a method by which estrogen modulates 1,25-(OH)2 sedentary life may reduce mechanical forces exerted on the
D3 activity in bone. skeleton and increase the tendency for bone loss.
While progestational agents are considered antiestrogenic, Diagnosis
they are known to act independently in a manner similar to
Osteoporosis may be diagnosed by a proper history. It is usually
estrogens. However, this effect may be limited to cortical bone.
a silent condition and may not be severe enough to bring the
When added to estrogen, progestins actually lead to a
patient to the doctor for diagnosis and treatment until the
synergistic increase in new bone balance of calcium. The daily
complications occur like bone pains, kyphosis, loss of height
continuous combination in estrogen and progesterone is equally
and fractures due to minor trauma.
potent in maintaining bone density as the standard sequential
regime. adiology Because of the high accuracy of these techniques to
The organic matrix of the bone acts like girders and confers measure bone mineral mass, they can be utilized not only as a
on bones its tensile strength and it has been suggested that a prognostic tool to predict fractures but also as a test for the
decline of this organic matrix is the primary pathological event presence of early osteoporosis. Methods of diagnosis by
leading to osteoporosis. Estrogen has a complex effect and most radiology are:
probably prevents osteoporosis by increasing connective tissue • Single photon absorptiometry in which protons from a
component of the bone. single energy source are used. 153
 • Dual proton absorptiometry in which photons from an low body weight, alcohol tobacco intake, a parent with
energy source are used. osteoporosis fracture.
• Dual energy X-ray absorptiometry (DE A) provides good Evaluation of BMD by DEXA is recommended for all
precision for all sites of osteoporotic fractures. DEXA technique women above years and for younger postmenopausal
measures three sites: the radius, the hip and the spine. This women with 1 or more risk factors.
is the gold standard for measuring bone mineral density. We also use some biochemical markers in serum which
• Quantitative CT is also used, but radiation exposure is indicate bone formation like alkaline phosphatase, osteocalcin,
higher than with DEXA and measurement of femur is not procollagen I, bone-specific alkaline phosphatase and some
available. others which show resorption (as detected in urine), e.g.
• Bone densitometry by ultrasound is also coming up, but it hydroxyproline, pyridoxyline, deoxy-pyridinoline, cross-linked
has a lower accuracy. N-telopeptide of type I collagen. Once the diagnosis of
Serial measurements are done by DEXA (at an interval of 2 osteoporosis is established, an attempt should be made to rule
Endocrinology in Gynecology

years) to measure progress of the disease and response to HRT out causes other than menopause.
and other treatment by a high degree of precision, and resonably
low radiation dose. PREVENTION AND TREATMENT OF OSTEOPOROSIS
Bone mineral density (B D) is essential for the diagnosis. WHO Prevention
T-score is measured at three sites, lumbosacral, hip and wrist • Patient education is indicated in all ages.
joint. T-score is the number of standard deviations from the • Emphasis should be on prophylaxis rather than treatment.
mean for a young healthy woman. – Prevention starts from childhood.
FR AX tool is developed by WHO and National – Good bone mass should be ensured right from the age
Osteoporosis foundation is useful to know fracture risk. of puberty.
Normal—T score witin 1 SD (+1 or –1) (Figs 22.2 and 22.3) – Dietary intake of milk with vitamin D supple-mentation
Osteopenia—T score between 1 and 2.5 SD (–1 or 2.5 SD) (200 ml of milk gives 420 gm calcium). Avoid aerated
(Fig. 22.4) drinks. Cessation of smoking and decreasing alcohol
It signifies an increased fracture risk but does not meet the intake should be promoted long before the menopause.
criteria for osteoporosis. – Physical activity and weight-bearing exercises should
Osteoporosis— T score below—2.5. So it has higher fracture be encouraged.
risk than osteopenia (Fig. 22.5). – Avoidance of certain drugs, e.g. long courses of
Section 3

US preventive services task force (USPSTF) recommen- corticosteroids, etc. will help.
dations for osteoporosis screening advise the screening for – Prevention of fall in old age is very important to reduce
women 65 years or older and also in women with a risk of morbidity and mortality. Change slippery floors at home
osteoporosis similar to that of a 65 years old or women to be install adequate lightening. Side supports in bathrooms
screened with one or more risk factors including advance age, will help prevent falls.

154 Fig. 22.2: Normal DEXA of femur

 Chapter 22
Menopause
Fig. 22.3: Showing normal DEXA of left femur

Fig. 22.4: Dexa showing osteopenic changes in the spine

Treatment
Indications for pharmacological therapy of osteoporosis activity. Deficiency can occur in some elderly patients owing to
• Women with fragility fracture or ‘T’ score 2.5 or below inadequate sun exposure, poor calcium intake, and decreased
• Borderline BMD with risk factors intestinal absorption of calcium.
• For established osteoporosis, calcitonin and alendronate are Adults need 400 IU per day, whereas elderly patients need
approved and recommended 800 IU per day. A once yearly intramuscular injection of 600,000
• Fractures must be managed by orthopedic surgeons. IU is easiest and cost effective way to maintain sufficient vit. D
level. It prevents secondary hyper-parathyroidism and
Drugs increased risk of fracture. Low vitamin D status also results in
itamin D is required for calcium absorption from the gut. It increased prostural sway and muscle weakness which increases
inhibits parathyroid hormone and stimulates the osteoblast the risk of falling. 155
Endocrinology in Gynecology

Fig. 22.5: Dexa showing osteoporotic changes in the spine

Calcium SE S Raloxifene 60 mg once daily acts as estrogen agonist

Section 3

• Adequate calcium intake is most important during the years on bone and lipid metabolism. Its only side-effect is venous
of skeletal growth. thromboembolism (VTE). It reduces the risk of fracture by 30%
• Postmenopausal women who are not on HRT should receive in cases with previous fracture and 50% in those without
1.5 gm calcium per day. previous fracture.
• Postmenopausal women on HRT should take 1 gm calcium alcitonin inhibits bone resorption by inhibiting osteoclast
per day. activity. It is produced by thyroid c cells. It is given as daily
• Patients having poor dietary calcium intake should take intranasal spray (200 IU/day) and it reduces fracture by 33–
several small doses of calcium to avoid overloading the 36%. Salmon-derived calcitonin is 10 times more potent.
intestinal calcium absorption.
• Calcium citrate is better absorbed but calcium carbonate is Parathyroid hormone has anabolic effect on bones.
cheaper. eriparatide is a recombinant parathyroid hormone. It increases
Other drugs for the treatment of osteoporosis given below. bone mass and improves bone microstructure by proliferation
of osteoblast progenitor cells and reducing death rate. It is given
are synthetic analogue of pyrophosphate and as SC daily dose of 20µg and it decreases vertebral fracture risk
have high affinity for calcium and get concentrated in bones by 65% and nonvertebral fracture by 53% after 18 months of
especially at the site of active remodeling. It favors apoptosis therapy. Side effects are nausea and headache. Hypercalcemia
of osteoclast and inhibits osteoclast function. It reduces fracture is transient and mild. Contraindicated in patients with moderate
risk by 50%. Etidronate and Clodronate are first generation renal impairment.
bisphosphates but are not used as they cause demineralization.
Second generation bisphosphonate are Alendronate rise Strontium ranelate is incorporated into bone and stimulates bone
dronate, Ibandronate and pamidronate. They inhibit osteoclastic formation and decreases bone resorption. 1–2g/day increases bone
function by interfering with mavelonate in the cholesterol density. Side effects include initial diarrhea and increases in VTE.
pathway and pegylation of proteins. It causes increase in BMD, Estrogen therapy (at the lowest possible dose for the shortest
decrease in vertebral and non-vertebral fracture. Risedronate 5 possible time, 2 years) and ibolone are indicated for treatment
mg/day and alendronate 70 mg/week is the dose. It must be only if the patient cannot take other drugs because of side effects.
taken in the morning fasting and with plenty of water and Fluorides It is useful in treatment. But not used commonly.
avoiding sitting and lying down for half an hour, otherwise
nausea, vomiting, esophagitis and gastric irritation may occur. alcitriol is identical to the active metabolite of vit D and
Ibandronate. 150 mg (10 times more patent than alendronate) alfacalcidiol is a chemical precursor of 1,25-(OH) 2D3. Both
has to be taken once a month with the same precautions. Next follow a slightly different metabolic pathway, after oral
generation bisphosphonates zolendronic acid are taken once a administration. This difference is important for both their
year (5 mg) by intravenous route slowly in 15 minute (1-4 mg) respective modes of action and risks of side effects. High doses
significantly reduces risk of vertebral and hip fracture risk. of vitamin K have positive effect.
Besides minor side-ffects a few incidences of jaw necrosis are Recently (Steven and Associates 2009) FCA has approved
reported. It is to be further investigated. an injectable use of more than one drugs adds to the benefits.

156
 Table 22.2: Classification of antiosteoporotic drugs alendronate: results from the PERSIST study. In. J. Clin. Pract
2006;60(18):896.
ethod of Action Drug 8. El-Sedeek M, Korish A, Dee M. Plasma orexin – A level in
Antiresorptive agents Bisphosphonates postmenopausal women: Possible interaction with estrogen and
SERMS, Denosumab correlation with cardiovascular risk Status Brit J Obstet. Gynae
Reforming agents Parathyroid hormones 2010;117(4):488.
Teripasotide 9. FOGSI FOCUS, Jan 08 – Women and osteoporosis.
Both Strontium 10. Freeman EW, Guthrie KA, Caan B, et al. Efficacy of escitalopram
Biological Therapy SERMS, bezedoxifene for hot flushes in healthy menopausal women. JAMA
2011;305(3):267.
11. Johnell O, Kanis IA. An estimate of the worldwide prevalence and
Monoclonal antibody Denosumab (Prolia) for the prevention of disability associated with osteoporosis fractures. Osteoporos Int
fractures in postmenopausal women with osteoporosis and high 2006;17:177.

Chapter 22
fracture risk, twice a year. Its most common complication is 12. Johwell O, Scheale WH, Lu Y, et al. Additive effects of raloxifene
back and musculoskeletal pain, pain in extremities, and alendronate on bone density and biochemical marker of bone
hyperlipidema and bladder infection. It suppresses bone remodeling in PM women with osteoporosis J. Clin. Endocrinol
turnover and may increase osteonecrosis of the jaw. New drugs metab. 2002;87:985.
under research are intergrins, osteoprotegerin RANK-L, growth 13. Jon HJ, Wu Se, Change FC, et al. Effect of intestinal production of
equol on menopausal symptoms in women treated with soy
hormone + recombinant insulin-like growth factor–1/insulin
isoflavones. Int J Gynaecol Obstet 2008;102(1):44.
like/growth factor binding protein 3 complex, etc. Table 22.2 14. Lacey JV Jr, Brinton LA, Leitzmann MF, et al. Menopausal hormonal
summarises the drugs used to treat osteoporosis

Menopause
therapy and ovarian cancer risk in the national institutes of health
AARP diet and health study. Cohort J Natl Caner Inst 2006;98:1397-
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4. Carol S Haven, Nancy D. Sullivan. Manual of out patient 18. Montgomery JC, Brincat M, Studd JWW. Effects of estrogen and
Gynaecology 4th edn, edited reprinted in 2003. testosterone implants on psychological disorders in climacteric
5. Casini ML, Marelli G, Papaleo E, et al. Psychological assessment of Lancet 1987;1:297.
the effects of treatment with phytoestrogens on postmenopausal 19. RCOG guidelines for HRT 2005.
women a randomized double blind cross over, placebo controlled 20. Simon J, Braunstein G, Nachtigall L, et al. Testosterone patch
study. Fertil steril 2006;85:972. increases sexual activity and desire in surgically menopausal
6. Chen WX, Manson JE, Hankinson SE, et al. Unopposed oestrogen women with hypoactive sexual desire disorder. J Clin Endoerinol
therapy and the risk of invasive breast cancer. Arch Intern Med Metabs 2005;90:5226.
2006;1027:166. 21. Steven R, Cumming R, Jevier SM, et al. Denosumab for prevention
7. Cooper A, Drake J, Brankin E. Treatment persistence with one-a of fractures in post menopausal woman with osteoporosis. N Eng
month ibandronate and patient support vs once-weekly J of Med 2009;361:756.

157
 Section 4 Disorders of Early Pregnancy

23 Bleeding in Early Pregnancy

Sudha Salhan, Indira Ganeshan, Harsha Gaikwad

Vaginal bleeding in the first trimester of pregnancy is a common 1. Chromosomal anomalies are responsible for at least half of all
complication of pregnancy and accounts for a significant early pregnancy loss, e.g. aneuploidies.
percentage of pregnancy loss and maternal morbidity and 2. Maternal and paternal factors:
mortality. • Age: Maternal age is very detrimental in human
The causes can be as follows: pregnancy. Miscarriage is more common after 40 years
of age or in teenage pregnancies. Incidence of
Obstetric Causes aneuploidy abortions increased dramatically after the
• Implantation bleeding 10–20% maternal age of 35 years. Reasons are not known but a
• Miscarriage (threatened, missed, genetic abnormality (as isolated mutation or polygenic
inevitable, etc.) 40% factor) may be present. As age advances, various
• Ectopic pregnancy 10–15% maternal factors also come into play contributing to the
• Hydatidiform mole 0.2% pregnancy loss. Increased paternal age also leading to
miscarriage due to paternal factors (aging gametes and
Nonobstetric Causes physiological systems).
• Bleeding from cervical erosion • Infections: Like TORCH group of infection in early
• Cervical polyp pregnancy may be a contributory factor.
• Carcinoma cervix. • Maternal syphilis.
• Vaginal infection with Group B streptococci, Mycoplasma
Implantation Bleeding hominis and Ureaplasma urealyticum (Quinn and
Coworkers, 1983).
The bleeding takes place about 6–8 days postovulation or
• Chlamydia trachomatis, Toxoplasma gondii, Neisseria
fertilization caused by invasion of the decidua basalis by the
gonorrohea, Streptococcus Galactiae and Listeria
chorion. It is characterized usually by spotting or slight bleeding
monocytogenes have been implicated in spontaneous
for a day or two and can be confused with intermenstrual
miscarriage, but their role is not established.
bleeding. Immunoassays, urine pregnancy test or USG can rule
• Spontaneous miscarriage is independently associated
out miscarriage.
with HIV antibodies in the mother.
Miscarriage Endocrinological Causes
Miscarriage is defined as termination of pregnancy, by any a. Thyroid autoantibodies and hyperthyroidism.
means (spontaneous or artificial) up to 20 weeks of pregnancy, b. Uncontrolled insulin-dependent diabetes especially in the
before the viability of fetus or when the fetus is less than 500 first trimester (Greene 1999) leads to marked increase in
gm of weight. abortion rate.
It is the most common complication of pregnancy. c. Progesterone deficiency: Manifest as luteal phase defect (LPD).
Spontaneous miscarriage is defined as any recognized involuntary d. Androgen excess: Elevated serum levels of testosterone and
pregnancy loss occurring before the period of viability (without dehydroepiandrosterone sulfate (DHEAS)
the use of any medical or mechanical means to empty the pregnant e. Polycystic ovary syndrome (PCOS): Elevated serum LH levels.
uterus). The word abortion usually denotes induced miscarriage.
Medical Disorders
Incidence Relative risk of miscarriage is increased in:
The actual incidence is difficult to assess. More than 80 percent a. Cardiovascular disorders
miscarriages occur before 12 weeks of gestation (Haslap and b. Hypertensive disorders
Shino, 1980). A large number of embryos fail to implant, and c. Renal diseases
pass off as a normal menstrual bleeding and thus the pregnancy d. Connective tissue disorders like systemic lupus erythematosis
goes unnoticed. Fifteen to 20 percent of clinically diagnosed e. Chronic disease like celiac sprue
pregnancies undergo miscarriages (Speiroffs and Fritz 2005). f. Inherited thrombophilias.
The causes of early miscarriage are usually an unembryonic
pregnancy or blighted ova. Drugs and Chemicals
Many drugs at higher dose and exposure early in the conception
Etiology
cause missed abortion or has a teratogenic potential (details in
The exact cause is not exactly known. But there are some factors chapter on Clinical Pharmacology in Obstetrics textbook by the same
seen associated with miscarriage: editor)
Immunological Causes is no muscle tone and its abdomen is filled with blood-stained
Antiphospholipid antibodies syndrome and other discharge. Fetal internal organs degenerate and get necrosed.
immunological conditions cause abortion (details in chapter 26 Amniotic fluid gets absorbed, the fetus is compressed upon itself
on Recurrent Abortion). and forms fetus compressus. It may get dry and compressed by
the uterine wall thus forming fetus papyraceous (mostly seen in
Anatomic Abnormalities of Uterus twins). Hemorrhage, infection and psychological depression are
a. Congenital, e.g. Mullerian duct anomalies and intrauterine seen.
exposure to diethyl stilboestrol may be the cause of Threatened Miscarriage (FIg. 23.1)
congenital anatomical defects.
Threatened miscarriage is a condition where the onset of the
b. Acquired: Asherman’s syndrome, incompetent os, embryo
process of miscarriage is started but further progression is
implanted on leiomyoma may end in miscarriage.
averted. The bleeding usually starts first; the amount of bleed

Chapter 23
Personal Habits could be variable between mild to moderate and rarely
excessive. The bleeding is usually fresh red color with or without
a. Cigarette smoking does increase miscarriage rate especially
mucus discharge in it. The bleeding could be accompanied with
euploid ones. (Risk increases linearly by a factor of 1.2 for
pain; sometimes, pain may start after a few hours of bleeding.
each 10 cigarettes smoked per day).
b. Alcohol consumption is also implicated by some as causes Management of Threatened Miscarriage
of miscarriage during the first 8 weeks of pregnancy. History taking should be proper and complete. Points to be
c. It is found that coffee consumption can also predispose to noted while taking history are:

Bleeding in Early Pregnancy

miscarriage. More than 4 cups per day increase the incidence 1. Period of amenorrhea (POA)
in early pregnancy. Maternal paraxanthine (a caffeine 2. Time of onset of bleed and duration
metabolism) high levels are associated with miscarriages. 3. Amount of bleeding (number of pads soaked)
d. Radiation does cause missed abortion, but exact dose is not 4. Any passage of product of conception (POC) or vesicles
clearly known. 5. Any associated pain
e. Contraception: IUCD failure may cause septic miscarriage 6. Was the pregnancy documented (by urine pregnancy test
in some cases. UPT or USG)
7. History of trauma
Trauma
8. Drug intake (mefiprostone, etc.)
Surgical trauma like laparotomy during early pregnancy may 9. Any history of interference (by dai or any other person)
cause miscarriage. Peritonitis also increases the incidence of 10. Any febrile illness
miscarriage. Physical traumas like direct blow over abdomen 11. Ask history of fainting attacks
or gunshot wound are stated as causes of miscarriage. 12. History of bleeding tendency.
Paternal Factors Clinical Examination
Chromosomal translocation in sperm may cause miscarriage. 1. General condition of patient, her nutritional status
Besides aging and immunological factors, some infections like 2. Pallor, temperature, pulse, BP
adenovirus or herpes simplex in the father may lead to 3. Systemic examination
miscarriage. 4. Per abdominal examination (Look for distension, mass, free
fluid or tenderness).
Environmental Toxins
Per Speculum Examination
There is an increased risk of spontaneous miscarriage for women
anesthestists. Besides role of arsenic, lead, formaldehyde, 1. Inspect the vulva, vagina and cervix for amount of bleeding
ethylene oxide and benzene is also found in the causation of 2. Any local lesion of cervix or vagina
early pregnancy loss. But exposure to electromagnetic fields 3. Is the cervix open?
(video display), short wave and ultrasound do not cause the 4. Any POC coming out through the external os
miscarriage. 5. Type (fresh or altered) and amount of bleeding.

Spontaneous miscarriage could be categorized into:

a. Isolated incidence
b. Recurrent miscarriage.
Types of spontaneous miscarriage.
1. Threatened miscarriage
2. Inevitable miscarriage
3. Incomplete miscarriage
4. Complete miscarriage
5. Missed miscarriage
6. Blighted ovum.

Pathology of Spontaneous Miscarriage

Hemorrhage into the decidua basalis is seen. Necrosis with
inflammation is witnessed at the implantation site. The products
of conception is partially detached and lie in the uterine cavity.
This stimulates uterine contractions and dilatation of the cervix,
expelling the conceptus. But if the embryo/or fetus is retained,
it may undergo maceration. Fetal skull bones collapse as there Fig. 23.1: Threatened miscarriage 159
 Pelvic Examination (Per Vaginal Examination)
• Do a gentle digital examination
• To see the state of cervix
• Size of the uterus, whether corresponding to period of
amenorrhea
• Any tenderness in the adnexa or any adnexal mass.
In threatened miscarriage, the uterus size corresponds to
the period of amenorrhea. The external os is closed; the bleeding
is variable but fresh red in color.

Investigations
1. Laboratory investigations
Disorders of Early Pregnancy

a. Urine pregnancy test (UPT)

b. Hemogram
c. Blood group—ABO and Rh typing
d. Serum progesterone level (optional)
e. Serum -hCG (only special cases).
2. Ultrasonography: In early pregnancy, transvaginal ultra-
sonography is better than transabdominal scanning. Points
Fig. 23.2: Inevitable miscarriage
to be noted in USG are:
a. Is it an intrauterine pregnancy, ectopic or molar
pregnancy? Inevitable miscarriage (Fig. 23.2): This is a condition where the
b. Look for cardiac activity process of miscarriage has progressed to a stage where it cannot
c. Is the gestational sac well formed? be averted. The patient gives history of period of amenorrhea
d. Is it single or multiple pregnancies? followed by bleeding per vaginum. The amount of bleeding is
e. Look for the position of the sac whether it is in the cavity again variable, but usually is more than threatened abortion.
or low lying The patient might give a history of leaking per vaginum due to
f. Is there any evidence of intrauterine collection of blood rupture of membranes. This is usually accompanied with severe
Section 4

or subchorionic hemorrhage? pain abdomen.

Treatment Management
a. Assure the patient, as the patient may be anxious 1. History (points same as threatened abortions)
b. Admit the patient and advice bedrest until the bleeding 2. General physical examination
stops The patient is usually bleeding profusely, so her general
c. Advice the patient to save pads, to observe any POC or clot condition might not be good. The patient might even be in
that is expelled out, and to document the amount of shock.
bleeding. Pulse rate might be increased (tachycardia) and BP might
d. Pain relief and sedation with tablet Phenobarbitone or be maintained or low. The patient may be pale, but it
Diazepam is to be given. depends on her previous hemoglobin level.
e. IV fluid/Oral fluid to be given to correct any dehydration 3. Per speculum examination
or hypotension in case of severe bleeding (may need blood • Internal and external os are open, clots and POCs could
replacement). be seen protruding through the external os along with
f. Hematinics, folic acid and calcium to continue if gestational bleeding; or POCs could be seen in vagina.
age more than 12 weeks. 4. Pelvic examination
g. Anti-D prophylaxis if patient is Rh Negative (100 mg /ml). Clots and POCS may be felt in vagina, internal and external
os is open.
Follow-up Size of the uterus is smaller than period of amenorrhea
a. The patient is advised to rest till bleeding stops and not to or may correspond to POA. Sometimes, POCs can be felt
exert herself. lying in cervical canal.
b. The patient should abstain from sexual intercourse. 5. Investigations
c. A repeat USG after 3–4 weeks to note for the cardiac activity Hemogram (Hematocrit), in case of acute bleeding
and growth of the fetus. Blood grouping and cross matching, urine routine
d. To continue the medicines prescribed earlier. examination, other investigations for anesthesia check-up.
Ultrasonography (not always needed). Usual findings are:
Prognosis • Cardiac activity is usually absent
In majority of the cases, the progress of threatened abortion is • Product of conception are separated from the decidual
inevitable or in complete abortion could be averted, if immediate attachment
measures are taken. But some percentage of patients will abort • Products are usually seen lying in lower part of uterine
in course of time. cavity or cervical canal.
The probability to abort is increased if the bleeding starts 6. Treatment
early in the gestation. The long-term prognosis in these patients Admit the patient; treatment will start with correcting the
is good. Patients who have repeated bouts of bleeding have patient’s general condition and hypovolemia, the use of
more chances of intrauterine growth restriction (IUGR), preterm crystalloids and colloids. If required, blood is arranged and
labor and low birth weight babies. However, the risk of fetal transfused. Preferably, the patient should have two patent
160 malformation is not increased in these patients. IV accesses with number 18 or 16 cannula.
 The patient should be immediately prepared and taken
up for evacuation in OT after taking consent. Injection
Tetanus toxoid 0.5 ml IM to be given (if not immunized).
First trimester
• In patients who are less than 12 weeks of gestation,
procedure performed is usually dilatation and
evacuation (D and E) or suction evacuation or manual
vacuum aspiration (MVA) (chapter 65)
• In second trimester miscarriages.
Once second trimester miscarriage is diagnosed, the
patient is admitted in the hospital. All investigations
required by miscarriage are done. Blood is arranged

Chapter 23
(may be required if bleeding is more). Two veins are
secured. Different methods of augmentation of
inevitable second trimester abortion are as follows:
– Oxytocin drip with 10 units in Ringer lactate 500 ml
is started and dose is escalated till good contraction
or patient aborts the fetus (maximum 40 units in
one bottle). Special precaution should be taken to Fig. 23.3: Incomplete miscarriage

Bleeding in Early Pregnancy

avoid fluid overload and electrolyte imbalance,
because of antidiuretic hormone (ADH) like action a. On examination: General condition depends on the amount
of oxytocin. If the patient is hypotensive, oxytocin of bleeding and her hemodynamics status.
drip is a relative contraindication. b. Per speculum examination: Bleeding may or may not be seen
– Injection prostadine (carboprost 250 mg) IM 3 hourly in vulva and vagina. Os may be closed.
is given till the patient aborts the fetus. Special c. Pelvic examination: External cervical os may be closed and
precautions to be taken for GI side effect of the drug. may feel firm. In some cases, the os is open. The size of the
Injection prostadine is a relative contraindication in uterus will not correspond the period of amenorrhea
patients with history of previous uterine scar and (smaller than period of gestation).
with compromised lung pathologies. Nowadays, Investigations Same as Previous One
oral prostaglandins like misoprostol are also used USG findings:
in place of injectables (200–600 mg); 200 µg is given • Uterine cavity will show POCs
every four hours till the products are expelled. Send • Cardiac activity will not be localized
products for histopathology. • Fetus is usually not seen.
When the fetus and placenta are expelled, USG can
be performed; and if the uterine cavity is empty, the Management
patient can be given methergine orally/IM/IV to • The patient is admitted in the hospital
control excessive bleeding. • Hypovolemia to be corrected
In cases, where fetus is expelled and placenta is • Antibiotics to be started
retained, placenta could be removed with ovum • Tetanus and anti-D prophylaxis to be given for the required
forceps or by digital evacuation under anesthesia patients (If she is Rh negative)
(local or general). • Pain relief is given by Mefenamic acid, etc.
In rare cases, the patient might have to be taken up • If the bleeding is mininal can give mesoprostol.
for hysterotomy (if bleeding does not stop).
Surgical procedure: D&E, suction evacuation or MVA is done if
7. Follow-up
bleeding. Sent tissue obtained for histopathology (Fig. 23.4)
• Antibiotics and tablet. Methyl ergometrine and
Hematinics are prescribed Follow-up: Same as in inevitable abortion.
• Anti-inflammatory and pain killers are advised
• Anti-D prophylaxis is given in Rh negative patients (100
µg IM)
• The patient is put on oral contraceptive pills for 3
months, to help her endometrium to heal better and for
regulation of hypothalamo-pituitary-ovarian axis.
• She is advised to avoid pregnancy for 6 months.
• To report immediately, if bleeding is more, if there is fever
or pain lower abdomen. Otherwise, report after 6 weeks
for investigation of the cause of miscarriage.
• Investigations like blood sugar, VDRL, TORCH and, if
required, immunological profile may be advised.

Incomplete Miscarriage (Fig. 23.3)

In this condition, the patient has already aborted a major part of
her conceptus and only some amount is left in the uterine cavity.
The patient gives history of amenorrhea followed by bleeding per
vaginum with history of passage of clots and POCs. The patient Fig. 23.4: Histopathology of products of conception
might not be bleeding actively when she attends the hospital. (courtesy Dr Hari Om Gupta and Dr Rashmi Arora) 161
 Complete Abortion by clotted blood with a disorderly capsule of varying thickness
In this condition, the patient has been pregnant, which is having degenerated chorionic villi scattered through it. If the
followed by bleeding per vaginum and expulsion of all the pregnancy was of longer duration, collapsed skull can be seen
products of conception from the uterus. The cavity is completely in the center.
empty at the time when the patient presents in the hospital. Clinical Features
Examination The patient gives the history of amenorrhea and typical signs
• General condition is usually stable and symptoms of pregnancy. These signs usually regress after
• Pulse and BP are normal. some time, but amenorrhea continues. Some patients may give
history of brownish or dark colored vaginal discharge. Most of
Per-speculum Examination the patients are diagnosed only after examination and
• Bleeding may or may not be observed at vulva and vagina ultrasound scan.
Disorders of Early Pregnancy

• External os is closed.
On Examination
Pelvic Examination
General condition is stable unless the patient is bleeding. Vitals
Size of the uterus is normal or slightly bulky but never are maintained.
corresponds to the period of amenorrhea. The consistency of Per abdominal examination: FHS will not be localized with
the uterus is firm. USG or Doppler.
USG Finding Per speculum examination: Brownish discharge may be
observed, external os is usually closed.
Uterus normal in size or bulky and the cavity is found to be
empty. Pelvic Examination
Management • External os is closed and feels firm.
• If the patient is bleeding, methylergometrine is advised • Size of the uterus is less than the period of amenorrhea.
• Antibiotics may be prescribed, if infection is suspected
Investigations
• Hematinics and calcium to be prescribed
• Oral contraceptives given for 3 months. • Urine pregnancy test (UPT) may be negative
• Serum -hCG levels are very low or level not corresponding
Follow-up and investigations are same as the previous case. to period of amenorrhea.
Section 4

Missed Miscarriage (Fig. 23.5) Ultrasound Findings

Definition a. Cardiac activity is absent
It is the death of the fetus up to 20 weeks of gestation with b. Evidence of collapse of fetal skeleton is seen. If the
retained product of conception. In this condition, the fetus dies pregnancy is more than 16 weeks, collapse fetal skull can
in utero; but instead of getting expelled, it is retained for a be seen.
variable period of time. The reason responsible for retention is
Management
not exactly known. But there is a hypothesis which believes
that the estrogen falls reducing the contractility. The fetus which Admit the patient and investigate her.
dies after 12 weeks may undergo maceration or may mummify
Laboratory Investigations
as the liqor is absorbed. The fetus dies without any symptoms
of spontaneous miscarriage. The patient knows about it when • Hemogram
she is examined by a doctor and confirmed by ultrasound. • Blood group
• BT, CT and CRT
Carneous Mole • Blood fibrogen level
The bleeding and clot from a missed miscarriage can become • Coagulation profile
organized and laminated and this is called a carneous mole. • Investigations for preanesthetic check up (PAC)
Histologically, there is an ovum or macerated fetus surrounded • Arrange for blood.
Medical procedure—Mesoprostol 200 µg is given every 4
hourly till expulsion.
Surgical Procedures
Category I
• Pregnancy less than 12 weeks
• Suction evacuation, D&E or MVA under antibiotic cover.
• Special precautions to be taken during evacuation. To keep
a watch on the amount of bleeding, as coagulation disorder
may be precipitated because of consumption coagulopathy.
Category II
• Pregnancy more than 12 weeks
• Dinoprostone gel instillation to soften the cervix followed
by oxytocin drip or prostaglandin injection or tablet
mesoprostol is used. Close watch is kept for expulsion of
the products of conception. Surgical evacuation may be
Fig. 23.5: H/P missed abortion. Dr R Yadav, RML Hospital needed.

162
Follow-up Non-obstetric Causes of Bleeding First Trimester
• Antibiotics are prescribed Bleeding from Cervical Erosion
• Tablet Methergine 3 times a day for three days advised. It is a lesion over the cervix, can be diagnosed on visual
• Anti-D prophylaxis is given in Rh negative patients inspection either by naked eye examination or by colposcopy.
• Investigation of miscarriage is advised. It can produce irregular spotting or bleeding per vaginum, if
• Oral contraceptives given for 3 months. the erosion is extensive, infected or traumatized. For example,
by examining the cervix, by speculum, doing a Pap smear,
Blighted Ovum intercourse, etc. But it can also be associated with pregnancy,
Blighted ovum is an ultrasonological diagnosis. In this, the in which case, the presence of other signs or USG are helpful to
patient has amenorrhea which may be followed by bleeding. confirm the diagnoses.
There is absent or degenerated embryo. USG reveals gestational
sac but no fetal pole is visualized. Fetal tissue is absent on the Cervical Polyp

Chapter 23
histological examination of products of conception. Cervical polyp is a benign mucoid or polypoidal growth from
the uterine body or the cervix. It can give rise to metrorrhagia
Management
(irregular bleeding) and can present the picture of miscarriage.
Surgical evacuation of uterus. Medical treatment is by
mesoprostol 200 µg 6 hourly. Carcinoma Cervix
Ectopic Pregnancy Carcinoma cervix is a malignancy of cervix. It presents with
irregular bleeding, postcoital bleeding or blood-stained

Bleeding in Early Pregnancy

The patient presents with a period of amenorrhea with history
discharge per vaginum. Cervical biopsy is confirmatory. At
of spotting or bleeding per vaginum, acute and severe pain in
times, it can be found concurrent with pregnancy (see chapter
abdomen, which may be associated with a fainting attack.
45, Carcinoma of Cervix).
Clinical examination, USG and immunoassays usually confirm
the diagnosis (Chapter 24). BIBLIOGRAPHY
1. Green MF. Spontaneous abortions and major malformations in
HYDATIDIFORM MOLE
women diabetes mellitus. Semin Reprod. Endocrinol 1999;17:127.
Introduction 2. Quinn PA, Shewchuck AB, Shuber J, et al. Serologic evidence of
ureaplasma urealyticum infection in women with spontaneous loss.
Hydatidiform mole (H mole) is an abnormal conception
Am J Obstet Gynecol 1983;145:245.
resulting in hydropic swelling of the chorionic villi and 3. RCOG Guidelines No. 38, Feb 2004.
trophoblastic hyperplasia leading to formation of grape-like 4. Spiroff L, Fritz MA. Early pregnancy loss clinical gynecologic endo-
vesicles (see chapter 25, Trophoblastic Disease). crinology and infertility 7th edn. Wilhelm & Walkin; 2005.p.1070.

163
 24 Ectopic Pregnancy (EP)

Sudha Salhan

DEFINITION d. Tubal sterilization and tuboplasty (postectopic

Ectopic pregnancy (EP) occurs when a fertilized ovum (embryo) pregnancy, postsalpingitis) and recanalization and other
implants outside the uterine cavity. If not diagnosed promptly, tubal surgeries make the fallopian tubes structurally
it is a life-threatening condition leading to maternal morbidity vulnerable to ectopic pregnancy.
and mortality. In the past, it was diagnosed only on postmortem Surgical obstruction: After tubal sterilization, the
examination. We still get patients in critical stages in our hospital. fertilized ovum sometimes implants on the stump of
Incidence: The exact incidence is not well-known, but it the tube or sometimes spontaneous recanalization
has increased after 1970 partly because of higher prevalence of occurs with narrowing of the lumen results in ectopic
risk factors and partly because of the development of more pregnancy. The author has seen cases who undergo MTP
sensitive diagnostic techniques. Uzelac and Garmel (2007) before 6 weeks pregnancy (where the fertilized ovum
showed an increase to 4.5/1000, assigned due to higher incidence has not reached the uterine cavity) leading to EP. The
of salpingitis, increase in ovulation induction, assisted surgical procedure of MTP causes removal of decidua
reproductive technology and more tubal sterilization. The from the uterus; and there is blockage of uterine ostia
incidence of second ectopic pregnancy is 10–15 . (opening of fallopian tubes in the uterus) due to reactive
edema. Hence, the fertilized ovum is trapped in the
EPIDEMIOLOGY fallopian tube and iatrogenic ectopic pregnancy happen.
The exact etiology of ectopic pregnancy is not well-known. But 2. Fertility regulatory methods: Intrauterine contraceptive
there are many risk factors, which lead to ectopic pregnancy. devices (IUCD) per se do not increase ectopic pregnancy.
The major ones are given below. But they may be more effective in preventing intrauterine
pregnancy and pregnancy in the medial half of the tube,
1. Factors of the fallopian tubes than lateral part of the tube. The incidence of tubal
a. Development errors Hyperplasia, hypoplasia, undue pregnancy is slightly higher with progesterone-containing
tortuosity of a segment of fallopian tube, congenital IUCD. If IUCD inserted with all aseptic techniques, there is
absence of a segment of fallopian tube, fistula, congenital no increase in salpingitis. In 99.5 of cases, the ectopic
diverticula, and intramural polyp. Rarely, congenital pregnancy is in the lateral half of the fallopian tubes.
abnormalities of the tubes are seen due to DES exposure Similarly, users of progesterone only oral contraceptive have
in the fetal life. a higher incidence of ectopic pregnancy. This is probably
b. History of previous inflammation of the tubes because these contraceptives are supposed to limit
(Salpingitis) is present in 50–60 patients due to septic propelling effect of fallopian tube at the ampullary-isthmic
miscarriage, medical termination of pregnancy by junction resulting in trapping of fertilized ovum and hence
surgical means, pelvic inflammatory disease, tubercular ectopic pregnancy.
salpingitis, etc. 3. Assisted reproductive technologies are shown to increase
At present, the hlamydia trachomatis infection is most the incidence of ectopic pregnancy due to an increased
common. It is a very slowly damaging infection. Many number of ova in seminated.
ectopic pregnancies have history of salpingitis. 4. Overdevelopment of the ovum due to delay in transport
Salpingitis causes damage to the fallopian tubes, may cause ectopic pregnancy
especially to the lining of the tubes. It damages cilia 5. Endometriosis
and hence hinders the propulsion of fertilized ovum 6. Smoking
towards the uterus. Other anatomical changes caused 7. Causes in the embryo: The embryo may have severe growth
by infection are adhesions in the tubal cavity, e.g. in anomalies.
tubercular salpingitis. This causes entrapment of the The common sites are as follows: (Fig. 24.1)
fertilized ovum in the fallopian tubes. Fallopian tubes 1. Fallopian tube: Most of them occur in the lateral half of the
are also affected secondary to pelvic peritonitis caused fallopian tubes—95
by appendicitis or other causes. As a result, tubal Infundibulum and fimbrial end—17
pregnancy is more common on the right side. Since tubal Ampula—55 (most common)
disease is always bilateral, there is a strong tendency Isthmus—20–25 (more dangerous)
for ectopic pregnancy to occur first on one side and then Interstitial—2–4 —in the intramural portion of the tube,
recur on the other side in another pregnancy. where it traverses the wall of the uterus.
c. Distortion of the tube externally by a large tumor or 2. Rudimentary horn of bicornuate uterus
endometriosis, etc. may also cause ectopic pregnancy. 3. Cervix
 1. istory The presentation is variable. A higher index of
suspicion is a must. The three common symptoms
amenorrhea, pain and bleeding may not be always present
(in 50 cases).
A history of amenorrhea of a few days or none with severe
pain abdomen and fainting attack or the patient is in a state
of shock may be all that the doctor has to look upon. There
may be no need and no time for any investigation in cases
of a ruptured ectopic except hemoglobin and blood group
examination.
2. Physical examination is performed to confirm the
diagnosis. Additional tests are often needed to establish the

Chapter 24
diagnosis and to assess the risk factors. It includes eliciting
vital signs and examination of the abdomen and pelvis.
Before rupture, vital signs may be normal. Abdomen may
have mild tenderness with or without rebound tenderness.
The cervix and uterus feel softer due to an increased level
of progesterone. Cervical motion tenderness (due to
Fig. 24.1: Sites of ectopic pregnancy stretching of fallopian tubes due to ectopic pregnancy) may

Ectopic Pregnancy (EP)

or may not be present. It is also called pain of cervical
excision. On moving the cervix, the uterus moves in the
4. Abdominal cavity opposite direction. There is increased tension on the side of
5. Broad ligament the ectopic pregnancy and it causes pain. After rupture,
. Heterotropic pregnancy (combined pregnancy) is there is tachycardia, hypotension and signs of shock,
pregnancy occurring simultaneously in the fallopian tube depending on the amount of hemorrhage. Abdominal
and uterine cavity. The previous incidence was around one tenderness with or without distension and cervical motion
in 30,000 pregnancy. The incidence has increased with IVF tenderness is present.
techniques to more than 1.2 . A viable intrauterine pregnancy
Pregnancy test Urine pregnancy test is positive in 50–60 of EP
is seen on ultrasound which is exactly what was wanted. The
cases. A negative pregnancy test is of no value. Culdocentesis
radiologist may miss the heterotopic pregnancy if he/she does
will yield blood which does not clot.
not keep it in mind to look at the fallopian tubes as well.
3. Cudocentesis is a simple technique to identify hemo-
. Chronic ectopic pregnancy
peritoneum (Fig 24.2).
Diagnosis of ectopic pregnancy: Not very long back, ectopic
A 20-gauge spinal needle is introduced through the
pregnancy was diagnosed only on postmortem examination.
posterior vaginal fornix into the cul-de-sac.
However, now, advances in diagnostic techniques have made
If the patient is stable, further diagnostic tests are required
it possible to diagnose it even before rupture. Meticulous
to confirm ectopic pregnancy.
history, examination and diagnostic tests are required for the
4. ltrasonography It is useful in the diagnosis and
diagnosis of ectopic pregnancy.
management of ectopic pregnancy. A positive pregnancy

Fig. 24.2: Culdocentesis 165

 8. terine curettage Only decidual tissues and no villi—such
a picture is diagnostic of ectopic pregnancy.
If placental tissue is seen, it is threatened or incomplete
abortion.
9. Laparoscopic diagnosis may be used, if available.
(Fig 24.4).
10. Raised interleukin and tumor necrosis factor-2 alpha (TNF-
Disorders of Early Pregnancy

2 ) levels in the serum are higher in ectopic pregnancy than

in normal pregnancy and miscarriage (Soriano and
Associates, 2003).
test with empty uterus is suggestive of EP. TVS gives a clear
11. Glycodelin serum levels are significantly lower in ectopic
image of pelvic organs, and intrauterine pregnancy at 5
pregnancy compared with intact pregnancy and abortion
weeks. If the uterine cavity is empty, the fallopian tubes
(Foth and Romer, 2003) (glycodelin is a glycoprotein of the
may show the fetus. Color Doppler may show a ball of fire
lipocalin superfamily which has a major role in the
around the ectopic pregnancy. Fluid in POD signifies
reproductive axis).
rupture of the ectopic pregnancy.
12. Serum placental protein 14 (PP14) is a secretory endometrial
An adnexal mass with fetal heart is EP in unruptured ectopic
protein. Low concentration is suggestive of ectopic
pregnancy (Figs 24.3, 56.14 and 57.49A to C).
pregnancy.
5. Other tests corroborating the diagnosis of EP are:
13. Serum relaxin, produced by corpus luteum of pregnancy.
• Low Hb
Its potential as marker for ectopic pregnancy is under further
• Increased leukocyte count
evaluation.
• The ESR might be increased
14. Human placental lactogen (HPL) assay
• Raised serum bilirubin is chronic EP
15. Pregnancy-associated plasma protein A assay (PAPP-A)
• Presence of porphyria in urine—suggestive of
Section 4

16. Schwangerschaft protein 1 (SP1) assay.

hematoma formation.
6. Serum -hCG level 6,500 IU/l is suspicious of EP or missed Differential diagnosis from other conditions causing acute
abortion; but if there is no intrauterine pregnancy, a lower abdomen pain is important.
diagnosis of EP is made. 1. Acute abdomen: Conditions like splenic rupture, perforated
Serum -hCG levels double every 2 days in a normal appendix, acute pancreatitis, perforated gastric and
pregnancy. duodenal ulcer, etc. In these conditions, the abdomen has
If the patient is hemodynamically stable, we can repeat board-like rigidity that is absent in EP. There will be no
-hCG. amenorrhea and no vaginal bleeding in these conditions.
If the rise is 66 from the previous reading, EP should be 2. Rupture of corpus luteal hematoma: Simulates EP both in
suspected. history and clinical findings and may be the cause of a few
If the rise is double or the level is 6,500 IU/l, USG invariable negative laparotomies.
reveals a uterine pregnancy in 95 of cases. 3. Miscarriage of early pregnancy: Bleeding is large in volume
7. Serum progesterone level A single level cannot predict EP. and pain occurs in lower midline abdominal area.
Serum progesterone indicates the viability of the corpus 4. Salpingitis: Most commonly mistaken for EP. Negative
luteum. Values more than 25 ng/ml, exclude ectopic pregnancy test with leukocytosis and fever confirm the
pregnancy. diagnosis.
Serum progesterone level 15 ng/ml 83 EP 5. Ovarian torsion or torsion of pedunculated fibroid: Pain
Serum progesterone level 25 ng/ml indicates normal IU usually waxes and wanes and later becomes constant as
pregnancy. the vascular supply is compromised.

166 Fig. 24.3: USG ectopic pregnancy, Dr Uppal Fig. 24.4: Right cornual ectopic pregnancy
 6. Intrauterine device—associated with severe dysmenorrhea Treatment
7. Red degeneration in fibroid with pregnancy Whenever tubal pregnancy is diagnosed, immediate
8. Intraperitoneal hemorrhage from any other source (e.g. hospitalization is required. Treatment depends on the clinical
liver) condition of the patient and future fertility prospects. Treatment
9. Retroverted gravid uterus with retention of urine options are surgery, medical and expectant management
10. Pyosalpinx (acute stage) usually bilateral depending on whether the patient is in shock (ruptured ectopic)
11. Rupture of chocolate cyst or stable.
12. Urinary tract infection. If in shock, the patient must be treated and simultaneously
Risks of ectopic pregnancy. The blood lost may be massive preparation for laparotomy should be made.
endangering the woman’s life. Implications for future pregnancy Acute stage: A rupture of ectopic pregnancy can occur in
is not well-known. very low hCG concentration. In ruptured ectopic surgical
treatment is the only option.

Chapter 24
FATE OF ECTOPIC PREGNANCY • As soon as the diagnosis of EP is made, management should
Fate of ectopic pregnancy depends on many factors. Important start.
among them being site and duration of ectopic pregnancy. The • Blood transfusion is required before, during and after
main serious outcome is rupture. Timing of rupture depends on operation.
the site of ectopic pregnancy. Isthmic pregnancy ruptures at 6–8 • Resuscitation and operation is performed simultaneously.
weeks of gestation as the isthmic region has the smallest diameter. Depending on the availability, laparoscopic or laparotomy
The ampullary region rupture is late at 8 weeks. The rudimentary sugery is performed.

Ectopic Pregnancy (EP)

horn takes still longer to rupture. The greater the duration of • Identifying the affected tube, clamping of the bleeding vessel
pregnancy at the time of rupture, the more massive and life- may be the only means of saving the patient’s life as her
threatening the bleeding will be (Table 24.1). shock is because of this bleeding in the ruptured fallopian
Sometimes, the ectopic pregnancy is expelled through the tube.
fibrial end (tubal abortion). If it remains attached to the tube • Before deciding for the surgical treatment of the affected
after rupture, then it may continue to grow as a secondary tube, opposite tube and ovary must be examined and
abdominal pregnancy. patient’s desire for future pregnancy is to be considered.
Spontaneous resolution of the ectopic pregnancy is also
Indications of laparotomy: Laparotomy is done when the
seen.
patient is in a hemodynamically unstable condition and the

Table 2 .1: Clinical manifestation of tubal abortion and tubal rupture

Symptoms ubal abortion ubal rupture
Amenorrhea May or may be present May or may not be present.
Pain 95 Aching in one or other iliac fossa due to distension Severe lancinating pain in one iliac fossa due to
of tube rupture and escape of large quantity of blood
Sharp stabbing pain due to choriodecidual into the peritoneal cavity.
hemorrhage and escape of blood into the peritoneal Blood trickles up to the undersurface of the
cavity (severity depends upon the intraperitoneal diaphragm; causes shoulder trip pain and
hemorrhage) epigastric pain
Vaginal spotting or bleeding
Abnormal vaginal bleeding Small amount; dark altered
60–80 . Due to withdrawal of hormones
Discharge of decidual cast
5–10 of case Profound collapse
Syncope Always associated with syncope Marked pallor
Momentary feeling of faintness to collapse Sweating

Retention of urine Blood collects in the pouch of Douglas— Pelvic

hematocele
Forms irregular mass—displaces the cervix
against bladder neck
Fever 10 When pelvic hematocele gets secondarily infected.
Sign of shock and anemia Pallor Weak rapid pulse
Subnormal temperature
Low blood pressure with marked pallor
Generalized tenderness and Over lower abdomen especially Lower abdomen is acutely tender
muscle guarding in 45 on the affected side with muscle
of cases guarding
Distension of abdomen Intestinal distension Extreme tenderness can be elicited in the lower
Hemoperitoneum of 2–3 weeks causes bruising abdomen
around the umbilicus called Cullen s sign (15 Cervical movement causes severe pain leading
of cases) sign
Abdominal tenderness present on bimanual
examination
Difficult to feel the uterus and pelvic mass.
167
 surgeon is not an expert in laparoscopic surgery. Other
indications are:
1. Most ovarian and abdominal pregnancies
2. Chronic ectopic pregnancy
3. Non-availability of laparoscopic equipment
4. Adhesions preventing laparoscopic approach
5. Cornual or interstitial pregnancies
6. Started as laparoscopic approach but converted to
laparatomy due to complications
7. If large blood clots, prevent estimation of intra-abdominal
lesion.
The following operations can be done either by laparotomy
Disorders of Early Pregnancy

or laparoscopically, depending on the availability of instruments

and expertise at that time.
a. Radical Salpingectomy (Fig 2 . ): It was first performed
by Robert Lawson Tait in 1884. Removal of entire fallopian
tube is done when the condition of ruptured fallopian tube is
unsalvageable or the fallopian tube is diseased, e.g. tuberculosis
(ovary is separated from the adnexal mass). Advantage of
salpingectomy is that the ovarian function will continue and
during IVF ova can be collected from this ovary also. The
disadvantage of preservation of the ovary is the theoretical
danger of transperitoneal migration of the ovum from this
intact ovary going to intact tube on the other side and causing
Figs 24.6A to D: Removal of a midampullary pregnanc y:
ectopic pregnancy. Hemostasis is achieved by catching hold
(A) Midampullary ectopic; (B) antimesenteric incision with diathermy
of the bleeder and securing it. Clean the abdominal cavity of needle; (C) The pregnancy removed by grasping tissue while blunt teasing
blood and products of conception by doing a saline lavage. the tissue away from the endosalpinx; (D) Serosa and muscularis are closed
b. Salpingo-oophorectomy: When the ovary is completely with 5.0 nonreactive suture material
Section 4

involved with the adnexal mass, it is removed with the

fallopian tube.
c. Segmental resection and end-to-end anastomosis can also a laparoscope and products can be aspirated with a suction
be done in ruptured EP when hemostasis has been secured irrigation cannula. In fimbrial ectopic pregnancy, expulsion
by catching the bleeding vessel in the mesosalpinx. of embryo is achieved. But this procedure is associated with
d. Linear salpingostomy with scissors or diathermy or laser is a two-fold increase in the rate of recurrent ectopic pregnancy.
done in an unruptured ectopic and the products of conception Always send the tissue obtained for histopathological
are sucked out, followed by suturing (Figs 24.6A to D) or not examination to confirm diagnosis.
suturing (Fig. 24.7). The tissues obtained are to be sent for Conservative surgery is not done in uncontrolled
histopathology (Fig. 24.8) hemorrhage when hemostasis cannot be achieved by using
e. Milking (Milking of the tube): If the EP is at fimbrial end conservative techniques. It is also not done in cases of
or just at the outer end of the ampullary portion of the tube,
milking of the tube can be done with grasper forceps through

Fig. 24.7: Laparoscopic salpingostomy for ectopic pregnancy. An incision is

Fig. 24.5: Salpingectomy for tubal pregnancy: The tube has been made with the monopolar diathermy needle along the antimesenteric border
delivered and the merosalpinx is being clamped and cut with a of the oviduct. The trophoblastic tissue is removed with forceps. The lumen
succession of Kelly clamps is left to heal by secondary intention
168
 6. Serum hCG level below 6,000 IU/ml.
7. No contraindication to methotrexate therapy
8. Persistent ectopic pregnancy after conservative surgery.
9. Cervical and intestinal pregnancy where surgical
intervention is not easy.
10. Desiring future fertility.
Methotrexate is an antifolic acid drug: It interferes with the
synthesis of DNA in rapidly dividing trophoblast cells
• If hCG fails to fall below 15 in 4–5 days or increases a
dose of methotrexate is repeated.
• Posttreatment tubal patency is demonstrated in 82 cases
Side effects of methotrexate: Stomatitis is the most common

Chapter 24
side effect. Methotrexate may also cause nausea, vomiting,
diarrhea, gastric upset, rarely neutropenia. But these side
effects are rare in a single dose regimen and folinic acid is
not needed. Side effects are to be told to the patient before
Fig. 24.8: Ectopic pregnancy in fallopian tube
starting the treatment. Follow-up is essential.
(Dr A Gupta, Sikkim, Manipal Medical Institute)
Contraindications of Medical Treatment

Ectopic Pregnancy (EP)

unrepairable tubal damage and in cases with no desire for 1. Patients with prior surgeries on fallopian tubes (tubal
further fertility. Conservative surgery does not give good results ligation) and tubercular salpingitis. As chances of
in isthmic and large corneal ectopic pregnancies. Thermal needle development of an ectopic pregnancy again are more.
and direction of a powerful ultrasound beam accurately at the 2. Breastfeeding
ectopic sac alongside an imaging transducer, can eliminate the 3. Immunodeficiency
need for any infection (under research). 4. In patients who cannot remain under follow-up
Treatment of unruptured EP: Options are: 5. Blood dyscrasias and thrombocytopenia
Surgical treatment – Salpingectomy 6. Alcoholism
Salpingostomy 7. Active pulmonary diseases
(both by laparotomy and laparoscopy) 8. Sensitivity to methotrexate
Salpingotomy 9. Patients who have elevated liver enzymes
Evacuation and end-to-end 10. Renal dysfunction
anastomosis 11. Fetal sac more than 4 cm
Surgically administered medical treatment 12. Fetal heart present (some authors give ultrasound-guided
Around the EP – Laparoscopically by falloposcope or potassium chloride injection in the fetal heart. Look for
TVS guided – Transcervical injection: First aspirate the arrest of cardiac activity and then inject methotrexate).
contents of the sac and then inject 50 mg Counseling before medical treatment it is an essential step.
of methotrexate into the gesational sac. The patient should be told about the seriousness of the disease,
Medical treatment – can be given systemically by the IV or importance of follow up and that in case of failure of medical
IM route treatment, surgery may be needed.
– Orally For medical treatment, the following investigations are
Surgically administered medical treatment is carried out required:
in stable patients with unruptured ectopic pregnancy.
• Hemoglobin level, TLC, DLC and platelet count
It involves local administration of the following trophotoxic
• Liver function tests, especially SGOT, SGPT
drugs in the EP sac by laparoscopy or by TVS guided.
• Serum hCG level
A total of 5 mg of methotrexate is injected into the gestational
• Blood group and Rh typing
sac. Other drugs under research are:
• Blood urea nitrogen, creatinine
Anti-hCG antibodies
• Informed consent is taken.
Etoposide, danazol
Hyperosmolar glucose The patient is instructed not to have sexual intercourse till
Prostaglandins hCG levels are negative. She is also asked not to take
Mifepristone multivitamin tablets containing folic acid and alcohol
Potassium chloride. consumption is prohibited. Measure the hCG level on day 4–7
and then repeat weekly till undetectable. TLC, DLC, and
CRITERIA FOR MEDICAL TREATMENT platelets are also measured repeatedly. After the hCG level is
Medical treatment: All the above trophotoxic drugs can be given negative for two months, contraception is advised. Failure of
IV, IM and by the oral route. But methotrexate, generally as a medical treatment is when the hCG level increases or plateaus
single dose, is most commonly used. or the decrease is less than 15 from day 4–7 postinjection. A
Whom to give methotrexate The following selection repeat single dose of methotrexate can be given.
criteria are needed: Careful monitoring is done by:
1. The patient is stable hemodynamically with no sign or • Careful clinical assessment
symptoms of active bleeding or hemoperitoneum. • Complete blood count
2. The fallopian tube is unruptured • Liver function test
3. Mean duration of pregnancy is 54 days. • Serum hCG level closely monitored at least once a week
4. Absent fetal heart and less than 4 cm ectopic mass. until negative.
5. Serum progesterone less than 10 ng/ml. • Ultrasound scanning. 169
 Advantage of medical treatment
• Minimal hospitalization
• Shorter time interval to normal activity
• Outpatient treatment
• More than 90 success in selected cases.
Expectant treatment: Expectant management, i.e.
observation and monitoring until EP resolves. Ectopic
pregnancy is a life-threatening condition. So expectant treatment
is not fre uently used and should rigidly follow the set criteria.
This mode of treatment should be started only if the hCG is
less than 1000 IU/l.
1. Falling level of serum hCG at 2-day intervals.
Disorders of Early Pregnancy

2. No sign of intrauterine pregnancy.

3. Diameter of EP sac 4 cm and rapidly decreasing within 7
days (U/S after 1 week).
4. No sign of rupture or acute bleeding by TVS and no fetal
heart activity.
5. Progesterone level less than 10 ng/ml.
6. Constant supervision is essential.
The selected patients are counseled about the follow-up and Fig. 24.9: Cervical ectopic pregnancy
other treatment protocols and consent is taken. In case of any
danger signs, the patient is instructed to contact the emergency.
Till the patient is symptoms free, she is followed with weekly Expectant management, i.e. observation and monitoring
hCG and U/S until hCG levels are less than 20 IU/l. until EP resolves.
Spontaneous resolution occurred in 72 of cases; resolution Persistent ectopic pregnancy (PEP) denotes continued
time is 20 13 days. growth and enlargement of residual trophoblastic tissue. This
is the complication of salpingostomy and evacuation of EP. Here,
Heterotropic EP the removal of pregnancy is incomplete. PEP may also occur
Section 4

Definition: When one pregnancy is in the uterus and other is after medical treatment if residual trophoblast continues to
in the fallopian tube. The incidence used to be 1:30,000 survive. Close follow-up is essential. Untreated PEP can cause
pregnancies. But, now in cases of IVF, it is 12 . It may occur tubal rupture and severe hemorrhage. Treatment consists of:
due to IVF diagnosed ultrasonographically (TVS). To avoid • Reoperation and further evacuation or
missing it, these cases in patients of IVF, after seeing an • Salpingectomy or
intrauterine pregnancy, do not stop the ultrasound procedure; • Segmental resection or
exclude concomitant ectopic pregnancy. On laparoscopy, two • Methotrexate single dose IM 50 mg/m2 body surface area.
corpora lutea are seen. Cervical ectopic pregnancy (Fig. 2 . ): Is rare occurring in
Treatment: Potassium chloride or hyperosmolar glucose is 0.1–0.2 of ectopic pregnancies. It is more common in apan
injected into the ectopic sac either under ultrasound guidance which is attributed to high rate of MTPs. High incidence is seen
or laparoscopically. in cases of curettage.
Surgical removal of EP can be carried out by laparoscope Rubin gave three criteria for the diagnosis of cervical
or one can give drugs in sac by laparoscopy: ectopic pregnancy.
• Methotrexate 1. Cervical glands must be opposite the plancental attachment.
• Ru-486.

170
 Chapter 24
Ectopic Pregnancy (EP)
2. The placental attachment be below the uterine vessels or we start evacuating (confusing it with inevitatble abortion)
below the peritoneal reflection of the anterior and posterior severe hemorrhage ensures.
surface of the uterus.
3. Fetal elements must be absent from the corpus uteri. Ovarian Ectopic Pregnancy
These criteria are difficult to evaluate unless we study the Ovarian ectopic pregnancy is also a rare condition. The exact
whole of the uterus. Hence, Paalman and McElin gave five more etiology is difficult to find. However, it is more often seen with
criteria. IUCD users. The ovum is fertilized within the follicle itself
1. Uterine bleeding without cramping pain following a period before ovulation (extrusion).
of amenorrhea. Spiegelberg criteria for ovarian pregnancy: Besides a
2. Hour glass uterus showing soft enlarged cervix equal to or preserved corpus luteum in the wall of the gestational sac, there
larger than the fundus. must be:
3. Products of conception entirely confined within and firmly 1. Tubes including the fimbria ovarica are intact and clearly
attached to the endocervix. separate from the ovary.
4. Internal cervical os is closed. 2. Gestational sac definitely occupies the normal position in
5. External cervical os is partially open. the ovary.
The diagnosis is often delayed until second trimester when 3. Gestational sac is connected to the uterus by the utero-
severe hemorrahge occurs leading to high morbidity and ovarian ligament.
mortality. An index of suspicion is very important. Transvaginal 4. The ovarian tissue is demonstrated in the sac.
ultrasound and hCG levels help in the diagnosis. Color Doppler A close differential diagnosis is a leaking corpus luteum
may be useful. Classically, the treatment is surgery with hematoma. Though there is more bleeding in ovarian ectopic
hysterectomy as the mainstay leading to loss of reproductive pregnancy.
capability. Recently, treatment by injection of potassium Treatment is surgical in both cases (to be on the safer
chloride into the gravid sac under transvaginal U/S guidance is side). Conservative resection of the bleeding portion of the
used. Methotrexate along with uterine artery embolization helps ovary is carried out. Rarely, oophorectomy is required for
to preserve future fertility. Some gynecologists give a hemostasis.
combination of methotrexate and mesoproston. Verma and Abdominal ectopic pregnancy: It is very rarely seen. The
Goharkay (2009) used IM methotrexate (50–75 mg/m2). If the incidence varies. It is as rare as 1 in 10,000–25,000 live births. It
fetal cardiac activity was seen they injected KCl 2 ml (2 mg/ml) can be primary or secondary abdominal pregnancy.
(intracardiac) under ultrasound guidance. They concluded that Studdiford (1992) criteria for primary abdominal ectopic
medical management of cervical ectopic pregnancy is a safe include the following:
and viable option in most patients with cervical ectopic 1. Both tubes and ovaries must be in normal condition with
pregnancy. Early diagnosis of cervical pregnancy is crucial for no evidence of recent or remote injury.
effective conservative management with low morbidity. 2. No evidence of uteroperitoneal fistula should be found.
Hystrectomy may be required in massive hemorrhage. 3. The pregnancy must be related exclusively to the peritoneal
Differential diagnosis of cervical ectopic preg-nancy is surface and be early enough in the gestation to eliminate
from carcinoma of the cervix and incomplete abortion. It is the possibility that it is a secondary implantation following
important to differentiate from inevitable abortion because if primary implantation in the tube.
171
 Secondary abdominal pregnancy is more common of the MRI may be used, if available.
two abdominal pregnancies. It occurs when a tubal pregnancy Management includes keeping blood ready and close fetal
or pregnancy in the rudimentary horn ruptures and attaches monitoring. Intact fetal membranes are crucial; if they rupture,
itself to other viscera. The placenta in the fallopian tube spreads the fetus dies quickly of respiratory distress. Due to lying in
to gain blood supply from peritoneal site also, besides the restricted space, there are anomalies in the fetus like joint
original site in the tubes. Rarely, it can develop after spontaneous deformities, torticollis, etc.
separation of an old cesarean section scar, after perforation of The fetus is extracted by laparotomy. Try not to remove
the uterus in medical termination of pregnancy or after subtotal the placenta if it is morbidly adherent to surrounding
and total hysterectomy. Fetal hemorrhage can occur after viscera. Fiddling with placenta usually leads to fatal
separation of the placenta (Figs 24.10 A and B). hemorrhage. Its removal is only attempted when after
Diagnosis of abdominal pregnancy is very important. examining it, the surgeon is sure that it can be removed
Hence, one must keep it in mind in cases who have amenorrhea, completely without any damage to the surrounding organs.
Disorders of Early Pregnancy

and present with a history of sudden pain in the abdomen in Otherwise, the cord is cut as close to the placenta as possible
the first trimester. The patient often complains of pain in the and the placenta is left in the abdomen. It will get absorbed in
abdomen and visible fetal movements in the upper abdomen. due course of time. We can give methotrexate orally and can
Hyperemesis late in pregnancy is also a complaint. On follow -hCG levels.
examination, the fetus is felt superficially with malpresentation Chronic ectopic pregnancy: The ectopic pregnancy
and malposition. The cervix is long and unaffected and the ruptures, the patient survives this catastrophe. The ectopic mass
uterus can be felt separately and is small in size. gets organized and present as chronic pain. There is a pelvic
ray abdomen (Lateral view) shows fetal parts overlying mass. Treatment is surgical removal of the mass (which is
the maternal spine along with transverse or lateral position. difficult because of inflammation and subsequent adhesions).
ltrasound Confirms the diagnosis by an empty uterus and Anti-D prophylaxis should be given in all Rh negative
the fetus lying in the abdomen. There may be oligohydramnios. mothers with ectopic pregnancy.
Section 4

Figs 24.10A and B: Abdominal ectopic pregnancy

172
 Influence on fertility: The subsequent fertility depends on BIBLIOGRAPHY
the condition of the fallopian tube (damage by ectopic 1. Bamhart K, Espositom, Coutifaris C. An update on the medical
pregnancy), previous disease (tuberculosis, chlamydial infection). treatment of ectopic pregnancy. Obstet Gynaecol Clin North Am
With the availability of antibiotics, if there is minimum damage, 2000;27:657.
the prospects are good for a subsequent pregnancy. However, 2. Seeber BE, Barnhart KT. Suspected ectopic pregnancy. Obstet
damage to tubal function with hlamydia or tuberculosis is usually Gynaecol. 2006 Feb; 107 (2 pt 10: 399-413. Review.
bilateral and irreversible and hence leads to repeated ectopic 3. Soriano D, Hugal D, uang NT, et al. Serum concentration
pregnancy. Definitive future outcome cannot be predicted. of interleukin-2R (1L-2R), 1L-6, 1L-8 and tumor necrosis factor
alpha in patients with ectopic pregnancy. Fertyl steril 2003; 79 (40:
When the contralateral fallopian tube is normal, the
975).
subsequent results may be good. It is seen that most of the 4. Uzelac PS and Garmet SH: Early pregnancy risks. Current diagnosis
patients with previous ectopic pregnancy are not able to have a a treatment obstetrics and gynaecology. McGraw Hill
live child. Publication;2007.p.259.

Chapter 24
Follow-up is especially important in medical treatment, 5. Verma U and Goharkhay N. Conservative management of cervical
expectant treatment and conservative surgery to prevent ectopic pregnancy. Fertility and Sterility 2009;91:671.
persistent ectopic pregnancy. Weekly -hCG should be 6. Van MNM, Mol F, Mol BW, et al. Conservative management of tubal
measured; required till it becomes negative. It clears within ectopic pregnancy. Best Pract. Res. Clin. Obstet Gynecol.
2009;23:509.
2–3 weeks but may take up to 6 weeks.

Ectopic Pregnancy (EP)

173
 25 Trophoblastic Disease

Sudha Salhan, Jyotsana Suri

Trophoblastic disease arises from trophoblastic tissue. It can be Definition: An abnormal pregnancy or conception without an
divided into: embryo and with gross hydropic swelling of the chorionic villi
1. Gestational trophoblastic disease, (GTD), and and trophoblastic hyperplasia. The incidence varies with
2. Non-gestational trophoblastic disease (NGTD). geographic location and is greatest in South-East Asia.

GESTATIONAL TROPHOBLASTIC DISEASE Pathology

Definition Hydatidiform mole is the most common gestational
trophoblastic tumor.
Gestational trophoblastic disease (GTD) is a term that encompasses
It can be complete or partial depending on the presence or
a spectrum of tumors associated with the result of an abnormal
absence of an embryo or fetus.
pregnancy, which arises from human placental trophoblastic
tissue of paternal genome with rarely any maternal genetic Complete Hydatidiform Mole
share. They are diagnosed by the serum marker -hCG and are Complete mole is a product of an abnormal conception lacking
the first solid disseminated tumor highly curable by identifiable embryonic or fetal tissue on microscopic
chemotherapy. After treatment of choriocarcinoma, the patient examination. Gross examination shows grape-like vesicles of 1–
can conceive again. Hence, any woman coming with a history 3 cm in diameter (hydropic villi) (Figs 25.1A and B).
of bleeding or tumor with a recent history of hydatidiform mole, On microscopic examination (Figs 25.2A and B), the chorionic
abortion or term pregnancy should have at least one -hCG villi have generalized hydropic swelling and there is diffuse
examination to rule out GTD. All evacuated tissues in a cytotrophoblastic and syncytiotrophoblastic hyperplasia and
miscarriage should be seen with naked eyes and sent for intestitial edema. Also, there are no fetal vessels in the stroma
histopathology. (The author detected choriocarcinoma in one of the villi. There is no trophoblastic stromal invasion. A
case diagnosed as incomplete abortion). This is done to rule complete mole produces human chorionic gonadotropin (hCG).
out gestational trophoblastic tumor because these tumors once Karyotype: These are diploid (90% are 46XX and 10% have
diagnosed are highly amenable to treatment by drugs. 46XY). The chromosomes are entirely of paternal origin even
Gestational trophoblastic diseases are histologically divided though the mitochondrial DNA is of maternal origin. It appears
into: that a complete mole arises when an “empty-ovum” is either
1. Hydatidiform mole: fertilized by a haploid sperm which duplicates its own
a. Complete hydatidiform mole chromosome (homozygous monospermic androgenic
b. Partial hydatidiform mole fertilization) or by two haploid sperms with fusion and
2. Invasive mole (Chorioadenoma destruens) replication (heterozygotic dispermic diandrogenetic
3. Choriocarcinoma fertilization). There is transformation of the embryonic cell mass
4. Placental site trophoblastic tumor (PSTT). just before lying down of endoderm. Hence, there is no
Hydatidiform mole: The word is derived from the Greek word differentiation into ectoderm and endoderm. This gives rise to
hydatis–a drop of water and the Latin word mole—a mass. vesicles with loose primitive mesoderm in their villous core.

Figs 25.1A and B: (A) Hydatidiform mole (Gross view); (B) Molar pregnancy
 Chapter 25
Figs 25.2A and B: (A) H mole (4x); (B) Hydatidiform mole (Microscopic view)

Clinically, it is usually detected between 8 and 24 weeks of fetus being present with a partial mole, it exhibits growth

Trophoblastic Disease
conception. The uterus is larger than the period of amenorrhea, restriction and multiple congenital malformations hCG is
feels doughy, and the patient gives a history of amenorrhea and produced.
sometimes even passage of vesicles. Hyperemesis and pre- Karyotype: Ninety percent of the partial moles are triploid with
eclamptic toxemia (even before 20 weeks of gestation) may be an extra haploid set of chromosomes of paternal origin (69XXX
seen. Hyperthyroidism may develop (molar tissue may secrete or 69XXY with two-third of DNA of paternal origin. One haploid
thyroid-stimulating hormone-like product). Respiratory distress maternal and two haploid paternal chromosomal sets). This occurs
is seen as trophoblasts travel to the lungs. Theca lutein cysts in in fertilization of a haploid ovum with two sperms or with a diploid
both ovaries may be seen. No fetal heart is heard. H mole is sperm (Table 25.1).
rarely seen in ectopic pregnancies, fallopian tubes (5%) and
ovaries. Invasive mole (Chorioadenoma destruens): Ten to sixteen
About 10% of complete H mole progress to persistent percent of complete moles progress to invasive moles. Invasive
trophoblastic disease and 3–5% go on to developing mole is a locally invasive, rarely metastatic lesion. Microscopic
choriocarcinoma. H mole is to be differentiated from examination depicts trophoblastic invasion of the myometrium
spontaneous abortion in which there may be confusion of and its blood vessels without intervening endometrial stroma
hydropic changes of a few villi. Microscopic examination helps or identifiable villous structures. This lesion also shows
because cistern formation is not present; villi are less edematous
and are without blood vessels. Atypia of trophoblasts is not
seen. Flow cytometry also helps in differentiating the two.
Ultrasound shows snow storm appearance (Fig. 25.3).
Partial Hydatidiform Mole
The partial mole, in contrast to the complete mole, has the
presence of identifiable embryonic or fetal tissues (Figs 25.4
and 25.5). Gross examination of the placenta shows both normal
and hydropic villi. There is variation in the size of the chorionic
villi and the microscopic examination shows focal swelling,
cavitations and trophoblastic hyperplasia along with normal
villi. A normal amniotic membrane is seen. Trophoblastic
stromal invasion is present. Scalloping of the hydropic villi may
be seen. Fetal vessels are often seen. There may be nucleated
fetal red blood cells (RBC) in these vessels. In the event of a Fig. 25.4: Ultrasound showing partial mole

Fig. 25.3: USG H mole Fig. 25.5: Partial mole (fetus with molar tissue) 175
 Table 25.1: Differences of complete H mole and partial H mole

Complete H mole Partial H mole

1. Embryonic tissue of fetus Not identified Identified
2. Hydropic swelling of chorionic villi Generalized Localized
3. Proliferation of trophoblasts Generalized Localized
4. Chorionic villi scalping Not seen Seen
5. Trophoblastic stromal invasion Not seen Seen
6. Clinical diagnosis by history Possible Not possible
7. Size of uterus Mostly larger that Mostly appropriate for period
period of amenorrhea of amenorrhea
8. Theca lutein cyst Present Not seen
9. Pre-eclampsia Seen Not seen
Disorders of Early Pregnancy

10. Hyperemesis Seen Not seen

11. Thyrotoxicosis Seen Not seen
12. Karyotype Paternal only Both maternal and paternal
13. DNA concentration—flow cytometry Diploid 50% 43% tetraploid Triploid
14. Conversion to malignancy Seen (10% persistent and Rare
3–5% develop choriocarinoma
15. Immunochemistry epidermal growth Localization of hCG and HPL Localization of hCG and HPL
factor detected
16. In situ hybridization P53 staging more intense MVC P53 staging less intense
MVF-ras and sis onchogene different than complete mole
seen not seen

hyperplasia of cytotrophoblastic and syncytial elements as well Complications of choriocarcinoma

as the persistence of villous structures. Hence, it is diagnosed 1. Bleeding
only if there is persistence of hCG in blood for a long time 2. Complication of metastasis, e.g. CNS metastases, which can
after evacuation of a complete mole. It is more common in lead to intracranial hemorrhage.
Section 4

women aged more than 40 years. Due to invasion by Placental site trophoblastic tumor (Atypical choriocarcinoma
trophoblasts, the symptoms of bleeding, amenorrhea, pain in or trophoblastic pseudotumor): It is a rare type of GTD. It occurs
the abdomen (which may be acute in case of uterine perforation) at an earlier age (25–30 years). These tumors produce small
are seen. Molar villi are seen in the blood vessels (deportation quantities of hCG and mostly secrete human placental lactogen
lesion). Nowadays, the morbidity and mortality is less because (hPL). Trophoblastic cells infiltrate the myometrium locally and
follow-up can diagnose the disease in the persistent gestational there can be vascular invasion as well. Their behavior is
trophoblastic stage (when the bhCG level plateaus or stops unpredictable. In the majority of cases (90%), this tumor remains
falling) and prompt chemotherapy cures the disease. benign. The main complaint is bleeding. There may be
Complications of H mole and invasive mole: amenorrhea and enlargement of the uterus and the pregnancy
1. Bleeding, which may be life-threatening test is positive. The growth is localized and may protrude into
2. Systemic disease the uterine cavity. Histopathology shows anastomizing cells,
3. Development of malignancy—choriocarcinoma. single mononuclear cells infiltrating the myometrium and blood
4. Acute pulmonary insufficiency—seen in some cases of H vessels. Usually, intermediate trophoblasts are seen.
mole with sudden dyspnea and cyanosis 4–6 hours after Cytotrophoblast and syncytiotrophoblast are fewer (unlike
evacuation. This may be due to pulmonary embolism. other GTD). The mitotic figures vary from 2/10 to 5/10 HPF
Hence, oxytocin is not used now before evacuation is complete. (more fatal). HPL immunoreactivity is strong and widespread
Choriocarcinoma (Figs 25.6 and 25.7A to B): It is a highly compared to hCG which is focal. Keratin is also positive in the
aggressive malignancy of trophoblastic tissue. Gross cytoplasm. Diploid flow cytometry for DNA pattern is present.
appearance, nowadays, chemotherapy is the mainstay of
therapy and surgery is rarely required. Therefore, gross
appearance of the tumor is not usually seen. The tumor is red,
granular with extensive necrosis and hemorrhage. Microscopic
examination is characterized by a dimorphic population of
cytotrophoblast and syncytiotrophoblast with numerous mitotic
figures and giant cells, without formed chorionic villi. There are
hemorrhagic nodules and extensive necrosis. Choriocarcinoma
cells are positive for hCG and keratin on immunohistochemistry.
Reactivity can be seen to pregnancy specific beta-1-glycoprotein
and CEA. Massive amounts of hCG is produced.
Choriocarcinoma has a highly metastatic potential. It can arise
as a result of any type of gestation. About 45% of the cases of
choriocarcinoma arise after a preceding H mole, 25% after normal
term pregnancy, 25% after spontaneous miscarriage and 5% after
an ectopic pregnancy. It can be seen several years after the last
conception.
Karyotype is variable.
176 Fig. 25.6: Gross choriocarcinoma
 Chapter 25
Figs 25.7A and B: (A) Choriocarcinoma (Mircorscopic appearance); (B) High view demonstrates biphasic nature of choriocarcinoma. The
syncytiotrophoblastic elements are enwrapped by more eosinophilic cytotrophoblastic tumor cells, Dr Anurag Mehta (Rajiv Gandhi CRIC)

It usually metastasizes to the lungs. But metastases can be seen Clinical Features

Trophoblastic Disease
in the brain, liver, kidney, vagina, stomach, spleen and lymph Complete Mole
nodes. The tumors, which tend to metastasize, can be life- Vaginal bleeding: Vaginal bleeding, especially in the first
threatening. These tumors arise and in 95% of the cases after a trimester, is the most common presenting complaint. Hence,
term pregnancy and 5% after molar pregnancy are extremely history of amenorrhea is important. Molar tissue may separate
insensitive to chemotherapy. It is amenable to surgery alone. from the decidua and be expelled as grape-like vesicles. The
Follow up is done by serum hPL levels. Differential diagnosis blood may be retained inside the endometrial cavity. This gives
is from other GTD (choriocarcinoma—by a less hemorrhagic the typical ‘prune juice’ like appearance to the discharge in these
histopathological picture and non-neoplastic proliferation of cases.
intermediate trophoblasts). Fetal heart: No fetal heart is heard.
Karyotype is variable.
Uterine size larger than the gestational age: Excessive uterine size
Epidemiology and Risk Factors relative to the gestational age is seen in about half the patients
of complete H mole. The size of the uterus often correlates with
Hydatidiform Mole
the level of serum hCG.
Incidence: The incidence of H mole is about 1/1000 pregnancies Differential diagnosis of hydatidiform mole is as follows:
in the United States of America. The incidence is higher in Asian 1. Multifetal gestation
countries ranging from 1/500 to 1/200 pregnancies. 2. Polyhydramnios
Maternal age: Women at the extremes of reproductive age are at 3. Uterine fibroid (especially with pregnancy when it enlarges
an increased risk. The incidence is two times higher after the rapidly)
age of 35 years and 7.5 times higher after 40 years. The incidence 4. Ovarian tumor in early pregnancy.
also rises sharply in the less than 20 years’ age group. Theca lutein ovarian cysts: About half the patients with complete
Blood group: ABO blood group of the GTD patient and her H mole have large theca lutein cysts, often more than 6 cm in
husband is important. A woman of group A with a group O partner diameter. They may cause pain. These cysts develop due to the
has about 10-fold greater risk of developing choriocarcinoma than hyperstimulation of the ovarian tissue by the high serum hCG
a woman of group A becoming pregnant with a group A partner. levels. In the majority of the cases, they regress spontaneously
Gestational trophoblastic tissue may also suppress the maternal in 8–12 weeks after the evacuation of H mole. Rarely, surgical
immune response through interleukin and tumor necrosis factor intervention may be required, as in rupture or hemorrhage or
(TNF). infection in these cysts. Patients with these cysts are more likely
Previous H mole: Risk of GTD is increased upto ten times when to develop choriocarcinoma.
there is history of previous H mole. Pre-eclampsia: Pre-eclampsia develops in about one-fourth of
Diet: Low dietary intake of carotene, protein and animal fats the cases of complete H mole in the first and second trimesters.
may be associated with increased risk of complete molar The reason for this may be the release of vasoactive substances
pregnancy. from the trophoblastic tissue.
Hyperthyroidism: High levels of serum hCG are sometimes
Choriocarcinoma associated with elevated free thyroxine (T4) and tri-
Incidence: In the United States of America, the incidence is 1/ iodothyronine (T3). This is possibly due to the thyrotropic effect
24,000 pregnancies; and in Asia, it is 1/6,000 to 1/8,000 of hCG. Sometimes a limited course of antithyroid drugs may
pregnancies. be needed.
Maternal age: As in the case of H mole, increasing maternal age Partial H Mole
increases the risk. So much so that the risk is 8-fold in women
The clinical features may be different in cases of partial mole.
of more than 40 years age.
Less than 10% of the patients have uterine enlargement greater
Previous H mole: The most important risk factor, however, is the than the period of amenorrhea. The incidence of theca lutein
history of previous H mole. These women have a 4–10 times cysts, hyperthyroidism, toxemia and respiratory insufficiency
higher risk of developing it. is also very low. The diagnosis of partial H mole is usually by 177
 ultrasound and histopathological. hCG levels are also to be
tested.
Invasive mole: It is reported within six months in
10–15% of cases who had hydatidiform mole. It is locally
invasive and sometimes produces distant metastases. By
penetrating the myometrium, it may cause hemoperitoneum. A
diagnosis can be made at hysterectomy only.
Choriocarcinoma: The patient is of a younger age. Previous
history of complete H mole, miscarriage or ectopic pregnancy
and normal delivery can be elicited in 25%. There is a higher
proportion of women with blood group A with the partner also
Disorders of Early Pregnancy

having the same blood group. The most common complaint is

continuous or intermittent bleeding which may be quite
massive. It is a very rapidly growing tumor.
Many organs show hyperplasia due to high levels of hCG
in the blood. This is seen as hyperplasia of endocervical glands,
decidual reaction of the endometrial glands, theca lutein cysts
of the ovaries, breast lobule hyperplasia and Arias Stella
phenomenon.
Placental site trophoblastic tumor (PSTT) is rare. It is preceded by
H mole or normal term pregnancy. It is limited to the uterus
Fig. 25.8: Pulmonary metastasis
and mostly spreads through lymphatics and rarely via vascular
channels. Metastases are very late as there is very little or no Gastrointestinal lesions may result in severe hemorrhage or in
syncytiotrophoblast. -hCG is not secreted, but hPL levels give perforation peritonitis requiring emergency intervention.
the diagnosis and are useful for follow up.
Work up Before Treatment
Metastatic Trophoblastic Disease
1. History of abortion, H mole or normal delivery
Section 4

Complete H moles have a potential for local invasion and 2. Examination of the patient including general and pelvic
dissemination. After molar evacuation, local uterine invasion examination.
occurs in 15% of patients and metastasis in 4% (Berkowitz and
Goldstein, 1981). Investigations
Metastasis in the majority of cases has the histology of Laboratory studies:
choriocarcinoma. Metastatic spread is hematogenous; and 1. Serum -hCG. This glycoprotein hormone is secreted by
because of its extensive vascular network, metastatic GTD the syncytiotrophoblast. Because all trophoblastic tumors
produces local bleeding. secrete -hCG, this hormone serves as an excellent marker
Common metastatic sites of GTD are lungs (80%); vagina for tumor activity in the non-pregnant patient. In normal
(30%); pelvis (20%); liver (10%); brain (10%); and bowel, kidneys pregnancy, the values are below 60,000 MIU/ml. Values
and spleen (5% each). (Berkowitz and Coworkers, 1994) and above 100,000 MIU/ml are diagnostic. The -hCG level is
bones. always elevated in a molar pregnancy and, therefore, should
Pulmonary metastasis (Fig. 25.8) is the most common and may be measured in all cases. Serial -hCG levels must be
present as hemoptysis, cough, chest pain, dyspnea or monitored during therapy to ensure adequate treatment.
asymptomatic lesions on chest X-ray. The radiological features The level of the hormone is proportional to tumor burden.
can be alveolar, nodular or miliary patterns. There may be The ratio of -hCG in serum and cerebrospinal fluid
discrete round densities (Kumar and Associates, 1988). Pleural (CSF) is measured in cases of metastatic disease to exclude
effusions may also be seen.
Some patients present primarily with respiratory symptoms
and their reproductive organs may be free of the disease. In
such cases, establishing a diagnosis is possible only after
histopathological examination of the lung or pleural tissues.
Vaginal metastatic lesions are highly vascular bluish nodules,
which may bleed vigorously if biopsied. The patient presents
with irregular bleeding and purulent discharge (Fig. 25.9).
Hepatic metastasis usually present with right upper quadrant
pain due to stretching of the Glisson’s capsule. Rarely, the
hepatic lesions may cause liver rupture and exsanguinating
intraperitoneal hemorrhage (acute abdomen).
Central nervous system: Involvement from metastatic GTD
suggests widespread disease and poor prognosis. These patients
may present with headache, hemiparesis, vomiting, giddiness,
coma, convulsions, visual disturbances, aphasia and slurred
speech. All patients have concurrent pulmonary metastases. Fig. 25.9: Vaginal metastatic lesion
178
 cerebral involvement. The serum/CSF -hCG ratio of less numeral after the stage in Roman numeral, separated by a colon.
than 60 is considered positive for brain metastases. For example, a patient who has been classified as stage II and
2. Complete blood counts has the risk scoring of 5 will be expressed as FIGO stage II: 5.
3. Hepatic, thyroid and renal function tests.
Risk factors affecting staging include the following:
1. Level of human chorionic gonadotropin >100,000 mIU/ml
Radiologic Studies
and
1. Chest X-ray and CT scan of the chest: X-ray is always done to 2. Duration of disease longer than 6 months from the termination
rule out metastatic lung disease. Chest CT scan is very useful of antecedent pregnancy.
to evaluate any non-specific lesion. It may also demonstrate Gestational trophoblastic disease can be non-metastatic and
micrometastases in the presence of normal X-ray. metastatic:
2. Ultrasonogram or CT scan of the abdomen and pelvis: 1. Non-metastatic GTD: There is no disease outside the uterus.
Ultrasonography is the preferred diagnostic modality as it

Chapter 25
2. Metastatic GTD: The disease is spread outside the uterus.
is reliable, safe and economical to confirm diagnosis of GTD. In these cases, the following factors should be considered
There is no fetus in complete H mole and snow storm and noted in reporting:
appearance filling the uterus, confirm the diagnosis (Fig. i. Duration of disease shorter (duration less than 4 months)
25.3). Partial mole may show a fetus too (Fig. 25.4). A ratio has better prognosis,
of transverse diameter and anteroposterior dimensions of ii. Serum hCG level (less than 40,000 mIU/ml has better
the gestational sac greater than 1.5 is seen in partial molar outcome,
pregnancy. There are multiple echoes. iii. Metastatic sites: Lung and pelvic metastasis has better

Trophoblastic Disease
3. These days, Doppler ultrasonography has been found to prognosis than metastasis to the brain or liver.
be very useful in the diagnostic assessment of GTD (Carter iv. Prior chemotherapy: If no chemotherapy is given before,
and Coworkers, 1993). it a has better response.
4. CT scan head: CT scan of the head is not routinely advocated v. GTD following abortion gives better results with
as normally brain metastases are very rare in the absence treatment than one following full term pregnancy.
of lung involvement. Only if the X-ray shows lung vi. Placental site tumors should be reported separately;
secondaries should a CT scan of the head be done. histologic verification of disease is not required (Table
5. Magnetic resonance imaging (MRI): MRI may be useful in 25.5).
equivocal cases, particularly for evaluating the cerebellum Metastatic tumors seen are usually choriocarcinoma. It can
and the brainstem, which are sites of occult metastasis. It mimic many diseases and may present with the sign and
can be used for the evaluation of the abdomen and the pelvis. symptoms of stroke, intracranial bleeding, cerebral or spinal
6. In selected cases, angiography of the abdominal and pelvic cord tumors, liver infections, blood in urine or stools and
organs may be indicated. pulmonary disease. Acute abdomen may be due to rupture of
liver or ovarian cyst. The hCG titer clinches the diagnosis. Tissue
Staging of Gestational Trophoblastic Disease
diagnosis of choriocarcinoma is unnecessary; it can be
The FIGO staging system (Table 25.2) is based on the anatomic misleading and may be dangerous.
criteria. In GTD stage I, the disease is confined to the uterus; The FIGO 2000 staging and Risk Factor Scoring system
stage II includes disease limited to the genital structures; stage for gestational trophoblastic neoplasia (GTN).
III involves metastasis to the lungs, and stage IV is metastasis In September 2000, a combined FIGO anatomic staging with
to any other site. a revised WHO risk factor scoring system was promulgated,
The anatomic staging system remains basically the same which was accepted by the FIGO oncology committee in 2002.
(Table 25.2). The only difference in the revised 2002 classification One of the prerequisites of the staging system is to
is that the actual numerical risk factor is mentioned in Arabic define its inclusion criteria. The criteria for diagnosis of

Table 25.2: FIGO Staging gestational trophoblastic tumors (Anatomical)

Stage I Disease confined to uterus
Stage A Disease confined to uterus with no risk factors
Stage B Disease confined to uterus with one risk factors
Stage C Disease confined to uterus with two risk factors
Stage II Gestational trophoblastic tumor extending outside uterus but limited to genital structures (adnexa, vagina, broad
ligament)
Stage II A Gestational trophoblastic tumor GTT involving genital structures without risk factors
Stage II B GTT extending outside uterus but limited to genital structures with one risk factor
Stage II C GTT extending outside uterus but limited to genital structures with two risk factors
Stage III Disease extending to lungs with or without known genital tract involvement
Stage IIIA Gestational trophoblastic tumor extending to lungs with or without genital tract involvement and with no risk
factors
Stage IIIB Gestational trophoblastic tumor extending to lungs with or without genital tract involvement and with one risk
factors
Stage IIIC Gestational trophoblastic tumor extending to lungs with or without genital tract involvement and with two risk
factors
Stage IV All other metastatic sites
Stage IVA All other metastatic sites without risk factors
Stage IVB All other metastatic sites with one risk factor
Stage IVC All other metastatic sites with two risk factors
Placental site tumors should be reported separately.
179
 Table 25.3: Criteria for the diagnosis of post-hydatidi-form mole Table 25.5: Criteria for methods used to diagnose metastases in
trophoblastic neoplasia (GTN) trophoblastic neoplasia

1. GTN may be diagnosed when the plateau of human chorionic 1. Chest X-ray is appropriate to diagnose lung metastases and it is
gonadotropin (hCG) lasts for 4 measure-ments over a period of chest X-ray that is used for counting the number of lung
3 weeks or longer, that is days 17, 14, 21. metastases to evaluate the risk factor score.
2. GTN may be diagnosed when there is a rise of hCG on three 2. Liver metastases may be diagnosed by CT scanning or by
consecutive weekly measurements over a period of two weeks ultrasound.
or longer days 1, 7, 14. 3. Brain metastases may be diagnosed by MRI or CT scanning.
3. GT N is diagnosed if there is histologic diagnosis of 4. To diagnose intra-abdominal metastases, CT scanning is
choriocarcinoma. preferable.
4. GTN is diagnosed when the hCG level remains elevated for 6
months or more.
Disorders of Early Pregnancy

prior chemotherapy. Patients with high-risk scores should be

post-hydatidiform mole trophoblastic neoplasia are given as treated with combination chemotherapy to avoid the risk of
in (Table 25.3). resistance.
Certain changes from the 1983 WHO classification have been
made in this new FIGO 2002 classification for risk scoring (Table Treatment of Gestational Trophoblastic Disease
25.4). The risk score for ABO blood group is eliminated and H Mole
risk factor for liver metastases is upgraded from 2–4. Another Suction evacuation is the method of choice for evacuation of
major change is that the middle risk category of the WHO complete molar pregnancies. The procedure can be carried out
classification has been eliminated. A score of 6 or less is low under I/V sedation but should always be performed in the
risk and 7 or more is high risk. presence of an anesthetist. Adequate blood should be arranged
Table 25.5 shows the criteria recommended by FIGO to before starting the procedure. The cervix should be dilated up
diagnose metastases in trophoblastic neoplasia. to 12 mm. The routine use of oxytocic agents should be avoided
Placental site trophoblastic tumor will be categorized before or during the procedure as the contractions of the
separately from other gestational trophoblastic neoplasia. myometrium may lead to embolization and dissemination of
The actual level of hCG or the amount of rise will be trophoblastic tissue through the venous system from the site of
determined by the individual investigator.
Section 4

placenta. Hence, it is recommended that where possible, the

This may not apply for patients with unexplained low level oxytocic infusion should commence only once evacuation has
hCG without clinical or imaging evidence of GTN. been completed (RCOG Guideline No 38, Feb 2004). However,
The identification of an individual patient’s stage and risk if the patient is experiencing significant hemorrhage prior to
score will be expressed by allotting a Roman numeral to the evacuation, then oxytocic infusion should be started earlier.
stage and an Arabic numeral to the risk score separated by a Sharp curettage should be done at the end of the procedure.
colon. All the products of conception along with the curetted material
Anatomical Staging and Prognostic Scoring Systems should undergo histological examination. There is no role of
FIGO anatomical staging is commonly followed. A number repeat curettage after one week or later. Rh prophylaxis is to
of adverse prognostic factors have been identified. These be given in Rh negative patients according to gestation period.
include: (i) type of antecedent pregnancy, (ii) the interval from If on ultrasound, one viable fetus is seen along with molar
the antecendent pregnancy, (iii) the serum -hCG concentration, changes, the mother is to be counseled. If she desires, the
(iv) number and size of metastases, and (v) the site of specific pregnancy can be continued till term. If she wants termination,
metastases and failure of prior chemotherapy with two or more a medical method can be used.
drugs.
Hysterectomy as the mode of treatment in H mole can be
Based on the above factors, the WHO has proposed a
considered if the patient is more than 40 years of age and does
prognostic scoring system that reliably predicts the potential for
not desire future pregnancy. Ovaries need not be removed. But
resistance to chemotherapy (Table 25.6). A patient is considered
postoperative follow-up monitoring is a must for these patients
to have high risk of chemotherapy-resistant disease if the
also.
prognostic score is higher than 7. A higher score is generally seen
in patients with liver or CNS metastases. The distinction between Role of prophylactic chemotherapy in H mole: The role of prophylactic
low risk and high risk, therefore, applies to patients with stage II chemotherapy in cases of H mole after suction and evacuation is
disease (vaginal metastases) or stage III disease (lung metastases). controversial. High-risk patients such as those with (i)
A high-risk score is generally associated with a large tumor preevacuation -hCG levels >100,000 mIU/ml, (ii) uterine size
burden (multiple metastases, large metastases), a protracted delay more than the period of amenorrhea, and (iii) theca lutein cysts
in diagnosis, a nonmolar antecedent pregnancy, or the failure of >6 cm have been seen to benefit after a single course of

Table 25.4: FIGO risk factor scoring values (Modified WHO scoring) of H mole

FIGO Scoring 0 1 2 4
Age <4 >4 – –
Antecedent pregnancy Mole Abortion Term –
Interval in months from index pregnancy <4 4–<7 7–<13 13
Pretreatment serum hCG (IU/L) <103 103–<104 104-<105 105
Largest tumor size (including uterus) cm <3 3–<5 5 –
Site of metastases Lung Spleen, kidney Gastrointestinal tract Liver brain
Number of metastases – 1–4 5–8 >8
Previous failed chemotherapy – – Single drug 2 or more drugs
180
 Table 25.6: WHO scoring system based on prognostic factors of H mole

Prognostic Factor Score

0 1 2 4
Age (years) 39 >39
Antecedent pregnancy H Mole abortion Term
Interval (mon) between <4 4–6 7–12 >12
Antecedent pregnancy and
Start of chemotherapy
-hCG(mIU/ml) <1000 1000–10,000 10,000–1 lac >1lac
Largest tumor
Including uterine (cm) <3 3–5 >5

Chapter 25
Site of metastases Lungs spleen, GIT Brain
kidney liver
No of metastases 1–3 4–8 >8
Identified
Prior chemotherapy One drug Two or
more drugs
The total score for a patient is obtained by adding the individual score for each prognostic factor. Total score <6 = low risk, 7 or more high risk.

Trophoblastic Disease
prophylactic chemotherapy with Methotrexate or Dactinomycin. reproductive function. Chemotherapy is instituted for non-
The disadvantage of giving prophylactic chemotherapy is the metastatic as well as metastatic gestational trophoblastic disease
risk of developing resistance to the drugs and also over treatment according to the risk scoring.
of a large percentage of patients with such toxic drug who in the
normal course will not develop persistent gestational Single Agent Chemotherapy
trophoblastic disease. Thus, the role of prophylactic For low-risk patients (mostly corresponding to clinical stages I
chemotherapy is limited to high-risk patients and those patients and II) with no metastasis, single agent chemotherapy is started.
(in Safdarjung Hospital) who are unlikely to come for close follow The most commonly used drug for single agent chemotherapy
up (as most of our patients are from different states). It can also is methotrexate. Methotrexate is an antimetabolite. It binds to
be given in patients in whom follow-up hCG titer is high. dihydrofolate reductase. This prevents purine production. Side
Follow-up: Strict follow up in cases of H mole is of utmost effects seen in Safdarjung Hospital are nausea, vomiting,
importance. Normally, after evacuation, serum -hCG anorexia and stomatitis. Folinic acid is used as ‘rescue’ in all our
progressively declines and comes to normal within 14 days. The cases. Pretherapy hemoglobin level, TLC, DLC, platelet count,
patient is examined one week after evacuation and the first blood blood urea nitrogen, creatinine, liver function tests, and chest
sample for -hCG is taken. The uterine size is examined and radiographs are done.
ovarian cysts are looked for. Vulva, vagina, urethra and cervix The most preferred regime is injection methotrexate 1 mg/
are inspected to rule out secondaries. She is again examined after kg/day on days 1, 3, 5 and 7 and injection folinic acid 0.1 mg/
one month. If pre-evacuation chest X-ray showed pulmonary kg/day on 2, 4, 6 and 8. After completion of each cycle, blood
metastasis, then another X-ray is done after 4 weeks. If remission is sent for serum -hCG, complete blood counts, liver function
is seen, a repeat X-ray is done every 3 months till 1 year. test and kidney function test. The cycle can be repeated after
A weekly serum -hCG level is done. If there is a steady a week depending on the marrow recovery. The cycle is
decline, the follow up is continued in this manner till three stopped if WBC count is less than 3,000, neutrophils are less
consecutive values are normal. After this, monthly titers are than 1,500, platelets are less than 100,000 or there are
done for 1 year (i.e. a total of one year after three consecutive alterations in blood urea nitrogen, creatinine, AST, ALT or
negative reports). bilirubin or side effects (stomatitis, gastrointestinal ulceration
or fever) are severe.
Persistent Gestational Trophoblastic Tumor The other regime for low-risk GTD uses methotrexate alone
In case the hCG titer plateaus for 3 weeks or the titer rises, the as 0.4 mg/kg IM or IV daily for 5 days and repeated every 7–10
diagnosis of persistent gestational tropho-blastic tumor is made days.
after excluding pregnancy by ultrasound examination. Such Dactinomycin (Actinomycin-D) as a 5-day course (10
patients often present with irregular vaginal bleeding, they are microgram/kg IV) every alternate week or as pulse dose of 1.25
more likely to develop dyspnea or abnormal neurological mg/m2 IV every two weeks are alternate regimens.
complaint from metastasis. A complete metastatic work up is Adequate response to treatment is defined as fall in -hCG by 1 log
warranted in such cases, which includes a chest X-ray, complete after a course of chemotherapy. Therapy is continued for three
hemogram, liver function test, ultrasound and CT of the whole cycles after 3 consequent negative normal serum beta-hCG levels is
abdomen and brain. The tumor should be staged according to achieved.
the FIGO staging (Table 25.2). The WHO prognostic scoring Single agent chemotherapy is less toxic and this toxicity
(Table 25.6) is done and treatment advocated according to the gets reversed easily and hence is well- tolerated. In a study
risk. by Berkowitz and Associates (1986), only 14% patients
Follow-up is the same as in H mole. developed hepatotoxicty, 6% granulocytopenia and 1.6%
thrombocytopenia following methotrexate-folinic acid therapy.
Chemotherapy
The chief side effects of Dactinomycin are nausea and vomiting.
Chemotherapy has radically changed the prognosis of GTD If single agent therapy fails, then multidrug chemotherapy is
without surgery and hence has helped in preserving started.
181
 Multiagent Chemotherapy EMA-EP: This regime uses cisplatin (100 mg/m2) and etoposide
Multidrug chemotherapy is the first line treatment for the high- (200 mg/m 2) combined with etoposide, methotrexate and
risk group according to the WHO prognostic scoring. It is also dactinomycin as in EMA-CO (Surwit and Childers, 1991).
given for low-risk cases, which shows resistance to single drug EMA-POMB: It combines EMA along with cisplatin, vincristine,
treatment (less than one log fall of -hCG). methotrexate and bleomycin.
Some of the multiagent regimens are MAC (methotrexate,
PEBA: In this regime, cisplatin, etoposide, bleomycin and
dactinomycin and cyclophosphamide or chlorambucil); EMA-CO
doxorubcin are given.
(etoposide, methotrexate, dactinomycin, cyclophosphamide and
vincristine [oncovin]); EHMMAC (etoposide, hydroxyurea, ICE: This consists of ifosfamide, carboplatin and etoposide. This
methotrexate, dactinomycin, vincristine and cyclo- regime has been used along with autologous bone marrow
phosphamide), and CHAMOCA (cyclophosphamide, transplantation with some success. Lung metastases have a very
hydroxyurea, methotraxate, vincristine and dactinomycin). good prognosis in 90% of cases. Treatment failure is mostly
Disorders of Early Pregnancy

Pretreatment work up is done. due to bone marrow and gastrointestinal toxicity.

EMA-CO at present provides the best results with lowest Irradiation: It is helpful especially in brain and liver metastasis
side effects and this drug regimen is used in the Department of concomitantly with multidrug chemotherapy. On diagnosing
Obstetrics and Gynecology at Safdarjung Hospital (Table 25.7). brain metastases on history, clinical examination and CT,
The drugs are given on every other week schedule. immediate treatment is 2,000–3,000 cGY whole brain
-hCG level is monitored every week. Drugs are continued till irradiations (in 10 fractions). This prevents hemorrhage at once
three consecutive -hCG values in the serum are less than 1 and treats the tumor. There is a 50% cure. For liver metastasis
mIU/ml. A minimum of three courses are given after a normal (difficult to control), irradiation is also used. There are chances
titer has been reached. of massive hemorrhage leading to death. Some authorities
If the courses are not given according to schedule, the tumor recommend whole liver irradiation of 2,000 cGY in case of
recovers and it cannot be treated because of so-called extensive or subcapsular metastasis. There is about 25% cure.
development of resistance.
Arterial embolization; It is considered in cases of acute bleeding
EMA-CO Regime for High-risk GTD in brain and hepatic metastasis.
The most preferred regime for high-risk GTD is the EMA-CO
Role of Surgery in Metastatic Disease
regime. This is also used for single drug-resistant low-risk
Section 4

group. The therapy is quite well- tolerated without any serious It is considered in resistant cases and cases where no
side effects. Mild bone marrow depression, stomatitis and reproductive function is desired.
alopecia are the common side effects seen in our cases in Hysterectomy
Safdarjung Hospital, which are entirely reversible.
Hysterectomy has a definite role in patients with bulky uterine
An important point to be kept in mind while giving
disease to reduce the tumor load. This decreases the number of
chemotherapy to high-risk patients with a heavy tumor load is
chemotherapy cycles required for complete cure (Soper, 1994).
the possibility of hemorrhage into the tumor and surrounding
It is also useful in high risk group, atypical hystologic findings,
tissue after initiation of chemotherapy.
frequent need for salvage chemotherapy.
Any unusual symptom reported by the patient after starting
Hysterectomy is also required in patients who have repeated
chemotherapy should be viewed with a high index of suspicion.
and uncontrolled hemorrhage.
Treatment for Refractory Cases But it should be emphasized that even after surgery,
chemotherapy is a must with proper follow-up. This takes care
For women who are refractory to EMA-CO and fail to achieve
of the secondaries and recurrence.
complete remission, alternative regimens are to be considered.
Almost all these regimens use cisplatin as one of the drugs. Because Craniotomy
of significant nephrotoxicity, cisplatin containing regimens are not Craniotomy may be required in some cases of cerebral
given for primary therapy in GTD. They are, however, an effective metastasis for decompression and control of bleeding. Local
salvage therapy. resection of cerebral tumor resistant to chemotherapy has also
The various regimens which have been clinically tried with been tried in a few patients.
favorable results are:
Thoracotomy
Table 25.7: Showing EMA-CO – Regimen
Thoracotomy has a role in cases of localized pulmonary
Course 1 (EMA) DRUG DOSAGE metastases which are not sensitive to chemotherapy. The
Day-1 Etoposide 100 mg/m2 IV over 30 min resistant focus is excised.
Methotrexate 100 mg/m2 IV bolus
Laparotomy
Methotrexate 200 mg/m2 IV as 12h continuous
infusion Laparotomy for perforation peritonitis in cases of
Dactinomycin 0.5 mg IV bolus gastrointestinal metastasis is needed as an emergency procedure
Day-2 Etoposide 100 mg/m2 IV over 30 min (very rarely).
Leucovorin 15 mg IV/IM/PO every 12 h for 4 Hepatic Resection
doses, beginning 24 h after start
of methotrexate Hepatic resection may be required as an emergency life-saving
Dactinomycin 0.5 mg IV bolus measure to control hemorrhage from the tumor in an occasional
Course 2 (CO)
case of hepatic metastasis.
Hepatic resection may also be needed for focal-resistant
Day-8 Cyclopho- 600 mg/m2 IV over tumor.
sphamide 30 min
182 Vincristine 1 mg/m2 (up to 2 mg) IV bolus Follow-up in choriocarcinoma involves measuring weekly hCG
levels till three consequent normal studies are obtained. Give two
more courses of drug. Follow-up every month for 24 months The tumor is often rapidly growing and may present as
because higher stage cases have an increased risk of late pressure symptoms of bladder or bowel and in some cases as
recurrence. menstrual irregularities. In the prepubertal girl, it may present
Treatment of placental site trophoblastic tumor (PSTT): It is usually as precocious puberty.
resistant to drugs and hence hysterectomy is required. If it has The most important diagnostic marker of these tumors is
metastasized, then EP-EMA regimen gives better results. the presence of high -hCG levels in the serum. A complete
Paclitaxel and topotecan may be used in resistant cases. metastatic work up which includes liver function tests, chest
X-ray, ultrasonogram of the abdomen and pelvis and a CT or
Prognosis MRI of the chest and skull should be undertaken.
• H mole: After evacuation, it has a very good prognosis. The These tumors are chemosensitive. Although surgery plays
patient is kept under surveillance. an important role in the diagnosis and initial treatment (staging
• Choriocarcinoma: Nonmetastatic, survival is 90% with laparotomy), complete resection of the reproductive organs is

Chapter 25
chemotherapy. In metastatic tumor, EMA-CO regimen has rarely necessary in the group of young women who wish to
the best prognosis. Lung metastases have the best prognosis. preserve their fertility.
Brain and liver give 50–80% prognosis. The mainstay of the treatment is chemotherapy. Different
If prior chemotherapy is given and has failed, the prognosis regimes as describe for gestational trophoblastic tumors have
is not good. been used with varying results.
Recurrence occur mostly in the first 6 months but can be seen The prognosis is poor, as most patients have already
after 3 years. metastasized at the time of diagnosis.

Trophoblastic Disease
Contraception in Patients of GTD BIBLIOGRAPHY
The patients of gestational trophoblastic disease require a very 1. Alhamden D, Bignardi T and Condons G. Recognising GTD. Best
effective contraception during the period of follow-up. This is Pract. Res. Clin Obstet Gynecol. 2009;23:565.
2. Bagshawe KD, Lawler Sd, Paradmas FJ, et al. GTT following initial
because a fresh pregnancy will raise the hCG levels and cause
diagnosis of partial H. Mole Lancet 1990;335:1074.
confusion in the follow-up. 3. Berkowitz RS, Goldstein DP, Bernstein MR. Ten years experience
Combined oral contraceptives are a safe and effective means with methotrexate and folinic acid as primary therapy for GTD.
of contraception once the hCG levels have come back to normal. Gynecol Oncol 1986;23: 18,111.
Patients with H mole are advised not to conceive until the hCG 4. Berkowitz RS, Bernstein MR, Laborde O, et al. Subsequent pregnancy
levels are normal for at least six months. Women who undergo experience with gestational trophoblastic disease: New England
chemotherapy should not conceive until at least one year after Trophoblastic Disease Center, J Reprod. Med 1994;39:228-32.
the completion of treatment. In chorio-carcinoma, a total of two 5. Berkowitz RS and Goldstein DP. Chorionic tumors. New Eng Jn
Med 1996;335:1740-48.
years before conception is considered safe by many authors.
6. Carter J, Fowler J, Carlson J, et al. Transvaginal color flow Doppler
sonography in the assessment of gestational trophoblastic disease.
Future Pregnancy Experience J Ultrasound Med 1993;12:595-9.
The risk of a repeat molar pregnancy after H mole is only about 7. Fine C, Bundy AL, Berkowitz R. et al. Sonographic diagnosis of
1%. However, the risk increases to about 15–28% after two molar partial H mole. Obstet Gynaecol 1989; 73:414.
pregnancies. The recurrence is mostly of the same histological 8. Kumar J, Ilancheran A, Ratnam SS. Pulmonary metastasis in
type. The chances of developing persistent disease increase by gestational trophoblastic disease: A review of 7 cases. Br. J Obstet
Gynaecol 1988;95:70.
three times in case of a repeat mole. Hence, when pregnancy
9. Kim SJ, Bae SN, Kim JH, et al. Effects of multiagent chemotherapy
occurs after proper follow-up, -hCG and ultrasound are and independent risk factors in the treatment of high risk GTT-25
essential. years experiences of KRI-TRD. Int J Gynecol and Obstet
Recovery of fertility after chemotherapy normally takes 1998;60(1):S85-S96.
place within one year. The rate of premature deliveries and 10. Lee YS. P53 expression in gestational trophoblastic disease. Int J
congenital malformations is the same as in the general Gynecol Pathol 1995, 14, 114. - Lage JM, Popek EJ, The role of DNA
population. But early monitoring with ultrasound and -hCG flow cytometry in evaluation of partial and complete hydatidiform
is necessary for recurrent GTD. After delivery, send the placenta mole and hydrops abortions. Semin Diagn Pathol 1993;10:267.
11. Mc Greger C, Ontiveros E, Vargas LE, et al. Hydatidiform mole,
for histo-pathological examination and call the patient after 6
analysis of 145 patients. Obstet Gynecol 1969;33: 343.
weeks and measure serum -hCG. 12. Newlands ES, Bower M, Holden L, et al. The manage-ment of high
Secondary tumors: Tumors like myeloid leukemia colon cancer risk gestational trophoblastic tumors (GTT). Int J Gynecol and
and breast cancer as seen after multiple drug regimens Obstet. 1998;60(1):S65-S70.
(especially ones with etoposide) but not with single drug 13. Rusting CJS, Newland ES, Lutz JM et al. Combi-nation but not single
agent methotraxate chemo-therapy for gestational trophoblastic
therapy (Rusting and Associates, 1996).
tumor increase the incidence of second tumor J Clin Oncol
1996;14:2769.
Non-gestational Choriocarcinoma
14. Soper JT: Surgical therapy for gestational tropho-blastic disease. J
Non-gestational pure choriocarcinoma of the ovary is a very Reprod med 1994;39:168-74.
uncommon tumor. It is seen mostly in the adolescent age group. 15. Surwit EA, Childers JM: High risk metastasic gestational
This tumor is a germ cell tumor derived from primordial germ trophoblastic disease: A new dose intensive, multiagent
cells of the ovary. Although most germ cell tumors arise in the chemotherapeutic regimen. J Reprod Med 1991;36:45-8.
gonad; sometimes, they may be formed in extragonadal sites 16. Tham BW, Everand JE, Tidy JA et al. Gestational trophoblastic
disease in Asian Population of Northern England and North Wales.
such as the retroperitoneum and the mediastinum.
Brit. J Obst Gynae 2003; 110:555.
Histologically, the tumor is the same in appearance as the 17. Woolas RP, Bower M, Newlands ES, et al. Influence of chemotherapy
gestational choriocarcinoma which has metastasized to the for gestational trophoblastic disease on subsequent pregnancy
ovary. outcome. Brit Jn Obstet and Gynaecol 1998;105:1032-5.
183
 26 Recurrent Pregnancy Loss

Sudha Salhan, Indira Ganeshan, Harsha Gaikwad

A miscarriage causes a great emotional setback in the woman d. Tetraploidy: Fetal death may also be the result of mutation.
and the family. Recurrent pregnancy loss is defined as three or e. Isolated mutation or polygenic factors.
more consecutive spontaneous miscarriages, without f. Inherited thrombophilia in mother.
intervening term pregnancy. Some obstetricians start g. Chromosomal rearrangement.
investigating after two consecutive miscarriages. Most of the h. Chromosomal inversion. X-chromosome inactivation (of
pregnancy loss occurs before implantation, which is either parent) may carry an X-linked recessive fetal-lethal
approximately 70–75% of the fertilization, and only 25–30% is trait making them susceptible to recurrent early pregnancy
clinically recognized. Early pregnancy loss is limited to those loss (Lansasa and Coworkers, 2000).
pregnancies, which are lost after implantation. The incidence of i. Aneuploidy
pregnancy loss is increased after each miscarriage. Hence, an
Reasons
endeavor to find out the exact cause is of paramount importance.
The risk of spontaneous miscarriage for a lady with no previous Increasing age of both the partners is important as chromosomal
history of abortion is 15%, the likelihood of repeat miscarriage abnormalities are more if the woman is more than 35 years of
after the first pregnancy loss is 20%, with two previous age and the man 40 years or more.
miscarriages the risk is 30–35% and in patients with three • Error in maternal or paternal meiosis.
previous miscarriages it is nearly 50%. • Fertilization of one ovum by more than one sperm.
The history of a blighted ovum with spontaneous • A chromosomal division takes place but no cytoplasm
miscarriage signifies a genetic origin. This is unlike the patients division occurs.
who abort after the fetal tissues are formed in whom one needs
Anatomic Abnormalities of the Uterus
to investigate for a non-genetic causes of pregnancy loss.
These are responsible for 15% of all miscarriage with normal
ETIOLOGY fetal development. The anatomic abnor-malities of uterus could
The exact etiology of recurrent pregnancy loss is not completely be categorized into:
understood, but the following factors are contributory: a. Congenital defects of the uterus.
1. Genetic abnormalities b. Acquired defects of the uterus.
2. Anatomic abnormalities of the uterus a. Congenital defects of the uterus could be Mullerian duct
3. Endocrine factors abnormalities, defects due to DES exposure in utero, or
4. Coagulation and immunological causes cervical incompetence. The Mullerian anomalies could be
5. Infections and chronic diseases of formation or fusion like septate uterus, bicornuate uterus
6. Defective placentation (Figs 26.2, 26.3, 56.3, 57.13 and 58.15) or unicornuate uterus.
7. Environmental toxins These are associated with early pregnancy loss because of
8. Psychological depression. deficient blood supply or because of implantation in the
relatively avascular endometrium or septum.
Genetic Abnormalities
Eighty percent of miscarriages in this category occur at less than
8 weeks and are often blighted ova.
Chromosomal abnormalities most commonly found in
miscarriages are:
a. Autosomal Trisomy: like chromosome 16, 21 and 22. The
commonest one is trisomy of chromosome 16, which is
because of non-disjunctional defects (Fig. 26.1).
b. Monosomy X: The karyotype seen usually in this category is
45X. Many of these are not aborted and present at birth as
Turner ’s syndrome. This is as a result of loss of X
chromosome at the time of fertilization or because of non-
disjunction.
c. Triploidy: The sac might be empty or may have a malformed
fetus. The cause is double fertilization of a single ovum. Fig. 26.1: Trisomy 16
 a very reliable guide, as the production of progesterone is
pulsatile and there is marked fluctuation in serum levels.
Secondly, the low serum progesterone level is the
consequence of a blighted ovum or some fault in the
pregnancy rather than it being a cause of early pregnancy loss.
17-hydroxy progesterone is a better marker than serum
progesterone.
b. Thyroid function abnormalities: Hypothyroidism is not a usual
cause of miscarriages. But thyroid autoantibodies are
associated with an increased incidence of pregnancy loss
despite no overt hypothyroidism. This point is debated by
some (Esplin et al, 1998).

Chapter 26
c. Diabetes mellitus: Patients with elevated glycosy-lated
hemoglobin level HBAIC (uncontrolled state) and elevated
blood glucose in the periconceptional and early conceptional
Fig. 26.2: Bicornuate uterus at laparotomy period have a higher incidence of spontaneous miscarriage.
Impaired GTT, hypertension, hypertriglyceridemia and a
procoagulant state (syndrome X) may also cause recurrent
miscarriage. Well-controlled diabetic women do not suffer

Recurrent Pregnancy Loss

from recurrent miscarriage.
d. Maternal hyperandrogenicity: Elevated levels of serum
testosterone and dihydroepiandrosterone sulfate—DHEAS,
(either from ovarian or adrenal glands or both) cause
dysfunction of the corpus luteum. The mechanism is not
well-understood but androgens may be an extraglandular
source of estrogen.
e. Polycystic ovarian disease: Chances of spontaneous abortion
are more in these patients than in the rest of the population.
The elevated serum LH levels seen in this condition cause
corpus luteal dysfunction. This high level may directly
influence the oocyte and the endometrium or indirectly the
ovarian hormone production. Increased levels of LH
Fig. 26.3: Bicornuate uterus on hysterosalpingography
concentration throughout the cycle (a single high level is
DES exposed uterus is usually a small T-shaped uterus not predictive) increase the chance of miscarriage. Insulin
and can also have an incompetent cervix, this usually causes resistance is also investigated as a cause.
late or second trimester miscarriage. f. Premature ovarian failure: In this condition, the oocytes are
b. Acquired defects could be an incompetent cervix, defective and may cause repeated miscarriage.
Asherman’s syndrome and fibroid uterus. Asherman’s
Coagulation and Immunological Causes
syndrome or uterine synechiae are because of surgical
trauma to a large area of the endometrium by curettage or a. Autoimmune factors against self
intrauterine infections leading to varying degrees of b. Positive antinuclear antibody test (ANA)
obliteration of uterine cavity depending on the degree of c. Alloimmune factors against the fetus and the male partner.
adhesions. Cervical incompetence is associated with Hereditary and acquired thrombophilia is an important
recurrent second trimester pregnancy loss. The fetus is factor. Deficiency of antithrombin; Protein C and Protein S,
normal in such cases but is not retained. The most common factor V Leiden and prothrombin A variant are known to cause
cause is acquired following surgical procedures like D&E, recurrent miscarriage.
D&C and MTP or could be following cone biopsy of the Autoimmune factors (Immunity against self): Approximately 15%
cervix, cauterization or amputation. The size of the fibroid of recurrent pregnancy loss has a recognized autoimmune
is not important, but its location plays a significant role in factor. High levels of antiphospholipid (APL) antibodies (IgG,
causing miscarriage. Submucousal and intracavity fibroids IgA or IgM isotopes) lead to repeated miscarriage and are
are associated with implantation defects and miscarriage responsible for 3–5% of cases. The frequency of miscarriage in
(Pritts, 2001). Rarely, cervical incompetence could be the untreated group in this condition is almost 85–90%. There
congenital. are several antiphospholipid antibodies. Most relevant of these
are lupus anti-coagulant, anticardiolipin antibodies and the
Endocrine Factors antibody that causes false-positive syphilis test. The majority
a. Progesterone deficiency: Progesterone is important to maintain of pregnancy loss is in the second trimester. Fetal death is caused
the quiescence of the uterus. However, empirical use of by extensive thrombosis and infarction of placental vessels.
progesterone on all patients of threatened abortion is of no Inhibition of endothelial cell product—prostacyclin release, thus
use and hence not recommended. It is beneficial only in causing vasoconstriction and platelet aggregation. Hence,
patients with luteal phase defects (LPD) and in cases of facilitating thromboxane A2 and thus thrombosis occurs. There
insufficient progesterone production by the corpus luteum is also inhibition of protein C activation. APL antibody also
or placenta. Patients with recurrent miscarriages have a directly produces cellular injury to trophoblasts and inhibits
greater incidence of LPD than the general population. The syncytium formation. The fetus is normal morphologically and
serum progesterone concentration during pregnancy is not there is no other maternal factor detected.
185
 Antinuclear antibody (ANA): Patients with recurrent miscarriage Table 26.1: Management chart for recurrent pregnancy loss
who have positive ANA titers should be investigated for other
First trimester abortions Find genetic or non-genetic origin
autoimmune factors and anti-DNA antibodies as well.
Luteal phase defects Progesterone supplement
Alloimmune (immunity against other person-fetus and male partner) PCOD Pituitary suppression with GnRH
factors: This factor is under further investigation. It is diagnosed analogs followed by ovulation
by maternal and paternal HLA comparison, detection of cytotoxic induction.
Hyperandrogenism Treatment with prednisone
antibodies to paternal leukocytes and testing for blocking factors
Abnormal placentation Low dose aspirin and dipyridamole
for maternal–paternal mixed lymphocytes reactions. Uterine anomalies Surgery (in between pregnancy)
Local endometrial immunity is also a cause under research Immunological causes Low dose aspirin or prednisone or
(King, 2000). aspirin and heparin
Cervical incompetence Cervical encirclage operation
Infections and Chronic Diseases
Disorders of Early Pregnancy

Psychological support Good nutrition is needed in all

a. Ascending infection: This is not a common cause of abortion,
as the fetal membranes are protective. The patient complains
of uterine cramps and fever, and may have leaking or • Was it a genetically normal fetus or congenitally malformed?
bleeding per vaginum. The placenta shows signs of • Did cardiac activity appear before bleeding or not?
chorioamnionitis. The organisms which are implicated are • Was the patient on any kind of prolonged treatment?
as follows: • Any history of autoimmune disorder or family history of
i. Group B Streptococci autoimmune disorder?
ii. E. coli • Any history of endocrine disorder?
iii. Mycoplasma hominis • Any history suggestive of sexually transmitted disease like
iv. Ureaplasma urealyticum syphilis?
v. Chlamydia • Any history of gynecological procedure undergone, e.g.
vi. Genital herpes simplex D&E/D and C/cone biopsy to rule out cervical incompetence
vii. HIV and Asherman’s syndrome.
viii. Maternal syphilis. • Any live birth earlier?
Chronic illness like celiac sprue has been seen to cause • Any history of genetic abnormality in the partner or the
habitual miscarriage. family?
Section 4

• Menstrual history, amount and regularity of menstrual cycle

Defective Placentation to rule out PCOD.
During normal placentation, the spiral arteries undergo Investigations
adaptive changes; the lack of these changes has been named
Baseline investigations include:
abnormal placentation. These kinds of abnormal placentation
• Hemogram and ESR
are seen in pre-eclampsia, severe IUGR, preterm labor and also
• Blood sugar
in cases with early fetal deaths. The frequency of abnormal
• VDRL
placentation is the same for both chromosomally defective or
• Blood group and Rh typing
normal fetuses. The patients who have recurrent early
• Urine routine examination for any proteinuria, reducing
pregnancy loss because of abnormal placentation are at a high
substance and microscopy.
risk of developing pre-eclampsia and IUGR beyond the second
trimester. Special tests:
• Semen examination for any abnormality in sperms
Environmental Toxins • Thyroid profile
Heavy alcohol and coffee consumption cause recurrent • Glycosylated hemoglobin
miscarriage. Alcohol has a dose-dependent teratogenic effect. • Serum insulin level
Caffeine in coffee has been incriminated for causing abortion. • TORCH
• Anti-cardiolipin antibodies
Psychological Depression • Anti-phospholipid antibodies
The role of pre-existing psychologic depression is under study. • Lupus anticogulant antibody
Despite these extensive tests, there are certain cases of • Anti-DNA antibody
repeated miscarriage where we are not able to find a cause. • Hormone profile (FSH, LH, Prolactin)
• If hyperandrogen state suspected:
MANAGEMENT (TABLE 26.1) – Serum and free testosterone
– 17-hydroxyprogesterone level
The first and most important point in evaluation of patient of
– DHEAS.
recurrent abortion is taking good and detailed history and thus
• Karyotype
categorizing patients into early first trimester, late first trimester
• USG pelvis
and second trimester miscarriages. Further, the patient needs
• Hysterosalpingography (HSG) (in between pregnancies)
to be asked or the records need to be checked to see whether
• Hysteroscopy (in non-pregnant patient)
the baby was normal or abnormal, structurally and genetically.
• Laparoscopic evaluation of pelvis and abdomen (optional)
Communication skills are very important in these high-strung
• MRI for anatomical defects of uterus.
women with previous pregnancy losses.
History should include the following points: Examination
• Was the pregnancy confirmed by laboratory test or USG? General observation of the patient for health and nutritional status:
• What was the period of gestation at which miscarriages took Height, weight and BMI of patient
186 place? Pulse rate, BP and respiratory rate.
 Look for anemia, galactorrhea, thyroid or lymphatic surface (LEOS) helps in spontaneous ovulation and conception
swelling, hirsutism. in some patients.
Systemic Examination Hyperandrogenism: These patients who have hyperandrogenism
Per abdomen examination: Look for any mass, scar of surgery, of adrenal origin will benefit from treatment with
free fluid and inspect the hernial orifices. dexamethasone.
Abnormal placentation: These patients are recommended low
Per Speculum Examination
dose aspirin and dipyridamole.
• Exclude any vaginal infection. Take a swab for culture and
sensitivity. Uterine anomalies: Such patients may benefit from surgery for
• To examine the external os and see whether it is patulous. resection of uterine septum or adhesiolysis of synechiae with
• Hegar dilator test to be performed if indicated to rule out an operative hysteroscope. Patients with bicornuate uterus may
sometimes be recommended metroplasty.

Chapter 26
cervical incompetence. If Hegar number 8 easily passes
through the internal os of the cervix it is positive for cervical Immunological causes: Patients with antiphospholipid antibody
incompetence. syndrome have been seen to benefit from low dose aspirin and
• To rule out Mullerian duct anomaly, e.g. double cervices, prednisone. These medications are started as soon as the patient
vaginal septum, etc. (see Figs 4.23 and 4.24B) is tested pregnancy positive or just before conception. The dose
In cases of incompetent cervix, the miscarriage usually of aspirin is usually 80 mg per day and prednisone is 40–60 mg
occurs in the usually second trimester miscarriage with viable per day. With this treatment, these patients have live births but
fetus. It is spontaneous without much pain. have greater maternal and fetal morbidity. In another protocol,

Recurrent Pregnancy Loss

aspirin is given with low dose heparin. The dose of heparin is
Per Vaginal Examination
5,000 units 12 hourly. It is seen to be successful in 80% patients.
To assess the size of the uterus and to look for other masses Antibodies bind directly to heparin thereby decreasing the
which can be palpated (like rudimentary horn) and consistency adverse effects of antibodies. A trial of intravenous
of the cervix. immunoglobulin does not help. Treatment with heparin also helps
Preconceptional Treatment in inherited thrombophilia. For alloimmune causes, different
therapies are under trial, viz. injection of paternal leukocytes
Check up is done by all the above parameters. If a cause is
or pooled human immunoglobulin and low dose intravenous
detected, then it is managed accordingly. Use of heparin and
immunoglobulin (IVIG) are not proving useful.
aspirin before pregnancy may help in patients with lupus
anticoagulant. If there are congenital causes, karyotyping of Cervical incompetence: In this group, there is second trimester
both partners and of any affected child is done. pregnancy loss. Patients complain of leaking per vaginum
In hyperandrogenism, suppression of ovarian androgen by followed by painless dilatation of the cervix. The fetus is later
GnRH agonists and adrenal androgen by dexamethasone may expelled. On per speculum examination, the cervix will be seen
be fruitful. to be open, and membranes could be seen bulging through the
In preconceptional diagnosis of incompetent cervix, some external os. On ultrasound, the cervical length is less than 3 cm
surgeons perform a preconceptional encirclage. However, if the and the internal os is open. In non-pregnant patients, cervical
diagnosis is known, encirclage can be done early in pregnancy. incompetence can be diagnosed by passage of number 8 Hegar
Control of diabetes before pregnancy with insulin is very dilator beyond the internal os. Funneling of the cervix is seen
rewarding. on USG and HSG. The treatment is cervical circlage.
On ultrasound, width of the internal os more than 1.5 cm in
Treatment of Specific Etiology the first trimester and more than 2.0 cm in the second trimester.
Luteal phase defect Lower uterine segment is shaped as V or U and not the normal Y.
Estimation of urinary LH daily will reveal hyper-secretion
of LH, if present. Funnel length + 1
Cervical index =
Assessment of luteal phase is done before pregnancy by: Edocervical length
• Progesterone level at day 21 (in 28 day cycle)—less than 10
Normally, this value is 0.32. But if it is 0.52, it is incompetent
ng/ml is diagnostic.
cervix (Gomez, 1994).
• Endometrial histology and dating
• Serial ultrasound evaluating endometrium (thickness, Indications of USG in Recurrent Pregnancy Loss
echogenicity) • To know the gestational age of pregnancy and viability
Color Doppler—detection of vascularity • To rule out blighted ovum
• Daily salivary progesterone • To rule out morphological and structural abnormalities of
• Progesterone-associated endometrial protein (PAEP) level the fetus
• Progesterone receptor assay. • To rule out cervical incompetence
In these patients, progesterone supplements in the form of • To evaluate the placenta for abnormal placentation and
vaginal pessary, vaginal gels or injectable progesterone are grade the placenta
recommended. Some clinicians prefer giving injectable hCG • To study the Doppler parameters
weekly or biweekly. But it has not been seen to be any superior • In patients of Mullerian duct anomaly, to see the size, shape
to the progesterone preparation. and number of uteri
PCOD patients are advised pituitary suppression with GnRH • To rule out uterine septum, especially with 3D and 4D scans
analogs and induction of ovulation followed by hCG injection. • To rule out LPD, by measuring endometrial thickness
These patients when they conceive are further supported with • To rule out Asherman’s syndrome or uterine synechiae, with
progesterone preparations. The LH level can be reduced by 3D or 4D scan. Consent for genetic testing of the products
diathermy of the ovary. Laparoscopic electrocautery of ovarian of conception is taken, if miscarriage could not be prevented.
187
 BIBLIOGRAPHY 7. Lanasa MC, Hogge A, Kabik W, et al. A novel X-chromosome -
1. Check JH, Novrozi K, Chase JS, et al. Ovulation induction and Linked genetic cause of recurrent spontaneous miscarriage. Am J
pregnancies in 10 consecutive women with hypogonadotropic Obstet Gynecol 2000;186:563.
amenorrhoea. Fertile Steril 1990;53:811. 8. Leigh AJ, Peattie AB. Polycystic ovaries and levels of gonadotropin
2. Desai P and Patel P. Recurrent miscarriages. Acedoma and androgens in recurrent miscarriage. Prospective study of 50
Publishers;2003.p.1. women (letter) Br J obstet Gynecol 1994;101:275.
3. Esplin MS, Branch DW, Silver R, et al. Thyroid autoantibodies are 9. Loke YW King A: A human implantation cell biology and
not associated recurrent pregnancy loss. Am J Obstet Gynecol immunology Cambridge University Press, 1995.
1998;179:1583. 10. Okon MA, Laired SM, Tuckerman EM, et al. Serum androgen levels
4. Hamperl H, Hellwig G: Glandular endometrial stromal cells. Obstet in women who have recurrent miscarriage and their correlation
Gynecol 1985;11:379. with markers of endometrial function. Fertile Steril 1998;69(4):
5. Jokhi PP, King A, Sharkay AM, et al: Screening for cytokine in RNA’S 682.
in purified human decidual lymphocyte populations by the reverse 11. Pritts EA. Fibroids and infertility. A systemic review of the evidence.
Disorders of Early Pregnancy

transcriptase PCR J Immunol 1994;153:4427. Obstet Gynecol Survey 2001;56:483.

6. King A. Luteine leukocytes and decidualization. Hum Reprod. 12. Zaveroni I. Hyperinsulinemia, obesity and syndrome X. J int med
Update 2000;6:28. 1994;235:51.
Section 4

188
 Section 5 Abnormalities and Injuries of Genital Tract

27 Malformations of Female Genital Tract

Sudha Salhan, Priyanka

Malformations of female genital tract cause infertility, poor Characteristics

reproductive outcome and menstrual abnormalities, etc. 1. Congenital absence of uterus and vagina (although small
rudimentary uterine bulbs and rudimentary fallopian tubes
CLASSIFICATION may be present).
In 1988, American Fertility Society (AFS) classified Mullerian 2. Ovaries are present with normal function, i.e., ovulation.
anomalies according to similarities of clinical manifestation; 3. Phenotype Female (with normal development of breasts/
treatment and prognosis for fetal salvage. body proportions/hair distribution and external genitalia).
AFS classification of uterine anomalies is as follows: AFS– 4. Genetic sex Female (46 ).
1. Class I: Uterine agenesis and hypoplasia 5. Many cases (around 47 ) are associated with urological
2. Class II: Unicornuate uterus with or without rudimentary and renal anomalies, e.g. unilateral renal agenesis, unilateral
horn. or bilateral pelvic kidney, horseshoe-shaped kidney, etc.
3. Class III: Didelphyus uterus—complete non-fusion. Associated skeletal abnormalities could be:
4. Class IV: Two horns two cervices are fully developed with • Spine deformity
bicornuate uterus. The central myometrium may extend to • Syndactyly.
the internal os (bicornuate unicolis, or the external os Individuals with absent vagina and classic MRKH
(bicornuate bicolis). syndrome are usually first seen by the gynecologist at the age
5. Class V: Septate uterus (Shallow septum—sub-septate or of 14–15 years with complaints of primary amenorrhea or
extend to the external os. These may be septate cervix or painful intercourse in later life.
vagina). Diagnosis: History is important. There is normal history of
6. Class VI: Arcuate uterus C single cavity but convexity development of secondary sexual development with
towards the cavity. amenorrhea and dysparonea.
7. Class VII: T-shaped uterus DES related. • Examination: Normal development in height and secondary
AFS classification included defects of lateral fusion and does sexual growth is seen.
not include associated vaginal anomalies; tubal anomalies or Investigations needed besides routine tests are ultrasound,
urinary tract anomalies. Therefore, a modified American -ray abdomen, intravenous pyelography, and MRI.
Fertility Society classification of uterovaginal anomalies was Examination under anesthesia and diagnostic laparoscopy
suggested. is required to plan for surgery.
1. Class I: Dysgenesis of Mullerian ducts
2. Class II: Disorder of vertical fusion of the Mullerian ducts:
a. Transverse vaginal septum
b. Cervical agenesis or dysgenesis.
3. Class III: Disorders of lateral fusion of Mullerian ducts
• Asymmetric—unicornuate uterus with one fallopian
tube
• Symmetric:
– Didelphic uterus
– Septate uterus
– Vaginal septum
– Bicornuate uterus
– Unicornuate uterus
– T-shaped uterus.
4. Class IV: Unusual configuration of vertical–lateral fusion
defect.

Class I: Dysgenesis of Mullerian Ducts

• Includes agenesis of uterus and vagina (Figs 27.1A to C).
• It is a part of a syndrome called Mayer-Rokitansky-Kuster- Figs 27.1A to C: Agenesis of uterus and vagina: (A) Complete agenesis
Hauser (MRKH) (Fig. 27.2) syndrome; which also includes of uterus and vagina; (B) Agenesis of uterus and vagina except for
other genetic, endocrinal and metabolic manifestations. lower 1/3rd of vagina; (C) Agenesis cervix and of upper 2/3rd vagina
 Class II: Disorders of Vertical Fusion
Disorder of development between the Mullerian tubercle and
urogenital sinus and cervical agenesis.
Transverse vaginal septum:
1. Most cases are result of sex-linked autosomal recessive
transmission.
2. Location of vaginal septum:
• 46 upper vagina
• 40 mid vagina
• 14 lower vagina.
3. Associated with imperforate anus and bicornuate uterus;
coarctation of aorta; atrial septal defect (ASD); spinal
Abnormalities and Injuries of Genital Tract

deformities and endometriosis in a few cases.

4. In neonate and young infants, imperforate transverse
vaginal septum with obstruction can lead to serious and
life-threatening problems caused by compression of
surrounding organs by collected mucoid fluids (which
Fig. 27.2: Typical findings in MRKH syndrome comes from endocervical glands and Mullerian glandular
epithelium) (Figs 27.3A and B).
• USG/MRI During puberty: Hematocolpos may develop. Symptoms are
• Chromosomal analysis. cyclic lower abdomen pain with no visible menstrual discharge
Method of treatment is given in Flow chart 27.1 or spotting; gradual distension of central lower abdomen and
It has become usual to perform operations for formation of pelvic mass; cyclic hematuria (if communication exists between
vagina when the patient is 17–20 years of age and is intelligent bladder and upper vagina). On per rectal examination, cervix
enough to understand her problem and comply with the with a distended corpus (vagina) with ovaries are palpable
treatment methods. which may be adherent at times due to development of
endometriosis. Ultrasound and MRI may help in diagnosis (Figs
McIndoe Operation 41.1 and 41.2).
A space is created between bladder and rectum and lined with
a skin graft carried on a mold made up of light plastic material Treatment
or foam. After the operation, even when the graft is taken, the Surgical excision of transverse vaginal septum
patient has to wear mold for another 6 months and has to have Transverse incision is made through vault of short vagina.
normal sexual activity. Probe is introduced through the septum after blunt and sharp
Rectum and bladder could be injured during the procedure. dissection, carefully palpating urethral catheter anteriorly and
Section 5

One of its late sequelae is enterocele formation. insertion of gloved finger along anterior wall of rectum posteriorly
Nowadays, amnion and peritoneum, etc. have been used to as is done in agenesis of vagina.
line new vaginal space. But the risk of transmission of infections After dissection continued for short distance, cervix can be
like HIV is always there in amnion. palpated and continuity established with upper segment of
vagina.
William’s Vaginoplasty
A pouch superficial to the vestibule and opening anteriorly is
created by suturing together a linear U-shaped incision in inner
side of labia majora. Once coitus is established, it keeps on
lengthening vestibule. The angle of neovagina is not physiological
and there occurs problems of urine collection if the pouch is too
close to urethra.
Nowadays, muscle and skin flaps have been used for
reconstruction of vagina.
Laparoscopic techniques which use olive device, which
exerts traction on the pseudohymen through the abdominal
wall—Vichietti’s operation.
Before performing any of the above operations, the presence
of associated kidney malformation and impairment of renal
function should be excluded (by IVP, 4 SG and MRI). (Details
in chapter 75).
Flow chart 27.1: Method of treatment

Figs 27.3A and B: (A) Imperforate vagina with hematometra;

190 (B) Imperforate vagina with hematocolpos and hematometra
 The edges of upper and lower vaginal mucosa are
undermined and mobilized enough to permit stitching at
vestibule with delayed absorbable sutures (advancement of
vagina) (Fig. 41.3).
Soft rubber vaginal foam covered with sterile latex sheath
(we use condom) can be placed in vagina and removed after 10
days for evaluation of healing process. The foam can be worn for 4
to 6 weeks until healing is complete after which coitus is permitted.
Alternatively, if the patient is not sexually active, vaginal mold by
dental material/wax candles/silastic vaginal foam inserted at night
time.

Chapter 27
Class III: Disorders of Lateral Fusion
It can be asymmetrical and symmetrical.
Asymmetric Absence or incomplete development of one Fig. 27.5: Ectopic in rudimentary horn of uterus
Mullerian duct (Figs 27.4A to C).
Unicornuate uterus with only one fallopian tube (Fig. 27.4A) Treatment
or one well-developed horn and tube with second rudimentary • No treatment is required for true unicornuate uterus.
horn can be communicating (Fig. 27.4B) or non- • Excision of rudimentary horn is done only if it causes

Malformations of Female Genital Tract

communicating (Fig. 27.4C) with normal fallopian tube: The symptoms if the non-communicating functioning horn is
non-communicating horn may be accumulating menstrual present.
blood and cause unilateral hematometra.
1. Cervix and vagina may be normal in appearance and Symmetric: Imperfect Fusion of Mullerian Duct
function. 1. Didelphic uterus:
2. Association with renal tract abnormalities of the same side. • If two Mullerian ducts remain separate, the two walls
3. Can be present above or with a rudimentary horn or bulb of the uterus remain distinct and each has its own cervix
on the opposite side. (Figs 27.6A and B); occasionally, the two horns may be
4. There is a danger of pregnancy in rudimentary horn from widely apart. (see Figs 57.10,11,12,13 and 58.15).
transperitoneal migration of sperm or ovum from opposite • On per speculum examination, two hemicervices are
side, or sign and symptoms of ectopic pregnancy may visible and most of the patients have longitudinal
develop. The rupture is delayed (2–3 months of pregnancy) vaginal septum (Fig. 27.7).
as the rudimentary horn is bigger and thicker than fallopian • Of all uterine anomalies (except arcuate uterus), the
tubes. The hemorrhage is dangerous and very excessive didelphic uterus is associated with best possibility of
(Fig. 27.5). But, otherwise, unicornuate uterus causes very successful pregnancy. But there are chances of perinatal
few signs and symptoms and are usually discovered during
pregnancy complications.
5. It does not lower fertility by itself, but it favors abortion
and premature labor and breech presentation and fundal
insertion of placenta; but the uterus contracts efficiently in
all stages of labor.
Diagnostic Signs
1. Uterus which is deviated well to one side of pelvis and
which cannot be easily straightened.
2. HSG helps in diagnosis during non-pregnant state.

Figs 27.4A to C: Incomplete or absent development

of one Mullerian duct Figs 27.6A and B: Double cervix 191
 mortality; premature
birth, breech presentation
and cesarean delivery.
• Didelphic uterus should
not be considered as an
indication for metroplasty.
2. Septate uterus (Figs 27.8A
and B and 27.12, 57.14 and 57.15).
Uterus is normal from outside
Fig. 27.7: Didelphic uterus
but contains a complete or with septate vagina
incomplete (subseptate)
septum, which reflects a failure in absorption of the wall
Abnormalities and Injuries of Genital Tract

between the two Mullerian ducts.

3. Bicornuate uterus (Figs 27.9 to 27.11) (HSG)
Only lower part of the ducts fuse leaving the corneal
separate. The cervix or vagina may be single or double (Figs
27.13A and B) also see (Fig. 57.13).
4. Arcuate uterus (Fig. 27.14). Fig. 27.10: Bicornuate uterus USG by Dr Uppal
Clinical Symptoms
• Mostly recognized during pregnancy due to pregnancy
mishaps
• Usually normal
• Menorrhagia may occur at times because of large bleeding
surface area offered by two horns
• Spasmodic dymenorrhea seen because of unusual
arrangement of musculature and because of
abnormal contractions
• Coital difficulties in septate vagina
• Obstetrical complaints:
– Infertility especially in septate uterus
– Cornual pregnancy
– Miscarriage
– Premature labor:
Section 5

Occurs because of abnormal contractions, inade-quate

stretching/poor implantation and placentation on the Fig. 27.11: HSG bicornuate uterus

Figs 27.8A and B: Septate uterus

Fig. 27.12: Septate uterus

septum. Uterine malformation tends to cause late rather

than early miscarriage
– Malpresentation:
The patient usually gives a history of malpresentation in
several pregnancies.
Subseptate/bicornuate uterus favors a transverse lie.
Uterus didelphys/unicornuate uterus favors a breech
presentation. It is usually diagnosed at cesarean section.
• Insufficient uterine action:
It is seen in the third stage of labor. Manual removal of
placenta may be necessary in cases of bicornuate/septate/
subseptate uterus and as a result of which postpartum
192 Fig. 27.9: Bicornuate uterus hemorrhage is increased.
 Chapter 27
Figs 27.13A and B: (A) Bicornuate uterus with single vagina;
(B) Uterus didelphys with double vagina
Fig. 27.15: T-shaped uterus

4. Hysteroscopic resection of the septum with the help of

resectoscope, CO2, laser (after inducing endometrial atrophy
with the help of GnRH). This avoids a scar on uterus. Such a
patient can be permitted for vaginal delivery in a subsequent

Malformations of Female Genital Tract

pregnancy.
T-shaped uterus
This is a flat topped uterus in which fundal bulge has not
developed after fusion of ducts, if only the exterior of uterus is
affected, the fundal myometrium is abnormally thin.
EE – (diethylstilbestrol) related abnormalities.
DES exposure during intrauterine life in female fetuses can
Fig. 27.14: Arcuate uterus
lead to:
• High vaginal septum can prevent the cervix from dilatation • Benign vaginal adenosis
and lead to obstructed labor • Cervical hoods, septate collars
• In uterus didelphys, non-pregnant uterine horn is also • T-shaped uterus (Figs 27.15 and Fig. 57.16)
subjected to the same hormone influences as the pregnant • Vaginal clear cell carcinoma.
horn. Non pregnant horn of uterus didelphys also enlarges during These patients also have cervical defects. They have higher
pregnancy Sometimes, it remains low and hampers delivery risk of ectopic pregnancy, spontaneous miscarriage and
of the baby. premature deliveries. Cervical encirclage is the only treatment
• Gynecological aspects e.g. in uterus didelphys, Pap smear may available in this category.
be taken from two cervices. IUD may be inserted separately Main Complication of this Method
into two horns. Uterine perforation and fluid overload (in hysteroscopic
Diagnosis is made by hysteroscopy. resection)
Clinical examination/USG Class IV: Rare anomalies include isolated vaginal
Laparotomy/Laparoscopy hypoplasia making a vaginoplasty helps the patient. But very
MRI. rarely, these patients are associated with isolated agenesis of
Treatment the cervix. In these cases, abdominoperineal approach is tried.
Laparotomy is done and uterine cavity is opened. The cervix is
Many non-symptomatic patients are left as such; unless, there
made to communicate with the vaginoplasty done perennially
is prospect of marriage and childbearing. Rudimentary uterine
uterus and abdomen is closed. An indwelling catheter is kept
horns, especially those not communicating with the main cavity;
in the uterine cavity for drainage of menstrual blood and
often require excision (to treat hematometra).
epithelialization of cervical canal. Repeated dilatation was
Prior to surgery, a thorough work up is mandatory to
required in patient till she married and conceived (Fig. 43.1).
exclude all other causes of recurrent pregnancy loss.
1. Strassman metroplasty It is a procedure of choice for
BIBLIOGRAPHY
unification of the two endometrial cavities of an externally
1. American Society for reproductive medicine classification of
divided uterus both bicornuate horns. The two uterine
adnexal adhesions, distal tubal occlusion, tubal occlusion secondary
cornua are incised on their media side in their longitudinal to tubal ligation, tubal pregnancies, Mullerian anomalies and
axis; deeply enough to expose the uterine cavities, (carefully intrauterine adhesions. Fertil Steril 1988;49:944.
avoiding any injury to fallopian tubes) and uterus is sutured. 2. Auen P, Acien M, Sanchez-Ferrer, M. Complex malfor-mations of
The risk of rupture of repaired uterus during future labor the female genital tract. New types and revisiting of classification.
is there and generally elective cesarean section is performed. Hum Reprod 2004;19:2377.
2. odified one’s metroplasty Uterine septum (in septate 3. Reichman DE and Laufer MR. Congenital uterine anomalies
uterus) is surgically excised as a wedge beginning from the affecting reproduction. Best Pract Res Clin Obstet Gynecol
2010;24(2):193.
fundus of the uterus (taking care not to injure fallopian
4. Rock A and Breech LL. Surgery for anomalies of the Mullerian
tubes) and then suturing uterus in three layers. ducts. In Te Linde’s operative Gynaecology Tenth Edition-Editor
3. om ins operation For a septate uterus consists of incision Rock A and ones HW. Lippincott Williams Wilkins;2003.p.539.
of the fundus in midline exposing the septum and excising 5. The uterus. In clinical gynaecologic endocrinology and infertility. Eds.
it followed by reuniting the two parts in the midline. Speroff L and Fritz MA 7th edn;2005.p.132. 193
 28 Disorders of Sex Development (DSD)

Leena, Sakshi

INTRODUCTION NOMENCLATURE AND CLASSIFICATION

“Is it a boy or a girl?” Terms such as ‘intersex’, ‘hermaphrodite’, ‘pseudo-
The sex assignment under most circumstances is hermaphrodite’ have been perceived as pejorative and
instantaneous, based on the external genitalia of the baby. The stigmatizing, leading to a feeling of shame in affected patients
birth of a baby with external genitalia that cannot be readily and their families. A new nomenclature and classification
identified as that of a boy or a girl comes as a shock for all based on the genetic and endocrine basis of each condition,
parents. Since the first words spoken in the delivery room create therefore, was proposed, e.g. ‘intersex’ to be replaced by the
a lasting impact on the parents and their bond with the baby; it generic term ‘disorders of sex development’ (DSD). This
is important for the attending obstetrician to deal with this classification is outlined in (Table 28.1).
situation skillfully and with sensitivity. Abnormality of
external genitalia requires a formal evaluation. It occurs 1 in NORMAL SEX DEVELOPMENT
4,000 babies, though there may not be a difficulty in gender An understanding of the normal embryology of the
assignment in all cases. urogenital system and mechanism of hormone production,

Table 28.1: Revised nomenclature of disorders of sex development

Previous terminology New terminology Examples
Intersex Disorder of sex development (DSD)
Male pseudohermaphroditism 46, XY DSD Disorders of testicular development:
Undervirilized XY male • Complete gonadal dysgenesis (Swyer
Undermasculinized XY syndrome)
male • Partial gonadal dysgenesis
• Gonadal regression
• Ovotesticular DSD
Disorders in androgen synthesis or action:
• Androgen biosynthesis defect
• Defect in androgen action (e.g., CAIS, PAIS)
• Luteinizing hormone receptor defects
Others:
• Severe hypospadias
• Cloacal exstrophy
• Persistent Mullerian duct syndrome
Female pseudohermaphrodite 46, XX DSD Disorders of ovarian development:
Overvirilized XX female • Ovotesticular DSD
Masculinized XX female • Testicular DSD (e.g., SRY +)
• Gonadal dysgenesis
Androgen excess:
1. Fetal (e.g., CAH) congenital adrenal hyperplasia.
2. Fetoplacental (e.g. aromatase, POR- p450
oxidoreductase deficiency)
3. Maternal (luteoma, exogenous, e.g. Danazol,
Testosterone, Progesterone)
Others:
• Cloacal exstrophy
• Vaginal atresia
True hermaphrodite Ovotesticular DSD
XX male or XX sex reversal 46, XX testicular DSD
XY sex reversal 46,XY complete gonadal dysgenesis
Chromosomal abnormalities Sex chromosome DSD • 45, X (Turner’s syndrome and variants)
mixed gonadal dysgenesis • 47,XXY (Klinefelter’s syndrome and variants)
• 45,X/46,XY (MGD, ovotesticular DSD)
• 46,XX/46,XY (chimeric, ovotesticular DSD)
 Flow chart 28.1: Pathway of steroid biosynthesis and the enzymes involved

Chapter 28
Disorders of Sex Development (DSD)
* 17 hydroxylase (P 45 C 17)
** 17 hydroxysteroid dehydrogenase (17 HSD) bound to endoplasmic recticulum
# 5 reductase bound to nuclear membrane. Type I is skin. Type II in reproductive tissue

(Flow chart 28.1) action is important for diagnosing otherwise develop into fallopian tubes, uterus, cervix and upper
these disorders. The process of sex development occurs third of the vagina). Testosterone stimulates the differentiation
in two steps; sex determination—whereby the bipotential of the Wolffian structures into the seminal vesicles, vasa differentia,
gonad develops into either testis or ovary; and sex and epididymides. Testosterone is synthesized from cholesterol
differentiation—where the phenotype differentiates into in a series of enzymatic reactions; defect in any of the enzymes
appropriately either male or female due to the hormones will result in inadequate testosterone production leading to
secreted by the gonads. undervirilization of male fetus. It is further converted into
Male and female embryos appear identical till the 7th week. dihydrotestosterone (DHT) by 5 reductase enzyme which helps
The testis-determining factor (TDF) on the Y chromosome is in virilization of the external genitalia (penis and scrotum),
responsible for the genital ridge to develop into testes. In its development of the prostate, and elongation and formation of
absence, ovarian development occurs. A number of other genes the male urethra.
are also implicated in sex determination like WT1, MSF1, SOX9,
DHH, ATRX, ARX, DMRT1, DAX1, and WNT4. The subsequent CLINICAL EVALUATION
male differentiation is coordinated by two hormones produced Criteria that suggest a DSD are outlined in (Table 28.2).
by testis; Müllerian inhibitory substance (MIS) and testosterone. Clinical evaluation includes a thorough family and antenatal
MIS, produced from the Sertoli cells by 7 weeks of gestation, history and a careful clinical examination. Some essential points
causes the regression of Müllerian structures (that would to be noted during evaluation are presented in (Table 28.3). 195
 LABORATORY INVESTIGATIONS (TABLE 28.4) Table 28.2: Criteria that suggest DSD in the neonatal period
The majority of virilized 46,XX infants will have congenital
1. Overt genital ambiguity (e.g., cloacal exstrophy)
adrenal hyperplasia (CAH), whereas only half of 46,XY children 2. Apparent female genitalia with an enlarged clitoris, posterior
with DSD will receive a specific diagnosis. A rapid and labial fusion, or an inguinal/labial mass
systematic evaluation is initiated immediately to define the 3. Apparent male genitalia with bilateral undescended testes,
karyotype, gonadal function (LH, FSH, testosterone), androgen micropenis, isolated perineal hypospadias, or mild hypospadias
biosynthesis (testosterone precursors, dihydrotestosterone) and with undescended testis
the internal anatomy (ultrasonography, MRI, genitogram, 4. Family history of DSD such as CAIS
laparoscopy). The detection and treatment of any associated 5. Discordance between genital appearance and a prenatal karyotype
adrenal disorder (serum sodium, serum potassium, and blood
glucose) should be a priority. Hormone measurements need to making should be encouraged, their concerns respected and
be interpreted in relation to the specific assay characteristics
Abnormalities and Injuries of Genital Tract

addressed in strict confidence.

and to normal values for gestational and chronologic age. Adrenal disorders need to be anticipated and treated.
No single evaluation protocol can be recommended in all Careful attention to fluid and electrolyte abnormalities should
circumstances. Investigations need to be individualized for each be given. Newborns require a higher dose of glucocorticoids
patient. A general approach is outlined in (Flow chart 28.2). (10–25 mg/m2/24 hrs), added salt and frequent feeding (to avoid
hypoglycemia) as compared to their older counterparts.
MANAGEMENT
General Concepts of Care Gender Assignment in Newborn
Gender assignment must be avoided until the appropriate Gender assignment depends on the underlying disorder, existing
assessment has been done by an expert multidisciplinary team. anatomy of the genitalia, likely appearance of the reconstructed
Subsequently, all individuals should receive a gender genitalia, need for lifelong replacement therapy, potential for
assignment. Any surgical procedure required to make the normal sexual intercourse, and potential for fertility. As has been
genitalia concordant with that assignment can, if necessary, be emphasized, socioeconomic—cultural aspects and views of the
deferred until later. Open and intense communication with the family should be a priority.
family is mandatory. Participation of the family in decision- More than 90% of patients with 46,XX CAH and all patients with
46,XY complete androgen insensi-tivity syndrome (CAIS) assigned

Table 28.3: Clinical evaluation of a newborn with ambiguous genitalia

History
Family history Ambiguous genitalia, history of perinatal/ neonatal deaths, consanguinity,
infertility, sparse pubic hair, delayed/ incomplete puberty, pubertal
gynecomastia
Section 5

Antenatal history Maternal virilization, administration of androgenic drugs/ hormones

Examination
Dysmorphic features Syndrome of multiple congenital anomalies
Webbed neck, edematous hands and feet Partial (mixed) gonadal dysgenesis (45,X/46,XY)
Hyperpigmentation, dehydration, systemic illness CAH
Palpable gonads Careful palpation: exclude incompletely descended gonads (inguinal),
ectopic gonads (suprapubic, femoral, perineal): Two palpable gonads
almost certainly are testes.
Stretched phallic length*; Corporal tissue (penile Record of genital anatomy, etiological diagnosis, feasibility
width); Urethral opening, grooves, chordee; of surgical reconstruction
Labioscrotal folds (fusion, rugosity, pigmentation)
*Phallic length measured in stretched state along the dorsum from the pubic ramus to the tip of glans. Normal values of stretched penile length
(SPL) for a term Indian newborn male—3.6 ± 0.4 cm, penile width 1.14 ± 0.07 cm. Premature female infants may normally appear to have
clitoromegaly.

Table 28.4: Investigations in a newborn with ambiguous genitalia

First line testing Remarks

Biochemistry Serum sodium, Potassium, CAH: Hyperkalemia, hypoglycemia; hypernatremia
blood sugar (dehydration)/ hyponatremia (mineralocorticoid
deficiency)
Hormonal 17-OHP (on day 3–4 of life) Elevated in CAH
Testosterone Low in biosynthetic defects/ leydig cell aplasia, high/
normal in 5RD
Genetics Karyotyping To detect Y chromosome
Imaging Abdominopelvic ultra- Detect Mullerian structures/ nonpalpable gonads
sonography/ MRI
Genitogram with retrograde Delineate urethral anatomy, detect Mullerian structures
contrast injection
Laparoscopy Detection of gonads and biopsy, if necessary
Other tests: 11-deoxycortisol, androstenedione, DHT,
AMH, LH, FSH, hCG stimulation, molecular genetics,
196 gene sequencing etiology Depending on the suspected
 Flow chart 28.2: Approach to newborn with ambiguous genitalia

Chapter 28
Disorders of Sex Development (DSD)
female in infancy identify as females. Evidence supports the enzymes required for adrenal synthesis of cortisol leading to
current recommendation to raise even markedly virilized 46,XX diversion of precursors to the synthesis of androgens causing
infants with CAH as females. masculanization. Enzyme defects seen in CAH are:
Untreated patients with 5 reductase deficient (5RD) and 1. 21-hydroxylase deficiency. It occurs in three forms—salt
partial androgen insensitivity syndrome (PAIS) virilize at wasting, simple virilizing and late onset (non-classical). It
puberty. Majority of 5RD patients assigned female gender in occurs due to CYP 21 mutation on chromosome 6. This form
infancy but virilizing at puberty (and all assigned male) prefer is the most common and occurs in 95% of the cases.
to live as males. Among patients with PAIS, androgen 2. 11 hydroxylase deficiency. There is a mutation in
biosynthetic defects, and incomplete gonadal dysgenesis, there chromosome 8. Due to excessive 17 deoxy-corticosterone,
is dissatisfaction with the sex of rearing in 25% of individuals there is hypertension and hypokalemia. Virilization is also
whether raised as male or female. In ovotesticular DSD, seen. This is diagnosed by elevated levels of 17 deoxy-
potential for fertility on the basis of gonadal differentiation and corticosterone and compound S (17 deoxycortisol). This
genital development should be considered during gender form occurs in 5–8% of cases.
assignment, assuming the genitalia are, or can be made 3. 3 hydroxy steroid dehydrogenase deficiency. This form is
consistent with the chosen gender surgically. rare and affects both adrenals and ovaries. Mineralo-
corticoids, glucocorticoids, androgens, esterogens all are
Surgical Management defective so this is incompatible with life.
Emphasis is on functional outcome rather than a strictly cosmetic In CAH, there is impaired production of mineralocorticoid
appearance. It is prudent to defer surgery until later if cosmetic and glucocorticoid with an excess of androgens. The typical
factor is the sole indication. Gonadectomy needs to be done in patient presents with hyperpigmentation, symmetrical but
PAIS and gonadal dysgenesis due to risk of gonadal tumor. ambiguous genitalia and nonpalpable gonads. Rectal
Psychosocial counseling and support groups go a long way examination reveals a cervix. Female internal genitalia can be
in helping the family cope with the situation. demonstrated by imaging. There may be a family history of
Mothers should also be counseled regarding prenatal testing affected siblings. Around the first week of life, the child may
in subsequent pregnancies. have salt wasting crisis (vomiting, dehydration, hypoglycemia,
hyperkalemia). Hence, CAH must be promptly diagnosed and
SOME COMMON CONDITIONS managed aggressively to save the life of the newborn.

Congenital Adrenal Hyperplasia Diagnosis

(Adrenogenital Syndrome) CAH 1. In prenatal life, detection can be done when there is a
The most common cause of abnormal sex differen-tiation in an familial history by measuring steroids level in amniotic
XX individual is CAH. This is autosomal recessive. This fluid. There will be increased levels of 17 OHP,
syndrome is the result of a deficiency in one of the multiple androstenedione, 11 deoxycorticosterone. Genetic testing
197
 in chorionic villus biopsy by molecular DNA study can be Reifenstein’s syndrome.
performed to look for specific gene mutations. The characteristics of this syndrome can be summed as
2. In neonates, measurement of 17 OHP at day 2 can be done. follows:
Level between 3,000–40,000 ng/dl are diagnostic of CAH. • Genotype – XY
3. In adults, measurement of 17 OHP is done • Phenotype – Female
<200 ng/dl- Normal • Normal female breast development
200–800 ng/dl – Requires ACTH stimulation test • No pubic/axillary hair
>800 ng/dl – Diagnostic of 21 hydroxylase deficiency. • Primary amenorrhea
• Blind vagina
Treatment
• No uterus, tubes, cervix
1. In utero therapy is given by administering dexamethasone • Poor visuospatial ability
to mothers in the dose of 1.5 mg per day in three divided • Accounts for 10% of cases of primary amenorrhea
Abnormalities and Injuries of Genital Tract

doses in all high-risk patients starting at 4–5 weeks and • Sex of rearing female
continuing throughout pregnancy though it causes • Gonadectomy at 16–18 years followed by estrogen
significant side effects in the mother. This is to save male replacement 0.625 mg of conjugated estrogen or 1 mg of
fetuses (one in four fetuses is involved and one-half at risk estradiol.
will be male). To avoid therapy for all 8 fetuses, if sex of the
fetus can be known, the treated mothers will be reduced to 5 Reductase Deficiency
one-eighth. This is an autosomal recessive disorder. There is a defect
2. Treatment after delivery consists of administering in conversion of testosterone to dihydrotestosterone
glucocorticoids in the form of hydrocortisone 10 mg/day in leading to various degrees of feminization of male external genitalia
three divided doses or prednisolone in two divided doses to at birth. Genotype is XY. Gonads and internal genitalia are male.
the baby. Mineralocorticoids in the form of fludrocortisones Subjects with deficient 5 reductase-2 enzyme are similar to PAIS
100 mg per day can be added if salt wasting is seen. Monitor with ambiguity and virilization at puberty, but they do not develop
response with 17 OHP, testosterone, androstenedione and gynecomastia. Serum levels of hCG stimulated testosterone/DHT
rennin. Maintain 17 OHP in the rage of 100–1000 ng/dl. is high. Sex of rearing is usually male with appropriate surgical
Majority of 46,XX CAH patients have a female gender correction and hormone replacement.
identity with fertility potential and should be preferably
raised as females. Ovotesticular DSD
XY Gonadal Dysgenesis Previously known as ‘true hermaphroditism,’ it is characterized
by the presence of gonadal tissue that contains both ovarian
XY gonadal dysgenesis is usually referred to as “mixed gonadal follicles and normal appearing seminiferous tubules in one
dysgenesis”. Subtle features of Turner’s syndrome (edema of individual. Patients usually have ambiguous genitalia although
hands and feet, webbing of neck, hypoplastic upturned finger genitalia range in appearance from completely female to
Section 5

nails) may be seen. One or both gonads may be palpable in the completely male. Karyotype is most commonly 46, XX (in 70%
labioscrotal folds or groin. Karyotype is usually 45, X/46, XY. cases). There occurs a mix of Wolffian and Mullerian duct
Serum levels of plasma testosterone are low in the newborn structures. Examination under anesthesia and laparoscopy
period, as are levels following hCG stimulation. Gender provides the most detailed information about internal structures
assignment can be difficult in individuals with 45, X/46, XY and allows biopsy to confirm the diagnosis of ovotesticular DSD
mosaic. Most infants with minimally androgenized genitalia when all other forms of DSD have been excluded. Most infants
are raised as females. Infants with hypospadias and reasonable with female or minimally androgenized genitalia are raised as
phallic development are usually raised as males. Intra- female; whereas infants with hypospadias and reasonable
abdominal streak and dysgenetic gonads are thought to be at phallic development are usually raised as male. Intra-abdominal
significant risk of malignancy and should be removed. streak and dysgenetic gonads should be removed due to risk
Testosterone can be given to promote phallic growth in infancy. of malignancy. Hormonal treatment is required later on.
Androgen Insensitivity Syndrome
Testosterone Biosynthetic Defects
Androgen insensitivity syndrome is an X-linked recessive 17 HSD deficiency which is the most common defect mimics
disorder. There is a defect in androgen nuclear receptor leading PAIS anatomically. Following hCG stimu-lation, affected
to complete insensitivity to androgens (testosterone). History patients show an abnormally high ratio of androstenedione to
of brothers and uncles with genital ambiguity, pubertal testosterone.
gynecomastia, or sparse pubic hair might be obtained. Testes
may be palpable intra-abdominally. Mullerian structures are OTHER SYNDROMES
absent. The diagnosis is suspected if serum testosterone levels
are normal to high and the testosterone/DHT ratio is normal. Swyer Syndrome
Complete androgen insensitivity (CAIS) is characterized This is a disorder of male gonadal development. Genotype is
by female genitalia with blind vaginal pouch. Gender XY. There is a mutation in SRY gene because of which testis
assignment and sex of rearing is uniformly female in CAIS. does not form or gets eliminated before external and internal
Newborns with partial androgen insensitivity (PAIS) usually genitalia development. Gonads are in the form of streaks/bands
have ambiguous genitalia with blind vaginal pouch but may bilaterally. Both external and internal genitalia are female.
have a completely male phenotype. Virilization with
gynecomastia occurs at puberty. The majority of PAIS infants Congenital Anorchia (Disappearing Testis Syndrome)
are raised as males. Because of a risk of germ cell tumor in the In this, genotype is XY. Testis disappears early in gestation due
gonads; gonadectomy is undertaken early and appropriate to mutation or environmental insult. Internal and external
198 hormone replacement instituted later on. PAIS is also called genitalia are infantile. But gonads are absent/ streak.
Turner’s Syndrome CONCLUSION
In this, genotype is XO. About 60% of this cases are due to Disorder of sex development is a social emergency. Rapid and
deletion of one X chromosome; rest are due to structural systematic evaluation of the baby along with open and intense
abnormalities in X chromosome or mosaicism. The features are communication with the parents skillfully go a long way in
as follows (Fig. 14.1): managing this delicate situation; sometimes, in saving the life
Short stature (142–147 cm) Sexual infantilism of the baby.
Webed neck Streak gonads
High arched palate *Renal anomalies BIBLIOGRAPHY
Low hair line #Cardiovascular anomalies 1. Achermann JC, Hughes IA. Disorders of sex develop-ment. In:
Cubitus valgus deformity Thyroid disorders Kronenberg HM, Melmed S, Polonsky KS, Larsen PR, eds. Williams
(Hashimoto’s thyroiditis) Textbook of Endocrinology. 11th edn, Philadelphia, USA: Saunders;
Shield chest Progressive hearing loss 2003.pp.783-48.

Chapter 28
Short legs Insulin resistance 2. Clayton PE, Miller WL, Oberfield SE, et al. Consensus statement
Short fourth metacarpal Defect in visuomotor and on 21-hydroxylase deficiency from the European Society for
spatiotemporal processing. Paediatric Endocrinology and the Lawson Wilkins Pediatric
* Renal anomalies: Unilateral pelvic kidney, horseshoe Endocrine Society. Horm Res 2002;58:188-95.
kidney, duplication of collecting system. 3. Lee PA, Houk CP, Ahmed SF, et al. Consensus statement on
# Cardiovascular anomalies: mitral valve prolapse, bicuspid management of intersex disorders. International Consensus
Conference on Intersex. Pediatrics 2006;118:753-7.
aortic valve, aortic stenosis, aortic aneurysms.

Disorders of Sex Development (DSD)

199
 29 Pelvic Organ Displacements

SB Khanna, K Dash, Kaushiki, Sudha Salhan, R Bharti, R Kumari

The main displacement is judged by the position of the uterus. ani muscles. Hence, it plays more active support to lower vagina
Commonly encountered pelvic organ displacements are—Prolapse, and urethra.
inversion, retroversion, lateral displacement. Perineal body is situated between lower end of vagina and
Pelvic organ prolapse (POP): The word prolapse comes anus. It is triangular in shape. Bulbocavernosus, superficial
from Latin word, prolapsus meaning Slipping forth or falling transverse perineal, levator ani (Pubovisceral part), muscles are
out of place of the uterus refers to the abnormal descent or attached to it medially besides the two halves of the perineal
herniation of the pelvic organs, i.e. uterus, bladder or bowel, membrane (DeLancey 1999): It is directly attached to the
from their normal attachment sites or their normal position in posterior vaginal wall and anal sphincter.
the pelvis. The perineal body supports the lower vagina and rectum.
Uterine prolapse was first recorded on the Kahun Papyri in Its anatomy is important because the perineal body is cut during
about 2000 BC. Though not life-threatening, it causes much episiotomy and the meticulous repair is essential to prevent
morbidity and affects the quality of life in the patients. It causes prolapse of the vagina.
problem in walking, sitting, lifting and squatting. They also
have low back pain, pain in the abdomen, dyspareunia, dysuria LIGAMENT AND FACIAL SUPPORT (FIG. 29.3)
and difficulty in passing stools. The vaginal vault is supported by the uterosacral cardinal
ligament complex. This ligament complex is the most important
BASIC ANATOMY OF PELVIC FLOOR support for uterus and vaginal vault. Anterior vaginal wall is
(FIGS 29.1 AND 29.2) supported by the pubocervical fascia (pubocervical ligament)
Pelvic floor is the lowest boundary on which pelvic and which is attached distally to the urethra and superior vaginal
abdominal contents rest. The pelvic floor anatomy is divided outlet, proximally to fascia around cervix and laterally to arcus
artificially into passive and active structures (Table 29.1). Pelvic tendineus fascia pelvis (ATFP) on both sides forming
floor mucles (the pelvic diaphragm) is made of levator and anterolateral fascial support. Posterior vaginal wall is supported
coccygeus muscles along with their superior and inferior facial by rectovaginal fascia, attached proximally to uterosacral
layers. Below it are the perineal membrane and perineal body cardinal ligament complex, distally to perineal body and
framing the pelvic floor. laterally to fascia over iliococcygeus. Arcus tendineus fascia
Perineal membrane is also called urogenital diaphragm. rectovaginalis is condensation of connective tissue which
It has 2 parts viz. a sheet of dense fibrous tissue posteriorly attaches posterior vaginal walls to pelvic side walls. While the
attached to ishchiopubic rami laterally and perineal body and apex of the posterior vaginal wall is attached to uterosacral
lower one third of vagina medially. It is closely associated with ligament (part of cardinal ligament extending to POD and
compressor urethra and urethrovaginal sphincter muscles connected to perineal body).
ventrally. It is continuous anteriorly with the insertion of the Round ligament has smooth muscles and fibrous tissues and
arcus tendineous fascia of the pelvis. It is also attached to levator broad ligament composed of loose areolar tissue. They are not
the true support of the uterus and adnexa.
The muscles of the pelvis are covered by connective tissue
(parietal fascia). This parietal fascia attaches muscles to the bones
of the pelvis (endopelvic fascia). e.g. arcus tendineus levator ani
(ATLA) and arcus tendineus fascia pelvis (ATFP). In contrast the
facial covering the pelvic organs (endopelvic fascia) these fascia is
not a support to pelvic organs. Connective tissues of the pelvic
floor undergo matrix remodeling in pregnancy, during delivery
and puerperium. Elastinopathy due to disturbances in the
balance between synthesis and degradation of matrix of
connective tissue will slowly but progressively lose pelvic organ
support (Word and Associates 2009).

PELVIC FLOOR INNERVATION

The pudendal nerve innervates the striated urethral and anal
Fig. 29.1: Passive supports of Fig. 29.2: Active support structures sphincters as well as the deep and superficial perineal muscles
pelvic floor (Sagittal view of of the pelvic floor with divisions of
and provides sensory innervation to the external genitalia.
pelvis) levator ani
 Table 2 .1: Passive and active support structures of pelvic floor (Figs 2 .1 and 2 .2)

Passive Support Structures Active Support Structures

Bony pelvis Muscles
Sacrum Levator ani
Coccyx lliococcygeus muscle
Pubic ramus Pubococcygeus muscle
Ischium Puborectalis muscles
Connective tissue Pubovisceralis muscle
Parietal fascia Nerves
Arcus tendineus levator ani (ATLA) Pudendal nerve (S2, 3,4,)
Arcus tendineus fasciae pelvis (ATFP) Sacral plexus:nerve to the levator ani (S3, S4,)

Chapter 29
Visceral fascia

New insight into the levator ani innervations indicates that anteriorly, posteriorly and laterally. Defects at this level cause
the levator ani muscles are innervated solely by a nerve traveling anterior and posterior compartment prolapse in mid vagina
on the superior (intrapelvic) surface of the muscles without (cystocele and rectocele) and stress urinary incontinence (Figs
contribution from the pudendal nerve which innervates the 29.8 and 29.9).
muscles on the perineal surface. This levator ani nerve originates Level III: At this level vaginal wall is directly attached to

Pelvic Organ Displacements

from S3, S4 and S5 and innervates both the coccygeus and the surrounding structures without any intervening paracolpium.
levator ani muscle complex. Anteriorly, it fuses with distal urethra and posteriorly with
perineal body. Laterally, it blends with the margins of levator
BIOMECHANICS OF GENITAL PROLAPSE ani muscles. Defects at this level cause hypermobility of urethra
The present concept of female pelvic support divides it into three or deficient perineum.
compartments: The anterior compartment with the urethra and Besides these three levels, there can be anal incontinence,
bladder, posterior compartment with the anus and rectum, and constipation and defecatory dysfunctions.
the middle compartment containing the cervix, uterus or vault
in the hysterectomized women (Fig. 29.4). EPIDEMIOLOGY OF PELVIC ORGAN PROLAPSE
De Lancey (1992) described three integral levels of Incidence
connective tissues suspension system named as: i) Level
WHO has reported a global prevalence of prolapse to be 2–20
I- apical, ii) Level II- mid vaginal and iii) Level III- distal vaginal.
in women under the age of 45 years. The incidence increases
(Fig. 29.5).
with further increase in age.
Level I: Uterosacral cardinal ligament complex
Prolapse is seen in 10–20 of gynecological admissions in
(Paracolpium) suspends uterus and upper vagina in its normal
India. The number of women with POP who are managed
orientation. It is responsible for suspending the apex of the
without hospitalization and surgery and the number with POP
vagina after hysterectomy. The defects at Level I cause prolapse
who never seek medical attention are unknown.
of uterus, enterocele and post hysterectomy vault prolapse (Figs
29.6 and 29.7). Age
Level II: At the level of ischial spines, contiguous to level I Commonly seen in postmenopausal women when they seek
is level II support. Paracolpium at this level supports mid vagina medical help.

Fig. 29.3: Ligamental supports of the uterus 201

Abnormalities and Injuries of Genital Tract

Fig. 29.4: Anatomy of the pelvic floor

Section 5

Fig. 29.5: Levels of vaginal support Fig. 29.6: Normal anatomy of uterosacral cardinal ligament complex
at Level I in dorsal position

Fig. 29.7: Anatomy of cardinal ligament in vault prolapse Fig. 29.8: Cystocele
on standing position
202
 decrease in extracellular matrix and increased glycacion
cross-linkage in prolapse tissue.
8. Increased intra-abdominal pressure by chronic pulmonary
disease, constipation, smoking, etc.
9. From epidemiological studies, there is grade III to IV
evidence that development and recurrence of POP are
related to pervious surgery, i.e. previous colposuspension,
hysterectomy, Manchester repair and anterior colpopexy.
10. It’s also been thought that the increased levels of hormone
relaxin is more important for causing prolapse than the
delivery itself.
11. Genital cause may be contributing in some cases as seen in

Chapter 29
nulliparous patients due to weakness in pelvic tissues. It is
seen in families.
12. Malnutrition and poor nutrition may be an associated cause.
13. Oxydative stress damages cells and tissues. This is
Fig. 29.9: Enterocele measured by isoprostone levels (Chong et al, 2008).

Parity CLASSIFICATION OF PROLAPSE

Pelvic Organ Displacements

Prolapse increases with parity. The risk is 8 times more in para Wilfred Shaw’s Classification
2 than in a nullipara and 11 times greater after 4 or more
Anterior Vaginal Wall
childbirths.
Upper two-thirds - cystocele cystourethrocele
ETIOLOGY OF PROLAPSE Lower one-third - urethrocele
The exact etiology is not known. But multiple factors are Posterior Vaginal Wall
incriminated. The main are as follows: Upper one-third - enterocele (pouch of Douglas hernia)
1. It is generally accepted that childbirth trauma leads to Lower two-thirds - rectocele
pelvic floor dysfunction. It is most important factor in the
etiology of prolapse. The stretching and tearing of levator terine descent
ani muscles, endopelvic fascia, perineal body and the pelvic 1st degree descent of the cervix in the vagina.
floor innervation is associated with labor. Thus, risk of 2nd degree descent of the cervix to the introitus
prolapse increase in multiparous women, more so, if the 3rd degree descent of the cervix outside the introitus.
successive pregnancies take place at shorter intervals. The Procidentia—all of the uterus lying outside the introitus.
birth of big babies, premature bearing down efforts,
MALPAS CLASSIFICATION
lacerations in the perineal body, inadequate puerperal
rehabilitation (doing heavy manual work or lifting heavy It is based on anatomical background:
weight in immediate postpartum period). 1. Uterovaginal prolapse of 1st, 2nd and 3rd degree.
2. Vaginal childbirth may act as an inciting event in causing 2. General prolapse involving all pelvic viscera.
POP due to nerve damage. Partial perineal and pudendal 3. Anterior vaginal wall prolapse with/without urethrocele
neuropathies are also seen after labor. Nerve transmissions and cystocele.
get impaired leading to less nerve transmission 4. Posterior vaginal wall prolapse
predisposing muscles to less tone resulting in further a. Upper segment as vault prolapse and enterocele.
sagging and stretching. This neuronal damage might result b. Rectocele
in change in blood flow due to decreased neuropeptide c. Deficient perineum
expression in (N P) in vagina leading to atrophy—lexicity 5. Nulliparous prolapse
of pelvic floor muscles in patients with POP. 6. Prolapse after hysterectomy
3. Congenital anomalies that effect spinal cord pathway and 7. Arrested prolapse
pelvic floor roots like muscular dystrophy, meningo-
PELVIC ORGAN PROLAPSE
myelocele result in flaccid paralysis of pelvic floor muscles
QUANTIFICATION SYSTEM (POPQ)
and POP. 80 of uterine prolapse in newborn girls and
nulliparous women is associated with spina bifida occulta. It requires measurement of nine points in the vagina and
There is abnormal connective tissues in congenital prolapse. perineum, which are then recorded in a 3 × 3 grid (Fig. 29.10).
Total collagen content is less and there is higher otal
collagenolytic activity in pubocervical fascia. Genital iatus Perineal Body aginal Length
4. Genital atrophy with advancing age. (G ) (PB) ( vl)
5. Hypoestrogenic condition in postmenopausal women is also A B D
a contributory factor. Though the exact mechanism is not
fully discernible yet. 3 3 grid recording: Prolapse measurements from quantitative
6. Pelvic tumors may aggravate prolapse. pelvic examinations.Top row anterior vagina: bottom row
7. The medical conditions like diabetic neuropathy, chronic posterior vagina.
and repetitive increase in the intra-abdominal pressure, i.e, The hymenal remnant is taken as reference point 0. The
obesity, chronic cough, smoking, constipation, loss of measurements are done in centimeters and examination is done
lumbar lordosis and accentuation of the thoracic kyphosis while patient is straining. Bivalve speculum and a ruler or ring
due to aging, etc. Certain collagen diseases like Marphan’s forceps with engraved centimeter markings is used for
syndrome may increase the severity of prolapse. There is examination. Examination is done anteriorly, superiorly, 203
 Vaginal Length (Tvl): Total vaginal length is measured at rest
in centimeters. While examining the total vaginal length, one
should avoid excessive pressure and stretching, as the vagina
is relatively plastic. In normal support of uterus and cervix, it
measures 10 cm.
enital Hiatus ( h): The genital hiatus is measured from the
middle of the external urethral meatus to the inferior hymenal
ring. In normal support it measures 2 cm.
Perineal Body (Pb): The perineal body is measured from the
inferior hymenal ring to the middle of the anal orifice. In women
with severe prolapse the perineal body may be thin and
Abnormalities and Injuries of Genital Tract

expanded. The thickness of Pb measures 3 cm in non-prolapse

women.
Staging: A staging system has been developed to describe the
populations of patients. The prolapse is staged by the structure
that protrudes the most during forceful straining (Table 29.2).
As per the POP classification, some examples of the
Fig. 29.10: POPQ classification various types of prolapse quantification are depicted in the (Figs
29.11 to 29.14). The 3×3 grid provides the easy method to record
posteriorly and of external introitus surface. Three points as is evident from these figures.
remaining above the hymen are designated as negative numbers
and three points protruding beyond the hymen are designated MANAGEMENT OF PELVIC ORGAN PROLAPSE
as positive. The numbers are then translated into an ordinal History: Patient present with something coming out per
staging system with values from 0 to 4, 0 being excellent support vaginum with perineal weakness and bearing down feeling
and 4 being procidentia or vaginal vault eversion. especially after squatting or prolonged standing. History of
Terminology: The terminologies used are anterior vagina, child births at home, short interchild intervals and history of
posterior vagina and vaginal apex. This terminology prolonged labor is to be taken. Postpartum period is important.
acknowledges that no speculation is to be done on what is on Did she get postpartum hemorrhage Was the puerperium
the other side of the vaginal epithelium.
Points of Reference (Fig. 2 .1 ): There are three points
anteriorly (Aa, Ba, and C) and three points posteriorly (Ap, Bp,
and D).Two measurements are taken externally—genital hiatus
Section 5

(gh) and perineal body (pb) and the total vaginal length (Tvl) is
noted.
Point A—is located 3 cm proximal to or above the hymen in
the midline anteriorly and posteriorly. Anteriorly, Aa,
corresponds roughly to the urethrovesical junction. By
definition, points Aa (anteriorly) and Ap (Posteriorly) may have
values between –3 cm (no prolapse) to 3 cm (maximal prolapse)
Points B: The B point are defined as the lowest extent of the segment
of vagina between point A and the apex of vagina anteriorly (Ba)
and posteriorly (Bp). B points are not fixed and they vary
depending on the extent of the prolapse.
Point C: Point C is the most distal part of cervix or vaginal cuff
in post-total hysterectomy status.
Point D: Point D is the posterior fornix and is usually omitted
in women after total hysterectomy. Fig. 29.11: Normal support of uterine Cx

Table 2 .2: Staging of pelvic organ prolrpse based on POP examination

Stage No prolapse is demonstrated. Point Aa, Ap, Ba and Bp are all at –3 cm and either point C and D is between -TVL
cm and -(TVL-2) cm i.e., the quantitation value for point C or D is –(Tvl –2) cm .
Stage I The criteria for stage 0 are not met but the most distal portion of the prolapse is more than 1 cm above the level
of the hymen (i.e., its quantitation value is –1 cm).
Stage II The most distal portion of the prolapse is 1 cm or less proximal to or distal to the plane of the hymen( i.e., its
quantitation value is –1 cm but 1 cm)
Stage III The most distal portion of the prolapse is more than 1 cm below the plane of the hymen but protrudes no
further than 2 cm less than the total vaginal length in centimeters i.e., its quantitation value is 1 cm but
(Tvl –2) cm .
Stage IV Essentially complete eversion of the total length of the lower genital tract is demonstrated. The distal portion of
the prolapse produes to at least (TVL-2) cm i.e., its quantitation value is (Tvl-2) cm . In most instances, the
leading edge of stage IV prolapse will be the cervix or vaginal cuff scar.
204
 Chapter 29
Fig. 29.14: Predominant posterior support defect

Pelvic Organ Displacements

friction between the thighs). There may be coital problem due
Fig. 29.12: Complete vaginal vault eversion to mass obstructing the vagina.
In examination observe her gait. Check the nutritional status
and built. Spine and hernial sites are specially observed. Rule
out chronic bronchitis, bronchial asthma, and other respiratory
illness. Check blood pressure as hypertension is to be controlled
before operation. Any ascities is to be excluded besides looking
for any abdominal mass. Obesity is important.
Local examination is done both while the patient is lying
down and standing, at relaxed position and during maximum
straining. Look for degree of prolapse. See if there is only
cystocele or rectocele or procidentia or there is only elongation
of cervix (as seen in young patients (Figs 29.15A and B). Any
ulceration or hyperpigmentation (due to old healed ulcer) (Figs
29.16 A and B). Any other vulvar or perineal abnormality is to be
looked for examples piles (Fig. 29.17).
Per-speculum examination is done with Sim’s speculum to
exclude enterocele. The roughosities of vagina and status of cervix
are observed (Figs 29.18A and B). Pervaginal examination is done
to know reducibility and any adnexal masses. Ask her to cough
(with full bladder) and check for stress incentinence. See the
cervical lengthening. Try to find the strength and quality of
pelvic floor supports by asking her to tighten the levator
muslces. Per rectal examination can delineate rectocele. See the
consistency of rectovaginal septum (usually thin in rectocele)
Fig. 29.13: Predominant anterior support defect with partial vault descent

smooth with proper rest. Any history of chronic cough. Take

history of diabetes mellitus, tuberculosis or any other chronic
debilitating diseases. Any history of pelvic surgery is to be
obtained. A detailed sexual history is crucial in planning type
of surgery. Family history of prolapse is to be elicitated,
socioeconomic status to be evaluated.
Duration of prolapse is important. Ask for its reducibility
while lying down. Degree of discomfort. Urinary and bladder
symptoms (difficulty in passing urine without first reduction
of the prolapse, first they start with increased frequency and
finally a feeling of incomplete empting). There may be sense of
incomplete emptying of bowel. Specially ask for any stress
incontinence symptoms. Any discharge per vaginum may be
inquired. Infections may occur. Blood stained discharge usually
comes from decubitus ulcers (caused by stretching of veins Figs 29.15A and B: (A) Only elongation of cervix; (B) With cystocele
leading to venous stasis and less blood supply, besides constant and rectocele 205
 Differential diagnosis of uterovaginal prolapse include:
• Vaginal cyst
• Chronic retroversion of the uterus
• Vulval cyst
• Cervical fibroid polyp
• Rectal prolapse
• Vericocele of the vagina
• Urethral diverticulum.
Prevention: Genital prolapse can be prevented to a certain
extent. Preconceptional health check-up, antenatal care and
perineal exercises are important. Intrapartam premature bearing
down is to be avoided. Proper stiching of episiotomy is crucial.
Abnormalities and Injuries of Genital Tract

Postnatal perineal exercises help prevent development of

prolapse later on. Nutrition and rest in puerperium is required
to rehabilitate the muscles. Interval between 2 deliveries must
be 3 years. Avoid obesity, get chronic cough treated. Prevent
Figs 29.16A and B: Hyperpigmentation and ulceration of procidentia straining and cure constipation. To prevent vault prolapse after
hysterectomy proper support is to be performed during the
primary operation.
Treatment depends on (a) relation with delivery (2) age of
the patient (3) desire to preserve reproduction function (4) type
and degree of prolapse (5) degree of disability. Treatment is
done to improve the quality of life.
Preoperative Investigation: Blood hemogram, liver and
kidney function tests are done. Urine for routine and
microscopic examination and culture is required, may see for
residual urine (more than 100 ml is not normal) serum
electrolytes, blood sugar fasting and postprandial ECG and -
ray chest are other preoperative investigations required.
Non-operative options include pelvic floor muscle
exercises, estrogen therapy and pessary.
1. Pelvic floor muscle exercises: Pelvic organ prolapse
occuring just after delivery rarely need surgical correction.
She is advised pelvic floor muscles exercises. These exercises
Section 5

Fig. 29.17: External piles strengthen these muscles. Stopping the urinary flow and
other Kegel exercises are given in chapter 32.
2. Estrogen therapy in the form of creams, rings or tablets is
mostly used in postmenopausal patients awaiting surgery. It
makes the tissue healthy, improve muscle tones and increase
the vascularity of the tissue. It’s use preoperatively for a
fortnight improves operation results also by healing of the
decubitus ulcer and making operation plans of dissection easy.
Pessary may also be used simultaneously to reduce the
prolapse.
Pessary supports the uterus and vaginal wall. They can be
made of rubber, silicon material, plastic, etc. Commonly
used pessary in our hsopital is ring pessary (Figs 29.19A
and B and 29.20). Others are Hodge pessary, Donut pessary
(Fig. 29.21), Gellhorn pessary (Fig. 29.22), Cube pessary (Fig.
29.23), etc. Proper size pessary is selected for each patient.
Indications for Pessary Use
1. Patient not willing for surgery
Figs 29.18A and B: Roughosities of vagina
2. To gain time for definitive surgery to get past an event (e.g.
and perineum and ask her to strain perineal muscles. This gives some training, social event)
tone of levalor ani muscles. Also note thickness of perineal 3. To delay surgery for one more child
muscles and length of perineum. Rectovaginal examination 4. Tempory treatment to improve quality of life
done by keeping one finger in the rectum and one in the vagina 5. Retention of urine in early pregnancy retroverted uterus
the patient is asked to strain. A bulge into the space between with prolapse
the cervix and the upper posterior wall helps in the diagnosis 6. Severe medical conditions making patient unfit for surgery
of enterocele. The prolapse is reduced and bladder is filled with 7. Age greater than 65 years
300 ml sterile water or saline. When asked to cough if she leaks 8. Edema and ulcerations of the prolapsed uterus. The pessary
we have to do complete urodynamic testing. Assess anal will keep the uterus temporarily in position so that kinking
sphincter tone at rest and at active use. Also look for in vessels (obliteration of blood supply) is corrected and
206 hemorrhoids. edema subsides and ulcer heals—making her fit for surgery.
 Chapter 29
Figs 29.19A and B: Ring pessary

Pelvic Organ Displacements

Fig. 29.20: Ring pessary insertion Fig. 29.21: Donut pessary in position

Fig. 29.22: Gellhorn pessary in position Fig. 29.23: Cube pessary in position

9. In cases of urinary retention due to anterior vaginal wall Contraindication for Pessary use are:
prolapse causing urethral kinking. Pessary is used to replace 1. Acute genital tract infections
the anterior vaginal wall and undo the kinking. 2. Adherent retroversion of the uterus
10. As a diagnostic tool—Trial of pessary (up to a month) 3. Very fragile vaginal tissue as in postmenopausal women.
will help find whether the prolapse is the cause of the In them, use estrogen cream locally to make the vaginal
symptom (e.g. low back ache). Stress urinary incentinence tissue healthy.
cured or not. If yes, then surgical treatment is prescribed Surgical treatment: It depends upon the degree of prolapse,
accordingly. wish of the patient to preserve her uterus, age of the patient, her
The patients are taught how to insert the pessary and its general condition and marital status.
frequent cleaning. Use for a prolong period may sometimes Conservative operations (preserving uterus) are given in
cause pressure necrosis (a cause of post-menopausal bleeding). chapter 69. They include:
207
 I. Vaginal operations like anterior colporraphy, posterior
colpoperineorrhaphy, Manchester Fothergill operation,
Shirodkar’s modification of Manchester operation, Lefort
operation, Perijee and Iliococcygeal vaginal suspension on
both sides.
II. Abdominal operations mostly are slings.
Radical operation: Vaginal hysterectomy with anterior
colporrhaphy and posterior colpo perineorrhaphy is done
mostly in postmenopausal women. It is given in detail in chapter
70.

Complications of Prolapse Uterus

Abnormalities and Injuries of Genital Tract

The following complications can occur in pelvic organ prolapse.

1. Decubitus ulcer: This is due to streching of veins leading
to less blood supply, venous congestion and blockage of
venous return. There is avascular necrosis. Besides there is
friction by the thighs on the prolapsed tissues leading to
ulceration (Fig. 29.16).
2. eratinization: When the decubitus ulcer heals there is
Fig. 29.24: Chronic inversion of uterus
keratinization and hyperpigmentation.
3. These decubitus ulcers when chronic can lead to carcinoma
of the vagina (was seen in a post-menopausal women).
4. Incarceration of the prolapse—Prolonged prolapse without
reposition may lead to incarceration, i.e. loss of reducibility.
5. Stress urinary incontinence (SUI) develops because the
urethrovaginal angle descends with formation of cystocele
and rectocele and stress incontinence develops.
6. Obstructive uropathy is seen in long-standing prolapse
mostly with procidentia . The ureters get kinked leading to
obstruction to urinary flow and hydronephrosis due to
retention of urine backflow.
7. Cystitis and hypertrophy of bladder may be seen.

INVERSION OF UTERUS (Figs 29.24 to 29.26)

Section 5

Definition
Uterine inversion is the prolapse of the fundus to or through
Fig. 29.25: Inversion of uterus seen at operation
the cervix so that the uterus is turned inside out. Most of the
cases of uterine inversion occur after delivery and nonpuerperal
uterine inversion is very rare. Acute uterine inversion is associated
with profound shock due to the traction on the infundibulopelvic
ligaments, round ligaments and compression of the ovaries. In
addition, complication of hemorrhage may occur.
Uterine inversion may be acute, subacute or chronic
• Acute—within 24 hours of delivery
• Subacute—greater than 24 hours but less than a month from
delivery
• Chronic—beyond one month post delivery.

Incidence
Incidence of acute inversion of uterus is about-1 in 20,000 to 1
in 25,000 deliveries.

Classification
First degree: The fundus is inverted but does not pass below
the cervix.
Fig. 29.26: Details of chronic Inversion of uterus at laparotomy
Second degree: The inverted fundus protrudes through the
cervix and lies in the vagina.
Third degree: The uterus is completely inverted and the fundus 1. Mismanagement of the third stage of labor: This may result
appears outside the vulva. from fundal pressure before the placenta has separated or
Total: The inverted uterus and vagina appear outside the perineum. from traction on the cord when the uterus is relaxed without
countertraction.
Causes The likelihood of this occurring increases if the placenta
is situated at the uterine fundus.
208 Inversion of the uterus may be caused by:
2. Short cord Occasionally the uterus undergoes incomplete inversion at
3. Manual removal of the placenta: Uterine inversion may the time of delivery without producing much shock. It is also
occur if the Accoucher’s hand is quickly withdrawn from possible that inversion occurs gradually during puerperium.
the uterus while the other hand is still applying some degree Senile inversion of uterus is sometimes associated with
of fundal pressure after the completion of the procedure. trachelectomy leading to incompetent cervical os and cervical
. Precipitate delivery atony.
. Spontaneous inversion Pedunculated myoma arising from the fundus of the uterus
. Nonpuerperal uterine inversion is rare and can be caused may lead to inversion (Fig. 45.10).
by a sessile tumor attached at the fundus or by a leiomyoma Accidental cutting of fundus may be done if possibility of
of the uterus. Fibroid causes thinning and weakness of the inversion is not kept in mind.
uterine wall due to pressure atrophy. Contractions of the
Diagnosis
uterine musculature excited by the prolapse of the tumor

Chapter 29
into the cavity of the organ may cause inversion of the uterus. Symptoms
Acute inversion is the provision of obstetrics (given in • Vaginal discharge
Textbook of Obstetrics by Dr Sudha Salhan) we will deal with • Irregular bleeding per vaginum
chronic inversion of the uterus here. • Postcoital bleeding
• Low backache
Management of Chronic Inversion of the Uterus • Chronic pelvic pain.
Prophylaxis Cord traction should be avoided if the uterus is Local examination

Pelvic Organ Displacements

relaxed and on no account should the attendant leave the patient • Infected hemorrhagic mass seen in vagina
unless the uterus is firmly retracted after the administration of
Differential diagnosis
uterotonic drugs. Active management of third stage of labor is to
• Prolapse uterus
be practiced with controlled card traction. (Figs 29.27A and B).
• Infected cervical, uterine or placental polyp
Chronic Inversion • Ulcerated prolapsed cervix
• Cervical malignancy.
Due to the advancements in obstetrics, chronic uterine inversion
is rarely met. Diagnosis on Examination
• Mass comes out of the cervix. No fundus is felt in pervaginal
examination
• Short uterocervical length demonstrated by uterine sound
• Ultrasonography Shows no roundness at fundus.
The walls of the chronically inverted organ are in a state of
complete involution and retraction, and thus have little
elasticity. It is not only the resistance of a constricting ring to be
overcome, but also the inelastic walls of the uterus. Further,
there is the resistance offered by the adherent peritoneal surfaces
of the inverted fundus.
Treatment can be nonsurgical and surgical.

Nonsurgical Method
Aveling’s Repositor
A cup attached to metal stem is placed over the fundus of
inverted uterus and pressure is applied by bracing it to the
patient’s waist and shoulders. This requires some days to
achieve reposition.

Surgical Methods
There are several surgical methods of treating chronic inversion
of the uterus, and these may be divided into two groups, namely,
• Vaginal method, and
• Abdominal method
Before attempting reposition, it is important to clear local
infection. This is achieved by douching and antiseptic vaginal
packing.
Vaginal surgical methods include two common procedures,
the conservative method known as the posterior (Kustner
operation) anterior (Spinelli operation) and the radical method
of vaginal hysterectomy.

Conservative Methods
Spinelli Procedure
The conservative vaginal surgery was first done by
G Spinelli, of Naples, on anuary 15, 1899. He reposited uterus
by vaginal incision and anterior hysterotomy. Taylor, Peterson 209
Figs 29.27A and B: Controlled cord traction and Oui were others to use the same technique.
 ustner and Piccoli, were able to achieve success by Advantages of Abdominal Procedure
posterior colpotomy and incision of the entire posterior wall The procedure is simple and less time consuming.
of the uterus. Uterine incision is small.
echnique The abdominal cavity is reached with an anterior Hemostasis is better and easy to achieve.
or posterior incision in the vagina. No subsequent displacement of uterus.
The inversion ring is identified and the left index finger is Pregnancy outcome is better.
placed through the vaginal incision into the inversion funnel. Retroversion and lateral displacement are themselves not
The inversion ring is divided in the midline and the fundus of the cause of any complication. But retroversion is associated
the uterus is reposited. The cervix is grasped at posterior lip and with retention of urine in early pregnancy, uterovaginal descend
pulled out. The incision on the uterine wall is closed in two layers. and pathologically caused by endometriosis or malignancy.
Disadvantages of Vaginal Method
BIBLIOGRAPHY
Abnormalities and Injuries of Genital Tract

Failure rate is high.

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of Epidemiology 1991;541-7.
of the uterine wall from the cervix to the fundus.
2. Baden WF, Walker TA. Genesis of vaginal profile: A correlated
Complete closure of the uterine incision is difficult. classification of vaginal relaxation: Clin Obstet Gynaecol
Hemorrhage from the inverted fundus is profuse and 1972;15:1048-54.
difficult to control. 3. Barber MD, Brewer RE, Thor KB, Dolber PC, Kuchl T , Coates KW.
In posterior colpotomy (Kustner method), the displacement Innervation of the female levator ani muscles: Am Obstet Gynaecol
at the time of surgery and subsequent adhesions leads to fixed 2002;187:64-71.
retroversion in majority of the cases. 4. Brown S, Waetjen E, Subak LL, et al. Pelvic organ surgery in United
In anterior colpotomy the same difficulties occur as in States: Am Obstet Gnyaecol 1997;186:712-6.
5. Cervign M and Natak F. The use of synthetic in the treatment of pelvic
posterior.
organ. Prolapse Curr Opin Uro 2001;11:429-35.
Vaginal hysterectomy is done after making the uterus into 6. Chong KW, Liu M, Chu C , et al. High isoprostone levels in cardiac
normal position. ligaments derived fibroblasts and urine samples of women with
uterine prolapse. Brit Obst Gyn 2008;115(9):1179.
Abdominal Method
7. Dalley AF. The riddle of the sphincters: The morphophysiology of
We prefer the abdominal route as it is simple, associated with the anorectal mechanism revisited: Am Surg 1987;53:298-306.
less complications and results are satisfactory. 8. De Lancy OL. Anatomic aspects of vaginal eversion after
hysterectomy: Am Obstet Gyanecol. 1992;166:1717-28.
Huntington Procedure 9. De Lancy OL. Structural anatomy of the posteior pelvic
In this procedure Allis forceps are placed within the dimple of compartment as it relates to recocele. Am Obstet Gyanecol
inverted fundus (Figs 29.25 and 29.26) and gentle upward 1999;180:815.
traction exerted with the clamps with further placement of 10. Fidas A, Mac Donald HL, Elton RA, et al. Prevalence of spina bifida
forceps on the advancing fundus. occulta in patients with functional disorders of lower urinary tract
Section 5

and its relation to urodynamic and neurophysiological measure-

Haultain Technique ments: BM 1989;298:357.
11. Friedman EA, Little WA. The conflict of nomenclature for discensus
The commonest abdominal method is the Haultain technique.
uteri: Am Obstet Gynaecol. 1961;81:817-20.
In this procedure the posterior ring of the inversion is cut from 12. Hall AF, Theofrastous P, Cemdiff GC, et al. Interaobserver and
the abdominal cavity and then the uterus is replaced by means Intraobeserver reliability of the Proposed International Continence
of Allis forceps, along with some pressure upon the fundus of Society, Society of Gynaecological Surgeons and American
the uterus from the vagina. Urogynaecologic Society Pelvic Organ Prolapse Classification
echnique Abdomen is opened by Pfannenstiel incision, the System: Am Obstet Gynaecol 1996;175:1467-71.
site of the inverted fundus is seen as a narrow transverse slit; 13. Hendrix SL, Clark A, Nygaard I, et al. Pelvic organ Prolapse in the
into this a pair of artery forceps is passed and opened as widely Women’s Health Initiative: Am Obstet Gynecol. 2002;186:160-6.
14. Howkins and Bourne G. Prolapse: Shaw’s Textbook of
as possible to break any peritoneal adhesions in the inversion
Gynaecology, 9th Edition Published by The English Language Book
tunnel. Both round ligaments, as they pass into the slit, are held Society and Churchill Livingstone; 1978.pp.505-46.
firmly and pulled upwards and forwards, at the same time an 15. Hsu , Lewicky-Gaupp C, DeLancey O. Posterior compartment
assistant pushes the fundus of uterus upwards from the vagina. anatomy as seen in MRI and 3 dimensional reconstruction from
By this means a thick ring of the uterine walls is seen asymptomic mulliparas. Am Obstet Gyanecol 2008;198:651.
surrounding the slit formed by the inverted uterus. This ring is 16. Kelly HA. Operative Gynaecology. New ork: Appleton and Co.
divided posteriorly by passing the incision through the entire 1898.
thickness of the uterine wall. By this partial reduction is obtained 17. effcoat Sir Norman. Genital Prolapse: Principles of Gynaecology:
Fourth Edition Published by Butterworths; 1983.pp.253-68.
by the vaginal pressure, and the portion of the uterus wall still
18. Lazarou G and Scott R ; Uterine Prolapse: www.emedicine.com /
constricting is exposed through this the posterior uterine med/topic 3291htm. 2003.
incision is continued until a sufficient opening is formed to 19. Lindsay P. Complications of the Third Stage of Labour. In:
permit the introduction of the index finger to below the fundus. Henderson C, Macdonald S, editors. Mayes’ Midwifery A textbook
Now a firm, regulated pressure is applied on the fundus for Midwives. 13th ed. London: Bailliere Tindall; 2004.p.987-1002.
and reduction of the uterine fundus is easily achieved. Incision 20. Livingston SL, Booker C, Kramer P, Dodson WC. Chronic Uterine
in the posterior uterine wall is closed by two or three deep Inversion at 14 Weeks Postpartum. Obstetrics ynecology.
sutures and covered by a superficial Lembert sutures. At times, 2007;109(2):555-7. (Clinical Guideline Section B: 9.1.3 Prophylactic
and therapeutic oxytocin administration and infusion regimens).
bleeding from the uterine incision and needle punctures require
21. Maresh M , Metcalfe MA and Mcpharson K. The value national
some superficial sutures for its control, but hemorrhage is study of hysterectomy: Br Obstet Gnyecol 2002;109:302-12.
usually very slight.

210
22. Maclennan AH, Tayler AW, Wilson DH and Wilson D. The 28. Symmonds RE, Williams T , Lee RA, et al. Post- hysterectomy
prevalence of pelvic floor disorders and their relationship to gender, enterocele and vaginal vault prolapse. Am Obstet Gynaecol
age, parity and mode of delivery: Br Obstet Gynaecol. 1981;140:852.
2000;107:1460-70. 29. Tetzschner , Sorensen M, onsson L, et al. Delivery and pudendal
23. Mount . Epidemiology of genital prolapse-Oxford Family Planning nerve function. Acta Obstet Gynaecol Scend; 1997;76:324.
Association study : Br obst Gynae 1997;104:579-85. 30. Patrick Hogston. Advances in the surgical management of vaginal
24. Oslen AL, Smith V , Colling C, et al. Epidemiology of surgically prolapse. Recent Advances in Obstet and Gynaecol (22) edited by
managed pelvic organ prolapse and urinary incontinence: Obstet ohn Bonnar and Willams Dunlop: 2003.pp.159-172.
Gynecol 1997;89:501-6. 31. Swift S. Current opinion on the classification and definition of
25. Petros PE. Papa: Vault Prolapse I: Dynamic Supports of vagina: genital tract prolapse: Current opinion in Obstetrics and
Int. urogynaecol 2001;12:292-5. Gynaecology 2002;14:503-7.
26. Samuelsson EC, Victor AFT, Tibblin G, et al: Signs of genital 32. Word RA, Pathis and Schoffer I. Pathophysiology of pelvic organ
prolapse in a Swedish Population 20-59 years and possible related prolapse. Obst. and Gyn Clinics of North America 2009;36(3):521.

Chapter 29
factors: Am Obstet Gnyecol 1999;180:299-305. 33. nu L, Lang L, Tiang , et al. Neuropeptide expression in vagina
27. Seth S and Selhan S. Genital prolapse in manual gynecology (ed.) especially of women with POD and SUI. Int. . Gynae and Obst
Sam Sundar S CBS Publishers and Distributors; 2007. 2008;102:65.

Pelvic Organ Displacements

211
 30 Violence Related to Gender and Sexuality

Sudha Salhan

Definition – Sexual (forced sexual intercourse, forced to watch

It is the violence inflicted on women by men who are known pornography, forcibly using the victim to entertain
to them (e.g. husband, partner and other family members) others and any other act of sexual nature)
and also by unknown men. It is gender-based violence as it – Emotional/verbal (casting accusations/aspersions on
evolves due to women’s subordinate status in the society. It character, insults, ridicule, name calling, humiliation
is both a human right violation and a public health concern with regard to not having child/male child, threats to
as it increases other health problems like chronic pelvic pain, cause physical pain to loved ones)
physical disability, drug and alcohol abuse and depression. – Economical including depriving the victim of financial
Sexually transmitted diseases and adverse pregnancy resources, disposal of household assets, (movable,
outcome are also seen. immovable) prohibition of access to resources or
The Protection of Women from Domestic Violence Act facilities which the person is entitled to enjoy by virtue
(PWDVA) is a mixture of civil and criminal law. It is applicable of shared household.
to two people living under the same roof (marriage, live-in – Dowry related harassment
relation, adoption, joint family, consanguinity). • List of documents attached (e.g. medicolegal certificate,
Definition of domestic violence: Domestic violence can doctor ’s certificate or any other prescription, list of
be—harms, injuries which, endanger the health, safety, life, streedhan)
limb or well-being of the person. • Order that is needed under the PWDVA 2005 (such as
• Includes physical, sexual, verbal, emotional abuse protection order residence order, maintenance order,
• Intends to coerce the woman or any person related to custody order, compensation order)
her to meet any unlawful demand for dowry or any • Assistance needed (counselor, police assistance, shelter,
property/valuable security medical facilities, legal aid, etc.).
• Has the effect of threatening her or any person related Different forms of violence include:
to her. • Sexual coercion (includes rape)
• Female genital mutilation (FGM)
Relief Offered Under this Law • Physical aggression
Relief officer can give protection order (immediate), • Psychological abuse
monetary relief, residence and custody order, and • Economic abuse.
compensation.
It also includes non-spousal violence, sexual harassment
Role of Health Care Providers in PWDVA and intimidation at work and in school, female infanticide,
trafficking in women, etc.
• Identify the abuse
It is linked to social norms and expectations with regards
• Provision of medical treatment
to masculinity and femininity and to a perceived need to
• Give information about the Act
control women’s behavior. In some societies wife beating is
• Prepare domestic incident report (DIR) in medicolegal
regarded as a man’s right.
form
• Refer the victim to appropriate agencies (protection Economic dependence on men is the most important factor.
officer) for further help. Health providers as a team must know how to ask women
about violence related to gender and sexuality by giving
A DIR contains
empathy and support. They can provide medical treatment,
• Details of the complainant/aggrieved person (Name, age,
offer counseling, document injuries and refer their clients to
address, phone number)
legal assistance and support services. They must reassure
• Details of respondents (Name, relation with aggrieved,
her that violence is unacceptable and no woman deserves
address, phone number)
to be beaten, sexually abused or made to suffer emotionally.
• Details of children (number, name, age, sex, residing with)
• Details of incidents of domestic violence Sexual coercion including rape: Rape (sometimes called sexual
– Date, place, time assault) involves sexual intercourse with another person
– Person who caused the domestic violence without their consent even if they are husband and wife (rape
in marriage). In Roman times, rape was considered a ‘Public General History
wrong’ or injuria publica, as opposed to a ‘Private wrong’ or Demographic
injuria privada. Rape along with arson, treason and murder • Name
has always been a capital offence. Rape is increasingly • Parent’s name
reported, giving rise to the perception that its incidence is • Age
rising across the world. • Marital status
The laws relating to rape and sexual assault are proposed • Educational qualification
to undergo radical overhaul to plug the loopoles in them. • Address
Section 375 of IPC will also include other forms of penetrative • Religion
acts that do not fall in the original definition. It will include • Name and number of accompanying policeman
humiliation-physically, emotionally and psychologically (an • Mark of identification
act of brutal violation and not simply an act of penetration).

Chapter 30
• Brought by MLC number
This will be made gender neutral including not only females
but also young boys who are sexual assault victims. This will Medical History
make the law more humane. A recent Delhi High Court History of any past illnesses, allergies, medications and
judgment (2009) rules that hospitals in Delhi is expected to immunization should be taken.
streamline the process of examination and evidence
collection among survivors of sexual assault and suggested Gynecologic History
use of a safe kit. Last menstrual period (LMP) to rule out ongoing pregnancy

Violence Related to Gender and Sexuality

and also to determine risk for a new pregnancy. History of
MANAGEMENT OF A RAPE VICTIM consensual sexual activity up to 5 days prior to rape is
Approach towards rape victim important to avoid confusion in semen analysis.
1. All female rape victims are to be examined in the casualty Informal consent (12 yrs and above can give valid
by the Medical Officer on duty and Medicolegal case consent).
(MLC), is to be made. If the Medical Officer is a male, a EXAMINATION OF THE ASSAULT VICTIM
female member of the medical team is to be present.
2. Request for medical examination is normally made by Thumb Impression (Right) is Taken
the police. However, if this is not possible due to valid 1. Note the date and time of examination.
reasons, the victim can be examined on her own/her 2. General physical examination pulse BP temp. respirate,
relatives’ request. In such cases, police constable on duty pupils clothing fresh form, stain of blood semen, etc. H/o
in the main casualty (of the hospital) should be contacted bathing douching cleaning, change of clothes.
to register the case and complete the other formalities. 3. Complete skin examination. The color and shape of
3. Give prompt attention to the victim, as delay causes loss injuries should be recorded precisely. Color, swelling and
of valuable forensic evidence. tenderness.
4. Consent should be taken for medical examination, 4. Any foreign material or stains on the body to be noted.
treatment, investigation and disclosure of the medicolegal Inspect body surface for bruises, scratches and bites.
examination in court. The patient or her guardian may 5. Presence of secondary sexual characters to be recorded
refuse to give consent for any part of the examination. In (important for approximate age estimation).
this case the patient should be apprised of the 6. Genital area to be examined last. Pubic hair—combing,
implications. labia majora—any swelling, tears edema, bruises
5. Explain the entire procedure to the victim and her abrasion. Labia minora—scratch, bruising, finger,
relatives. Inform the victim that she may, if she wishes, nail marks, tear, infection. Fourchette—bleeding, tear.
ask the doctor to stop proceeding at any point of time. A vulva. Any injury, bleeding, discharge. Perineum.
note to this effect will be made in the record and Hymen—intact/torn injury fresh/edema/congestion/
implications of the same explained. tenderness vagina and cervix mucopurulent dis-
6. Offer privacy to her. The examination room should be charge.
well lit. Anus—bleeding, mucopurulent discharge from anus,
7. Allow the victim to set her own pace of narrating the edema and tenderness. Tears (shape and extent.
experience. Show empathy towards her. Samples for leborating blood, vaginal swab, culture
8. In case of a minor victim her mother or any other female specimen of urine)
attendant, giving informed consent, should be present in 7. Oral examination if there is history of oral sex.
the examination room along with the doctor and the nurse.
Evidence collection and investigations required
9. Accompanying policewomen/men should not be present
Blood (blood group, drug intoxication if required. Urine—to
in the examination room.
test for suspected pregnancy, drug testing).
10. The findings of the case should be recorded legibly and
1. The clothes worn by the victim during assault are to be
without any ambiguity by the doctor on duty with his/her
sent for analysis along with any foreign material on her
full name and signature and stamp.
person, e.g. grasses, twigs, etc.
11. Maintain a non-judgmental attitude and boost her self-
2. Her reference hair samples–scalp and pubic to be taken.
es teem.
3. Pubic hair combings taken and sent (to look for assailants
12. Disclosure of victim’s identity in public is not permitted.
hair) for analysis.
4. Fingernail scrapings of the victim
HISTORY
5. Vaginal pool sample and cervical swab to be taken and
Important aspects to be covered while history taking are: sent for forensic analysis and wet smear.
213
 6. Oral and rectal swabs if indicated by history and along with active immunization consisting of 3 doses (0,1,6
examination. months) of Hepatitis B vaccine.
7. Seminal stains (blood group)
Follow-up
8. X-ray of long bones for age estimation.
9. All samples are to be labeled, sealed signed and stamped Advise the patient to come for follow up after 2 weeks and
immediately and handed over to the policemen/women. again after 6–12 weeks. In these visits:
In the end give opinion, if possible. • General assessment of emotional status is made
• Healing of injuries is noted and investigations conducted
TREATMENT OF RAPE VICTIM if indicated.
• Referral to psychiatrist, or social worker may be required.
Curative
• Ask regarding LMP
a. Clean any lacerations with antiseptic and give tetanus If periods have been missed look for evidence of
Abnormalities and Injuries of Genital Tract

toxoid injection, if not immunized. If required suture the pregnancy and offer termination if pregnant.
tears or lacerations. In case of minor girls, general
anesthesia may be required for satisfactory examination FEMALE GENITAL MUTILATION (FGM)
and treatment. It is a form of violence towards women.
b. If the victim is pregnant, she should be admitted and
observed for onset of preterm labor. Tocolysis should be Definition: It comprises all procedures involving total or
started. Ultrasound is done to know the damage, if any. partial removal of external female genitalia or other injuries
c. Necessary referral and follow up is advised. to the female genital organs that causes anatomical changes
for non-therapeutic reasons. (It is also called female
Preventive circumcision).
Pregnancy Prevention Annually around 100-140 millions girls have FGM mainly
in Africa, part of Southz-East Asia and Arab countries. The time
Emergency contraception should be offered to all victims of
of FGM in girls and women is from one week of age up to the
reproductive age group. If duration since assault is less than 72
age of a young woman. Three million girls are at risk of being
hours, then advise 150 µg of Tab Levonorgestrel stat.
subjected to FGM each year.
Prevention of Sexually Transmitted Diseases The cultural misconception which perpetuates this
• Tab azithromycin 1 gm practice includes keeping cleanliness, virginity is protected,
• Tab fluconazole 150 mg as a single stat dose fertility is enhanced, rite of passage to womanhood, female
• Tab secnidazole 2 gm. promiscuity is prevented and still births do not occur. Women
fear that they will not get married without undergoing FGM.
HIV Counseling FGM is the expression of the society’s control over its women.
• HIV counseling is advised for all the rape victims. The This practice violates many well-established human right
victim should be advised to contact HIV counselor in principles, norms and standards, including the priniciples of
Section 5

Obstetrics and Gynecology, Deptt in the antenatal equality and non-discrimination on the basis of sex, the right
outpatient department (OPD) next day, between 9 am to to bodily integrity, the right to life (if the procedure leads to
1 pm. death) and the right to the highest attainable standard of
• CDC (2005) recommends a 28 days course of HAART to a physical and mental health. If it is done in childhood, it also
person who has had nonoccupational exposure to blood, violates the right of the child. It is not free, informed and is
genital secretion or other potential infected body fluids usually not uncoerced.
of a person known to be HIV infected when that exposure The practice of FGM includes piercing (Fig. 30.1) pricking,
presents a substantial risk for HIV transmission (nPEP) started cutting and stretching labia and clitoris. Clitoris and its
within 48–72 hours. The source person (who assaulted in surrounding tissues may be burned. It also includes angurya
rape) is to be counseled and tested for HIV. cuts, i.e., scraping or cutting of tissues around the vaginal
• First find out the exposure risk. Negligible risk for HIV opening or gishiri cuts, i.e. cutting the vagina.
exposure—exposure of vagina, rectum, eye, mouth or
other mucous membranes, intact or non-intact skin or
percutaneous contact with urine, nasal secretions, saliva,
sweat or tears, if not visibly contaminated with blood
regardless of the known as suspected HIV status of the
source. Substantial exposure risk for HIV exposure—
exposure of vagina, rectum, eye, mouth or other mucous
membranes non-intact skin or percutaneous contact with
blood, semen, vaginal secretions, rectal secretions, breast
milk or any other body fluid visibly contaminated with
blood when the source is known to be HIV infected.
Hepatitis B Prevention
• Draw blood for HBsAg (Australia Antigen) and hand over
to the relative along with completely filled form with
instructions to give the sample in the laboratory next
morning (In summer months the sample should be
refrigerated).
• 0.05 ml/ kg birth weight of Hepatitis B immunoglobulin
214 should be advised (useful within 72 hours of assault only), Fig. 30.1: Piercing of vulva
Classification of FGM 4. Internal cervical os is closed.
WHO has classified FGM as follows: 5. External cervical os is partially open.
Type I—Excision of the prepuce with or without excision 6. Recurrent infection leads to chronic pain and backache.
of whole or part of clitoris. (clitoridectomy) 7. Repeated urinary tract infection (UTI).
Type II—Partial or total excision of clitoris with total or 8. Infertility.
partial removal of the labia minora (with or without excision 9. Sexual dysfunction.
of labia majora ). 10. There may be hepatitis B and C, HIV infection.
Type III—Excision of part or all the external genitalia and 11. The extent of psychological damage produced by FGM is
stitching, narrowing the vaginal opening with or without difficult to ascertain. Negative psychological and
excision of the clitoris. (infibulation) psychosexual development of the girl are seen. Influence
Type IV—Unclassified. All other harmful procedures to on girls education, absenteeism, poor concentration, low
the female genitalia for nonmedical purposes, e.g. academic performance and loss of interest are

Chapter 30
cauterization, scraping and piercing and incision, etc. associated with FGM.
Complication—All FGMS have heavy adverse effect on 12. Keloid may form, chronic irritation may lead to retention
health. The excised tissues of the genital tract cannot be of urine and menstrual blood in the vagina due to
replaced. The complications vary with the degree of deformity.
mutilation (type I–IV). The mutilation is often carried out by 13. Obstetric problems were highlighted by a landmark study
a barber, traditional practitioner or a family member without by WHO collaborative group (2006). These women have
antisepsis and anesthesia by non-surgical instruments, e.g. greater risk of cesarean section and extended stay in

Violence Related to Gender and Sexuality

barber’s razor, knife or broken glass. The complications can hospital and postpartum hemorrhage. The infant of
be immediate, short-term or long-term. mothers with extensive FGM (type II and III) were at an
increased risk of dying at birth.
Immediate complications include A joint statement on the elimination of female genital
1. Pain—As the procedure is done without anesthesia may mutation by the office of the High Commissioner for Human
lead to shock (neurogenic). Rights (OHCHR), joint United Nations Program on HIV/AIDS
2. Hemorrhage can be torrential and even life- threatening (UNAIDS), United Nations Development program (UNDP),
(hemorrhagic shock). Economic Commission for Africa (ECA), United Nations,
3. Acute retention of urine due to edema and pain. Educational, Scientific and Cultural Organization (UNESCO),
4. Painful and difficult defecation. United Nations High Commission for Refugees (UNHCR) and
5. Anemia. the United Nations Development Fund for Women (UNIFEM).
Healing takes up to 8 weeks depending on the extent of This joint statement draws on current evidence and evidence
FGM. of interventions that have worked to eliminated FGM.
Short-term: The mutilation is not carried out under Programs aimed at eliminating. FGM also need to be
sterilization conditions. It is performed by crude nonsurgical community led to be successful. This can be done by
instruments. Infection (septicemia and gangrene) is emphasizing the negative health implications. All countries
therefore, a common complication. e.g. perineal abscess and and communities must stop this practice. The medicalization
genital ulcer. Usually Anesthesia is not given, hence it is of FGM (medical practioners performing the procedures) is
very painful. Hemorrhage may be profuse (clitoris has to be strongly condemned.
abundant blood supply) and life-threatening.
Long-term complications: There may be chronic pain, BIBLIOGRAPHY
repeated UTI, infertility, sexual dysfunction, etc. 1 . Behrendt A Mortiz. S, Post-traumatic stress disorder and memory
These long-term complications are both physical and problem after female genital mutation. Am J Psychiatry
psychological. 2005;162:1000.
1. Uterine bleeding without cramping pain following a period 2 . CDC Anti-retroviral post-exposure prophylaxis after sexual, injection.
Drug use, or other non-occupational exposure due to HIV in the
of amenorrhea.
United States nPEP, MMWR Jan 21, 2005/54/RR02;1-20.
2. Hour glass uterus showing soft enlarged cervix equal to 3 . Eke N, Nikanginiema C. Female genital mutilation and obstetric
or larger than the fundus. outcome. Lancet 2006;367:1799. (WHO Study)
3. Products of conception entirely confined within and finally 4 . http://www/who.int/reproductive health published/ fgm/fgm-
attached to the endocervix. statement_2008 .pdf.

215
 31 Reproductive Morbidity

Sudha Salhan

Health of women, (reproductive health in particular), is occurred immediately thereafter. No antenatal check up was
receiving considerable attention in the current trend of health done. She was anemic at that time. She delivered a 7-month
care practices. There is enough data on reproductive deaths preterm male child at home and had excessive bleeding during
(mortality), but not on morbidities. It is estimated that for each delivery. The child died within one month due to diarrhea. She
maternal mortality there are about 20 cases of morbidity, which conceived again after one year with no check up or treatment
can stretch beyond reproductive years (e.g. prolapsed uterus, in between. She had a normal male delivery at home, who was
vesicovaginal fistual, etc.). breastfed for 2 years, further depleting her iron reservoirs
The heavy burden of reproductive disease plays a very besides her other nutrients. This time she was complaining of
important role in the economic development of any nation breathlessness, tiredness and was brought to the antenatal clinic.
(World Bank 1993). The project Global Burden of Disease and All this reflects early marriage, lack of preconception and
Injury (GBDI) undertaken by the WHO, Harvard School of postconceptional check-up intrapartum care and improper
Public Health and the World Bank has estimated the Years Lived dietary and family planning advice. The anemia is getting severe
with Disability (YLD). They thus quantify the total impact of due to lack of quality care.
diseases and injuries in global and regional populations. WHO If neglected, it will not only cause severe morbidity but may
(2000) has done this in assessing the burden of sexual and also be fatal.
reproductive ill health by calculating disability adjusted life Duration: Some obstetric morbidities are short lived. The patient
years (DALYS). All these help in assessing the needs of the is either dead or survives without permanent sequelae (e.g.
community and region. These data are useful for planning and postpartum hemorrhage when handled properly). But some
investment in various health interactions, especially in countries obstetric morbidities may have long-term sequelae (e.g.
like India, where the resources are limited. The subject of obstructed labor causing obstetric fistulas).
morbidity was not tackled till recently in any detail. There is a Time of onset: At a particular age the incidences of some specific
massive burden of these morbidities (more so in countries with morbidities are seen to have a higher incidence. For women
high adolescent fertility), which can undermine the quality of between 15–45 years the cluster of diseases occur commonly
women’s life for long. These problems are, almost always, are called reproductive diseases. Some reproductive events
preventable. Hence, providing adequate quality services during cause morbidity in later life (uterine prolapse, fistulae, cervical
pregnancy, miscarriage, delivery, etc. will go a long way in cancer).
reducing these disabilities.
Accumulation: Some morbidities accumulate over time and grow
DEFINITIONS progressively worse because of:
• Continued exposure to the disease causing agent like
Reproductive health was defined in the 1994 United Nations Cairo
HPV virus and cervical cancer, repeated child birth and
Conference on Population Development as a “State of complete
uterovaginal prolapse.
mental, physical and social well-being in all matters related to
• Lack of exposure to disease preventing agent (presence of
the reproductive system and to its functions and processes.”
iron in diet)
Women’s morbidity: Women’s morbidity refers to all types of • A combination of both.
diseases in women. This is a broad heading.
Sequelae: Some morbidities lead to sequelae. The sequelae may
Reproductive morbidity: Refers to disease that affects the be more life-threatening than the original morbidity (e.g. chorio-
reproductive system, although not necessarily as a consequence carcinoma following molar pregnancy). Mrs Rekha (name
of reproduction. It can extend beyond reproductive years. changed) came to us with bleeding per vaginum for 2 months.
Reproductive morbidity can be measured using several There was no history of preceding amenorrhea. She has delivered
different dimensions. a male child normally 4 years ago and had miscarriage 6 months
These are etiology of the disease, the severity of the morbidity, back. On examination, she was anemic. Her pervaginal
the duration of morbidity, etc., e.g. anemia progressively examination showed a bulky uterus. Her chest radiograph
becomes more severe leading to severe disability with each showed secondaries in the lungs, the liver and skull. Her serum
pregnancy. -hCG was 2,50,000 IU/ml. She was diagnosed with chorio-
An example is given by the following case (name changed) carcinoma and was given appropriate chemotherapy and was
Mrs. Seema, aged 22 years came to an antenatal clinic. She was declared cured after 3 negative -hCG reports.
third gravida with seven-month pregnancy with a hemoglobin Appropriate treatment of the original morbidity may
of 4.5 gm%. She was married at the age of 17 years. As the family prevent sequelae (e.g. early cesarean section for obstructed labor
was poor she got inadequate nutrition. Her first pregnancy can prevent obstetric fistulae).
The Social context of the disease is always important. A resource Indirect obstetric morbidity: In these cases, the morbidity is not
poor household cannot access medical care for the pregnant caused by pregnancy but is made worse by it. It may be due to
member of their family. The power to make personal decisions a compromised immune function which occurs in pregnancy.
relating to health, including sexual behavior and reproduction Several infections, e.g. malaria, tuberculosis, hepatitis, etc. are
have important bearing on reproductive (and women’s) health. more serious during pregnancy. Some chronic diseases may be
Complications of pregnancy and childbirth are the leading cause of exacerbated by pregnancy, e.g. rheumatic heart disease, chronic
death (mortality) and disability (morbidity) among women of hypertension, sickle cell anemia. Breast cancer also progresses
reproductive age (15–45 years) in developing countries like more rapidly during pregnancy.
India. Around 270 million births occur in our country per year. Psychological disorders can result because of pregnancy. These
About half of these mothers experience some complications are due to stress or due to hormonal changes of pregnancy.
(acute morbidity) and between 15–20 million develop Nonobstetric morbidity: These are conditions which occur during

Chapter 31
disabilities (chronic morbidity). Hence, maternal morbidity can pregnancy, delivery or puerperium but appear to be unrelated
be classified as: to pregnancy. The relation sometimes is not that clear, e.g. an
• Acute attempted suicide or homicide in an unmarried pregnant girl.
• Chronic Pregnant women are more prone to burn accidents because of
Acute maternal morbidity are APH, PPH, obstructed labor sepsis, etc. their unstable gait and posture. There is a growing acceptance
Chronic maternal morbidity: It manifests as genital prolapse, of defining such deaths and morbidities being included in
obstetric fistula, urinary stress incontinence, PID, AUB, Sheehan maternal mortality and morbidity.

Reproductive Morbidity
syndrome, infertility, choriocarcinoma and carcinoma of the • Gynecological morbidity: They include pelvic inflammatory
cervix. Sheehan’s syndrome is not well-documented, though it disease after puerperal sepsis or septic miscarriage
can cause chronic weakness, premature aging, amenorrhea, Asherman’s syndrome (after miscarriage), infertility.
mental apathy and confusion, etc. • Contraceptive morbidity: They occur when due precautions
Our country has a high adolescent fertility (almost one third are not taken while providing contraceptive services. Pelvic
births occur in women between 15–19 years). Hence the burden of inflammatory disease can develop, if during copper-T
reproductive disabilities (morbidities) is expected to be very high. insertion or female sterilization proper aseptic precautions
Reproductive morbidity refers to diseases that affect the are not taken. There can be secondary infertility.
reproductive system although not necessarily as a consequences • Sexual morbidity: If perineal tears (especially third degree
of reproduction. Years lived with disability (YLD) estimates perineal tear) are not stiched properly there may be
suggest that a substantial number of women may be affected dyspareunia.
for many years beyond their reproductive age. Reproductive We have a massive burden of reproductive morbidity in our
morbidity can be divided into the following subcategories: country. About 270 lakh deliveries take place per year in India.
• Obstetric (or maternal) morbidity This is a highly neglected issue and there is an urgent need for
• Gynecologic morbidity awareness of reproductive morbidities and placing it on the
• Contraceptive morbidity national and international policy agenda. These morbidities
• Sexual morbidity. undermine the quality of women’s life, and have a far-reaching
effect on the economy of any nation. Most of these can be reduced
Obstetric maternal morbidity: It refers to morbidity that is a by quality care before pregnancy, during pregnancy, during
consequence of pregnancy or childbirth or the consequence of delivery, miscarriages and contraceptive disposal.
treatment received during pregnancy or child birth. It refers to
conditions that occur to women who are pregnant, in labor or BIBLIOGRAPHY
in the puerperium. This category also includes conditions that 1. Abou Zahr C, Ahmed E, Guidotti R. Puerperal sepsis and other
persists beyond the puerperium. Obstetric morbidities are puerperal infections in health dimensions of sex and reproduction.
further subdivided into: Global burden of disease and Injury Series vol. III Harvard School
• Direct obstetric morbidity of Public Health, World Bank, and WHO Geneva;1998.p.191.
• Indirect obstetric morbidity 2. Abou Zahr C, Guidotti R. Hypertensive disorders of pregnancy in
• Psychological morbidity health dimensions of sex and reproduction. Global Burden of
Disease and Injury Series vol. III Harvard School of Public Health,
• Non-obstetric morbidity.
World Bank, and WHO Geneva;1998.p.219.
Direct obstetric morbidity: These are the conditions, which arise 3. Abou Zahr C, Guidotti R. Prolonged and obstructed labour in health
due to pregnancy or labor (hence not seen in non-pregnant dimensions of sex and reproduction, Global Burden of Disease and
women), e.g. hemorrhage (antepartum and postpartum), Injury Series vol. III Harvard School of Public Health, World Bank,
and WHO Geneva;1998.p.243.
puerperal sepsis, hypertensive disorders, miscarriage
4. Abou Zahr C, Ahmed E. Unsafe Abortion and Ectopic pregnancy
(spontaneous or induced). Hypertensive disorder of pregnancy in health dimensions of sex and reproduction. Global Burden of
may lead to chronic hypertension, renal failure and neurological Disease and Injury Series vol. III Harvard School of Public Health,
disorders. This subgroup also includes obstetric morbidities World Bank, and WHO Geneva;1998.p.267.
caused from the treatment of direct obstetric morbidities, e.g. a 5. Datta KK, Sharma RS, Razack PMA. Morbidity pattern among rural
woman with obstructed labor undergoes a cesarean section and pregnant women in Alwar, Rajasthan. A Cohort study. Health and
develops wound infection. Population 1980;3:282.
Usually these direct obstetric morbidities are short lived. 6. Howard D. Aspects of maternal morbidity: The experience of less
developed countries. In. DP Jelliffe and EFP Jelliffe (eds): Oxford
The patient either recovers or dies. Sometimes, they may have
Cleasendon Press, 1987.
long-lasting sequelae. Massive hemorrhage may lead to 7. World Bank, World Development –Report 1993: Investing in Health.
Sheehan’s syndrome. Choriocarcinoma is a direct result of a Oxford University Press, 1993.
pregnancy (miscarriage, molar pregnancy or normal 8. World Health Organization. Measuring reproductive morbidity.
pregnancy). If not treated, it is always fatal. Obstetric fistulae Report of a technical working group Geneva, 30 Aug , 1st Sept 1989.
and uterovaginal prolapse also are long-term morbidities. Documented WHO/ MCH/ 904 Geneva: WHO. 217
 32 Role of Rehabilitation Medicine
in Gynecology Practice

Sindhu Vijay Kumar

Rehabilitation Medicine or Physical Medicine and Postoperative Instructions

Rehabilitation (PMR) encompasses a special body of The chief objective is to reduce the recovery time and avoid
knowledge and procedural skills to help patients with acute the preventable complications (e.g. DVT). It is easier to
or chronic disease, maximize their level of function and communicate with the patient and she would be more
independence. “Rehabilitation is the process of helping a receptive to instructions if the patient has been seen
person to reach the fullest physical, psychological, social, preoperatively and a rapport has been established to teach
vocational, avocational, and educational potential consistent her the following:
with his or her physiologic or anatomic impairment, • Comfortable and correct positioning
environmental limitations, and desires and life plans.” • Pelvic floor exercises can be started as soon as possible after
Through the combined use of medications, physical a vaginal surgery after clearance from the surgeon.
modalities, physical training with therapeutic exercise,
movement and activities modification, adaptive equipments
and assistive device. Rehabilitation can be either hospital or
non-hospital based; and it treats all age groups.

REHABILITATION OF THE PATIENT UNDERGOING

GYNECOLOGICAL SURGERY
It may be cost-effective for the patient undergoing
gynecological surgery to have a rehabilitation assessment
prior to surgery for management of poor posture, backache,
weak pelvic floor, chest conditions, or general debility.

Preoperative Instructions
• Stop or reduce smoking, and do dietary modifications. It
is a good practice to encourage the patients to talk. Let
them confront their fears regarding surgery and prepare
them for the life-style changes that have to be made.
• Slow, relaxed, deep lower costal, diaphragmatic, and
posterior basal breathing, in crook lying without using
the accessory muscles.
• Coughing techniques supporting the proposed site of incision.
Forward lean sitting with feet and knees apart, with a soft
pillow across the thighs, and supporting the abdomen, and
with the shoulders as near to the knees as possible, is the
most pain-free position to cough. This can be achieved by
sitting over the side of the bed or in a chair (Fig. 32.1).
Fig. 32.1: Position for coughing (protecting the incision)
• Full range ankle movements and later of hip
and knee movements to prevent the incidence of deep
vein thrombosis (DVT) and pulmonary embolism.
• Bed mobility techniques and different positions she can
achieve for comfort can be taught to patients in the
preoperative phase itself.
• Pelvic floor contractions are easier to learn in the
preoperative stage rather than after the surgery.
• Posture and back care can be taught.
• Other exercises like gentle pelvic tilt exercises and
abdominal exercises appropriate to the diagnosis and
treatment (Figs 32.2 to 32.8).
Fig. 32.2: Pelvic tilt exercise
• Advice regarding hygiene, skin and wound care.
 Fig. 32.3: Pelvic lift—bridging exercise

Chapter 32
Role of Rehabilitation Medicine in Gynecology Practice
Fig. 32.4: Low back stretching

Figs 32.7 A to C: Hand-knee rocking

Fig. 32.5: Hip extension in standing position

Fig. 32.8: Wall slide

Fig. 32.6: Hip extension in prone position 219
 • Abdominal exercises—pelvic tilting and knee rolling or radiotherapy. Gentle, aerobic conditioning exercises help
exercises combined with static abdominal exercises in but activity and exercise level will depend on the patient’s
crook lying help to ease backache, stiffness and flatulence. condition.
In case of abdominal surgeries, simple abdominal muscle 3. Lymphedema management is mentioned later.
strengthening exercises can be started towards the end 4. Neural, musculoskeletal or genitourinary complications of
of first week. cancer treatments, either surgical and/or radiation warrants
• Posture and back care should be reinforced and patients adequate rehabilitation management.
should be encouraged to sit, stand and walk ‘tall’.
• Mobility should be encouraged as many patients simply URINARY INCONTINENCE
don’t get out of bed as they are not told to do so. Many Urinary incontinence is defined, by the International
patients may be able to sit in a chair after 24 hours. Coughing Continence Society (ICS), as the involuntary loss of urine
position as previously described should be attempted. that represents a hygienic or social problem to the individual.
Abnormalities and Injuries of Genital Tract

Patients should be encouraged to walk around the bed, and The management of neurogenic dysfunction of bladder is a
be helped to the toilet or wash room. By the third or fourth major part of rehabilitation management of patients with
day, repeated short walks are usually possible and beneficial. neurological disorders.
Stairs should be attempted before leaving the hospital if Bladder training has been used primarily to manage urge
the patient has steps or stairs at home. incontinence; however, it also may be used for stress and
• Adequate and appropriate rest and relaxation techniques mixed incontinence. This form of training is useful in young
are taught. women but is difficult to implement in cognitively impaired
Postoperative complications like chest infections, DVT, persons. Bladder training may not be successful in frail
wound infection, and incontinence can be prevented with women who are older. Medical reports demonstrate that
adequate preoperative training and institution of bladder training is effective in reducing urinary incontinence.
rehabilitation measures in the immediate postoperative With bladder training, the rate of patients with mixed
period. If at all they should occur, the medical management incontinence that have been cured is reported to be 12%.
of these conditions should be combined with rehabilitation • Anti-incontinence exercises emphasize rehabilitating and
measures for faster recovery. strengthening the pelvic floor muscles that are critical in
Essential advice following uncomplicated major maintaining urinary continence. If aggressive physical
gynecological surgery: therapy does not work, surgery is warranted.
1. The first two weeks should be extended hospital care, Pelvic muscle exercises may be used alone, augmented
with frequent rests and someone around to prepare with vaginal cones, reinforced with biofeedback therapy, or
meals and shop at least for the first week. enhanced with electrical stimulation. If the patient is using
2. Avoid standing, constipation, and lifting anything that abdominal muscles or contracting the buttocks, these
weighs more than 1 kg, for four weeks. exercises are being performed improperly. If patients have
3. Continue with the hospital exercises, gradually increasing difficulty identifying the levator muscles, biofeedback
therapy may be instituted. For selected individuals, electrical
Section 5

the number of repetitions.

4. Do only light jobs. stimulation further enhances pelvic muscle rehabilitation
5. After two to three weeks, begin regular short walks, therapy.
progressively increasing the distance.
6. After four to six weeks, driving may be considered, Pelvic Floor Exercise
providing that concentration is good and there is Pelvic floor exercise refers to strengthening the levator muscles
confidence. lining the floor of the bony pelvis. The first step in pelvic muscle
7. At about six weeks, returning to work may be discussed with rehabilitation is to establish a better awareness of the levator
the surgeon as well as resuming sexual activity. muscle function. Pelvic floor exercises, sometimes called
Kegel exercises, are a rehabilitation technique used to tighten
CANCER REHABILITATION and tone the pelvic floor muscles (i.e, levator ani) that have
Cancer rehabilitation addresses the physical impairments become weak over time. These exercises empower the
related to tumor effects or to cancer treatment. external urinary sphincter to prevent stress incontinence
Patients undergoing surgery for malignancy have to be and build up the pelvic floor muscles to avert impending
prepared for the long-term care and the need for regular pelvic prolapse. In addition, Kegel exercises may be
follow-up. Psychological and sociovocational counseling is performed to eliminate urge incontinence. Contraction of
important as the depression rates may be high in this the external urinary sphincter induces reflex bladder
population. In patients receiving radiotherapy simple, low relaxation. Pelvic floor muscle rehabilitation may be used to
activity exercises can be advised. Slow, deep breathing; strong, reprogram—the urinary bladder to decrease the frequency
slow foot movements; slow, static contractions of large of incontinence episodes. Individuals who benefit the most
muscles; and gentle arm and head movements are possible from pelvic floor exercises tend to be young, healthy women
with care. who can identify the levator muscles accurately. Older adults
Major areas where rehabilitation can help are: with weak pelvic tone or women who have difficulty recognizing
1. Bone metastases—for lytic secondaries, orthosis (brace) the right muscles need adjunct therapy such as biofeedback
is given to prevent pathological fractures, especially of or electrical stimulation. Pelvic floor exercises work best in
spinal metastases. Heavy activities, exercises and heat mild cases of stress incontinence associated with urethral
therapies are contraindicated. The appropriate advice hypermobility but not intrinsic sphincter deficiency. These
depends on the site and extent of metastasis. rehabilitation exercises may be used for urge incontinence as
2. Deconditioning and fatigue could be associated with the well as mixed incontinence. Pelvic floor muscle exercises are
cancer per se, or the treatment, be it surgery, chemotherapy, performed by drawing in or lifting up the levator ani muscles
220
as if to control urination or defecation with minimal contraction external urethral sphincter, the bladder automatically relaxes,
of abdominal, buttock, or inner thigh muscles. They can start so the urge to urinate eventually subsides. Strong contractions
by stopping the urine stream while urinating. of the pelvic floor muscles suppress bladder contractions.
Whenever patients feel urinary urgency, they may try to stop
Pelvic Floor Muscle Exercise Instructions the feeling by contracting the pelvic floor muscles. These steps
General Information provide the patient more time to walk slowly to the bathroom
• Perform 45 contractions daily with urinary control. By regularly training the external
• 10-second contractions sphincter, patients can gradually increase the time between
• 10-second relaxation periods between each one urination from 1–3 hours. Patients should start to note
• Three groups of 15 contractions each spread out during improvement in 3–4 weeks. Thus, this technique may be used
the day—standing, sitting, lying for stress and urge symptoms—mixed incontinence.
• If weak pelvic floor muscles, contract 2–5 seconds, Patients should practice contracting the levator ani

Chapter 32
increase up to 10 seconds. muscles immediately before and during situations when
leakage may occur. This conditions the external sphincter
Pelvic Floor Muscle Exercise Technique instinctively to contract with increases in abdominal pressure
• Pretend that you are trying to avoid passing gas or a or when the need to urinate is imminent. This is known as the
bowel movement by tightening these muscles guarding reflex. Involuntary urine loss is thwarted by tightening
• Bring the same tightening motion forward to the muscles the external urinary sphincter just as the patient is about to
around the vagina sneeze. The sensation of impending bladder contraction

Role of Rehabilitation Medicine in Gynecology Practice

• Move the contraction up your vagina toward the small of dissipates by squeezing the levator ani muscles, when the
your back patient feels the sense of urgency. By making this maneuver
• Contract only the pelvic muscles a habit, patients develop a protective mechanism against
• Do not strain down or tighten your thighs or buttocks stress and urge incontinence.
• Exhale gently and keep your mouth open each time you The beneficial effects of pelvic floor muscle exercises
tighten your muscles alone have been well-documented in medical literature.
• You can check with mirror Successful reduction in urinary incontinence has been
• You can check with finger vaginally reported to range from 56–95%. Pelvic floor exercises are
• Interrupt urine stream once weekly. effective, even after multiple anti-incontinence surgeries.
Patients should be instructed to squeeze their pelvic floor Vaginal weight training is an effective form of pelvic floor
muscles by performing one of the following techniques: 1) muscle rehabilitation for stress incontinence in women who
stop the flow of urine during micturition, 2) squeeze the anal are premenopausal. Vaginal weights are tampon like special
sphincter as if to prevent passing gas, 3) tighten perivaginal help aids used to enhance pelvic floor muscle exercises.
muscles by squeezing penis during sexual relations or squeezing Shaped like a small cone, vaginal weights (identical shape
a finger inserted into the vagina. and volume) are available in a set of 5, with increasing weights
For stress incontinence, the recommended exercise (i.e., 20 g, 32.5 g, 45 g, 60 g, 75 g). As part of a progressive
programs is different. For beginners, the individual should resistive exercise program, a single weight is inserted into
perform the squeezing exercise 5 times, holding each the vagina and held in place by tightening the perivaginal
contraction for a count of 5. Five contractions equals 1 set. muscles for as long as 15 minutes. As the levator ani muscles
Patients should do 1 set every hour while they are awake, become stronger, the exercise duration may be increased
e.g., while driving, reading, or watching television. After a to 30 minutes. This exercise is performed twice daily. The
while, the patient becomes proficient at this. Then, the patient intravaginal weight provides the sensory feedback for the
may be able to hold each contraction for at least 10 seconds, desired pelvic muscle contraction. The sustained contraction
followed by an equal period of relaxation. The pelvic floor required to retain the weight within the vagina increases the
exercises must be performed daily for at least 3–4 months to strength of the pelvic floor muscles. The best results are
be effective. Another regimen is to perform the exercises for achieved when standard pelvic muscle exercises (i.e. Kegel
10 minutes twice a day using an audiocassette tape. The exercises) are performed with intravaginal weights. In
audiocassette coaches the patient to contract the levator premenopausal women with stress incontinence, the
ani muscles for a count of 10 seconds and then to relax for a subjective cure or improved continence status is
count of 10 seconds, performing 25 repetitions in a row. approximately 70–80% after 4–6 weeks of treatment. Vaginal
Twenty-five contractions equal 1 set. Perform the first set weight training also may be useful for postmenopausal
slowly, followed by a second set performed rapidly. In order women with stress incontinence; however, vaginal weights
to gain the most benefit from this program, patients may are not effective in the treatment of pelvic organ prolapse.
need to continue this exercise indefinitely. If patients have Biofeedback therapy is recommended for treatment of stress
not significantly improved after a regimented program of incontinence, urge incontinence, and mixed incontinence. It is
4–6 months, they may need electrical stimulation. intensive therapy, with weekly sessions performed in an office
Another alternate regimen is to suggest that the patient or a hospital by a trained professional, and it often is followed
repeats a set of 5 exercises each time he or she goes to the by a regimen of pelvic floor muscle exercises at home. During
bathroom. Again, this ensures that the exercises are performed biofeedback therapy, a special tampon-shaped sensor is inserted
many times during the day. If patients are unable to perform in the patient’s vagina or rectum and a second sensor is placed
the exercise for the optimal 5–10 seconds, they may need to on her abdomen. These sensors detect electrical signals from
start at only 2–3 seconds of contraction until they are able to the pelvic floor muscles. The patient then is instructed to
perform the exercise properly. contract and relax the pelvic floor muscles upon command.
For urge incontinence, pelvic floor muscle exercises are When performed properly, the electric signals from the pelvic
used to re-train the bladder. When the patient contracts the floor muscles are registered on a computer screen. Biofeedback,
221
 using multi-measurement recording, displays the simultaneous does not appear to benefit patients who are cognitively
measurement of pelvic and abdominal muscle activity on the impaired.
computer monitor.
Biofeedback allows the patient to correctly identify the REHABILITATION MANAGEMENT OF GENITAL
pelvic muscles that need rehabilitation. The benefit of DISPLACEMENTS AND PROLAPSE
biofeedback therapy is that it provides the patient with minute- Rehabilitation management of patients with genital
by-minute feedback on the quality and intensity of her pelvic displacements include pelvic floor muscle strengthening
floor contraction. Combining bladder and urinary sphincter exercises, treatment of chest and other infections,
biofeedback allows the patient to regulate the pelvic muscle management of obesity, constipation and work and activity
contraction in response to increasing bladder volumes and to modification.
monitor the bladder activity. Biofeedback is best used in
conjunction with pelvic floor muscle exercises and bladder MANAGEMENT OF LYMPHEDEMA
Abnormalities and Injuries of Genital Tract

training. Studies on biofeedback combined with pelvic floor Lymphedema may develop in lower limb secondary to
exercises show a 54–87% improvement with incontinence. The inguinal lymph node dissection or radiotherapy to inguinal
best biofeedback protocol is the one that reinforces levator region or in upper limb, secondary to breast cancer surgery
ani muscle contraction with inhibition of abdominal and bladder or radiotherapy.
contraction. Medical studies have demonstrated significant The principles of management include elevation of limb
improvement in urinary incontinence in women with above heart level, manual massage from distal to proximal,
neurologic disease and in the frail older population when a intermittent pneumatic compression, isometric and isotonic
combination of biofeedback and bladder training is used. exercises for distal muscles, elastic support stocking or
Biofeedback provides a specific reinforcement for pelvic sleeve, etc. Sources of increased load on lymphatics should
muscle contraction that is isolated from the counterproductive be avoided. These are:
abdominal contraction. Overall, the medical literature • Static dependent positioning of limb
indicates that pelvic muscle exercises and other behavioral • Application of local heat
strategies, with or without biofeedback, can cure or reduce • Prolonged use of muscles for even light tasks
incontinence. However, the maximum benefit is derived from • Hot environments
any pelvic muscle rehabilitation and education program when • Infection and cellulitis should be prevented.
ongoing reinforcement and guidance, such as biofeedback
therapy, are provide. CHEST PHYSIOTHERAPY AND POSTURAL DRAINAGE
Electrical stimulation is a more sophisticated form of Chest physiotherapy is important for any patient undergoing
biofeedback used for pelvic floor muscle rehabilitation any type of surgery especially gynecological surgery.
involving stimulation of levator ani muscles using painless Teaching techniques of chest physiotherapy prior to surgery
electric currents. Electrical stimulation of pelvic floor muscles may be more helpful postoperatively as the patient would
produces a contraction of the levator ani muscles and understand better and the compliance with the program is
external urethral sphincter while inhibiting bladder better. It includes breathing exercises and breathing
Section 5

contraction. This therapy depends on a preserved reflex arc techniques and coughing techniques.
through the intact sacral micturition center. Similar to Postural drainage is important if the patient develops lower
biofeedback, electrical stimulation can be performed at the respiratory infections postoperatively. This is the placement of
office or at home. Electrical stimulation can be used in patient in particular positions to assist in drainage of secretions,
conjunction with biofeedback or pelvic floor muscle exercises. depending on the bronchopulmonary segment involvement
Electrical stimulation therapy requires a similar type of probe (Fig. 32.9).
and equipment as those used for biofeedback. This form of
muscle rehabilitation is similar to the biofeedback therapy, PELVIC INFLAMMATORY DISEASE
except small electric currents are used. Nonimplantable pelvic The general rehabilitation management does not apply to
floor electrical stimulation uses vaginal sensors, anal sensors, patients with acute infections and inflammations of the female
or surface electrodes. Adverse reactions are minimal. As in genital system. However, in the chronic phase, when adhesions
biofeedback, pelvic floor muscle electrical stimulation has
been shown to be effective in treating female stress incon-
tinence, as well as urge and mixed incontinence. Electrical
stimulation may be the most beneficial when stress
incontinence and very weak or damaged pelvic floor muscles
coexist. A regimented program of electrical stimulation helps
these weakened pelvic muscles contract so they can become
stronger. Research indicates that pelvic floor electrical
stimulation can reduce urinary incontinence significantly in
women with stress incontinence and may be effective in
men and women with urge and mixed incontinence. Electrical
stimulation appears to be the most effective when
augmented with pelvic floor exercises. Long-term data report
that the rate of patients cured or improved from electrical
stimulation ranged from 54–77%; however, in order to derive
significant benefit, stimulation must be performed for a
minimum of 4 weeks, and patients must continue pelvic floor Fig. 32.9: Postural drainage position for right lateral
exercises after the treatment. Unfortunately, this treatment bronchopulmonary segment
222
are causing pain, continuous or pulsed short-wave diathermy Management of osteoporosis has to be mentioned specifically
(SWD) or therapeutic ultrasound (US) may be used. Short as the incidence is very high and can lead to serious
wave diathermy and US, both of which are deep heat modalities complications, if fractures occur, especially in postmenopausal
have been used in the treatment of pain and infertility in women. It is important, for all health care professionals, to
patients with adhesions of the female genital tract. Available have an idea about the various principles of management of
literature for the use of pelvic SWD and US is prior to 1960, osteoporosis as effective medications are available and when
thanks to advances in modern medicine and use of newer and combined with rehabilitation measures, all the complications
more effective techniques for the management of these can be prevented.
conditions. In India, however, probably due to the higher Major principles of management of osteoporosis are:
incidence of infections and secondary complications there of, 1. Drugs like bisphophonates, calcitonin, HRT, anabolic steroids.
there still remains some limited role of these modalities. Deep 2. Calcium and vitamin D supplementation.
heat modalities have many contraindications and complications 3. Diet changes and modifications.

Chapter 32
and should not be used without the advice of a specialist in the 4. Aerobic activity for at least half and hour daily.
field. It is absolutely contraindicated in the presence of any 5. Fall prevention techniques.
acute infection or inflammation. These are dangerous to the Women with carcinoma of breast are increasingly
gravid uterus and should not be used when the patient is surviving their illness and living fuller lives than before.
menstruating. Rehabilitation interventions can definitely improve their
quality of life.
Back Ache
BIBLIOGRAPHY

Role of Rehabilitation Medicine in Gynecology Practice

Back ache is possibly the commonest complaint a rehabilitation
specialist sees in the OPD and inarguably, the most common 1 . Kisner C and Colby LA. Therapeutic Exercise: Foundations and
cause of absenteeism in working women. The causes are Techniques, 3rd Edn. Jaypee Brothers, India 1996.
2 . Kirschner KL, Gill CJ, Reis S, et al. Health issues for women with
manifold and the management depends on the diagnosis.
disabilities. Rehabilitation Medicine. Principles and Practice, 3rd
However, faulty posture is one of the common causes and Edn. Editor’s DeLisa JA and Gans BM. Lippincott-Raven Publishers,
accurate ergonomic advice is necessary. Philadelphia 1998.
Peri- and postmenopausal symptoms can be alleviated to an 3 . Polden M and Mantle J. Physiotherapy in obstetrics and
extent with rehabilitation measures when combined with the gynaecology, 1st edn. Jaypee Brothers, India 1994.
gynecological management.

223
 Section 6 Genitourinary Problems in Gynecology

33 Urinary Tract Infection (UTI)

Sudha Salhan

The commonest urinary problem in gynecology outpatient Investigation: Routine examination and culture of the
department is urinary tract infection in patients between 20-65 midstream urine by clean catch method is required. Signs of
years of age. suprapubic tenderness (cystitis) and renal angle tenderness
Etiology: The cause is the proximity of urethra to the anal region. (pyelonephritis) may be elicited.
Besides the urethra being short there is no anatomical closing Most of the organisms are sensitive to nitrofurantoin and
mechanism at external urethral meatus, hence the infection can dose of 100 mg QID for one week to 10 days is sufficient. Other
travel up easily. drugs are quinolones (ciprofloxacine, nitrofloxacine, of loxacine,
The mechanism can be pushing the bacteria up during gatifloxacine, etc.), aminoglycosides (gentamycin, amikacin—
defecation (when cleaning from back to front), sexual need to be given intramuscular) trimethoprime-salfame-
intercourse, catheterization, etc. thoxazole combination, cephalosporines (cefotaxime), etc.
Blood-borne and lymphatic spread of the infection is not Besides drugs, they are advised plenty of fluids orally and
common. pass urine frequently. Urinary analgesics may give some relief
It is more frequent in patients of diabetes mellitus, vaginal during acute phase. Diabetic patient must control her blood
prolapse, vesicovaginal fistula, pregnancy, etc. Local causes in sugar levels. In postmenopausal women local estrogen cream
the urinary bladder viz. calculi, deverticuli may be the cause of vaginally may help.
recurrent UTI.
Indwelling catheterization for long periods is also a cause Recurrent UTI’s
(iatrogenic). This entity needs further investigations like ultrasound of
Organisms: Escherichia coli are the commonest causative abdomen to exclude calculi in urinary tract. Any structural
organism, because of the location of urethra. Other causative abnormality (urinary bladder deverticuli) may be seen by
organisms being Proteus mirabilis, Pseudomonas aeruginosa, intravenous pyelography. In some cases cystoscopy is required
Klebsiella pneumoniae, Staphylococcus(coagulase negative), to exclude any local pathology. Sometimes neurological
Mycoplasma, Staphylococcus aureus and rarely Chlamydia. examination may be needed. The administration of drugs, to
Symptoms: There is frequency of micturition, pain after which the causative organism is sensitive, is to be given for
completion of evacuation of urine (cystitis) or burning longer period (2–3 weeks). Renal tuberculosis should be
micturition. The urine may have pus or blood. excluded.
 34 Urinary Incontinence in Females

Monika Gupta, Aruna Batra, Sudha Salhan

Definition The striated urethral sphincter invests the distal two thirds
Urinary incontinence is the involuntary loss of urine which of the female urethra. Proximally, it forms a complete ring around
causes a social or hygienic problem and is objectively the urethra that corresponds to the zone of highest urethral
demonstrable (International Continence Society-ICS). It can be closure pressure. The suspensory ligament of the clitoris and the
a symptom, sign or condition. The challenge to the clinician is pubourethral ligaments form a sling that suspends the urethra
determining which type of incontinence the patient has and beneath the pubis. The arterial supply to the female urethra is
confirming its cause so that the correct management can be derived from inferior vesical, vaginal and internal pudendal
instituted. arteries. Blood from the female urethra drains into the internal
pudendal veins.
Incidence
All over the world around 200 million lives with this problem, Female Urogenital Triangle
though all are not reporting to the doctor (less than 50%). The vestibule of the vagina runs vertically throughout the length
of the urogenital triangle. The labia majora forms its lateral sides
Anatomy of Female Genitourinary System and fuse anteriorly as the hood of the clitoris. The subcutaneous
(GUS) (Fig. 34.1) fat pad of the mons pubis continues posteriorly in the labia
Female Urethra majora to frame the vestibule. The urethra enters the vestibule
The female urethra is a 4 cm long opening above the introitus. between the clitoris and the vagina.
The lining epithelium gradually changes from transitional to The blood supply to the urogenital triangle is derived from
nonkeratinized stratified squamous epithelium. Many small the internal pudendal vessels. The internal pudendal veins
mucous glands open into the urethra. Distally these glands communicate freely with dorsal vein complex by piercing the
group together on either side of urethra and known as Skene’s levator-ani muscles.
gland and empty on either side of external urethral meatus. The pudendal nerve follows the vessels in their course
The submucosa of female urethra is thick, richly vascular and through the perineum (Fig. 34.2).
supports the urethral epithelium and glands. The mucosa and Mechanism of Normal Continence of Urine (Fig. 34.3)
submucosa together form a cushion that contributes significantly It is an intricate coordination between the urinary bladder,
to urethral closure pressure. These layers are estrogen dependent. urethra, pelvic muscles and the surrounding connective tissue.
At menopause the atrophy resulting in stress incontinence. In Bladder gets filled up without increasing intravesical pressure
contrast to the male proximal urethra, no circular muscle sphincter (not seen in any other viscera). Filling is under pontine micturition
can be identified in the females. center in the brain modulating neurologic impulse to detrusor
smooth muscle.

Fig. 34.1: Anatomy of pelvic floor

 detrusor to contract, thus raising intravascular pressure to empty
the contents.
First desire to void is felt at 200 ml of urine but depending
on surroundings (whether toilet is available or not) it may reach
up to 600 ml. Maximum detrusor pressure at filling is <15 cm
H2O, at voiding is <70 mm H2O urine flow it is >15 ml/sec.
Urinary incontinence may be Transient or True Incontinence.

Transient Incontinence
Urinary incontinence may result from transient causes
mentioned below which can be elicited through a proper history,
physical examination and laboratory tests. This can be told by
Genitourinary Problems in Gynecology

the word DIAPPERS (Delirium, Infection, Atrophic,

Pharmaceutical, Psychological rest, such and size of ways).
a. Psychological: Delirium, depression and anxiety can cause the
patient to leak urine. The mechanism is usually a combination
of induced bladder overactivity and inappropriate urethral
sphincter relaxation.
b. Infection: Cystitis and urethritis cause frequency, urgency
and dysuria, leading to urge incontinence. Atrophic
urethritis and vaginatus may be the cause.
c. Pharmaceutical: Drugs like diuretics lead to increased urine
load on the bladder and if the patient cannot find a toilet in
time, urge incontinence can result. Anti-cholinergic agents
and sedatives can cause detrusor atonia and thereby, chronic
urinary retention and overflow incontinence. Rarely, calcium-
channel blockers given for hypertension antagonize the tone
of the external urethral sphincter and simulate stress
incontinence. Laxatives tranquilizers, etc. may aggravate.
d. Endocrine: Diabetes mellitus through its osmotic diuresis
effect can cause an overactive bladder. Diabetes insipidus
similarly presents an increased urine load of as much as 10
Fig. 34.2: Nerve supply to bladder liters/day to the bladder and this easily leads to overflow
Section 6

incontinence. Hyperthyroid states can induce the bladder

Continence is achieved by (i) urethra (skeleton muscles to become overactive, leading to urge incontinence. On the
rhabdosphincter) small type muscles fibers in its middle third. other hand, hypothyroidism causes a hypotonic bladder and
There are smooth muscles also in the urethra in longitudinal overflow incontinence is the result. The recognition and
and circular layers. Both skeleton and smooth muscles maintain adequate treatment of these endocrine diseases should
the resting tone and while the former also respond to rises in reverse the incontinence.
intra-abdominal pressure. (ii) Major role in continence is played e. Diseases like hypertension, stroke, orthritis, etc.
by pelvic muscles. Contraction of levator ani pulls the vagina f. Restricted Mobility: Limited mobility due to severe arthritis or
forward towards the pubic symphysis creating a backstop for stroke causes functional incontinence because such patients are
the urinary tract. Compressing the two walls of the urethra unable to get to the toilet in time.
prevening incontinence of urine in cases of increased intra- g. Stool Impaction: Impacted feces distort the bladder neck and
abdominal pressure including coughing sympathetics (T3.12) press on the nerves supplying the urethra and bladder, leading
pudendal in pulses (S2–4). to urinary retention and overflow incontinence is the result.
It is important to rule out this group of causes because they
Voiding of urine: First the urethra relaxes by inhibition then the spinal
are simple to treat and unnecessary tests, especially
reflex pathway is activated. Parasympathetic impulses (S2–4) causes
urodynamics are avoided.

True Incontinence
Once the above category is excluded, this leaves the cases that
are important to recognize because they will need further
assessments and correct treatment. It can be classified into:
1. Stress urinary incontinence
2. Overflow incontinence over active bladder (Detrusor
instability)
3. Urge incontinence
4. Reflex incontinence
5. Total incontinence (in genitourinary fisfulas—see chapter 35).

STRESS URINARY INCONTINENCE

Stress incontinence presents as leakage of urine as a result of
coughing, sneezing and physical activities that increase the
226 Fig. 34.3: Mechanism of normal continence of urine intra-abdominal pressure. (Fig. 34.4)
 of caucasian race. They are more prone for development of
incontinence. It may be associated with uterine descend or fecal
incontinence (in one fifth of cases).
ISD can also occur as a result of partial denervation as in
radical pelvic surgery, and irradiation for malignant diseases
like carcinoma of the cervix and rectal cancer. Vaginal surgery
is also incriminated and chronic constipation is seen in a few.

Classification of Stress Urinary Incontinence

Type ‘O’: The patient complains of a typical history of stress
incontinence but no urinary leakage is demonstrated during
clinical and urodynamic investigations. Video urodynamic

Chapter 34
study reveals bladder neck and proximal urethra are closed at
rest and situated at or above the lower end of pubic symphysis.
Failure to demonstrate incontinence is probably caused by
momentary voluntary contraction of the external urethral
sphincter during examination.
Fig. 34.4: Stress incontinence—when increased intra-abdominal Type ‘I’: The bladder neck is closed at rest and situated above
pressure leads to leakage of urine the inferior margin of the symphysis. During stress the bladder

Urinary Incontinence in Females

neck and proximal urethra open and descend less than 2 cm
Genuine stress incontinence (GSI) (also called urodynamic resulting in urinary incontinence.
stress incontinence) occurs when the intravesical pressure Type ‘IIA’: The bladder neck is closed at rest and situated above
exceeds the maximum urethral pressure in the absence of the inferior margin of pubic symphysis. During stress the
detrusor activity due to incompetent urethra. bladder neck and proximal urethra open and there is a rotational
GSI is due to two causes: descent resulting in incontinence associated with
1. Urethral hypermobility, i.e., descent of the bladder neck (loss cystourethrocele.
of this support)—bladder neck hypermobility and proximal Type ‘IIB’: The bladder neck is closed at rest and situated at or
urethra downward and away from retropubic position below the inferior margin of the symphysis pubis. During stress
(Fig. 34.5) there may or may not be further descent but the proximal
2. Intrinsic sphincter deficiency (ISD), i.e., loss of urethral urethra opens and incontinence ensues.
resistance may be because of neuromuscular compromise. Type ‘III’: The bladder neck and proximal urethra are open at rest
This is along with normal detrusor function. in the absence of a detrusor contraction. The proximal urethra
Frequently the two are combined. The former is due to a no longer functions as a sphincter. There is obvious urinary
failure of equal transmission of intra-abdominal pressure to the leakage which may be gravitational or associated with minimal
proximal urethra, leading to a reversal of the normal pressure increase in intravesical pressure.
gradient between the bladder and urethra resulting in a negative
urethral closure. Where there is loss of urethral resistance, the OVERFLOW INCONTINENCE
resting intraurethral pressure is below the intravesical pressure. This is due to over-distension of bladder to a point where the
Urethral hypermobility is most common in parous women elevated intravesical pressure overcomes the urethral resistance,
following direct neuromuscular and or endopelvic connective but in the absence of detrusor activity. This condition occurs in
tissue damage resulting from child birth. Vascular damage due two situations:
to tumor to compression of fetel heard. 1. Bladder outlet obstruction, e.g. urethral stenosis.
Estrogen deficiency in postmenopausal states leads to pelvic 2. Atonic bladder, e.g. diabetic neuropathy, spinal cord trauma.
floor laxity and poor urethral mucosa coaptation. This entity of The classic history is that of nocturnal enuresis. However,
poor mucosal apposition is commonly referred to as intrinsic sometimes the patient perceives it as “stress incontinence,” i.e.
sphincteric deficiency. Infections, medication and smoking, etc. the leakage of urine tends to occur upon coughing or sneezing.
is also cited as a cause. The incidence is more in elderly women The suspicion lies in the finding of a distended bladder on
abdominal examination and large residual urine on ultrasound.
It is difficult to differentiate between the two etiologies
(especially in an elderly diabetic) and the unequivocal test lies
in the pressure-flow study (PFS) which will show low pressure-
low flow in the case of bladder atonia.

URGE INCONTINENCE
This type of incontinence is preceded by a strong desire to void
and the patient is unable to get to the toilet in time. The history
is usually typical in that there is a long history of overactive
bladder symptoms (frequency, urgency) and the precipitating
event is identifiable, e.g. cold weather, stressful situations, and
sound of running water. On urodynamics, urge incontinence is
usually, but not always, associated with the finding of
involuntary detrusor contractions, termed detrusor instability
(DI) or overactive bladder. It may be associated with GSI.
Fig. 34.5: Rotational descent of bladder neck in GSI Most of them are idiopathic. Deterioration of CNS control 227
 6. Surgical: Previous pelvic surgery, continent surgery, radical
surgery for gynecological malignancies, instrumental
delivery.
7. Drugs: Drugs used for chronic constipation diuretics,
sedatives, alcohol, anticholinergics, alpha adrenergic
blockers may be causative.
A number of questionnaire formats are available, e.g. MESA
questionnaire to know the type of incontinence.

Physical Examination
Thorough physical examination especially vaginal and
neurological examinations must be conducted. Coexisting
Genitourinary Problems in Gynecology

diseases are to be ruled out.

Organ systems are examined.
1. General conditions: Mobility, obesity, blood pressure,
cognitive status, edema, etc.
2. Lungs: Chronic bronchitis, asthmatics.
3. Abdominal: Abdominal and pelvic mass, scars, anal sphincter
tone, and fibroid.
Fig. 34.6: Detrusor Instability—involuntary detrusor contractions. Early 4. Pelvic: Estrogenization, vulval excoriations, pelvic floor
first desire and limited cystometric capacity seen during filling cystometry prolapse, demonstrable stress incontinence lying down and
standing vaginal capacity and mobility, pelvic muscle tone
of urine storage including spinal cord injuries, Parkinson’s vaginal atrophy.
disease (Fig. 34.6). 5. Bonney’s test: After demonstating stress incontinence
DI can be subdivided into: strength of pelvic floor during per vaginal examination and
a. Primary (idiopathic) ability to squeeze examining fingers. Examiner places two
b. Secondary to bladder outlet obstruction fingers, one on each side of the urethra and exerts upward
c. Neuropathic or detrusor hyperreflexia. pressure against the subpubic angle; the patient is requested
The etiology of DI remains unclear. However, theories to cough, without emptying the bladder and if no urine
currently postulated to explain DI include postjunctional escapes while the pressure is maintained digitally, operative
supersensitivity, altered adrenoceptor function, afferent nerve correction can be planned. It causes direct urethral pressure
dysfunction, imbalance of neurotransmitters and primary or hence cannot diagnose urethral hypermobility. For the later
Section 6

acquired myogenic deficit. There may be irritable bowel Miyazaki’s modification is useful. Here the anterior vaginal
syndrome associated. wall is streched superiolaterally till lateral pelvic wall by
Concomitant conditions are pelvic organ prolapse and feces ring forceps. Demonstration of urine lekage with coughing
incontinence. or valsalva in lying down positon and may be even in
standing.
CLINICAL PRESENTATION 6. Neurological: Spina bifida occulta, lower limbs and vulval
Women with urinary incontinence present with symptoms such skin sensation and anal reflexes (S2–S4). Multiple sclerosis,
as frequency, urgency, stress incontinence, urge incontinence, Parkinson’s disease.
enuresis, etc. However, bladder symptoms often do not correlate
with the underlying diagnosis. Investigations
Many clinicians have demonstrated discrepancy between
EVALUATION clinical findings and urodynamic studies. The difficulty lies in
Clinical assessment of a woman with urinary incontinence the overlap of symptoms in the history.
includes an accurate history and a thorough physical Following investigations need to be done:
examination to enable a presumptive diagnosis to be
formulated. In uncomplicated cases, a short trial of conservative Basic Investigations
treatment can then be initiated on the basis of the presumptive 1. Urinalysis: To rule out infection, detect glycosuria and
diagnosis. Having a structured questionnaire will facilitate the hematuria.
clinical assessment. 2. Postvoid residual urine (RU) normal is less than 50 ml estimation
is done: Via catheterization, bladder scan or ultrasound
History estimation. A high RU (more than 200 ml) reflects impaired
Many women do not report to the physician due to detrusor contractility and can be the cause of overflow
embarrassment. A detailed and accurate history is essential and incontinence.
includes the following points: 3. Frequency/volume Chart: Maintained for 2–3 days;
1. Incontinent symptoms: How long, frequency, severity, time objectively demonstrates frequency, nocturia, incontinent
of day (day or night) quality of life, precipitating factors. episodes, urinary output and fluid intake.
2. Other urinary symptoms: Frequency, nocturia, urgency, 4. ICS 1-hour Pad Test and Erect Stress Test: to confirm
enuresis, voiding difficulty, dysuria, hematuria. incontinence, quantify severity of leakage before and after
3. Any previous continence treatment. treatment.
4. Gynecological: Menopause, pelvic mass, pelvic floor 5. Biochemical Tests: Selective usage to assess renal function or
prolapse, bowel dysfunction. diabetes.
5. Medical: Chronic cough, constipation, Diabetes, mellitus and 6. Urinary diary or Bladder Record: This records patient’s voided
228 insipidus neurological history and their level of control. volumes, leakage episodes including amounts and
 associated activities, and type and volume of fluid intake. ii. Restriction of fluid to one liter a day (particularly if
Review of the diary can help clinician to suggest simple frequency is a problem) in patients with high fluid intake.
behavioral interventions such as fluid intake and medication iii. Patients with chronic cough should be advised to stop
adjustments. smoking, and constipation should be treated, weight is to
be reduced.
Specialized Investigations iv. Pelvic floor exercises may be helpful in the puerperium.
1. Uroflowmetry: objective assessment of voiding function. v. Estrogen replacement therapy in postmenopausal women
Indicated in incontinent women to exclude voiding is advised.
dysfunction which may be asymptomatic. Bladder volume vi. Diuretics may have to be stopped or reduced if prescribed
should be >150 ml to accurately assess the flow rate. The for some ailment.
flow rate should be more than 20 mI per second in normal vii. In patients with chronic urinary incontinence, especially
women. elderly women, it may be easier to provide an indwelling

Chapter 34
2. Filling and Voiding Cystometry: Measures the pressure- catheter, although clean intermittent self-catheterization
volume relationship of bladder to diagnose DI, GSI and (CISC) is preferred since the female urethra is short and
voiding disorders. easily catheterized.
3. Urethral Pressure Profilometry (Resting and stress UPP). A viii. Bladder tracting (bladder drill): The patient is asked to
UPP of <20 cm H2O or a negative pressure transmission urinate at designated intervals (say every 2 hours) and is
ratio indicates intrinsic sphincter deficiency as a cause of taught to resist the feeling of urgency between these
GSI. intervals. In due course of time the interval between

Urinary Incontinence in Females

4. Valsalva Leak Point Pressure (VLPP): Measures the urethral micturition is gradually increases.
opening pressure or leak point pressure during a Valsalva Treatment of the cause of transient incontinence will cure
maneuver. A VLPP of less than 60 cm H2O indicates intrinsic the condition, e.g. treating UTI or reduction of uterovaginal
sphincter deficiency. descend with or without Burch colposuspension.
5. Ultrasound: Can help in estimation of residual urine,
detection of pelvic mass; structural abnormalities (e.g. CONSERVATIVE MANAGEMENT
bladder diverticula, hydronephrosis). Transperineal USG Conservative and surgical treatments for Genuine Stress
can also demonstrate urethral hypermobility and descent Incontinence will depend on the patient’s preference, condition
of bladder neck with valsalva. and urodynamic diagnosis.
6. Videocystourethrography (VCU): Cystometry and radiological Conservative therapy is indicated when:
imaging of bladder/urethra with contrast. Only selectively a. The patient refuses or is undecided about surgery.
used in evaluating women with failed continence surgery. b. The patient is mentally or physically unfit.
Detects position and mobility of bladder neck, ureteric c. Childbearing is to be continued.
reflux, incontinence, etc. d. There is uncontrolled detrusor instability or voiding
7. Intravenous Pyelogram or Micturating Cystogram: Indicated difficulty.
in women with genitourinary fistula to demonstrate the
presence of fistula and to assess renal function. BEHAVIORAL TECHNIQUES
8. Cystourethroscopy: Visualize disease at bladder/urethra (e.g. 1. Pelvic Floor Exercises (Kegel’s Exercises): Regular contractions
tumors, stone, interstitial cystitis). It is not indicated in GSI. of pelvic floor muscles. Patient is also asked to stop the
9. Q-tip test demonstrates urethral hypermobility. Patient is urinary stream in between for a few seconds. Pelvic floor
put in dorsal position. Sterile cotton tipped stick is muscles are just like other striated muscles which can
introduced in the urethra till bladder neck. Angle between become stronger with exercise. Women with detrusor
the vaginal plane and stick is measured before and after overactivity or stress incontinence can regain control through
valsalva maneuver. If the angle increases by 30 degrees or these Kegel’s exercises. Patients are instructed to perform 10
more it indicates urethral hypermobility. to 20 ten-second pelvic floor contractions 3–4 times per day.
10. Pediatric Foley’s Test—Used to see intrinsic sphincter Bladder control improves until after 4 to 6 weeks.
deficiency. Number eight French is introduced in the 2. Bladder Retraining: Simple techniques are suggested after
urethra. The bulb is inflated and try to remove the catheter. review of urinary diary, including adjustments in type and
If it comes out, it confirms the diagnosis. volume of fluid intake, e.g. timed voiding for females with
11. Subtraction cystometry and uroflowmetry. detrusor overactivity. Bladder training by gradually
12. Cystometrograph: Measures pressure volume relationship of increasing voiding interval from 1 hr to 2–3 hrs during day
the bladder. time, suppression of urge with distraction or relaxation
13. Carbon dioxide cystometry: Not very accurate. techniques (to prevent leakage). Avoidance of caffeinated
14. Water cytometry: It is time consuming but more accurate. beverages for patients with urgency and frequency.
15. Three-swab Test: Indicated in women with continuous 3. Acupuncture
leakage of urine to differentiate between vesicovaginal and 4. Hypnosis
uretrovaginal fistula. (See chapter 65). 5. Weighted Vaginal Cones: A cone of graded weight is placed
inside the vagina and patient attempts to keep the cone
MANAGEMENT falling out by squeezing the pelvic floor. This is done 10–20
Management is individualized. It includes many modalities, minutes a day.
e.g. lifestyle change, medicines, surgery, etc. 6. Electro stimulation: Stimulation of the pudendal nerve with
electrodes placed in the vagina or anus. This produces a
General Measures—Lifestyle Change
contraction of the levator ani, external urethral sphincter,
The quality of life of incontinent women may be improved by and anal sphincters, accompanied by reflex inhibition of
simple advices such as: the detrusor. This reduces detrusor overactivity and stress
i. Use of incontinent pads and garments. incontinence in 50–70% of patients. 229
 7. Devices: Includes elevating and occlusive devices. improvement in nocturia secondary to estrogen therapy in
a. Elevating Devices: For mild GSI, a tampon, reusable foam postmenopausal women.
pessary, or prosthesis that supports the bladder neck
(introl bladder back prosthesis) may temporarily cure SURGICAL TREATMENT
incontinence by elevating the bladder neck. Such Nonsurgical methods must be tried first. Continence
prostheses are recommended for incontinence at known surgery is indicated when conservative treatment fails or the
times, such as during sports. Side effects include urinary patient wants definitive treatment. Surgery aims to elevate the
tract infections and soreness of the vaginal mucosa (Ring bladder neck, support the mid-urethra, or increase urethral
incontinence pessary). resistance. Mainly stress at the same time, any genital prolapse
b. Occlusive Devices: Devices for occluding both external should be corrected. In general, the first attempt at continence
and internal urethra are available for patients who leak surgery produces better results than repeat procedures. Hence
only under known circumstances or while awaiting selection of the procedure is crucial. Clinical features,
Genitourinary Problems in Gynecology

surgery. The efficacy, cost, comfort, and adverse effects urodynamics data, and operation characteristics influence the
including urinary tract infection must be considered. choice of surgery. If the patient has not completed her family,
Compliance seems to be a major problem with all the continence surgery can be performed but should be
devices. subsequently conceive and remain dry, an elective cesarean
c. Tissue engineering technique-tissues, e.g. myoblasty section is advised. The patient should be counseled on avoiding
fibroblasts neuronal stem cells adipose-derivatives. unnecessary heavy lifting or abnormal straining after continence
Stem cells are injected transurethrally under ultrasound surgery. Surgery includes retropubic urethropexy and
guidence (experimental). pubovaginal slings.
a. Colposuspension: The Burch colposuspension is the most well-
PHARMACOTHERAPY known and involves hitching the paravaginal tissue to the
a. Urge Incontinence: Drug treatment is aimed at reducing pectinate ligament Cooper’s ligament (Fig. 34.7). It has been
inappropriate detrusor contractions. These are typically found to be the most durable operation with long-term success
antimuscarinic or anticholinergic agents. Examples in this rates of up to 90%. However, it also has a high morbidity,
category are; Oxybutynin chloride (antispasmodic, especially bleeding and may cause voiding dysfunction and
anticholinergic) (2.5 mg bid–5 mg tid), Flavoxate enterocele. Still, it is quoted as the “gold-standard” procedure
hydrochloride ( 100 mg bid – 200 mg qid). Tolterodine for type II GSI (bladder neck descent of >2 cm). It also
(4 mg once a day), trospium 20 mg twice a day and simultaneously corrects lateral defect cystourethrocele.
propiverine 15 mg twice a day are other drugs tried. Adverse Another method is suspension of bladder neck to
effects of these drugs include dry mouth, blurred vision, periosteum of the public symphysis abdominally Marshall—
drowsiness, constipation and cost. They should be used with Marchetti-Krantz cystourethropexy procedure (MMK)—Three
caution in females with cardiovascular disease and absolutely pairs of double sutures were applied placed on either side
Section 6

contraindicated in patients with narrow-angle glaucoma. of the urethra. The most proximal being at the level of the
The medications can be self-titrated over a period of 6– bladder neck. May have osteitis pubis as complication.
8 weeks with written instructions and scheduled follow- Kelly’s operation—Anterior Vaginal wall repair with Kelly
ups. Intramuscular injection of botulinum toxin via buttressing of the bladder neck by three non- absorbable sutures.
cystoscope. Transvaginal electric stimulation is also helpful. Laparoscopic colposuspension have been tried in an attempt
Implantable sacral neuromodulators are used in refractory to minimize the scar and operative bleeding but they have
cases. an even longer operative learning cure, expensive
b. Stress Incontinence: Medications that stimulate alpha- intruments and longer time and have been shown now to
receptors are used to increase urethral tone in an effort to be not as effective.
reduce stress incontinence episodes. Examples are b. Needle Suspension (Pereyra Raz and Stamey procedures): This
Phenylpropanolamine and Pseudoephedrine. These drugs was first popularized by Stamey. This simple technique of
may cause hypertension. Imipramine a tricyclic re-suspending the bladder neck by means of two prolene
antidepressant is also tried. Duloxetine hydrochloride has nylon sutures are suitable for older and less fit women. A
documented efficiency for stress incontinence. It is a dual vaginal or an abdominal route is taken. However, because
serotonin (5HT)-norephinephrine reuptake inhibitor (SNRI). of poor long-term durability its use has dwindled.
It potentiates the physiological effects of endogenous c. Sling Operations: These are currently the procedure of choice
serotonin and norepinephrine thereby enhancing the CNS’s and applicable for all types of GSI. Native rectus fascia or
natural continence control mechanisms of stimulating fascia lata strip of 9 cm length is harvested, slung across the
receptors in onuf’s nucleus. Thus augmenting the function bladder neck and tied over the rectus sheath to provide a
of urethral rhabdosphincter by increasing pudendal nerve hammock-like suspension. To save time on harvesting this
efferent activity and increases tone of external urethral fascia strip, other sources like cadaveric strips and synthetic
sphincter months. Dose is 40 mg twice daily for 12. Nausea material are also available.
is commonest side effect. Of current interest is the tension-free vaginal tape (TVT)
c. Mixed Incontinence: Imipramine hydrochloride (Fig. 34.8), which is a minimally invasive procedure using
(25 mg qid–75 mg bid), a tricyclic antidepressant may be a prolene tape that slings across the mid-urethra to restore
beneficial in mixed incontinence. It provides combination its retropubic position. The 3-year results show a promising
of anticholinergic effect for detrusor overactivity and alpha- 86% success rate and this abdomino-sling procedure is
receptor stimulation for increasing urethral pressure. Some simpler, faster and has the advantage of being done under
also prescribe antimuscarinic drugs and SNRIs (serotonin/ local anesthesia as a day care. Complications encounter are
norepinephrine reuptake inhibitors) for mixed incontinence. bladder peforation and tape erosion.
Duloxetine comes in later category. Transobturator tension free vaginal tape places the tape
230 d. Estrogen: Role of oral or vaginal estrogen in management of by specially designed needles through the obtartor foramina
incontinence remains unclear. Many studies have shown without entering retropubic space.
 Chapter 34
Urinary Incontinence in Females
Fig. 34.7: Burch colposuspension

d. Bulking Agents: These are injected into the periurethral tissue e. Artificial Urinary Sphincter (AUS): This is an alternative
at the bladder neck under local anesthesia in attempt to choice for GSI due to ISD after failure of primary surgery.
overcome intrinsic sphincteric deficiency (ISD). Teflon Although the device is expensive and prone to mechanical
(PTFE) was the first to be used. However, because of a complications, it has a role in neurogenic cases and those
number of reports of particle migration to distant sites, who have failed conventional bladder neck surgery.
collagen was promoted. Studies subsequently showed poor The common and effective continence surgeries today, their
long-term durability, resulting in repeated injections. Since success rates, clinical indications and complications are shown
then, other agents like fat, silica particles (Macroplastique) in Table 34.1.
and micro-carbon particles have come into the scene. These
particles are large molecules and because they are not taken OVERACTIVE BLADDER (OAB)
up by macrophages, distant migration is not an issue. Overactive bladder is characterized by an increased
However, their long-term durability remains to be seen. It frequency of micturition, a strong and sudden desire to void
needs a long term care and repeated infections are to be and may or may not be associated with urge incontinence. It is
prevented. a form of urinary leakage due to involuntary bladder muscle
contraction.
The risk of developing OAB increases with age. The
incidence is 12–22% in females between 40 – 60 years of age
and rises to 30 – 40% at 70 years of age. Higher prevalence may
be seen in women with positive family history.
Diagnosis of OAB is confirmed by urodynamics evaluation.
The condition is characterized by uncontrolled contraction of
bladder muscle during bladder filling phase resulting in
increased frequency, urgency and incontinence (urge).
In majority of cases the cause of OAB is unknown. In some
patients there may be neurological causes like Parkinsonism,
spina bifida, multiple sclerosis, spinal cord damage.

Treatment of OAB
• Medical: Anticholinergic drugs-Oxybutynin, Tolterodine.
For all antimuscarinic drugs, the dosage must be titrated
depending on the subjective response and side effects (dry
mouth) and each should be given for at least 6 weeks.
Tolterodine L-tartrate is a prolonge release capsule of 2–4
mg once daily is effective and well-tolerated. Other
anticholinergic drugs like darifenacin are bladder selective
and have less side effects. The patient should be warned
that overactive bladder is a relapsing and remitting
condition and that treatment should be adjusted accord-
ingly. Calcium antagonists-nifedipine and terodiline are
under research Fesoterrodine fumurate 8 mg daily is used 231
Fig. 34.8 Tension-free vaginal tape for stress incontinence by some.
 Table 34.1: Various continent surgeries; cure rates, indications and complications

Access Operation Cure % Clinical indications Complications (%)

Vaginal Periurethral or 31–48 Mild stress incontinence, Transient urinary
transurethral (objective) primary and failed retention, urinary tract
bulking agents surgery, physically frail infection
Vaginal and Tension free 86 Primary and secondary Bladder perforation,
suprapubic
Suprapubic
vaginal tape
Colposuspension
[ inside out and
outside in 60–90
stress incontinence
Primary and secondary
retention, urgency
Voiding difficulty,
stress incontinence with detrusor instability,
cystocele prolapse
Sling 85 Proximal urethra needs Voiding difficulty,
support; contracted urinary tract infection,
Genitourinary Problems in Gynecology

vagina sling erosion, detrusor

instability
Artifical urinary 92 Neurogenic, Erosion, mechanical
sphincter (subjective) reconstructive surgery; failure
failed conventional
bladder neck surgery
Laparoscopic 60–80 Primary or secondary Bladder injury, recurrent
colposuspension stress incontinence stress incontinence

• Bladder training and behavioral therapy: The patients are 4. Blaivas JG and Groutz A. Urinary incontinence: Pathophysiology,
instructed to void at increasing time intervals and to resist evaluation and management overview. Campbell’s Urology, 8th
the urge to void between times. The degree of patient edn. Philadelphia; WB Saunders 2002;2:1027-52.
5. Blaivas JG, Appell RA and Fantil JA. Definition and classification
compliance determines the success.
of urinary incontinence; Recom-mendations of the Urodynamics
• Incontinence pads and protective devices for absorbing Society. Neurourol Urodyn, 1997a; 16:149-51.
leakage. 6. Burch JC. Urethrovaginal fixation to Cooper ’s ligament for
• Physical methods such as intermittent clean self- correction of stress urinary incontinence, cystocoele and prolapse.
catheterization (if patient cannot empty their bladder) Am J Obstet Gynaecol 1961;81:281-90
• Surgical—Bladder augmentation, cystoplasty and detrusor 7. Burton G. A five-year prospective randomised urodynamic study
myectomy. comparing open and laparoscopic colposuspension. Neurourol
Urodyn 1999;18:295-6.
REFLEX INCONTINENCE 8. Corcos J, Beaulieu S, Donevan J, et al. Quality of life assessment in
Section 6

men and women with urinary incontinence J Urol 2002;168:896.

This is urinary loss without warning or sensory awareness. It is 9. Mochowski D, Duloxetine RR. A summary of published clinical
usually seen in paraplegics, although it can also occur in patients experience. Rev Urol 2004;61(3)S:56-63.
without any overt neurological dysfunction and may be related 10. Hurley DJ, Turner CL, Yalcin I, et al. Duloxetine for the treatment
to inappropriate urethral relaxation or some form of sphincter of SUI in women: an integrated analysis of safety. Eu J Obstet
abnormality. Gynecol Reprod Priol 2006;125(1):120.
The assessment of success looks for change of frequency of 11. Javis GJ. Surgery for genuine stress incontinence. Br J Obstet
episodes of urinary dysfunction and also the amount of urine Gynaecol 1994;101:371-4
loss by recording the events. Also see the quality of life by scale 12. Lee JX, Cannon TW, Pruchnic R, et al. The effect of periurethral
muscle-derived stem cell injection on leak point pressure in a rat
of incontinence quality of life (1-QOL). Scale-disease specific, 2
model of Sul. Int. Urogynecol V. Pelvic floor Dysfunct 2003:14:31.
item instrument in 3 domains-avoidance and limited behavior, 13. Morknd S, Bok Fjortoft T. Effect of additing biofeedback to pelvic
social embarrassment and psychosocial impact (WHO). floor muscle training to treat urodynamic stress in continence.
Obstet Gynecol 2000;100:730.
TOTAL INCONTINENCE 14. Oelke M, Roovers JP, Micheem. Safety and tolerability of duloxetine
This occurs in two situations: in women with Sul. Br. J. Ob Gy 2006;133:22.
1. When there is congenital abnormality of the lower urinary tract, 15. Percyra AJ. A simplified surgical procedure for the correction of
e.g. ectopic urethral insertion below the external sphincter. The stress urinary incontinence in women. J urol 1992;148:845.
16. Quinn M J, Beynon J, Mortensen N. and McC N. Vaginal
patient complains of continuous dribbling of urine.
endosonography in post-operative assessment of colposuspension.
2. Postobstetric and postsurgical (e.g. hysterectomy) vesico-
Br J Urol 1989; 63:295.
vaginal fistula. There is continuous leakage and the bladder 17. Rentzhog L, Stanton Sl, Cardozo L, et al. Efficacy and safety of
is no longer able to perform its storage function. They are tolterodine in patients with detrusor instability: a dose ranging
described in chapter 35. study. Br J Urology 1998; 81: 42-8.
18. The international Continence Society Committee on
BIBLIOGRAPHY Standardisation of Terminology. The standardisation of
1. Abdel-Fattahm, Pringle S, Hardwick C, et al. Randomised terminology of lower urinary tract function. Br J Obstet Gynaecol
prospective single blinded study comparing inside out versus 1990; 97(6):A-16.
outside in transobturator taps in the management of urodynamic 19. Ulmsted U, Johnson P, Rezapour M. A three-year follow up of
stress incontinence: 1-year outcome from the E-TOT study. BJOG tension free vaginal tape for surgical treatment of female stress
2010;117(1):870. urinary incontinence. Br J Obstet gynaecol 199;106:345-50.
2. Abrams P, et al. Consensus on assessment and treatment of urinary 20. White R D, McQuown D. and McCarthy T. A real-time
incontinence. Lancet 2000; 355: 2153-8. ultrasonography in the evaluation of urinary stress incontinence.
3. Abrams P, Cardozol, Fall M. The standardisation of terminology Am J Obstet Gynecol 1980; 138:235.
of lower urinary tract function: (International Continence Society. 21. Zhu L, Lang L, Chen J, et al. Study of nerve fibre density in anterior
232 Neurourol Urodyn 2002;21:167. vaginal epithelium for SUI. Int. Urogynecol. J 2004;15:272.
 35 Genital Fistula

Sudha Salhan

Urogenital fistula is present with us since the start of human In developing countries most VVFs are the result of child
race. There are descriptions of the existence of a large birth. Obstetric fistulas occur for two reasons.
vasicovaginal fistula (VVF) in an Egyptian mummy that is 1. Obstructed labor, in which the presenting part of the fetus
estimated to be over 4000 years old. This mummy has a complete causes pressure necrosis and sloughing of the urinary
laceration of the perineum pointing that both findings were bladder and perhaps urethra. During labor the urinary
the result of childbirth. First mention of VVF was made by bladder is pushed upwards into the abdomen. The bladder
Platter in 1597 without the treatment part. Van Roodhouse of base and the urethra are compressed between the presenting
Amesterdam, in 1663, recommended denudation and suturing part and the posterior surface of the pubis. In obstructed
of tissue around VVF. Fatio in 1752 published his earlier cure labor, this compression, continues for a long time (as
of VVF. The majority was caused by child-birth injuries. ohn happens in many neglected cases delivering at home) the
Peter Mettauer, a surgeon of Verginia, in 1840, reported one intervening soft tissues between the fetal head and pubic
successful cure of VVF. However, history credits ames Marion symphysis (urinary bladder or urethra and vaginal tissue)
Sims of Montgomery, Alabama, (in 1852) with being the first to become devitalized due to ischemia (impaired blood supply).
cure VVF in USA. It was, in fact, such an important surgical Mostly the anterior vaginal wall and urinary bladder neck is
achievement that he is often referred to, both in the USA and the site affected but the ischemia may be higher up. There
abroad, as the Father of Modern ynecology. (Photo in may be compression posteriorly between the fetal head and
chapter 1). sacral promontory, leading to ischemia of posteriorly vaginal
Definition: A fistula is an abnormal opening wall and anterior rectal wall (rectovaginal fistulas). The
communicating a hollow viscus or serosal cavity with another devitalized area sloughs out between 3–10th day. There is
hollow viscus (internal fistula) viz. bladder with uterus after loss of tissue this leads to incontinence of feces.
cesarean section, intestines with uterus after injury to intestine 2. Injury to the urinary bladder or urethra during an operative
during MTP . A urogenital fistula in female refers to an delivery, e.g. traumatic forceps delivery and during cesarean
abnormal communication of the urinary tract, i.e. ureter, bladder section, etc. In a case of previous cesarean section, urinary
or urethra (normal or abnormal before the fistula was bladder mobilization is to be done by sharp dissection or
established) with the genital tract (normal or abnormal before the bladder may be injured as the tissue planes are not well-
the fistula was developed). Urinary fistula is a gauge of gender formed due to adhesions. During repair of rupture uterus,
and reproductive health status of women in that country. The urinary bladder may be included in a suture while stitching.
existence or establishment of a urogenital fistula in the female During symphysiotomy. Used in severe disproportion cases
is always a serious problem in terms of prognosis and treatment. urinary bladder neck may be injured. If the urine is blood-
The close anatomical and functional relationship of the female stained after vaginal or abdominal operative delivery this
genital tract and urinary tract have their origin in their functional gives a warning of urinary bladder injury.
development. The commonest being VVF. Rupture of uterus especially in a case of previous cesarean
Incidence of VVF in any given population is unknown. section may cause injury to the urinary bladder. Peripartum
Especially in developing countries of the world reports on the hysterectomy, forceful rotation of head, craniotomy (direct
incidence of VVFs are based on the number of women who are trauma from specules of bony pieces, perforator may slip and
hospitalized, but do not include the women who do not seek injure the urinary bladder directly) and precipital labor are
treatment for their fistulas, because they are unaware that a other causes of developing obstetric fistulas.
cure is possible or because they are too embarrassed to admit
that they have a problem. GYNECOLOGIC CAUSES
Incontinence is the primary symptom. It is usually total but In United States over 70 of VVF are a postoperative
occasionally when a fistula is small, it may be remarkably complication of a surgery. The majority of VVF develop after
intermittent. abdominal or vaginal hysterectomy, performed for a benign
Etiology: Most urogenital fistulas are acquired but a few condition. VVF occurs less often following radical hysterectomy
can be congenital. conducted for malignant conditions because say in Wertheim
Congenital urogenital fistulae include ectopic vesicae and operation, urinary bladder is extensively dissected and as a
ectopic ureter opening in vagina. precautionary measure Foley’s catheter is put in for a 15 days or
Ac uired urogenital fistula has the following orign: more days (hence help healing).
 Other gynecological procedures whose outcomes are of urine was seen. A para three of 26 years of age with no history
associated with an increased risk for later development of VVF of difficult delivery. An irregular papillary lesion was seen at
are: anterior fornix and urine was coming out of the growth (Fig.
• Cervical conization, whether by scalpel, electrosurgical 35.1). A biopsy and PCR diagnosed it as a case of VVF due to
excision or laser excision tuberculosis. Patient was given antitubercular treatment. In the
• Anterior colporrhaphy meantime she became pregnant and delivered a term live child.
• Urethral diverticulectomy The growth had disappeared but a small fistula persisted which
• Burns during laparoscopic cauterization was repaired successfully by abdominal route.
– VVF is also reported to be a complication of periurethral Classification of vesicovaginal fistulas is done according
sling procedures, urinary bladder neck resection and to a etiology, organ involved, anatomical location. For the
other lower urinary tract and bowel surgeries purpose of treatment and prognosis these three classifications
– I have encountered a bladder injury during vaginal are interrelated.
Genitourinary Problems in Gynecology

hysterectomy in a chronic inversion of uterus It is suggested that surgeon should further clarify each
– After completion of abdominal hysterectomy if these fistulas as:
are bleeding from the vault and blind stitch is placed to • Simple is easily accessible with healthy tissue surrounding
control the bleeding per-vaginally it may involve a part it. or
of urinary bladder which will later cause VVF (seen a • Difficult and Complex in which associated lesions require
couple of cases) additional urologic genital or gastrointestinal operations.
– Extensive electrocautery or permanent (non- In them there is loss of tissue or scarring, there is also
absorbable) suture around urinary bladder area. difficult access and had several unsuccessful attempts for
Surgical injuries of urinary bladder and urethra that are repair. It may also involve ureteric opening, urethra or
thought to induce the formation of VVF include partial or coexisting retrovaginal fistula.
complete laceration of the bladder wall, pressure necrosis and
slough of the bladder wall from the placement of transfixing Etiological Classification of VVF
sutures, staples, or ligatures or the application of crushing • Congenital anamolies
instruments and more rarely, devascularization of the trigone • Surgical—Ligation, transaction, crushing, puncture, kinking
and base of urinary bladder. • Obstetrical—Ischemic necrosis (obstructed labor) or direct
Uterovesical fistula ( oussef syndrome) is rare. It is mostly injury (cesarean section, rupture uterus, vaginal operative
iatrogenic, usually seen after cesarean section. There is periodic delivery)
hematuria (during menstrual period). Other causes seen are • Malignant, e.g. in cancer cervix in fourth stage.
curettage, difficult vaginal delivery, migration of an intrauterine • Radiation—It is a very slow avascularization—may manifest
device and delivery by a forceps. There is no dribbling after years
(incontinence). It may lead to bladder endometriosis which is • Infection—Tuberculosis and lymphogranuloma venereum
Section 6

not easy to treat. • Foreign body, e.g. long standing bladder stone, neglected
It has been suggested by Kusch et al (1998) that patients vaginal pessary causing pathological pressure
who are prone to develop VVF after hysterectomy also have • Traumatic-accidents
more immediate complications postoperatively, the course of • Spontaneous/Idiopathic.
recovery is delayed, with more postoperative pain, abdominal
Anatomical Classification of VVF According to
distention, paralytic ileus, pyrexia, and symptoms of bladder
Vaginal Location (Fig. 35.2)
irritability. They suggested that these patients leak urine at the
site of bladder injury and a urinoma develops, that later rup- • Vaginal vault ( uxtacervical)
tures and progresses into a VVF. They further suggested that it • Mid-vagina
may be possible to extend the period of postoperative urinary • Urethra vesicle (Vesicourethrovaginal).
bladder catheter drainage in these patients thereby preventing VVF Classification According to Organ Involvement
leakage of urine and promoting healing without subsequent
• Vesicovaginal
development of VVF.
• Vesicourethrovaginal
Malignancies can cause fistula formation, if a tumor
becomes necrotic or infected and invade the urinary bladder.
Surgical and radiation therapy themselves may be a cause.
Cervical cancer is more frequently a cause of VVFs than other
cancers of the uterine fundus, urinary bladder, or vagina.
Pelvic irradiation may be followed by VVF development,
later on. It produces hot spots’ that involves the base of the
bladder. The upper limit of tolerance for radiation to the bladder
is about 6500 cG . When the trigone and base of the bladder
receive a dosage in excess of this limit, the likelihood of
development of a VVF increases. The distal ends of the ureters
are more resistance to radiation therapy than the bladder.
Less fre uent causes of VVF include pelvic infections,
bladder stones, foreign bodies or neglected pessaries, sexual
intercourse and trauma. Crush injuries may traumatize the
bladder and cause VVF. In the tropics lymphogranuloma
venereum (LGV) infection causes vulval ulceration and
destruction of urethra. Tubercular infection is also seen as a
234 cause in our country. We had a case in which 3 months leaking Fig. 35.1: Vesicovaginal fistulas
 effect on the lifestyle of the patient. Prolonged labor, difficult
labor or any pelvic surgery is to be taken in detail. Previous
irradiation for treatment of any malignancy may be asked. After
how many days of the above event she started dribbling of urine.
Any earlier attempt for diagnosis and cure. It makes the surgery
more difficult and needs more expertise.
A detailed preoperative evaluation includes both physical
examination and some essential investigations.
eneral physical examination and local examination: The
typical odor can immediately identify the patient. To determine
the severity of any medical or psychological condition that
might affect the patients ability to cure for herself, to withstand

Chapter 35
surgery and heal her fistula. Look for her nutritional status,
including anemia, and evidence of any intercurrent infection.
Per abdominal examination for tenderness at renal angles or
Fig. 35.2: Sites of vesicovaginal fistula enlarged kidneys is done, suprapubic area is examined.
• Vesicoureterovaginal Most VVFs are obvious during visual examination of the
• Vesicocervicovaginal vagina. Some, however, are small in size and the course of their
• Vesicouterinovaginal fistulous tract is complex and any associated anatomical or

Genital Fistula
• Uterovaginal pathologic condition may not be so easily identified. The fistulas
• Other complex fistula. may be multiple. Excoriation of skin round the vulva and thigh
to be seen.
VVF Classification According to Size Psychological history of depression is taken
• Small less than 2 cm Diagnostic Procedures: Most VVFs are seen during visual
• Medium 2–3 cm inspection of the vagina. Some, however, are small in size and
• Large 4–5 cm the tortuous course of their fistulous tract and any associated
• Extensive 6 cm or more. anatomic or pathologic condition may not be so easily identified.
It is seen immediately after injury to bladder from It must be kept in mind that fistulas may be multiple.
instrumental trauma during delivery. In pressure necrosis (in Digital examination of the vagina should be done to assess
cases of obstetrics) or inclusion of bladder in a suture (in the amount of scarring and stenosis. Sim’s speculum is mostly
gynecological operation) is the cause incontinence is seen after used, preferably in lateral position as anterior vaginal wall
1 1 days. In cases of fistula caused by radiation injury the cannot be easily visualized in the dorsal position.
complaint of constant dribbling of urine may be after months If fistulous opening cannot be readily demonstrated by
and sometimes years. (As there is very slow devascularization) careful pelvic examination, often it may be found by filling the
Any collection of fluid in the vagina that resembles urine bladder with a dilute solution of methylene-blue and then
but is not diagnosed as urine should be collected and tested for inspecting the anterior vaginal wall and vaginal vault. If the
urea nitrogen and creatinine contents. The concentrations are fistula is still not discovered then the patient is put in dorsal
at least 20 times higher than in blood. lithotomy or knee-chest position. The three tampon test of Moir
A painful perineal dermatitis (Fig. 35.3) often develops from is used. In this 3 cotton tampons are placed in the vagina in
the protective garments and the irritation caused by the urine. tandem (placed one behind the other). Diluted Methylene blue
They may be forced to give up their outdoor interests and their is installed in the bladder. After having the patient walk about
job because of the repugnant odor of urine accompanying them, 10–15 min the tampons are removed one by one and examined.
wherever they go. If the lower swab is wet and stained blue the patient may be
Many became depressed and see themselves as social presumed to have transurethral urinary incontinence. If the
outcast. middle tampon is wet and blue a VVF is indicated if the upper
History: It is very important—History of her age, parity, swab is wet and not blue, a ureteral fistula is the likely diagnosis.
marital status, occupation and any recent medication. Incessive Another test Roberston’s test.
questions to be asked to determine the cause of fistula and its Examine posterior vaginal wall and do per-rectal and per-
rectovaginal examination to exclude rectovaginal fistula as they
may be sometimes co-existing.
Investigations: Blood is tested for complete hemogram,
electrolytes and kidney function tests. Urine examination for
albumin, sugar, microscopic study and culture is done. ray
chest is done. Plain -ray abdomen, intravenous pyelography
is advised (for condition of kidneys and location of any ureteric
fistula). Micturating cystourethroscopy may be required for any
congenital abnormality cystoscopy and urethroscopy, if
possible, may be resorted to. Biopsy of tissue margin may be
done whenever indicated (Cancer, tuberculosis) Position and
number of fistulas are needed to chalk out operative procedure
sometimes one may need examination under anesthesia.

Preoperative Management
It is very important for good surgical treatment results. Correct
any anemia and malnutrition before operation. Any urinary 235
Fig. 35.3: Condition of vulva in VVF (Dermatitis) tract infection is to be treated before any surgery is planned. If
 any other infection, like tuberculosis or lymphogranuloma through an indwelling catheter per vaginally or suprapubically
venereum, is present, it must be completely treated, for 6 weeks. The empty bladder wall will rest and heal. Natural
preoperatively. By sitz baths and local emoluents the local healing reduces the size of the fistula and will close some
irritation and infection of the vulva and vagina is to be cleared. completely. Cystoscopic fulgration of the Moir fistulous tract
Preoperative counseling is very essential. The patients and and subsequent drainage have successfully cured VVF less than
relatives are told about the number of days of hospitalization, 3 cm diameter.
absolute necessity of continuous bladder drainage for 10–15 Most important measure to further reduce the incidence and
days. She may be told about the frequent complications. They morbidity of urogenital fistula must be directed towards proper
are also be made aware of possibility of failure. techni ues of gynecological operation and towards immediate
Selection of operation is a very crucial preoperative step in recognition and prompt repair at the time of injury so that fistula
the management of urogenital fistulas. will not develop.
1. During all major gynecological operations (except one with
Genitourinary Problems in Gynecology

Special Problems
first time cesarean operation) and previous cesarean section
Complicated VVF are those that are: cases indwelling catheter drainage is essential just prior to
• Large surgery. This assures better exposure and reduces likelihood
• Have several unsuccessful attempts at repair of bladder injury. The walls of full a urinary bladder are
• Involving urethra very thin (as a full balloon) and can be easily injured. But a
• Involving vesical neck decompressed urinary bladder has thick walls which are
• Involving ureter and even associated with rectovaginal fistula. not easy to injure. It is helpful when beginning a difficult
hysterectomy (endometriosis) to insert a catheter to drain
PREVENTION OF VVF the bladder of urine and then to install undiluted indigo
The first and most essential step in limiting the morbidity of carmine (5 ml) through the catheter into the bladder and
urogenital fistulas is prevention. Major contributions in clamp the catheter to lock the dye in the bladder. Sharp
prevention have been improved obstetrics management and dissection is always better. During dissection between the
technique of delivery especially in more liberal use of cesarean bladder and the lower uterine segment and vagina,
section for delivery with concomitants decrease for difficult (especially in cases that follow repeated lower segment
forceps maneuvers and improved labor management, include cesarean sections), it is possible to partially incise the
emergency obstetric care (EMOC). Prevention of early marriage bladder musculature. Immediate recognition of bluish
and early age delivery are important social steps which must mucosa allows one to avoid entering the bladder by
be emphasized. Good nutrition and prevention of anemia immediately redirecting the dissection. A partial thickness
during pregnancy is very critical. Pressure necrosis can be injury can be successfully repaired. On those occasions when
prevented by efficient obstetric care, anticipation of difficulties the bladder is entered and the spillage of blue urine occurs,
before labor begins and early termination pregnancy by the spillage is an immediate signal that leads to prompt
Section 6

cesarean section, if the labor in prolonged because of recognition and immediate repair to prevent more extensive
disproportion, before the stage of obstruction is reached. injury. Adequate exposure of the surgical site is essential.
Extensive electrocautery injuries of the bladder wall should 2. Adequate light on the surgical site will promote better
be carefully avoided when securing hemostatsis. Permanent visualization on less injury to urinary bladder or ureters.
suture material should not be allowed to penetrate the inner 3. Restoration of anatomical relationships are essential.
wall of the bladder. If it does, it becomes a nidus for stone 4. Appropriate traction and counter traction of the uterus is
formation which may predispose the patient to transmural required for proper dissection.
infection and subsequent fistula formation. 5. Sharp dissection along anatomical plans is safer.
However, it is still sometimes possible to prevent a urinary 6. Extraperitoneal cystotomy for visualization during difficult
fistula from formation in a patient first seen in obstructed labor abdominal dissections.
by keeping the bladder at rest after delivery by continuous 7. Filling the urinary bladder with sterile diluted methylene
drainage and controlling sepsis by systemic broad spectrum blue to test for bladder injury.
antibiotics improved nutrition and gentle daily vaginal irrigation 8. Urethrocystoscopy.
with a mild antiseptic. All these may prevent full thickness 9. Multi-layered tension-free repair of overt bladder injuries
sloughing of the bladder wall and hence fistula formation. after adequate mobilization of the surrounding tissue.
Catheterization will be required anyway for at least first 48 One must be especially careful when making an abdominal
hours after delivery following obstructed labor as the edema incision in a patient who has previous abdominal operation.
and ecchymosis round the urinary bladder neck (produced by Adhesion and scarring may cause difficulty. Also advancing
a traumatic labor), will otherwise cause retention. If there is pregnancy produces altercation in relation of the bladder and
any possibility of pressure necrosis, particularity if the urine is uterus with the abdominal wall. Bladder may become an
blood stained after delivery, continuous drainage per urethra abdominal organ.
should be maintained for 10 days. The catheter should not be Whether a vertical or transvers skin incision is made, the
removed unless a speculum examination reveals no signs of peritoneum should be opened vertically and in the abdominal
necrosis of the anterior vaginal wall and the urine show no cavity is entered as cephalic as possible.
microscopic hematuria. Full bladder will prevent healing, Do not open the peritoneum in layers’ as bladder is more
increase the damage to its wall and make it full blown VVF in likely to be injured. Similarly in closing the peritoneum close in
due course of time. But continuous catheterization reduces strain single layer. While approaching the bladder, the areolar tissue is
on damaged bladder wall to make it rest and heal by itself. thickened and vessels are more evident. To get maximum incision
Nonsurgical management of VVF is possible in recent the surgeon can transilluminate the area which clearly identifies
acquired fistula, where no epithelialization of the tract has the borders of the bladder, only incise transparent area.
occurred. These are to be treated conservatively in the first The second point in the performance of abdominal
236 instance. Continuous drainage of the urinary bladder is done hysterectomy in cases where the bladder is at risk during the
mobilization off the cervix. The vesicovaginal fold of the visceral General condition should be improved during waiting
peritoneum is best entered laterally after the round ligaments period by good nutrition. Correct anemia and other medical
have been divided and ligated. The peritoneum over the cervix conditions (tuberculosis, etc.).
is elevated with tissue forceps and a curved scissor is directed
at that point. If the bladder incision is made too high on the Choice of Operation
corpus of the uterus the peritoneum is closely applied to the Examination under anesthesia (EUA) is done few days before
uterus with the absent areolar tissue. This incision causes definitive operation helps in plan of repair operation.
bleeding which obscures the field and exposes the bladder to Whenever possible, vaginal repair should be done.
possible injury. Certainly a history of previous cesarean section Inaccessible juxtacervical and vault fistula may be tackled
should be a warning that the dissection must be carefully by abdominal route.
performed and the bladder tested for integrity (by methylene
blue solution) before the operation is complete. Fistula Exposure

Chapter 35
In previous cesarean section the tissue plans are obliterated. Dorsal lithotomy position is commonly used.
In such cases sharp dissection is best performed with scissors An episiotomy or Schuchardt incision may be needed
with the tip directed again, the cervix. A history of previous whenever there is a tight vaginal outlet, scarring of vagina or
radiation causes similar difficulty and requires the same deep and fixed vaginal vault. Traction or stay suture on each
precautions. In cases of cesarean section or repair of uterus, side of fistula is applied. Foley’s catheter can be passed through
particular care should be taken to identify the ureter before fistula in case of small fistulas to give traction.
placing hemostatic sutures. Through and through sutures which

Genital Fistula
include the posterior leaf of broad ligament, to which ureters Excision of Fistula Tract
are related, are especially dangerous. Entire tract from vaginal orifice to bladder orifice should be excised
In total abdominal hysterectomy for benign uterine disease, and sent for histopathology examination (if required).
bladder and ureteric injury between the uterine artery and ide mobilization of vaginal mucosa from urinary bladder
bladder base can be avoided by adherence to the Richardson around fistula is done. So that the fistula edges can be
intrafascial technique using inverted T or V incision in the approximately without tension. This improves healing.
subvesicocervical fascia covering the cervix anteriorly. As the Normal saline injection may be used to define tissue planes,
vagina is sutured and suspended surgeon should always note vasopressor should not be used.
carefully what is included in each stitch. Diathermy also should not be used.
uite different is the avascular necrosis of ureters rather
than direct injury in Wertheim, hysterectomy. The blood supply Choice of Sutures
to the ureter is stripped (Waldeyer’s sheath). Before clamps can
be safely placed on the cardinal ligaments and before an incision Silver wire sutures have been abandoned. Now 3–0 chromic catgut
is made through the anterior vaginal wall, the bladder must be is used for first layer. For second and third layer 3–0 delayed
mobilized inferiorly and laterally and the vesicocervicovaginal absorbable vicoryl suture swayed on fine, small caliber, semi-
space completely developed thoroughly. malleable round body needle is used.
Constant traction on the uterus superiorly and retraction There should be no tension on the sutures.
of the bladder inferiorly with accurate placement of clamps and If defect is large, labial fat pad graft is developed for vaginal
sutures will help prevent bladder injury. Inadequate defect or Martius bulbocavernosus fat pad graft is used and
mobilization can lead to placement of sutures through the sutured to fascia of bladder.
bladder base when the vaginal cuff is sutured. If repair has left stenosis, counter incision in vagina may be
VVF resulting from vaginal hysterectomy are best prevented given.
by finding the proper plan of dissection between the bladder Packing of vagina is avoided.
base and the lower uterine segment anteriorly. Adequately Cystoscopy to test the integrity of ureters may be done, if
mobilizing the bladder laterally and properly placing clamps required, (to see urine coming out of both ureteric openings).
and ligatures on paracervical and parametrial tissue as close to
uterus as possible is important. TECHNIQUES OF REPAIRS
During formation of neovagina, as in McDonald operation,
injury to bladder is prevented by slowly going though the space Vaginal Approach
by gradually enlarging the two depressions (see chapter 75 1. Flap splitting method (Lawson-Tait)—(Figs 35.4A to E)
vaginoplasty). defects up to 6 cm can be repaired by this method. A circular
In stress incontinence correction operation, bladder injury incision is given around the fistula, vaginal flap is separated
can be avoided by careful layered dissection of the vaginal from the urinary bladder for comfortable distance so that
mucosa from the underlying pubovesicocervical fascia. In a case there is no tension in bladder stitches. During first layer
of previous surgery, a sharp controlled dissection is less bladder stitching does not enter the cavity of the urinary
hazardous than forceful blunt separation of the dense adhesions. bladder. It is a continuous layer. After stitching first layer
Management principles of all urinary fistula include the bladder integrity is tested by dilute methylene blue or sterile
following points: milk (which will not stain). If the stitches are no leak from
stitch-line intact, second layer of stitching is done. Vagina
Time of Repair is closed by a single layer of suture preferably at right angle
Most experts now recommend waiting 3–4 months after the to bladder stitching to prevent tension (Fig. 35.5A to C).
fistula develops to let the inflammation and fibrosis subsides. 2. Saucerization—most suitable for residual fistulae which
Radiation fistula repair can be delayed up to 1 year. remain after a partially successful repair.
Role of cortisone to shorten waiting period was never proven. 3. High colpocleisis or Latzko’s operation—suitable for
Estrogen in hypoestrogenic women should be used. posthysterectomy fistula at the vault.
237
Genitourinary Problems in Gynecology
Section 6

Figs 35.4A to E: Flap splitting method

4. Complete colpocleisis done in radiation fistula. water may be used. If it does not reestablish, catheter may
In extensive VVF where tissue is less, tissue grafts (gracilis be replaced.
muscle flaps or Martius labial fat pade graft) are interposition • Urinary infection
for increasing blood supply. Suprapubic pain, pyrexia, passage of cloudy urine
Indication for abdominal approach. Urine is sent for culture and sensitivity and appropriate
• Fistula with a diameter 2 cm. chemotherapy is started
• Fistula near the ureteric orifice (trigone) • Vaginal bleeding occurs after the 6th day
• Multiple fistulas Management is conservative with simple irrigation of
• Recurrence of a fistula vagina and antibiotics.
• Poor quality of local tissue (following irradiation chronic If bleeding is severe, patient is taken to OT, remove clot
infection or in diabetes mellitus). and if possible stitch the bleeding area.
• Hemorrhage into the bladder:
The abdominal methods are: – May originate from the edge of inverted mucosa or
The transvesical route—open the urinary bladder and repair hematoma between the layers of repair. Treatment
then close the opening through which we entered. should be conservative
The transperitoneal route and combined route. – Break down of repair in the most dreaded complication
occurs after operation re-repair is attempted after 2
Intraoperative Complications
months
Intraoperative complications include: • Complication of ureteral obstruction
• Ureteric injury • Cystoscopy is used for diagnosis.
• Bowel injury
• Hemorrhage. Late Complications
Postoperative complications important ones include— Incompetence of urinary sphincter (especially in fistulas
Blockage of drainage and hemorrhage. involving the urethra.
• Vaginal stenosis
Postoperative Complications • Misdirection of menstrual flow
• Difficulties with catheter drainage like Kink Block by Those associated with intestinal fistula resulting from
sediments mucus or blood clot. Gentle syringing with sterile radiation for gynecological malignancy.
238
 Chapter 35
Fig. 35.6: Rectovaginal fistula

Genital Fistula
Vesicouterine fistula: It is seen mostly after cesarean section
( ouseff syndrome). The symptoms include hematuria during
period. Excision of the connection and repair of urinary bladder
and uterus per abdominally is the treatment.
Uteroenteric fistula: Was encountered in a case with history
of medical termtination of pregnancy. The small instestines and
uterus were separated and repaired separately per abdominally.
Congenital ectopia vesical was seen in a married woman.
The ureters were implanted in a neobladder and abdominal
opening was closed.
Urinary fistulas other than VVF.
Figs 35.5A to C: Layers of repair Urethrovaginal fistula: These are mostly associated with a
big VVF. The sphincter mechanism is usually lost. Posterior
tightening may reduce the lumen (No 12 or 14 Foley) may help.
Postoperative Management Ureterovaginal fistula: It is rarely seen as congenital
Bladder Drainage abnormality. Commonest cause is gynecology surgeries. If
Urethral catheter for 10–14 days-record to prevent blockage. diagnosed at operation table end-to-end anastomosis on a ureter
Meticulous hourly output observation is very important for cather (which is kept in urinary bladder for 2–3 weeks) will
good results. suffice.
Suprapubic drain to avoid trauma to operative site. Old fistula is diagnosed by
Urine for culture every other day. • 3 swabs test: The wet swab is not colored
• Injection of IV indigo carmine will stain the swabs
Bowel Movement • Cystoscopy will clinch the diagnosis as no urine comes out
It is advisable to confine the bowel for first four days. from the affected ureteric orifice.
Liquid paraffin should be given from the second evening. The treatment depends on the site-lower ureter can be
reimplantation in the bladder (if there is space) support may
Care of Perineum be needed for blood supply.
The vulva should be covered with sterile Pad until 4th day and A ureteric catheter is kept in place for 2–3 weeks and later
swabbed daily. removed by cystoscopy.
Bladder retraining after removal of catheter. Middle and upper ureter injuries required end-to-end
Catheter should be removed between 10–14 days or even anastomosis on a ureteric catheter.
later in large fistula. Rectovaginal fistula (Fig. 35.6) can co-exist in big VVF.
After that she is asked to pass urine frequently. Gradually Depending on the site, lower end-convert it into third degree
decreasing the frequency over time when the urinary bladder perineal tear and repair.
has regained its muscle tone. Middle ones can be repaired by flap splitting technique.
Instruction to patients on discharge.
No intercourse for three months. BIBLIOGRAPHY
Avoid vagina examination and manipulation 1. Agarwal M, Singh AS, Sailo SL. A rare case of ouseff syndrome.
If she becomes pregnant elective LSCS should be done. Intern Gynae and Obstet 2008;11(5):15:56.

239
 Section 7 Infections of Genital Tract

36 Reproductive Tract Infections and Sexually

Transmitted Diseases (RTIs and STDs)

Sudha Salhan, Poonam Puri, V Ramesh

REPRODUCTIVE TRACT INFECTION (RTI) (being a single layer, is not able to give adequate protection).
Similarly, in postmenopausal women the epithelial layers
Definition
are less thick and, therefore, give poor protection from
Reproductive tract infection in females is the infection of the pathologic infections.
genital tract, i.e. perineum, vulva, vagina, cervix, uterus, adnexa 4. Acidity: Acidic pH (3.5–4.5) of vagina is due to lactic acid
and ovaries. Not all sexually transmitted infections (STI) involve produced by the action of Doderlein’s bacillus (lactobacillus
the reproductive tract. RTI is, therefore, a broad term. It is acidophilus) on glycogen of the desequamated vaginal cells.
further, divided into three viz. Sexually transmitted infections, These organisms also produce Hydrogen Peroxide (H2O2)
endogenous infection and iatrogenic infection. which is toxic to aerobic organisms, gram positive, gram
Reproductive tract infections form a major part of negative and anaerobic pathologic bacteria.
gynecological morbidities and sometimes mortality. More than 5. In cervix, there is narrow endocervical canal, producing
340 million new cases of the treatable STI (Syphilis, gonorrhea, downward flow of mucus. Also presence of antibacterial
chlamydia and trichomoniasis) occur every year. By adding viral lysosome and local IgA in the secretion prevent infection.
STI, e.g. human immunodeficiency virus (HIV), herpes simplex 6. Hormones: Progesterone, in a reproductive age group
virus (HSV), human papilloma virus (HPV) the total incidence woman, produces a thick cervical mucus plug, stopping any
may become 1020 million (3 times) cases per year. Such is the progression of infection. Besides mechanical block it is
importance of STI that RTI infections are often written as RTIs/ bacteriolytic also.
STIs. Hence, understanding its pathophysiology and knowing 7. Periodic shedding of endometrium in menstrual cycle
proper diagnostic methods will go a long way in ameliorating precludes any permanent settlement of infection. Besides the
these illnesses. RCH II has added prevention and treatment of ciliary activity of fallopian tube linning towards the uterus
RTI/ STI as a component. prevents any ascending infection.
8. Production of certain chemicals:
Natural Defence Mechanism of Female Genital Tract
a. Healthy skin of perineum produces salts (of sweet)
The genital tract opens to the exterior and there is always certain b. There is also secretions of sebaceous glands
tissue trauma during delivery and abortion. It is also in c. Secretions of apocrine glands (undecylenic acid).
approximation to anal canal behind and urethra in front. But They all inhibit growth of pathogenic organisms.
all women do not get genital infections as there are natural
defences in-built in the body. Factors Influencing Natural Defence Mechanism
The natural defence mechanism in the reproductive tract These natural defence mechanisms are affected by a number
are mostly seen in reproductive age group. They are as follows: of factors.
1. An intact surface provides more than a mechanical barrier. 1. Female sex hormones: Except for a few days after birth,
Healthy skin of perineum produces salt (of sweat) and when maternal hormones are circulating in the neonate, the
sebaceous gland secretion as well it is multilayered. Intact cervical and vaginal covering epithelium is single layered
vulval and vaginal coverings protect to a large extent against in neonatal period and early adolescent period,
invasion by any infection. predisposing to infection. Estrogen is responsible for
2. Virtual closure of inlet: The vulvar opening is virtually converting single columnar layer of cervical epithelium of
closed as both labia are in apposition. The anterior and the child and the adolescent into multilayered squamous
posterior surfaces of vagina are close together. The potential epithelium of reproductively matured women. Similarly,
cavity of the uterus is also obliterated by the anterior and after menopause the cervical covering becomes thin and
posterior walls coming in contact. hence falls an easy prey to infection due to lack of estrogen.
3. The Vulva has cornified stratified s uamous epithelial Same changes are seen in vagina and vulval coverings.
covering in the reproductive age group. It is thick enough Progesterone also helps in preventing ascending infection
to ward off many infections. Its apocrine glands produce by the formation by cervical plug, in reproductive age group
undecylenic acid which prevents the growth of yeast and which is absent till adolescence and after menopause.
other infections. 2. Age: Before 20 years of age the vaginal lining is single layer
The vaginal portion of the cervix and the vagina are covered columnar epithelium which can be easily injured during
by non-cornified stratified squamous epithelial compared intercourse compared to multilayers noncornified stratified
to a single layer of columnar cells in the vagina and cervix squamous epithelium of an adult woman of reproductive
of young adolescent girls which predisposes to infection age group.
3. Nutrition: Malnutrition reduces the immunity of the SYMPTOMS OF STDs
individual. The symptoms vary among the different types of STDs. These
4. During menstruation the alkaline blood increases vaginal include:
pH and hence predisposes the genital tract to infection • Unusual discharge from the vagina
(which otherwise has bacteriostatic acidic secretions). • Sores or warts on the genital area
5. After delivery, meticulous asepsis is essential. The big raw • Burning micturition or dysuria
placental site, gapping genital tract, and the generalized low • Itching and redness in the genital area
immunity makes her an easy pray to infection. Besides lochial • Anal itching, soreness, or bleeding
discharge which increases vaginal pH predisposing the • General body symptoms due to widespread systemic
genital tract to infection. involvement. Some STIs do not have reproductive tract
Hence, isolation from visitors is essential to prevent symptoms at all. A brief description of some of them are
reproductive tract infection (Puerperal sepsis). given below.

Chapter 36
6. Invasion of sanctity of genital tract by operations done
without optimum aseptic care, e.g. during MTP, D and E, 1. Syphilis: Syphilis is an infectious disease caused by the
endometrial biopsy, hysteroscopy, hysterosalpingography, spirochete reponema pallidum. It is mostly transmitted by sexual
etc. In adults, forgotten tampons may lead to genital contact with a person having infectious lesions, but it also can
infections. Also in cases of children who introduce foreign be transmitted and via blood transfusion. According
bodies in the vaginal (like pencil, etc.). to recent report it has resurfaced in many countries, e.g. China.
7. Use of birth control measures, e.g. During insertion of Copper-T Syphilis has a myriad of presentations and can mimic many
diseases, hence, it has earned the nickname “the great imposter.”

Reproductive Tract Infections and Sexually Transmitted Diseases (RTIs and STDs)
a small number of pathogenic organisms may be introduced
into the endometrial cavity if proper antiseptic precautions The complex and variable manifestations of the disease prompted
are not taken. Also forgetting cleaning of cervix twice with Sir William Osler to remark that, “The physician who knows
iodine before introduction of any object in the uterus. Users of syphilis knows medicine.”
oral contraceptive pills may also harbor. Chlamydia
Classification of Syphilis
trachomatis in their endocervix compare to nonusers. In
addition, it is postulated that these hormones may alter the (i) Acquired syphilis
squamocolumnar junction tissue, making it more susceptible A. Early syphilis
to invasion by pathogenic organisms e.g. human papilloma a. Primary syphilis
virus and Chlamydia trachomatis. b. Secondary syphilis
8. There are also sexually transmitted diseases like c. Early latent syphilis
Trichomoniasis, gonorrhea, syphilis, etc. which are acquired B. Late syphilis
by sexual act. i. Late latent syphilis
ii. Tertiary syphilis
RTIs are classified into: a. Benign tertiary
1. Sexually transmitted infection b. Cardiovascular syphilis
2. Endogenous infection c. Neurosyphilis
3. Iatrogenic infection. (ii) Congenital syphilis—Early and late congenital syphilis.
I. Sexually transmitted diseases (STD)/Sexually transmitted
infections (STI) are infections that can be transmitted from Pathophysiology
having sex (vaginal, oral or anal) with someone who already pallidum penetrates abraded skin or intact mucous membranes
has the disease. STDs are caused by bacteria, parasites protozoa, easily and disseminates rapidly, although asymptomatically, via
fungus and viruses. the blood vessels and lymphatics.
Classification: Sexually transmitted diseases and infections The initial lesion of primary syphilis develops at the site of
(STD/STI) according to the causative agent transmission after an incubation period of 1 days, with a mean
A. Bacterial 1. Syphilis ( reponema pallidum) of about 3 weeks, and then heals spontaneously in 3–7 weeks.
2. Chancroid ( emophilus ducreyi) Secondary syphilis develops about 4–10 weeks
3. Donovanosis (Granuloma inguinale) after the appearance of the primary lesion and has a wide range
4. Lymphogranuloma venereum ( hlamydia of presentations. The most common manifestations at this stage
trachomatis) include malaise, fever, myalgia, generalized lymphadenopathy
5. Gonorrhea (Neisseria gonorrheae) with a generalized body rash. During secondary infection, the
6. Nongonococcal urethritis ( reaplasma immune reaction is at its peak and antibody titers are high.
urealyticum) Symptomatic secondary syphilis usually resolves without
7. Bacterial vaginosis (Gardnerella vaginalis) treatment. The disease then enters a latent stage that may be
B. Fungus 8. Vulvovaginal candidiasis ( andida divided into early and late latent phase. Tertiary syphilis is
albicans) defined as seroreactivity greater than 2 years with symptoms.
C. Protozoa 9. Trichomoniasis ( richomonas vaginalis) This can include all organ and systems and manifests in many
D. Parasitic 10. Scabies (Sarcoptes scabiei) ways. As many as 40% of untreated infections can develop into
11. Crab louse (Pediculosis pubis) tertiary disease.
E. Viral 12. Acquired immunodeficiency syndrome
(AIDS) both (HIV-1 HIV-2) Clinical Features
13. Hepatitis B (hepatitis B virus) Primary syphilis (Primary chancre, hard sore or Hunterian
14. Genital warts ( uman papillomavirus ( P )) chancre).
15. Herpes genitalis ( erpes simplex virus ( S ) The initial lesion of primary syphilis known as ‘chancre’
16. Molluscum contagiosum (Pox virus) develops at the site of transmission. It usually begins as a single,
17. HPV infection painless papule that rapidly becomes eroded. It has well-defined 241
 edges, is nontender with-indurated base. The ulcer heals
spontaneously leaving a thin atrophic scar.
Common primary sites in women include the cervix and
labia, fourchette and clitoris.The primary lesion usually is
associated with regional lymphadenopathy that may be
unilateral or bilateral. The lymph nodes are discrete, nontender,
firm, shotty, mobile, painless and do not suppurate.

Secondary Syphilis
Secondary syphilis develops about 1 weeks after the
appearance of the primary lesion. Constitutional symptoms
of secondary syphilis include malaise, sore throat, headache,
Infections of Genital Tract

fever, anorexia, and rarely meningismus.

It has a wide range of presentations which includes a
localized or diffuse mucocutaneous rash and generalized
nontender lymphadenopathy. The exanthem may be macular,
papular, pustular, or mixed. Typical early lesions are usually
nonpruritic, and bilaterally symmetrical distributed on the
trunk and proximal extremities. Lesions also may appear on
the palms and soles. Patchy and nonpatchy alopecia may occur.
In intertriginous areas, papules may coalesce to form large
fleshy masses with flat tops and broad bases. These highly
infectious lesions are called condylomata lata (Figs 36.1 and
36.2). Mucus patches which appear as a grayish white plaque Fig. 36.2: Condylomata lata
are seen on the oral and genital mucosa.

Early Latent Syphilis Neurosyphilis may be asymptomatic or symptomatic. In

Section 7

asymptomatic neurosyphilis, no signs or symptoms are present,

Early latent syphilis is defined as acquired syphilis within the
but cerebral spinal fluid (CSF) abnormalities are demonstrable,
preceding year in which there are no clinical signs and
including possible pleocytosis, elevated protein, decreased glu-
symptoms and diagnosis is based on positive reaginic and
cose, or a reactive VDRL test in CSF. Symptomatic neurosyphi-
specific tests of syphilis.
lis may manifest as syphilitic meningitis, meningovascular
Late Latent Syphilis syphilis, or parenchymatous neurosyphilis.
Late latent syphilis is defined as seroreactivity, in the absence Syphilis and HIV
of symptoms, greater than 2 years after inoculation. During the
HIV patients with syphilis may present with multiple chancres,
late latent stage, patients typically do not have infectious lesions.
painful persistent lesions. Rapid progression to tertiary stage
Late Syphilis (Tertiary Syphilis) and neurosyphilis is common. Biological false positive VDRL,
seronegativity and delayed titer response may be seen.
Symptomatic tertiary syphilis is the result of a chronic,
progressive inflammatory process that eventually produces Laboratory Diagnosis
clinical symptoms, (years to decades), after the initial infection.
pallidum cannot be cultivated in vitro , therefore, direct
The characteristic lesion is a gumma’ which manifests as coalescent
visualization of the organism by dark field microscopy,
granulomatous lesions that usually affect skin, bone, and mucous
immunofluorescent staining, or serologic testing is necessary
membranes, but may involve any organ system. The lesions often
for diagnosis of syphilis.
cause local destruction of the affected organ system.
Cardiovascular syphilis results from endarteritis of the Primary Syphilis
aorta, subsequent medial necrosis, aortitis, and aneurysm • Serology and Dark field microscopy or immunofluorescent
formation. Other large arteries may be affected as well. staining confirms the diagnosis of syphilis.
Secondary Syphilis
• The manifestations of secondary syphilis may mimic many
other diseases, and laboratory evaluation should reflect the
particular presentation and the concerns of the physician. A
complete blood count (CBC), electrolytes, erythrocyte
sedime-ntation rate (ESR), blood cultures, and other
laboratory studies may be appropriate, depending on the
presentation of the patient.
Tertiary Syphilis
• Serology and dark field microscopy are used in diagnosis.
Evaluation of neurosyphilis requires a lumbar puncture (LP)
and evaluation of the CSF.

Dark Field Microscopy

242 The most specific and easiest method of diagnosing syphilis is
Fig. 36.1: Condylomata lata: Secondary syphilis by detection of organisms in the lesions. It is most useful during
primary and secondary syphilis when large number of almost all patients treated for secondary syphilis have a
treponemas are present (Fig. 36.3). negative VDRL result within 2 years.
• A small minority of patients remain seropositive in spite
Serological Tests of successful treatment. Therapy is considered a failure if
These are classified into two groups: the signs and symptoms of syphilis return. This occurs when
1. Nontreponemal tests, which detect non-specific treponemal the titer of the nontreponemal test increases 4-fold or a 4-
antibody, e.g. Venereal disease Research Laboratory (VDRL) fold decrease from the initial VDRL titer does not occur
or Rapid Plasma reagin(RPR) tests within 1 year.
2. Treponemal tests which detect specific treponemal • Patients with neurosyphilis should have follow-up at 6-
antibody, e.g. Treponema pallidum hemagglutination month intervals for at least 3 years with physical
assay(TPHA), fluorescent treponemal antibody-absorption examinations and CSF and serologic testing.
(FTA_abs) tests.

Chapter 36
Patients with a reactive VDRL or RPR should have the result Prognosis
confirmed by specific treponemal testing. These tests include The prognosis in primary and secondary syphilis is excellent.
the fluorescent treponemal antibody absorption (FTA-ABS) and pallidum remains highly responsive to the penicillins and cure
the microhemagglutination assay for pallidum (TPHA). is likely.

Treatment Special Concerns in Pregnancy

Primary, Secondary, and Early Latent Syphilis Penicillin is the recommended treatment. Pregnant females

Reproductive Tract Infections and Sexually Transmitted Diseases (RTIs and STDs)
Recommended regimen—Single dose of benzathine penicillin who are allergic to penicillin should be desensitized and
G, 2.4 million U IM after a test dose. treated with penicillin only. Tetracycline or doxycycline is
Alternative regimen (only for non-pregnant, penicillin- contraindicated.
allergic patients)—
CHANCROID (SOFT CHANCRE/SOFT
doxycycline 100 mg PO bid or
SORE/ ULCUS MOLLE)
tetracycline 500 mg PO qid, or
erythromycin base 500 mg PO qid. Introduction
Above treatment is given for 2 weeks. Chancroid is a sexually transmitted ulcerative disease of
Azithromycin has been used as an alternative. It has been genitoinguinal area, characterized by painful ulcers and painful
suggested that penicillin-allergic patients must be desensitized suppurative inguinal lymphadenopathy (buboes). It is caused
in order to receive standard drug therapy by emophilus ducreyi a gram-negative coccoid-bacillary rod.
Late Latent Syphilis, Syphilis of Undetermined
Incubation Period
Duration and Late Syphilis
It is usually less than 10 days (3 – 7 days).
Recommended regimen—Benzathine penicillin G, 2.4 million
U IM once weekly for 3 consecutive weeks. Clinical Features
Alternative regimen—Doxycycline 100 mg PO bid or
The patient usually presents with painful genital ulceration.The
tetracycline 500 mg PO qid daily for 4 weeks in non- pregnant.
lesion begins as a tender erythematous papule (Fig. 36.4) which
Patient must be informed of the possibility of a
progresses into a pustule which breaks down to form an ulcer.
Jarisch-Herxheimer reaction that may occur at the outset of
Multiple ulcers are common. Classically the ulcers are painful,
treatment.
non-indurated, with undermined ragged edges, necrotic base
Follow-up covered with purulent exudate. The ulcers are usually tender
and bleed easily.
• Patients treated for primary, secondary syphilis and early
The common sites of involvement are the fourchette,
latent syphilis should have followed up VDRL at 6, and 12
vestibule, labia, clitoris, vagina and the perianal area.
months after treatment. And those with late syphilis should
Painful inguinal lymphadenitis occurs within 1–2 weeks
have repeat VDRL at 6,12 and 24 months after treatment.
after the appearance of ulcers in 50% of patients. It is unilateral
• Patients with HIV should be monitored closely as they
in most of the patients. If untreated,the inguinal adenitis may
are known to have more rapid progression of disease.
progress to abscess formation—a bubo. The buboes, if untreated,
Most patients with primary syphilis who are treated
rupture through the skin with formation of a single sinus.
adequately have a nonreactive VDRL within 1 year, and
Chancroid and HIV Infection
Ulcers may be large, necrotizing with longer incubation peri-
ods.
Increased severity, slow healing and treatment failures may
occur.

Laboratory Diagnosis
1. Smears taken from the undermined edges of the ulcer and
stained with Gram stain show gram negative coccobacilli
arranged in parallel chains as “schools of fish” (Fig. 36.5).
2. Culture: Gold standard for diagnosis.
3. Histological findings include neutrophils, fibrin,
erythrocytes, and necrotic tissue.
4. Polymerase chain reaction (PCR) is 100% sensitive.
Fig. 36.3: Treponema seen under dark field microscopy However, it is expensive.
243
 Pathophysiology
GI is caused by alymmatobacterium granulomatis an obligate
intracellular gram negative pleomorphic bacillus. The mode of
transmission is primarily through sexual contact. It is considered
to be only mildly contagious, and repeated exposure may be
necessary for clinical infection to occur.

Incubation Period
It may range from 3 days to 3 months (average 17 days).

Clinical Features
Infections of Genital Tract

Primary lesion affects anogenital region, and presents as papule

or nodule which breaks down to form a well-circumscribed
Fig. 36.4: Chancroid: Ulcers suppurative inguinal lymphadenopathy ulcer, nonindurated with beefy red granulomatous base. In
women, lesions may occur on the labia minora, the mons
veneris, the fourchette, and/or the cervix. Four clinical variants
Treatment
of ulcer may occur.
Azithromycin 1 g orally in a single dose Ulcerovegetative type (most common): These lesions develop
or from the nodular type and consist of large, usually painless,
Ceftriaxone 250 mg IM in a single dose spreading, exuberant ulcers. The ulcers have clean, friable bases
or with distinct, raised, rolled margins. The ulcers are typically beefy
Erythromycin 500 mg orally qid for 7 days red in appearance and bleed easily. Autoinoculation is a common
or feature, resulting in lesions on adjacent skin.
Ciprofloxacin 500 mg orally bid for 3 days Necrotic type (Phagedena): Shows extensive tissue
destruction due to secondary anaerobic infection.
Management of Bubo
Cicatricial type: Dry ulcers evolve into cicatricial plaques
Section 7

Fluctuant bubo should be aspirated using a wide bore needle. and may be associated with lymphedema.
Treatment of partners is similar to the infected patient. Hypertrophic or verrucous type (relatively rare): Ulcers are
Follow-up large, vegetating, with raised irregular edges and may resemble
Patients should have outpatient follow-up within genital warts.
1 week to evaluate progress of healing of ulcers. Extragenital involvement occurs in — of cases.
Lymphadenopathy does not occur due to GI, but lymph node
Complications enlargement due to secondary bacterial infection may occur.
Scarring, ruptured buboes with severe pain, and fistula Infection spreads by direct continuity or by autoinoculation.
formation are seen. Sexual dysfunction due to scar formation Prior to rupture the groin lesions may look like lymph nodes
may also occur. and have been referred as ‘pseudo-bubo.’
Hematogenous dissemination to the spleen, the lungs, the
Donovanosis liver, the bones, and the orbits may occur and occasionally
Synonyms Granuloma inguinale (GI), Granuloma venereum, results in death.
Calymmatobacterium granulomatis. Elephantiasis like swelling of the external genitalia is
frequent in later-stage lesions.
Introduction
Granuloma inguinale (GI) is primarily a sexually transmitted Laboratory Diagnosis
disease which manifests as genital lesions, which are indolent, Although isolation of granulomatis has been reported, the
progressive, ulcerative and granulomatous. organism is extremely fastidious and culture is beyond the
capability of most laboratories. The most effective method of
establishing a diagnosis is direct visualization of the organisms
by tissue smear preparations stained with Giemsa or Leishman
stain in which organisms are seen within the macrophages as
bipolar staining, safety pin-shaped intracytoplasmic inclusions,
known as ‘Donovan bodies.’
Polymerase chain reaction (PCR) techniques demonstrate
granulomatis however, it is currently only used for scientific
research.
An indirect immunofluorescent technique is available to test
serum; however, it is not accurate enough for confirmatory
diagnosis.

Histologic Findings
The epidermis displays acanthosis at the ulcer edge, with
pseudoepitheliomatous hyperplasia variably present. A dense
dermal infiltrate of histiocytes and plasma cells is present, with
Fig. 36.5: Chancroid: Gram-negative cocobacilli in school a scattering of small neutrophilic abscesses. The macrophages
of fish arrangement are large and vacuolated, and they may demonstrate
244
intracellular bacilli (Donovan bodies) when prepared with a occurs in fewer than one-third of patients. The nodes most
Warthin-Starry or Wright-Giemsa stain. granulomatis does not commonly involved are the horizontal group of inguinal lymph
stain with hematoxin and eosin. nodes; however, vertical and femoral nodes may also be
affected. A characteristic physical finding, termed the ‘Groove
Treatment sign of Greenblatt’ occurs in approximately one-third of patients.
Doxycycline 100 mg orally bid This sign is caused by enlargement of the nodes above and
or below the inguinal ligament.
Erythromycin 500 mg orally qid One-third of the inguinal buboes become fluctuant and
or rupture, while the remaining two thirds involute to form a hard
Azithromycin 500 mg orally bid. nonsuppurative inguinal mass.
The antibiotics should be given for at least a 3-week course Women often have primary involvement of the rectum,
and continued until reepithelialization of the ulcer and vagina, cervix, or posterior urethra, which drain to the deep

Chapter 36
resolution of any signs of the disease. If the ulcers do not respond iliac or perirectal nodes; therefore, only 20–30% have the classic
within the first day of therapy, add an aminoglycoside (e.g. finding of inguinal lymphadenopathy.
gentamicin 1 mg/kg IM 8 hourly). Relapse may occur up to 18 Constitutional symptoms, such as fever, chills, malaise,
months after treatment. myalgias, and arthralgias, are common in this stage of
the disease. Women may complain of lower abdominal or
Surgical Care back pain because they often have involvement of deep pelvic
Once healed, disfiguring genital swellings may need to be nodes.

Reproductive Tract Infections and Sexually Transmitted Diseases (RTIs and STDs)
corrected by plastic surgery. Tertiary stage/anogenital rectal syndrome: may occur years
after the initial infection. Females are more likely to present in
Complications this stage. Symptoms include fever, pain, tenesmus, pruritus,
The most serious complication is carcinoma, which is reported and purulent or bloody diarrhea. These symptoms are
to occur in 0.25–0.5% of the patients. This includes squamous associated with proctocolitis, abscesses, and fistulae. Chronic
and basal cell carcinomas. infection can result in extensive scarring with ischemia and
Once the lesions have healed, extensive fibrosis, stricture tissue necrosis. The end result can be esthiomene (elephantiasis
formation, leading to significant deformity and functional of the female genitalia characterized by fibrotic labial
disability, may occur. thickening).
Elephantiasis of the genitals (Esthiomene) may occur
secondary to lymphatic destruction. Complications
GI may also progress to involve extragenital sites with Complications usually arise from progression to the third stage
potentially fatal systemic spread to the viscera of LGV. Scarring and local tissue destruction is the rule, with
stricture and fistula formations and deformity of genitalia.
Prognosis Complete bowel obstruction from rectal stricture may occur.
Relapse may occur up to 18 months after treatment. Systemic spread occasionally can result in arthritis,
If untreated, the lesions may continue to expand for years. pneumonitis, hepatitis, or rarely perihepatitis.

LYMPHOGRANULOMA VENEREUM (LGV) Laboratory Diagnosis

Synonyms Lymphogranuloma inguinale, Tropical bubo. It is difficult to culture the organism. The best results have been
obtained using aspirates from an involved inguinal lymph node.
Introduction Culture requires growth in cycloheximide-treated McCoy or
LGV is an STD that primarily involves the lymphatic channels HeLa cells, and even under these conditions, yields of only
caused by Chlamydia trachomatis. 30–50% are reported.
It should be included in the differential diagnosis of any Complement fixation test: An antibody titer of 1:64 or
patient presenting with genital ulcer and/or inguinal greater or a 4-fold increase in titer is supportive of the diagnosis.
lymphadenopathy. Identification of . trachomatis in tissue by use of special
stains.
Pathophysiology Other tests used are microimmunofluorescence and
Chlamydia trachomatis, an obligate intracellular organism is polymerase chain reaction (PCR). But the usefulness of these
the causative agent. Its serotypes L1, L2, L3 are known to cause methods is limited by availability.
it. The organism travels through the lymphatics to multiply
within the macrophages in regional lymph nodes. Treatment
Doxycycline (100 mg PO bid)
Clinical Features Or
LGV occurs in 3 stages: Primary, secondary and tertiary stages. Erythromycin (500 mg qid)
Treatment is continued for 3 weeks, combined with
Primary Stage aspiration of the lymph nodes, if needed. Incision and drainage
It has an incubation period of 3 days to 6 weeks (average 7 days) may result in nonhealing fistula formation, which can be
and is characterized by a painless genital papule or a herpetiform minimized by draining involved lymph nodes from above the
ulcer which heals rapidly without leaving a scar in a few days. It inguinal ligament. Symptomatic treatment with nonsteroidal
usually remains unnoticed by the patient, therefore, it is rare for anti-inflammatory drugs (NSAIDs) and local heat for pain relief
a patient to present in this stage of this disease. may be useful adjuncts.
Secondary Stage/Inguinal Syndrome Surgical Care
It occurs 2–6 weeks later and manifests as unilateral painful Surgery often is necessary for repair of late complications such
inguinal lymphadenopathy (bubo). Bilateral lymphadenopathy as fistulas and strictures.
245
 Prognosis
Prognosis is excellent if LGV is treated early; however, late
complications can cause significant morbidity.

GONORRHEA
Introduction
Gonorrhea is caused by Gram negative bacterium Neisseria
gonorrheae. Gonorrhea spreads during sexual intercourse.The
bacterium infects the columnar epithelium of the urethra (Fig. 36.6)
and endocervix. Non-genital sites in which it thrives are in the
rectum, the oropharynx and the conjunctivae of the eyes. The cervix
Infections of Genital Tract

is the usual first site of infection.The vulva and vagina in females

are usually spared because they are lined by stratified squamous
epithelium.
Infected women also can pass gonorrhea to their newborn Fig. 36.7: Gram-stained smear sowing intracellular
infants during delivery, causing conjunctivitis in their babies gram-negative diplococci
(which if left untreated, can cause blindness).
Treatment
Clinical Features efixime 400 mg orally in a single dose.
The incubation period varies from 2 to 14 days. Between or
30–60% of women with gonorrhea are asymptomatic or have eftriaxone 125 IM in a single dose.
subclinical disease. The woman may complain of burning or
micturition and increased frequency. The combination of iprofloxacin 500 mg orally in a single dose
urethritis and cervicitis strongly supports a gonorrhea or
diagnosis, as both sites are infected in most gonorrhea patients. Azithromycin 2 g orally in a single dose
The fluoroquinolones are contraindicated in pregnancy.
Section 7

Diagnosis In areas where co-infection with chlamydia is common,

The diagnosis includes microscopy and culture. The bacteria combination of antibiotics, such as ceftriaxone with doxycycline
are identified as intracellular gram negative diplococci in pairs (100 mg orally bid for 7 days) is recommended to treat both diseases
on Gram staining of the cervical or urethral smears (Fig. 36.7). or Azithromycin given as a single dose of 2 gm may be given.
Culture is the most specific investigation.
NON-GONOCOCCAL URETHRITIS
Complications Introduction
Pelvic inflammatory disease (PID): It is the most important Non-gonococcal urethritis (NGU) is an inflammation of the urethra
complication of gonorrhea in women. It presents with lower which is caused by organisms other than gonorrheal infection.
abdominal pain, bleeding between menstrual periods and
dyspareunia. PID causes scarring of the fallopian tubes which Etiology
leads to increased risks of causing an ectopic pregnancy. It can be caused by a number of organisms, including hlamydia
Bartholin’s gland cyst abscess It is commonly unilateral. trachomatis, reaplasma urealyticum, ycoplasma genitalium,
Disseminated gonococcal infection (DGI) It can occur in both richomonas vaginalis, erpes simplex virus, and andida albicans,
sexes leading to multiple distant sites of infection which can and by a number of non-infectious causes, including urethral
include the brain, heart and joints. stricture, foreign bodies, trauma, eiter’s syndrome, and various
ectal gonorrhea Gonococcal proctitis It may affect both men autoimmune and allergic conditions.
and women and is often asymptomatic. It may present with Of these many causes, the vast preponderance of cases are
anal discharge, pain on defecating and rectal bleeding. due to chlamydia. It is currently estimated that 50% of NGU cases
Proctoscopy may show an inflamed mucous membrane with little are caused by chlamydia, with the remainder due to other causes.
mucus. It is transmitted by penetrative anal sex and is diagnosed
on rectal swab. Incubation Period
It is usually between 1–3 weeks but can be shorter.

Clinical Features
It causes cervicitis and urethritis in women. Althouh women are
usually asymptomatic, few women present with mucopurulent
discharge. The usual complaints are dysuria, increased frequency
or pyuria. Abdominal pain or abnormal vaginal bleeding may be
an Indication that the infection has progressed to Pelvic
Inflammatory Disease (PID).

Diagnosis
icroscopy Gram’s stain of the urethral/cervical discharge under
a microscope show increased number of polymorphonuclear
leukocytes.
ell culture It is the gold standard for detection of
246 Fig. 36.6: Gonorrhea: Urethritis (white arrow) trachomatosis, however, it is expensive and technically difficult.
 Antigen detection tests and polymerase chain reaction are Partner Treatment
also there. Some controversy remains over the sexual transmission of
Treatment bacterial vaginosis. While it occurs more commonly in women
with more than one sexual partner, bacterial vaginosis can also
Azithromycin 1 g orally in a single dose.
occur in women who are not yet sexually active. Treatment of
Or
male partners has not resulted in improved cure rates or a reduced
Doxycycline 100 mg twice daily for 7 days.
rate of recurrence.
Or
8. Vulvovaginal candidiasis is usually not sexually transmitted.
Erythromycin base 500 mg orally 6 hourly for 7 days.
Abstinence from sex is advised for 7 days after receiving therapy. TRICHOMONIASIS (TRICHOMONAS VAGINALIS)
Partner treatment is essential. Introduction

Chapter 36
Complications Trichomoniasis is a sexually transmitted disease caused by the
Women who are infected with the organisms that cause NGU flagellate protozoan trichomonas vaginalis. The individual
may develop pelvic inflammatory disease and infertility organism is slightly larger (9 × 7 µm) than a white blood cell.
Four flagella project from the anterior portion of the cell.
BACTERIAL VAGINOSIS
Pathophysiology
Synonyms Hemophilus vaginalis vaginitis, Anaerobic
vaginosis. T. vaginalis principally infects the squamous epithelium of the

Reproductive Tract Infections and Sexually Transmitted Diseases (RTIs and STDs)
genital tract. Incubation time is generally between 4 and 28 days.
Introduction In females, vaginitis is the most common manifestation of
Bacterial vaginosis, previously known as nonspecific vaginitis infection. Infection with T. vaginalis is a marker of high-risk
or Gardnerella vaginitis, is a polymicrobial superficial vaginal sexual behavior. Co-infection with other STDs is common.
infection involving a loss of the normal lactobacilli and an
Risk Factors
overgrowth of anaerobes.
Infection with other STDs, especially gonorrhea
Diagnosis • Four or more lifetime sex partners
Amstel et al proposed a criteria for the clinical diagnosis of BV. At • Sexual contact with an infected partner
least three of these criteria must be present for diagnosis. • Not using barrier contraception.
• Homogeneous vaginal discharge
Clinical Features
• Presence of clue cells (Fig. 41.19)
• Amine (fishy) odor when potassium hydroxide solution is Presenting signs and symptoms may include vaginal or urethral
added to vaginal secretions (commonly called the “Whiff discharge irritation, itch, dysuria, abdominal pain, and
test”) (Fig. 41.18) dyspareunia. One third of asymptomatic women become
• Vaginal pH greater than 4.5 (Fig. 41.9). symptomatic within 6 months.
The most common symptoms are a thin, homogeneous On examination vaginal discharge is found in 42% of
vaginal discharge and a malodorous, “fishy” smell. The normal infected women described as thin and frothy; (Fig. 36.8)
pH of vaginal secretions is less than 4.5. In women with bacterial however. The discharge is often yellow. Sometimes, it is thick
vaginosis, the pH is usually greater than 4.5. enough to be confused with candidiasis.
When a drop of a 10% potassium hydroxide solution is Abnormal vaginal odor may be seen in 50% of infected women.
added to the vaginal secretions of a woman with bacterial Edema or erythema may be seen in 22–37% of infected
vaginosis, an amine, or “fishy” odor is released. This test, women.
commonly referred to as a “Whiff test,” is positive in women Vaginal pH is often elevated (>4.5).
with bacterial vaginosis. Colpitis macularis (strawberry cervix) is the finding
Another diagnostic criterion for bacterial vaginosis is the of punctate hemorrhages and occasionally vesicles or
presence of clue cells (>20%) on wet mount. Clue cells are papules on the cervix. It is the most specific clinical sign for the
vaginal epithelial cells that have a stippled appearance due to
adherent coccobacilli . The edges of the cells are obscured and
appear fuzzy compared with the normally sharp edges of
vaginal epithelial cells.
The term vaginosis is used because of the superficial nature
of the infection. The wet mount usually does not show the
increased number of leukocytes seen in other types of vaginitis.
Culture is not a diagnostic tool as it is positive in 50% cases.

Bacterial Vaginosis and Pregnancy

BV is associated with premature rupture of the membranes
preterm delivery, low birth weight, postpartum endometriosis.
Treatment
Metronidazole 400 mg twice daily for 7 days.
Or
Metronidazole 2 g single dose.
Or
Clindamycin vaginal pessary 100 g OD at bed time for 3 days. Fig. 36.8: Trichomonal discharge 247
 diagnosis of trichomoniasis. It is rarely detected without GENITAL WARTS (FIG. 36.10)
colposcopy. Synonyms Condyloma acuminata, Venereal warts
Laboratory Diagnosis Introduction
et mount This procedure is performed by placing a small Genital warts is a viral infection caused by human papilloma virus
amount of vaginal discharge on a microscope slide and mixing (HPV). There are more than 100 different types of HPV, but only a
with a few drops of saline solution. The slide is then examined few (HPV 6, 11, 16, 31, 33) can cause genital warts. These strains of
under a microscope at low or medium power. The presence of viruses are highly contagious and spread through sexual contact
flagellated, pyriform protozoa indicates a positive result (Fig. with an infected person.
36.9). Slides must be read within 20 minutes of obtaining sample About two-thirds of people who have sexual contact with
due to loss of characteristic motility of the trichomonads. an infected person develop genital warts within three months
Sensitivity is poor, 40–60%. of contact, but in some cases they do manifest for years
Infections of Genital Tract

Papanicolaou smear Sensitivity is similar to that of wet

mount, 60%. Clinical Features
ulture It is performed in Diamond medium. Sensitivity Genital warts affect the moist tissues of the genital area. The
approaches 100%. lesions appear after an average incubation period of three
Polymerase chain reaction PCR is based on DNA amplification months. They appear as small, flesh colored papules or have a
and detection using known primers to TV specific genes. It is cauliflower like appearance. Genital warts may be as small as
used for research purposes only. one millimeter in diameter or may multiply into large clusters.
In women, genital warts can grow on the vulva, the walls
Treatment is given to both partners of the vagina, the area between the perineum, the anus, and the
Metronidazole 2 g orally in a single dose cervix. Genital warts can also develop in the mouth or throat of
Or a person who has had oral sexual contact with an infected
Tinidazole 2 g orally in a single dose. person. The occurrence of such lesions in the anogenital in
children is a strong evidence of sexual abuse. Often genital
SCABIES (SARCOPTES SCABIEI) warts, cause no symptoms.
Section 7

Treatment includes Permethrin cream 5% applied all over the

body from the neck down and washed off after 8–14 hours (Not Screening and Diagnosis
for pregnant women). Alternative regimen includes Lindane 1 For women, it is important to have regular pelvic examination
oz of lotion or 30 gm of cream applied in a thin layer to all areas and Pap’s test, which can help in detection of vaginal and
of the body from neck down and wash off after 8 hours (Not cervical warts.
for pregnant women). Bedding and clothing should be
decontaminated. Treatment
Medical: Drugs that can be applied directly to the skin include:
CRAB LOUSE (PEDICULOSIS PUBIS) 2 Podophyllin in tincture benzoin: It works by
It is also sexually transmitted and need both partner’s hygiene destroying genital wart tissue. It is applied with a cotton tipped
improvement and treatment by permethrin 1% cream applied swab once or twice a week for six weeks. Necessary care is to
to affected area and washed off after 10 minutes or pyrethrina wash the area after 4–6 hours and to avoid aggressive treatment.
with piperonyl butoxide applied to the affected area and washed It should never be applied internally. This medication is not
off after 10 minutes. recommended for use during pregnancy. It can cause fetal
Alternative regimens are Mulathion 0.5% lotion applied for deaths and abortions.
8–12 hours and washed off or 1 vermection orally 200 µg/kg Imi uimod cream: This cream is a immune response
repeated in 2 weeks (Note for pregnant women). Topical modifier. It does not have a direct antiviral activity. It is not
application of 0.9% suspension of spinosed can be used. advocated in pregnancy.
Trichloroacetic acid or TCA: This chemical treatment burns
AIDS (HIV I AND HIV II) off genital warts. It can be used safely in pregnancy (70–90%).
Mostly do not have local reproductive manifestations.

HEPATITIS B (HEPATITIS B VIRUS)

Though a sexually transmitted disease there is no reproductive
tract involvement.

248 Fig. 36.9: Trichomonas vaginalis Fig. 36.10: Venereal warts

 Surgical: Surgery may be necessary to remove larger warts, individuals still have episodes of viral shedding and can transmit
warts that don’t respond to medications, or—if the patient is the virus to their sexual partners.
pregnant—warts that baby may be exposed to during delivery.
Surgical options include: Laboratory Diagnosis
• Freezing with liquid nitrogen (cryotherapy) 1. zanc smear Smear taken from the base of the vesicle stained
• Electrocautery with Giemsa stain shows multinucleate giant cells.
• Surgical excision 2. Histopathology
• Laser treatments can be expensive and is usually reserved 3. iral culture Definitive method of diagnosis are
for very extensive and tough-to-treat warts cumbersome.
• Intralesional injection of alpha interferon. 4. Serology Differentiates first episode(IgM) from recurrent
episodes(raised IgG).
Complications

Chapter 36
Ulceration, secondary infection and hemorrhage are Management
complications of anogenital warts. The drugs acyclovir, famcyclovir and valacyclovir are
Cervical cancer has been closely linked with HPV infection. nucleoside analogues and prevent replication of virus by
Certain types of HPV also are associated with cancer of the vulva. formation of viral DNA.
Human papillomavirus infection doesn’t always lead to cancer These are used in different ways:
and valva but it is still important for women, particularly those 1. Symptomatic management to reduce symptoms.
who have been infected with certain higher risk types of HPV, to 2. Intermittent therapy to abort or reduce the duration of

Reproductive Tract Infections and Sexually Transmitted Diseases (RTIs and STDs)
have regular Pap tests. episodes.
Genital warts may cause problems during pregnancy. Due 3. Continuous(suppressive) therapy to prevent recurrences.
to increased hormones, vascularity and immune deficiency,
warts enlarge in size and number making it difficult to urinate. Initial Episode
Warts on the vaginal wall may reduce the ability of vaginal Acyclovir—200 mg 5 times daily for 7 days or 400 mg thrice
tissues to stretch during childbirth. Rarely, a baby born to a daily for 7 days
mother with genital warts may develop warts in throat. Warts Famcyclovir—250 mg twice daily for 5 days
may resolve without treatment after delivery. Valacyclovir—1g twice daily for 7 days.

HERPES PROGENITALIS Recurrent Episodes

Genital herpes is usually caused by a DNA virus, herpes simplex Acyclovir—200 mg 5 times daily for 5 days or 400 mg thrice
virus type 2 (HSV-2). It is characterized by grouped vesicles on daily for 5 days
an erythematous base. Famcyclovir—125 mg twice daily for 5 days
Valacyclovir—500 mg twice daily for 5 days.
Pathophysiology
Indications for Suppressive Therapy
HSV invades and replicates in neurons as well as in epidermal
and dermal cells. Virions travel from the initial site of infection • Immunocompromised patients.
on the skin or mucosa to the sensory dorsal root ganglion, where • More than 6 recurrences per year.
latency is established. Viral replication in the sensory ganglia • Severe recurrences.
leads to recurrent clinical outbreaks. These outbreaks can be • Psychological problems.
induced by various stimuli, such as trauma, ultraviolet Suppressive herapy It is given for 6 months duration.
radiation, extremes in temperature, stress, immunosuppression, Acyclovir 400 mg twice daily
or hormonal fluctuations. Famcyclovir 250 mg twice daily
Valacyclovir 500 mg daily (<10 recurrences per year) or
Clinical Features
1000 mg once daily (>10 recurrences per year).
Primary infection with HSV is clinically more severe than
recurrent outbreaks. Herpes and Pregnancy
Primary infection Primary herpes genitalis occurs within 2 The manifestation of genital herpes do not differ between
days to 2 weeks after exposure to the virus and has the most severe pregnant and non-pregnant women but consequences of
clinical manifestations. Symptoms of the primary episode typically
last 2–3 weeks.
In women, primary herpes genitalis presents a painful
vesicles on the external genitalia or as vesicular/ulcerated
lesions on the cervix (Fig. 36.11). The vesicles rupture in a few
days leaving behind superficial erosions with polycyclic
margins. They can also occur on the vagina, perineum, buttocks,
and at times legs (in sacral nerve distribution). Associated
symptoms include fever, malaise, inguinal lymphadenopathy
and dysuria.
ecurrences After primary infection, the virus may lie latent
for months to years until a recurrence is triggered. Reactivation
of HSV-2 in the lumbosacral ganglia leads to recurrences below
the waist. Recurrent clinical outbreaks are milder and often
preceded by a prodrome of pain, itching, tingling, burning, or
paresthesia.
More than one half of individuals who are HSV-2 seropositive 249
Fig. 36.11: Herpes genitalis
do not experience clinically apparent outbreaks. However, these
 maternal genital herpes can be severe in fetus with manifestation
of neonatal HSV disesase, severe intrauterine growth restriction.
Most women who deliver infants with neonatal HSV have no prior
history, signs, or symptoms of HSV infection. Risk of transmission
is highest in pregnant women who are seronegative and acquire a
new HSV infection in the third trimester of pregnancy.
Factors that increase the risk of transmission from mother
to baby include the type of genital infection at the time of delivery
(higher risk with active primary infection), active lesions,
prolonged rupture of membranes, vaginal delivery, and an
absence of transplacental antibodies. The mortality rate for
neonates is extremely high, if untreated.
Infections of Genital Tract

Maternofetal Transmission
Women who have primary HSV infection are more likely to Fig. 36.12: Molluscum contaniosum: Pearly white
transmit the virus to their infants than are woman who have umbilicated papules
recurrent infection. Genital Herpes can be detected by
conducting a TORCH test. STD and HIV Infection
The relationship between STIs and HIV infection is three-fold.
Management of Herpes during Delivery Firstly, STIs and HIV infection are associated with the same risk
Patient should be delivered by cesarean section before the rupture behavior, that is, unprotected sexual intercourse with multiple
of amniotic membrane if any vesicular lesions are detected. partners. Thus, the same measures that prevent STIs also prevent
sexual transmission of HIV infection. Secondly, the presence of
Complications STIs has been found to facilitate the acquisition and transmission
The most common complication of primary HSV-2 genital of HIV infection. A 10-fold increased risk for HIV transmission
infection is bacterial superinfection. has been associated with diseases that cause genital ulcers, such
Section 7

In women, systemic complications, such as urinary retention as syphilis, chancroid and genital herpes. The risk associated with
and aseptic meningitis (seen in up to 25% of women), can occur. diseases causing discharge, especially gonorrhea, chlamydial
The associated pain, paresthesia, and discomfort, as well infection and trichomoniasis is up to 4-fold. Thus, early diagnosis
as the psychosocial impact, of herpes simplex outbreaks cause and effective treatment of STIs can contribute significantly
significant morbidity to the individuals who are affected. towards the reduction in HIV transmission.
Another serious consequence of HSV infection is the
transmission of the virus to a neonate by a mother who is infected. HPV INFECTION
The risk of HSV transmission to the newborn is maximum if the It is also a sexually transmitted disease.
mother has acquired a new HSV infection near the time of Fundamental goal of the RTI/STI control program, is early
delivery. The risk of transmission is less if the women has acquired detection and prompt and complete treatment of the disease at
HSV infection before their third trimester of pregnancy. the point of the patients first contract with the health system.
Women with RTI/STI report late because Many are
Patients Counseling asymptomatic.
Patients should be educated regarding their condition. • Inadequately or improperly treated by quacks
Abstinence from sexual intercourse is required once lesions • Lack of time due to household duties
are there or if prodromal symptoms are present. • Lack of awareness of consequences
Asymptomatic shedding may occur thus condoms are • Fear of stigmatization
advisable at all times. The Piot-Fransen model (Fig. 36.13) depicts the usual
Various negative thoughts can disturb normal social and outcome of STI management.
psychosexual life. Hence, the patients need advice and We have dealt with etiological diagnosis and treatment of
emotional support. RTI/STI. But there are some problems with etiological diagnosis.

MOLLUSCUM CONTAGIOSUM
Molluscum contagiosum is a common benign viral infection of
the skin caused by the poxvirus. Transmission in children
requires direct skin to skin contact with infected hosts or
contaminated fomites. In adults the transmission is through
sexual contact (mostly).
Multiple pearly white dome shaped umbilicated papules are
seen on the genitalia varying in size from 1 to 10 mm in diameter
(Fig. 36.12). The lesions are asymptomatic. Multiple large sized
lesions around genitalia should arouse the suspicion of HIV
infection. Molluscum contagiosum is a self-limited disease, which,
if left untreated, will eventually resolve in immunocompetent hosts
but may be protracted in immunocompromised individuals.
Multiple local therapeutic options (cryotherapy, evisceration
and curettage) are available. For patients with impaired immune
functions with widespread and potentially disfiguring
250 eruptions, the usual local destructive therapies are ineffective;
antiviral and immunomodulatory medications have been more. Fig. 36.13: Piot-Fransen model of STD management
1. Skilled personnel and sophisticated equipment are needed Table 3 .1: Table showing most common STI
to identify the causative agent. associated syndrome
2. Laboratory t ests and diagnosis are expensive and time
cousuming. STI syndrome Possible causes
Urethral discharge N gonorrhea hlamydia trachomatis
3. Treatment does not begin until the results are obtained. The
Genital ulcer disease pallidum, emophillus ducreyi
women may not return to collect the report for starting the trachomatis erpes
treatment. simplex virus
4. Testing facilities are not available at the primary and secondary Vaginal discharge N. gonorrhea,
health care level where people with RTI/STI seek care. trachomatis, Trichomonas, vaginalis,
Hence WHO and NACO started syndromic approach for Cadida albicans, Gardnerella vaginalis
the treatment of RTI/STI. Here the infections agents are grouped Lower abdominal N gonorrhea, C. trachomatis
according to the syndrome they cause. Flow charts are used as pain (Pelvic inflam- and anaerobic bacteria

Chapter 36
matory disease PID)
tools. All important causes of syndrome are treated on the first
Inguinal bubo ducreyi, and C. trachomatis
visit. The patient is also educated for prevention and compliance (acute inguinal
of treatment. Advise on sexual behavior is given. She is educated lymphadenitis)
for condom use and partner treatment. Necessary clinical Scrotal swelling N gonorrhea, C. trachomatis
follow-up is required. viruses and surgical conditions

Reproductive Tract Infections and Sexually Transmitted Diseases (RTIs and STDs)
Table 3 .2: Showing strategies for primary prevention of RTI STI
ype of infection Preventive strategy
Sexual transmitted Delaying sexual initiation, reducing number of sexual partners or rate of partner change. Changing the dynamic
of partner selection. Reducing non-consensual sexual exposure (e.g anal sex, etc.). Encouraging safer sexual practices.
Promoting condom use. Providing voluntary counseling and testing. Promoting use of other barrier methods.
Encouraging penile hygiene.
Endogenous Improving knowledge of reproductive physiology menstrual and personal hygiene providing appropriate help
seeking behavior. Reducing the use of harmful intravaginal substances, i.e. douches, and vaginal drying agents
and disinfectant on vulva they displace normal flora and encourage growth of harmful bacteria desiccants) gravid
women or women on oral contraceptives or diabetic mellitus women are more prone to Candida infection. They
must control their diabetic mellitus. Clean perinueum and vulva with soap and water is a good hygienic measure.
Clean vulva from before backward. In vulnerable section treatment for candida albicans if present, must be treated.
Iatrogenic Reducing the imappropriate use of systemic antibiotics. Improving access to safe delivery and abortion services.
If a woman comes with incomplete abortion take all precautions to prevent infection during surgical evacuation
of the uterus. During operation like CuT insertion, dilatation and curettage evaluate and treat infection before
undertaking the procedure. If there is no infection then only the procedures be undertaken after cleaning the
cervix twice with iodine solution. Improving infection control competence. Enhancing the management of service
delivery (quality of care). Providing antibiotic prophylactically 1 hour before operations.

The commonly encountered syndromes are given in (Table Tertiary Prevention

36.1). The main component is septic abortion and puerperal sepsis
treatment.
SEQUELAE AND COMPLICATIONS OF RTI/STI
Clinical management of tertiary prevention are:
1. Development of HIV/AIDS
• Alertness and prompt diagnosis and treatment of ectopic
2. Infertility
pregnancy
3. Fetal wastage
• Management of infertility
4. Ectopic pregnancy
• Cervical cancer screening.
5. Cancer of the cervix
Reproductive tract infections can be divided into (1).
6. Death.
Infection of the lower genital tract (vulva, cervix, vagina) (2).
PREVENTION OF RTI/STI Infection of the upper genital tract (fallopian tubes). Also called
Comprehensive RTI/STI. Control programme requires three pelvic inflammatory disease (PID).
levels of prevention. Lower genital tract infections: They mostly cause vaginal
1. Primary prevention discharge. There may or may not be itching and pain. They are
2. Secondary prevention (identification and prompt and delt in their respective chapters.
complete treatment)
3. Tertiary prevention by minimizing the impact of BIBLIOGRAPHY
complication of infection. 1. CDC treatment guidelines. 2006.
2. Newman L, Moran JS, Wakowski Ka. Update on the management
Primary Prevention of gonorrhoea in adults in the United States. Clin. Infect Dis
Table 36.2 is showing strategies for primary prevention of RTI/STI. 2007;44:84-5,101.
http://www.cdc.gov/std/gonorrhoea/org.
Secondary Prevention 3. Wang QQ, Mabey D, Peeling RW, et al. Validation of syndromic
Secondary prevention is identification and prompt treatment algorithm for the management of genital ulcer disease in China.
and complete follow-up of RTI/STI infection. Int J STD AIDS 2002;12:469.
251
 37 Pelvic Inflammatory Disease (PID)

Sudha Salhan, Mahua

Definition 5. Menstrual cycle timing influences the environment of lower

Pelvic Inflammatory Disease (PID) is a term for the genital tract. During the menstrual period and just after that
inflammation of the upper genital tract. CDC defines it as, “the local host mechanism breaks down and increases
clinical spectrum of upper genital tract infection attributed to susceptibility to acquiring infection.
ascending spread of micro-organisms from the vagina and The remaining 15% of infections occur after procedures that
cervix to the endometrium (endometritis), fallopian tubes break the cervical mucus barrier (e.g. IUCD insertion, MTP, D
(salpingitis) and/or contiguous structure (tubo-ovarian abscess and C) if not performed with proper antiseptic precautions. Also
and peritonitis).” The disease process may be acute, chronic can be seen in bowel damage in pelvic or abdominal surgery.
and acute on chronic. It is more common in sexually active Direct spread from adjacent organs, e.g. appendicitis (right
younger women. acute salpingitis and abscess formation) and abdominal TB, etc.
is seen in <1% of cases (Flow chart 37.1).
Incidence
It is most frequent serious infection in women. It is seen in about Bacteriology of PID
1% of women in the reproductive age group though the incidence Usually it is polymicrobial.
peaks to 2% in the age group of 20–24 years. It forms about 5% of a. Sexually transmitted organisms (see chapter 36 for details).
gynecological admissions in India. • Neisseria gonorrheae (It becomes attached to the
nonciliated mucous secretory epithelial cells to produce
Etiology endotoxin (lipopolysaccharide) damaging ciliary cells.
Most cases of acute PID are the result of a-polymicrobial Peptidoglycan on the surface of the bacteria also damage
infection caused by organisms ascending from the vagina and fallopian tube mucosa. It also produces IgA proteases
cervix to infect the mucosa of the endometrium and fallopian and IFNa.
tube. About 60–75% of the cases are sexually transmitted as is • Chlamydia trachomatis (It attaches to the tubal
seen below. epithelium and enters its both ciliated and non-ciliated
1. STDs : 60–75% cells and replicates inside it). A specific 57-kd protein
2. Pyogenic infections : 15–20% and various cytokines causing inflammation and scar
3. Tuberculosis : 5% formation are detected. It is very important to prevent
4. Rarely, due to schistosomiasis, actinomycosis (in 14% repeated infection by treating sexual partners (Fig. 37.1).
cases), etc. • Mycoplasma hominis.

Flow chart 37.1: Pathogenesis of PID

 Fallopian Tubes
• Patent tubes
• Ciliary activity of tubes towards uterus.

Acute PID
Diagnosis of Acute PID
Acute salpingitis is the most important component. Acute PID
presents with a broad spectrum of clinical symptoms. All the
following features should be present for diagnosis (CDC
criteria). Because of the serious potential complications of
untreated PID and the endemic prevalence of the infection CDC

Chapter 37
has adopted an approach to maximize diagnosis by using
minimal criteria and by urging provider to maintain a low
threshold for diagnosis and emperical treatment.
Gonorrhea infection has abrupt onset and more toxic
Fig. 37.1: Chlamydial inclusion body symptoms than other causative organisms.
Minimum Criteria
b. Aerobic genital bacteria • History of abdominal pain and lower abdominal tenderness

Pelvic Inflammatory Disease (PID)

• Group B streptococci (90%)
• Other streptococci • Cervical motion tenderness
• Coagulase—negative staphylococci • Adnexal tenderness (95.5%).
• Escherichia coli
• Gardnerella vaginalis Additional Criteria
• Hemophilus influenzae One of the following:
• Other facultative gram negative bacteria. • Temperature >38.3°C (101°F)
c. Anaerobic genital bacteria • Leukocytosis >10, 000 /mm3
• Peptostreptococci • Abnormal vaginal or cervical discharge (75%)
• Peptococci • Low back pain
• Bacteroides bivius • Purulent material from peritoneal cavity (culdocentesis/
• Mycoplasma, ureaplasma laparotomy)
• Block pigmented bacteroides • Irregular vaginal bleeding
• Other bacteroides species. • Dysuria
In India, as in other developing countries, deliveries are • Pelvic abscess/ inflammatory complex (PV or USG)
conducted at home by ‘Dais’ (untrained midwives). Criminal • Raised ESR and or C-reacting protein (CRP)
abortions continue to take place despite Government of India’s • Intracellular diplococci on gram stain from endocervix, i.e.,
liberal policy on induced abortions. Postabortal and puerperal laboratory documentation of genorrhea or Chlamydia
sepsis are, therefore, common occurrences. It is estimated that at trachomatis
least 50% of the PID cases of developing countries are caused in • More than 5 WBC/HPF on gram stain from endocervix.
this manner. Previous history of Chlamydia or other STD, prior Revised Criteria
PID, more number of sexual partners, early age of initiation of
In this, the following parameter is also included: Inflammatory
sexual activity are also predispose for PID. It is not common in
cells (WBCs) on saline microscopy of vaginal secretions.
pregnancy due to increased vascularity and mucous cervical plug
A detailed history is to be taken. Do careful examination. The
preventing upward transmission of infection but can be seen in
above signs and symptoms are looked for.
first trimester.
Differential Diagnosis of Acute PID
Natural Barrier for PID
1. Acute appendicitis
There are several natural barriers to the ascent of pathogenic
2. Ectopic gestation (Do urine pregnancy test)
organisms from the vagina to the fallopian tubes (given in detail
3. Acute diverticulitis
in chapter 36).
4. A twisted ovarian cyst/subserous myoma
In Vagina 5. Endometriotic cyst, when ruptures
• Acidic pH 6. Gastroenteritis
• Multilayered squamous epithelium 7. Ruptured ovarian follicle/corpus luteal hematoma
• Doderlein’s bacilli 8. UTI (cystitis)
9. Enterocolitis
Cervix 10. Intestinal obstruction
• Narrow endocervical canal 11. Renal calculi
• Downward flow of mucus 12. Irritable bowel syndromes
• Presence of antibacterial lysosomes 13. Pain of unknown origin.
• Local IgA.
Chronic PID
Endometrium Chronic PID is mostly due to repeated acute episodes leading
• Monthly shedding of endometrium. to adhesions, scarring and tubal obstruction.
253
 Differential Diagnosis of Chronic PID • Elevated temperature
1. Chronic ectopic gestation • Endocervical smear with gram-negative intracellular
2. Uterine myoma diplococci suggestive of N. gonorrhea or a smear with C.
3. Pelvic endometriosis trachomatis (ELISA, Fluorescent antibody test, DNA probe—
4. Ovarian tumor if available)
5. Tubercular tubo-ovarian mass • Palpable adnexal mass.
6. Chronic appendicitis/diverticulitis U/S can be done in acute PID to exclude other causes of
7. Congestive dysmenorrhea. pain (as differential diagnosis. May show tube wall thickness
Perform urinalysis to exclude cystitis or pyelonephritis. greater than 5 mm, incomplete septae in the fallopian tubes,
fluid in POD and Cogwheel appearance in fallopian tube
Confirm Diagnosis By
(cogwheel sign). This is not routinely used. CT and MRI are
• Histopathologic evidence of endometritis on endometrial not commonly recommended.
Infections of Genital Tract

biopsy or hydrosalpinx. Inflamed adenexa are seen at laparotomy (Figs 37.2 and
• Tubo ovarian abscess on USG/ other imaging study. There 37.3). It shows adhesions between anterior surface of liver and
may be fluid in POD. diaphragm-Fitz-Hugh-Curtis syndrome (Fig. 37.4)
• Laparoscopy: It is performed in non-respondents cases.
There may be perihepatic thread like (violin stringe) Treatment
adhesions seen between the anterior surface of the liver and Patients of acute PID require hospital admission for proper
the diaphragm (Fitz-Hugh-Curtis Syndrome). This hydration and intravenous antibiotics. Treatment should be
syndrome is seen in acute salpingitis (patient gives history prompt due to evidence that prevention of long-term sequalae
of upper quadrant pain). It is mainly caused by Chlamydia is linked with timely administration of appropriate antibiotics.
trachomatis. But other organisms causing acute salpingitis Therapy regimens for PID must provide empiric, broad-
may be responsible. spectrum coverage of likely pathogens including Neisseria
PID diagnostic algorithm (Flow chart 37.2) gonorrheae, Chlamydia trachomatis, gram-negative facultative
Classify clinical presentation bacteria, anaerobes, and streptococci (CDC recommendation)
Mild Severe also called syndromic management. It also includes treatment of
Section 7

Complete pelvic examination the sexual partner.

• If neither adnexal tenderness (AT) nor cervical motion
Out-patient (OPD) Treatment
tenderness (CMT) is present, PID is unlikely. (For Mild to Moderate PID)
• If both AT and CMT are present, PID can be diagnosed in
Regimen A
women with mild presentation.
• Ceftriaxone 2g IM, plus probenecid, Ig oral OR ceftraxone
Evaluate simple diagnostic indicators
250 mg IM OR equivalent cephalosporin PLUS
• Abnormal vaginal discharge to be tested by wetmount slide • Doxycycline 100 mg orally BD x 14 days PLUS
examination • Treatment for anaerobic infection: Metronidazole 400 mg
• VDRL test orally BD x 14 days.
• HIV test
• Elevated ESR Regimen B
• Elevated CRP • Ofloxacin 400 mg orally BD x 14 days PLUS

Flow chart 37.2: Show PID diagnosis algorithm

254
 Table 37.1: Grading of PID
Clinical criteria On laparoscopy
Mild Uncomplicated—limited The tube is hyper-
to tube or/and ovaries emic, mobile but with
with or without perito- no purulent exudates
nitis
Moderate Complicated PID with Tube is edematous,
inflammatory mass or shows gross purulent
abscess involving material and the
tubes and/or ovaries fimbriae may be
adherent with tubal
blockage.

Chapter 37
Severe Spread to structures Pyosalpinx, inflam-
beyond the pelvis; matory tubo-ovarian
large (>8 cm) rutptured complex or abscess
tubo-ovarian abscess (Figs 37.3 and 37.4).

Indications for Hospitalization (CDC Criteria)

Fig. 37.2: Pyosalpinx
1. Uncertain diagnosis (surgical emergencies, e.g. ectopic

Pelvic Inflammatory Disease (PID)

pregnancy, appendicitis cannot be excluded)
2. Temperature >38.3°C
3. Adolescents
4. Pregnancy
5. Nausea/Vomiting precluding oral medication
6. Suspected pelvic/Tubo-ovarian (T-O) abscess
7. Signs of upper peritoneal irritation
8. Severe illness, nausea, vomiting or high fever which
cannot be managed at home
9. Failure to respond to oral antibiotics within 48 hours of
out-patient therapy
10. No facilities of clinical follow-up within 48-72 hours
11. Non-compliant patient—unable to follow or tolerate on
OPD regimen
12. HIV positive/ immuno compromised patient with low
CD4 counts, or on immunosuppressive therapy or has
another disease.
In-Patient Treatment is for acute PID with severe pain or
Fig. 37.3: Tubo-ovarian mass higher fever. The goal is to resolve the infection. There are at
present 2 regimens.
Regimen A
• Ceftriaxone 2 gm IV 6 hourly OR Cefotetan 2 gm IV 12 PLUS
hourly
• Doxycycline 100 mg IV or orally BD.
Regimen B
• Clindamycin 900 mg IV 8 hourly PLUS
• Gentamicin loading dose IV or IM (2 mg/kg) followed by
maintenance dose (1.5 mg/kg) 8 hourly.
• Parental therapy may be discontinued 24 hours after clinical
improvement. Followed by oral doxycyclin 100 mg BD and
clindamycin 450 mg OD for 14 days. Clindamycin is
preferred in TO absess.
• Sexual partners of women with PID should be evaluated
and treated.
CDC recommends the treatment of partners who had sex
with the patient during 60 days preceding the onset of
Fig. 37.4: Fitz-Hugh-Curtis syndrome (thread-like adhesions symptoms. This is required to prevent reinfection. Sexual
between anterior surface of liver and diaphragm) abstinence or use of condom is advised till cure is achieved.
In cases with PID caused by actinomycosis penicillin/
tetracyclin or doxycyclin can be used for at least two weeks.
• Clindamycin 450 mg orally QID OR Metronidazole 400 mg
orally BD x 14 days Indications for Surgical Management of PID
Follow in 3 days to monitor clinical response. 1. When symptoms do not improve or worsen
Grading of PID is given in Table 37.1. 2. Intra-abdominal rupture of tubo-ovarian (TO) abscess 255
 3. Uncertain diagnosis: suspected Surgical emergencies Table 37.2: Management of sex partners
4. No response to medical treatment in 48 to 72 hours of women with acute PID
5. TO abscess in postmenopausal patient (44% have
malignancy) Infection Recommended Alternate regimen
6. Size of TO mass >8 cm : unlikely to respond to medical regimen
management. C. trachomatis Doxycycline Ofloxacin 300 mg BD x
100 mg orally BD 7 day or Erythromycin
Operative Procedures x 7days or Azith- 500 mg QID x 7 days.
• Laparotomy romycin 1g orally
• Laparoscopy once
PLUS
• Colpotomy
N. gonorrhea Ofloxacin 400 mg Spectinomycin 1 gm
• Percutaneous abscess drainage (PAD). orally once or cefi- IM or ceftizoxime
Infections of Genital Tract

Historically, panhysterectomy and drainage is the standard xime 400 mg orally 50 mg IM or

operation. But in young patients one ovary should be conserved. once or ceftriax- cefotaxime 1gm IM
Prognosis: Good prognosis is seen if diagnosed and treated one 125 mg IM or cefoxitin 2 gm
early. The prognosis is poor in late therapy and when the patient once. IM + probenecid 1 gm
continued unsafe life-style. oral or Norfloxacin
Education of the patient: The patient is encouraged to 80 mg oral once
complete 14 days treatment for full cure
• It is essential to get the sexual partner treated to prevent
reinfection.
Risk of Ectopic
• The patient is advised to practice safe sex with the use of
After 1 episode 6%
condoms and limiting the number of sexual partners.
After 2 episode 12%
Partner treatment is given in Table 37.2.
After 3 episode 22%
• Avoid vaginal douching as it is a risk factor for PID
6. Recurrent vaginal discharge
• Have planned pregnancy. MTP and induced abortion
7. Inter-menstrual bleeding
predispose to PID.
Section 7

8. TO abscess
Complications/Sequlae of PID 9. Preterm delivery
1. Infertility 10. Pelvic thrombophlebitis and ovarian vein thrombosis.
The overall infertility rate is 12–50% after PID increasing 11. Small bowel obstruction
with each episode due to tubal damage. In acute PID there Because of all these complications the US Preventive Service
may be salpingitis causing the swelling of the delicate tubal Task Force (USPSTF) recommends all non- pregnant women
mucosa and epithelium is shed at places. This also damages younger than 24 years should be screened for Chlamydia,
cillia thus delaying ovum transport and preventing regardless of their risk factors. Women older than 25 years
implantation. Mostly both tubes are damaged irreversibly. should be screened if they are at increased risk (A level
In cases of hydrosalpinx (more than 3 cm). It is better to do recommendation) (2007).
salpingectomy and go for IVF rather than trying complex
tubal surgery (as there may be more chances of ectopic BIBLIOGRAPHY
pregnancy). 1. CDC (Guideline): Update of CDC’s STD treatment guidelines 2006
Risk of infertility Fluoroquinolones are not longer recommended for treatment of
After 1 Episodes 8% gonococcal infection MMWR morb mortal weekly report
After 2 Episodes 15% 2007;56(14):332.
After 3 Episodes 40% 2. Meyers DS, Halversen H, Luckhaupt S (Guideline). Screening for
chlamydial infection an evidence update for US PSTF Ann Intern
2. Deep hydrosalpinx (dropped in POD) may cause persistent
Med 2007;147(2):135.
and recurrent vaginal infection and Dyspareunia 70%
3. Ness RB, Hillier SL, Kip KE. Bacterial vaginosis and risk of PID.
3. Chronic pelvic pain 15–20% Obstet Gynecol 2004;104(4):761.
4. Recurrent PID: 25% 4. Savaris RF, Teixeira LM, Torres TG, et al. Comparing ceftriaxone
5. Ectopic pregnancy: It is six times more than those with no plus azithromycin or doxycyclin for PID: A randomized control
PID Risk increases with each episode. In chronic PID trial. Obstet Gynecol 2007;110(1):53.
intraluminal adhesions may form leading to entrapment of 5. Wiesenfeld HC, Sweet RI, Ness RB, et al. Comparison of acute and
fertilized ovum and ectopic pregnancy ensures. subclinical PID. Sex transm Dis 2005;32(7):408.

256
 38 Genital Tuberculosis

Jyotsana Suri, Sudha Salhan

Introduction and an increase in its incidence has been reported. In India,

Tuberculosis, a scourge of humanity has been known since about 1% of all gynecological admissions have been reported
time immemorial. It was popularly referred to as to be due to genital tuberculosis in one study. Most of the
‘consumption’ in the older Western Literature because, the time there are no symptoms, at the start of the illness.
person afflicted, was consumed by this disease. Inspite of Therefore, exact incidence cannot be obtained.
the development of effective chemotherapy and various Genital tuberculosis carries with it a very high morbidity
other advancements, tuberculosis still kills more people (Two due to its destructive sequelae and is one of the major
billion people-one-third of the world’s population is infected causes of infertility (9–13%) in the developing countries.
with tubercle bacillus) than any other infectious disease About 5% of all females pelvic infections are due to gential
(nearly 500,000 in our country per year). India has the largest tuberculosis.
number of tuberculosis cases in the world and about 2–2.5
million are being added annually (one third of global burden). Pathogenesis
Resurgence of the disease in the last two decades is mainly Tuberculosis is caused by acid fast mycobacterium bacillus
because of emergence of multidrug resistant strains of Myco- (AFB).
bacterium tuberculosis and outbreak of the HIV pandemic Female genital tuberculosis is mostly secondary to infection
(Fig. 38.1). elsewhere in the body. The primary site of infection is usually
Tuberculous infection of female genital organs known as the lung and can also be kidney, the gastrointestinal tract or
genital or pelvic tuberculosis is a major public health problem bones. The disease can spread to genital tract through—

Fig. 38.1: Incidence of TB around the world (Africa and Southern Asia are worst affected)
 a. Hematogenous spread: This is the commonest mode of
spread of the bacilli to the genital tract. During the
formation of the primary complex, hematogenous
dissemination can take place, resulting in seeding of
Mycobacteria in any part of the body including the genital
tract. If this spread occurs during puberty, when the
genital organs are in the growing phase, at that time the
pelvic infection is more likely to occur. Hence, history of
pulmonary tuberculosis in the adolescent period should
always be taken from patients suspected to be having
genital tuberculosis. Other primary sites being lymph
nodes (more commonly in neck-cervical lymph nodes)
Infections of Genital Tract

urinary tract, bone and joints.

b. Lymphatic spread: Lymphatic spread takes place when
primary focus is in the gastrointestinal tract which
happens, only if the person is infected by bovine
Fig. 38.3: Tubercular endometrium (10x magnification)
tuberculosis due to ingestion of unboiled unskimmed milk.
(Dr Yadav, RML Hospital)
c. Direct spread: Direct spread from contiguous areas can
take place from lesions in the intestine, kidney and
peritoneal surfaces to the ovaries and fallopian tubes. menstruation and fresh reinfection takes place through the
d Sexual contact: Some cases of primary complex in the tubal ostia cyclically. In severe endometritis, extensive
external genitalia, vagina and cervix have been reported adhesions and destruction of the endometrium can lead to
due to contact with infectious secretions of a male partner, amenorrhea. (Asherman syndrome).
suffering from urogenital tuberculosis. Tuberculosis of the ovaries is normally a perioophoritis
and results due to direct extension of infection from the
Pathology
peritoneal surface or from the fallopian tubes. Occasionally,
Infection of the fallopian tubes is the commonest
Section 7

hematogenous spread occurs, leading to parenchymal

(Fig. 38.2), in about 90–100%. The disease is usually bilateral disease. The ovaries may be involved in about 20–25% of the
and begins from the submucosal layer of the ampulla. cas es.
Gradually, the infection spreads to other areas of the tube. The cervical lesions are usually ulcerative and mimic
During active stage of the disease, the tubes are swollen and carcinoma of the cervix (Fig. 38.4). Histopathology is
red. In some cases the tubes may be studded with small, confirmatory with presence of typical granulomatous lesions,
white tubercles. Sometimes there is formation of pyosalpinx Langhans giant cells, epitheloid cells and central caseation.
which may contain either caseous or even purulent material The cervix is involved in only 2% of the cases. One of our
due to superadded bacterial infection. patients came with vesicovaginal fistula.
In the healing phase of the disease dense fibrous tissue Tuberculosis of vagina and vulva is very uncommon seen
replaces the muscular tissue of the tubes and calcification only in less than 2% cases. It usually results due to venereal
can also occur. In about 25% of the patients the tubes may infection (through sexual contact) and presents as an ulcerative
remain patent though functionally damaged, ‘lead pipe’-like lesion simulating carcinoma. The ulcers are having undermined
fallopian tubes. But in the rest of the cases there will be edges. The diagnosis is made by biopsy and demonstration of
occlusion of the tubes. the bacilli in culture.
Tuberculous endometritis occurs in 60% to 70% of the women, In tuberculosis the adhesions are exteremly dense. The
being the second most common pathology in cases of pelvic fallopian tube, though damaged, is open at the fibrial end
tuberculosis. The lesions are limited to the endometrium with and the uterine ostia. If the disease is extensive, it may
infrequent spread to the superficial myometrium (Fig. 38.3). involve the surface of fallopian tube and uterine fundus
This is because the infected endometrium is shed off during causing ascites and, hence be confused with ovarian

258 Fig. 38.2: Tubercular salpingitis Fig. 38.4: Cervical tuberculosis

malignancy (Ascitic fluid contains more than 3 gms of conglomeration of omentum and gut with the diseased tube
proteins/100 ml and lymphocytes). and ovary. Occasionally, nodules in the cul-de-sac may be
palpated due to tubercles on the serosal peritoneal surfaces.
Clinical Features These findings may mimic endometriosis. Also differentiate
Genital tuberculosis can occur in any age group though it is from ovarian carcinoma due to the presence of ascites in both
most commonly seen in the reproductive age group. cas es.
The patient may present with unexplained weight loss,
low grade fever and malaise. However, in majority of the Investigations
cases there are no systemic features and the patient presents 1. Complete blood count with ESR. Anemia and lymphocytosis
to the gynecologist with either infertility, pelvic pain or may be there. Raised ESR is nonspecific but it points to the
menstrual disturbances. Infertility is the presenting suspicion of tuberculosis.
complaint in about 40–50% of the cases. 2. Mantoux test: Intradermal injection of 0.1 ml of 5 tuberculin

Chapter 38
The infertility results from tubal as well as endometrial disease. units (TU) of purified protein derivative (PPD) tuberculin
The tubes may be patent on hystero salpingography (HSG) but is given.
there is functional loss due to destruction of tubal musculature The reaction is read after 48–72 hours. Induration
and mucosa with its cilia which leads to impairment of ovum produced, and not erythema, is measured in millimeters.
pick up and its transport. In majority of the cases the fibrosis Interpretation—less than 5 mm induration is negative;
will lead to multiple stricture formation and beaded appearance 5–10 mm is intermediate and may be seen in contacts of
on HSG. In the rare event of the patient conceiving, ectopic TB cases, HIV or other immunosuppressed patients (on

Genital Tuberculosis
pregnancy is a very common occurrence. Subendometrial blood steroids, leukemia); more than 10 mm induration is
flow decreases leading to reduce receptivity and hence infertility. positive and is seen in infected patients.
Chronic pelvic pain is another common presenting It is important to understand that positive reaction is
symptom. The pain is due to chronic pelvic inflammatory only indicative of infection and not of active disease and
disease and may be due to tubo-ovarian abscess, pyosalpinx, can be seen after BCG vaccination. Mantoux test may be
salpingitis and oophoritis. Adhesion may be the cause of negative in immunosuppressed patients, extensive
pain. The patient will complain of dull aching pain in the lower tuberculosis, Hodgkins disease, recent live viral
abdomen which will not respond to the usual antibiotic vaccination, etc.
courses. 3. Chest X ray: As there is an association of genital
In an unmarried virgin girl with pelvic inflammatory tuberculosis with pulmonary tuberculosis, a radiograph
disease, tuberculosis of the genital tract should be the first may reveal opacities, cavities, pleural effusion or old
diagnosis to be considered. healed calcified patches (primary lesion) especially at
Menstrual complaints may be seen in about 40–50% of the the upper lobe (See Fig. 55.13).
patients. In the early stage of the endometrial disease, But past or present pulmonary tuberculosis is seen in
menorrhagia may be seen due to inflammation of the 50% of cases only.
superficial layers of endometrium and endometritis. There 4. Endometrial biopsy: The best time of collection of specimen
may be scanty bleeding during menstruation and eventually is at 1–2 days before or 12 hours after onset of menses.
amenorrhea due to destructive disease of the endometrium The sample should be divided in two bottles one
and replacement of the endometrium by fibrous tissue. containing formalin solution, to be sent for histological
Depressed ovarian function is seen if the ovaries are involved. examination and the other saline solution, for microscopic
It may be a cause for irregular periods. examination for AFB and culture. Histopathology shows
In the postmenopausal period, the patient may present granulomatous Langhan giant cells and central caseation
with discharge per vaginum and postmenopausal bleeding. (Fig. 38.3).
Infection in this age group can lead to pyometra formation as Histological examination is positive in about 50% of
the internal os is tightly closed. the patients suffering from pelvic tuberculosis, whereas
Diagnosis: Diagnosis is very important because early culture is positive in about 25%. Direct smear for AFB is
diagnosis will give excellent results. Late diagnosis causes positive in very few cases.
irreversible extensive damage including infertility. For culture to be positive there should be 10–100 bacilli
Past history of pulmonary tuberculosis is of great per ml of the material being tested.
significance, when genital tuberculosis is suspected. As many The conventional culture medium used is the
as 10% of patients who have pulmonary tuberculosis in Lowenstein Jensen Medium (30–40% sensitivity) and this
adolescence many have pelvic tuberculosis in later life. takes 4–6 weeks to give the result. Now- adays automated
History of tuberculosis in family members or close contact is culture methods liquid medium is also available BACTEC
also important. 460 and Bact alert 3D radiometric culture which yields
Night hyperpyrexia, anorexia and weight loss history may the result in 10–14 days. Measure CO 2 released by the
be forthcoming. bacteria. It has a sensitivity of 80–90%.
Pelvic tuberculosis should be strongly suspected in In unmarried girls, the menstrual blood can be
patients with unexplained infertility, chronic pelvic collected in cervical caps and sent for the above
inflammatory disease as well as chronic pelvic pain which is mentioned tests. However, the blood should be collected
unresponsive to the standard management. within 12 hours of onset of menses. Smear to be stained
General examination may reveal wasting. by Ziehl Neelsen stain. Fluorochrome staining method, if
Per-vaginal examination will reveal normal pelvic findings in available, is more sensitive. It is done in our hospital.
about half of the cases. Some patients will have palpable Rapid Molecular Techniques for detecting
adnexal masses due to tubo-ovarian abscess formation, mycobacterium tuberculosis have been developed and
pyosalpinx, hydrosalpinx, thickened tubes, oophoritis or are replacing older microbiological methods that took
259
 several weeks to give a result. DNA probes have a high pyrazinamide for 2 months followed by isoniazid and
sensitivity (83–100%) and specificity (98–100%). rifampicin for 4 months (2EHRZ + 4HR) is the usual treatment.
Nucleic acid amplification tests of polymerase chain Despite vigorous propaganda we were not able to pin
reaction (PCR) can detect mycobacterium tuberculosis down the disease. Therefore, was started DOTS.
within hours compared to 2–4 weeks required for cultures.
Directly Observed Treatment Short Course (DOTS)
It can detect as little as 10–20 bacilli per ml of the
specimen (compared with 10,000 or more). Its sensitivity Under the Revised National Tuberculosis Program (RNTCP),
is 90% and specificity is 80–92%. DOTS was implemented as a pilot project in 1993 and full-fledged
Recent additions to laboratory investigation are in 1997. Under this strategy the onus of cure rests on the health
isothermal amplification technique—using amplification care system and patient compliance is taken care of.
for micro-bacterium tuberculosis. A case of genital tuberculosis can be referred to the area
Ribosomal gRNA based probes: These probes target DOTS center near her residence. The drugs are given three
Infections of Genital Tract

gRNA, ribosomal DNA and spacer and flanking times a week and the patient is made to swallow the drug in
sequences which are useful for quick identification of front of the health worker. The same schedule of drugs is
mycobacterium. They are chemi-luminescent. recommended as for daily treatment, i.e. 2(EHRZ) 4(HR).
A new fully automated nucleic acid amplification test First lines drugs for daily treatment and DOTS along with the
(NAAT) is being endorsed by WHO specially for early dosage and adverse effects are shown in Table 38.1.
diagnosis of TB as well as multidrug resistant resident TB Look for toxically during treatment, do complete blood
and TB in HIV patients which are difficult to diagnose. test and liver function tests.
5. Ultrasonography: This may reveal tuboovarian masses, Treatment response is determined through clinical
pyosalpinx calcification or collection in the pouch of examination, relief of symptoms and USG follow-up of size
Douglas. Endometrium and its thickness can also be of the mass. If the patient does not respond clinically and
evaluated with USG. remains smear or culture positive after 5 months of
6. Hysteorsalpingogram (HSG): HSG should be done only if treatment, it is labeled as treatment failure and a strong
active infection of the genital tract is ruled out as suspicion of multidrug resistant tuberculosis (MDR TB) should
this may spread the infection further into the peritoneal be considered. The diagnosis of MDR TB is made with culture
cavity. and drug sensitivity tests.
Section 7

The typical findings in cases of tuberculosis are MDR TB is defined as infection by Mycobacterium
extravasation of dye, uterine cavity deformed due to tuberculosis bacteria resistant to at least isoniazid and
synechial (adhesions), ragged outline of tubes with rifampicin. Resistance can be primary, which occurs in fresh
multiple strictures giving ‘seculation’ or ‘diverticulation’ cases not previously given antitubercular treatment,
of a beaded appearance, pipe like tubes, terminal because of infection by resistant organism which indicates
hydrosalpinx, tubal or ovarian and peri-intravasation past-program failure. The resistance can also be acquired
aortic and iliac lymph node calcification and venous and which occurs in cases who are already receiving treatment.
lymphatic intravasation (Kleen Associates 1976). This is an indicator of current program weakness. MDR TB is
7. Urine examination and intravenous pyelograph can be treated by second line antitubercular drugs given in Table
done in patients giving history suggestive of renal 38.2 aminoglycoside, ethionamide, prothionamide, ofloxacin,
disease, as about 10% cases of genital tuberculosis also ethambutol with or without cycloserine or PAS are given for
have renal tuberculosis. 3 months daily (intensive). In the continuation phase
8. Vaginal cytology may be helpful in cervical tuberculosis. ethionamide, ofloxacin, ethambutol with or without
9. Sputum examination is performed on 3 consequent days, cycloserine or PAS is given for 18 months (Table 38.2) shows
if there is productive cough. dose and side effects of drugs used in MDR TB.
10. In case of tubo-ovarian masses computerized tomography
(CT) and magnetic resource imaging (MRI) may be rarely
requied for further evaluation. Table 38.1: Showing first line antitubercular drugs
11. Test all tuberculosis patients for HIV. and adverse effects
12. Laparoscopy: If other less invasive tests do not give results Drug Dose Daily adult Adverse effects
in a clinically suspicious patient, diagnostic laparoscopy mg/kg dose (mg)
and aspiration of any fluid present and directed biopsies /BW
can be done. This is not free of hazards as bowel INH 05 30 0 Hepatitis, raised liver
adhesions may be present which make trocar entry enzymes, peripheral
dangerous. During laparoscopy can see bilateral neuritis
occlusion; at the ampullary region with diverticuli. There Rifampicin 10 450-600 Orange discoloration of
may be nodules scattered on the fallopian tubes and secretions, nausea,
uterine surface. There may be limited spill due to partial vomiting, febrile
closure of fimbrial end. reactions hepatitis,
purpura
To sum up, diagnosis of genital tuberculosis should
Pyrazina- 30 1500–2000 Hyperuricemia
be based on either one culture positive specimen or mide hepatotoxicity
histological evidence of tuberculosis or strong clinical Etham- 12– 25 750–1000 Optic neuritis, skin
evidence consistent with active genital tuberculosis. butol rash
Strepto- 20 – Ototoxicity,
Treatment mycin (not
Antitubercular chemotherapy is the mainstay of the recommen-
ded in preg-
treatment. Genital tuberculosis is included in category I of
260 WHO classification ethambutol, isoniazid, rifampicin and
nancy)
 Table 38.2: Doses and adverse effects of second line abdominal hysterectomy with bilateral salpingo oopho-
antituberculosis drugs rectomy is indicated. In young women conservative surgery
in the form of adhesiolysis can be done after counseling the
Drug Daily adult Dose Adverse drug patient. Preservation of uterus and ovaries can make future
dose (max) mg/kg reaction; IVF treatment feasible for these patients. Tuboplasty operations
drug reaction for infertile women with blocked tubes due to proven tubercular
Ofloxacin 400 mg BID 8 – 10 Abdominal distress salpingitis should be avoided. There is a risk of reactivation of
Ciprofloxacin 750 mg BID 15 – 20 Headache, anxiety dormant infection in these cases. Besides, partial opening of
Sparfloxacin 400 mg BiD 8 – 10 Tremulousness tubes pose a very serious risk of ectopic pregnancy. In any
Kanamycin 1 gm/0.75 gm 15 Vestibular case of tuberculosis start antitubercular treatment for at least
Capreomycin 1 gm/0.75 gm 15 Vestibular 3–6 weeks prior to surgery to prevent sinus or fistula formation.
Amikacin 1 gm/0.75 gm 15 Auditory

Chapter 38
Cycloserine 250 mg 15 Seizures, psychosis, Future Pregnancy
BID or TID impaired cognition Tuberculosis of the genital tract affect the fallopian tube and
Ethionamide 250 mg 15 Abdominal distress affect endometrial receptivity. The chances of achieving
BID or TID diarrhea pregnancy are dismally low with only 5% of patients
Prothionamide 250 mg BID 15 Anorexia and conceiving unless diagnosed and treated in very early stage.
metallic taste Furthermore, there is higher incidence of pregnancy losses
Para-amino 10–12 gm 200 Gastrointestinal
and ectopic pregnancy making the live birth rate even lower.
salicylate (PAS)

Genital Tuberculosis
The women desirous for an issue should be directly referred
Roxithromycin – 9–10 Gastrointestinal
for an IVF program or counseled for adoption.
Azithromycin – 9–10 Gastrointestinal
Clarithromycin – 15–16 Gastrointestinal
BIBLIOGRAPHY
Clofazimine 100-200 4–5 GIT and skin
Rifabutin 450 – – 1 . Arora R, Arora R, Arora VK. Female Genital Tuberculosis – Need
for more research. Int J Tub 2003;59:9.
2 . Arora R, Rathore A. Female Genital Tract Tuberculosis in
“Practical approach to tuberculosis management” editor VK
Patients who are more susceptible to MDR TB are those Arora, Jaypee Brothers;2006.pp.113-9.
who have history of contact with MDR TB case, irregular 3 . Bastian I. Current thinking on the management of tuberculosis.
treatment, patients with low resistance, HIV infection, patients Rick Stapledon and Robert. Current opinion in pulmonary
on steroid therapy and with malignancies. medicine;2003.pp.186-92.
4 . Drobniewski F, Balabanova Y and Cober R. Clinical features,
Surgical Management diagnosis and management of multiple drug resistant tuberculosis
since 2002 curr opinion pulm med. Lippincott Williams & Wilkins
Before the era of effective chemotherapy, surgical treatment 2004;10:211-7.
was instituted in several cases. Surgery in these cases 5 . Klein TA, Richmond JA, Mishell Dr Jr Pelvic Tuberculosis Obstet
carries a lot of risk due to dense adhesions without a plan of Gynaecol 1976:48:99.
cleavage with the bowel and the omental adhesions to the 6 . Marterns G. In pelvic inflammatory disease in Telinde’s Operative
peritoneum and pelvic organs. Long term complications Gynaecology. 9th edition 2003 Lippincott Williams & Wilkins.
include fistula formation and persistant draining sinuses. A 7 . Schaefar G. Female genital tuberculosis. Clin Obstet Gyanecol
case of tubercular vesicovaginal fistula was diagnosed and 1976;19:223.
8 . Sutherland AM, Mac Farlane. Transmission of genitourinary
successfully treated by medical treatment in our depart-
tuberculosis. Health Bull (Edinb) 1982;40(2):87-91.
ment. However, today the role of surgery is limited. The 9 . Sutherland AM. Postmenopausal tuberculosis of the female
indications of surgery are persistence of tubo-ovarian masses genital tract. Obst Gynaecol 1982;59:545.
or pelvic pain inspite of 6 months of antitubercular treatment. 10 . Varma TR ‘Genital Tuberculosis and subsequent fertility’. Int
In older patients who have completed their families, a total Gynaecol Obstet 1991;35:1-11.

261
 Section 8 General Principles of Gynecology

39 Screening for Gynecological Cancers

Veena Singh, Sudha Salhan

Definition 2. The woman should not be menstruating at the time of Pap

Screenings for gynecological cancers involve testing of test.
asymptomatic population to detect precancerous lesions or very 3. Intravaginal antibiotics or antifungal agents should be
early stages of cancer where treatment is feasible to bring about stopped one week before the test.
reduction in incidence and mortality from the disease. World 4. Pap test should be done before bimanual examination.
Health Organization (WHO) has laid down certain criteria for 5. A minimum amount or no lubricant should be used before
any screening program. These criteria are: Pap test.
1. The disease should be an important public health problem. 6. Acetic acid should not be applied before Pap test.
2. Biological behavior of the disease should be clearly and
adequately understood. Methods Used to Obtain Cervical Smear
3. The disease should be present in latent or early symptomatic Two methods are:
stage where suitable screening test or examination is available. 1. Conventional cytology
4. Screening test should be acceptable to the population. 2. Liquid-based cytology.
5. Facilities for early diagnosis and treatment exist. After visualizing the cervix a wooden
6. An agreed healthy policy should be present on whom to Ayre’s type of spatula is used to take a cervical scrape (Figs
screen. 39.2A and B). The spatula should be rotated twice through 360°
7. Cost of diagnosis and treatment should be economically around the cervix with firm pressure. A cyto-brush (Fig. 39.3)
balanced. should be immediately placed in the external os, rotated 360°
8. Diagnosis and treatment should be a continuing process and then withdrawn. Cells obtained with the spatula and
and not a once for all project. cytobrush should be spread on the same slide. The slide should
Screening for cervical and breast cancer satisfies the WHO immediately be fixed by putting it in 95 alcohol or by using
criteria for screening. Screening for high risk population for spray fixative. After proper labeling, the slide should be sent to
ovarian cancer can also be attempted. For other gynecologic the cytopathology laboratory for staining and evaluation.
sites such as vagina, vulva, fallopian tubes and corpus uteri,
screening is not feasible as per WHO criteria.

SCREENING FOR CERVICAL CANCER

Cervical cytology: Cervical cytology involves evaluation of cells
obtained from cervix and was first proposed by Dr Papanicolaou
in 1940. From time to time different sampling sites were used to
obtain exfoliated cells for examination. The most ideal and the
most frequently used site is the s uamocolumnar junction of
the cervix (also called the transformation zone) along with the
endocervical canal (Fig. 39.1). The other two sites used are the
vaginal pool smear, and the vault smear, the latter being used
for hysterectomised patients. The choice of the sampling site is
biologically and clinically relevant as it affects the adequacy of
the smear significantly. As most of the cervical cancers arise within
the transformation zone, scraping of the squamocolumnar
junction provides adequate and the most appropriate cell
material. Ade uacy of the cervical smear is judged by the
presence of endocervical cells from the endocervical canal.
Vaginal smears, on the other hand, involve collection of exfoliated
cells from the vaginal pool and do not involve scraping.

Methods to Obtain an Optimal Pap Smear

Prerequisite to Obtain a Pap Smear
1. The woman should not douche, engage in wash her vagina Fig. 39.1: Showing squamocolumnar junction (transformation zone)
or coitus for 2 hours before obtaining the specimen. with multiple nabothian follicles (X10) (colposcopic view)
 Terminology of Cytologic Reports
After staining, the slides are evaluated by the cytopathologist.
Reporting is done utilizing one of the three terminologies given
below.
1. Papanicolaou classification.
2. WHO classification.
3. Bethesda system.
The comparative features of the three classification are
depicted in Table 39.1.
At present the Bethesda System is most extensively used to
categorize the normal and abnormal cytological changes for
reporting (Figs 39.4A and B).

Chapter 39
Accuracy of Pap Screening
Pap smear screening has proved to be effective in reducing the
Figs 39.2A and B: (A) Visualization of cervix; (B) Scraping
of transformation zone by Ayre’s wooden spatula
incidence of cervical cancer in developed countries, but its
accuracy was never tested adequately. The accuracy of any
diagnostic test is assessed by its sensitivity and specificity.
Sensitivity of a test indicates the proportion of true cases (as

Screening for Gynecological Cancers

confirmed through gold standard) detected by the test.

Fig. 39.3: Cytobrush

Recently, liquid-based cytology has been

introduced for cervical cytology screening. The sample is
obtained from the cervix in the same manner as in conventional
cytology. Either an Ayre-type spatula and a cyto-brush or new
collection devices such as cell brooms are used. The sample is then
transferred to a vial containing a liquid preservative fluid. This
removes the blood, mucus and inflammatory cells. The sample is
then sent to the cytology laboratory where a slide is prepared.
Two methods are currently available.
i. ThinPrep test: A filter method is used to collect a monolayer
of epithelial cells from blood, mucus and inflammatory
debris. The suspended cells are then gently sucked onto
the filter membrane and the filter is pressed onto a glass
slide to form a thin monolayer and then it is stained.
ii. Autocyte prep: A density centrifugation method is used to
enrich for epithelial cells and reduce blood and
inflammatory cells. Automated computerized image
processor eliminates 25 of most likely negative smears
and the remaining 75 are selected for the cytotechnician.

Advantages of Liquid-based Cytology

over Conventional Cytology
• Increased number of satisfactory samples
• Increased detection of SIL (Squamous intraepithelial lesion).
• Residual cellular material can be used for a variety of Figs 39.4A and B: (A) Low grade SIL (HPV infection); (B) High grade
molecular test such as reflex HPV DNA testing. SIL (Severe dysplasia) Pap smear

Table 3 .1: Comparison of Papanicolaou, HO and Bethesda cervical cytology terminology

Papanicolaou O System Bethesda System

Class I Normal Within normal limits
Class II Atypical Benign cellular changes (or) typical squamous cells
of undetermined significance
Class III Dysplasia Squamous epithelial cell abnormality
– Mild dysplasia Low-grade intraepithelial lesion (SIL)
– Moderate dysplasia High grade SIL
– Severe dysplasia High grade SIL
Class IV Carcinoma in situ High grade SIL
Class V Invasive squamous cell carcinoma Squamous cell carcinoma
Adenocarcinoma Adenocarcinoma
263
 Specificity is indicated by the correctly detected true negatives cumulative incidence by about 45 . With the availability of
(as confirmed by gold standard) by the test system. Pap smear more resources, frequency of screening could be increased to a
is not found to be a very sensitive test though the specificity is decadal screening, i.e., every 10 years.
quite high. The sensitivity of this test in detecting cervical intra- For women older than 30 years, are appropriate screening
epithelial neoplasia (CIN 2–3) ranged from 70–80 and its is cytology combined with HPV DNA testing. If both are
specificity is 95–98 in developed countries, but in developing negative the patient is low risk and rescreen every 3 years.
countries the sensitivity drops to 47–62 whereas the specificity
ranged from 60–95 . Evaluation of Abnormal Pap Test Patients
The low sensitivity may be due to: Pap test showing abnormalities such as high grade squamous
intraepithelial neoplastic cells (HSIL) and malignant cells should
Sampling errors: A distinct sample to sample variation is be followed by colposcopic examination and directed biopsies
observed regarding number of cells per smear. Specimens if needed. Low-grade squamous intraepithelial lesions (LSIL),
General Principles of Gynecology

collected from an inappropriate site or by the inade uately if associated with infections should first be treated with
trained personnel invariably result in an inadequate sample. antibiotics. Pap test should be repeated after three months and
Cells collected from the vaginal pool give highly unsatisfactory if the cellular abnormality persists, the woman should be
results. On the other hand use of a wooden spatula (Ayre’s subjected to colposcopy and directed biopsy.
spatula) designed to scrape transformation zone gives the best Another approach for managing LSIL could be to triage with
results. Sampling the endo cervical canal by means of an high-risk HPVs (HR-HPV). Those LSIL without accompanying
endocervical brush also reduces the false negative rates. The HR-HPV infection could be left untreated. The LSILs positive
number of endocervical cells and the yield of HSIL is higher for HR-HPVs need to be properly evaluated through colposcopy
when a cytobrush is used rather than a saline moistened cotton and directed biopsy.
tip applicator. The Bethesda system identifies a proportion of
The quality of the smear may also show deterioration because cellular abnormalities called atypical s uamous cells of
of air drying effect or due to blood in the smear. Rapid fixation undetermined significance (ASC-US). Three approaches are
of cells prevents artifactual changes secondary to air drying. available for evaluating these abnormalities. The screening
Laboratory errors: Two types of errors can be made in the algorithm is given in Flow chart 39.1.
laboratory resulting in low sensitivity of Pap test: 1. Repeat smear after 3 months.
i. Screening error When the diagnostic cells present in the 2. Perform colposcopic examination and do directed biopsy.
smear were missed either due to small quantity or due to 3. HPV triage.
poor quality of the cells. landular cell abnormality: Four categories are identified
Section 8

ii. Interpretative error This could be because of the in Bethesda system in 2001 viz. (i) atypical glandular cells
misinterpretation of diagnostic cells by either over- (AGC), (ii) atypical glandular cells-favor neoplastic, (iii)
diagnosing or under-diagnosing. endocervical adenocarcinoma in situ (AIS) and (iv)
To overcome these deficiencies, strict quality control measures adenocarcinoma. The endocervical canal can be further
should be followed in the cytology laboratories. visualized by endocervical retractor (Fig. 86.33). Further
The various steps taken for quality assurance should include: colposcopic evaluation is required.
i. Proper upkeep of laboratory instruments, reagents, etc. Visual screening (Visual Inspection) of cervix: For
ii. Adopting a uniform approach of reporting cervicovaginal developing countries such as India, cytology screening is not
smears (Bethesda classification). possible because of unavailability of cytology services and
iii. Either 10 random re-screening or 100 rapid re- management facilities. Visual screening is one potential
screening of negative smears by cytopathologist. approach, could make cervical cancer screening more available
iv. Confirmation of all positives by cytopathologist. in low resource settings. It could be (i) Unaided visual
v. Mixing known positives periodically amongst the inspection, (ii) Aided visual inspection. This is called down
unknown slides to assess the efficacy of screeners. staging.’
Flow chart 39.1: Screening algorithm
vi. Re-training of screeners through various teaching pro-
grams like conferences, CMEs and symposiums.
vii. Cytohistological correlation should be done.

Eligibility of Cervical Screening

American College of Obstetrics and Gynecology has issued new
guidelines for screening of cancer cervix (2 ). All sexually
active women start screening at 21 years followed by Pap smears
every 2 years till 30 years. After 3 consecutive negative smears
the frequency is reduced to every 3 years. Women with HIV or
a weakened immune system in utero DES exposed women get
screened every year. This stands also for patients with previous
cervical abnormalities. If there are 3 negative Paps in the
previous 10 years one can stop screening at age 65–70 years.
Women vaccinated against HPV should follow the same screening
guidelines as unvaccinated women according to the revised
guidelines.
In developing countries where there is extreme paucity of
trained cytologists, the recommendation is once in a lifetime
screening after the age of 35 years. It is expected to reduce
264
Unaided Visual Inspection
Unaided visual inspection of the cervix has been tried in our
country as a measure to detect early cancers (case detection
approach) in women. The cervix is visualized using a speculum
and a good light source. Certain high risk criteria for detecting
early staged cancers are cervical ectopies that bleed on touch,
small growths, and suspicious looking cervices. Unaided visual
inspection is an important step to diagnose frank cancerous
lesions which sometimes may be missed after using acetic acid
application.

Aided Visual Inspection

Chapter 39
Aided visual inspection-based screening is currently being
evaluated as a potential alternative to conventional cytology in
the early detection of cervical neoplasia in developing countries.
Different methods are:
a. Visual inspection of aceto-white area (VIA)
b. Visual inspection of aceto-white area after using low level
magnification (VIAM)

Screening for Gynecological Cancers

c. Visual inspection using Lugol’s iodine application (VILI).
3–5 Acetic acid
application is used to identify abnormal areas as aceto-white
squamous epithelium. It produces an osmotic dehydration of
squamous epithelial cells and reversible coagulation of nuclear
protein. Abnormal epithelium contains increased nuclear
activity and DNA contents. A positive test is defined as the
detection of well defined dull aceto-white (AW) areas leading
to early diagnosis of HSIL and early-stage cancer. (Fig. 39.5)
The sensitivity of VIA varied from 49 – 86 in these studies.
The estimates of these results are comparable with that of
cervical cytology. A high rate of false positivity would result in Figs 39.6A and B: (A) Normal squamous epithelium (VILI-Negative);
unnecessary referrals for colposcopy and biopsy and over (B) Dysplastic epithelium:Non-stain areas on Posterior lip (VILI Positive)
treatment in many cases.
It has been observed in studies that VILI had a significantly
Low level higher sensitivity than VIA in detecting HSIL but the specificity
magnification is used for better visualization of Aceto-white is similar.
changes. The results of various studies did not show any
improvement in the test performance over and above that of Cervicography: Cervicography is a method of detecting
naked eye visualization of aceto-white areas of cervix. cervical lesions using the same principle as Colposcopy and
can be used as a screening method in the population. Two
VILI, photographs of the cervix are to be taken using a specially
similar to the Schiller’s iodine test of the 1930s, involves naked designed camera after application of 3–5 acetic acid. The
eye examination of the cervix to identify mustard yellow iodine film (cervicograms) is developed as 35 mm slides and are
uptake areas after application of Lugol’s iodine. Normal projected and interpreted by experienced reviewer even in
squamous cells contain glycogen which takes up iodine and remote areas. The sensitivity of this method is as high as 89
becomes mahogany brown, while abnormal areas remain but it has a low specificity.
unstained (Figs 39.6A and B). Speculoscopy and spectroscopy are the two screening
methods which are at various stages of development and are
still experimental.
The advantages of visual screening techniques are easy to
perform and brief training of paramedical personnel, less time
involved in examination, and prompt evaluation of the lesion.
As compared to cytology examination, it does not require
repeated visits of the patients. A new concept of See and treat
approach is being tested in remote areas of Asia and Africa.
This approach involves direct treatment of aceto-white lesions
even without resorting to histologic examination. This method,
however, cannot be recommended where moderate health
facilities are available.
HPV Screening: Persistent infection with certain oncogenic
types of HPV has been clearly established as the primary cause
of cervical cancer. This has led to the evaluation of HPV testing
as a screening tool, either as an adjunct to cytology or as a
primary screening method to detect cervical precancer and
Fig. 39.5: Positive VIA test cancer. 265
 Different HPV tests are used Hybrid Capture I, Hybrid Electro-optical techni ue: It is a new technique of
Capture II and PCR (Polymerase chain reaction). screening for carcinoma of the cervix which cause minium
All HPV positive cases should be referred for colposcopic discomfort and gives immediate results. It is a real time
examination. Where colposcopy reveals a lesion consistent with optoelectronic device also called the polar-probe or true screen
precancerous and cancerous lesions of cervix it should be (Fig. 39.15). It has a pen-shaped probe or hand piece with a
colposcopically directed biopsied. Biopsy proved lesions should flating. It is connected to the console (which has a computer-
be appropriately treated. based expert system—a software-implemented classifier) with
The HPV test, however, suffer from a prohibitively high a flexible cable. The probe scans the cervix. The probe delivers
cost, which may have impedance in the implementation in de- low level electrical pubes and optical signals to the cervical
veloping countries. In young patients with transient HPV in- tissue. The response is compared algorithmically in real time
fection, it causes great anxiety. Hence must be done after the to that stored as data base of cervical tissue type. The results
age of 30 years only. are classified into normal, low grade abnormality and
General Principles of Gynecology

The advantages and limitations of different screening, meth- cancer or high grade abnormality. The results are given
ods for cancer cervix are given in Table 39.2. then and there. Hence, it is low technology for operation
and there is no need of expert physician. The hand set is
COLPOSCOPY disinfected in 2 (glutaraldehyde solution). Put in a Cusco’s
Hinselman introduced it in 1925 (Fig. 39.7). It is considered as speculum and visualize the cervix. Place gently the probe in
adjunctive technique to cytology for investigation of genital tract contact with cervix and methodically reposition till whole of
malignancies (cervix, vagina and vulva, etc). It gives a the endocervix and evered position of exocervix is covered in
magnification of 8–18 times. A green filter accentuates the one or two minutes. Fourteen tissue measurement are
vascular pattern. In the cervix we focus on the transformation automatically performed per second. At the end a summary
zone. The common abnormal findings include aceto-white printout of the screening result is given the method has great
lesions, punctation, mosaicism, atypical vessels, etc. A directed potential in screening positive patients by sending for
biopsy can be more precise (Figs 39.8 to 39.14). colposcopy.

Table 3 .2: Advantages and limitations of different screening methods of cancer cervix
Different screening methods Advantages Limitations
Cytology-based 1. Considerable experience worldwide 1. Only successful in high resource settings,
Section 8

screening in its use. where organized screening programs can be

2. Only established screening test for cervical implemented. In our country no such
facilities are available.
cancer has been shown to reduce the incidence
2. Has overreliance upon reproductive health
and mortality of the disease. services where women covered are usually
too young.
3. Low sensitivity compared to other screening
methods. Liquid-based cytology (LBC) has
been used to improve sample accuracy and
sensitivity. Because of its heavy cost LBC
screening is not feasible in low-resource
setting like our country.
4. Paucity of trained health care professionals
and uality control measures are the main
barriers to the success of cytology-based
screening programs in developing
countries.

1. This test has low specificity which may lead

to unnecessary referrals for colposcopy,
biopsy and overtreatment in many cases.
Visual examination of 1. It is a simple, inexpensive technology 2. Inherent difficulties in identifying
aceto-white cervix (VIA) that requires minimal infrastructure endocervical disease. Thus, VIA has limited
screening for use. use in postmenopausal women.
2. Sensitivity of this test appears to be similar to 3. The training methods competency
that of conventional cytology. evaluation has yet to be standardized.
3. Short period (1–2 weeks) is required to train
the workers (Paramedical staff). 1. High cost of the test.
4. It is a real time test because the test results are 2. Depends upon the reagents currently
available immediately. produced by a single commercial
5. See and treat method is possible in this test. manufacturer.
3. Low specificity in younger women owing to
HPV-based screening 1. HPV-based testing has higher sensitivity and a high level of transient—HPV infections.
objectivity of the test.
2. There are standard levels of quality and in-
built quality control procedures.
3. Identifies women at risk of developing cervical
neoplasia within the next 3–10 years.
266
 Chapter 39
Fig. 39.7: Colposcope Fig. 39.9: Atypical vessels (X16) (Colposcopy)

Screening for Gynecological Cancers

Fig. 39.8: Leukoplakia (Hyperkeratosis) of the cervix (X16) Fig. 39.10: Dense raised aceto-white epithelium (X6)
(Colposcopic view)

Fig. 39.11: Normal colposcopy (X6) Fig. 39.12: Low grade disease (CIN with HPV infection) (X10)

Optical coherence tomography: It is an imaging modality advanced stage. Survival is not only stage dependent but also
that uses non-invasive harmless infrared light to create high grade dependent. Women having bloating, pelvic/abdominal
resolution, real time in vivo images of soft and hard tissues. It is pain, difficulty eating or feeling full quickly or urgency or
used in cases of suspicious lesion of cervix and vulva. frequency of urination may be early symptoms of ovarian
malignancy. Hence, a history is very important.
SCREENING FOR OVARIAN CANCER The available screening test such as pelvic ultrasound serum
In ovarian cancer, the premalignant conditions progressing to CA-125 levels and pelvic examination suffer from poor specificity.
invasive cancer have not been defined, the preclinical phase The different screening tests have been evaluated in many
remains asymptomatic and thus a woman presents at an individual and population-based studies. 267
General Principles of Gynecology

Fig. 39.13: Higher grade lesion with dull opaque aceto whitening (X6) Fig. 39.14: Cauliflower growth in invasive cancer

the postoperative period to measure response to treatment and

progression of the disease.
Multimodal Screening; (Combined Pelvic examination,
CA-125 serum measurement and trans-vaginal ultrasound):
Results from an ongoing NCI (National Cancer Institute)
supported multicentric trial evaluating the utility of transvaginal
ultrasound and serial CA-125 measurement in 74000 women
who have been randomized to either pelvic examination with
CA-125 measurements and pelvic ultrasound or annual pelvic
examination without CA-125 or ultrasound evaluation.
Section 8

In short currently available screening techni ues are not

cost-effective for the general population and have not proven
to be effective in reducing disease-specific mortality.
Fig. 39.15: Electro-optical technique Screening is highly recommended in high risk patients who
have personal or family history of ovarian cancer, breast, and
certain other genetic cancers. However, this group represents
Pelvic Examination: Although the pelvic examination should less than 10 women with ovarian cancer, so current screening
be included in every annual physical examination, studies have efforts are applied to a small minority of women at risk.
shown that it is not extremely effective in diagnosing adnexal
masses. Pelvic examination alone is a poor screening test for SCREENING FOR BREAST CANCER
ovarian cancer because of the inability to detect cancer prior to Cancer of the breast accounts for approximately 10 of all breast
extra ovarian spread in most cases. diseases presenting at the clinics. Screening of breast cancer
Ultrasonography: (Fig. 39.16) Transabdominal ultrasonography
can be used as a screening procedure which is easy to perform
and has good patient acceptability. Though it is a sensitive
technique to diagnose ovarian mass, its specificity as a routine
screening procedure has not been sufficiently established.
Although the use of transvaginal ultrasound in
postmenopausal women yielded more favorable results (only
16 laparotomies to diagnose ovarian cancers), the number of
false-positive was still too high.
Currently coupling Doppler Color Flow imaging with
transvaginal ultrasonography (TVS) has been shown to improve
the accuracy of sonography and to reduce the high false positive
results.
CA-12 : CA-125 is a high-molecular weight glycoprotein which
is recognized by a monoclonal antibody (OC-125). It can detect
only in of stage-I, 60 of stage II and 83 of advanced
ovarian cancers. In addition, CA-125 is also elevated in a
percentage of normal or pathological conditions such as pelvic
infection, endometriosis, pregnancy, menstruation, etc. Due to
this fact this test is not very specific.
The real value of this tumor marker is to use it in Fig. 39.16: Bilateral ovarian carcinoma
268 postmenopausal women having a pelvic mass particularly after (Transvaginal sonography)
should be aimed to detect preinvasive lesions such as ductal
carcinoma in situ (DCIS), Lobular-carcinoma in situ (LCIS) or
early stage breast cancers that have the potential to be cured
with limited treatment. The various screening tests are:
i. Self-breast examination
ii. Clinical breast examination by healthcare professional.
iii. Screening mammograms.
Self-breast examination: It is done by the woman herself to
check her breasts for any change (lumps) or thickening which
may signal breast cancer (Fig. 39.17). By regular breast self-
examination 90 of all breast masses can be detected, out of

Chapter 39
which 80 are not cancerous. Breast self-examination should
Fig. 39.18: Dense shadow of breast cancer (Mammography)
be performed on a monthly basis especially three to five days
after menstruation in premenopausal women whereas in
1. Baseline mammogram at age 40 years
postmenopausal women it should be performed on a fixed date
2. Between ages 40 and 50, a mammogram yearly or every
of each month. Data suggested that though breast self-
other year
examination can detect 10 of malignant breast disease, it does
3. At age 50 or older, a mammogram yearly
not decrease overall mortality rates.
The breast cancer detection demonstration project (BCDDP)

Screening for Gynecological Cancers

Clinical examination: Routine regular clinical breast showed that the most effective combination in decreasing the
examination by various health care professionals have shown incidence of invasive disease is the clinical breast examination
an important role in early detection of breast cancer. Any and mammography. The sensitivity of clinical breast
retraction, bulging of the breast tissue, skin edema, peau d’ examination and mammography together was 70 to 80 , with
orange or erythema should be observed. The nipples should be even increased sensitivity in older women. 3D mammography
examined for crusting, bleeding, irregularity or retraction. is more accurate.
Palpation should include thickening, nodules or induration Mammography is the only tool which has been shown to
of the breast skin followed by firm and gentle palpation of both reduce mortality from breast cancer at the population level.
breasts in their entirety. Either a concentric circular or radial Mammography, however, cannot be recommended as a public
search pattern is effective. Palpation should extend to the health measure in finding because a large proportion of women
clavicle, to the sternum, to the lower rib-cage and into the axilla with breast cancer are pre-menopausal in whom mammography
in which much breast tissue is located especially in older is not as sensitive as in postmenopausal women due to dense
women. Documentation of any abnormalities should include breast in tissue of the young women. Mitra et al, from TMH,
size, location, mobility and character. Bombay have shown that a tumor of 3 cm can reasonably be
Final examination includes supraclavicular region and both well-palpated by trained paramedical workers and detecting
axillae for nodal involvement. The axillae are best examined such a mass world reduce mortality from breast cancer by 55 .
with the physicians supporting the flexed arm with one hand, Recently, use of digital mammography, MRI (magnetic
palpating with the other. resonance imaging), optical scanning, ductal lavage for
It is recommended that average-risk in asymptomatic cytology’s, molecular tests, nipple aspirates, blood and urine
women in their 20s and 30s have clinical breast examination assays for growth factors, auto-antibodies to onco-proteins and
performed every three years. Asymptomatic women aged 40 tumor DNA are being evaluated for the enhancement of primary
years and older should have clinical breast examination and secondary prevention. Position emission tomography is
annually. being used for screening in some studies.
Screening mammograms (Mammography) (Fig. 3 .18):
Mammography is done with -rays to take pictures of breast- ENDOMETRIAL CANCER
lumps which are not clinically felt (non-palpable lumps). Because of identifiable symptoms (bleeding per vaginum), the
According to the American Cancer Society mammogram diagnosis can frequently be made in early stages with excellent
screening should be done as follows: (83 ) overall survival.
Any vaginal bleeding determined by physical examination
to be of uterine origin requires an endometrial biopsy in woman
over age 40.
Routine screening for general population is not
recommended. However, it is highly recommended in high-
risk patients. Most current practices reserve transvaginal
ultrasound, hysteroscopy and directed biopsy for women with
symptoms. Other modalities include saline infusion sonography
is better than ordinary ultrasound.
Surveillance of patients on tamoxifen therapy remains a
diagnostic dilemma. The options, range from educating the
women regarding symptoms to semi-annual clinical
examination, transvaginal-ultrasound, periodic endometrial
diagnostics hysteroscopy if possible with directed biopsy
sampling, and progesterone withdrawal testing. Pap smear may
also help sometimes.
The American Cancer Society suggests that all women at
Fig. 39.17: Self-breast examination menopause should be informed about the symptoms of 269
 endometrial cancer and strongly encouraged to report any menstural cycle and burning micturition must be closely
unexpected bleeding or spotting. Ultrasound showing scrutinized. Colposcopy of the suspicious area with 5 acetic
endometrial thickness more than 5 mm in postmenopausal acid (flooded for a longer time 20–30 mm) (as vulval skin is
women needs further confirmatory tests. Transvaginal keratinized stratified squamous epithelium). Aceto-white area
ultrasound in postmenopausal women showing endometerial along with normal area is biopsied. Toluidine blue smear also
thickness of 5.15 mm and more to 80.5 sensitive and 86 highlights the pathological area for biopsy.
specific for cencer or atypical hyperplasia.
TUMOR MARKERS IN GYNECOLOGY
VAGINAL CANCER
Definition: The term tumor markers is not yet well- defined.
Vaginal cancer is rare and in primarily a disease of old age In broad terms we can take it to mean any identifiable change
group. Vaginal cancer is frequently found as synchronous or in a body component that is indicative of the presence of cancer.
metachronous neoplasm of cervical cancer. This has led to the
General Principles of Gynecology

suggestion that there may be shared etiologic features between An ideal tumor marker should:
vaginal and cervical cancer. Other etiologic agents may be HIV 1. Secrete specifically in all specific tumors.
infection chronic irritation, immunosuppression, radiation and 2. Secrete under all circumstances when the tumor is present.
use of diethylstilbestrol exposure in utero 3. Not detected in secretions in benign disease.
Although the upper vagina is the most common site for 4. Reflects tumor status at all times. The requirement of
invasive disease, about 25 to 30 is confined to lower vagina. successful tumor marker including sensitivity, specificity
The potential risk factors identified are low socioeconomic and availability of effective treatment.
level, history of genital warts, vaginal discharge or irritation, No one tumor marker is ideal.
previous abnormal Pap smear, early hysterectomy and vaginal The first large sole use of markers was morphological viz.
trauma. Rare occurrence of vaginal adenocarcinoma in young cytology (Pap smear). It is useful for tumors which or are either
women is essentially an iatrogenic disease related to in utero exfoliate to the surface in blood or lymph forming tissues. But
exposure to diethylstilbestrol and other estrogens. in most other tumors (e.g. ovarian) a biochemical approach is
Abnormal vaginal bleeding, which may occur as more practical. Hence, the focus is on markers detected in the
dysfunctional bleeding or postcoital spotting is the presenting blood or body fluids. Tumor markers can be employed for
symptom in 50–75 of patients with primary vaginal screening–
carcinomas. • Risk assessment
Vaginal cancer does not ualify to be a suitable candidate • Diagnosis
for gynecological screening programs because of its rare • Prognosis, and
Section 8

incidence, multiple etiologies, etc. However, women with • Monitoring.

cervical cancer or precancerous cervical lesions need to be put For screening the marker not only gives an indication
under surveillance for detection of concurrent or subsequent of the presence of cancer but also sometimes its site of
vaginal cancer or vaginal intraepithelial neoplasia (VAIN). origin.
To date, no tumor marker has been shown to be specific (no
VULVAR CANCER false positive) and sensitive (no false negative) enough to be
Carcinoma of the vulva is a rare genital neoplasm which occurs used in the detection of asymptomatic tumors in the general
primarily in older women. Cancers of the vulva occurs population. However, in the case of highly suspicious history
significantly more frequently among women with primary and examination findings they may have a role.
cancers of the cervix. Frequently approximately 15–20 women Risk assessment: Tumor markers have a role in hereditary
with vulvar cancer have a second primary cancer occurring or family history of malignancies like BRCA.
simultaneously or non-simultaneously in the cervix, vagina or Diagnosis can be guided by tumor markers but needs organ
anogenital area. If the multiple primaries are not diagnosed or histology proof.
simultaneously, cancer of the cervix usually precedes cancer of Prognosis can be given by DNA ploidy, monitoring—
the vulva. Many patients with vulvar cancer have multiple currently tumor markers have a major role in monitoring
genital lesions, commonly including a mixture of acumina treatment.
condyloma planum and intraepithelial neoplasia. They may Tumor associated antigens are nonspecific markes that are
have similar changes at another anogenital site. frequently elevated in some malignancies. Most common is Ca-
No cost effective screening tool is available for early 125. It is more effective in monitoring treatment than screening.
detection of vulvar cancer nor is there a need because of the An elevated Ca-125 of 30–35 units/ml along with pervaginal
low frequency of the disease. However, the following methods examination and ultrasound and family history is considered
are advocated for screening. useful. Other tumor associated antigens are Ca 15.3, Ca 19.9,
Vulval self-examination in a comfortable place, which is Ca 195, cancer associated serum antigen (CASA), HER-2/NEU,
well-lighted as toilet or shower. Hold a mirror in one hand. Human milk fat globule membrane antigen 1 and 2, inhibin
Look for a mole, wart or growth which of any kind, a new area (granulose cell tumor), lipid-associated sialic acid in plasma,
of hyperpigmentation viz. black for melanoma. Any ulcer or nonbound 70 KD. Fraction of a surface membrane glycoprotein
area of continuous pain or inflammation or itching. Any change (NB/70K) in mucinous and serous tumors) Ovx-1, Sialyl TN,
of texture of the vulval skin is to be prompty brought to the TAG-72 (mucinous tumor), urinary gonadotropin fragment-
notice of the physician. It is best performed between periods UGP (in urine of women of ovarian malignancy), other markers
once a month. may be cytokine colony-stimulating factor type 1 (CSF-1),
Optical Coherence Tomography (OCT) is a new approach soluble interleukin-2 Receptor 2 (alpha) - SIL-2Ra- seen in serum
for the early identifcation of cervical and vulval cancers. and ascitic fluid.
All suspicious lesions should be biopsied prior to treatment Oncofetal proteins as markers are a-fetoprotein (elevated
(steroid cream, etc). The patients giving history of pruritis, lump, in germ cell malignancies viz. endodermal sinus tumor,
270 mass, ulceration, pigmentation and bleeding unrelated to embryonal carcinoma, immature teratoma and polyembryoma)
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271
 40 Chemotherapy and Radiotherapy in
Gynecological Malignancies

Tarun Puri, Shikha Goyal, PK Julka, GK Rath

Cancers of the female genital tract are important for several and intensity modulated radiotherapy (IMRT) constitute
reasons. Foremost is the high incidence of such neoplasia in sophisticated techniques with a more efficient irradiation
developing countries such as ours; particularly for cancer cervix. of the volume bearing the tumor and subclinical disease
The accessibility of the genital tract to clinical examination while minimizing the radiation delivered to the surrounding
makes evaluation of gynecologic malignancies convenient. In normal tissue, thus reducing radiation-associated morbidity
developed countries, the routine use of Pap smear as a screening without compromising cure. Recently cyber knief is also
modality has led to a substantial reduction in the incidence of available at some centers (Fig. 40.1). It improves dose
invasive cervical cancers, unlike the developing countries, where conformity while significantly shortening treatment time.
most cervical cancers present in an advanced stage. Newer 2. Brachytherapy The radiation source is placed inside the body
chemotherapy agents have resulted in better outcomes for within or close to the disease site to deliver the dose at a
ovarian cancer while better radiation techniques have resulted short distance. As a result, the tissues distal to the disease
in superior outcomes for cancer of the endometrium and cervix. site are not irradiated. It is categorized into 3 types
This chapter gives a discussion of gynecologic malignancies depending on the location of the implant:
namely cancers of the cervix, endometrium and ovary, vagina a. Intracavitary—the radioactive material is placed inside
and vulva and gestational trophoblastic neoplasia. the uterine cavity or vagina.
b. Interstitial—the radioactive material is placed within the
RADIATION THERAPY tissues in the form of needles or seeds.
adiation therapy is an essential component of both the primary c. Surface application (Molds or Plaques)—the radioactive
nonsurgical management and adjuvant postoperative treatment material is placed on the surface of the tumor. This
of selected malignancies arising in the female genital tract. As a technique is not very useful in gynecological
general principle, early stage cancers can be managed with malignancies.
surgery alone. Malignancies at a high risk of local or regional Brachytherapy can be delivered at different dose rates:
recurrence are given adjuvant treatment in the form of a. Low dose rate (LDR)—0.4 – 2.0 Gray per hour (Fig. 40.2A)
radiotherapy. Primary radiotherapy can provide a chance for b. Medium dose rate (MDR)—2 – 12 Gray per hour
cure for women with locally advanced disease or for women c. High dose rate (HDR)—more than 12 Gray per hour (Fig. 40.2B)
with medical risk factors that contraindicate primary surgical d. Pulsed dose rate (PDR)—this is a different technique with
therapy. Unfortunately, for women with distant metastatic disease same dose rate as HDR, but treatment is delivered in pulses
at presentation, disease cure is unlikely. Palliative radiotherapy, for a few minutes every hour (Fig. 40.2C).
frequently, can improve a patient’s quality of life when used for
the relief of symptoms.
Two modes of radiation delivery exist:
1. Teletherapy
2. Brachytherapy
1. eletherapy The radiation source is located at a distance from
the body and the radiation beam is shaped according to the
volume that needs to be irradiated. The treatment portals
are designed to include the gross disease and the subclinical
or potential regional extent including lymph nodes. The
radiation may be delivered using a cobalt teletherapy unit
or a linear accelerator. The cobalt-60 unit houses a radioactive
source for radiation delivery and emits radiation in the form
of gamma rays for the purpose of treatment while the linear
accelerator uses a system where high energy electrons from
an electron gun are accelerated and made to strike a metallic
target to generate high energy -rays, which have variable
energies and have a higher penetrating power and thus are
useful in treating tumors situated deep inside the pelvis such
as the gynecological malignancies. The newer treatment
modalities including 3D conformal radiotherapy (3D-CRT) Fig. 40.1: Cyberknife
 Chapter 40
Chemotherapy and Radiotherapy in Gynecological Malignancies
Figs 40.2A to C: Brachytherapy treatment units. (A) LDR; (B) HDR and; (C) PDR

Most of the earlier experience with brachytherapy has been techniques; microinvasive cancers invading less than 3 mm
with LDR, but studies with HDR also have shown equivalent (stage IA1) are managed with conservative surgery (excisional
efficacy. With its shorter treatment times, better treatment conization or extrafascial hysterectomy); early invasive cancers
optimization, greater patient and clinician convenience and the (stages IA2 and IB1 and some small stage IIA tumors) are
option of out-patient treatment, HDR has gained popularity managed with radical surgery or radiotherapy; and locally
and is becoming the modality of choice in most centers. advanced cancers (stages IB2 through IIIB) are managed with
Classically, Radium-226 was used for brachytherapy and radiotherapy. Selected patients with centrally recurrent disease
most initial systems before the s were designed with radium after maximum radiotherapy may be treated with radical
as the standard, but it fell into disrepute once the radiation exenterative surgery. Isolated pelvic recurrence after
hazards associated with it became apparent. Nowadays several hysterectomy is treated with irradiation. The results of
isotopes are in use, the most popular being Cesium-13 for LDR randomized trials have led to the addition of concurrent cisplatin-
and Iridium-1 2 for HDR brachytherapy. PDR also uses an containing chemotherapy to radiotherapy for patients whose
Iridium-192 source having lower activity than the HDR source. cancers have a high risk of locoregional recurrence.
It attempts to combine the radiobiologic advantage of LDR to
the optimization and convenience of HDR. In India, All India Microinvasive Carcinoma (Stage IA)
Institute of Medical Sciences, New Delhi is the only institute Patients who have this conservative treatment must be followed
using PDR for gynecological malignancies. closely with periodic cytologic evaluation, colposcopy, and
Treatment of most gynecological malignancies requiring endocervical curettage. For patients with FIGO stage IA2, the
radiation therapy as a part of their treatment includes a recommended treatment is surgery. Patients with medical
combination of both teletherapy and brachytherapy, either problems or other contraindications to surgery can be
sequentially or in interdigitated schedules, depending on disease successfully treated with brachytherapy alone with outcomes
characteristics and stage. similar to surgery.
Image Guided adiation herapy (IG ) identify and map
more accurately, the exact area affected by the cancer. It Stage IB and IIA Disease
improves the focus and precise delivery of radiation and is best Stage IB and IIA cervical carcinomas can be treated effectively
suited for sites where internal organ motion is expected (e.g. with combined external beam irradiation and brachytherapy
cervical malignancy). Thus, reducing side effects of radiation, or with radical hysterectomy and bilateral pelvic
reduce overall treatment time, increases compliance. After initial lymphadenectomy. Overall survival range for patients treated
few treatment sittings the treatment is replanned based on the with surgery or radiation is between 80 and 85 . Surgical
tumor shrinkage (Adaptive readiotherapy). Cyberknife is treatment tends to be preferred for young women with small
image-guided device uses computer—controlled robotics to tumors because it permits preservation of ovarian function and
deliver an extremely precise dose of radiation to the tumor. may cause less vaginal shortening. Radiotherapy is often
selected for older postmenopausal women to avoid the
CANCER OF THE UTERINE CERVIX morbidity of a major surgical procedure. In 1997, Landoni and
The choice of local treatment is influenced by factors including colleagues reported results from the only prospective study
tumor size, stage, histologic features, evidence of lymph node comparing radical surgery with radiotherapy alone for stage
involvement, risk factors for complications of surgery or IB or IIA. In the surgery group, findings of parametrial
radiotherapy, and patient preference. However, as a rule, involvement, positive margins, deep stromal invasion, or
intraepithelial lesions are managed with superficial ablative positive nodes led to the use of postoperative pelvic irradiation. 273
 Although the 5-year survival rates were similar in the 2 groups,
there was a higher rate of complications in the surgery group
especially when surgery was followed by radiotherapy.
Radiotherapy after Radical Hysterectomy
The following histopathologic features necessitate postoperative
radiotherapy after hysterectomy:
1. Positive lymph nodes on histology
2. Close ( 3 mm) or positive margins
3. Deep stromal invasion
4. Vascular/ lymphatic permeation
5. Parametrial infiltration
General Principles of Gynecology

6. Bulky disease ( 4 cm diameter)

7. Carcinoma cervix inadvertently treated with simple
hysterectomy.
Some authors have demonstrated that addition of
chemotherapy to postoperative radiotherapy might be beneficial
for patients having high risk features on operative
histopathology.
Radical Radiotherapy
A combination of external beam radiotherapy to pelvis and
brachytherapy is used to sterilize the disease in the cervix,
paracervical tissues, and regional lymph nodes in the pelvis. Fig. 40.3: Standard portals (anterior-posterior, and lateral) used for
An initial course of external irradiation may improve the teletherapy in a case of cancer cervix or endometrium. The field
boundary is indicated by the white lines in the periphery, while the scale
efficacy of subsequent intracavitary treatment by shrinking
markings indicate the field dimensions in cms
bulky tumor and bringing it within the range of the high dose
portion of the brachytherapy dose distribution. It is recom-
mended that for optimal results, the overall treatment duration Brachytherapy
of external radiotherapy and brachytherapy should be less than Three basic systems have been proposed for intracavitary
8 weeks. brachytherapy of carcinoma cervix- Stockholm (1964), Paris
Section 8

External radiotherapy is delivered conventionally by a two- (1951) and Manchester (1948) systems, from which other
field (anterior and posterior) or four-field box technique systems in use today have been derived. Each system specifies
(anterior, posterior and two lateral fields). The field borders a set of rules for the source strengths, geometry, method of
are determined using an -ray or CT simulator. On the simulator application, and calculating the dose rate at specified points.
film, the superior border of the field is taken at L4–L5 junction, The Manchester system (Figs 40.4A and B) employs an
and the lower border is taken 2 cm inferior to the most inferior intrauterine source (tandem) and two vaginal sources (ovoids)
extent of the growth in the vagina. The lateral borders on the AP placed in each of the lateral fornices. A Fletcher-Suit applicator
film lie 1–1.5 cm lateral to the pelvic brim. On the lateral film, the is most commonly employed (Figs 40.5A and B). The
anterior border is taken just anterior to the superoanterior part of intrauterine tandem and vaginal applicators are positioned,
the pubic symphysis, and the posterior border cuts the S2–S3 usually under anesthesia, to provide an optimal relationship
junction posteriorly. (Fig. 40.3) between the system and adjacent tumor and normal tissues.

Figs 40.4A and B: (A) The Manchester system for brachytherapy in gynecological malignancies;
274 (B) Determination of bladder and rectal reference points
 Chapter 40
Chemotherapy and Radiotherapy in Gynecological Malignancies
Figs 40.5A and B: (A) Fletcher-Suit applicator set for HDR brachytherapy; (B) A completed HDR
intracavitary application for carcinoma cervix

Vaginal packing is done to hold the applicator in position and (Fig. 40.6 A). A line is drawn from S1-S2 junction to the top of
to maximize the distance between the source of radiation and the pubic symphysis. Another line is drawn from the center of
the bladder and the rectum. Urinary catheterization with a this line to the midpoint of anterior surface of the body of L4. A
Foley’s catheter is done prior to insertion of the applicators. trapezoid is constructed in a plane passing though the transverse
7 cc of radioopaque contrast is used to inflate the catheter bulb, line in the pelvic brim plane and the midpoint of the anterior
and the catheter is pulled down to rest against the lowest part part of body of L4. The lateral extent of the lower border lies
of the bladder. Two orthogonal radiographs are obtained with 6 cm from the midline on either side, and on the upper border,
the applicators in place—an anteroposterior and a lateral film the lateral edge lies 2 cm from the midline. The lower corners
are taken and after dose prescription, the applicators are signify the dose to the right and left external iliac lymph nodes,
connected to the radiation source and treatment delivered. and the upper corners signify the dose to the low para-aortic
Remote after loading sources are used, with minimal radiation area. The midpoint of a line connecting these points on either
exposure to the treating personnel. side estimates the dose to the common iliac lymph nodes.
The International Commission on Radiation Units and The pelvic wall reference points (Fig. 40.6B). Lower panel)
Measurements (ICRU 38) has recommended a system that represents the absorbed dose in distal parametria and the
relates to the dose distribution to the target volume in obturator lymph nodes. On the AP film, it is located at the
gynecological malignancies. The Manchester system was intersection of the horizontal line passing through the highest
designed to deliver a constant dose rate to define points near point of the acetabulum, and the vertical line tangential to the
the cervix, irrespective of structural and positional variations inner aspect of the acetabulum. On the lateral film, the highest
in the uterus and vagina, namely point A, point B, rectal point points of the acetabula are identified the pelvic wall reference
and bladder point. Classically, point A was defined as a point point is located at the mid-distance of these points.
2 cm lateral to the central uterine canal, and 2 cm superior to The reference volume, which is the volume of the isodose
the mucosal membrane of the lateral fornix, and point B as a surface that just surrounds the target volume, is set at 60 Gray,
point 5 cm from the midline, in the transverse axis through point and includes the dose contributions from both external beam
A. In clinical practice, point A is taken as a point 2 cm superior to and brachytherapy. The discretion of determining the relative
the flange of the intrauterine source (abutting external os) and 2 contribution from each lies with the treating oncologist. The
cm lateral to the central axis. Point A represents the location where maximum dose to bladder and rectal reference points should
the uterine artery crosses the ureter, and the tolerance of these be less than 80 of the dose to point A.
structures is the major limiting factor in irradiation of cervix.
The bladder reference point is taken at the center of the Foley’s Interstitial Brachytherapy
bulb on the anteroposterior film, and most posterior point on In cases when an ideal intracavitary application is not feasible,
the bulb on the lateral film on the transverse line is drawn such as unsuitable patient anatomy in the form of a short or
though the center marked on the anteroposterior film. The rectal stenotic vagina, vaginal synechiae or unfavorable tumor
reference point is a point located 5 mm behind the posterior distribution such as in lateralized lesions, endocervical tumors,
vaginal wall, in the transverse line drawn from the lower end tumors obstructing the cervical os, etc., interstitial implants are
of the intrauterine source, on the lateral radiograph. On the placed transperineally within the substance of the growth to
anteroposterior film, it is situated at the lower end of the enable irradiation of the entire tumor. The implant is placed,
intrauterine source or at the middle of the intravaginal sources. guided by a Lucite template which encourages parallel placement
The posterior vaginal wall is visualized by using a radioopaque of hollow needles that penetrate the cervix and paracervical
gauze for packing. spaces. Several commercially available templates for this
Other reference points are defined in relation to the bony procedure are available, some of which are specific to gyne-
structures according to the lymphatic trapezoid of Fletcher cological malignancies such as the Syed-Neblett template, and 275
General Principles of Gynecology

Figs 40.6A and B: (A) Upper panel. Anteroposterior and lateral views of the lymphatic trapezoid of Fletcher;
(B) Lower panel. Determination of the right and left lateral pelvic wall reference points.

some that can be used for other pelvic tumor as well, such Stage IIB – IIIB Disease
as MUPIT (Martinez Universal Perineal Interstitial Template), Radiotherapy is the primary local treatment for most patients
which can also be used for prostatic, anal canal or other with locoregionally advanced cervical carcinoma. Five-year
tumors approachable through the perineum (Figs 40.7A
Section 8

survival rates of 65–75 and 35–50 are reported for patients

and B). treated with radiotherapy alone for stage IIB and IIIB
Chemotherapy Followed by Radical Surgery respectively. External beam radiotherapy with concurrent
chemotherapy is used to deliver a homogeneous dose to the
Neoadjuvant chemotherapy (NACT) with cisplatin, bleomycin
primary cervical tumor and to potential sites of regional spread.
and a few other drugs has been tried in bul y stage IB
The brachytherapy can be given as either LDR (low dose rate)
or II cancers and has shown better or equivalent disease-free
or HDR (high dose rate). Clinicians have found HDR attractive
survival compared to surgery followed by postoperative
because of the aforementioned reasons.
radiotherapy, but an efficacy superior to concurrent
chemoradiation has not been reported. A recent meta-analysis Concurrent Chemoradiation
carried out by the Neoadjuvant Chemotherapy for Cervical During the past 5 years, prospective randomized trials involving
Cancer Meta-analysis (NACCCMA) Collaboration compared patients with locoregionally advanced cervical cancer have
cisplatin-based NACT followed by surgery with radical provided compelling evidence that the addition of concurrent
radiotherapy alone. The results indicated a 35 reduction in cisplatin-containing chemotherapy to standard radiotherapy
the risk of death with NACT, with an absolute improvement of reduces the risk of disease recurrence by as much as 50 and
14 in survival at 5 years. thereby improves the rates of pelvic disease control and

Figs 40.7A and B: (A) The instruments for performing interstitial implant including MUPIT;
276 (B) A completed interstitial implant procedure for carcinoma cervix
survival. Based on the results of five large randomized trials (3 Treatment of recurrent disease depends on prior treatment,
GOG, 1 RTOG, 1 SWOG), the National Cancer Institute issued site or extent of recurrence, disease-free interval and patient’s
an alert in 1999 stating that strong consideration should be given performance status. Patients after surgical therapy should be
to adding chemotherapy to radiation therapy in the treatment treated with chemo-radiation. Central pelvic relapses following
of invasive cervical cancer. A meta-analysis published by Green primary or adjuvant radiation should undergo surgery. Radical
et al showed chemoradiation to improve overall and disease- hysterectomy may be adequate for small ( 2 cm) lesions, but most
free survival, and reduction in risk of local or distant recurrence, patients need pelvic exenteration. Interstitial brachytherapy may
albeit with a higher incidence of grade 3 or 4 hematological and be used for delivering high dose within the tumor without
gastrointestinal toxicity. Most studies included in the meta- irradiation already compromised surrounding normal tissue.
analysis used cisplatin, either as a single agent or in combination Role of chemotherapy in patients with recurrent or metastatic
with fluorouracil, vincristine or bleomycin. disease is merely palliative.

Chapter 40
Neoadjuvant Chemotherapy (NACT) with Radiotherapy CANCER OF THE UTERINE BODY
Several investigators have explored the role of NACT before Endometrial Carcinoma
radiotherapy for locally advanced cervical carcinoma and
The basic treatment for all patients with endometrial carcinoma
shown a local response rate of 50–80 . Seven prospective trials
is total abdominal hysterectomy and bilateral salpingo-
comparing NACT followed by radiotherapy with radiotherapy
oophorectomy; sampling of pelvic and para-aortic lymph nodes;
alone have been reported but none has shown superiority of
and peritoneal washings. The role of postoperative adjuvant
the neoadjuvant approach in terms of survival. Only one small
therapy depends on the stage and grade of tumor.

Chemotherapy and Radiotherapy in Gynecological Malignancies

trial, published by Sardi et al in 1998, appears to have
The benefit of adding postoperative radiotherapy after surgery
demonstrated improved survival with NACT in patients with
has been clearly shown by three large trials. The GOG-99 conducted
stage IIIB disease. The 2003 NACCCMA meta-analysis also
by the gynecologic oncology group randomized patients with stage
evaluated the benefit of cisplatin-based NACT followed by
IB, IC and occult stage II endometrial carcinoma to radiotherapy
radical radiotherapy versus radical radiotherapy alone. NACT
versus no radiotherapy after surgery. Two-year relapse free interval
tended to improve survival in trials using chemotherapy cycle
was significantly superior for the radiotherapy arm. The PORTEC
lengths of 14 days or cisplatin dose intensities 25 mg/m2/week
trial compared pelvic radiotherapy to observation in patients with
while it proved detrimental in those using cycle lengths 14
stage IB grade 2, grade 3 and stage IC grade 1, grade 2 tumors.
days or cisplatin dose intensities 25 mg/m2/week. There was
The locoregional failure rates were significantly lower in the
no evidence to suggest that chemotherapy was differentially
radiotherapy group. Another randomized trial conducted by GOG
effective in groups defined by age, stage, histology, grade or
showed benefit of adding postoperative radiotherapy in women
performance status. The total cisplatin dose given did not affect
with high intermediate risk endometrial carcinoma (moderate to
outcome. No trial has compared NACT with concurrent chemo-
poorly differentiated tumor, presence of lymphovascular space
radiation, which is the current standard of care. Combinations
invasion, and outer third myometrial invasion).
of neoadjuvant plus concurrent chemotherapy have not been
Postoperative radiotherapy can be given as either
tested in randomized trials; such combinations should probably
intravaginal brachytherapy, external radiotherapy or a
be avoided outside of investigational trials because neoadjuvant
combination of both.
chemotherapy could compromise patients’ tolerance of
Table 40.1 outlines the protocol for treating carcinoma
subsequent chemoradiation.
endometrium that we follow at our department at All India
At our department, the protocol followed for cancer cervix
Institute of Medical Sciences, Delhi.
stage IIB-IIIB is:
External radiotherapy—to whole pelvis.
• External pelvic radiotherapy 40 Gray in 22 fractions to whole
50.4 Gray; 28 fractions; 5 weeks
pelvis followed by 10 Gray in 5 fractions with midline
Intravaginal brachytherapy (delivered with a SORBO
shielding; along with weekly Injection Cisplatin 40 mg/m2
vaginal applicator) (Figs 40.8 A and B)
intravenously.
a. With RT
This is followed by intracavitary brachytherapy with
i. Low Dose Rate (LDR)- 20 Gray (at 0.5 cm from surface
either HDR (7 Gray to point A per fraction for 3 fractions
of applicator)
delivered at weekly intervals) or LDR (30 Gray to point A).
ii. High Dose Rate (HDR)- 6 Gray (at 0.5 cm from surface
Stage IVA- IVB of applicator) 2 sessions , 1 week apart
b. Alone
Stage IVA and IVB are managed with palliative radiotherapy
i. Low Dose Rate (LDR)- 40 to 45 Gray (at 0.5 cm from
with or without palliative chemotherapy.
surface of applicator)
Recurrent Carcinoma of Cervix
The recurrence rate of cervical cancer is between 10 and 20 Table .1: Protocol for treating carcinoma endometrium
for FIGO stages IB–IIA and 50–70 in stages IIB–IVA. Patients
Stage Grade Grade Grade 3
should be evaluated for possible recurrent disease if a new mass
Stage IA FU only FU only RT IVB
develops; if the cervix remains bulky or nodular or cervical
Stage IB IVB only RT IVB RT IVB
cytologic findings are abnormal 3 months or more after irradiation;
Stage IC RT IVB RT IVB RT IVB
or if symptoms of leg edema, pain, or bleeding develop after initial
Stage II RT IVB
treatment. Diagnosis must be confirmed by tissue biopsy and
Stage III RT IVB Chemotherapy
disease extent evaluated with cystoscopy, sigmoidoscopy and
Stage IV Palliative radiotherapy followed by assessment
radiologic investigations. Both persistent and locally recurrent pelvic
FU Follow-up
tumors are characterized by an advanced malignant progression
RT external beam radiotherapy
and often exhibit an anatomically complex topography rendering
IVB intravaginal brachytherapy
curative treatment very difficult and rarely successful. 277
General Principles of Gynecology

Figs 40.8A and B: (A) SORBO applicator assembly for intravaginal brachytherapy; (B) Completed SORBO application
in a case of carcinoma endometrium

ii. High Dose Rate (HDR)- 7 Gray (at 0.5 cm from surface role of chemoradiotherapy in the postoperative setting for
of applicator) 3 sessions , 1 week apart high risk individuals.
Unfavorable Histologic Types Radioactive Phosphorus 32P
Papillary serous and clear cell histologies of endometrial Intraperitoneal radioactive 32P can be effective in decreasing
carcinoma pose a therapeutic challenge. These tumors are recurrence in patients having subclinical intraperitoneal disease.
extremely aggressive and demonstrate patterns of It can be used as an alternative to, but not in combination with
intraperitoneal spread similar to ovarian carcinoma. Treatment whole abdominal radiotherapy, to avoid excessive toxicity.
of these cancers is controversial. Total abdominal hysterectomy
Recurrent Endometrial Carcinoma
and bilateral salpingo-oophorectomy with debulking of
Section 8

metastatic deposits should be carried out. Treatment approaches Most recurrences after treatment occur in the first two years;
have included whole abdominal irradiation, intraperitoneal 32P, hence frequent follow up is essential. Therapy for recurrent
and adjuvant chemotherapy. A phase II study by the disease depends on extent of recurrence, previous treatment
Gynecologic Oncology Group (GOG-94) studied whole received and interval between primary treatment and
abdominal irradiation in papillary serous or clear cell patients recurrence. Therapeutic options include radiotherapy (if not
and recorded 5-year survivals of 65 (Stage I, II) and 35 (Stage given before), surgery, chemotherapy or hormonal therapy.
III, IV).
Uterine Sarcomas
Hormonal Therapy Uterine sarcomas comprise less than 10 of all uterine fundal
The presence of estrogen and progesterone receptors in neoplasms. Surgical staging with total abdominal hysterectomy
endometrial tumors has been shown to correlate with well- and bilateral salpingo-oophorectomy, lymph node sampling and
differentiated cancers and with response to progestogens. peritoneal cytology should be done as for uterine carcinomas.
Patients with widespread metastatic disease or with previously The role of radiotherapy in uterine sarcomas is controversial.
irradiated, recurrent local disease are candidates for hormonal Various chemotherapeutic agents have shown benefit;
therapy. The agents that are commonly used are: doxorubicin in leiomyosarcoma; and ifosfamide, cisplatin and
1. Depot medroxyprogesterone acetate paclitaxel in mixed Mullerian tumor.
2. Megestrol acetate
3. Tamoxifen CARCINOMA OVARY
These agents can be continued till unacceptable toxicity or
Epithelial Tumors
disease progression occurs. oung women with well-
differentiated lesions may be treated with hormonal therapy Borderline umors (or tumors of low malignant potential) occur
alone if they do not desire surgery. in premenopausal women and remain confined to the ovary in
most cases (75 ). They represent about 10 of non-benign
Chemotherapy ovarian neoplasms. These tumors have atypical proliferation
Patients with stage III or IV disease, recurrent lesions or clear but no stromal invasion on histopathological examination. They
cell or papillary serous histology are candidates for systemic are not associated with hereditary ovarian cancer syndromes.
chemotherapy. In addition, some authors recommend the use The recommended treatment is primary surgical resection with
of chemotherapy in the setting of absent hormone receptors staging. A borderline tumor diagnosed on a frozen section
and preoperative elevation of CA125. mandates a surgical staging. Presence of invasive peritoneal
Chemotherapy combinations that are used are cisplatin implants correlates with an adverse prognosis and such cases
and doxorubicin; paclitaxel and carboplatin; and cisplatin, may be considered for cytotoxic chemotherapy. In early stage
paclitaxel and doxorubicin. The GOG-122 trial randomized disease, chemotherapy or radiotherapy have no impact on
optimally debulked stage III to IV patients to whole survival. Long term survival is excellent.
abdominal radiotherapy or doxorubicin-cisplatin Peritoneal carcinoma is a disseminated serous peritoneal
278 chemotherapy; with the chemotherapy arm showing better adenocarcinoma in the presence of normal ovaries. Criteria for
results. Newer trials (RTOG 99-05) are now investigating the defining peritoneal carcinoma (GOG 1993) include:
a. Ovaries normal in size or enlarged due to a benign process both in terms of toxicity and efficacy. Regarding the addition of
b. Extraovarian involvement exceeding ovarian involvement an anthracycline (doxorubicin or epirubicin) to the established
c. Predominantly serous histology combination, data suggest that it only leads to increased toxicity,
d. Surface involvement of depth and width less than 5 mm. without improving survival. The concept of maintenance
chemotherapy beyond the standard 6 cycles has potential
Invasive Neoplasms benefit, but is not yet the standard of care.
a. Stage Ia Ib grade Intraperitoneal chemotherapy is the administration of
i. Premenopausal—after staging laparotomy is completed, chemotherapeutic drugs into the peritoneal cavity. There have
these women can undergo unilateral salpingo- been several important studies evaluating the role of intraperitoneal
oophorectomy to preserve fertility. Follow-up should chemotherapy with platinum and taxanes. Although three
include regular pelvic examination and CA125 levels. randomized trials have shown a survival benefit from the use of
ii. Postmenopausal—these women should undergo total intraperitoneal chemotherapy, it has not been adopted into routine

Chapter 40
abdominal hysterectomy and bilateral salpingo- clinical practice due to associated toxicity despite a recent US
oophorectomy with complete surgical staging and National Cancer Institute statement indicating that clinicians
thereafter, a close follow-up. should now consider intraperitoneal chemotherapy as one option
b. Stage Ia Ib grade and 3 Stage Ic—these women are treated for standard first-line treatment.
by total abdominal hysterectomy and bilateral salpingo- The role of neoadjuvant chemotherapy is stage III-IV
oophorectomy and surgical staging followed by epithelial ovarian tumors is evolving and is associated with
chemotherapy. Combination of paclitaxel and carboplatin higher optimum debulking rate with reduced postoperative

Chemotherapy and Radiotherapy in Gynecological Malignancies

chemotherapy is recommended. morbidity and improved quality of life.
c. Stages II III I —these patients are managed with
cytoreductive surgery or debulking and chemotherapy. Relapsed Disease
Surgical debulking may be done during initial management The treatment free interval is an important predictor of response
before adjuvant therapy (primary cytoreduction), after to second line treatment. When the interval is more than
several cycles of chemotherapy (interval cytoreduction), or months, these patients are considered to have platinum-
after all adjuvant therapy is completed (secondary cyto- sensitive disease and should be retreated with platinum-based
reduction). Optimal cytoreduction has been defined regimen. However, when the interval is less than 6 months,
differently through the years, but at present, cytoreduction these patients are considered to have platinum refractory
with residual disease is most widely acceptable. disease and should be treated with nonplatinum-based agents
Some authors also recommend a second loo laparotomy, such as pegylated liposomal doxorubicin or topotecan. For
which is performed to determine the response to therapy women who have residual neurotoxicity as a result of first line
of a patient who has no clinical evidence of disease after a chemotherapy, gemcitabine may be used in place of paclitaxel
prescribed course of chemotherapy. However, controversy as second line therapy.
exists about its utility and benefit.
Radiation Therapy
Chemotherapy The propensity of ovarian cancers at any stage to disseminate
Table 40.2 lists the chemotherapeutic agents used in epithelial widely prompts the use of therapy directed at the peritoneal
ovarian cancer. cavity as a whole. As a result, techniques using whole-
Currently, the gold standard regimen for ovarian cancer is abdominopelvic external beam therapy or instilled
carboplatin and paclitaxel for six cycles at 3-week intervals. intraperitoneal radioisotopes have evolved into the most
For early stage ovarian cancer, cisplatin or carboplatin with commonly prescribed regimens.
doxorubicin and cyclophosphamide (CAP) have been The principle of abdomino-pelvic radiotherapy involves
traditionally used with good outcome. However, despite the irradiating the entire abdomen and pelvis, from the diaphragm
lack of hard evidence, taxanes have now been incorporated into to the floor of the pelvis and laterally to the abdominal sidewalls.
the first-line treatment of early stage disease. All peritoneal surfaces, abdominopelvic lymphatics, and the
For advanced stage disease, the combination of paclitaxel undersurface of the diaphragm should be treated. Doses of
and carboplatin is clearly established as the first line treatment; approximately 20 to 30 Gray should be delivered to the entire
despite the fact that a large trial, ICON-3, failed to show peritoneum, with consideration of a whole-pelvis boost to a
superiority of this combination to single agent carboplatin or cumulative dose nearing 40 to 50 Gray.
the CAP regimen. Studies have demonstrated that patients who received
Trials comparing the combination of paclitaxel with either whole-peritoneum external beam irradiation did not benefit
carboplatin or cisplatin have shown that the former combination from radiation therapy alone unless only microscopic disease
is better tolerated and yields similar outcome. Along with was present at the start of adjuvant treatment.
paclitaxel; another taxane, docetaxel has been studied in As an alternative to externassl beam therapy, intraperitoneal
combination with carboplatin, with a good clinical outcome, instillation of radioisotopes, such as gold and phosphorus, has
been used in clinical practice. 32P is the preferred and most
frequently administered isotope. It is a pure -radiation emitter
Table .2: Chemotherapy for epithelial ovarian cancer
and allows for a superficial or directed administration of
Drugs currently used as first Drugs under evaluation for radiation to target areas seeded with tumor. The use of 32P is
line treatment first line treatment however limited to less bulky disease and it is not useful for
• Carboplatin • Docetaxel patients with large tumor volume, disease beyond the abdomen
• Cisplatin • Irinotecan or disease in the lymphatic channels after surgery. Optimal
• Paclitaxel • Gemcitabine administration of 32P requires instillation of the isotope within
• Pegylated liposomal 12 – 24 hours after initial debulking or staging surgery as this
doxorubicin allows for greater mobility of the isotope throughout the
• Topotecan peritoneal cavity before the onset of formation of adhesions.
279
 Germ Cell Tumors ovarian function, verrucous or nonepithelial tumors, or
The principles of surgical staging of germ cell tumors are similar irradiation failures.
to those for epithelial tumors. Particular attention should be When radiation is considered, intravaginal brachytherapy
paid to the para-aortic and pelvic lymph nodes, because these alone to a dose of 60 – 70 Gray in superficial disease and
are more frequently involved than in epithelial tumors. interstitial implant and brachytherapy for thicker lesions is used.
However, even in the presence of widespread metastatic disease, External beam radiation is reserved in stage I disease for more
because of the efficacy of chemotherapy, contralateral ovary can invasive, infiltrating or poorly differentiated lesions to
frequently be preserved. supplement brachytherapy.
Stages II through IVA are treated with a combination of
Treatment external beam radiotherapy to whole pelvis to a dose of 45 – 50
Dysgerminomas are the most common malignant germ cell Gray followed by intracavitary or interstitial brachytherapy to
tumors of the ovary and are considered the female equivalent a total dose of 75 – 80 Gray to the tumor. oung, physically fit
General Principles of Gynecology

of a seminoma. In contrast to nondysger-minomas, patients with advanced disease may be considered for pelvic
dysgerminomas are more frequently Stage I, involve both exenteration. As an alternative to exenteration, radiation therapy
ovaries, spread to retroperitoneal lymph nodes, and are to treat pelvic disease combined with a radical vulvectomy and
markedly sensitive to radiotherapy. Because these tumors are bilateral inguinal dissection to treat the external genital tumor
also exquisitely sensitive to cisplatin-based chemotherapy, the has also been proposed. Palliative radiotherapy is used in cases
role of curative radiation therapy has decreased. Radiotherapy with highly advanced local or metastatic disease. The role of
is currently used for residual disease, disease refractory to chemotherapy is unclear, and it is used only as a salvage therapy.
chemotherapy and for palliation of metastases. The
chemotherapy regime that is most commonly used is BEP CARCINOMA VULVA
(bleomycin, etoposide and cisplatin) which is recommended to For early stage squamous cell carcinoma, surgery is the treatment
be used after surgery for all stages except IA. Women with stage of choice. Vulvar intraepithelial lesions may be managed with
IA disease can be kept on observation only after surgery, without wide local excision. Superficial ablative techniques such as CO2
compromising cure. laser may suffice in warty growths.
The vast majority of nondysgerminomatous germ cell Early invasive lesions with close or positive margins should
tumors of the ovary are treated with surgery followed by be considered for adjuvant radiotherapy. A dose of 50 Gray is
combination chemotherapy with BEP. Reproductive function sufficient after gross total resection with higher doses given for
may be preserved in at least 80 of patients who undergo residual disease. A GOG trial reported that in patients with
fertility-sparing surgery and chemotherapy. Cure rates positive inguinal nodes following radical vulvectomy and bi-
Section 8

approach 100 for patients with early-stage disease, and at least lateral inguinofemoral lymphadenectomy, who were random-
75 for advanced-stage disease. ized to either pelvic lymphadenectomy or adjuvant radio-
therapy to pelvis and inguinal region, there was a significantly
Sex Cord-Stromal Tumors high rate of local control and improved survival in the radio-
Ovarian sex cord stromal tumors represent approximately 7 therapy arm.
of all ovarian cancers. They tend to present with stage I disease Stage III or I lesions with minimal involvement of urethra or
and are frequently associated with hormonal effects, such as anus may be taken up for surgery followed by adjuvant
precocious puberty, amenorrhea, postmenopausal bleeding, or radiotherapy, if close surgical margins near critical areas are
virilizing symptoms. Granulosa cell tumors are the most acceptable. Other cases may be taken up for preoperative
common (70 ) and may be associated with endometrial radiotherapy to dose of 45–55 Gray followed by definitive
hyperplasia and endometrial carcinoma. surgery. Inoperable cases may be treated with concurrent
Surgical staging of sex cord-stromal tumors is the same as chemoradiation. Radiation doses of 60–70 Gray are used with
that for epithelial ovarian cancers. Surgical management of sex concomitant use of chemotherapeutic agents such as 5FU,
cord-stromal tumors is based on the stage of the tumor as cisplatin and mitomycin C. Although no randomized trials are
well as on the age of the patient. Premenopausal women or available, drug schedules have been extrapolated from those
patients in the reproductive years tend to have stage I disease. used in other sites such as cervix and anal cancers and have
These women can be managed with unilateral salpingo- shown good results. Exenteration may be considered for young
oophorectomy without adjuvant therapy. Women older than patients with good general condition and nonmetastatic disease
40 years at diagnosis should undergo complete surgical staging following failure of initial surgery or chemoradiation. More
and some authors also recommend adjuvant therapy for older advanced or metastatic cases may be offered palliative
patients. radiotherapy for local disease along with symptomatic
Patients with advanced stage disease (i.e., stage II to IV) measures.
are managed with surgical staging followed by adjuvant
platinum-based chemotherapy, the most popular regimen being GESTATIONAL TROPHOBLASTIC DISEASE
BEP, though recent trials are investigating taxane-platinum Gestational trophoblastic diseases comprise a spectrum of four
combinations with similar responses but a better toxicity profile. distinct entities:
a. molar pregnancy (including complete and partial
CARCINOMA VAGINA hydatidiform moles),
Surgery, when considered, is reserved for stage I or II tumors b. invasive mole (chorioadenoma destruens),
and consists of a radical hysterectomy, pelvic lymphadenectomy c. placental site trophoblastic tumors, and
and vaginectomy. d. choriocarcinoma.
Radiation therapy is the treatment of choice for most vaginal
carcinomas owing to excellent tumor control and good Choriocarcinoma
functional results. Surgical treatment is reserved for patients Metastatic disease occurs in 4 of patients after local
280 with localized intraepithelial disease, young patients to preserve management of hydatidiform moles. Metastases are found in
 Table .3: Prognostic Scoring System for estational stage I endometrial carcinoma: Multicentre randomised trial. Lancet
Trophoblastic Disease 2000;355:1404.
5. De Crevoisier R, Sanfilippo N, Gerbaulet A, et al. Exclusive
Factor Score radiotherapy for primary squamous cell carcinoma of the vagina.
Radiother Oncol 2007;85:362.
6. Dembo A . Epithelial ovarian cancer: the role of radiotherapy. Int
Age – 39 y – 39 y
Radiat Oncol Biol Phys 1992;22:835.
Antecedent Mole Abortion Term –
7. Ehrlich CA, oung PCM, Cleary RE. Cytoplasmic progesterone and
pregnancy
estradiol receptors in normal, hyperplastic, and carcinomatous
Interval from 4 4–6 7–12 12
endometrium: therapeutic implications. Am Obstet Gynecol
pregnancy (mo)
1981;141:539.
Serum HCG 103 103–104 104–105 105
8. Fleming GF, Brunetto VL, Bently R, et al. Randomised trial of
IU/L IU/L IU/L IU/L
doxorubicin (DO ) plus cisplatin (CIS) versus DO plus CIS plus
Largest tumor 3 cm 3–5 cm 5 cm –

Chapter 40
paclitaxel (TA ) in patients with advanced or recurrent endometrial
Metastatic sites Lung Spleen, GI tract, Brain
carcinoma: a Gynecologic Oncology Group (GOG) study. AM Soc
Kidney Liver
Clin Oncol 2002;21:202a (abst 807).
Number of – 1–3 4–8 8
9. Green A, Tierney M, Symonds F, et al. Survival and recurrence
metastases
after concomitant chemotherapy and radiotherapy for cancer of
Prior chemo- – – One Two or
the uterine cervix: a systematic review and meta-analysis. Lancet
therapy drug more
2001; 358:781.
drugs
10. Grigsby PW, Perez CA. Radiotherapy alone for medically

Chemotherapy and Radiotherapy in Gynecological Malignancies

inoperable carcinoma of the cervix: stage IA and carcinoma in situ.
Int Radiat Oncol Biol Phys 1991;21:375.
lung (80 ), vagina (30 ), pelvis (20 ), brain (10 ), and liver 11. Hacker NF, Berek S, Lagasse LD, et al. Preoperative radiation
(10 ). CSF titres of -hCG can be used to monitor CNS disease. therapy for locally advanced vulvar cancer. Cancer 1984;54:256.
Anatomic staging of choriocarcinoma (I, confined to corpus; 12. Homesly HD, Bundy BN, Sedlis A, et al. Radiation therapy versus
pelvic node resection for carcinoma of the vulva with positive groin
II, metastases to pelvis and vagina; III, pulmonary metastases
nodes. Obstet Gynecol 1986;68:733.
with or without uterine, pelvic, or vaginal involvement; and 13. ICRU. Dose and volume specification for reporting intracavitary
IV, other metastases, such as brain, liver, kidneys, or therapy in gynecology. ICRU Report No. 38. Bethesda, MD:
gastrointestinal tract) has been superseded by a prognostic International Commission on Radiation Units and Measurements,
scoring, (Table 40.3) which helps to identify high risk 1985.
choriocarcinoma requiring intensive combination 14. International Collaborative Ovarian Neoplasm (ICON) Group.
chemotherapy versus single agent or simple combination Paclitaxel plus carboplatin versus standard chemotherapy with
chemotherapy for low-risk patients. either single-agent carboplatin or cyclophosphamide, doxorubicin,
cisplatin in women with ovarian cancer: the ICON3 randomised
Chemotherapy is highly effective for all forms of gestational
trial. Lancet 2002;360:505.
trophoblastic disease. Hysterectomy with single agent 15. Keys HM, Roberts A, Brunetto VL, et al. A phase III trial of surgery
chemotherapy must be considered for Stage I disease to combat with or without adjunctive external pelvic radiation therapy in
both local and systemic disease, if any in perimenopausal intermediate risk endometrial adenocarcinoma: a Gynecologic On-
women. cology Group study. Gynecol Oncol 2004;92:744.
For low-risk patients (Stage II, III; score 7), methotrexate 16. Kohorn EI, Goldstein DP, Hancock BW, et al. Combining the staging
alone or with leucovorin rescue or dactinomycin has most system of the International Foundation of Gynecology and
commonly been used. In high-risk patients (Stage IV; score 7), Obstetrics with the scoring system of the World Health Organisation
for Trophoblastic Neoplasia. Int Gynecol Cancer 2000;10:84.
the combination of EMA-CO (etoposide, dactinomycin, and
17. Kumar L, Hariprasad R, Kumar S, et al. Neoadjuvant chemotherapy
folinic acid; vincristin and cyclophosphamide) is most (NACT) followed by interval debulking surgery versus upfront
commonly used. In patients who are resistant to EMA-CO, a surgery followed by chemotherapy (CT) in advanced epithelial
combination containing cisplatin has been shown to have good ovarian carcinoma (EOC): A prospective randomized study—
results. In patients with brain metastases, radiation to whole Interim results. lin Oncol, 2007 ASCO Annual Meeting
brain should be given concomitantly with chemotherapy; and Proceedings Part I. 2007;25 ( une 20 Supplement): 5531.
doses up to 30 Gray have been used. 18. Landoni F, Maneo A, Colombo A, et al. Randomised study of radical
With chemotherapy, overall survival for choriocarcinoma surgery versus radiotherapy for stage Ib-IIa cervical cancer. Lancet
1997; 350: 535.
is 80–90 . Newer anti-cancer agents such as paclitaxel and
19. Neoadjuvant Chemotherapy for Locally Advanced Cervical Cancer
gemcitabine, as well as high-dose chemotherapy may play a Meta-analysis Collaboration. Neoadjuvant chemotherapy for
role in the future. locally advanced cervical cancer: a systematic review and meta-
analysis of individual patient data from 21 randomised trials. Eur
BIBLIOGRAPHY Cancer. 2003;39:2470.
1. Alberts DS, Liu P , Hannigan EV, et al. Intraperitoneal cisplatin 20. Neijt P, Engelholm SA, Tuxen MK, et al. Exploratory Phase III study
plus intravenous cyclophosphamide versus intravenous cisplatin of paclitaxel and cisplatin versus paclitaxel and carboplatin in
plus intravenous cyclophosphamide for stage III ovarian cancer. N advanced ovarian cancer. Clin Oncol 2000;18:3084.
Engl Med 1996;335:1950. 21. Newlands ES, Mulholland P , Holden L, et al. Etoposide and
2. Axelrod , Bundy , Roy T, et al. Advanced endometrial carcinoma cisplatin/etoposide, methotrexate and actinomycin D (EMA)
(EC) treated with whole abdominal irradiation (WAI): a chemotherapy for patients with high risk gestational trophoblastic
Gynecologic Oncology Group (GOG) study. Gynecol Oncol tumors refractory to EMA/cyclophosphamide and vincristine
1995;56:135 (abstr). chemotherapy, and patients presenting with metastatic placental
3. Boronow RC, Hickman BT, Reagan MT, et al. Combined therapy site trophoblastic tumors. Clin Oncol 2000;18:854.
as an alternative to exenteration for locally advanced vulvovaginal 22. Papadopoulos A , Foskett M, Seckl M , et al. Twenty five years’
cancer: II. Results, complications, and dosimetric and surgical clinical experience with placental site trophoblastic tumors.
considerations. Am Clin Oncol 1987;10:171. Reprod Med 2002;47:460.
4. Creutzberg CL, van Putteri WL, Koper PC, et al. Surgery and 23. Peters WA 3rd, Liu P , Barrett R 2nd, et al. Concurrent
postoperative radiotherapy versus surgery alone for patients with chemotherapy and pelvic radiation therapy compared with pelvic 281
 radiation therapy alone as adjuvant therapy after radical surgery 28. Sardi , Giaroli A, Sananes C, et al. Randomized trial with
in high-risk early-stage cancer of the cervix. Clin Oncol 2000; neoadjuvant chemotherapy in stage IIIB squamous carcinoma
18:1606. cervix uteri: an unexpected therapeutic management. Int Gynecol
24. Randall ME, Spirtos NM, Dvoretsky P. Whole abdominal ancer 1998; 6:85.
radiotherapy versus combination chemotherapy with doxorubicin 29. Sebire N, Mackydimas G, Agnantis N , et al. Updated diagnostic
and cisplatin in advanced endometrial carcinoma (Phase III): criteria for partial and complete hydatidiform moles in early
Gynecologic Oncology Group Study No 122. Natl Cancer Inst pregnancy. Anticancer Res 2003;23:1723.
Monogr 1995;19:13. 30. Soto-Wright V, Goldstein DP, Bernstein MR, Berkowitz RS. The
25. Reed NS, Sadozye AH. Role of chemotherapy in the management management of gestational trophoblastic tumors with etoposide,
of epithelial ovarian cancer. Expert Rev Anticancer Ther 2005;5:139. methotrexate, and actinomycin D. Gynecol Oncol 1997;64:156.
26. Roberts A, Brunetto VI, Keys HM, et al. A phase III randomized 31. Vasey PA. CRC trials unit. Survival and longer-term toxicity results
study of surgery vs surgery plus adjuvant radiation therapy in of the SCOTROC study: docetaxel-carboplatin (DC) vs paclitaxel-
intermediate risk endometrial adenocarcinoma (GOG 99). Pro- carboplatin (PC) in epithelial ovarian cancer (EOC). Proc Am Soc
General Principles of Gynecology

ceedings SGO 1998;70 (abstr). Clin Oncol 2002;21:202a (abst 804).

27. Rose PG, Bundy BN, Watkins , et al. Concurrent cisplatin-based 32. ordan EL, Schlaerth , Gaddis O, et al. Radiation therapy in the
chemotherapy and radiotherapy for locally advanced cervical management of gestational choriocarcinoma metastatic to the
cancer. N Engl Med 1999;340:1144. central nervous system. Obstet Gynecol 1987;69:627.
Section 8

282
 Section 9 Diseases of Vagina

41 Benign Conditions of the Vagina

Sudha Salhan

Vagina is the connecting link between the uterus and An abdomen mass is seen when hematometra occurs. In
outside(including vulva). The benign conditions include the extreme cases the fallopian tubes also become filled with blood
following: (Hematosalpinx). It is extremely rare to see hematoperitoneum
1. Congenital abnormalities due to spillage of blood through fibrial opening into the
2. Infections peritoneal cavity.
• Fungal On examination a bulging hymen is seen (Fig. in chapter
• Parasitic 4). Per abdominally a midline suprapubic regular mass is felt.
• Bacterial Renal structural abnormalities may be associated and hence to
• Viral be excluded by IVP. A per rectal examination shows vagina full
3. Non-infectious lesions and bulging in the rectum. The excision of the imperforate
• Burns hymen is done. A crucial incision is made on the imperforate
• Foreign body in the vagina hymen. Tarry colored thick fluid comes out. Either excise the
4. Cysts hymen and stich the edges to the mucosal margin or tie the 4
• Tumors tips of the crucial incision to the mucosa. No other
5. Miscellaneous. instrumentation should be performed. The patient is kept
ambulatory to ensure drainage. In most of the cases no further
CONGENITAL ABNORMALITIES treatment is required.
It includes developmental defects and growth of vestigial
organs. Non-canalization of Vagina
a. Imperforate hymen This is usually seen in cases of Mullerian agenesis. The
b. Non-canalized vagina noncanalization can be partial when the (i) upper part is
• Partial noncanalized(Mullerian part) because of agenesis of whole of
• Total Mullerian ducts. And the lower part is formed(urogenital
portion). In some of these cases the lower portion becomes
Imperforate Hymen sufficiently large for copulation after marriage. These patients
A thin layer hymen is situated just at the entrance of the vagina. have no complaint regarding sexual act but come for infertility.
Mostly it is sieve like to let out the uterine and vaginal contents Ultrasound and laparoscopic examination revealed agenesis
(due to canalization in the embryonic life). Failure of of uterus and fallopian tubes but ovaries are seen. The
canalization leads to imperforate hymen: Though rare, this management is counseling and advise for adoption and
condition is seen now and then in teenage girls in gynecology exclusion of any urinary abnormalities (often associated with
out-patient department. Mullerian agenesis).
Very rarely, it is seen in neonates. In these cases the Partial agenesis of lower vagina and transverse vagina
imperforate hymen do not allow the cervical and vaginal septum: The Mullerian ducts are well-developed but the
secretions to come out(formed due to maternal estrogen urogenital sinus has not canalized (Figs 41.1 and 41.2). This is a
secreting in her blood). The hymen is seen bulging. This is rare congenital abnormality. These patients report at the age of
mucocolpos. The neonate may have constipation or retention menarche because of not establishing of menstrual
of urine. Mucoid fluid comes out when this hymen is incised. cycle(primary amenorrhea)lower abdominal pain and swelling.
But most of these patients are seen at the time of menarche. There may be urinary or bowel disturbances. They present
It may present as chronic cyclic pain in the lower abdomen or sooner than cases of imperforate hymen because the space in
dysuria. Secondary sexual characters are well-developed but the vagina is limited (part of it is not canalized)and hematometra
she has not started the monthly bleeding(menarche). Actually, develops much earlier. Exclusion other congenital abnormalities
the menarche is there. She has started bleeding every month (including renal) is mandatory.
but due to imperforate hymen it is not coming out. The Treatment is surgical. The two dimples at the
menstrual blood starts accumulating above the imperforate introitus are gradually dilated(see chapter on vaginoplasty).
hymen, i.e. in the vagina. The vagina has a great capacity to The septa, finally developed in between, is excised. The septum
expand hence no acute emergency occurs. As the time passes like tissue in the vagina is incised in the middle. After the tarry
the vagina becomes full of altered blood (Hematocolpos) the thick fluid is drained the incised septal tissues are advanced
blood now starts accumulating in the uterus ( ematometra). As down and stitched at introital mucosa. No further
the vagina is distended uterus is pushed up in the abdomen. instrumentation is done at this sitting (Fig. 41.3).
Diseases of Vagina

Fig. 41.3: Vaginal flap advancement in partial

agenesis of lower vagina

Physiological Discharges
The slight discharge normally seen at the vulva and in the vagina
Fig. 41.1: Transverse vaginal septum (Early stages) is a mixture of the following, all of which vary in amount
character with ovarian function.
• Vulvar secretions from Bartholin’s glands sebaceous glands,
Section 9

sweat glands, apocrine glands, Skene’s glands.

• Vaginal discharge—the transudate of the vaginal epithelium
(as vagina has no glands) and the desqumated calls of the
cornified layer.
• Mucus secretion of the endocervical glands which is
alkaline.
• Endometrial glandular secretion
• Fallopian tube secretion
• Micro-organisms and their metabolic products.
This may also contain a contribution from peritoneal fluid.
The normal vaginal discharge is white in color. floccular in
consistency and is seen in the posterior fornix on per-speculum
examination.
Amount The amount of the vaginal discharge ordinarily
present in the adult is such that the introitus feels comfortably
moist.
It is normally increased to the extent of becoming noticeable
in the following circumstances—
• At the time of ovulation, due to cascade from the cervix
(Hormonal effect).
• During a few days premenstrually when there is secretion
Fig. 41.2: Transverse vaginal septum (Late stage) from all parts of genital tract.
• During pregnancy when there is an increase in vaginal and
Follow-up is done after 3 months to exclude cervical cervical discharge.
agenesis. Total non-canalization of vagina is dealt with in the • During sexual excitement when there is an outporing of
chapter of vaginoplasty. Bartholin secretion on to the vulva.
Hence physiological discharge can be influenced by the
INFECTIONS
following factors:
Causes of vulval, vaginal and cervical infections often overlap. Age Prepubertal, reproductive age, post menopausal.
The commonest symptom being discharge per vaginum. Its ormones Pregnancy, hormonal contraceptive and cyclical
color per odor is noted. The pH of vaginal discharge is obtained. hormonal changes.
Whiff test is performed. A wet slide is made by mixing the Local factors Menstruation, postpartum, malignancy, semen
secretion with normal saline cover it with cover slip and look and personal habits and hygiene.
for any mobile organism. Another similar slide is made with
potassium hydroxide solution. Slide of the discharge is also Leukorrhea
made and stained with gram’s stain. Leukorrhea means a running of white substance’ and the term
Vaginal Discharge is one of the most common complaints should be restricted to mean an excessive amount of the normal
of women who are attending the gynecology in outpatient discharge.
department. Leukorrhea consists manly of the cervical component.
It is characteristics of the normal discharge that although
Types of Vaginal Discharge white or cream when fresh, it leaves a brownish yellow stain
284 Vaginal discharge can be physiological and pathological. on clothing.
• Microscopically the discharge contains mucus, epithelial Rare Finding
debris, organisms of various kinds and in the second half • Intermittent emptying of a hydrosalpinx
of the cycle, some leukocytes. • Discharges of ascites fluid through the fallopian tubes and
• Leukorrhea never causes pruritus and is never offensive. It uterus.
is more troublesome premenstrually, midcyclically and • Carcinoma of fallopian tube—intermittent profuse vaginal
during pregnancy and can give rise to fears of cancer and of discharge may occur.
sexually transmitted diseases. • Other malignancies of genital tract
• Local trauma vault, granulation tissue
Causes of Leukorrhea
For the management of vaginal discharge knowledge of
• At birth—newborn babies may have mucoid vaginal exact cause of discharge is necessary.
discharge for 1–10 days. This is due to stimulation of the A good idea of the type and cause of the discharge can be
uterus and vaginal by placental estrogens. obtained from the following observations from history:

Chapter 41
• Puberty Leukorrhea is not uncommonly seen in young girls • Age of the patient
during and few years before and after menarche. This is a • Amount of discharge as judged by the need to wear a
temporary phenomenon which corrects itself. sanitary pad and by the staining of underclothing.
• Active or passive congestion of the pelvic organs. This • Onset—Leukorrhea has a gradual onset. A sudden onset of
results in increased secretory activity by the glands and is discharge nearly always means infection or a chemical or
the mechanism where by prolonged ill health anxiety states physical insult. There may be a history of exposure to the
and neurosis, sedentary occupation and standing for long risk of venereal infection or the case of candidiasis, a history

Benign Conditions of the Vagina

period in hot atmosphere. Prolapse, retroversion, chronic of recent treatment with antibiotics.
pelvis inflammatory disease cause leukorrhea. • Relationship to menstruations, ovulation and pregnancy.
• An increase in the glandular element in the cervix- as in • Use of toilet preparation. These include douching and the
case of cervical erosion or ectopy, ectropion, chronic application of antiseptics or deodorant.
cervicitis, mucus polyp. • Color of discharge—Care is necessary to distinguish
• aginal adenosis Vaginal epithelium is replaced by columnar between a brown or blood stained discharges and the
epithelium at many places. normal creamy discharge which dries leaving a brown or
• Estrogen Progestogen oral contraceptives—usually caused yellow stain in clothing.
by the development of an ectopy on the cervix. • Offensiveness—If the discharge is offensive it is usually caused
• Regular douching—washing away of natural secretions
by a foreign body, infection or neoplasm.
encourage the cervical glands to secrete more, particularly
• Pruritus—Is usually associated with infection with
if irritant antiseptic solutions are used. It also predisposes
Trichomonas vaginitis or Candida albicans.
to injection by washing away naturally protective lactobacilli
and by altering the pH causing discharge of secondary Examinations
infection.
After inspection of the vulva and the opening of the vaginas
PATHOLOGICAL DISCHARGES urethra per speculum examination should be done to determine
the nature and amount of the discharge, and to study the vaginal
Inflammatory Discharge wall and cervix.
Infections of the vagina: These are commonly seen in Specimen are obtained from the vagina and these are
gynecology outpatient department. Most of these overlap with examined for the pus cells.
the infection of cervix and vulva. If pus is not found, then irrespective of any organism present
Infection Discharges caused by infection is mucopurulent it can be concluded that the discharge is a true leukorrhea and
or frankly purulent; its color therefore varies from cream to not due to an infection.
yellow or green. It is often offensive. Its chief microscopic If pus cells are found and unless an obvious cause such as
characteristic is the presence of pus cells. cancer or foreign body is revealed the nature of organism
Commonest lesions causing discharge of the kind are— present must then be determined by study of fresh preparations,
• Vulvovaginitis—may be due to infection with the stained smears and cultures. The full investigations from the
gonococcus, trichomonas vaginitis, candida albicans, or standpoint of gonorrhea, bacterial vaginosis, candidiasis and
bacterial vaginosis in the adult and with nonspecific trichomoniasis should be done.
organisms in childhood and old age.
• Cervicitis—gonococcal, chlamydial, anaerobic or infection. Treatment of Discharge
• Endometritis—puerperal or senile After taking detailed history, clinical examinations and
• Secondary infection of wounds, abrasions, burns chemical investigations, exact cause of vaginal discharge is diagnosed
injuries and neoplasm, sited in any part the genital tract. and then treated accordingly.
• Neoplasms—any growth which is exposed to the lumen of • If there is foreign body, then it should be removed
the genital tract can cause a continuous discharge which is • Infections are treated according to the causative oraganism.
at first white or cream colored. The necrotic tissue is exposed • Neoplasms are operated upon.
to the large number of organisms present in the vagina. The Leukorrhea—explanation and reassurance are usually
discharge then becomes purulent, offensive and blood stained. necessary especially when the discharge is noticed only
• Foreign body, e.g. tampons, forgotton pessary, etc. premenstrually, at the time of ovulation, during pregnancy and
in the course of taking oral contraceptive.
Urinary and Feculent Discharge Cleanliness is ensured by bathing and by change of
Discharges through urinary and fecal fistula can be confused underclothing.
with a vaginal discharge but is usually recognized easily by its General health should receive attentions and anxiety states
smell and color. should be corrected.
285
 Cervical erosion should be treated by cryotherapy, laser ode of transmission Predominantly transmitted by sexual
cautery or diathermy when it becomes certain that this is the contact. It is more common in blacks, smokers, use of illicit
cause of a persistent discharge after evaluation to rule out drugs, less educated and low socioeconomic status.
cervical dysplasia or malignancy. Transmission may also be possible by the toilet articles from
one woman to the other or through examining gloves incubation
Vaginal Infection
period is 3–28 days.
• Vulvovaginitis in childhood Pathology In about 25% of women in the reproductive
• Trichomoniasis period, the parasites live in the vagina in asymptomatic stage.
• Moniliasis When the local defence is impaired—during and after
• Vaginitis due to chlamydia trachomatis menstruation, after sexual stimulation and following illness,
• Gonococcal infection/ Bacterial vaginosis the pH of the vagina is raised to 5.5–6.5. At this level of pH the
• Atrophic vaginitis trichomonas thrive. The organism usually lies between the rugae
Diseases of Vagina

• Non-specific vaginitis. and produces surface inflammatory reaction. In about 75%

Vulvovaginitis in Childhood cases, the organism can be isolated from the urethral (Skene’s
tubules) or even from the Bartholin glands secretions.
Inflammatory condition of the vulva and vagina are the
commonest disorders during childhood. Due to lack of estrogen, Clinical Features
the vaginal defence is lost and the infection occurs easily, once • There is sudden profuse and offensive vaginal discharge
it attacks vulva or introduced inside the vagina. often dating from the last menstruation
Etiology • Irritation and itching of varying degrees within and around
the introitus. The discharge is green and frothy, with high
• Non-specific vulvovaginitis
pH and fishy odor
• Presence of foreign body in the vagina.
• There may be dysuria and increased frequency of
• Associated intestinal infestations-threadworm being the
Section 9

micturition
commonest
• There may be history of previous similar attacks
• Rarely more specific infection caused by candida albicans
• pH of vaginal secretion is increased.
or
• Gonococcus may be implicated. On Examination
Clinical Features • There is thin, greenish yellow and frothy offensive discharge
Nonspecific volvovaginitis may cause sticking together of labia per vaginum
majora of the child which require separation cleanliness and • Vulva is inflamed with evidence of pruritis
estrogen cream (Fig. 50.4). • Vaginal examination may be painful. Vaginal walls become
There is pruritus of varying degree red and inflamed with multiple punctate hemorrhagic spots
(Fig. 41.4). Similar spots are also found over the mucosa of
Painful micturition may also be associated. the partiovaginalis part of the cervix (strawberry cervix) on
Inspection reveals soreness of the vulva, and labia minara speculum examination giving the appearance of strawberry.
may be swollen and red. Vaginal discharge varies from scanty
to copious and at times offense. If a foreign body is suspected a Diagnosis
rectal examination may help in diagnosis. If rectal examination a. Identification of the trichomonas is done by wet drop
fails then examination under anesthesia using thudicum nasal preparation of the causative organism. Vaginal secretion
speculum is to be done (photo in chapter 11). taken in post-menstual period from posterior fornix is put
Vaginal discharge is collected with a platinum on a slide and normal saline is added and seen under high
loop and two smears are taken, one for direct examination and power of the microscope wet mount (Figs 41.5 and 41.6).
other for Gram stain. There are 10–23 leukocytes per high power field. If found
A small amount may be taken with a pipette for culture in negative even on repeat examination, the confirmation may
Stuart’s media. be done by culture. Trichomonas are seen as unicellular
• Stool examination to exclude intestinal infestation mobile flagellate parasites (Fig. 41.7). Recently
• Treatment—in most cases, the cause remains unknown. immunochromatic graphic assays have been developed. Self-
• Simple perineal hygine will relieve the symptoms rapid tests are also available. One is trichomonas rapid test
• In case of soreness or after removal of foreign body estrogen
ointment is to be applied locally every night for two weeks.
• Alternatively, half tablet of ethinyl estradiol 0.03 mg is to
be given daily for 3 weeks to improve the local vaginal
defence. Lactic acid solution wash helps in many cases.
• Specific therapy should be given when specific organism is
isolated as will be seen.
Trichomoniasis
Vaginal trichomoniasis is the most common and important
cause of vaginitis during child bearing period.
ausative organism It is caused by trichomonas vaginalis, a
pear-shaped unicellular protozoan.
It measures 20 m long and 10 m wide. It has got four flagella
and a speal like protrusion at the other end with an undulating
membrane surrounding its anterior two third. It is actively
286 motile. Fig. 41.4: Discharge of trichomonas vaginalis
 Metronidazole—2 gm in a single oral dose for both partners
or 400 mg twice daily for 1 week for both partner.
Tinidazole—2 gm as a single oral dose for both partners.
Secnidozole—2 gm as a single oral dose for both partners.
If the symptoms persist, a second course of treatment is
given after an interval of 7 days.
To present recurrence it is a sound policy to initiate the
treatment schedule to both the husband and wife for 7 days
following menstruation for 3 consecutive cycles.
• In case of intolerance to oral metronidazole or 1st trimester
of pregnancy or in unresponsive cases—Intravaginal
medication with metronidazole or clotrimazole (100 mg)

Chapter 41
pessaries one per night for 6 consecutive nights has been
found effective.
Fig. 41.5: Preparing • Husband should use condom during coitus irrespective of
Fig. 41.6: Single wet mount of trichomonas
wet mount bacterial vaginosis and candidia contraceptive practice until both are cured.
If untreated, it may lead to pelvic inflammatory disease,
infertility, chronic pelvic pain and ectopic pregnancy.
Moniliasis: This condition is called vaginal thrush

Benign Conditions of the Vagina

Causative organism is candida albicans a Gram positive yeast
– like fungus but glabrata rusei and tropicalis may be
the caustive organisms. It thrives on carbohydrate and like an
acid medium (pH 4–5.5) (Fig. 41.9).
Pathology It is present in vagina in about 20 percent of
women without producing any symptoms.
Infection is more likely in patients of diabetes mellitus (more
glycogen in the cells and glycosuria)
• Pregnancy (increased vaginal acidity, increased glycogen
and renal glycosuria)
• Having broad spectrum, antibiotics (destroying acid
farming lactobacilli)
Fig. 41.7: Microscopic picure of trichomonas vaginalis showing • Corticosteroid therapy having oral pills
trichomonas (arrow) • Also common in association with thyroid, parathyroid
disease and with HIV infection or immunosuppressed state
in which self swab from vagina is taken, it is dipped in a test • Recurrence is from the bowel by glabrata
tube provided and rotate. The result is read like pregnancy There may be temporary relief during or soon following
test (Fig. 41.8). menstruation because of diminished acidity of vaginal flora.
b. Culture of the discharge collected by swabs is done in Vulvovaginal candidiasis can be classified into:
Kupferberg’s or Feinberg Whitlington medium. Also Uncomplicated—Sporadic or infrequent, mild to moderate
perform tests to exclude other STI. non-immune no compromised women, likely to be albican.
Treatment Educate the patient about the prevention of Complicated—Recurrent, severe non albicans, with
spread by using condom and getting full treatment for both uncontrolled diabetes, immunosuppression, debilitation and
partner. The following drugs can be given: those who are pregnant.

Fig. 41.8: Rapid test for trichomonas 287

 Diagnosis is conformed by direct smear of the discharge of
the flakes with 10% potassium hydroxide showing hyphae or
by culture in Nickerson’s or Sabouraud’s media (FIgs 41.11 to
41.13).
Treatment
Treatment with fungicides needs to be accompanied by
controlling glycosuria, (in cases of diabetes mellitus)
discontinuing oral contraceptive temporally and eliminating
any other etiological factor.
Drugs Topical preparations are available as pessaries and
creams.
Diseases of Vagina

• Oldest treatment is application of gentian violet

• Nystatin lotion is also useful.
• Clotrimazole or miconazole (100 mg) vaginal pessary- to
be inserted daily at bed time for 6 nights or 2 tablets daily
for 3 nights after wetting it with water.
• Clotrimazole (500 mg vaginal tablet) is administered in a
single dose.
• Sertaconazole ntirate 500 mg vaginal tablet single a day
• Clotrimazole 1% cream vaginally 7–14 days
• Micronazole 2% cream vaginally for 7 days Sertaconazole
2% cream vaginally for 7 days
Section 9

• Ticonozole 300 mg inserted once only

• Terconzaole (80 mg) vaginal suppository daily for 3 nights
• 1% clotrimazole or 2% micronazole vaginal cream for 7 nights
• 8% terconazole or 2% butoconazole cream for 3 nights
• 1% ciclopirox olamine 5 cm 3 of cream is inserted in the
vagina for 7 days
Oral systemic drugs include
• Fluconazole 150 mg for 1 day
• Ketoconazole 100–200 mg BD for 5 days
Fig. 41.9: pH testing of vaginal discharge • Itraconazole 200 mg BD for 1 day.
(pH strip showing pH) Associated intestinal moniliasis should be treated by
fluconazole 50 mg daily orally for 7 days.

Clinical Features
• The patient complains of vaginal discharge with intense
vulvo vaginal pruritus and burning. The pruritus is out of
proportion to the discharge.
• There may be dyspareunia due to local soreness. Dysuria
may be misdiagnosed as cystitis.
On Examination
The discharge is thick, curdy, white and in flakes, often adherent
to the vaginal wall (Figs 41.10 and 49.2).
Vulva may be red and swollen with evidence of pruritus.
Vaginal examination may be tender. Removal of the white
flakes reveals multiple oozing sports. Fig. 41.11: Budding cells. (A) and; (B) pseudohyphae
of candida on wet mount

Fig. 41.12: Budding cells and pseudohyphae of candida

288 Fig. 41.10: Curdy white discharge of candida on gram staining (arrow)
 Chapter 41
Fig. 41.15: Urethral vaginal and cervical smears for gram staining

Benign Conditions of the Vagina

Fig. 41.13: Vaginal candidiasis: Budding cells

Recurrent vulvaginal candidiasis is 4 or more episodes per

year. HIV may be suspected. Newer antifungal agents are
voriconazole, rilopirox, eberconazole and terbinafine are under
research.
Bacterial Infections
Gonococcal discharge The discharge is coming from urethra or
cervix. It has mucopain appearance.
Diagnosis Gram stain shows more than 30 leukocytes per field
and intracellular gram negative diplococcus (Fig. 36.7). Prepare
Fig. 41.16: Plating of smear sample on glass slide for gram staining
a slide for that (Figs 41.14 to 41.16).
reatment CDC do not advise fluoroquinone. Give a single dose Diagnosis—by enzyme immunoassay, direct fluorescent
cefitraxone 125 mg IM. antibody staining, DNA, Probe and PCR.
Husband should use condom during the treatment. reatment: Azithromycin 1 gm daily for 7 days or Doxycycline
hlamydial discharge Is also mucopurulent. It also shows more 100 mg twice a day for 7 days or Erythromycin (in pregnant
than 30 leukocytes per field. patients) 250 mg QIDx 7 days.

Figs 41.14A and B: (A) Taking urethral swab (B) Taking vaginal swab 289
 Atrophic vaginitis (senile vaginitis)
Vaginitis in postmenopausal women is called atrophic vaginitis.
In postmenopausal women, there is atrophy of the vulvo-
vaginal structures due to estrogen deficiency. The vaginal
defence is lost and the mixed pathogens normally present in
the vagina gain footing. These may be desquamation of the
vaginal epithelium which may lead to formation of adhesions
and bands between the walls.

Clinical Features
Postmenopausal yellowish or blood stained vaginal discharge.
Discomfort and soreness at the vulva.
Diseases of Vagina

On Examination
• Evidence of vulval inflammation is seen.
• Character or the discharge is yellowish or blood stained.
Fig. 41.17: Discharge of bacterial vaginosis
• Vaginal walls are found inflamed.
Diagnosis
Senile endometritis may coexist and carcinoma body of the
uterus or the cervix and these should be excluded prior to
therapy. This can be achieved by examination under anesthesia,
diagnostic curettage, cervical cytology or biopsy.
Section 9

Treatment
Oral ethinyl estradiol (0.01 mg) daily for 3 weeks. Estrogen
improves the resistance of vaginal epithelium, raises the
glycogen content and lowers the vaginal pH. Alternatively,
estrogen vaginal cream (conjugated estrogen cream 1.25 mg)
can be applied locally by an applicator. Can also give
intravaginal 25 µg 17 estradiol for 2 weeks then once or twice
weekly for one year.

Bacterial Vaginosis (BV) Fig. 41.18: Performing Whiff test

Bacterial vaginosis is one of the common causes of vaginal
discharge in the reproductive age group. which gives the cells a stippled look with obscured borders
Pathology Causative organisms are many (Fig. 41.19).
Gardnerella vaginalis is the organism most commonly 4. Absence of Doderlein bacilli.
associated with it. It is a small pleomorphic cocco bacillus that It is linked with preterm labor in pregnancy and hence
may be visible when stained and is found attached to epithetical treatment is essential. It being a STI is not clear yet.
cells as ‘clue cells.’ They are seen in the smear of vaginal exudates Recently screening tests for BV includes BV Blue test
or discharge. (showing color change), proline test. They can be done by self-
Other microorganisms isolated from vaginal cultures in BV sampling but not after douching, sex spermicide, vaginal
include ycoplsama hominis and anaerobic bacteria such as lubricants or feminine deodorant spray, etc.
Peptostreptococcus, bacteroides species, Prevotella species In BV test sample is taken by the swabs provided in the kit
Mobiluncus species and reaplasma urealyticum. and then gently swire in the solution provided add developer
Lactobacilli are decreased or absent. Amines produced by solution and see the color change (Fig. 41.20).
the microbial flora, possible by microbial decarboxylase, result
in the characteristics fishy odor on mixing vaginal fluid with
10% KOH (Whiff test).
is factors are foreign body, multiple sexual partners, etc.
Clinical Features
The patient characteristically present with a homogeneous
white, nonviscous, malodorous, uniformly adherent vaginal
discharge (Fig. 41.17).
Diangosis BV is diagnosed when at least three of the
following are present (Amsel Criteria).
1. pH of vagina is elevated (alkaline)
2. Positive Whiff test—giving amide odor on the slide of
normal saline vaginal smear if potassium hydroxide is
added (Fig. 41.18).
3. Clue cell representing at least 20 percent of the vaginal
epithelial cells presence of clue cells is the most important
criteria for diagnosis. A wet mount examination shows Fig. 41.19: Microscopic picture of bacterial vaginosis
290 squamous epithelial cells covered with multiple bacteria, showing clue cells (Arrow)
 Chapter 41
Fig. 41.20: Rapid test for BV

Treatment
Metronidazole (400 mg) thrice a day for 5–7 days. Fig. 41.21: Tubercular vaginitis
Clindamycin (300 mg) twice daily for 7 days Treatment
Clindamycin intravaginal cream 2%–5 gm once daily for 7

Benign Conditions of the Vagina

There is no specific treatment
days.
Improvement of general health
Metronidazole gel (0.75%) 5 gm intravaginally twice day
Removal of the foreign body
for 5 days.
Local application of anti-bacterial cream twice for 7 days.
Treatment of the male partner is also done. Vaginal acidifiers
Summary of different vaginitis is given in Table 41.1.
may suppress but do not kill anaerobic organism and alternative
Aspetic aginitis It may be caused by drug reaction, e.g. due
treatment like lactobacillus, yoghurt and disinfection have
to iodine pessary in some patients. Discontinuation and retrieval
limited use in the treatment of BV.
of left over pessary is required.
Viral infections will be dealt within chapter 50.
Rarely chronic vaginitis, e.g. tubercular vaginitis is seen VAGINAL BURNS
(Fig. 43.21).
Vagina burns are seen in the following cirucumstances:
Non-specific Vaginitis • In cases of illegal abortion some acid or alkaline solution
may be introduced into the vagina.
During the reproductive period, when the vaginal defence is
• Potassium permagnate tablets are also used for the same
lost, the local pathogens-like Strepococcus Staphylococcus, E coli,
cause.
etc. gain footing and produce acute symptoms. Foreign bodies
• Using rock salt in vagina for making it small in the
– like pessary, tampon, IUCD or childbirth trauma or vaginal
puerperium causes extensive vaginal burns.
operations predispose to such infection.
• Doughing of vagina with very hot fluid.
Clinical Features • During cryocautery or electric cautry of cervix the cautry
There is varying amount of vaginal discharge, sometimes probe slipping and burning vagina.
offensive with irritation of the vulva. • Radium therapy.
Pain and discharge are the common symptoms.
On Examination
The color consistency and the amount of discharge varies. Treatment
Vulva may be congested and swollen with evidence of Douching with saline is done to drain out any debris. Local
pruritus. liquid paraffin or any other emollient will help. Analgesic drugs
Vaginal mucosa is red, tender and swollen. are recommended if pain is untolerable.

Table 1.1: Characteristics of different vaginitis

Na ed eye icroscopic slide view Odour P hiff test Itching reatment

appearance
Normal Thin white Only epithelial cells No 4.0 Neg No Reassurance
and doderlein bacilli
Bacterial Thin, grey Less doderlein Yes >4.5 Positive No Metronidazole
vaginosis white bacilli, clue cells 400 mg BDx 7days
Condidial Thick white On KOH proportion No 4.0–4.5 Neg Yes Fluconozole 150 mg
vaginosis (cheesy) Hyphae or spores once Treat partner
Trichomonas Milky thick Motile flagellated Yes >4.5 Yes Metronidazole
vaginitis grey-white trichomonas seen 400 mg 1BD × 7d
or even Treat partner
green
Atrophic Thin A few epithelial cells No 4.0–4.5 No Yes Estrogen cream
vaginitis watery locally or tablets orally
291
 If there is infection, antibiotics may be required. Local BENIGN CONDITIONS OF VAGINA
corticosteroid cream is also used to prevent adhesions. Congenital Cysts
A medicolegal case is made in cases of illegal abortion.
Gartner Duct yst The Wolffian duct passes literally from the
Follow up is required so that adhesions do not form. In
mesosalpinx from the side of uterus, cervix and vagina. It is
that case plastic operation is to be done to relieve the adhesions,
usually seen on one or the other lateral wall of the vagina.
etc.
Histopathology shows well-defined basement membrane,
FOREIGN BODIES IN THE VAGINA columnar or cuboidal lining (Fig. 41.23). The unstriated muscles
are present surrounding it. The contents are clear. It is to be
A large variety of foreign bodies are seen in the vagina.
differentiated from cystocele, urethrocele and urethral
Neglected packs or swabs forgotten in the vagina after
diverticule asymptomatic cysts may be left as such, if sure of
stitching of episiotomy, putting back the uterus in vaginal
the diagnosis. Larger cysts require excision or marsupilization.
prolapse uterus, postoperatively after vaginal surgery and after
Diseases of Vagina

Rarely remnants of Mullerian duct with dispersed cervical gland

cervical biopsy or catheterization is the commonest foreign body
or Mullerian duct diverticule may present as vaginal cysts.
seen in the outpatient department. Long retained vaginal pessary
Remnants of coelom may be seen as vaginal cysts. Other causes
is occasionally seen. Contraceptives like condoms may be seen.
of vaginal cysts (Fig. 41.24) may be cysts of Skene’s tubules
Miscellaneous items like seeds, sex toys, buttons, erasors may
urethral diverticule, etc.
be seen in all age groups. In cases of illegal abortion sticks, a
Endometriosis of the vagina. Epidermoid cysts are seen
bunch of grass, etc. may be seen. One case of a glass in the vagina
in the posterior vaginal wall (implantation) is mostly
came to our OPD (Figs 41.22A and B).
iatrogenic by including the vaginal mucosa (by obstetric
Discharge is the commonest Symptom which is often
injury or colporrhaphy, etc.). Endometriosis may develop in
offensive.
episiotomy scar in vagina. Intradermal cysts may be rarely
Treatment is removal of the foreign body. It mostly can be
found in rectovaginal septum. It is different shaped from
done easily. Anesthesia may be needed in long retained pessary
Section 9

rectocele or enterocele as it is circumscribed, tense and has a

or in cases of children. In majority of the cases no other treatment
different feel. It is shelled out after incising posterior vagina
is required besides for local irrigation to wash out infection and
wall.
foreign body pieces like local antiseptic cream, etc.

A Fig. 41.23: Vaginal cyst-40x Dr Chandok Pathology

Dept ESI Hospital

292 Figs 41.22 A and B: Foreign body—Glass in the vagina Fig. 41.24: Posterior wall vaginal cyst
Benign Tumors Mostly seen after child birth. There
The common vagina tumors may arise from the vaginal or may be vaginal tears. Ask her when and where she feels pain
paravaginal tissues. They are not very common. Benign tumors during intercourse. There may be spasm of the vagina. It may be
seen in gynecology outpatient department are as follows: due to infection caused by douching of vaginal discharge. Any
1. Fibroma conflict with the sexual partners may be the cause. Is she using
2. Lipoma contraception?
3. Adenoma Do abdominal and vaginal examination to exclude a
4. Papilloma physical cause. A counselor may be engaged if relationship
5. Angioma difficulties are suspected.
6. Granuloma. It consists of dyspareunia, tenderness
Fibroma and leiomyoma are very rare and are seen as uniform and erythema of the vestibule is described in this condition.
vagina profusion. If they break down, get ulcerated then it is There is severe pain on vestibular touch or attempted vaginal

Chapter 41
difficult to to differentiate from carcinoma. The whole tumor is entry, tenderness on pressure localized within. The vulvar
shelled out and sent for histopathology examination to clinch vestibular and physical finding of erythema. The
the diagnosis. pathophysiology is not understood local analgesias and patience
Papilloma caused by HPV infection and treated by excision. on the part of the husband is important start.
Angioma are mostly seen on the right or left walls of the Local corticosteroid and a low dose tricyclic
vagina. antidepressant will help.
Mostly they are congenital and treated with excision. It was first described by

Benign Conditions of the Vagina

Granulomas are not a tumor. They are granulation tissues Skene and then Kell. It is defined as a chronic vulvar pain
because of infection of previous vaginal operations. Only syndrome. There is pruritis or sensation of burning, stinging,
excision biopsy can differentiate them from malignancy on rawness or irritation. On examination findings are not detected in
histopathologic examination. all patients. There can be redness, or local pain. Treatment
according to cause may help.
MISCELLANEOUS CONDITIONS Etiology is not known but can be abrnormality of embryonal
It is not frequently seen in gynecology outpatient development, increased excretion of oxalate in urine, hormonal
department of a general hospital but is occasionally encountered factor (in menopause or with oral contraceptive use) infection,
in private practice. inflammation, genetic and immune factors. It is like other
Recurrent or persistent involuntary sexual intercourse complex regional pain syndrome, e.g. fibromyalgia.
tightening of the vagina, spasm of the muscles occurs at the Somatic depression is often associated. Tricyclic
attempt of the outer third of the vagina or penetration by the antidepressants are widely used for this gabapentin (used in
penis if painful or difficult make intercourse impossible. There neuropathetic pain) is seen to given good results.
is marked distress or interpersonal difficulty because of Accupuncture, pelvic floor physiotherapy and biofeedback
vaginismus. exercises, interferon and low oxalate diet, calcium citrate,
hypotherapy, local nitroglycerine, botulinum toxin and 5%
Behavioral Therapy lidocaine ointment are also being used. In extreme cases local
• Relaxation therapy, trigger point release and myofacial vestibulectomy is done.A 2–5 mm depth tissue is removed.
release.
BIBLIOGRAPHY
• Exposure to vaginal dilators deep inside in gradually
1. CDC update to CDC sexually transmitted diseases treatment
increasing sizes using lubricants 5 minutes at a time daily
guidelines 2006. Fluoroquinolones no longer recommended for
till she is completely comfortable before starting next size. treatment of gonococcal infection. MMWR Morb Mark weekly Rep.
• Stop if signs of muscle spasm April 13, 2007;56(14): 332.
• Wait and try again. 2. Centers of Disease Control (CDC) and prevention chlamydial
Other sexual dysfunctions encountered in gynecology screening among active females enrollees of health planes-United
practice include: States 2000 MMWR weekly April 17, 2009;58/14:362-5.
Dyspareunia Recurrent or persistent genital pain before, 3. Croxtall JD, Plosker GL. Sertaconazole. A review of its use in the
during or after intercourse and not caused exclusively by lack management of superficial mycosis in dermatology and
gynaecology, Drugs 2009;69(3):339.
of lubrication or vaginismus.
4. Lotery HE, McCluse N and Galask RP. Vulvodynia. Lancet
It is persistent or recurrent 2004;463:1058.
inability to attain, or to maintain arousal until, completion of 5. Sobel JD, Wiesenfield HC, Martens M, et al. Maintenance
the sexual activity. There is in adequate lubrication and swelling fluconazole therapy for recurrent vulvovaginal candidiasis. N. Engl
response of sexual excitement. J Med 2004;351:876.

293
 42 Premalignant and Malignant
Conditions of the Vagina

Sudha Salhan

PREMALIGNANT CONDITIONS OF THE VAGINA These lesions are treated by different ablation methods. In
The commonest premalignant condition of the vagina is Vaginal VAIN 3 excision is attempted to rule out associated full blown
intraepithelial neoplasma (VAIN). The exact cause is not malignancy. In cases who fail conservative treatment removal
known but human papilloma virus (HPV) is usually the culprit. of upper vagina, and if multicentric, total vaginectomy may
It is introduced into the vaginal epithelium through skin be required. Skin graft is given in that case. Superficial
abrasions caused by coitus and the use of the tampon. The cautery by electric cautery is done under colposcopic vision
vaginal cuts heal by metaplastic squamous cells and HPV (if available). Laser can also be used—(1–1.5 mm destruction
viruses grow in them. It is mostly multifocal (unlike CIN) Table is required). Repetition of the treatment may be needed.
42.1. There are mostly no complaint. Foul smelling discharge Surface irradiation with intravaginal application is also
and vulval or vaginal warts may be seen. It may be an extension tried successfully, though ovarian functions are affected and
of CIN into the vagina. fibrosis of vaginal vault may result. In them estrogen therapy
Diagnosis is made by taking biopsy of the suspicious area. may be considered (if postmenopausal and no cancer is
Histopathology of the biopsy shows koilocytosis (typical detected).
of HPV infection). Topical application of 5-fluorouracil (5 fU) cream has been
The lesion is classified into VAIN 1, VAIN 2 VAIN 3 used by some. Each night at bed time 5FU is applied (5–8 days)
showing progressive lesion. But the progression to malignancy 2 weeks rest given and the cycle is repeated. The vulva and
is much less than in CIN. It is usually a part of multiple site perineum is painted with petroleum jelly to prevent local effects.
intraepithelial neoplasm. Cases of CIN and carcinoma of the Next morning do warm water douch.
cervix (treated) must be followed and an index of suspicion is Silliman and Coworkers (1997) reported 5 progression to
very high for VAIN in these cases. This is especially so after invasive disease despite close follow-up.
irradiation therapy for invasive carcinoma of the cervix. Cryocautery is contraindicated in vagina as the depth of
To exclude this premalignant condition, the vagina should injury cannot be controlled and injury to bladder or rectum
also be carefully examined under colposcope (though it is may occur (VVF RVF).
difficult to perform). If one lesion is seen look for other lesions. Another premalignant conditions of vagina is Adenosis of
Speculum is fully inserted and the vagina is examined. Then vagina—It is seen especially in females who are exposed to
gradually withdraw the speculum and look for other lesions. DES in the intrauterine period. But it is also seen without this
Upper third of vagina is most commonly involved. The vaginal exposure. They appear as red (cervical like epithelium) colored
ridges are more often the site of disease. The affected area is granular areas in the vagina. Cytological specimen is to be
slightly raised. Acetowhite lesions are seen. Their iodine uptake examined and colposcopic examination is to be done.
is also low especially after local use of estrogen for several weeks Colposcopically directed biopsy is to be taken or apply Lugol’s
in a postmenopausal woman. Acetowhite area with coarse iodine and do biopsy of the less colored areas. The possibility
punctuations and vascular abnormalities are seen. But of developing into adenocarcinoma of the vagina is not certain.
mosaicism is not seen, in vaginal lesions. But marked mosaic and punctuation pattern is seen.
Management aim is to preserve the function of the vagina
but prevent invasive disease. Each patient’s treatment is VAGINAL CARCINOMA
individualized depending on the extension of the lesion. Primary Incidence Incidence of primary vaginal carcinoma is
very rare (about 0.6 per 100,000 women). It constitutes about
1 of all genital malignancies. Primary vaginal carcinoma
Table 2.1: Difference between CIN VAIN should fulfill the following criteria:
IN AIN • Primary site of growth is in the vagina.
• As columnar epithelium is • No columnar epithelium is • Cervix and the vulva must not be involved.
normally present present • There must not be clinical evidence of metastatic disease.
• one of metaplastic trans- • No metaplastic transformation • Cervical cancer treated at least 5 years earlier.
formation is there zone. Most of the vaginal malignancies are secondary to cervical
• Glandular involvement is • No glands hence glandular in- and vulval cancers.
present. volvement not present Epidemiology of primary vaginal carcinoma. The exact
• Transformation zone is there • No transformation zone hence
hence high incidence of
etiology is unknown. Following factors are often related:
low incidence of vaginal
cervical cancer. • HPV may have a causal relationship. Hence patient gives
cancer.
history of genital warts.
• Progression from vaginal intraepithelial neoplasia (VAIN).
Exact incidence of progression to invasive vaginal cancer
from VAIN is not known.
• Up to 30 of women with vaginal cancer have a history of
cervical cancer treated last 5 years earlier.
– History of past irradiation.
– Husband with history of penile carcinoma.
• Diethylstilbestrol (DES) exposure is related with clear cell
adenocarcinoma of the vagina. This is found in those who
had history of intrauterine exposure to diethylstilbestrol.
• Previous irradiation therapy to the vagina or immune
suppression.

Chapter 42
• Prolonged use of a vaginal pessary
• Chronic ulcer of uterovaginal procedentia (Fig. 42.1)
• Low socioeconomic status is a factor
Fig. 42.2: Malignancy of vagina
• There may be history of vaginal discharge or irritation
• History of early hysterectomy (30–40 years)
• Chronic irritation of procidentia.

Premalignant and Malignant Conditions of the Vagina

Clinical Features
Mean age of the patient is about 55 years. If it occurs in patient
under 20 years it is mostly adenocarcinoma.

Symptoms
• May be asymptomatic being accidentally discovered during
routine screening procedures.
• Abnormal vaginal bleeding including postcoital bleeding is
conspicuously present as an early symptom.
• Foul smelling discharge per vaginum
• With more advanced tumor, urinary retention, bladder spasm,
hematuria and frequency of urination may occur. Tumors
developing on the posterior vaginal wall may produce rectal
symptoms such as tenesmus, constipation, or blood in the
stool. Fig. 42.3: Malignancy of vagina
• Non-healing ulcer of chronic prolpase may come in the
history.
Signs
Speculum examination reveals an ulcerative nodular or
exophytic growth in the vagina (Figs 42.2 to 42.4).
It usually takes the form of an ulcer with a hard base and raised
edges, which is fixed to underlying structures. Its surface is friable
and bleeds easily on touching on per vaginal examination. Per
rectal examination is mandatory.
The cervix looks apparently normal in all primary vaginal
carcinoma.
Diagnostic tests: CT scan will give the extent of the disease.

Fig. 42.4: Malignancy of vagina (Melanoma)

Screening
Routine screening of all patients for vaginal cancer is
inappropriate according to WHO criteria of screening. For
women who have had a cervical or vulvar neoplasm, the Pap
test is an important part of routine follow-up with each
physician visit. It is recommended that Pap test surveillance
for vaginal cancer be performed yearly after the patient has
completed surveillance for cancer of the cervix and vulva.

Pathology
Site: Commonest site is in the upper third of the posterior wall.
Fig. 42.1: Vaginal carcinoma in prolapse uterus It may spread to cervix or vulva. But if the lesion is seen initially 295
 in cervix or vulva also it is not called primary vaginal
malignancy.
Naked eye: Growth may be ulcerative or fungative Biopsy is
diagnosic.
Histopathology types usually seen are:
1. S uamous cell carcinoma: It is the most common type
occurring in 80–90 of vaginal carcinoma (Fig. 42.5).
• Most commonly occurs in the upper posterior wall of
the vagina.
• Mean age of patient with squmous cell cancer is 60 yrs.
Small cell carcinoma containing neuroendocrine cells may
Diseases of Vagina

be rarely seen.
2. Malignant melanoma (Figs 2. and 2. ): It is the second
most common cancer of the vagina. It is rare in vagina. It
spreads to distant organs and is rapidly fatal. Accounting for
2.8 to 5 of all vaginal neoplasma.
• Most common location of these tumors is in lower third
of the vagina.
• Average age is 58 yrs.
• It carries a poor prognosis depending on the depth of
the epithelial invasion. Treatment is ineffective if it is
deeply invasive as it metastasizes early through the
Section 9

blood stream.
3. Adenocarcinoma: Primary adenocarcinoma of vagina is Fig. 42.7: Malignancy of vagina (operated specimen) melanoma
extremely rare.
Can arise in relics of the Wolffian duct. When it does occur it
forms a tumor deep in the lateral vaginal wall. Adenocarcinoma can also be of Mullerian duct origin. It is
arising possibly in misplaced cervical glands, but it is more
likely as a result of metaplasia or as a consequence of the
potential for Mullerian duct tissue to differentiate in different
ways.
A special form of adenocarcinoma is the clear cell
adenocarcinoma. It usually arises high on the anterior vaginal wall
and it is very superficial and is often polypoidal. It is found in
girls less than 25 years of age and in 80 of case there is history of
exposes of diethylstilbestrol (DES) in utero before the eighteenth
week of pregnancy.
The estimated risk for developing clear cell adenocarcinoma
from an exposed offspring is one in 1000 or less.
97 of cases of vaginal clear cell adenocarcinoma are
associated with adenosis.
Sarcoma of vagina: Various histopathological types are
described like fibrosarcomas, rhabdomyosarcoma. or
Fig. 42.5: Squamous cell carcinoma of vagina, Courtesy by
leiomyosarcoma. It is also extremely rare. All sarcomas carry a
Dr Chandok, Pathology Dept ESI Hospital poor prognosis because blood stream dissemination occurs
early.
• A special tumor of vagina mostly seen in children and infants is
Botryoid Rhabdomyosarcoma. Results of radial surgery are
not encouraging. Chemotherapy with vincristine, echinomycin-
D and cyclophosphamide has been reported to be successful
in about 82 of cases.
• Endodermal sinus tumor of the vagina occurs in young
women. They are treated with surgery and chemotherapy.

Spread of Vaginal Malignancies

• Carcinoma of the vagina spreads by direct extension to the
bladder (vesicovaginal fistula), rectum (rectovaginal fistula),
cellular tissues of the uterosacral and broad ligament, the
cervix and vulva.
• By lymphatics: (Fig. 42.8) When the growth is in upper
vagina lymphatic spread is same as in carcinoma of cervix.
If growth is in lower part of vagina then vulval lymphatic
drainage fields are implicated. Inguinofemoral lymph nodes
296 Fig. 42.6: Malignant malenoma of vagina and pelvic lymph nodes are commonly involved.
 • Blood borne spread involves the lungs, liver and bones. In
case of melanoma and sarcoma hematogenous spread is
relatively early.

Diagnosis
The diagnostic workup includes complete history and physical
examination. Careful speculum examination and palpation of
the vagina and bimanual pelvic and rectal examination is
essential.
• During screening procedure it can be suspected if abnormal
cytology is obtained.
• Colposcopic examination and targeted biopsy are helpful

Chapter 42
for patient with abnormal cytology or unexplained vaginal
bleeding
• A full thickness generous biopsy from clinically suspected
lesion is very important.

Staging of Vaginal Carcinoma

Tumor that extends to the vagina from cervix is regarded as

Premalignant and Malignant Conditions of the Vagina

cancer of the cervix. Cancers involving vulvo-vagina area are
classified as cancer of the vulva. But tumors confined to vagina
are vaginal carcinoma.
The clinical staging carcinoma of vagina (Figs 42.9A to G) as
outlined by FIGO is tabulated below:
Stage 0 Carcinoma in situ
Stage I Carcinoma is limited to the vaginal wall
Stage II Carcinoma invades paravaginal tissue but has not
Fig. 42.8: Lympthatic drainage of vagina extended to the pelvic wall.

Figs 42.9A to E 297

Diseases of Vagina

Figs 42.9F and G

Section 9

Figs 42.9A to G: (A to E) Staging of vaginal carcinoma (Stage I to III) (F and G) Staging of vaginal malignancy (Stage IV)

Stage IIA Subvaginal invasion, not into parametrium Surgical Treatment: (i) is used in localized growth in young
Stage IIB Parametrial infiltration not extending to pelvic wall patients who desire to preserve ovarian function. (ii) In patients
Stage III Carcinoma has extended to the pelvic wall with vaginal carcinoma. (iii) Verrucous carcinoma. Radical
Stage IV Carcinoma has extended beyond the true pelvis or vulvovaginectomy with bilateral groin lymph node dissection
has involved the mucosa of the bladder or rectum. is the operation performed in the patient with carcinoma in
Stage IVA Adjacent organs are involved (bladder, rectum) prolapse uterus (Fig. 42.1). (iv) Sarcomas are treated with
mucosa and /or extends beyond the true pelvis surgery, irradiation and chemotherapy.(v) Endodermal sinus
(only bullous edema is not sufficient evidence to tumor of the vagina needs surgery.
classify as stage IV) Hyperthermia seems to improve treatment outcome for
Stage IVB Distant organs are involved. patients with locally advanced vaginal carcinoma combined
Cystoscopy proctosigmoidoscopy, chest -ray and intravenous with chemotherapy. (Mertine et al, 2010).
phelography are required to asses the spread of the disease.
Transrectal ultrasound and MRI can be useful in assessing the Prognostic Factors
extent of the lesion. Location: Upper vagina lesion has better prognosis. Multiple
Treatment of vaginal carcinoma depends on the stage of lesions have bad prognosis. Non-epithelial (sarcoma,
the disease. melanoma) have bad prognosis. Aggressive growth with over
Stage I Depending on the site if the lesion is in upper expression of onchogenes in sarcomatous (HE -2 Neu wild type
vagina especially posterior and lateral fornix. The p53). Lesion has bad prognosis. Depth of penetration into the
treatment is radiation therapy which will pre- vaginal wall and surrounding tissues has bad prognosis.
serve vagina and its organs in close proximity Recurrence: Post-irradiation local recurrence can be treated
(urethra, bladder and rectum). If surgery is con- with local excision or partial vaginectomy or extensive surgery
templated it involves radical hysterectomy, pel- depending on the size of the lesion.
vic lymphadenectomy and partial vaginectomy. Follow-up: Regular and meticulous follow-up every 3 months
Radiation therapy is given in chapter 40. (initially) is essential for early detection of recurrences.
Stage II A A combination of interstitial and intracavity Secondaries in vagina comes from the choriocarcinoma (Fig
radiotherapy is the treatment. in chapter 25)
Stage IIB, Stage III and stage IV – Radiation therapy to treat
pelvic disease (internal genital) and radical BIBLIOGRAPHY
vulvectomy and bilateral lymph node dissection 1. Herbst AL, Green TH r, Ulfeder H. Primary carcinoma of the
for external genital tumor. vagina. Am Obstet Gynecol. 1970;106:210.
Small cell carcinoma is rapidly fatal. Surgical resection and 2. Hoffman MS, DeCesare SL, Roberts WS, et al. Upper vaginectomy
for in situ to occult superficial invasive carcinoma of the vagina. Am
radiation with adjuvant chemotherapy is required.
Obstet Gynaecol 1992;166:30.
Rhabdomyosarcoma treatment is a combination of surgi-
3. Martine F, acoba VD . Use of combined radiation and
cal resection, irradiation and systemic chemotherapy (vincris- hyperthermia for gynecological cancer. Curr. Opin. Obstet Gynecol
tine, dactinomycin and cyclophosphamide (VAC) for 1–2 years. 2010;20(1):9.
Melanoma (Figs 2. and 2. ) and Leiomyosarcoma: Treat- 4. Sillmen FH, Fruchter RG, Chen S, et al. Vaginal intraepithelial
ment is radical surgery (hysterectomy, pelvic lymphadenectomy neoplasm: Risk factors for persistence, recurrence and invasion and
298 and vaginectomy) (Fig. 42.7). its management. Am Obstet Gynecol 1997;176: 93.
 Section 10 Diseases of Cervix

43 Benign and Premalignant

Conditions of Cervix

Sudha Salhan, Harsha Gaikwad, Moni Tuteja

BENIGN CONDITIONS OF THE CERVIX suprapubic growth due to hematometra is seen. The
Benign conditions of the cervix can be classified into the diagnosis is by ultrasound and MRI. An IVP is necessary
following headings: to exclude coexisting renal congenital abnormality.
• Congenital abnormalities Surgical operation is by perineoabdominal approach.
• Inflammatory disease Vaginoplasty is done. Perabdominally uterus is opened
– Atypia of repair and the cervix is canalized and connected to the vagina.
– Tuberculosis, syphilis An indwelling catheter is put in uterus and brought out
– Mucus polyp, radiation-induced atypia Hyperkeratosis of vagina (Figs 43.1A to C).
and Parakeratosis 2. Multiple cervix (Fig. 43.2)
– Nabothian follicles 3. Hypertrophied of supravaginal cervix—causing
• Non-infectious cervicitis nulliparous prolapse. Sling operation is done to pull
• Metaplasia, Hyperplasia and Endometriosis the cervix up. Once she is pregnant elective cesarean is
– Tubal metaplasia performed to prevent recurrence of prolapse (Fig. 43.3).
– Microglandular endocervical metaplasia Also see chapter 29.
– Mesonephric duct remnants 4. On the side of the cervix Gartner’s duct cyst (persistent
– Inflammatory disease Wolffian duct cyst) can be seen. It is to be excised.
• Benign tumors 5. Mullerian duct diverticula can form cysts needing excision.
– Endocervical polyp For more congenital abnormalities—duplicate cervix, etc. see
– Pseudomyxoma botryoides chapter 27.
– Placental site trophoblastic nodule
– Leiomyoma Inflammatory diseases
– Adenoma
– Angioma, papilloma Atypia of Repair
– Miscellaneous tumor It occurs in cases of severe, acute or long-standing chronic
– Cysts inflammatory or infection, e.g. erosion, (Ectropion) (Figs 43.4A and
– Inclusion cysts. B). The squamous and endocervical epithelium undergo reactive
changes, i.e. epithelial disorganization and nuclear atypia.
Congenital abnormalities of the cervix Pathological changes: 1. Nuclear enlargement. 2. Mitotic
1. Atresia of cervix. It is usually seen with non-canalization figures
of the vagina. If the uterus is well-formed the young 1. Normal mitotic figures: Vacuolated cytoplasms which is
girl presents with cyclic pains in the lower abdomen. If eosinophilic. These changes are focal and upper epithelial
the complaint is of some duration a hypogastric layers are normal.

Figs 43.1A to C: Insertion of catheter in uterus after vaginoplasty and canalization of cervix
 3. Radiation inducted atypia: Treatment of cervix with
therapeutic levels of radiation can cause atypia in both
squamous and glandular epithelium. These changes can
exist up to 17 years.
4. Hyperkeratosis and Parakeratosis: Detected in 8% of women
undergoing Pap smear screening. Both lips of the grossly
appear thickened white epithelium which can be focal or
diffuse (Fig. 43.8).
When diffuse, entire portion is covered by thickened, white and
wrinkled epithelial membrane. When focal, a raised white
plaque is present (Leukoplakia of cervix Fig. 43.9) is mostly
due to trichomoniasis gonorrhea chlamydia or candidal
Diseases of Cervix

infection.

CERVICITIS
Trichomonas—Cervical infestation by T. vaginalis is quite
Fig. 43.2: Duplicate cervix frequent and associated with concurrent vaginitis. A foamy
yellow green vaginal discharge is typically described (Fig.
43.10). Diagnosis is made by visualizing trichomonas on wet
mount. A culture using diamond’s medium can be done.
Chlamydial and gonococcal infection causes mucopurulent
discharge (Figs 43.11 to 43.13).
Section 10

Fungal Disease
Cervical fungal infection by Candida albicans occurs as a part of
generalized lower genital tract infection. Antibiotic therapy,
poorly controlled diabetes mellitus, immunosuppression favors
fungal infection.
Typically Candida infection is associated with viscous and
curdy white vaginal discharge associated with vulval pruritis
(Fig. 43.14).
Cervical candida infection associated with increased
polymorpholeukocytes present in upper layer of epithelium and
fungal hyphae are seen on PAS stain.
Rare instances of parasitic infestation by Echinococcus a
Fig. 43.3: Hypertrophic cervix
hydatid cysts or amebiasis may be associated.

Abnormal mitosis distinguishes the inflammatory lesions Cervicovaginitis Emphysematous

from adenocarcinoma of cervix. Multiple, blue gray, subepithelial cysts of portiovaginalis and
2. Tuberculosis of the cervix (Figs 43.5 to 43.7): It is to be vagina characterize this unusual case.
differentiated from carcinoma of the cervix by biopsy.
Treatment is antitubercular treatment for 6 months. Syphilis HPV Infection
of the cervix is caused by Treponema pallidum. Diagnosis It (types 6, 11, 51, 53, 35) is usually associated with cervicitis. It
by VDRL, Specific tests and by biopsy. Treatment is by can cause exophytic condyloma accuminata which is a
Penicillin (chapter 36). cauliflower like growth arising from cervix. The classical

300 Figs 43.4A and B:Cervical erosion

 Chapter 43
Fig. 43.5: Tubercular cervicitis Fig. 43.6: Tubercular endocervicitis (10x) (40x)
(Dr Yadav, RML Hospital)

Benign and Premalignant Conditions of Cervix

Fig. 43.7: Tubercular endocervicitis (40x) Fig. 43.8: Leukoplakia of the cervix
(Dr Yadav, RML Hospital)

Fig. 43.9: Leukoplakia of cervix (Courtesy by Dr Chandok, Fig. 43.10: Trichomoniasis: Strawberry cervix
Pathology Department ESI Hospital)

histological features are papilomatosis with acanthosis, Multiple painful vesicles are present on cervix, vagina,
parakeratosis and hyperkeratosis with nuclear atypia and vulva and perineum. Occasionally ulcero-necrotic process is
koilocytosis. so extensive that a fungating, necrotizing mass appear on the
cervical portio that can be mistaken for carcinoma.
Herpetic Cervicitis Shedding of HSV from asymptomatic lesion is a hidden
Primary infection produces symptoms within 3–7 days after reservoir for propagation of infection.
exposure. If vulva is involved then severe vulval pain, Nabothian follicles (glandular hyperplasia and Nabothian
tenderness and profuse waterly discharge is present. Symptoms follicles) (Figs 43.15A and B). They are retention cysts of the
of recurrent diseases are less severe. cervical glands. A few small follicles do not produce any 301
Diseases of Cervix

Fig. 43.11: Mucopurulent cervicitis due to chlamydia

Fig. 43.14: Candida infection of the cervix

Section 10

Fig. 43.12: Chlamydial cervicitis

Figs 43.15A and B: Nabothian follicle

NON-INFECTIOUS CERVICITIS
Patients usually present with excessive vaginal discharge usu-
ally copious and nonfoul smelling. The causes include cervical
trauma during uterine gynecological procedures. Irritations due
to vaginal contraceptive fluid and tampons, postvaginal douch-
ing, or after use of vaginal pesarry or cervical diaphragm.
It may present as clinically congested and inflamed cervix,
which may even bleed on touch. It may be associated with
multiple Nabothian cyst and ulcerated ulcer lesions on the
cervix. Treatment is removal of the irritant and may need local
levage with metronidazole solution.

METAPLASIA, HYPERPLASIA AND ENDOMETRIOSIS

Tubal Metaplasia
It refers to endocervical glands all lined by a Mullerian type
epithelium that closely resembles that of a fallopian tube.
It can be found in 31% of patients not related to phase of
menstrual cycle.
Fig. 43.13: Gonococcal cervicitis
Ciliated cells may be seen on histopathological examination
which distinguishes it from neoplasia.
symptoms. But if they are in large number (chapter 4) and bigger
size will cause symptoms like pain. Endocervical Hyperplasia (Microglandular)
– On examination they are bluish small swelling (a few It is a florid endocervical hyperplasia.
millimeters in size) on the external os with maximum These cases appear to be benign as no malignant cases have
size of a pea. been reported.
302 – Treatment is ablation (by cautery). It is an incidental finding on biopsy.
Mesonephric Hyperplasia and Mesonephric Remnants polyps are single measule 2-3 cm. Rarely they may reach
Vestigial elements of mesonephric ducts may be present in gigantic dimension protruding beyond introitus and resembling
lateral aspect of cervix. They consist of small cysts deep in lateral carcinoma. Squamous metaplasia involving of surface of polyps
cervical wall. They may enlarge to become cysts of lateral is frequently observed (Figs 43.16 to 43.18).
cervical wall. It is extremely uncommon for either in situ or invasive
carcinoma to arise in cervical polyps.
Endometriosis Endocervical polyps with adenocarcinomatous change must
It refers lesions composed of ectopic endometrial glands and be distinguished from polypoidal adenocar-cinoma of
stroma. It may occur on the portio vaginalis of the cervix or in endocervix by looking for involvement of base of polyp which
the endocervical canal. They may appear as one or more small, is seen in the latter.
blue a red nodules measuring few millimeters in diameter. Cervical Fibroid (Fig. 43.19) may be seen. Myomectomy is
However, lesion may be larger or cystic or may produce difficult to perform. Mostly hysterectomy is the treatment.

Chapter 43
abnormal vaginal bleeding. The mechanism of development is
Inclusion Cyst
not known but it usually develops following cervical trauma
which supports the implantation metaplastic theory of Traumatic inclusion cysts are form of epidermal inclusion cyst
endometriosis. that commonly occur in vagina at sites of surgical repair of
episiotomies or a vaginal intrapartum laceration. They are
BENIGN TUMORS thought to develop from variable fragment of epithelium that
may become entrapped within the stroma at the time of obstetric
Endocervical Polyps

Benign and Premalignant Conditions of Cervix

trauma or subsequent surgical repair. They are uncommon on
It constitutes the most common new growth of uterine cervix. cervix—they are unilocular cystic structure 1–2 cm in diameter
They are focal, hyperplastic protrusion of endocervical fold, beneath native poeriaepithelium.
including epithelium and substantia propria.
It is found most commonly in fourth to sixth decades of life. Other Tumor Like Lesion
They may present with profuse leukorrhea caused by Decidual pseudopolyp and decidualization occur due to
hypersecretion of mucus from inflamed endocervical epithelium. decidual changes in cervix in pregnancy. On exocervix it may
They are rounded or elongated with smooth or lobulated appear as a raised plaque or pseudopolyp that can be mistaken
surface that is reddened due to increased vascularity. Most for carcinoma.

Fig. 43.16: Cervical polyp Fig. 43.18: Cx polyp (4x)

Fig. 43.17: Cx polyp (10x) Fig. 43.19: Cervical fibroid 303

 Other tumor like lesion which may appear as nodules on 43.21A and B) near squamocolumnar junction. There are
raised lesion over exocervix may pathologically be a variations in position of the transformation zone according to
postoperative spindle cell nodule or inflammatory age. Almost all sexually active women get infested with HPV
pseudotumor or lymphoma like lesion. Biopsy will settle the within 2 years of active sexual life. The virus remains latent in
issue. these cells (latent infection). They can be diagnosed only by
repeated HPV DNA testing. However, due to normal
PREMALIGNANT LESIONS OF CERVIX immunology of the host cells this infection clears spontaneously
AND THEIR MANAGEMENT 98% of women. In rest of the women the latent HPV starts
replicating (productive viral infection) especially in intermediate
On studying the natural history of carcinoma of the cervix uteri
and superficial cells. Therefore, it is the persistent HPV
(Flow chart 44.1) it is established that carcinoma in situ of the
infection which leads to premalignant and later malignant
cervix takes about 15.6 years to become a full blown carcinoma.
lesions of the cervix.
Diseases of Cervix

The easy accessibility of the cervix is also a great boon. Keeping

Pap smear followed by colposcopy and if need be, directe
these two points in view, it becomes necessary to have a
biopsy gives the severity of premalignant lesion.
knowledge of premalignant conditions of the cervix. So that
we can diagnose them and treat them before they become Cervical Intraepithelial Neoplasm (CIN)
cancerous. Screening by Pap smear and colposcopy is given in It is the most common premalignant condition of the cervix. It
the chapter on screening (Chapters 39 and 65). By screening includes CIN 1 (Figs 43.22 to 43.24), CIN 2 (Figs 43. 25 to 43. 27)
various premalignant conditions of the cervix can be diagnosed. and CIN3 or in situ carcinoma (Figs 43.28 to 43. 33) and
Their proper treatment in time, will prevent development of adenocarcinoma in situ.
full blown carcinoma of the cervix (secondary prevention). Clinical Presentation and Diagnosis of CIN CIN lesions
Hence, their knowledge is essential. are usually asymptomatic and cannot be diagnosed by naked
The causative agent is considered to be human papilloma eye examination as the cervix often looks normal. Currently,
Section 10

virus (HPV) in majority of these premalignant lesions. HPV the only reliable and practical way of diagnosing these patients
infect the epithelial cells especially the rapidly multiplying is by cervical cytology, colposcopy and colposcopic-guided
immature cells of the thin transformation zone (Figs 43.20, punch biopsy. In most reporting systems, there is generally no
issue with high-grade squamous intraepithelial lesions (HSILs)
like CIN 2 and CIN 3. The main problem lies in the borderline
group such as ASCUS (atypical squamous cells of unknown
significance) or AGUS (atypical glandular cells of unknown
significance).These two entities are not to be neglected, cut off
point being HSIL. Fifty percent of HSILs have previous ASCUS.
Colposcopy gives less than 50% specificity though more than
90% sensitivity. By doing HPV testing the cytology results can
be improved upon. As long as low grade intraepithelial lesions
(LSIL) are concerned, 30–40% have a HSIL coexisting within
the cervix, while 8–14% of women with ASCUS smear harbor a
HSIL. Interestingly, 50–70% of LSIL lesions regress. Hence,
cytology is repeated after 6 months in LSIL before colposcopy
and in ASCUS after 12 months before colposcopy. If HPV DNA
is positive in a woman more than 35 years of age than
colposcopy is a must even if the cytology shows LSIL or ASCUS,
because in only 3–5% of such females the HPV infection is
transient.

Management of CIN 1 (LSIL) and CIN 2

and 3 (HSIL) Based on Colposcopy
The management of CIN 1 lesions is more controversial as
many of them may regress with time and some may remain
the same or progress. In a longitudinal study, 100 women
with biopsy proven CIN 1 were followed up and 75% of the
cohort were noted to have spontaneous resolution of the
lesions as shown by consecutive negative cytology and
colposcopy (Falls 1991). Only 4.5% had progressed to higher
lesions. In young women, it is perhaps better to only observe
as treatment may affect the cervix by scarring and the risk
for malignant change is extremely small. In older women who
have completed their family, treatment may be advocated so
that the cervix may return to normal speedily thereby allaying
anxiety. Early treatment may be indicated in such patients. If
a watch policy is undertaken for CIN 1, it is important to
ensure that the patient is compliant for follow-up. Otherwise,
treatment may be indicated at an earlier stage. If the CIN 1
lesion persists for more than 12 months, treatment is usually
304 Fig. 43.20: Position of transformation zone in different age groups indicated.
 Chapter 43
Benign and Premalignant Conditions of Cervix
Figs 43.21A and B: (A) Pictorial depiction of squamocolumnar junction; (B) Progression to full blown cervical cancer

Fig. 43.22: CIN 1 epithelium Fig. 43.23: Early metastasis

• If the transformation zone (TZ) is completely or partially the epithelial basement membrane has not been breached.
visible on the ectocervix and the lesion is small then Hence, there is no chance of the lesion invading the
cryocautery or electrocautery is adequate.If the lesion is lymphatic or blood vessels in the stroma to result in regional
large then laser or electrocautery can be used. or distant spread. For this reason, treatment by either local
• If the TZ is not visible then conization is more appropriate. ablation or excision has been highly efficacious in
Premalignant lesions of the cervix do not disseminate as eradicating the lesions. It is generally agreed that high-grade 305
Diseases of Cervix

Fig. 43.24: CIN1 with koilocytosis (40x) (Dr Yadav, RML Hospital) Fig. 43.25: CIN 2 (40X) (40x) (Dr Yadav, RML Hospital)
Section 10

Fig. 43.26: Mild CIN 2 Fig. 43.27: CIN 2 (40X) (Dr Yadav, RML Hospital)

Fig. 43.28: CIN 3 Fig. 43.29: Severe dysplasia (CIN 3)

CIN lesion, i.e. CIN 2 and CIN 3, should be treated as soon Patients with extensive high-grade CIN 2 and 3 lesions
as the diagnosis is made as the risk for progression to should preferably be treated by excisional methods rather
invasive disease is significant. There is at present no way than ablation as there is a higher chance of treating
that we can predict how fast this process is going to take. unsuspected microinvasive disease in such cases. In
Progression even within 6 months has been reported. histological studies, it has been found that CIN 3 lesions
306
 Chapter 43
Fig. 43.30: CIN 3 (40X) ((40x) Dr Yadav, RML Hospital) Fig. 43.31: Carcinoma in situ-Cervix (H&E; 10x)

Benign and Premalignant Conditions of Cervix

(Dr Anurag Mehta Rajiv Gandhi CRIC))

Fig. 43.32:Carcinoma in situ Ecto-Cervix. See the full thickness Fig. 43.33: Cervical biopsy showing CIN 3
involvement of mucosa (Dr Anurag Mehta (Rajiv Gandhi CRIC))

with extensive involvement of the surface epithelium and 90% regardless of whichever method is chosen. Commonly
deep endocervical gland involvement are associated with used methods include:
higher incidence of microinvasion. A persistently positive 1. Laser vaporization with CO2 laser
high-risk HPV test after treatment for CIN has been found 2. Cold coagulation where the lesion is treated with teflon-
to be more predictive for conversion of CIN 2 to 3 than an coated probe to 100°C
abnormal PAP smear with a sensitivity of 90%. Negative 3. Cryosurgery
predictive value of a negative high-risk HPV was 99%. In 4. Diathermy.
another study, 45% of patients with persistent HPV infection All ablative methods can be performed as outpatient
after conization developed CIN recurrence whereas none procedure, usually taking less than 10 minutes. Laser
developed CIN recurrence in HPV negative patients. HPV vaporization can be done under local anesthetic, whilst
testing has, therefore, been advocated as a useful follow- cryosurgery and cold coagulation are well tolerated even
up test for treated CIN lesions. without any anesthesia.
The main drawback for ablative procedures is that of
Ablative Therapy for CIN inadvertent overlooking of an early invasive disease missed
The main aim of ablative treatment for CIN is the destruction of on colposcopy and colposcopy-directed punch biopsy. This can
the whole TZ of the cervix. It has been found that treatment of occur in about 4.7% of cases. There have been reports of cervical
only the abnormal areas sparing the normal looking part of the cancer occurring in women who had cervical ablative
TZ is associated with a high risk of persistent or recurrent disease. procedures for CIN.
The CIN lesions may affect cervical glands which may be as deep
as 5.2 mm below the cervical surface. It is therefore, important to Excisional Treatment for CIN
destroy the abnormal TZ up to a depth of about 6 to 8 mm from Cartier from France (1984) pioneered the low voltage small loop
the surface in order to have a high chance of cure. diathermy for biopsy of the cervix and he obtained good
Destruction of the whole TZ by various ablative methods histological specimens. It was Prendiville and associates from
have been used with consistent and high success rates of about the UK (1989), who modified and developed the large loop 307
 diathermy to excise the abnormal TZ (LLETZ). Since then, this stenosis a real problem. In patients with cervical stenosis, it is often
method has been used very commonly worldwide in the difficult and sometimes impossible to obtain adequate samples from
treatment of CIN. the endocervix for cytology. Colposcopy is also affected as the
It is important in LLETZ to ensure that colposcopy is squamocolumnar junction is often not visible and there are no
satisfactory as the therapeutic aim of LLETZ is to remove about reliable colposcopic features in these patients. However, there seems
8 mm depth of the cervical TZ (Fig. 43.20). to be a place for conservative treatment in a select group of young
women whose cone biopsy shows clear resection margins. In these
Cone Biopsy patients, it has been found that about 17% require further treatment
Cervical cone biopsy is indicated when: for recurrent cytological abnormalities and 15% are found to have
1. Colposcopy is unsatisfactory, recurrent disease at 4 years of follow-up. Therefore, women who
2. The cervical punch biopsy shows microinvasion, opts for conservative treatment have to be regularly followed up in
3. There is discordance between cervical biopsy and cervical the colposcopy clinic with cytology and colposcopy. As recurrence
Diseases of Cervix

smear of more than 1 grade, often occurs in the endocervical canal in these patients, cytology
4. The PAP smear shows atypical glandular cells favoring should include endocervical specimen using a cytobrush or similar
high-grade lesion, sampling device.
5. Persistent AGUS, or
6. Smear showing adenocarcinoma in situ cells. MANAGEMENT OF ABNORMAL CERVICAL
The main aim of a cone biopsy is to remove the cervical canal CYTOLOGY DURING PREGNANCY
and to look for and assess a possible endocervical lesion. In the The NIH/ASCCP sponsored 2001 Consensus Guidelines for the
case of microinvasion, the aim is to produce a large single cone Management of Women with Cervical Cytological Abnormalities
biopsy to remove the entire lesion so that the maximal depth of state:
invasion, horizontal spread of the disease and status of • It is preferred that the colposcopic evaluation of pregnant
lymphovascular invasion can be assessed accurately. A clear women with HSIL be conducted by clinicians who are
Section 10

disease-free resection margin should always be aimed as the experienced in the evaluation of colposcopic changes
chance of cure is affected by the resection margin status. induced by pregnancy.
Cone biopsy has been shown to be efficacious in eradicating • Biopsy of lesions suspicious for high-grade disease or cancer
CIN lesions. In a longitudinal study of 4417 patients with cold is preferred.
knife cone biopsy for CIN 3 where the resection margins are • Endocervical curettage is unacceptable in pregnant women.
clear, 99% of patients were free of CIN after a mean follow-up • Since unsatisfactory colposcopy may become satisfactory as the
period of 18 years Positive resection margin, however, is an pregnancy progresses, it is recommended that women with an
important risk factor for recurrence and persistent disease. In unsatisfactory colposcopy undergo a repeat colposcopic
those with involved margins recurrent CIN lesions usually examination in 6–12 weeks.
appear shortly after surgery indicating residual disease. • In the absence of invasive disease, additional colposcopic and
Harmonic scalpel is a new surgical tool that cuts and cytological examinations are recommended, with biopsy only
coagulates by converting electrical energy to ultrasonic if the appearance of the lesion worsens or cytology suggests
vibrations and has been advocated as a suitable cutting tool for invasive cancer.
cone biopsy. When compared to electrosurgical technique, • Unless invasive cancer is identified, treatment is
harmonic scalpel cone biopsy specimen is often removed in 1 unacceptable.
piece and the thermal artifacts are less than that produced by • Re-evaluation with cytology and colposcopy is recommended
electrosurgical techniques. Another method that was recently no sooner than 6 weeks postpartum.
described is needle excision of the TZ with a diathermy needle.
The operations were performed under local anesthesia and all CLINICAL RESPONSE TO NEOPLASIA IN PREGNANCY
cones were removed in single piece. The authors claimed high Preinvasive disease and microinvasive cancer of the cervix is
quality histological specimens, minimal blood loss, short not treated during pregnancy. The only indication to treat
operating time, mean depth of thermal damage of 0.29 mm and during pregnancy is histologically confirmed, frankly invasive
a cure rate of 94.8%. cancer. Conizations are rarely indicated during pregnancy since
the introduction of colposcopy. Conization in pregnant patients
Hysterectomy is associated with a 12% hemorrhagic complication rate, a 5%
Hysterectomy may be indicated when there is recurrent CIN perinatal mortality, and a preterm labor rate of 30%. Therefore,
after repeated treatment with less radical methods. conization is reserved for the rare cases in which invasive cancer
is strongly suspected by cytology, histology, or colposcopic
Adenocarcinoma in situ (AIS) impression. Conization during pregnancy is not performed for
It is a rare premalignant condition often diagnosed on a cervical unsatisfactory colposcopy, even in the presence of a high grade
cone removed for CIN. Although the treatment of squamous CIN lesion, unless invasive cancer is suspected. Instead, colposcopy
has been very well- established, the management of adenocarcinoma is repeated at intervals until the examination becomes satisfactory,
in situ of the cervix is far from clear as little is known about its which occurs by the second trimester, in most cases.
natural history and invasive potential. Generally, in patients who Vaginal delivery is avoided. In the presence of frankly
have completed their family, hysterectomy is advocated after a cone invasive cancer; the preferred method of delivery of a viable
biopsy has confirmed adenocarcinoma in situ with no evidence of pregnancy is by cesarean section with radical hysterectomy. This
invasion. This is because 29% of adenocarcinoma-in situ lesions are is done in our hospital.
not located near the TZ and 16% are found to be multifocal and
these lesions may extend as high as 3 cm up the endocervical canal. POSTPARTUM RE-EVALUATION
There may, therefore, be skipped lesions higher up in the Patients should be re-evaluated at least six weeks postpartum to
endocervical canal. Further, these patients generally need a deep allow healing to occur. Treatment, if indicated, should be based
308 and large cone biopsy to achieve complete excision, making cervical on the grade and location of disease identified at that time.
HIV Patients 6. Falls R K. Spontaneous resolution rate of grade I cervical
Although multiple procedures are often necessary in many intraepithelial neoplasia in a private practice population. Am J
Obstet Gynecol 1999;181:278-82.
patients, cone biopsy has been found to be effective in preventing
7. Flannelly G, Bolger B, Fawzi H, De Lopes A B, Monaghan J M.
cancer progression. HIV patients with low CD4 counts have a Follow up after LLETZ: Could schedule be modified according to
2-fold increase in the incidence of CIN compared to those with risk of recurrence? Br J Obstet Gynaecol 2001;108:1025-30.
high CD4 count. Antiretroviral treatment may reduce risk by 8. Martin-Hirsch P L, Paraskevaidis E, Kitchener H. Surgery for
improving immune function. cervical intraepithelial neoplasia. Cochrane Database Syst Rev 2000;
(2):CD001318.
BIBLIOGRAPHY 9. Nagai Y, Maehama T, Asato T, Kanazawa K. Persistence of human
1. Akihira J, Konno R, Moriya T, et al. Conization by harmonic scalpel papillomavirus infection after therapeutic conization for CIN 3: is
for cervical intraepithelial neoplasia: A clinicopathological study. it an alarm for disease recurrence? Gynecol Oncol 2000;79:294-9.
Gynecol Obstet Invest 2000;50:264-8. 10. Nobbenhuis M A, Meijer C J, van den Brule A J, et al. Addition of

Chapter 43
2. Cartier R. Practical colposcopy. 2nd edn. Paris: Laboratoire high risk HPV testing improves the current guidelines on follow-
Cartier;1984.p.139. up after treatment for cervical intraepithelial neoplasia. Br J Cancer
3. Chew G K, Jandial L, Paraskevaidis E, Kitchener H C. Pattern of CIN 2001;84:796-801.
recurrence following laser ablation treatment on long term follow up. 11. Prendiville W, Culimore J, Norman S. Large loop excision of the
Int J Gynecol Cancer 1999; 9:487-90. transformation zone (LLETZ). A new method of management for
4. Delmas M C, Larsen C, van Benthem B, et al. Cervical squamous women with cervical intraepithelial neoplasia. Br J Obstet Gynaecol
intraepithelial lesions in HIV-infected women: Prevalence, incidence and 1989;96:1054-7.
regression. European Study Group on Natural History of HIV Infection 12. Reich O, Pickel H, Lahousen M, Tamussino K, Winter R. Cervical

Benign and Premalignant Conditions of Cervix

in Women. AIDS 2000;14:1775-84. intraepithelial neoplasia III: long-term outcome after cold
5. Dobbs S P, Asmussen, T, Nunns D, et al. Does histological knife conization with clear margins. Obstet Gynecol 2001;97:428-
incomplete excision of cervical intraepithelial neoplasia following 30.
large loop excision of transformation zone increase recurrence 13. Soutter W P, Haidopoulos D, Gornall R J, McIndoe G A, Fox J, Maso
rates? A six-year cytological follow up. Br J Obstet Gynaecol Flanagan A, et al. Is conservative treatment for adenocarcinoma in
2000;107:1298-1301. situ of the cervix safe? Br J Obstet Gynaecol 2001;108:1184-9.

309
 44 Malignant Conditions of the Uterine Cervix

Sudha Salhan

Carcinoma of uterine cervix is still the most common cancer of Hence, it is a sexually ac uired disease which can be
female genital tract in India and second most common cancer prevented.
in women worldwide. It accounts for approximately 12 of all 2. Age: It is seen between are 35–40 years, though can be seen
cancer of the world. It is estimated that more than one million early. Early marriage, before 18 years, cervical immaturity
women, all over the world, currently have cervical cancer. Most and less protective mucus secretion are the predisposing
of them are not diagnosed are have no access to treatment that factors.
can treat them to prolong their life. Almost 500,000 new cases Age of first intercourse is very important. It is more common
(above 1/5th in India) are diagnosed and 250,000 deaths occur in women who had first sexual intercourse at an early age.
per year due to this malignancy, in the world, causing immense It causes early HPV infection.
morbidity and mortality. Developing countries like India, take 3. Multiple sex partners is also a very important factor.
the major burden (80 ) (Fig. 44.1). 4. So is multiple birth causing insult and injuries to the cervix
especially at transformation zone
EPIDEMIOLOGY OF CANCER CERVIX 5. History of genital wart is a predisposing factor.
It is a leading cause of death in females. 6. Race and region: Cancer cervix is rarely seen in Muslims
The exact etiology is not known but some high risk factors and ews. Circumcision may be the factor. It is common in
are obviously linked. The important ones are given below. Africa.
1. Human papilloma virus (HPV): (Figs 44.2A and B). 7. Cigarette smoking (both active and passive): Tobacco-
Francoise Barre—Sinoussi and Luc Montagnier first specific carcinogen and polycyclic aromatase hydrocarbons
suggested the association of HPV virus and Carcinoma of are identified in those patients. They can bind to and
cervix (Nobel Prize 2008) in 99.7 of cases. Almost all damage cellular DNA and may cooperate with HPV to
sexually active women acquire HPV infection within 2 years. produce malignant transformation.
But most of them (99 ) are able to eliminate this through 8. The correlation of oral contraceptive with cancer cervix
their immunological defences. It is the persistent of HPV (especially the adenocarcinoma cervix ) is being explored.
infection. (Especially type 16 and 18 but other oncogenic The benefit of preventing multiple births is to be taken into
types 31,33, 39, 45 and 51, 52, 56, 58 are less commonly found account in accessing the role of oral contraceptives.
which leads to development of cervical cancer). HPV viral 9. Factors in Husbands
E6 and E7 transcriptional units proteins interact with Tp53 a. Significantly higher association of cervix cancer among
and RbG to cells of the cervix. It causes gene inactivation the spouses with penile carcinoma (Martinez 1969) is
and thus influences the cellular growth and differentiation. reported.
b. There is also the report of multiple sexual partners of
husband of cancer cervix women.
c. Their husbands are seen with more genital warts,
gonorrhea and genital herpes.
d. History of carcinoma cervix in the first wife of their
husband is also seen.
e. Spermatozoa are themselves carcinogenic.
10. Prenatal exposure to diethylstilbestrol (DES) and
development of clear cell adenocarcinoma of the cervix and
vagina is also observed. (Herbert and Covercones 1979).
11. Association of herpes simplex type II (ASV-2) Chlamydia
trachomatis and HIV with cancer cervix in being under
research.
12. Low socioeconomic status and poor personal hygiene may
be a contributory factor.
13. Diet: Epidemiologic studies showed that diet deficient in
fruits and vegetables and a low intake of -carotene are
associated with an increasing risk of cervical dysplasia. The
mechanism of protective effect is not clear. It is mediated
through an effect on epithelial cell proliferation and
Fig. 44.1: Areawise distribution of cervical carcinoma differentiation. Beta-carotene also inhibits tumor cell
 NATURAL HISTORY OF CANCER CERVIX
(FLOW CHART 44.1)
Cancer of uterine cervix takes many years (10–20 years) to
develop. HPV infection (over 40 types) play a very important
role. It is sexually transmitted following onset of unprotected
sexual activity. Two types 16–18 are considered as high risk’
because of their strong association with cancer of the cervix,
vulva, vagina and anus in females. Other types 31,33 and 45
and 58 are also important. This virus along with the other
epidemiological factors (mentioned earlier) acting as cofactors
leading to development of invasive cancer of the cervix. The risk
increases with each new sexual partners. Most of them have no

Chapter 43
symptoms. In almost all of these women the HPV infections clears
spontaneously because of body’s immune mechanism. If it persists,
it may remain stable or lead to CIN 1. It usually disappears over
the time. Some cases, however, progress to CIN 2 and CIN 3. CIN
3 is the precursor to cervical cancer. It usually progresses from
CIN 1 over a period of several years, if not treated. The stepwise
development of invasive cancer include HPV infection acquisition,

Benign and Premalignant Conditions of Cervix

HPV persistence, development of cancer precursors and invasion.
It takes on an average 20 years but can be more rapid. This
relatively slow development of cancer following initial. HPV
infection has contributed to the success of cytology based cervical
Fig. 44.2A: HPV virus screening programs (Figs 44.3 A to D).
Early marriage and start of sexual activity (before 18 years)
proliferation by decreasing epidermal growth factor receptor has additional factor of cervical immaturity and inadequate
concentration on keratinocyte, immortalized with HPV – production of protective cervical mucus causing cervical ectopy
onchogenesis. Beta-carosine will not help in well-established making them more susceptible to HPV infection at
high grade biopsy proven cervical lesion but regresses transformation zone (Fig. 44.4) where the HPV virus gets
CIN 2 and CIN 3 with no HPV (Keefe and Coworkers 2001). attached to the DNA of cells.

Fig. 44.2B: Electron microscopy of Human Papilloma Virus (HPV). (I) 2% Agarose gel showing PCR Product (450 bp) of HPV L1 region using L1
P – Positive control, 1-4 - PCR products (450 bp), N-Negative control; (II) 2% Agarose gel showing PCR Product (217bp) of HPV 16, N-Negative
control, P – Positive control 1-4 - PCR products (217 bp); (III) 2% Agarose gel showing PCR Product (100 bp) of HPV 18; P – Positive control, N-
Negative control 1-4 - PCR products (100 bp) 311
 Flow chart 44.1: Stepwise development of invasive cancar (natural history)
Diseases of Cervix
Section 10

312 Figs 44.3A to D: Pap smear

 Chapter 43
Fig. 44.4: Transformation zone

DIAGNOSIS OF CERVICAL CANCER

It is done by meticulous history taking examination biopsy and
other tests.

History

Benign and Premalignant Conditions of Cervix

The following symptoms are common.
1. Bleeding: It is first to come. Earliest symptom of postcoital Fig. 44.5: Per-speculum examination showing cervical malignancy
bleeding or contact bleeding is pathognomonic. History of
spotting or slightly reddish leukorrheal discharge may alert
endophytic. Colposcopically directed biopsy is the best.
the gynecologist. In advance stages it may be obvious
Otherwise, take biopsy from acetowhite area (Fig. 44.6) or
bleeding not related to menstrual cycle. In a menopausal
hypopigmented area (Schiller-positive) with inclusion of normal
women—history of postmenopausal bleeding is present.
looking area. It is either taken by punch biopsy forceps or
2. Pain: It is seen in advance cases. It may be referred to the
incision by a scalpel. It is sent after placing in formaline solution
flanks, legs, etc.
for histopathology examination. Conization may be done in
3. Urinary symptoms include pain during micturation,
localized growth (Figs 44.7A to C).
hematuria, and urinary incontinence which is seen in late
Histopathology is essential to make the diagnosis. After
cases (Fistula formation).
confirmation of the diagnosis by biopsy the clinical staging is
4. Rectal bleeding is in late stage of the malignancy
done preferably by examination under general anesthesia.
5. Uremia, altered sansorium are seen when the kidney The size of the growth and extent of spread is found by
function are affected by hydronephrosis etc. pelvic and rectal examination.
6. Weight loss, and weakness is seen in advance cases.

On Examination STAGING CARCINOMA OF CERVIX (2009)

eneral physical examination may be normal or in some there Once histology diagnosis is made cancer of the cervix is staged.
may be emaciation. Anemia may be present due to bleeding. Invasive cancer is defined by the invasion of the malignant cells
Supraclavicular and groin nodes are usually not palpable. Other underlying the basement membrane. It starts with
systemic examinations may show no abnormal findings. microinvasive stage, which is not visible with the naked eyes
ynecological examination: It depends on the stage of on per-speculum examination and is diagnosed histologically.
lesion. Inspection may reveal bleeding or typical foul smell (due If left untreated, it progresses. The staging is given below.
to necrosis of cancerous tissue and superadded infection) may Staging is done by FIGO (Federation of International
be observed on per-speculum examination (Fig. 44.5). The Gynecology and Obstetrics) (Fig. 44.8).
endocervical growth and stage IAI growth may not be seen.
But mostly exophytic or ulcerative growth is seen. Exophytic
growths are friable and bleeds on touch. Note the size of the
growth and the extension of growth to vagina.
Per-vaginal examination: Even if there is no visible growth
the cervix will feel big and firmer then normal. Uterus may be
larger if there is pyometra. Extent and stage of the disease is
assessed. Side wall is felt through the fornix whether it is
thickened (up to the lateral pelvic wall) on one or both sides.
Mobility of uterus is ascertained. It can be performed under
anesthesia.
Pre-rectal examination is essential for finding involvement
of rectal mucosa, uterosacral ligament and the parametrium.
Diagnostic and preoperative work-up of cancer of the
uterine cervix.
Papsmear is to be taken. But it may be negative.
Biopsy is the confirmative test. The cervix is cleaned with
saline swab. Apply 3–5 acetic acid or Schiller’s iodine on
exocervix, in cases where the growth is not visible or is Fig. 44.6: Acetowhite area 313
 IBI clinical visible lesion not greater than 4 cm in
greatest diamension.
IB2 clinical visible lesion greater than 4 cm in size
in greatest dimension.
Stage II Cervical carcinoma extends beyond the uterus but
not up to the pelvic sidewalls or lower-third of
vagina.
Stage IIA Upper vaginal involvement without parametrial
involvement
Stage IIA1 Clinically visible cervical lesion 4 cm in greatest
dimension.
Stage IIA2 Clinically visible cervical lesion 4 cm in greatest
Diseases of Cervix

dimension.
Stage IIB Obvious parametrial involvement no vaginal
involvement (Fig. 58.23)
Stage III Lesion extend to the pelvic wall and/or lower third
of vagina and/or cause hydronephrosis or
nonfunctioning kidney.
Stage IIIA Tumor involving lower third of vagina but no
extension to parametrium.
Stage IIIB Extensive of parametrium up to lateral pelvic wall
and or/ hydronephrosis or nonfunctional kidney
Figs 44.7A to C: Cervical cone biopsy (Figs 58.24 to 58.26).
Section 10

Stage IV Carcinoma extends beyond the true pelvis or has

involved (biopsy proven) the mucosa of rectum
Stage 1 Cancer strictly confined to cervix (extension of or urinary bladder. Presence of urinary bladder
uterine body not to be regarded) bullous edema on cystoscopy does not qualify
Stage IA Cancer invasion diagnosed only microscopically for stage IVA. Malignant cells in urinary bladder
with maximum depth of 5 mm from base of the washings or histological confirmation by
epithelium. Not wider than 7 mm. Vascular space cystoscopy biopsy put the lesion is stage IVA.
involvement (venous or lymphatic) should not alter Stage IVA Extension to adjacent organs
the staging. Stage IVB Spread to distent organs
Stage IA1 Stromal lesion up to 3 mm
Stromal lesion and maximum width 7mm All macroscopically visible lesion—even with superficial
Stage IA2 Stromal lesion maximum width 3 mm and not invasion are alloted to stage 1B carcinoma. Invasion is limited
more than 5 mm and no wider than 7 mm to a measured stromal invasion with a maximum depth of 5
extension. mm and a horizontal extension of not 7 mm. Depth of invasion
Stage IB Growth is clinically visible lesion limited to the should not be 5 mm taken from the base of the epithelium of
cervix uteri or preclinical cancers greater than the original tissue. Superficial or glandular. The depth
stage 1A. of invasion should alway be reported in mm, even in those

314 Fig. 44.8: Staging of cancer cervix

cases with early (minimal) stromal invasion (m/mm). The ii. Parametrium involvement also causes more lymph node
involvement of vascular/lymphatic spaces should not change metastasis and adverse prognosis.
the stage allotment. iii. Endometrial extension may lead to distance metastasis
On rectal examination, there is no cancer-free space between and decreased survival. Patient without uterine
the tumor and the pelvic wall. All cases with hydronephrosis extension has 5-year survival rate of 92.4
or non-functioning kidneys are included unless they are known compared to 5-year survival rate of 53.8 in patients
to be due to another cause. In developing country like India the with uterine involvement (Noguchi and associates
diagnosis is made often in stage III and IV. 1988).
The staging is done before operation and is not changed iv. Lymph node metastasis decreases 5-year survival rate
after operation. (unlike staging laparotomy in ovarian cancer). 62 with one node involvement, 36 with 2, 20
Microinvasive carcinoma is a lesion with a depth of with 3 or 4 and no survival for 5 or more lymph
invasion up to 3 mm from the base of the epithelium without node involvement (Tanake and coworkers 1984)

Chapter 43
lymph vascular space involvement. v. Histopathology: The following points are considered
Laboratory examination includes hemoglobin, peripheral in histopathology to predict the prognosis
blood smear, blood urea nitrogen, serum creatine, uric acid, – Depth of invasion in the stroma
urine analysis, liver function test and serum electrolytes. – Tumor volume
ECG is done for finding the cardiac status. – Involvement of lymphovascular space
– Margin of operated tissue involved or not
Radiological Examination – Differentiation of tumor–more undiffere-

Benign and Premalignant Conditions of Cervix

1. -ray chest ntiated-bad progress
2. Plain -ray abdomen – Adenosquamous tumors and small cell
3. Intravenous pyelography to know the involvement of the carcinoma with neuroendocrine features have
urinary system and any local abnormality to be kept in mind poor prognosis.
during operation (e.g. double ureters). – CHaras Oncogene, Kiras oncogene, cmyc
4. Ultrasound of the abdomen and pelvis to know the extent oncogenes-expression in these tumors is now
of the disease. used for prognosis and the outcome.
5. FIGO recommended barium enema when involvement of Differential diagnosis: The growth is to be differentiated
rectum is suspected. from tuberculosis of the cervix, chronic cervicitis. Cervical
6. Cystoscopy is done to exclude stage IVA and proctosigmoid ectropion, condylomata accuminata of cervix, syphilitic ulcer,
scopy is done to exclude involvement of the rectum if choriocarcinoma, achinomyosis, schistosomiasis, etc. Biopsy
suspension is there. will confirm the diagnosis.
Other investigations (not recommended by FIGO).
7. Computed tomography (CT). To know the extent of the SPREAD OF CANCER CERVIX
diseases. It spreads into the:
8. Magnetic resonance imaging (MRI) is now used for knowing a. Locally vaginal mucosa
the extracervical spread b. Uterus
9. Position emission tomography (PET) c. Parametrium
10. Bone scanning d. Lymphatic spread
11. Lymphoangiography e. Blood-borne.
12. Laparoscopy. Direct speed to cervical stroma, body of the uterus, vagina and
Prognostic factors may be considered when counseling the parametrium may ocur. In later stages it spreads to urinary
patient and her relatives. bladder and rectum causing fistulas.
a. Stage of the disease. Five-year survival approaches 100 The rich lymphatic from uterus and cervix drain to
for those in stage 1A and 70-85 for patients in stage paracervical lymph nodes (Fig. 44.9). Then it goes to hypogastric
1B and smaller (size) 2A. It is 50–70 for stage 1B 2 and (internal iliac) and external iliac (obturator node is the innermost
IIA for stage III it is 30–50 and stage IV 5–15 . part) then the drainage goes to common iliac and para-aortic
b. Age: There is inconsistent association with age. Some
authors reported good prognosis for younger patients.
c. Race is sometimes considered. In African patients, the
spread is faster.
d. Socioeconomic strata—women of low socio- economic
strata report late and hence have bad prognosis due to
comorbidities (associated diseases).
e. Anemia may adversely affect the prognosis
f. If the patient has fever of longer duration it gives bad
prognosis.
g. HIV positive patients have bad prognosis compared to
non-HIV patients even in early stage disease.
h. Main tumor: Factors in the main tumor which
influencing prognosis are :
i. Size of the tumor—volume of the tumor influences the
prognosis. Patient with bigger size tumor have more
lymph node metastasis and recurrences and hence
bad prognosis. Fig. 44.9: Lymphatic drainage of cancer of the cervix
315
 lymph node. Dissemination is mostly in this order. But rarely a
small carcinoma may spread to pelvic lymph node, invade
bladder and rectum and distant organs.
Paramaterial lymph node may be involved. In stage I the
lymph spread is 15–20 , in stage II it is 25–40 stage III has
50 spread. Distant Hematogenous spread is less common.
Venous plexus to lungs, mediastinum, supraclavicular lymph
nodes, liver and bones may be involved in late stage.
e. Blood-borne metastasis is not common but may reach
lung, liver, kidney, bone marrow and brain, etc.
Pathological types of cervical cancers: The various
pathological types of cancer cervix are given below.
Diseases of Cervix

1. S uamous cell carcinoma cervix (Fig. .1 ): It forms 85–

90 of cervical cancers. They are classified according to the
predominant cell types viz large cell both keratinizing and
non-keratinizing. Second is small cell-about one third of
them stain positive for neuroendocrine markers
(Neuroendocrine carci-noma). The neuroendocrine Fig. 44.11: Adenocarcinoma cervix (10x) (40x)
carcinomas have higher incidence of lymph node and (Dr Yadav, RML Hospital)
lymphovascular space invasion recurrence and poor
prognosis. Chemo-therapy is to be integrated in the treatment
protocol. Verrucous Type A—It is rare, slow growing, locally
Section 10

invasive tumor mostly caused by HPV 6. It has well

differentiated squamous cells with papillae and little stromal
invasion, unfortunately it is very progressive and radical
surgery is the main treatment. It may cause vault recurrence
2. a. Adenocarcinoma (Figs 44.11 to 44.13) found in 10-15
of cases. It arises from glandular elements of the cervix
mucinous types are also seen (Fig. 44.13).
b. Villoglandular papillary—It is seen in younger woman
and has better prognosis.
c. Endometrioid.
d. Clear cell carcinoma mostly due to in utero exposure to
DES.
e. Adenoid cystic carcinoma on histopathology there is a
mixture of squamous and glandular cells.
f. Stem cell carcinoma (glassy cell carcinoma)—it is poorly
differentiated with a rapid course. Fig. 44.12: Adenocarcinoma cervix (40x) (Dr Yadav)
g. Adenoma malignum (Minimal deviation adenocarci-
noma). It is well differentiated adenocarcinoma. It makes
1 of all adenocarcinomas.
Very rare tumors are:
a. Collision tumor—synchronous adenocarcinoma and
squamous cell carcinoma that invade each other.

Fig. 44.13: Adenocarcinoma cervix—Intestinal type exhibits mucin

containing goblet cells

b. Leiomyosarcoma Adenosquamous carcinoma

c. Embryonal rhabdomyoscarcoma (in infants)
d. Tumors of Gartner’s duct
e. Undifferentiated carcinoma
f. Carcinoid—arising from argyrophil cells of the endocervical
Fig. 44.10: Squamous cell carcinoma cervix-10x epithelium. They are rarely associated with carcinoid
316 (Dr Chandok, Pathology Dept ESI Hospital) syndrome.
 Secondary cervical tumors: Directly invaded by are the only recommended primary treatment modalities for
neighboring organs mostly by endometrium, urinary bladder cervical cancer. Treatment modalities are:
and rectal carcinomas and rarely vaginal malignancy. Surgery
Radiotherapy
PREVENTION OF CERVICAL CARCINOMA Chemotherapy
To prevent cancer of uterine cervix, primary and secondary Chemoradiation.
prevention is done. Cancer of the cervix is now considered a Primary Treatment
preventable malignancy. Surgery has the advantage of preserving ovaries in young
Primary prevention targets prevention of HPV infection patients. The duration of treatment is shorters. Radiotherapy
and the epidemiological factors which increase the risk of the causes slow fibrosis leading to long-term complications like
causation of carcinoma of the cervix. Mass education to make dyspareunia, atrophy of epithelium. Moreover, radiotherapy is
the public aware of the association of early marriage, multiple not available at all facilities in India. Type of surgery depends on

Chapter 43
sex partners (print media, radio, television, etc.). Organized the stage of the disease.
cervical cancer control program is urgently needed to reduce Stage IA There is low risk of lymph node involvement
huge morbidity and mortality. It needs a constant team effort (i) Can be treated by cervical cone biopsy if she
promotion in the form of life-style changes will prevent this wishes to maintain her fertility. A careful
cancer. Health education should be an integral part of follow-up by pap smear and colposcopy is
comprehensive cervical cancer control. Do not marry girl early required.
in life. Prevention of unwanted pregnancies and multiparity, (ii) Simple hysterectomy (Fig. 44.14) with uterus

Benign and Premalignant Conditions of Cervix

concern of hygiene, limiting sexual partners is essential. Correct and cervix with resection of parametrium,
and consistent use of condom, is to be promoted to prevent uterosacral ligament and vagina with follow-
HPV infection. Awareness of screening services is to be raised, up
stopping of smoking and other forms of tobacco use is important. In stage IAI and IA2 modified radical hysterectomy and pelvic
Any pelvic infection to be treated. lymph node dissection (to prevent microscopic parametrial and
pelvic lymph node involvement) and upper part of vagina (Fig.
Vaccination for HPV
44.15) are removed.
As it is proven without doubt that cancer cervix is caused by Stage IB and IIA both surgery and radiotherapy produce
HPV infection. Vaccination against sexually activity high risk similar results (80–90 5-year survival rate) Hopkin and Morley
HPV strains is very important for primary prevention. 1991.
Almost 100 percent cervical cancer is caused by HPV Radical trachelectomy (Fig. .1 ): Trachelectomy is the
infection. Hence, logically vaccination (before starting sexual removal of the cervix. Radical trachelectomy includes removal
activity) against HPV will prevent development of cancer of uterine of the parametriun and upper vagina in addition to the cervix.
cervix. Two vaccines have been licensed throughout the world. It is a fertility preserving operation. Instead of radical
1. uadrivalent vaccine hysterectomy or chemotherapy in young women with stage IA2
2. Bivalent vaccine. to IB cervical cancer. Lymphadenectomy is done the same way as
They are manufactured by recombinant DNA technique in radical hysterectomy. They are subjected in frozen section. If
producing noninfectious virus like particles (VPL)with HPV L1 lymph nodes are involved then this operation is contraindicated.
protein. Hence, it is not a live vaccine. uadrivalent vaccine If they are not involved then the following steps are done. Do
protects against HPV types 16, 18, 6 and 11. These vaccines are transection of uterus at the level of internal os. A slice of the
preventing cancer cervix are also prevent genital warts, vaginal uppermost portion of cut cervix is sent for frozen section. If it is
intraepithelial neoplasia (VAIN) and vulval epithelial HPV type tumor free, then the cervix is removed with the parametrium and
16 and 18 related cancers are prevented by bivalent vaccine. upper third of vagina, proximal vaginal margin is sutured to the
retained body of the uterus. Pregnancies have reported to have
Schedule of Vaccination
occurred though 25 late miscarriage is reported. Recurrence is
Three doses of both vaccines are recommended. less common in properly selected cases.
ero point 1st dose, 1 month 2nd dose, months 3rd dose.
It can be started as early as 9 years but routinely in females
age 11–12 years.
Even after vaccination screening program to be continued
as per schedule. Its effect will take 10–15 years to show because
of natural history of the disease.
Secondary prevention: It is detection of precancer stage
(CIN I, CIN II, CIN III) or early stage of the disease (stage I).
Screening for cancer cervix and detection of early changes (CIN
I and II) and prompt treatment.
Public education to encourage screening and early
presentation without minimal symptoms.
Tertiary prevention—Includes treatment to prevent further
progress. Palliative Care—Symptomatic relief of pain, bleeding
and side effects of therapy. Also involve the family and the
community in her case.

Treatment of Cervical Carcinomas

Cervical carcinom treatment is directed towards the primary
lesion and potential sites of spread. Surgery and radiotherapy
317
Fig. 44.14: Simple hysterectomy
Diseases of Cervix

Fig. 44.15: Radical hysterectomy Fig. 44.17: Endocervical carcinoma

Carcinoma is the cervical stamp of subtotal hysterectomy reqire

surgery and radiotherapy in later stages.
Section 10

Concurrent chemoradiation for treatment carcinoma of cervix

is being tried. It is mostly given in stage IIIB and IVA. Systemic
chemotherapy may augment the effects of radiotherapy by
potentiation of sublethal damage induced by radiation, eradicate
occult metastasis outside radiation field. It increases survival rate
(Higgins and associates 2003). But there may be more severe
hematologic and gastrointestinal side effects Radiotherapy and
chemotherapy are given in detail in chapter 40.
Neoadjuvant chemotherapy followed by surgery in big size
growth is under trial. Preoperative cysplatin is given 40 mg/m2
(up to 70 mg) once a week for not more than six weeks.
The size decreases but difference in survival is not uniformly
documented. Only chemotherapy is given for palliation in very
advance cases. Patients with recurrent disease may be offered
surgery (isolated central at the vault). Recurrence after surgery
are offered radiotherapy. Chemotherapy is also under trial. In
Fig. 44.16: Radical trachelectomy advance cases pelvic exenteration can be offered. However,
radiotherapy is effective for palliation. The treatment plan is
Definitive surgery is radical hysterectomy (Fig. 44.15) summarize in Table 44.1.
besides removing the uterus and cervix with removal of Pyometra: For patients with a contraindication for
parametria, uterosacral ligament, 2 3 cm cuff of upper vagina chemotherapy in locally advanced cancer cervix (IIB and
and pelvic lymph nodes. Oophorectomy is not essential as upwards) a combination of radiation and hyperthermia should
metastasis to ovaries is uncommon. But if postoperative be considered as an alternative (Figs 58.8 and 58.9). It is pus in
radiotherapy is required saving of ovaries becomes of no avail. the uterine cavity. It is mostly linked with malignancy or
Hence, it is mostly removed. In very young patients previous radiotherapy. It can be seen in congenital uterine
transposition of ovaries are done out of the pelvic radiation abnormality, e.g. uterine didelphys. Dilatation and drainage is
field. If performed abdominally it is called Wertheim the treatment of choice. It is to be done repeatedly till all pus is
hysterectomy (first done by Wertheim more than 100 years ago). drained out. Then a gentle curettings and the histopathology
When done vaginally it is called Sauta’s operation or Moitra of the curretings is warranted to exclude malignancy. If it is
modified vaginal approach. In very young patient trachelectomy
is tried (mentioned above). After operation the uterus is cut to Table .1: Treatment plan for carcinoma of the cervix
the extent of spread (Fig. 44.17). Stage reatment
Cancer cervix in pregnancy it is not a common condition
1A1 If desire fertility—conization and follow-up otherwise
but we have operated 4 such cases. Pap smear is advised. Biopsy
simple hysterectomy
can be done. Depending upon the stage and duration of 1A2 Radical hysterectomy with pelvic lymph node dissection
pregnancy the case is handled. If it is early stage can wait till 38 or radiotherapy
weeks and do cesarean section with radical hysterectomy. If 1B1 Do
the neoplasm is in late stage. She is to be operated irrespective IIA Do with or without chemoradiation
of the stage of the pregnancy. IIB Chemoradiation
Information obtained during surgery viz. lymph node status III Do
and extent of the disease help in deciding about adjunctive IVA Do with pelvic exenteration
IVB Palliative chemotherapy/chemoradiotherapy
therapy.
318
due to malignancy then to be treated according otherwise 5. Keefe KA, Schall M , Brower C, et al. A randomized double blind
monitor for recurrence of pyometra. phase III trial using oral -carotene supplementation for women
with high grade CIN. Cancer Epitomicol Biomarkers Prev
BIBLIOGRAPHY 2001;10:1029.
6. Lingar L, Palfalvi L, Hogg R, et al. Abdominal radical trachelectomy:
1. FIGO Committee of Gynaecologic Onchology, Revised FIGO
A fertility preserving option for women with early cervical cancer
Staging for carcinoma of the vulva, cervix and endometrium. Int
Brit, Obst Gyn 2005;112:366.
Gyne Obst 2009;105:103.
7. Martinez I. Relationship of squamous cell carcinoma of the cervix
2. Herbst AL, Cole P, Norusis M , et al. Epidemiologic aspects and
uteri to squamous carcinoma of the penis. Cancer 1969;24:777.
factors related to survival in 384 registry cases of clear cell
8. Tanaka , Sawada S, Murata T. Relationship between lymph node
adenocarcinoma the vagina and cervix. Am Obstet Gynecol
metastasis and prognosis of patients irradiated postoperatively for
1979;135:876.
carcinoma of uterine cervix. Acta Radiol 1984;23:455.
3. Higgins RV, Naumann WR, Hall B, et al. Concurrent carboplastin
9. Ursin G, Peters RK, Henderson BE, et al. Oral contraceptive use
with pelvic radiation therapy in the primary treatment of cervix

Chapter 43
and adenocarcinoma of the Cervix. Lancet 1994;344:1390.
cancer. Gynaecol Oncol 2003;89(3): 499.
10. Wallbooners M, acob MV, Manos MM, et al. Human
4. Hopkins MD, Morley GW. Radical hysterectomy versus Radiation
papillomavirus is a necessary casue of invasive cervical cancer
Therapy for stage IB squamous cell cancer of the cervix cancer
worldwide. pathol 1999;189:12.
1991;68:272.

Benign and Premalignant Conditions of Cervix

319
 Section 11 Diseases of Uterus and Fallopian Tubes

45 Benign and Premalignant

Conditions of the Uterus

Shubha Sagar Trivedi, Monika Madaan, Sharda Patra, Sudha Salhan

terine leiomyoma commonly called fibroid uterus, is the most surrounding vascular organ and becomes a parasitic or
common benign neoplasm of female genital tract. Other terms wandering fibroid. They are mostly multiple accuring in
in common use are; fibroma, fibromyoma, myoma, etc. Since different sizes (Fig. 45.5).
it is composed primarily of smooth muscle cell the most • Cervical fibroid (Fig. 43.19) are located in the cervix with
appropriate terminology is leiomyoma. the body of the uterus sitting on it.

Incidence
It is estimated that around 20 of women in reproductive
age group have leiomyoma of uterus. Maximum incidence
is between 35–45 years of age. It is rarely seen before the
age of 20 or after menopause. It is more common in
nulliparous and in infertile women.

Pathogenesis
Exact etiology of leiomyoma is still unclear. However, it seems
that ovarian steroid hormones play a major role in the
initiation and growth of tumor. The following facts are
suggestive of the role of sex steroids in the causation of
fibroids:
• Myomas are rarely found before puberty and they cease
to grow after menopause.
• Leiomyomas grow during pregnancy.
• There is an increase in size of tumor if hormones, e.g.
oral contraceptive pills are given exogenously.
• Often myoma is associated with endometrial hyperplasia
and endometrial cancer.
• Myoma reduces in size following administration of GnRH
analogues.
• Incidence is higher in nullipara and in obese women and
it is lower in smokers. (Both passive and active).
Fig. 45.1: Location of fibroids
Types of Leiomyomas (Fig. 45.1)
Based on the location of myoma in the uterus, leiomyomas
are classified as intramural, submucous or subserous (Figs
45.1, 57.38 and 57.42).
• Intramural or interstitial myomas lie within the myometrial
wall. Most of the myomas (approximately 75 ) are
intramural (Figs 45.2 and 57.37).
• Submucous When the myoma grows towards the cavity of
the uterus and is lined by the endometrium it is called
submucous leiomyoma. 15 of the myomas are
submucous (Fig. 57.36). Submucous myoma may develop
a pedicle and become a myomatous polyp, it may grow
downwards and protrude through the cervix into the
vagina (Fig. 45.3).
• Subserous myomas grow (Figs 45.4A and B) towards the
serosa of the uterus and form about 10 of uterine
myomas. These also may become pedunculated. Rarely
a pedunculated subserous fibroid gets attached to a Fig. 45.2: Intramural fibroid
 Blood supply to the myoma comes from periphery hence
cystic changes take place in the center of tumor and
calcification occurs in periphery. In a subserous fibroid, blood
vessels may be seen over the fibroid beneath the peritoneum.
icroscopically a leiomyoma consists of non-striated
muscle fibers arranged in interlacing bundles of varying size
in different directions that give the typical whorled
appearance in cut section. The stroma usually consists of
fibrous connective tissue. This typical appearance
demarcates a myoma from the surrounding normal
myometrium (Figs 45.7 and 45.8).

Chapter 45
Conditions Associated with Leiomyoma
• Myometrium of the uterus gets hypertrophied due to
associated hyperestrogenism.
• Uterine cavity may be distorted and enlarged due to the
Fig. 45.3: Submucous fibroids
presence of intramural or submucous myomas.
• Thickened endometrium due to endometrial hyperplasia
• Broad ligament fibroid-fibroid arising from lateral wall of
(except over submucous myoma) is often present.

Benign and Premalignant Conditions of the Uterus

uterus growing between the broad ligament.
• At times, ovaries are enlarged, cystic and hyperemic.
Anatomical Features • In 15 of cases there is evidence of salpingo-oophoritis.
acroscopically as seen in figure 2–4 myomas are usually
Secondary Changes in Leiomyoma
round or oval-shaped, well-circumscribed tumors, firm in
consistency with a pseudo capsule formed due to condensed Atrophy Due to decreased vascularity, tumor atrophies,
surrounding myometrial tissue. They may be single but are shrinks in size, becomes firm and fibrotic as is seen following
commonly multiple and are of varying sizes (Fig. 45.6). menopause and in postpartum period.
The cut section of myoma appears pinkish white with the yaline degeneration It is the most common type of
characteristic whorled appearance. degeneration and is usually seen in tumors of more than

Figs 45.4A and B: (A) Subserous fibroid; (B) Subserosal fibroid

Fig. 45.5: Multiple fibroid in a patient Fig. 45.6: Myomectomy (leiomyomas) 321
 follows hyaline and cystic degeneration. Rarely it occurs after
menopause. Fat cells are found among muscle cells
(Fig. 57.39).
Sarcomatous change It is seen in less than 0.1 of all myomas
and usually occurs in women over 40 years of age. Clinically,
if there is rapid growth of a fibroid or there is irregular bleeding
and acute pain especially in a peri or postmenopausal woman,
it is often suggestive of sarcomatous change. Such myomas
are highly malignant and rapidly metastasize through blood
stream. Very often, however, the diagnosis is made only after
histopathological examination of the removed tumor or the
Diseases of Uterus and Fallopian Tubes

uterus. The tumor appears yellowish grey, is soft in consistency

and looks hemorrhagic. There is loss of pseudocapsule. The
intramural and submucous varieties are more liable to develop
into sarcoma.

Fig. 45.7: H/P leiomyoma × 10 (Dr A Gupta, Sikkim, Complications of Leiomyoma

Institute of Manipal Medical Sciences) orsion Torsion or rotation of a pedunculated subserosal
fibroid at its attachment to the uterus can occur giving rise to
acute pain in abdomen. Rarely there may occur axial rotation
of whole uterus along with the fibroid.
Inversion of uterus A submucous fibroid attached to fundus of
the uterus (Fig. 45.9) may sometimes cause inversion of
uterus. It usually occurs in a long-standing fibroid. Clinically,
woman presents with intermittent lower abdomen pain with
irregular blood stained offensive discharge or irregular
vaginal bleeding with something protruding through the
cervix or introitus. The condition may be confused with uterine
prolapse (neglected), cervical fibroid or with myomatous
polyp. Presence of cup-shaped depression on the uterine
fundus or inability to palpate the fundus of the uterus on
pervaginal examination suggests the diagnosis of inversion.
Diagnosis is confirmed on sounding the uterus or on ultra-
Section 11

sonography (Fig. 45.10).

Fig. 45.8: Histopathology leiomyoma X40 apsular rupture It is a rare complication. Sometimes a vein
on the surface of myoma ruptures causing intraperitoneal
hemorrhage.
4 cm. It causes no symptoms clinically. The tumor looks white,
loses the typical whorled appearance and is homogeneous Inflammation and infection Usually seen in a submucous
on cut section. Muscle cells are replaced by hyaline material. myoma or myomatous polyp. Infections from the vagina
infect the already thin epithelium of the myoma causing
ystic degeneration Generally seen in center of large
sloughing and blood stained discharge or irregular vaginal
intramural or subserous fibroid. Liquefaction of the hyaline
bleeding.
material results in formation of cystic spaces in the fibroid
and makes the tumor soft in consistency. Clinical Features of Leiomyoma
alcareous changes Occurs in long-standing myoma and is usually A fibroid may not produce any symptoms and may
seen in old women. There are deposits of calcium in the be detected incidentally on clinical examination or
periphery, along the course of vessels. The whole fibroid may
become calcified when it is sometimes called womb stone.’
These fibroids may not produce any symptoms.
ed degeneration It is a degenerative change that usually
occurs during pregnancy or in early postpartum period. Exact
cause is not known but it may be due to increased vascularity
during pregnancy. There is thrombosis of some of large veins
over the capsule and smaller vessels within the tumor. Tumor
becomes tense and tender, with a fishy odor. No specific
histological change is observed. Clinically there is pain and
fever with marked tenderness of uterus, The condition has
to be differentiated from other causes of acute abdomen
like appendicitis, ovarian torsion, accidental hemorrhage,
etc. Diagnosis is made by clinical picture and ultrasonography.
Management is conservative.
Fatty or myxomatous change It is an uncommon type of
322 degenerative change that is usually asymptomatic and Fig. 45.9: Fundal fibroid polyp
 congestion of uterus and adnexa. Spasmodic pain occurs
due to uterine contractility in an attempt to extrude the
myomatous polyp.
Acute pain may occur due to torsion, red
degeneration, infection or sarcomatous change.
Heaviness in lower abdomen causing dull aching pain
is due to the pressure of a large fibroid on the surrounding
structures.
• Infertility Although fibroids are often encountered in
pregnancy, infertility is sometimes attributed to fibroid
uterus. The exact cause of infertility due to fibroid is not
known. Probable causes of infertility due to fibroid are:

Chapter 45
– Cornual block or tubal block due to mechanical
obstruction.
– Uterine cavity distortion interfering with sperm
ascent.
– Failure of nidation if fertilized ovum happens to
implant on the submucous fibroid.
– Associated anovulation.

Benign and Premalignant Conditions of the Uterus

– Associated pelvic inflammatory disease (PID).
Miscarriage: Can occur if an embryo gets implanted on a
fibroid and cannot grow due to less blood supply.
Fig. 45.10: Fundal fibroid polyp causing inversion of uterus • Abdominal lump Myoma may present as an abdominal
lump, although it takes a long time to grow. If lump grows
on ultrasonography. Around 50 of the tumors are rapidly, malignancy should be suspected. A fibroid can
asymptomatic. grow up to xiphisternum.
The clinical features of fibroid depend on the location, • Pressure symptoms The myoma may cause symptoms due
size and number of tumors present. A small submucous to pressure on the bladder, bowel and vessels. Fibroid on
fibroid may be more symptomatic than a large subserous the anterior wall of uterus causes frequency of micturition,
fibroid. which could be more pronounced premenstrually due to
congestion. Cervical fibroid can cause retention of urine.
Symptoms
Fibroid on the posterior wall of uterus may get impacted
Only 20–50 are symptomatic rest are diagnosed incidently in Pouch of Douglas and cause frequency and later acute
on US or clinical examination. The leiomyomas may have retention of urine and constipation. Edema of feet can
menstrual disturbances, abdominal lump, pain, infertility or occur due to pressure on vessels. Broad ligament fibroid
pressure symptoms can cause hydroureter and hydronephrosis.
• enstrual disturbances enorrhagia is the most commonly • Other symptoms Palpitation, dyspnea and weakness occur
encountered symptom of leiomyoma. due to anemia.
The woman typically gives history of increased Rarely ascites may be present in a case of fibroid
menstrual bleeding starting from day two that continues uterus (pseudo Meig’s syndrome).
for 8–10 days. Causes of menorrhagia in leiomyoma Shock may occur due to capsular rupture and
include increased surface area of uterine cavity (normal intraperitoneal bleeding.
surface area is about 15 cm sq.), endometrial hyperplasia Polycythemia is sometimes present and is due to
increased vascularity imbalance of T A 2 and PGI2, and extramedullary erythropoiesis.
anovulation. Subserous tumors are usually not • Preterm delivery can occur.
associated with menstrual disorders.
Polymenorrhea It is often seen in large intramural myomas Physical Signs
and is due to hyperemia and pelvic congestion affecting the On clinical examination signs of anemia may or may not be
ovarian function. Associated PID and cystic ovaries are also present.
responsible for polymenorrhea. More often the menstrual On abdominal examination a lump arising from pelvis
cycles are short along with excessive menstrual flow may be palpable if uterus is more than twelve weeks of
(Polymenorrhagia). pregnancy. It feels firm in consistency irregular and is mobile,
etrorrhagia is usually seen in myomatous polyp or in unless there is associated PID or there is a broad ligament
infected submucous fibroid. However, if irregular bleeding fibroid.
is seen in child-bearing age group, pregnancy should be ruled On bimanual examination, uterus may be uniformly
out and if seen in women over 40 years then malignancy enlarged or it may be irregular due to the presence of multiple
(endometrial carcinoma) needs to be excluded. fibroids. Fibroids are attached to the uterus and movement
• Pain The other common symptom of fibroid uterus of fibroid is transmitted to the cervix. Ovarian tumor, in
(besides abnormal uterine bleeding) is pain. It may be in contrast, is felt separate from the uterus. Myomas feel firm
the form of dysmenorrhea, acute pain abdomen or dull to hard in consistency. It may feel soft in presence of cystic
aching pain. degeneration. Position of uterus varies according to the site
Dysmenorrhea—Both spasmodic and congestive of tumor. Careful palpation can identify the site of myoma,
dysmenorrhea is common in fibroid uterus. Congestive whether it is in the body of uterus, in cervix or in the broad
dysmenorrhea is due to increased vascularity and ligament.
323
 Differential Diagnosis
Pregnancy Pregnancy must be ruled out in all cases suspected
to be fibroid uterus is reproductive age group. History and
careful examination helps in the correct diagnosis. A cystic
degenerated myoma may be confused with pregnancy,
uterine pregnancy test and ultrasonography (USG) confirms
the diagnosis.
Ovarian tumor Ovarian tumor must be excluded by thorough
clinical examination. A pedunculated subserous fibroid with
no menstrual disturbances may be mistaken for an ovarian
tumor and it may be difficult to differentiate between the two
Diseases of Uterus and Fallopian Tubes

clinically. USG is of value.

Adenomyosis Adenomyosis causes symmetrical enlargement
of uterus to not more than 14 weeks and is associated with
progressive dysmenorrhea. In a fibroid of this size,
dysmenorrhea is infrequent. If the adenomyosis is localized,
it causes asymmetrical enlargement of uterus with Fig. 45.11: Ultrasound-leiomyoma (Dr Uppal)
tenderness. Clinically it may not always be possible to
differentiate between the two. Pap smear All sexually active females should be screened for
Endometriosis or chocolate cyst of ovary Both these conditions premalignant and malignant lesions of cervix.
cause menorrhagia, dysmenorrhea and infertility. Careful
Dilatation and curettage D and C or endometrial sampling is
history and pelvic examination helps in correct diagnosis. USG
done to exclude endometrial cancer in elderly women with
and diagnostic laparoscopy are confirmatory.
abnormal uterine bleeding and fibroid.
Pelvic inflammatory disease A chronic tubo-ovarian mass Diagnostic hysteroscopy Hysteroscopy helps to confirm the
adherent to uterus makes the uterine contour irregular and site and number of submucous fibroids and can be combined
may be confused with fibroid. Pain and tenderness is, with operative hysteroscopy for removal of submucous
however, associated with PID. fibroid or polyp.
Endometrial cancer Abnormal uterine bleeding in fibroid uterus Diagnostic laparoscopy Diagnostic laparoscopy is sometimes
may be because of associated endometrial cancer. In 3 of required to distinguish cases of endometriosis, ectopic
cases endometrial carcinoma is associated with fibroid pregnancy, PID, inversion of uterus from fibroid uterus.
uterus. Thus, in an elderly woman with fibroid uterus and
Other investigations
Section 11

menstrual abnormality, endometrial sampling is mandatory.

hronic inversion of uterus Inversion of uterus may be confused Intravenous pyelogram (I P) This is done
with myomatous polyp, uterine sounding and • In cases of very large fibroid with pressure symptoms.
ultrasonography helps in diagnosis. • Routinely in a broad ligament or a large cervical fibroid.
• In suspected cases of hydroureter or hydronephrosis.
Investigations I Very rarely done. In suspected cases of sarcoma, or
Following investigations are required for pre-operative adenomyosis it proves useful (Fig. 58.18).
assessment.
MANAGEMENT
Routine and / preoperative investigations
Management of a woman with fibroid uterus depends on
• Complete blood count (i) whether she is symptomatic or asymptomatic, (ii) the age
• Blood group and Rh typing of the woman, (iii) the size and site of fibroid and the (iv)
• Urine analysis: Urinary tract infection, if present, is treated desire for preservation of reproductive function.
• Liver function and kidney function test
• Blood sugar Expectant Management
• -ray chest
Asymptomatic women who are detected to have fibroid on
• ECG.
USG or during gynecological check-up can be followed up if
Investigations for Confirmation of Diagnosis the size of uterus is less than that of 12 weeks pregnant
ltrasonography ( SG) USG is done for confirmation, to check uterus and the diagnosis is certain. Women of
the number, location and size of fibroid and for any associated perimenopausal age group should be explained about the
lesion. On USG, a fibroid appears as a well-defined, possibility of regression of fibroid following menopause and
hypoechoic lesion. It appears cystic if degeneration is of the importance of regular follow-up as there is a small risk
present (Figs 45.11, Fig. 56.5, 57.36 to 38 and 57.40). of malignant transformation of fibroid. ounger woman with
small fibroid should be explained about the possibility of red
Sonohysterography Sonography with saline infusion in uterine degeneration during pregnancy.
cavity delineates intrauterine lesions better. Exact site and Follow-up is required every six months to one year.
size of submucous fibroid or polyp can be found out on
sonohysterography and treatment planned accordingly. Medical or Conservative Management
ysterosalpingography ( SG) In cases with associated Medical management is used to treat anemia, reduce
infertility HSG helps in diagnosis and location of submucous bleeding and to temporarily reduce the size of fibroid.
324 fibroid or polyp and in testing tubal patency. Medical management allows:
• Deferring of surgery in medically unfit woman e.g. in an ombined contraceptives are often used to control abnormal
anemic woman till her hemoglobin can be raised to bleeding for short term relief.
normal for surgery. Ormeloxifene (a selective estrogen receptor modulator) is used
• Decrease in the size of uterus allows vaginal hysterectomy in this extrogen dependent condition two tablets of 60 mg
in place of abdominal hysterectomy twice a week for first 12 weeks and then one tablet once a
• Pfannenstiel incision can be used instead of vertical at week for 12 weeks.
laparotomy when size decreases.
• There is decreased blood loss at surgery. Selected progesterone receptor modulated and progesterone
• Minimally invasive surgery, laparoscopic or hysteroscopic, receptor ligand, e.g. asoprisnil, is under trial.
becomes possible. Gestrinone Anti-estrogenic and anti-progestonic effect 2.5–5
• Medical management in a woman with symptomatic mg thrice weekly by mouth.
fibroids who is nearing menopause can avoid surgery as

Chapter 45
Androgens Testosterone proprionate in doses of 25–50 mg.
fibroids regress after menopause.
IM daily for 2–3 days is sometimes used to stop excessive
Medical treatment includes use of hormones like GnRH
bleeding in a perimenopausal woman awaiting surgery. This
analogues, hemostatic drugs and antianemics.
treatment should not be given in young woman because of
Gn analogues: The most commonly used hormones are the androgenic side effects.
GnRH analogues. GnRH analogues cause reduction in
Anti fibrinolytic drugs Tranexamic acid, 2–4 gm daily for three
25–36 size of fibroid and thereby reduce the symptoms.
to five days during periods is effective in controlling
These have a biphasic gonadotropin-gonadal steroid

Benign and Premalignant Conditions of the Uterus

menorrhagia.
response with an initial surge in gonadotropin and gonadal
steroid secretion flare, i.e. agonist phase, followed by Anti anemic reatment Iron therapy is supplemented for
sustained desensitization phase with low gonadotropin and improving anemia.
low gonadal steroid (estrogen) concentration.
GnRH analogues are available as goserelin, leuprolide, Surgical Management
buserelin, etc. and is given in 200 mgm daily dose by Surgical management includes:
subcutaneous injections or as 300–400 mgm intranasally daily. 1. Myomectomy
3.6 mg goserelin depot ( oladex) is given monthly for 4 2. Hysterectomy
months, or 3. Newer techniques
3.75 mg leuprolide acetate intramuscularly monthly can
Myomectomy
be given for 3–6 months.
This involves surgical removal or enucleation of myoma from
Disadvantages include regrowth of the tumor in 6–12 months the uterus leaving behind a potentially functioning organ
after stoppage of drug, state of hypogonadism resulting in capable of future reproduction. If myomectomy is being done
menopausal symptoms like hot flushes, insomnia, headache, for infertility, all other causes of infertility must be excluded
myalgia and if used for a longer period, bone loss and as myoma may not be the causative factor.
osteoporosis may occur. It is very expensive and does not
always avoid surgery. Difficulty during surgery may be Indications of myomectomy Myomectomy is indicated in
encountered due to thinning of capsule of myoma and tumor (i) young woman with symptomatic fibroids who are infertile,
may be missed during surgery due to shrinkage in size. (ii) those who have not completed their family, or (iii) those
nRH antagonists cause blockage of GnRH receptors who wish to preserve their reproductive function.
and rapid regression without the initial flare.’ Cetrorelix In some cases the myomas are so many that after
pamoate is given 60 mg I M on 2nd day of period. Monitor removal reconstruction of normal uterus is not possible.
serum estradoil level on day 21st if the level is less than 50 Hence during preoperative counseling; this point is stressed.
pg/ml give second dose of 30–60 mg on 28th day. If it is more Assure her about all our efforts to preserve the uterus but in
than 50 ng/ml give the second dose on 21st day. Besides unforeseen circumstances the uterus to be sacrified. Hence,
menopausal symptoms allergic reaction can occur. always take consent for hysterectomy in myomectomy.
Myomectomy can be done by abdominal or vaginal route
Danazol in the dose of 400–800 mg. daily has been used to or by laparoscopy or hysteroscopy.
reduce the size of fibroid, it is no longer recommended due
to the side effects. Abdominal myomectomy: Although minimally invasive
surgeries, i.e. laparoscopic and hysteroscopic, have certain
ifepristone (RU-486)—25–50 mg daily for 3 months causes advantages over conventional surgeries, abdominal
amenorrhea and shrinkage of tumor by 50 . Advantage is myomectomy is generally preferred especially if there are
that no bone loss occurs. multiple or large fibroids. Myoma screw is quite useful (Fig.
Progestogen Norethisterone or Medroxyprogesterone, 45.12). Hemostasis and reconstruction of uterus is better.
5–10 mg from day 5 to 20 helps to reduce menorrhagia. Since the main purpose of myomectomy is to retain or
improve fertility, proper reconstruction of uterus and
Levonorgestrel intrauterine devices (LNG –IUD) are used when
prevention of postoperative adhesions is essential. A
the uterine size is less than 12 weeks. It can be considered as
pregnancy rate following myomectomy is usually around
an alternative to hysterectomy. By profoundly reducing
40 . However, with myomectomy, there is a risk of
menstrual loss LNG-IUD are able to effectively address iron
recurrence of myoma (5–10 ), persistence of menorrhagia
deficiency anemia in women with menorrhagia linked with
(1–5 ) and need for relaparotomy (20–25 ) and
leiomyoma. It was seen also to reduce the size of both uterus
hysterectomy.
and leiomyoma over a course of an year. In addition, it
provides effective contraception (Grigorieva and Associates Laparoscopic myomectomy Laparoscopic myomectomy is
2003). performed in selected cases where myoma is less than 5 cm
325
Diseases of Uterus and Fallopian Tubes

Fig. 45.12: Myoma screw

and is subserous or intramural. Myomas more than 5 cm are

preferably treated with GnRH agonist before laparoscopic
removal. Broad ligament myomas have also been removed Fig. 45.14: Leiomyoma polyp histopathology
laparoscopically. The advantages of laparoscopic surgery (Dr Yadav, RML Hospital)
include faster recovery, reduced hospital stay and avoidance
of complications associated with major open abdominal MRI machine at the focus point to raise the temperature of
surgeries. the fibroid leading to its destruction under direct vision. The
Hysteroscopic Myoma Resection images of fibroid are seved and a treatment plan is developed.
The fibroid is targetted by points and every 15 seconds. It is
This is indicated if there is a submucous myoma less than 5
repeated every 90 seconds fill the entire volume of the fibroid
cm in size and projecting more than 50 in the cavity.
is cleared. No anesthesia is required and the patient is
Pedunculated submucous myoma can be removed by
observed for about half an hour and then sent home. It is
cauterizing and cutting the pedicle hysteroscopically.
done on patients not desiring further pregnancy.
aginal myomectomy Pedunculated myoma, e.g. fibroid polyp
ryomyolysis Freezing is used for reduction in size of uterine
(Figs 45.13 to 45.14) can be removed vaginally by tying the
fibroid. It is still under trial.
pedicle and cutting it or simply by twisting the pedicle off if it
Laparoscopic myolysis and uterine artery embolization has
is thin. If the pedicle is not accessible, vertical incision on the
been tried as a treatment of myoma and requires further
cervix after reflecting the bladder can reveal the base of the
evaluation.
pedicle, which can then be tied and cut thus removing the
myoma. Laparoscopic yolysis: Destruction of myoma (myolysis) by
Section 11

laser (Nd: AG), bipolar cautery or cryo and more recently

Hysterectomy is the treatment of choice in
by thermotherapy has been tried. Myolysis results in
women over 40 years of age with symptomatic or large
shrinkage and marked devascularization of myoma. It is
fibroids. It is also indicated in cases with rapid growth of
recommended only after family is completed. Intracavity
fibroid (as it may be due to malignancy). Rarely uncontrolled
fibroid can be removed by hysteroscope.
hemorrhage and unforeseen surgical difficulties during
myomectomy may require a hysterectomy. Hysterectomy terine artery embolization Bilateral uterine artery embolization
can be done by laparotomy or by laparoscopy. Large myoma as a treatment of myoma was introduced in 1995 and has
can be morcellated and removed laparoscopically and by been used in large number of women. The aim of the procedure
nondescend vaginal hysterectomy. is to cause avascular necrosis and shrinkage of fibroid by
occluding the feeding artery (uterine) with polyvinyl alcohol
Newer Techniques particle introduced through percutaneous femoral artery
catheterization. Although it is a simple procedure and is done
MRI guided focused ultrasound surgery (MRGFUS) exablate
under sedation, complications have, however, been reported.
is a nonsurgical treatment ultrasound waves are directed by
KEY POINTS
• Leiomyoma of the uterus is the commonest solid tumor
in women.
• These are estrogen dependent, firm, well-circumscribed,
non-encapsulated tumors of smooth muscle cells arising
in reproductive years.
• Symptoms depend on location, size and number of
fibroids and include abnormal uterine bleeding, pain, lump
lower abdomen, pressure symptoms, recurrent
abortions and infertility. A large number of myomas,
however, are asymptomatic.
• Diagnosis is made by careful history, examination and
ultrasound. Associated conditions particularly
malignancy must be ruled out.
• Management of asymptomatic fibroids less than 12 weeks
size of uterus includes observation and follow-up every
326 Fig. 45.13: Fibroid polyp 6–12 months.
• Medical management is used for treating anemia, Treatment
reducing menorrhagia and temporarily reducing size and It comprises eradicating the cause of reinfection occasionally
vascularity of fibroid and uterus. hysterectomy may be required in resistant cases.
• Medical management is particularly useful in avoiding
surgery in women nearing menopause as fibroids regress Senile Endometritis
after menopause. At menopause any infection which gains entrance persists
• Myomectomy is done in symptomatic women desiring and can give rise to a condition called senile endometritis.
preservation of reproductive function and hysterectomy Senile endometritis may be associated with endometrial
is done in older women. cancer or cancer cervix. There can be purulent serous
• Myomectomy or hysterectomy can be done by minimally collected in the endometrial cavity because of narrowed
invasive techniques, i.e. by hysteroscopy or laparoscopy, cervical canal and inability of myometiral contractions to
in selected cases. expel out the uterine contents.

Chapter 45
OTHER OF BENIGN CONDITIONS OF UTERUS Clinical Features
1. Congenital abnormalities (see chapter 27) Seen in postmenopausal women who present with soft
2. Infections enlarged uterus and purulent blood mixed intermitted vaginal
3. Abnormal uterine bleeding chapter 17. discharge which may or may not be preceded by colicky
abdominal pain.
Infective Conditions of Uterus
Diagnosis

Benign and Premalignant Conditions of the Uterus

1. Acute endometritis
2. Chronic endometritis Diagnosis is confined with a dilatation or curettage
3. Tubercular endometritis (See chapter 38) endometrial aspiration. It is absolutely necessary to rule out
4. Senile endometritris cancer body of uterus.
5. Pyometra nad hematometra Treatment
6. Metritis. Dilatation of cervix and drainage of pus under antibiotic cover.
Hysterectomy may have to be done if symptoms persist.
Acute Endometritis
Hysterectomy is treatment of choice in some cases due to
Causes—operations such as dilatation and curettage MTP, high association and malignancy.
HSG, cesarean section, puerperal and postabortal.
Clinical Features Pyometra
Seen in reproductive age group. There is increased bleeding It is seen in an enlarged pus filled uterine cavity. It may be a
per-vaginum in women who had previous nomal cycle. There number of conditions namely senile endometritis, cancer of
may be accompanying pain abdomen, fever and purulent the cervix, body of uterus, cervical sternosis due to any cause
discharge per vaginum. and puerperal endometritis.
Prevention—Proper precaution and taking antiseptic Treatment
measures is very importance. Pyometra should be drained and the patient should be given
Treatment antibiotics to cover bacteroids species, anaerobic
Appropriate antibiotics and symptomatic management staphylococcus and streptococcus and aerobic coliform
depending on the cause. bacterial infection. Placement of a longer mushroom (malcot
Fig. 86.34) catheter through the cervix has been advocated.
Chronic Endometritis Repeated dilation of cervix with aspiration of pus every 2–3
It is a disease of menopausal age group. During reproductive days is more effective. An endometrial curettage after infection
age. Uterus due to its inherent property of regrowth of is controlled with antibiotics for 2 weeks is essential to rule out
surface endoemtrium and shedding during subsequent carcinoma, is recommended.
menstruation prevents persistence of infection.
Hematometra
Causes Atresia of the lower genital tract vagina, and the cervix in an
• Malignancy incomplete or complete vaginal septum can lead to
• Foreign body hematometra. There can be accompanying to hematometra
• Infected endometrial or myomatous polyp (see in chapter 27 and 41).
• Salpingo-oophoritis
• Postradiotherapy. Clinical Features
May range from acute retention of urine to a case of primary
Pathology amenorrhea with cyclical menstrual pain.
Microscopically the endometrial biopsy in these cases show It can also present as irregular menstrual bleed or
large collection of plasma cells and lymphocytes in the metrorrhagia.
stroma.
Diagnosis
Clinical Features Ultrasound shows low level echoes in the uterine cavity.
These women commonly present with menorrhagia and
purulent discharge from the uterus. Treatment
Occasionally, chronic endometritis is diagnosed when our It is often surgical and requires drainage of the collected blood.
endometrial biopsy is obtained for evaluation of abnormal In care of stenosed cervix dilatation of cervix will achieve
bleeding in patient without specific risk factors for PID. the purpose. Though re-dilatation may be required after a 327
 few weeks, in case of hematocolpos and cryptomenorrhea a
circulate incision on the distending membrane may be
required. The flaps can be sutured to prevent reclosure.
In cases of vaginal sternosis and atresias of variable
degree leading to hematometra in cryptomenorrhea a plastic
surgery to connect upper vagina and uterus to lower vagina
and introitus is required.
Causes of benign uterine mass are:
1. Benign neoplasma
a. Leiomyoma
b. Rarely hemangioma glioma, chondroma osteoma.
2. Hypertrophy (Myohyperplasia)
Diseases of Uterus and Fallopian Tubes

a. Idiopathic active/passive congestion excessive

estrogen or progesterone stimulus.
3. Adenomyosis
4. Endometrial polyp
5. Distension by fluid hematometra, pyometra hydrometra Fig. 45.15: Adenomyosis low power
6. Pregnancy and related complications Dr A Gupta, Sikkim, Manipal Medical College
7. Cysts—from Mullerian diverticula which are very rare.

ADENOMYOSIS
Adenomyosis is defined as presence of endometrial tissue
within the myometrium, at least one high power field from
the basaris layer of the endometrium.

Background
It was first described by Rakitansky in 1860. Adenomyosis,
although a variant of endometriosis, is different because of
its bahaviors. In some women adenomyosis, endometriosis
and leukomyoma may coexist.
It is different from the other two as it causes chronic bleeding
unresponsive to hormonal therapy on uterine evacuation.

Classification
Section 11

In 1991, Sathyanarayna classified adenomyosis into three

categories depending on location of the lesion.
Fig. 45.16: Adenomyosis high power
• Those limited to the basal layer Dr A Gupta, Sikkim, Manipal Medical College
• Those in deep layers
• Those in surface layers
Barne suggested a new category intramyometrial cystic Signs
adenomyosis. Uterus is diffusely enlarged usually less than 14 weeks of
gestation in size and is often soft and tender, particularly at
Pathophysiology the time of menses. Mobility is not restricted and there is no
Pathologically adenomyosis is a condition in which stroma a associated adnexal pathology.
heterotopic endometrial glands are located deeper than
endomyometrial junction by more than 1 high-power field. Diagnosis
The stratum basal of the endometrium gives rise to the Adenomyosis is a clinical diagnosis. Imaging studies are not
hetrotopic endometrial tissue (Figs 45.15 and 45.16). definitive.
An adenomyoma is described as circumscribed nodular In women with diffuse uterine enlargement after a
aggregate of smooth muscle and endometrial glands with negative pregnant test with secondary dysmenorrhea can
compensatory hypertrophy of the myometrium surrounding be attributed to adenomyosis.
the ectopic endometrium. The imaging diagnosis of adenomyosis is usually made
by transvaginal sonography (Figs 45.17, 57.43 and 57. 44). A
Incidence magnetic resource imaging can be done (Fig. 58.19).
8–30 of all hysterectomy specimens. Because of its cost and only slight improvement in
diagnostic accuracy it is used only in patients undergoing
Age uterine sparing surgery.
Pre and peri-menopausal women, multiparous women and
those over 30 years are more commonly affected. Management
Treatment depends on patient’s age and desire for future
Symptoms fertility. The treatment of symptomatic adenomyosis in
It is often asymptomatic. Symptoms typically associated with women over 40 who have completed their families is
adenomyosis include heavy and prolonged menstrual hysterectomy. For all others conservative treatment which
bleeding and dysmenorrhea often beginning a week before includes NSAIDs, oral contraceptives and menstrual
328 the onset of the menstrual flow. It may cause infertility. suppression with progestins is advocated.
 The following Table 45.2 compares the older terminologies
with those given by International Society of Gynecological
Pathologists (ISOGP).
Pathophysiology
Endometrial hyperplasia is a precursor to endometrial
adenocarcinoma. Although it was initially thought that
precursors to endometrial adenocarcinoma began with
simple hyperplasia continuous worsening until endometrial
carcinoma developed. It is now known for sure that the
propensity of endometrial hyperplasia to develop carcinoma
of endometriosis can be predicted based on histologic

Chapter 45
morphological features.
Endometrial hyperplasia is considered as premalignant
condition of uterus. Most of these hyperplasia are reversible
(simple and complex cystic glandular hyperplasia) but
complex atypical hyperplasia, if not detected in time, may
Fig. 45.17: Transvaginal sonography
lead to adenocarcinoma (flow chart 45.1).

GnRH analogues can be used to treat the infertility that Clinical Features

Benign and Premalignant Conditions of the Uterus

can result from adenomyosis. Recently uterine artery Premenopausal women with EH present with heavy or
embolization with polyvinyl particles through uterine arteries prolonged menstrial bleeding, intermenstrual bleeding, a
may decrease the size of adenomyosis and it may also prolonged episodes of amenorrrhea (absence of menstrual
relieve the symptoms of adenomyosis. It also brings relief bleeding 90 days).
in excessive bleeding that troubles a woman with adenomyosis. Postmenopausal women with endometrial hyperplasia
present with vaginal bleeding or spotting. (Postmenopausal
PREMALIGNANT CONDITIONS OF UTERUS bleeding).
Endometrial Hyperplasia (EH) During perimenopause, transition bleeding patterns can
Endometrial hyperplasia represents a spectrum of be irregular. The normal pattern of bleeding in the transition
morphologic and biological alterations of the endometrial to menopause should be further and further apart
glands and stroma, ranging from an exaggerated (Intermenstrual period) and lighter and lighter. Flow should
physiological state to carcinoma in situ. be no closer together than 21 days and should not last longer
than 7 days with no spotting, bleeding or dirty discharge at
Age: The chance of developing endometrial hyperplasia may all in between. Any deviation from this pattern re uires
be increased during menarche and perimenopause. These evaluation. It is to be noted that presence of any irregular,
periods are characterized by anovulatory cycles, therefore, abnormal bleeding or spotting or dirty discharge determines
relatively unopposed endogenous estrogen can result in the need for evaluation. The only bleeding in postmenopause
development of EH. is that which occurs as a defined pattern as a result of
Causes: Any condition resulting in increased unopposed scheduled withdrawal on continuous combined hormone
estrogen can result in endometrial hyperplasia. replacement regimens. This also requires evaluation even if
Obesity, PCOD with chronic anovulation, estrogen it falls within the guidelines.
producing ovarian stromal tumors and estrogen only
replacement therapy are associated with increased rick of Physical Findings
EH. The evaluation of abnormal vaginal bleeding requires a
Use of combined oral contraceptive (COC) pills thorough physical examinations of vulva, vagina and cervix
decreased the risk of EH because of progesterone in it. as well as are endometrial evaluation. In most patients with
See Table .1 Histopathological classification and endometrial hyperplasia these are no gross findings on
progression to cancer of endometrium. physical examination. The uterus can be normally sized or
Some pathologists still give report using older slightly enlarged.
terminology like cystic glandular hyperplasia or benign The patient may show evidence of other conditions
hyperplasia. associated with endogenous estrogen such as obesity,

Table .1: Showing histopathological types of EH

istologic Dignosis ytolgical Atypia Architectural Pattern Progresion to arcinoma

Simple Absent Regular 1
Complex Absent Irregular glands back to back 3
Scruple atypical Present Regular 8
Complex atypical Present Irregular glands back to back 29

Table .2: Comparing older terminology of EH with ISO P terminology

ISOGP Simple omplex Atypical

Vellios Cystic Adenomatous Atypical CIS
Campbell Baler Benign Atypical type I Atypical type II Atypical type III
Beutler and Docherty Cystic Glandular Glandular atypia 329
 Flow chart 45.1: Natural history of adenocarcinoma uterus
Diseases of Uterus and Fallopian Tubes

conversion of androstenedione to estrogens in fat and Disadvantage

stigmata of androgen excess observed in PCOD (e.g. Less than 50 of endometrium is sampled in more than 60
hirsutism, increased facial hair, chest hair, enlarged clitoris of patients.
or acne). An adrenal mass may be present in patients with
There is increased complications:
estrogen producing tumors.
Section 11

The differential diagnosis in case of abnormal bleeding: of perforations - 6–12/1000

In addition to endometrial hyperplasia hemorrhage - 4/1000
• endometrial polyps infection - 3–5/1000
• endocervical adenocarcinoma
TVS
• submucous leiomyoma
• chronic endometritis There is a universal agreement that irrespective of HRT
• atrophy of lower genital tract endometrial thickness of 4 mm or less is atrophic
• unusual complications of pregnancy. endometrium.
Other genital tract lesions (cervix, vulva or vagina), Advantage of TVS
gastrointestinal GI lesions and genitourinary (GU) lesions There is an opportunity for examining the whole pelvis. An
must be included in the provisional diagnosis of vaginal ovarian tumor can be diagnosed which may be not be
bleeding because it is sometimes difficult to be sure of the palpated on per vaginal examination.
location of bleeding. Hysteroscopic directed biopsy is the gold standard now in
the evaluation of endometrial pathology in the case of
Investigations
bleeding (Figs 45.18 and 45.19).
Endometrial Aspiration
Office endometrial aspiration with endocervical curettage is Management
the accepted first step in evaluating a patient with abnormal For simple and complex endometrial hyperplasia without
uterine bleeding or suspected endometrial pathology. atypia → Progesterone only for 14 days.
Diagnostic accuracy of office based endometrial biopsy is Day 10-Day 24 → Medroxyprogesterone acetate 10 mg
92–98 when compared with subsequent findings at TDS or at a dose of (10 mg – 40 mg OD) 3 – 6 cycles
dialatation and curettage or hysterectomy. or
D5 - Day 25 → Tab Norethisterone (10–20 mg) daily x3–6
Endometrial Sampling months 14 day. This treatment is more effective than 10 day
Using pipelle or vabra aspirator attains a diagnostic accuracy treatment.
of 90–98 . Its advantage is no dilatations required. It can be For hyperplasia with atypia with the above medical
performed as an outpatient procedure. There is a decreased treatment 50 regress 25 progress and 25 remain same
risk of complications. on them, higher doses and 21 day treatment is recommended.
Dilatation and Curettage Hysterectomy is largely preferred in peri-and post-
menopausal female with endometrial hyperplasia with atypia.
Previously considered as the gold standard.
330
 Chapter 45
Fig. 45.18: Simple glandular hyperplasia without atypia (10X), Fig. 45.19: Simple glandular hyperplasia without atypia (40X),
(Dr Yadav, RML Hospital) (Dr Yadav, RML Hospital)

Benign and Premalignant Conditions of the Uterus

Flow chart 45.2: Treatment plan of endometrial hyperplasia Flow Chart 45.3: Types of polyps

For those with hyperplasia on medical treatment. A follow Treatment

up dilatation and curettage after 3–6 months of treatment is Polypectomy is done and tissue sent for histopathology.
recommended (flow chart 45.2). Further management depends on the report. In benign
condition follow up every 6 months will suffice. But in case of
Myometrial Polyp malignancy definitive treatment like hysterectomy is to be
A uterine polyp can be benign or malignant performed.
Benign adenomatous polyp
They can be symptomless and may present with irregular BIBLIOGRAPHY
menstrual bleeding which include menorrhagia, intermenstrual 1 . Ferenczy A, Gelfland M. The biologic significance of cytologic
discharge, postcoital bleeding and uterine colic (flow chart 45.3). atypia in progestogen treated endometrial hyperplasia. Am
Obstet Gynaecol 1989;160:126.
Pathology 2 . Grigorieva V, Chen Mok M, Tarasova M, et al. Use of
On cut section it shows endometrial glands which may or levonorgestrel – Releasing intrauterine system to treat bleeding
related to uterine leiomyoma. Fertil Steril 2003;79:1194.
may not respond to hormones.
3 . Pritts EA. Fibroids and infertility: A systematic review of the
evidence. Obstet Gynecol Surv 2001;56(8):483.
Diagnois 4 . reik TG, Rutherford TU, Palter SF, et al. Cryomyolysis, a new
Rarely by USG, more accurately by saline hysterography, procedure for the conservative treatment of uterine fibroids.
hysteroscopy or by biopsy. Am. Assoc Gynecol Laparoscope 1998;5(1):33.

331
 46 Malignant Conditions of
Uterus and Fallopian Tubes

Sudha Salhan, Pushpa Singh, Urvashi Miglani

MALIGNANCIES OF UTERUS 11. Hereditary non-polyposis colon cancer (HNPCC)

Malignancies of the uterus are mostly endometrial syndrome. It has autosomal dominant pattern of inheritance
adenocarcinoma and sarcoma. for colon and endometrial cancers.
Adenocarcinoma is the most common of the female genital 12. Atypical endometrial hyperplasia is precursor. Table 46.1
tract in the world. Every year about 1,42,000 women develop gives incidence of conversion to adenocarcinoma in cases
this cancer worldwide and 42,000 die. About 40,000 new cases endometrial hyperplasia (Kurman et al 1985) depending
are seen per year in USA with approximately 7000 deaths. White upon the type of hyperplasia.
women are more at risk than colored one. In India, it is second 13. Certain drugs (like Tamoxifen therapy for breast cancer)
commonest malignancy of the female genital tract first being can lead to atypical hyperplasia of the endometrium and
cancer of the cervix. It is fourth common cancer of females, the even adenocarcinoma. Hence yearly evaluation of
first three are cervix, breast and bowel malignancies. Incidence endometrium is advised in them.
of adenocarcinoma of the uterus is increasing due to increasing 14. Hypertension is more often seen in these cases. Incidence
life expectancy. is more than 1.3–2.8 times.
Epidemiology of cancer of uterine cervix: The true cause 15. At molecular level Ha: K-, N-ras, and Her -2 (neu)
is not known. But a few factors are more commonly seen in Onchogenes are found in the uterine cancer. VEG F (Vascular
these cases. endothelial growth promoting factor) are overexpressed.
1. Age: Mostly seen in perimenopausal and menopausal 16. Diet High content of animal fat in diet is more associated
women 75 women are over 50 years and more of age and with this malignancy. It is more so in patients of high
it is rare below 30 years. It is seen in 5–10 cases of socioeconomic status of the society.
postmenopausal bleeding. Bokhman (1983) postulated two pathogenic types of
2. Race though not a significant factor but do have poor endometrial cancer. The first type occurs in women who have
prognosis in colored races. the risk factors like obesity, hypertension, anovulation uterine
3. Family history of enodmetrial cancer is also important bleeding, late menopause, etc. The second type occurs in women
4. Effect of Hormones: (i) Women who used oral contraceptives with none of the predisposing factors. The difference between
at some time have lesser incidence of endometrial the two is given in the Table 46.2.
adenocarcinoma. (ii) Functional ovarian tumors producing Diagnosis: A high index of suspicious is essential. This is
estrogen (e.g. granulosa cell tumor) are associated with done by detailed history taking.
adenocarcinoma of the uterus. (iii) Exogenous unopposed • Examination
estrogen therapy (as in Hormonal Replacement Therapy— • Investigations.
HRT) is instrumental in endometrial hyperplasia leading to History (Symptoms): History of irregular, often profuse, uterine
adenocarcinoma of the uterus. Hypothyroidism is more bleeding in a perimenopausal woman is suspicious.
commonly seen with uterine malignancy. Postmenopausal bleeding may be the complaint only. The
5. Nulliparity, is mostly seen with this condition. They are at appearance of abnormal bleeding early is the reason for early
two times more risk of uterine cancer especially with stage disease at first presentation. Before menopause women
anovulatory infertility (more estrogenic.) Infertility and with abnormal uterine bleeding with risk factors for uterine
polycystic ovarian syndrome are associated with this cancer need to be investigated. A history of nulliparity, early
malignancy. Pregnancy produces progestogens by placenta. menarche, late menopause, etc. is significant. Also ask for
This hormone is protective against endometrial malignancy. diabetes mellitus, hypertension and hypothyroidism. History
6. Obesity: Obese women are more prone to endometrial of similar disease in any family member. Is there a history of
carcinoma. These patient have greater waist hip
circumference than abdominal or thigh obesity. Table .1: Showing incidence of adenocarcinoma
7. Early menarche is seen in these cases. in hyperplasia endometrium
8. Late menopause is related with more chances of
adenocarcinoma of the uterus. It leads to 2.5 times greater Endometrial Incidence of
risk. hyperplasia adenocarcinoma
9. Metabolic syndrome and diabetic mellitus are associated Simple hyperplasia 1
with adenocarcinoma of uterus. There is 2–10 fold more Complex hyperplasia 3
chances of developing uterine cancer than non diabetics. Atypical simple hyperplasia 8
10. Increased bleeding during menopause has 4 times more risk. Atypical complex hyperplasia 29
 Table .2: Showing the difference between Type I and Type II adenocarcinoma uterus

ype I ( ) ype II ( )

75–85 of case Less common

ounger, perimenopausal women Older, postmenopausal women
History of unopposed estrogen-either No such history
endogenous/exogenous
Endometrial hyperplasia is associated Not associated. Associated with endometrial atrophy
Estrogen dependent (Harmone sensitive) Not estrogen dependent.
Well to moderately differentiated with Poorly differentiated, deep myometrial invasion and
superficial invasion high frequency of metastasis in the lymph nodes.

Chapter 46
Better prognosis less tendency to recur Bad prognosis more tendency to recur and metastasis.
and metastasis
Molecular genetic alterations are in PTEN Associated with TP53 mutations and ERBB-2 (HER-2/
tumor suppressive gene and K-RAS2 new expression and most are non-diploid.
oncogene and microsatellite instability
There is DNA mismatch prepair and near diploid H/P poorly differentiated endometrioid or non-
karyotype H P well to moderate differentiated. endometrioid.
Primary lymphatic spread. Surgical treatment Higher incidence of extrauterine spread mostly like

Malignant Conditions of Uterus and Fallopian Tubes

include TAH with BSO with pelvic lymphadenectomy. ovarian malignancies
Surgical treatment like ovarian malignancy.

PCOS or breast cancer on late menopause in her Taking of is only of value when abnormal. A normal Pap smear does
drugs like hormonal replacement therapy (HRT) or for cancer not exclude endometrial cancer in symptomatic women and
(tamoxifen) is important. Past history of abnormal uterine needs histological examination of the endometrium.
bleeding is helpful. Only vaginal discharge is seen in a few. 5. Transvaginal ultrasound: (Fig. 46.1) Endometrial thickness
Pain in lower abdomen may be there to push out accumulated greater than 5 mm is suspicious in postmenopausal bleeding
clots in the uterus. Blood stained discharge may be the patients. The endometrial lining may be irregular. Also can
symptom. In late cases, there may be complaint of pelvic see space occupying lesions like polyp, etc. color Doppler
pressure or discomfort like backache, etc. due to enlargement may be useful (Fig. 46.2).
of the uterus and secondaries. If uterine contents become 6. Sonohysterography may delineate the endometrial lining,
infected it may form pyometra giving pus discharge per highlighting any abnormality. It may give the tumor volume,
vaginum. extent of invasion into the uterine wall and venous
On Examination (signs): General examination may show an lymphatic invasion.
obese woman with more obesity around the waist and hip. If 7. CT and MRI is used for finding the local spread and distant
the bleeding is excessive or of some duration, anemia may be metastasis (Figs 58.20 to 58.22).
present. Hypertension is detected. Peripheral lymph nodes are Differential diagnosis of endometrial cancer is all causes of
examined the breasts are palpated. Abdominal examination abnormal uterine bleeding.
usually shows no abnormality. Except in advance cases with 1. Endometrial bleeding—10
ascities or liver or omental secondaries. Perineum is also normal. 2. Endometrial atrophy—60–80
Pap smear is done at per speculum examination. Cervix is 3. Estrogen replacement therapy—15–25
usually normal looking but may show blood coming from 4. Cervical polyp—2–12
external os. Pervaginal examination shows a normal sized uterus 5. Endometrial hyperplasia—5–10
or slightly increased size due to endometrial hyperplasia. Look 6. Ovarian cancer
for the mobility of the uterus. Adnexal masses may be palpated
in estrogen producing ovarian tumors. Rectovaginal
examination is done for the same information. See parametrium
for induration and POD for any nodularity.

Investigations
1. Ordinary dilatation and curettage may miss some cases.
2. Hence classic fractional curettage is done. First a Pap smear
is taken. Then endocervical curettage is done. Do a careful
uterine sounding (as may cause perforation of the uterus)
and perform dilation of the cervix. Systemic curettage of
the entire uterus is performed very gently. The tissues from
different uterine sites are collected in different labelled
formaline bottles for histopathology examination.
3. New FIGO surgical staging for endometrial cancer no longer
mandates a fractional D and C before surgery because
hysteroscopy is helpful in the location of the lesion and for
taking biopsy from the affected site.
4. Pap smear is positive in 30–50 of cases. It may show Fig. 46.1: USG showing endometrial cancer, Dr Uppal
endometrial cells in postmenopausal women. A pap smear (see the thickened irregular endometrium) 333
 Surgery
Surgery is the mainstay in the treatment of endometrial cancer.
Some prognostic factors are known before operation. After
opening the abdomen take peritoneal washing or peritoneal
fluid. Assess the gross spread. If the tumor is confined to the
uterus extrafacial total abdominal hysterectomy with bilateral
salpingo-oophorectomy is done. The uterus is cut open and look
for location and size of the tumor and depth of myometrial
invasion. Frozen section can also give depth of myometrial
invasion. In cases where it is stage I grade 3 lesion, tumor is
more than 2 mm and more than 50 myometrial invasion is
seen or there is cervical or extra uterine spread staging is further
Diseases of Uterus and Fallopian Tubes

done by palpating and sampling lymph nodes, omentum liver,

etc. If some suspicious lesion is seen biopsy is to be taken. The
same surgery can be done laparoscopically. Omental, hepatic
and peritoneal biopsy is suggested in all high risk patients (Type
II). Whole vaginal irradiation postoperatively in high risk group
may prevent postoperative vault recurrence. Intraperitoneal P33
Fig. 46.2: Color Doppler showing uterine cancer, Dr Uppal
installation before closing of abdomen is done by some. Some
surgeons have attempted vaginal route for surgery (in early stages
in very obese patients).
7. Cancer cervix
8. Secondaries from bowel or bladder Lymphadenectomy
9. Premenopausal menorrhagia
Pelvic and periaortic lymph node dissection also to be done in
10. Complication of early pregnancy viz. Threatened or
grade 2 and grade 3 patient. Obturator fossa is cleared.
inevitable abortion.
Send the specimen for histopathological examination and
11. Leiomyoma
detection of estrogen and progesterone receptors.
12. Cervical, endometrial tuberculosis
Another approach in Type II endometrial cancer
13. Ovarian malignancies
neoadjuvant chemotherapy systemically followed by interval
14. Bleeding disorders.
surgery.
Treatment Follow-up: Vaginal bleeding pain and weight loss suggest
recurrence during 3 years following primary treatment.
After tissue diagnosis and classification, the woman is
Section 11

investigated for surgery. The following tests are performed: Postoperative Chemotherapy
Besides routine blood and urine examination
Doxyrubicin (Adriamycin) and paclataxel (Taxol) or cisplatin
1. Blood sugar (Fasting and postprandial)
are given in recurrent adenocarcinoma.
2. Serum electrolytes
Hormone therapy: Progesterone, if there are positive
3. Blood urea and serum creatinine
hormone receptors, can be added.
4. Liver function tests
Stage III and IV patients need individualized management.
5. ECG
Mostly hormone treatment chemotherapy are used besides
6. A chest -ray
surgery and radiotherapy.
7. CT
8. Sigmoidoscopy and barium enema in patients with distant
Radiotherapy
metastasis
9. Brain liver and bone scan is done only in extensive spread Intrauterine brachytherapy is curative but used in medically
10. Thyroid function test inoperable patients. Also used to treat pelvic lymph node
11. Stool for occur blood postoperativity. Also in pelvic recurrence (chapter 40).
12. If positive, colonoscopy is to be done
Recurrence
13. CA-125—For postoperative follow-up.
Recurrence is seen in adenocarcinoma.
5-yr survival rate Stage I 81–95 Recurrence—in the pelvis in
Stage II 67–77 Grade I and Grade II growth occur in 4 .
Stage III 31–60 Grade III superficial disease 14
Stage IV 5–20 Grade III significant muscle involvement 40 is seen.
Treatment is to be individualized after taking all the Ca-12 can be used to monitor recurrence post- operatively
prognostic factors into consideration. Most of the patients are Vault recurrence can be surgically treated by local wide
diagnosed early (because of bleeding per vagina) in grade I excision. May use radiotherapy also.
and II. The 5-year survival with surgery alone or surgery with
radiotherapy is the same. Patients with poorly differentiated Hormone Therapy
Grade III the slightly better prognosis with combined modality In recurrence beyond vault of the vagina, surgery may not be
is seen. Preoperative or primary radiotherapy is used nowadays helpful. Progesterone can be given in then Medroxyprogesterone
only in patients in advance pelvic cancers or if there is medical acetate 400 mg IM weekly especially in well-differentiated
contraindication for surgery (see chapter 40). It can also be used histological cases (have more receptors). If receptors are low
in advanced cases where bleeding cannot be stopped. It cannot the response with progestin will be poor. Tamoxifen can be used
be given in cases of pelvic mass, pelvic kidney, infection in poor responders. It blocks estrogen receptors and increases
334 (pyometra) previous radiation or laparotomies. progestin receptors. Then add progestin, it helps.
 Gonadotropin-releasing hormone (GnRH) analogues have
been evaluated in the treatment of endometrial cancer
recurrence. They suppress gonadotropins thus reducing
estrogen. GnRh analogues may have direct inhibitory action
on the cancer cells. Further research is required.

Chemotherapy
Cisplatin as a single therapy or with Doxyrubicin can also be
used in recurrences. Other drugs are also under study. 5 years
survival rate.
Screening for endometrial carcinoma is not recommended.
But can be performed in patients with hereditory nonpolyposis

Chapter 46
colorectal cancer (HNPCC) syndrome. Benign endometrial
sampling started at 30 years of age with yearly screening (WHO
criteria for screening).
The endometrial malignancies are treated according to the
histologic classification (type) of the lesion and FIGO Fig. 46.5: Endometrial endometrioid carcinoma complex glandular
structure with wisp of endometrial stroma (Dr Anurag Mehta (Rajiv
classification (spread).
Gandhi CRIC))
Histologic classification of carcinoma of uterus.

Malignant Conditions of Uterus and Fallopian Tubes

1. Endometrioid adenocarcinoma 80 (Figs 46.3 to 46.5)
a. Papillary or villoglandular 2 7. Squamous cell carcinoma
b. Secretory 1 8. Transitional cell tumor
c. Adenocarcinoma with squamous differentiation 15–25 9. Small cell tumor
2. Mucinous carcinoma 5 10. Miscellaneous carcinoma
3. Papillary serous carcinoma 3–4 (most aggressive) 11. Metastatic carcinoma (e.g. from cervix or ovarian or
4. Clear cell carcinoma 5 fallopian tubes)
5. Undifferentiated carcinoma 12. Endometrial carcinoma and sarcoma.
6. Mixed Histological grading applies to endometrioid carcinoma
only. Serous and clear cell carcinomas are put in high grade
only.
In serous adenocarcinoma, clear cell adenocarc-inoma and
glandular cell carcinoma, nuclear grading takes precedence.
Adenocarcinoma with squamous differentiation are graded
according to the nuclear grade of the glandular component.

Endometrioid Adenocarcinoma
It is the commonest histologic type.
• Composed of gland with columnar cells with basally
oriented nuclei endometrial type of gland little or no
intracytoplasmic mucin and smooth intraluminal surface.
Most of them are well or moderately differentiated. They
are mostly independent primary tumors. Ovarian tumor is
considered metastatic when the ovarian tumors are small
bilateral or multinodular with surface implants and
angiolymphatic invasion in the ovarian cortex.
Fig. 46.3: Endometrioid carcinoma well-differentiated (10x) • Less differentiated have more solid area, less glandular
Dr Yadav, RML Hospital formation and more cytological atypia variants
Gross appearance of Endometrial Adenocarcinoma as seen
in (Figs 46.6 to 46.8).
Different types of adenocarcinoma of endometrium behave
differently.

Mucinous Carcinoma
• Well-differentiated good prognosis
• Cells have intra cytoplasmic mucin.

Papillary Serous Carcinoma

• Composed of fibrovascular stalks lined with atypical cells
• Psammoma bodies seen
• High grade lesion
• Seen in postmenopausal ladies with endometrial atrophy
• Increased chances of lymphovascular space invasion,
myometrial invasion and extrauterine disease.
Fig. 46.4: Endometrioid carcinoma poorly differentiated (10x) Dr • Show strange diffuse immunohistochemical staining for
Yadav, RML Hospital TP53 antigen. 335
 Grading of Histologic Type
rade 1 ( 1): Well-differentiated glands with no more than
5 solid non-squamous area.
rade 2 ( 2): Moderately differentiated with 6–50 solid areas.
rade 3 ( 3): More than 50 solid nonsquamous area. Poorly
differentiated lesion with predominantly solid area. Nuclear
atypia, architectural abnormalities and ablation, the glandular
changes pattern of invasion and presence of humor necrosis
are components taken into consideration for grading.
The tumor is upgraded in cases of striking alypia. A tumor
is called high grade if at least 2 of the 3 conditions are met—
Diseases of Uterus and Fallopian Tubes

(i) More than 50 solid growth, (ii) diffusely infiltrative growth

rather than expansive and (iii) tumor cell measures.
Fig. 46.6: Endometrial carcinoma
FIGO Classification 2009
Stage I ( 123): Tumor confined to the corpus uteri
1A—No or less than half myometrial invasion
1B—Invasion equal to or more than half of the myometrium.
Endocervical glandular involvement only should be
considered as stage I.
Stage II ( 123): Tumor invaded cervical stroma, but does not
extend beyond the uterus (Endocervical glandular involvement
only should be considered as stage I and no longer as stage II).
Stage III ( 123): Local pelvic or regional spread.
IIIA Tumor invades the serosa of the corpus uteri and/or
adnexa.
IIIB Vaginal and/or parametrial involvement
IIIC Metastases to pelvic and or para-aortic lymph nodes.
IIICI Positive pelvic nodes
Fig. 46.7: Endometrium carcinoma
IIIC2 Positive para-aortic lymph node with or without pelvic
lymph nodes.
Section 11

Stage IV ( 123): Tumor invades bladder and/or bowel mucosa

and /or distance metastasis.
IVA Tumor invasion of bladder and or bowel mucosa.
IVB Distance metastasis including intra-abdominal
metastasis and/or inguinal lymph nodes.
Positive cytology has to be reported separated without
changing the stage.

Prognostic Factors
1. Higher histologic grades, e.g. G2 or G3 have poor
prognosis.
2. Histological type, e.g. papillary and clear cell have shorter
5-year survival.
3. More the depth of invasion of the myometrium poorer
the prognosis.
4. Tumor size is also an important factor.
5. DNA ploidy (Proliferative index genetic molecular tumor
markers) are valuable points detected by DNA flow
cytometry.
6. Mitotic activity of the tumor and chromosomal
anemology onchogenic mutation.
7. Age of the patient—younger patients have good prognosis.
Fig. 46.8: Adenomatous carcinoma extending to endocervix 8. Endocervical involvement gives poor prognosis
9. Involvement of lymph nodes with the malignant cells give
poor prognosis.
Clear Cell Carcinoma 10. Associated adnexal disease. Simultaneous malignancies of
It is seen in younger patient with diethylstilbestrol exposure in breast, ovary and large intestines is seen in about 8 of
utero. cases without evidence of direct extension.
• Highly atypical nuclei 11. Extra uterine spread
• Abundant clear or eosinophilic cytoplasm 12. ormone receptors In stage I and Stage II cancer women with
• Cells have hobnail configuration progesterone and estrogen receptor positive is a prognostic
• Very aggressive high grade tumors.
336 factor
13. Position of the malignancy in upper or lower uterine use of intrauterine contraceptive device (both copper and
segment is important. The lower segment tumors spread progesteron containing) and tubal ligation have been associated
faster to the lymph nodes. with a lower risk. Breast cancer put women are at a higher risk
14. Positive peritoneal cytology of endometrial cancer because of common risk factors. There is
15. Intraperitoneal disease risk of developing serous endometrial cancer (2.6 times higher
16. Lymphovascular space invasion risk). In addition use of tamoxifen triples the risk (even carcino-
17. Mode of treatment is also important concurrent sarcoma). Hence breast cancer patients are to be kept under
radiotherapy (Preoperative or postoperative), etc. and surveillance first degree relatives having endometrial cancer
postsurgery residual tumor. are to be kept under observation. Also in Mendelian dominant
Spread of uterine cancer is by direct extension (to cervix or HNPCC syndrome history extra-alertness is mandatory.
fallopian tubes) lymphatic spread, peritoneal implant by spread Secondary Prevention: Screening is not useful. Education
to the public about investigation in postmenopausal bleeding

Chapter 46
through tubes and through blood circulation. It can go to
inguinal lymph node through round ligament (Fig. 46.9). is essential. Do ultrasound of the uterus before starting
In type II adenocarcinoma hysterectomy and maximum tamoxifen. Apart from prophylectic surgery (in cases of HNPCC
cytoreduction is required as an ovarian malignant. syndrome where 40–60 chances of endometrial malignancy
and 12 of ovarian cancer) beyond 45–50 years identification
Indicators of Invasion in Endometrioid of such women is crucial.
Adenocarcinoma
Uterine Sarcoma
• Desmoplastic stroma

Malignant Conditions of Uterus and Fallopian Tubes

• Back to back glands without intervening stroma It is a rare mesodermal tumor of the uterus. It is very aggressive
• Squmous epithelial differentiation and constitutes about 1 of all uterine carcinoma. They are
• Extensive papillary pattern diagnosed earlier (5th and 6th decade of life). The incidence is
• Area of involvement 1/2 of a low power microscopic field. higher in African- American women than in caucasians. Pelvic
irradiation causes more of carcinoma (mixed form) than uterine
Prevention of endometrial carcinoma is possible in Type 1. Do sarcoma. Symptoms are vaginal bleeding, mass in the pelvis
not give unopposed estrogen. Progesterone for 10–14 days per and pain (as is seen in leiomyomas). A rapidly growing pelvic
month use of excessive fat in diet is to be avoided. BMI should mass is the typical presentation. A large mass in the upper
not go above 25 km/m2, that means avoid obesity, overweight abdomen (omental mass) and ascities may be seen (due to
causes insulin resistent, ovarian androgen excess, anovulation abdominal carcinomatosis) in late cases. Because of bleeding
and chronic progesterone deficiency. Obesity causes more anemia may be present.
estrogen from extraglandular conversion of androgen in 5-year survival rate ranges from 25–75 .
postmenopausal women stimulation endometrial proliferation Investigation includes completes blood and urine
and prevention of apoptosis and promote angiogenesis. Promote examination, liver function test (serum alkaline phosphatase
physical activity, even brisk walking, throghout life lowers prothrombin time, serum lactogen and serum dehydrogenase).
estrogen level and hence endometrial cancer. Use of phyto- Blood urea and serum creatinine. D and C is not always helpful.
estrogens in diet is a preventive measure. Infertility is to be Post-operative Ca-125 and estrogen and progesterone receptors
treated. Contraceptive pills used is helpful in prevention. Even are done. -ray of chest is done to rule out metastasis, CT of
abdomen is performed to know the extent of the spread to liver,
kidney and lymph nodes. MRI can give size and degree of
spread. Pelvic ultrasound. Sigmoidoscopy (if G1 bleed) and
cystoscopy (in cases of hematuria) is required.

Histology
Three characteristics are essential to diagnose sarcoma
1. Nuclear atypia
2. Mitiotic figures. Mitotic index (Mitotic figures/10 HPF) 10
or more
3. Coagulative necrosis
If all three criteria are not met, it is called leiomyoma variant or
hydropic leiomyoma with highly cellular growth pattern.
Histologic types of uterine sarcoma are:
1. Leiomyocarcoma (LMS)—arise from myometrial smooth
muscle cells or blood vessels lining of the myometrium.
2. Adenosarcomas homologous
i. heterologous
3. Malignant mixed Mullerian tumor (MMMT) is most rapidly
growing arises from undifferentiated embryonal stromal
cells (Figs 46.10 and 46.11).
4. Carcinosarcoma is more platinum sensitive and has better
prognosis.
5. Low grade endometrial stromal sarcoma (ESS)
6. Rare ones are:
a. Fibrosarcoma
Fig. 46.9: Lymphatic drainage of uterine malignancy b. Embryonal rhabdomyosarcoma
337
 Adjuvant radiation can reduce pelvic relapse but overall
survival is not affected.
Radiation is more effective after surgery is done.
Chemotherapy can be given postoperatively. Injection
gemcitabine and docetaxel is used.

FALLOPIAN TUBE CARCINOMA

Primary fallopian tube carcinoma (Figs 46.12 and 46.13) is a
rare cancer of the female genital tract. Its incidence is 1 of all
gynecological tumors (Schneider C et al., 2000). It most
frequently occurs between the fourth and sixth decade of life
with a median age of occurrence of 55 years (17–88 years).
Diseases of Uterus and Fallopian Tubes

However, it has been reported in young girls aged 17–19.

Primary fallopian tube carcinoma patients with BRCA mutation
are younger than those with sporadic primary fallopian tube
carcinoma. The distal part of the tube seems to be involved much
more than the isthmus. The pattern of spread, staging and
treatment of primary fallopian tube carcinoma are on the lines
Fig. 46.10: Mixed Mullerian tumor (40x)
of epithelial ovarian cancer.

ETIOLOGY
The exact etiology of primary fallopian tube carcinoma is not
known. However, various epidemiological studies have
revealed certain associations.
• There is a strong association with gross and/or histological
evidence of old pelvic inflammatory disease.
• Age, infertility and infertility treatment may be risk factors
to some extent (Hankinson et al., 1995, Auranen et al., 2005).
• An initial connection between primary fallopian tube
carcinoma and tuberculous salpingitis was reported
(Gungor T, 2003) but no other precise infectious agent has
been identified.
Section 11

Fig. 46.11: Mixed Mullerian tumor (2x) (Dr Yadav, RML Hospital)

Diagnosis: Awareness and alertness about the diagnosis is

important. Endometrial biopsy or fractional curettage may be
helpful. But sarcomatous changes in a leiomyoma is mostly
diagnosed when hysterectomy specimen are examined. Spread
is very rapid and metastasis to liver, lung and abdomen is very Fig. 46.12: Right fallopian tube malignancy
quick. The spread depends on the mitotic index, vascular
lymphatic and serosal extension and degree of anaplasia. Pap
smear may be helpful. Because of bleeding anemia may be there.

Prognostic Factors
• Increased tumor grade and higher stage, i.e. more number
of mitotic figures lead to less than 5 years survival rate
• Size of tumor
• Age of patient
• Vascular space involvement
• Molecular biology more aneuploid the sarcoma worst the
prognosis
• P53 tumor suppressor gene
• Recurrence rate is 45–73 with different authors.
Treatment: At laparotomy, take cytology specimen of the
peritoneal fluid by washing with normal saline. Frozen section,
if available, be used. Hysterectomy with bilateral salpingo-
oophorectomy is the treatment. Additional samples are taken
from peritoneum. Postoperatively histopathology and estrogen
338 and progestrone receptors are to be both detected. Fig. 46.13: Carcinoma of fallopian tube
• Various studies have suggested that primary fallopian tube distention of tube leading to stretching of mesosalpinx. The
carcinoma should be considered as a clinical component of presence of pain is highly significant since cancers of the
the hereditary breast ovarian cancer syndrome and it is ovary, endometrial, and cervix do not cause pain until their
associated with BRCA1 and BRCSA-2 mutations Baekelandt diagnosis is all too obvious.
et al 2000 (Aziz 2001 et al). • Abdominal distension: 14–23 of cases
• Latzko triad: Latzko called attention to a triad of
Hereditary Risks Associated with Primary intermittent profuse serosanguineous vaginal discharge,
Fallopian Tube Carcinoma colicky pain relieved by discharge, and abdominal or pelvic
BRCA mutations are found more frequently in primary fallopian mass, reported to be present in 15 of primary fallopian
tube carcinoma patients (43 - Cass et al 2005) than among tube carcinoma patients.
ovarian cancer patients (3–10 Malander et al 2004). It is • Hydrops tubae profluens—a pathognomic feature – implies
suggested that when prophylactic surgery is performed in such intermittent discharge of clear or blood-tinged fluid

Chapter 46
high risk women sectioning and extensive examination of spontaneously or on pressure, followed by shrinkage of the
Fimbria (SEE-FIM) along with the removal of the intrauterine adnexal mass. However, this occurs in only 5–9 of the
portion of the fallopian tube should be done. patients (Nordin 1994; Ajithkumar et al., 2005).
• Urinary urgency: 8 of cases
Classification of Carcinoma of Fallopian Tube • Acute abdomen: 5 of cases
• Pelvic mass felt clinically: 12–61 of cases.
Primary Secondary

Malignant Conditions of Uterus and Fallopian Tubes

Serous Ovary Diagnosis
Endometrioid GIT
Preoperative and intraoperative diagnosis is rarely made. It is
Mixed Breast
Undifferentiated reported that an intraoperative diagnosis is missed in up to
Clear cell 50 of patients. (Meng ML et al., 1985)
Transitional Preoperative diagnosis is possible only if a high index of
Mucinous suspicion is kept in certain clinical situations.
• The presence of the triad of symptoms-pain, serosanguinous
Histologically, serous adenocarcinoma is the commonest. Serous discharge and a pelvic mass
tumors are graded with respect to their differentiation and • Persistent unexplained pelvic, lower abdominal and/or low
extent of solid components. Most tumors are poorly back pain
differentiated. • Unexplained postmenopausal bleeding/discharge
Primary fallopian tube carcinomas are divided into three • Role of Pap smear and endometrial curettage: The
grades (Alvarado-Cabrero I et al 1999). Grade 3 (poorly effectiveness of cytologic diagnosis from cervical and/or
differentiated: 50 –65 ) is the commonest followed by Grade vaginal pool samples is widely variable and has been
2 (moderately differentiated: 20 –30 ) and Grade 1 (well- reported as positive in 40–60 of women with tubal
differentiated): 15 –20 ) respectively. Secondary carcinomas carcinoma. ( ohnson 1983) The presence of abnormal
of fallopian tube being so common, it is imperative to rule out glandular cells in the Papanicolau smear in the presence of
primary in the ovary, breast, and GIT before labeling a case as healthy cervix and normal endometrial cytology raises a
primary fallopian tube carcinoma. Stringent criteria have been strong index of suspicion for fallopian tube carcinoma.
laid by Hu et al for the diagnosis of primary fallopian tube
carcinoma. (Hu C et al 1950). ROLE OF IMAGING IN THE DIAGNOSIS OF
PRIMARY FALLOPIAN TUBE CARCINOMA
HU ET AL’S CRITERIA Imaging routinely carried out for suspected gynecological
a. Tumor should arise from the tubal epithelium with the malignancies includes USG, CT and MRI of the abdomen
majority of the cancer located in the tube. though they cannot confirm or refute the diagnosis of
b. Histological features resemble a tubal pattern. malignancy.
c. There is a demonstrable area of transition between normal • Sonography: On sonography Primary Fallopian Tube
and malignant endosalpinx. Carcinoma may appear as a cystic mass with spaces and
d. Uterus and ovaries are either normal or contain less tumor mural nodules, a sausage shaped mass or a multilobular mass
than the tube. with a cog and wheel appearance.
• Color Doppler: TVS with color Doppler may detect areas
Clinical Features of neovascularization and low impedance vascular flow in
Symptoms connected to primary fallopian tube carcinoma as the solid areas of the fallopian tube. 3D color Doppler may
noticed in different studies (Nordin 1994; Alvarado-Cabrero et show tubular wall irregularities and vascular abnormalities
al. 1999; Baekelandt et al. 2000; Obermair et al. 2001; Benoit like A-V shunts, blind ends, micro-aneurysms and
and Hannigan 2006) are as follows: dichotomous branching typical of malignant vessels.
• Postmenopausal or abnormal vaginal bleeding: It is the • CT scan and MRI: The lesion can have an appearance of a
most common symptom and seen in 35–60 of cases. The small solid lobulated mass on CT scan or MRI. Associated
uterine bleeding is obviously pathologic, since the majority findings include peritumoral ascites and hydrosalpinx. MRI
of patients are postmenopausal, and it is almost invariably seems to be better than CT scan or USG in detecting tumor
unexplained by uterine curettage. Thus, primary fallopian infiltration of the bladder, vagina, and pelvic side walls,
tube carcinoma must be considered in the differential pelvic fat and rectum.
diagnosis when postmenopausal bleeding persists after a
negative curettage. ROLE OF TUMOR MARKERS
• Abdominal pain: Seen in 30–49 of cases. Pain may be CA-125 is a nonspecific tumor marker and is raised in many
colicky because of forced tubal peristalsis and due to conditions like pregnancy, endometriosis, fibroids, tuberculosis, 339
 pancreatitis and ovarian tumors. Circulating levels of CA-125 and para-aortic lymph nodes through infundibulopelvic
are increased in 65–80 of primary fallopian tube carcinoma lymphatics. An intrapelvic course with drainage into
patients preoperatively (Hefler et al., 2000). superior gluteal lymph nodes is also possible. The existence
Concentrations of CA-125 though not diagnostic but have of anastomosis with lymphatics of the uterus in the round
been reported to be elevated in 20 of cases of stage I disease ligament may explain the development of inguinal node
and in 75 , 89 and 100 cases at stage II, III, and IV metastasis. On routine lymphadenectomy, 42–59 of
respectively (Takinshima et al., 1997). patients show lymph node metastasis with almost equal
involvement of para-aortic and pelvic lymph nodes.
Staging
Treatment
The staging of Primary fallopian tube carcinoma is shown in
Table 46.3. Surgery is the mainstay of treatment.
• Staging laparotomy: includes peritoneal sampling, total
Diseases of Uterus and Fallopian Tubes

Natural Course and Pattern of Spread abdominal hysterectomy with Bilateral Salpingo-
Because of its frequently observed cardinal symptom, i.e. oophorectomy, Infracolic omentectomy, pelvic and para-
painful distension in the tubes and an abnormal discharge of aortic lymphadenectomy. The increased survival time of
serous fluid, 17–56 of cases of primary fallopian tube patients of primary fallopian tube carcinoma who
carcinoma are at stages I and II compared with ovarian underwent lymphadenectomy (Rosen A Klein et al)
carcinomas in which two thirds are at stages III and IV at underlines the need for a systemic pelvic and para-aortic
diagnosis. Fallopian tube carcinomas spread in much the same lymphadenectomy.
manner as epithelial ovarian cancer. • Conservative: There is definitely a role of conservative
• Transcoelomic: It spreads principally by the transcoelomic surgery in young patients with in situ carcinoma and in
exfoliations of cells that implant throughout the peritoneal patients with stage I and grade I carcinoma desirous of
cavity. preserving fertility.
• Contiguous: Tumor spread can also occur by means of • Palliative: In patients with advanced disease, optimal
contiguous invasion and transluminal migration. (residual tumor 2 cm) cytoreductive surgery should be
• Hematogenous dissemination: Bilateral tubal involvement attempted as amount of residual tumor is an important
has been reported in 10–27 of cases. prognostic factor. If optimal debulking is not attainable,
• Lymphatic: The primary fallopian tube carcinoma is richly surgery should be attempted again after 3 courses of
permeated with lymphatic channels that drain into pelvic chemotherapy.
(common iliac, external iliac, internal iliac and obturator)
ROLE OF CHEMOTHERAPY
The high level of distant metastasis even after complete resection
Table .3: FI O staging (1 1) of primary in patients with early disease warrants the need for adjuvant
fallopian tube carcinoma
Section 11

therapy. An exception is patients with disease confined to the

Stage 0 Carcinoma in situ (limited to tubal epithelium) tube, not penetrating the serosa and without intraoperative tubal
Stage I Growth limited to the fallopian tubes rupture. The current chemotherapy guidelines are summarized
Ia Growth limited to one fallopian tube; no ascites; no tumor in following Table 46.4 (Gadducci 2002, Pectaside et al., 2006).
on the external surface; tubal serosa intact
Ib Growth limited to both fallopian tubes; no ascites; no ROLE OF RADIOTHERAPY
tumor on the external surface; tubal serosa intact
Radiotherapy has a role only for stage III residual negative
Ic Either stage Ia or Ib, but with tumor on the surface of one
patients or in the relapse setting.
or both fallopian tubes; tubal serosa ruptured or with
ascites present containing malignant cells, or with positive
Radiotherapy was the traditional adjuvant therapy for
peritoneal cytology primary fallopian tube carcinoma but in today’s era its role is
Stage II Growth involving one or both tubes with pelvic extension less well-defined and controversial because of
IIa Extension or metastases to the uterus and/or ovaries a. Low efficacy
IIb Extension to the other pelvic tissues b. High rate of serious complications
IIc Tumor either IIa or IIb or with ascites present containing c. The observation that the patients with external abdominal
malignant cells or with positive peritoneal washings pelvic adjuvant radiotherapy developed recurrences outside
Stage III Tumor involves one or both tubes with peritoneal abdominal cavity
implants outside the pelvis, including superficial liver d. Availability of effective chemotherapy (Barkelandt et al.,
metastasis, and/or positive retroperitoneal or inguinal 2000).
nodes. Tumor limited to pelvis except for histologically
proven extension to small bowel or omentum ROLE OF HORMONAL AGENTS
IIIa Tumor grossly limited to pelvis with negative nodes but
with histologically confirmed microscopic seedling of
Tubal epithelium embryologically is derived from the same
abdominal peritoneal surfaces source as endometrial epithelium. With this rationale
IIIb Tumor involving one or both fallopian tubes with grossly progestational agents have been used due to known cyclic
visible, histologically confirmed implants of abdominal response of the normal tube to hormonal changes during the
peritoneal surfaces, none exceeding 2 cm in diameter. menstrual cycle. (Brown MD et al 1985). Because of lack of
Lymph nodes negative randomized trials, no firm conclusions can be drawn with
IIIc Abdominal implants 2 cm in diameter and/or positive regard to their usefulness.
retroperitoneal or inguinal nodes
Stage IV Growth involving both tubes with distant metastases Survival
including parenchymal liver metastases. If pleural
Rarity of occurrence and discrepancies in the treatment
effusion is present, fluid must be positive cytologically
for malignant cells modalities of different countries has resulted in a wide
340 fluctuation of the survival rates.
 Table . : Chemotherapy of primary fallopian tube carcinoma

Stage reatment
Ia-Ib, optimal surgical staging, no pre- No further treatment
or intraoperative rupture
Ia-Ib, suboptimal surgical staging, pre- Paclitaxel (175 mg/m2)-carboplatin (AUC 5–6)
or intraoperative rupture every 3 weeks for 3–6 cycles
Ic-IV Paclitaxel (175 mg/m2)-carboplatin (AUC 5–6) every 3 weeks for 6–8 cycles
For relapse and for second-line therapy
Patients who failed paclitaxel-based Docetaxel (75–100 mg/m2)-carboplatin
chemotherapy (AUC 5) every 3 weeks
Platinum- and paclitaxel-resistant disease Liposomal doxorubicin (50 mg/m2) every 4 weeks

Chapter 46
Topotecan (1.5–2.0 mg/m2) a day for 3–5 days every 3 weeks

Five-year over all survival rates vary between 22 and 57 . However, it appears that lymph node metastasis and ascites
The survival rates according to the stages have been shown in are a maker of poor prognosis (Cornio 1996, di Re E 1996, Peters
Table 46.5. 1988).
Most recurrences are extra pelvic, and half or more of them Positive peritoneal cytology and elevated CA-12 : associated

Malignant Conditions of Uterus and Fallopian Tubes

are extraperitoneal, usually in combination with intraperitoneal with a poor prognosis.
recurrence (Podratz et al., 1986). Most recurrences have been
reported in the first 2–3 years (Takeshiman 2000) but have also Follow-Up
occurred many years later (Peters WA 1988). Because there is Close follow-up of all patients is mandatory because of high
no effective second-line or salvage chemotherapy, recurrent chances of recurrence. It should be done at least every three
disease is associated with a very poor prognosis. months for two years. At every visit:
• Detailed History: Especially about pain, distention,
Prognostic Factors
alteration in bowel habits and weight loss
Age: ounger age is associated with better prognosis. • Sonography of pelvis and whole abdomen
Menopausal status: Postmenopausal females are associated • CACT if indicated
with a worse prognosis. • CA-125
Site of involvement: Prognosis is poor with involvement of • Mammography.
fimbrial part. (Alvarado Cabrero 1999) CA-125 is a useful tumor marker not only for the diagnosis and
Stage: Stage of disease is one of the most significant prognostic assessment of response to therapy but is also very helpful in
factors (Benedet and Miller1992). Advanced stage is associated the detection of a recurrence during follow-up. The pretreatment
with bad prognosis. serum CA 125 is an independent prognostic factor of disease free
survival and overall survival in patient with primary fallopian
For patients with Stage I disease the depth of tubal invasion and tube carcinoma. Serum CA-125 levels post- surgery has also been
intraoperative tumor rupture has independent prognostic associated with response to chemotherapy. CA-125 is also a useful
significance (Baekelandt et al., 2000). marker for post treatment follow-up. It is also an early and sensitive
Residual Tumor Burden: Size of residual tumor is a very strong marker for tumor progression during follow up. It has been
prognostic factor. Patients with stage III-IV disease with residual reported that the lead time (elevated serum CA-125 levels prior to
tumor size of 1 had 55 survival in comparison to 21 for clinical or radiological diagnosis of recurrence) is 3 months (range
those with large residual tumor (Gadducci et al., 2001). 0.5–7 months).
rade: Prognostic significance is controversial.
ROLE OF SECOND LOOK LAPAROTOMY
In most studies though grade is marginally prognostic but Currently laparotomy does not have a defined role
remains non-significant in statistical analysis (Hefler 2000, in the management of primary fallopian tube carcinoma as there
Hellstorm et al., 1994, Gadducci et al., 2001). is no curative second line therapy for patients with positive
Histology: Histological subgroup does not have a significant findings at 2nd look operation. It should be currently reserved
impact on the prognosis of primary fallopian tube carcinoma for patients in clinical trials.
(Alvarado-Cabrero1999, Gadducci 2001). It was found that the
better prognosis of serous or transitional type correlated with Recent Advances
lower stage of the former and was not observed when analysis Beta hCG has been recently discovered as the marker of primary
was restricted to stage I and IIA. fallopian tube carcinoma (Riska A 2006). Human Chorionic
Lymph node status and ascites: Sparse information is available gonadotropin is a glycoprotein consisting of 2 polypeptide
on the role of primary lymph node status as prognostic marker. subunits, i.e. the and subunit. Secretion of -hCG reflects
the aggressiveness of this cancer. Serum -hCG is a good
prognostic marker and elevated levels reflects a worsened
Table . : - ear survival rates according to the stages prognosis.
Stage year Survival rate Conclusions
Stage I 62 • Primary fallopian tube carcinoma is a rare gynecological
Stage II 36 tumor.
Stage III 17
• Exact etiology is unknown but a strong association with chronic
Stage IV 0
tubal damage and infertility has been reported. 341
 • Women with BRCA-1/BRCA-2 mutations are at increased risk. and survival of patients with fallopian tube carcinoma: A
• Latzko triad and hydrops tubae-profluens are cooperation task force (CTF) study. Gynecol Oncol 2001; 81:150-59.
pathognomonic of fallopian tube carcinoma though seen in 14. Gadducci A. Current management of fallopian tube carcinoma.
Curr Opin Obstet Gynecol 2002;14:27-32.
5–9 of cases.
15. Gungor T, Keskin HL, ergeroglu S, Keskin EA, alcin H, Aydogdu
• Preoperative diagnosis rests on high index of suspicion in T, Kucukozkan T. Tuberculous salpingitis in two of five primary
the presence of Latzko triad, unexplained abnormal cervical fallopian tube carcinomas. Obstet Gynaecol 2003;23:193-5.
cytology or a negative D and C in women over 40 with 16. Hankinson SE, Colditz GA, Hunter D , Willett WC, Stampfer M ,
unexplained vaginal bleeding. Rosner B, Hennekens CH, Speizer FE. A prospective study of
• CA-125 is a very important marker for the follow up and reproductive factors and risk of epithelial ovarian cancer.Cancer
detection of recurrence. 1995;76:284-90.
17. Hefler LA, Rosen AC, Graf AH, Lahousen M, Klein M, Leodolter S,
• Pattern of spread, staging and treatment is on the lines of
Reinthaller A, Kainz C,Tempfer CB. The clinical value of serum
epithelial ovarian cancer.
Diseases of Uterus and Fallopian Tubes

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of 105 cases with observations on staging and prognostic factors. 22. Meng ML, Gan-Gao, Scheng-Sun, et al. Diagnosis of primary
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3. Amant F, Moreman P, Neven P, et al. Endometrial Cancer Lancet 1985;110:136-40.
2005;366:491. 23. Nordin A . Primary carcinoma of the fallopian tube: A
4. Auranen A, Hietanen S, Salmi T, Gr nman S. Hormonal treatments 20-year literature review. Obstet Gynecol Surv 1994;49:349-61.
and epithelial ovarian cancer risk. Int Gynecol Cancer 2005;15:692- 24. Obermair A, Taylor KH, anda M, Nicklin L, Crandon A , Perrin
700. L. Primary fallopian tube carcinoma: The ueensland experience.
5. Baekelandt M, orunn Nesbakken A, Kristensen GB, Trope CG, Abeler Int Gynecol Cancer 2001;11:69-72.
VM. Carcinoma of the fallopian tube. Cancer 2000;89:2076-84. 25. Papaioannou S, Tzafettas . Anovulation with or without PCOS,
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6. Benedet L, Miller DM. Tumors of fallopian tube: clinical features, hyperandrogenaemia and hyperinsulinaemia as promoters of
staging and management. In: Coppleson M, Monoghan M, Morrow endometrial and breast cancer. Best Prac Res Clin Obstet Gynecol
CP, et al, eds. Gynecologic Oncology: Fundamental Principles and 2010;24(1):19.
Clinical Practice.Edinburgh, London, Melbourne, New ork and 26. Pectasides D, Pectasides E, Economopoulos T. Fallopian tube
Tokyo: Churchill Livingstone, 1992;119:853-60. carcinoma: A review. Oncologist 2006;11:902-12.
7. Benoit MF and Hannigan EV. A 10-year review of primary fallopian 27. Peters WA,3rd, Andersen WA, Hopkins MP, Kumar NB, Morley
tube cancer at a community hospital: A high association of GW. Prognostic features of carcinoma of the fallopian tube. Obstet
synchronous and metachronous cancers. Int Gynecol Cancer 2006; Gynecol 1988;71:757-62.
16:29-35. 28. Podratz KC, Podczaski ES, Gaffey TA, et al. Primary carcinoma of
8. Bokhman V. Two pathogenic types of endometrial carcinoma the fallopian tube. Am Obstet Gynecol 1986;154:1319-26.
Gynaecol Oncol 1983;15:10. 29. Revised FIGO Staging for Corcinoma of the Vulva, Cervix and
9. Brown MD, Kohorn EI, Kapp DS et al. Fallopian tube carcinoma. Endometrium. Internal of Gynae and Obst 2009;105:103.
Int Radiat Oncol Biol Phys 1985;11:583-90. 30. Riska A, Alfthan H, Finne P, alkanen , Sorvari T, Stenman UH and
10. Cass I, Holschneider C, Datta N, Barbuto D, Walts AE, Karlan B . Leminen A. Preoperative serum hCG as a prognostic marker in
BRCA-mutation-associated fallopian tube carcinoma: A distinct primary fallopian tube carcinoma.Tumor Biol 2006;27:43-9.
clinical phenotype Obstet Gynecol 2005;106:1327-34. 31. Rosen A, Klein Aziz S, Kuperstein G, Rosen B, Cole D, Nedelcu R,
11. Cormio G, Maneo A, Gabriele A, Rota SM, Lissoni A, anetta G. McLaughlin , Narod SA. A genetic epidemiological study of
Primary carcinoma of the fallopian tube. A retrospective analysis carcinoma of the fallopian tube. Gynecol Oncol 2001;80:341-5.
of 47 patients. Ann Oncol 1996;7:271-75. 32. Schneider C, Wight E, Perucchini D, Haller U, Fink D. Primary
12. Di Re E, Grosso G, Raspagliesi F, Baiocchi G. Fallopian tube cancer: carcinoma of the fallopian tube. A report of 19 cases with literature
Incidence and role of lymphatic spread. Gynecol Oncol 1996;62:199- review. Eur Gynaecol Oncol 2000;21:578-82.
202. 33. Takeshima N, Hirai , amauchi K, Hasumi K. Clinical usefulness
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342
 Section 12 Diseases of Ovary

47 Benign Conditions of Ovary

and Fallopian Tubes

Manju Aggarwal, Payal Chaudhary, Sudha Salhan

Most diseases of the ovary and fallopian tubes present as Corpus luteal cysts are less common than follicular cysts.
enlargement of these organs with varied symptoms. These cyst may rupture leading to pain and hemoperitoneum
and thus requiring emergency surgical management. History
ADNEXAL MASS of anticoagulant therapy is a common risk factor. Right side
Ovaries and fallopian tubes along with broad ligament and cysts usually rupture and rupture is usually seen during
structures in broad ligament constitute adnexa. Adnexal masses intercourse (Fig. 57.64).
can be of ovarian, tubal, or paratubal origin. They can be Theca lutein cysts are the least common of functional
physiologic, functional, neoplastic either (benign or malignant), ovarian cysts. They are usually bilateral and occur with
inflammatory, or pregnancy-related. In addition, other pelvic pregnancy. Also seen in molar pregnancy, multiple gestation,
structures or pathologies can be mistaken for adnexal masses, choriocarcinoma, diabetes mellitus, Rh sensitization,
including duplicated uteri in Mullerian anomalies, pelvic clomiphene citrate use, hMG–hCG ovulation induction and
kidneys, retroperitoneal growth or peritoneal inclusion cysts. GnRh analogue use. They can reach up to 30 cm and are
Adnexal mass can originate from any of these structures and generally multicystic and resolve spontaneously.
thus complicate the differential diagnoses. Most common site
of origin of adnexal mass is ovary because of its propensity for POLYCYSTIC OVARIES (FIGS 56.13 AND 57.55 TO 57.57)
neoplasia. Patients with polycystic ovary syndrome (PCOS) are often
Various causes of benign adnexal mass according to the age anovulatory and will have multiple small (approximately 1 cm)
group are: follicles lining the periphery of both ovaries, often described as
a string of pearls appearance. Ovaries are enlarged to 2–5
PHYSIOLOGIC AND FUNCTIONAL times their normal size. Obesity, hirsuitism, anovulation are
OVARIAN CYSTS (TABLE 47.1) the classical triad of this disorder also known as Stein Leventhal
These are the most common adnexal mass in reproductive age syndrome. Polycystic Ovarian Syndrome : The morphology of
group, but can be found in any age group from infancy to polycystic ovary has been redefined as an ovary with 12 or more
postmenopausal period. These include follicular cyst, corpus follicles measuring 2–9 mm in diameter and/or increased
luteal cyst, theca lutein cyst and polycystic ovaries. They are ovarian volume of 10 mm cube. The other associated features
usually asymptomatic and spontaneously resolve within 4–6 of PCOS are oligo or anovulation, clinical or biochemical
weeks but sometimes can be associated with pelvic pain, hyperandrogenism. Management is symptom oriented.
discomfort and dispareunia. Cyst can even rupture leading to
peritoneal irritation, peritonitis and hemoperitoneum. It can ENDOMETRIOSIS (FIGS 57.53 AND 58.7)
also present with torsion and pain, leading to acute abdomen. It is a common cause of an adnexal mass. An endometrial cyst
Follicular cyst (Fig. 47.1) are the most common functional can develop into an endometrioma. An endometrial cyst is
cysts rarely larger than 8 cm. Cystic follicle can also be a follicular usually formed by an inversion of the ovarian cortex. The frontal
cyst once diameter is greater than 3 cm. surface of the ovary in proximity to the hilus is the most common

Table .1: Showing physiological and functional cysts at different age groups

Infancy Prepubertal Adolescent eproductive Perimenopausal enopausal

Follicular Follicular cyst Follicular Follicular cyst Benign ovarian Benign ovarian
cyst cyst tumor tumor
Dermoid Benign ovarian Follicular cyst Follicular cyst
tumor
Benign ovarian Pelvic inflammatory Paratubal cyst Paratubal cyst
tumor disease
Paratubal cyst Hematosalpinx
Endometrioma
Ectopic pregnancy
Trophoblastic disease
Benign cystic teratoma
Paratubal cyst
Diseases of Ovary

Fig. 47.1: Follicular cyst Fig. 47.3: Hydatid of Morgagni

site for the invagination process to occur. Endometriomas are conditions (e.g., trauma, surgery), a fluid-filled, serpentine
formed over a time span by extensive intracystic hemorrhage. structure consistent with a hydrosalpinx may be palpable or seen
Various sonographic features are cystic mass with few by HSG ultrasound or CT scan. A hydrosalpinx often can be
septations or minimal debris with low, homogeneous mistaken for a complex adnexal mass, as the dilated tube folded
Section 12

echogenicity, sometimes described as a ground glass on itself gives the appearance of a septation within a cyst. A
appearance, complex combination of cystic and solid elements hydrosalpinx is usually asymptomatic, and no intervention is
and largely solid features. necessary.
Criteria for the diagnosis of endometrioma on laparoscopy
are: BENIGN NEOPLASMS
• size 12 cm in diameter Benign neoplastic masses in the ovaries include dermoid cysts
• adhesions to the pelvic side wall, to the posterior broad (mature cystic teratomas), endometriomas, and epithelial ovarian
ligament or both cysts, usually serous, rarely mucinous. Neoplastic processes in
• powder burn lesions the ovary do not regress, and therefore, should be treated
• superficial endometriosis with adjacent puckering on surgically.
surface of the ovary and tarry thick chocolate colored fluid Benign neoplasms are classified according to their tissue of
content. origin:
Paraovarian cysts and cysts of margagni are cystic (Figs 1. Neoplasm arising from surface epithelium
47.2 and 47.3) enlargements of vestigial structures. a. Serous cystadenoma
b. Mucinous cystadenoma
INFLAMMATORY c. Mixed tumor
Inflammatory enlargements of the fallopian tubes and ovaries 2. Neoplasm of stromal origin
like hydrosalpinx and tubo-ovarian abscess arise due to pelvic a. Fibroma
infection. Hydrosalpinx is a postinflammatory abnormality of the b. Brenner tumor
fallopian tube. After the proximal and distal ends of the fallopian 3. Germ cell tumor
tube become scarred, the serous fluid produced by the normal a. Dermoid (mature cystic teratoma)
epithelium cannot drain and subsequently dilates the tube. 4. Miscellaneous hydrosalpinx.
Following clinical or silent PID or other inflammatory pelvic
DERMOID CYSTS (MATURE CYSTIC TERATOMAS)
Dermoids, or mature cystic teratomas, are benign germ cell
tumors of the ovary and are the most common neoplastic cysts
found in adolescents. They arise from totipotential cells in the
ovary and can give rise to tissues arising from the ectoderm,
mesoderm, and endoderm, including hair, bone, primitive
teeth, cartilage, sebaceous material, and nerve tissue.
Dermoids can be present with dull abdominal pain but are
frequently asymptomatic and often found by pelvic
examination or incidental imaging. Torsion is a common
complication. They have a characteristic ultrasound
appearance with fat fluid levels, diffuse or focal areas of
increased echogenicity with acoustical shadowing, often
thought to be hair fibers within the cyst and may contain a
mural hyperechoic nodule (Figs 47.4A to C and 56.11). In
addition, the presence of calcification within an ovarian mass
in adolescents. Plain film, ultrasound, CT or MRI is almost
pathognomonic for a dermoid cyst (Figs 57.60 and 58.6). In
344 Fig. 47.2: Paraovarian cyst adolescents, dermoid cysts are bilateral in approximately 7
 SEROUS CYSTADENOMA/MUCINOUS
CYSTADENOMA (FIGS 47.5 AND 47.6)
Epithelial ovarian tumors include serous and mucinous
cystadenomas and are seen infrequently in adolescents. They
should be considered in the differential of a persistent ovarian
cyst, because of their ability to become extremely large and the
possibility of borderline or low malignant potential features
being present.

Other Causes
Paratubal Cysts (Figs 47.2 and 47.3)

Chapter 47
Paratubal cysts are sonolucent cysts that hang off the sides
of the fallopian tubes, often near the fimbriated end. They can
range in size from a few millimeters to several centimeters in
diameter. Typically, they are described as a simple cystic
structure adjacent to the ovary, although they can be mistaken
for an ovarian cyst. Paratubal cysts can be congenital, vestigial
remnants of the embryological male Wolffian system (Hydatid
cysts of Morgagni), or they can be acquired following

Benign Conditions of Ovary and Fallopian Tubes

inflammation in the pelvis (e.g., postsurgical or PID). Unless
they are large, putting the adnexa at risk for torsion, or the
diagnosis is uncertain, no intervention is necessary.

Fig. 47.5: Simple ovary cyst, USG, Dr Uppal

Figs 47.4A to C: (A) Dermoid cyst (showing hair);

(B) Dermoid cyst; (C) Dermoid cyst

of patients, so careful evaluation of both ovaries is indicated

by imaging and at the time of surgery. Dermoid cysts are at
increased risk of torsion (Figs 68.3 and 68.4) and this may be
caused by the weight of their contents, or the fact that they
may float higher out of the cul de sac than other ovarian cysts
because of their fat content caused by sebaceous material.
Dermoid cysts rarely can rupture spontaneously, but chemical
peritonitis, foreign body reaction, and dense adhesions can
be a sequelae. Fig. 47.6: Benign ovarian tumor 345
 ECTOPIC PREGNANCY (FIG. 47.7) and cervix. Fluid typically is resorbed by the peritoneum over
Any adolescent with abnormal bleeding or pain should have a 48–72 hours, but the symptoms may not completely resolve until
sensitive urine or serum pregnancy test performed, and those then, although they should get better rather than worse over
patients with a positive test should undergo ultrasound that time. If there is significant associated bleeding from the
evaluation (preferably transvaginal). If an intrauterine site of the cyst rupture in the ovary, the patient may be
pregnancy is not seen, ectopic pregnancy must be considered symptomatically anemic and require inpatient treatment with
in the differential diagnosis, and close monitoring should be hydration and serial hematocrit monitoring. Indications for
done. Adolescents with early, small ectopic pregnancies may inpatient observation include management of severe pain,
be candidates for medical treatment with single dose treatment of nausea or vomiting, or concern regarding
intramuscular methotrexate therapy. Compliance is paramount, hemorrhage. Consultation with a gynecologist or surgeon
as patients must have close serial monitoring of quantitative should be considered, and the patient should be kept nil per
hCG levels to assure that adequate resolution of the ectopic orally until she improves, and it is determined that surgical
Diseases of Ovary

pregnancy is occurring. Alternatively, patients initially may be intervention is not needed. If an adolescent has been diagnosed
treated surgically, usually by laparoscopy. At laparoscopy, with a large (greater than 5 cm) ovarian cyst, she should be
incision of the tube and subsequent evacuation of the ectopic advised of the risks of cyst rupture or torsion and instructed to
tissue can be done if the tube is not damaged excessively seek care immediately if she becomes symptomatic. In addition,
(salpingostomy). Otherwise, excision of the tube patients should be counseled about the possible increased risk
(salpingectomy) is performed. Patients with advanced ectopic of rupture of large ovarian cysts with certain physical activities
pregnancies may present with tubal rupture, hemoperitoneum, such as running, jumping, contact sports, and sexual
and hemodynamic instability and likely will require emergency intercourse.
laparotomy and salpingectomy.
OVARIAN TORSION (FIG. 47.8)
CLINICAL PRESENTATION AND COMPLICATIONS Torsion of the ovary occurs when it becomes twisted on its
Section 12

Adnexal mass can have multiple presentations depending upon suspensory pedicles. In addition, isolated fallopian tube
the etiology of the mass. For instance, it may be an incidental torsion can occur. When the blood vessels in the pedicles
finding as generally in case of functional cysts or can also present initially become twisted and kinked, the ovarian vein becomes
as pain, abnormal bleeding, pressure symptom, precocious occluded before the ovarian artery because of its lower
puberty, torsion, rupture, hemorrhage, urinary complications pressure, and therefore, the ovary becomes engorged and
and primary and secondary amenorrhea. The reported edematous. If the torsion is not relieved spontaneously or
incidence of ovarian malignancy in-patient with preoperative surgically, the ovary becomes progressively ischemic and
diagnosis of ovarian mass ranges from 13–21 in various eventually necrotic. Torsion causes acute-onset, intense pain,
surgical series. The most important predictor of malignancy frequently associated with immediate, severe nausea and
being the age of the patient. 12-fold increase in risk is seen in vomiting. Additionally, a low-grade fever may be present.
age group 12–29 to 60–69 yrs. However, even in postmenopausal Clinical diagnosis of torsion can be difficult, but the index of
women the majority of adnexal masses are benign (55 ). suspicion should be high, so that loss of the adnexa can be
prevented if possible. There are several nonspecific findings
OVARIAN CYST RUPTURE AND HEMORRHAGE associated with torsion, including a mildly elevated
Although most adnexal masses in adolescents are nonemergent, sedimentation rate, a very mild leukocytosis, and a mildly
physicians and patients must be vigilant for the signs and elevated C-reactive protein. Diagnosis usually is made based
symptoms of acute complications, including cyst rupture or on symptoms and ultrasound findings of an enlarged,
hemorrhage and torsion of the adnexa. Ovarian cysts can edematous ovary with decreased or absent Doppler blood
rupture and cause peritoneal signs, including severe, sudden- flow. Torsion remains in the differential diagnosis, despite
onset pelvic pain and nausea and vomiting. If an ovarian cyst improvement in symptoms, because pain diminishes as the
has ruptured recently, cyst fluid and associated blood or blood ovary becomes necrotic. Intermittent torsion can be
clot are visible by ultrasound in the cul de sac behind the uterus particularly difficult to diagnose because of a waxing and

346 Fig. 47.7: Ectopic pregnancy Fig. 47.8: Twisted ovarian cyst
waning of symptoms. Patients with large functional ovarian and vomiting, can cause alterations that must be known before
cysts being managed expectantly or those with dermoids or anesthesia and surgery are considered.
other cysts awaiting surgery should be advised of the signs Measuring other hormone levels is generally of limited value
and symptoms of torsion and instructed to seek care in the evaluation of adnexal masses. Obtaining estrogen and
immediately if any symptoms develop to facilitate early progesterone levels may be helpful in women suggested to have
intervention with the improved likelihood that the ovary can functional tumors, such as germ cell tumors, or if a girl younger
be untwisted and saved. In the past, surgeons have been than 12 years is being evaluated.
reluctant to detorse undo the torsion in the ovarian ligament
ovaries and leave them in place because of theoretical concerns IMAGING STUDIES
of thromboembolic phenomena. Several recent studies, The most commonly performed test to evaluate an adnexal mass
however, support the safety and effectiveness of this is transabdominal or transvaginal ultrasonography. This test
intervention with subsequent resumption of function helps demonstrate the presence of the mass and its location

Chapter 47
following detorsion in 87–95 of ischemic/necrotic-appearing (e.g., ovarian, uterine, bowel). It also provides the mass size,
ovaries, with no evidence of increased pulmonary embolism consistency, and internal architecture. The parameters of
risk. importance are size, number of loculi, overall echo density,
presence of papillary or solid excrescences or nodules within
EVALUATION the mass. The findings that suggest malignancy include size
Evaluation consists of a clinical history, including a larger than 6 cm in postmenopausal women and larger than 8
gynecological history and family history of ovarian and breast cm in premenopausal women, presence of thick septations,

Benign Conditions of Ovary and Fallopian Tubes

cancer. The physical examination should also include papillary projections within the lumen of the cyst, complexity
abdominal, pelvic and rectovaginal examination. Imaging of the mass, presence of the nodules within the wall. Scoring
studies are also required to distinguish between benign and systems, such as that suggested by DePriest and associates,
malignant mass and for further evaluation. Sassone et al can then be used to determine the likelihood of a
malignant component. The variables in the scoring system
LABORATORY STUDIES
included the inner wall structure of the adnexal cyst,
Possible laboratory tests in the evaluation of adnexal mass wall thickness, presence and thickness of septa and
include serum markers, Papanicolaou test, CBC count, echogenicity. Hysterosonography (ultrasonography with the
urinalysis, stool for blood, and serum electrolytes. presence of fluid in the uterine cavity) may be used to help
CA-125 is a marker that is elevated in approximately 80 distinguish between uterine masses and those arising from other
of women with ovarian cancer with sensitivities of 50 in pelvic structures.
women with stage I disease and 90 in patients with advanced Color Doppler ultrasonographies can be used to evaluate
disease. However, it can be elevated in many other conditions, the resistive index(0.4–0.7), pulsatality index ( 1) of the mass
including gynecologic etiologies such as endometriosis, uterine
vessels, which, when low, has been indicative of a malignancy.
fibroids, and pregnancy, and nongynecologic conditions such
Pelvic radiographs are generally not helpful in the
as gastroenteritis, pancreatitis, cirrhosis, and congestive heart
evaluation of adnexal masses. A dermoid cyst generally contains
failure. As such, the specificity of CA-125 is limited and is not
areas of calcification that may be picked up on a plain
recommended for routine screening purposes in the general
radiograph (Fig. 55.2).
population. Urine or serum beta human chorionic gonadotropin
CT scans are most useful for assessing the remainder of the
( -hCG) should be obtained in women of reproductive age to
abdomen and pelvis when metastatic disease is suspected.
rule out pregnancy and pregnancy-related etiologies of adnexal
Incidental adnexal masses are sometimes found when CT is
masses. Other serum markers such as alpha fetoprotein AFP
performed for evaluation of other conditions. As with
and LDH can be helpful when a germ cell tumor is suspected.
Papanicolaou test should be considered in women ultrasonography, CT scan can help identify the size, location,
undergoing a gynecologic surgery. This test should be used to and relationship to other organs. CT scan is less effective than
help rule out any unknown cervical pathology. ultrasonography for determining the internal architecture of
In extremely rare situations, this test may reveal the presence these masses.
of an adnexal malignancy. MRI scans can help characterize adnexal mass
CBC count helps evaluate for presence of inflammation and characteristics in select cases when ultrasonographic findings
anemia. are limited (Fig. 58.61).
An infected mass such as a tubo-ovarian abscess results in an
DIAGNOSTIC PROCEDURES
increased WBC count with an associated left shift. Adnexal masses
rarely cause anemia, but because they often require surgical In limited settings, aspiration of the mass can be performed.
removal, this information should be known. However, this approach must be reserved for those women in
Urine analysis results are generally normal in the presence whom an extremely low chance of a malignant mass exists and/
of an adnexal mass. or when surgical intervention is contraindicated.
Bladder pathology may present with symptoms of an
MANAGEMENT
adnexal mass and may be discovered based on urine analysis
results. In reproductive age women: Cystic adnexal mass that are less
Appendicitis can present similar to an adnexal mass but is than 8 cm in diameter could be followed expectantly in the
often associated with WBCs in the urine analysis findings. asymptomatic patient by giving oral contraceptive for 3 months,
Results from testing stool for blood should be negative for as 70 of these masses will resolve spontaneously.
adnexal masses but may be positive in those women with Indications of surgery are:
colonic pathology. 1. Ovarian cystic mass 6 cm without regression for
Serum electrolytes should not be altered by an adnexal mass; 6–8 weeks.
however, symptoms associated with masses, such as nausea 2. Any cystic structure 8 cm 347
 3. Any solid ovarian lesion is I omen ( ) is of cancer ( )
4. Ovarian lesion with papillary excrescences in the wall
5. Palpable adnexal mass in premenarchal or postmenopausal Low 25 40 3
patient. Moderate 25–250 30 20
6. Ascites. High 250 30 75

PREMENOPAUSAL WOMEN RCOG guidelines for management of ovarian cysts in

postmenopausal females are:
Pelvic masses in premenopausal women are usually benign.
• Simple, unilateral, unilocular ovarian cysts, less than 5 cm
Evaluation in this population depends on the presence or
in diameter, have a low risk of malignancy. It is
absence of symptoms; those with symptoms typically require
recommended that, in the presence of a normal serum CA-
immediate treatment. Evaluation may include a thorough medical
125 levels, they be managed conservatively.
history and physical examination, measurement of -human
Diseases of Ovary

• Aspiration is not recommended for the management of

chorionic gonadotropin, complete blood count, and transvaginal
ovarian cysts in postmenopausal women.
ultrasonography. Other studies (e.g. serial hematocrit
• It is recommended that a risk of malignancy index’ should
measurements, cultures) may also be needed.
be used to select women for laparoscopic surgery, to be
undertaken by a suitably qualified surgeon.
PREMENARCHAL AND POSTMENOPAUSAL WOMEN
• It is recommended that management of ovarian cysts in
Presence of adnexal mass of any size is considered an indication postmenopausal women should involve oophorectomy
for surgical removal of the mass. The role of expectant (usually bilateral) rather than cystectomy.
management of simple menopausal cysts less than 5 cm has
been studied by Bailey and colleagues. These cystic masses are SUMMARY AND SUGGESTED
estimated to occur in 3–5 of menopausal women. The MANAGEMENT PROTOCOL
Section 12

American College of Obstetricians and Gynecologists (ACOG)

Low Risk: Less than 3 risk of cancer.
has issued guidelines for the expectant management of these
1. Management in a gynecology unit.
masses. The malignant potential is believed to be less than 1 .
2. Simple cysts less than 5 cm in diameter with a serum CA-
INDICATIONS FOR SURGERY OF ASYMPTOMATIC 125 level of less than 30 may be managed conservatively.
MENOPAUSAL ADNEXAL MASS 3. Conservative management should entail repeat ultrasound
scans and serum CA-125 measurement every four months
• Solid mass
for one year.
• Complex mass
4. If the cyst does not fit the above criteria or if the woman
• Presence of ascites
requests surgery, then laparoscopic/laparotomy
• Fixed mass or cul-de-sac nodularity
oophorectomy is acceptable.
• Elevated CA-125 level.
Moderate Risk: Approximately 20 risk of cancer.
The first aim should be to triage women in order to decide the
1. Management in a cancer unit.
most appropriate place for them to be managed. A decision 2. Laparoscopic/laparotomy/oophorectomy is acceptable in
can then be made as to the most appropriate management. In selected cases.
order to triage women, an estimate needs to be made as to the 3. If a malignancy is discovered then a full staging procedure
risk that the ovarian cyst is malignant. should be undertaken in a cancer center.
An effective way of triaging postmenopausal women into
those who are at low, moderate, or high risk of malignancy and High Risk: Greater than 75 risk of cancer.
who, hence, may be managed by a general gynecologist, or in a Management in a cancer center. Full staging procedure is
cancer unit or cancer center respectively, is to use a risk of recommended.
malignancy index. There are three well-documented risk of
OPERATIVE CONSIDERATIONS
malignancy indices.
Those women who are at low risk of malignancy also need The type of incision and procedure performed will be dependent
to be triaged into those where the risk of malignancy is on the patient’s age, the surgeon’s expertise, and the type and
size of adnexal mass encountered. Pelvic access may be obtained
sufficiently low to allow conservative management, and those
through laparoscopy or laparotomy, and once pelvic access is
who still require intervention of some form.
obtained, several procedures are possible, including ovarian
Risk of malignancy index in postmenopausal women (flow
cystectomy, oophorectomy, or salpingo-oophorectomy. For tubal
chart 47.1).
ectopic pregnancies, salpingostomy (preservation of the tube)
Calculating risk of malignancy index
or salpingectomy is performed depending on the circumstances.
× ×
0 (for ultrasound score of 0); Laparoscopy
1 (for ultrasound score of 1);
Laparoscopy can be done for smaller (greater than 8 cm), benign
3 (for ultrasound score of 2–5).
appearing cysts, and it has been shown to be a safe and effective
Ultrasound scans are scored one point for each of the following alternative to laparotomy in adolescents. It sometimes can even
characteristics: multilocular cyst; evidence of solid areas; be accomplished with large adnexal masses.
evidence of metastases; presence of ascites; bilateral lesions.
3 for all postmenopausal women dealt Laparotomy
with by this guideline Several indications exist for laparotomy for adnexal masses in
is serum CA-125 measurement in u/m adolescents, including high suspicion for malignancy, large
Protocol for triaging women using RMI cysts, history of or risk factors for abdominopelvic adhesions,
348
 Flow chart 47.1: Management of ovarian cyst in postmenopausal women

Chapter 47
Benign Conditions of Ovary and Fallopian Tubes

morbid obesity, or a hemodynamically unstable patient. In involvement, surgical expertise, and availability of specialized
addition, some medical conditions may preclude the increased equipment may determine whether a laparoscopic approach is
intra-abdominal and subsequent increased intrathoracic appropriate and attempted. All patients undergoing operative
pressure caused by the pneumoperitoneum necessary for laparoscopy should be counseled that conversion to laparotomy
laparoscopy, including significant cardiopulmonary disease or may be necessary.
hypovolemia. Benign ovarian cysts and paratubal cysts are often
amenable to cystectomy, allowing preservation of the remaining MANAGEMENT IN PREGNANCY
ovarian cortex. This often can be done, even with large cysts There are few data available on managing adnexal masses in
with little or no normal obvious ovarian tissue visible. There is patients who are pregnant. The prevalence of adnexal masses
risk of intraoperative spillage of cyst contents during in pregnancy ranges from 0.05–3.2 percent of live births.
manipulation with cystectomy, and this is problematic if the Common diagnoses include mature teratomas and paraovarian
cyst exhibits borderline or frank malignancy, or if a dermoid or corpus luteum cysts. Rates of malignancy range from
spills with its risk of peritonitis and subsequent adhesion 3.6–6.8 of persistent masses, with most malignancies being
formation. Ovariotomy, Cystectomy, oophorectomy, ovariotomy germ cell or stromal tumors, or epithelial tumors with low
salpingo-oophorectomy, salpingostomy and salpingectomy can malignancy potential.
be done laparoscopically or by laparotomy, but age of the The recommended evaluation of pregnant patients with
patient, size of the cyst, etiology of the cyst, bilateral pelvic masses is similar to that of premenopausal women; 349
 however, imaging will depend on gestational age. Abdominal 6. Flotho C, Ruckauer K, Duffner U, Bergstasser E, Bohm N, Niemeyer
ultrasonography can be used in addition to transvaginal CM. Mucinous cystadenoma of the ovary in a 15-year-old girl.
ultrasonography in women who are farther along in their Pediatr Surg 2001;36(6):E6.
7. Hricak H, Chen M, Coakley FV, et al. Complex adnexal masses:
pregnancy because the ovaries may be outside of the pelvis
detection and characterization with MR imaging—multivariate
later in gestation. If additional imaging is needed, MRI is the analysis. Radiology 2000;214 (1):39-46.
modality of choice because it does not expose the fetus to 8. Lack EE, Goldstein DP. Primary ovarian tumors in childhood and
radiation. CA-125 antigen levels reach their highest elevation adolescence. Curr Probl Obstet Gynecol 1984;8:1.
in the first trimester and then gradually decrease; therefore, 9. Logsdon-Pokorny VK. Adnexal masses in the young female. In:
low-level elevations during pregnancy typically are not Pokorny S, editor. Pediatric and adolescent gynecology. New ork7
associated with malignancy. Chapman Hall; 1996.pp.87- 103.
Surgical removal of persistent masses in the second 10. McGovern PG, Noah R, Koenigsberg R, Little AB. Adnexal torsion
and pulmonary embolism: case report and review of the literature.
trimester is common; however, data supporting this practice
Diseases of Ovary

Obstet Gynecol Surv 1999;54(9):601-8.

are lacking. Persistent masses are typically larger than 5 cm and 11. Modesitt SC, Pavlik E , Ueland FR, DePriest PD, Kryscio R , van
have complex morphology on transvaginal ultrasonography. The Nagell R r. Risk of malignancy in unilocular ovarian cystic tumors
actual occurrence of acute complications has been reported to less than 10 centimeters in diameter. Obstet Gynecol
be less than 2 , and approximately 51–70 of masses 2003;102(3):594-9.
spontaneously resolve during pregnancy. Most masses in 12. Mol BW, Bayram N, Lijmer G, Wiegerinck MA, Bongers M , van
pregnant women appear to have low risk of malignancy and der Veen F, et al. The performance of CA-125 measurement in the
acute complications; therefore, expectant management can be detection of endometriosis: ameta-analysis. Fertil Steril
1998;70(6):1101-8.
considered.
13. Oelsner G, Bider D, Goldberg M, Admon D. Long-term follow-up
REMNANT OVARIAN SYNDROME of the twisted ischemic adnexa managed by detorsion. Fertil Steril
1993;60:976-9.
This syndrome follows oophorectomy with or without
Section 12

14. Postma VA, Wegdam A, anssen IM. Laparoscopic extirpation of a

hysterectomy. It occurs because of reimplantation of ovarian giant ovarian cyst. Surg Endosc 2002;16(2):361.
tissue on intact or abraded peritoneal surfaces and resumption 15. Shalev E, Bustan M, arom I, Peleg D. Recovery of ovarian function
of endocrine function. The patient often presents with chronic after laparoscopic detorsion. Hum Reprod 1995;10(11):2965-6.
pelvic pain with or without pelvic mass. uality of pain varies, 16. Silva PD, Ripple . Outpatient minilaparotomy ovarian cystectomy
often cyclically, and ranges from a sensation of pressure or dull for benign teratomas in teenagers. Pediatr Surg 1996;31(10):
1383-6.
aching to a severe stabbing pain. Diagnosis can be made by
17. Stovall TG, Ling FW, Gray LA, Carson SA, Buster E. Methotrexate
ultrasonography with use of color Doppler. Use of GnRh treatment of unruptured ectopic pregnancy: a report of 100 cases.
agonists stimulation tests has specific utility. Premenopausal Obstet Gynecol 1991;77:749.
levels of follicle stimulating hormone may facilitate the 18. Strickland L. Ovarian cysts in neonates, children and adolescents.
diagnosis. Thus great care should be exercised to remove all Curr Opin Obstet Gynecol 2002;14:459-85.
ovarian tissue. Associated chronic pelvic pain frequently 19. Templeman C, Fallat ME, Blinchevsky A, Hertweck SP.
responds to suppressive therapy with GnRh agonists. The Noninflammatory ovarian masses in girls and young women.
treatment of choice is adequate excision of the ovarian remnant Obstet Gynecol 2000;96:229-33.
with removal of contiguous adherent tissue. 20. Templeman CL, Hertweck SP, Scheetz P, et al. The management of
mature cystic teratomas in children and adolescents: a retrospective
RESIDUAL OVARIAN SYNDROME analysis. Hum Reprod 2000;5:2669-72.
21. The role of the generalist obstetrician-gynecologist in the early
In this ovary is purposely saved and pathologic process detection of ovarian cancer. Gynecol Oncol 2002;87(3):237-9.
subsequently develops in the ovary. The benefits of preserved 21. Tingulstad S, Hagen B, Skjeldestad FE, Onsrud M, Kiserud T,
ovarian function thus outweigh the risk of subsequent ovarian Halvorsen T. Evaluation of a risk of malignancy index based on
pathology. It is characterized by either recurrent pelvic pain or serum CA-125, ultrasound findings and menopausal status in the
a persistent pelvic mass. Surgical intervention is the treatment pre-operative diagnosis of pelvic masses. Br Obstet Gynaecol
of choice. 1996;103:826-31.
22. Tingulstad S, Hagen B, Skjeldestad FE, Halvorsen T, Nustad K,
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1. Alcazar L, Ruiz-Perez ML, Errasti T. Transvaginal color Doppler ovarian cancers in local hospitals. Obstet Gynecol 1999;93:448-52.
sonography in adnexal masses: which parameter performs best . 23. Topalak O, Saygili U, Soyturk M, Karaca N, Batur , Uslu T, et al.
Ultrasound Obstet Gynecol 1996;8(2):114-9. Serum, pleural effusion, and ascites CA-125 levels in ovarian cancer
2. Carlson K , Skates S , Singer DE. Screening for ovarian cancer. Ann and nonovarian benign and malignant diseases: a comparative
Intern Med 1994;121(2):124-32. study. Gynecol Oncol 2002;85(1):108-13.
3. Castillo G, Alc zar L, urado M. Natural history of sonographically 24. Twickler DM, Forte TB, Santos-Ramos R, et al. The ovarian tumor
detected simple unilocular adnexal cysts in asymptomatic index predicts risk for malignancy. Cancer. Dec 1 1999;86(11):
postmenopausal women. Gynecol Oncol 2004;92(3):965-9. 2280-90.
4. DePriest PD, Gallion HH, Pavlik E , et al. Transvaginal sonography 25. azici M, Etensel B, Gursoy H, Erkus M. Mucinous cystadenoma: a
as a screening method for the detection of early ovarian cancer. rare abdominal mass in childhood. Eur Pediatr Surg 2002;
Gynecol Oncol. un 1997;65(3):408. 12(5):330-2.
5. Devarbhavi H, Kaese D, Williams AW, Rakela , Klee GG, Kamath 26. oshida S, Harada T, Iwabe T, Terakawa N. Laparoscopic surgery
PS. Cancer antigen 125 in patients with chronic liver disease. Mayo for the management of ovarian endometrioma. Gynecol Obstet
Clin Proc 2002;77(6):538-41. Invest 2002;54(1):24-7.

350
 48 Ovarian Malignancy

Sunesh Kumar, Lalit Kumar

Epithelial ovarian cancer (EOC) is the second most common ovulation inducing agents and a positive family history of
gynecological cancer among women in India first being ovarian and breast cancer. Among all the known predisposing
cancer cervix. Its incidence varies from 4.5–5.5 per 100,000 factors family history has strongest co-relation.
women in India. Ovarian cancer is the most common cause
Familial and Hereditary Ovarian Cancers
of cancer deaths among women in America and accounts
for 5% of all cancer deaths. Death rate due to ovarian cancer Approximately 5–10% cases of ovarian cancer occur in
accounts for more deaths than deaths due to cancer cervix women with a family history of ovarian cancer. When a single
and cancer endometrium combined. At Institute Rotary family member develops ovarian carcinoma other female
Cancer Hospital, (IRCH) New Delhi, ovarian cancer members of the family have a 4–5% risk of developing disease
accounts for 12–15% of female genital tract malignancies and risk increases to 7% when two relatives are affected by
seen annually. Ovary is the site of most varied form of the disease.
tumors seen in body. A large number of histological type of In hereditary ovarian cancer syndromes, a woman has
tumors arise from ovary. Depending upon cell of origin, 25–50% lifetime risk of developing ovarian cancer. Two well-
ovarian tumors are classified as epithelial, germ cell tumor, defined clinical syndromes of familial ovarian cancer have been
sex cord stromal tumor, metastatic and undifferentiated identified, Hereditary Breast Ovarian Cancer Syndrome (HBOC)
histological type. Various types of ovarian tumors seen at and Hereditary Non-Polyposis Colorectal Syndrome (HNPCC).
All India Institute Rotary Cancer Hospital, New Delhi over Hereditary Breast Ovarian Cancer Syndrome (HBOC)
a ten-year period from 1991–2000 is given in Table 48.1.
This syndrome is associated with mutation of BRCA1 gene.
EPIDEMIOLOGY OF OVARIAN CANCER Those association with mutation of BRCA 1 gene have a life-
time risk of 28–44% for developing ovarian cancer. Less
Most data related to Ovarian Cancer is based on cancer
commonly mutation of BRCA 2 gene has also be associated
statistics published from tumor registry set up in some of
with Hereditary Breast Ovarian Syndrome. Family pedigree
the countries. Surveillance, Epidemiology and End Results
may show increased propensity for development of ovarian
Program (SEER) of National Cancer Institute, America is one
cancer without simultaneous increase in breast cancer.
source of authenticated data related to ovarian malignancy.
Estimated incidence of ovarian cancer in America is 15–16/ Hereditary Nonpolyposis Colorectal Syndrome (HNPCC)
1,00,000 among women at the age of 40–44 years and peaks It is an autosomal dominant genetic syndrome earlier known
to 57/1,00,000 among women 70–74 years of age. Majority of as Lynch Syndrome II. This syndrome is associated with
women tend to be more than 40 years of age and tend to be colorectal cancer in proximal colon and increased
postmenopausal, however, it is not uncommon to see disease predilection for endometrial, ovarian and stomach cancer.
occurring in younger women. Germ cell tumor of ovary Hereditary Ovarian Cancers tend to occur at a younger
(OGCT) tends to occur in adolescents and young women. age in comparison to Epithelial Ovarian Cancer where there
Sex cord tumors can be seen in any age group, however, is no such family history. Rubin described 53 patients with an
they are more commonly seen after the age of 40 years with average age of 48 years and majority of tumors being serous
a median age of 48 years. adenocarcinomas.
In women with Hereditary Ovarian Cancer Syndromes,
Predisposing Factors a prophylactic oophorectomy has been advocated at the
Very little is known about etiology of ovarian cancer. Few age of 35 years.
factors which are known include, parity, anovulation, use of
Environmental Factors
Table 48.1: Institute rotary cancer hospital Japan has lowest incidence of ovarian cancers, Japanese
experience (1991–2000)
immigrants to America tend to have higher incidence in
Histological Type No. of Patients Percentage comparison to residents of Japan. Dietary factors have been
implicated in the causation of ovarian cancer. However, no
Epithelial ovarian carcinoma 67 7 83.0
Germ cell tumors 78 9.5 case control study has proved this facts.
Sex cord stromal tumors 26 3.2 Use of talcum powder over perineum which can reach
Metastatic tumors 26 3.2 ovaries via lymphatics has been implicated in the causation
Others 08 1.0 of ovarian carcinoma. Similarly, exposure to asbestos has
Total 815 100 also been implicated in causation of ovarian cancer.
 Dietary factors such as use of coffee have not been found Table 48.2: Classification of epithelial ovarian tumors
to be associated with increased risk of ovarian cancer. Use of
alcohol slightly increases risk of ovarian cancer. Serous : Resemble lining epithelial of fallopian tube.
Use of ovulation inducing agents such as clomiphene a. Benign—Serous cystadenoma
citrate was implicated with increased risk of ovarian b. Borderline—Serous cystadenoma with nuclear atypia,
proliferative activity but no destructive or infiltrative activity.
carcinoma. However, latest reports do not support this view.
c . Malignant—Serous cystadenocarcinoma.
Protective Factors Mucinous: Resemble epithelial lining of endocervical canal.
a. Benign—Mucinous cystadenoma
Use of oral contraceptive pills, tubal ligation and prophylactic
b. Borderline—Mucinous cystadenoma with nuclear atypical, mitotic
oophorectomy are the only known protective factors against activity and proliferation but no destructive or infiltrative growth.
ovarian carcinoma. c . Malignant—Mucinous cystadenoma carcinoma.
Use of combination oral contraceptive pills (COC) is
Diseases of Ovary

Endometroid: Resembling lining epithelium of body of uterus.

associated with reduced incidence of ovarian carcinoma. a. Benign
Protective effect may persist even after discontinuation of b. Borderline
use of oral pills. Inhibition of ovulation is reported to be the c . Malignant
mechanism behind reduced risk of ovarian cancer in users Clear Cell: Resembling endometrial glands of pregnancy, rich in
of oral contraceptive pills. This protective effect of usage of glycogen.
oral pills has been noted in women who have used pills for a. Benign
more than two years. b. Borderline
Tubal ligation has also been reported to offer protection c . Malignant
against ovarian carcinoma. However, hysterectomy does Transitional Cell: Resemble epithelium lining of urinary tract.
not offer similar protection. a. Benign
Prophylactic oophorectomy when performed at the age b. Borderline
Section 12

c . Malignant
of 35 years in women with family history of Hereditary Breast
Ovarian Cancer Syndrome has been shown to reduce the Brenner Tumors: These are tumors of uroepithelial differentiation
risk of Ovarian Cancer. and are believed to arise as a result of transitional cell metaplasia.
They are rarest of all epithelial tumors comprising 2% of all epithelial
tumors.
PATHOLOGY
a. Benign
Ovarian carcinoma have been classified into various b. Borderline
histological categories depending upon cell of origin in the c . Malignant
ovary. Most common tumors are Epithelial Ovarian Undifferentiated Carcinoma: When histological examination reveals
Carcinoma (EOC) which are thought to arise from epithelial tumor which is difficult to be classified among above categories
lining of ovary. They comprise 80–85% of all ovarian but demonstrates malignant tumor is classified under undifferentiated
carcinoma. Similarly, depending upon cell of origin remaining category.
cancers tend to be Germ Cell Tumor (GCT), Sex Cord Tumors,
Mixed Tumors and Metastatic tumors. They are mostly unilateral and can attain large size. They are
mostly seen in 30–60 years age group. Malignant mucinous
Epithelial Ovarian Tumors (EOC) tumors can be bilateral in 10% of the cases. These tumors have
Epithelial ovarian tumors comprise great majority of ovarian a thick capsule, contents being mucinous in character. Cut
cancers (80–85%). These tumors are further classified into section reveals multiseptated tumor. Microscopically tumor
serous, mucinous, endometrioid, clear cell, transitional cell, resembles lining epithelium of endocervix with foamy pale cells
mixed and undifferentiated type depending upon their (Figs 48.12 to 48.17).
histological resemblance to tubal, endocervical or
endometrial epithelium. Histologically these subtypes are Endometrioid Tumors
further classified as benign, borderline and malignant Endometrioid ovarian tumors tend to have epithelial lining
depending upon various features such as nuclear atypia, resembling endometrial glands. They account for 8-10% of
invasion, etc. Classification of epithelial ovarian tumors is all epithelial ovarian tumors. Approximately 10% of
given in Table 48.2. endometrioid tumors are associated with pelvic
endometriosis. These tumors may vary in size from few cm
Serous Tumors to up to 10 cm. On cut section they tend to have a fleshy
They are the most common tumors arising from ovary appearance.
accounting for almost half of all ovarian tumors. Whereas
benign serous tumors tend to be cystic and unilocular, serous Clear Cell Tumors
cystadenocarcinoma usually has a variegated appearance. These tumors resemble endometrial glands seen in
They vary in size from 3 cm to large size. These tumors tend pregnancy, rich in glycogen. They account for 3–5% of all
to be bilateral in 40% cases. Tumor often is present on the epithelial ovarian cancers. Approximately, 50% tumors are
surface, cut section may show cystic areas with papillary associated with pelvic endometriosis. Most tumors are seen
projections. Microscopically psammoma bodies are in postmenopausal women. Some studies have reported clear
encountered in serous tumors. Presence of psammoma cell carcinoma to have more aggressive behavior than other
bodies is associated with better prognosis in comparison to epithelial ovarian tumors.
serous tumors without psammoma bodies (Figs 48.1 to 48.11).
Transitional Cell Tumors
Mucinous Tumors These tumors resemble lining epithelium of urinary tract.
They are second commonest variety of epithelial ovarian They account for approximately 2% of all epithelial ovarian
tumors comprising 15–30% of all epithelial ovarian tumors. tumors.
352
 Chapter 48
Fig. 48.1: Serous cystadenoma ovary (Dr Yadav, RML Hospital) Fig. 48.2: Papillary serous cystadenocarcinoma (4x)
Dr Yadav, RML Hospital

Ovarian Malignancy
Fig. 48.3: Papillary serous cystadenocarcinoma (10x) Fig. 48.4: Papillary serous cystadenocarcinoma (40x)
Dr Yadav, RML Hospital Dr Yadav, RML Hospital

Fig. 48.5: Borderline serous tumor of the ovary. Note the sharp Fig. 48.6: Borderline serous tumor of the ovary. Note the sharp
interphase between tumor and stroma without any stromal invasion. interphase between tumor and stroma without any stromal invasion.
Dr Anurag Mehta (Rajiv Gandhi CRIC) Dr Anurag Mehta (Rajiv Gandhi CRIC)

Brenner tumors are believed to arise as a result of When tumor resembles lining epithelium of urinary tract
transitional cell metaplasia in pelvic mesothelium. Majority without any evidence of transition from benign Brenner
of tumors are benign, tend to be small in size and tend to tumor, tumor is labelled as transitional cell carcinoma.
be solid. However, malignant Brenner tumors do occur.
Microscopically sheets of cells with grooved nuclei (coffee Squamous Cell Carcinoma
bean shaped) is the diagnostic features for Brenner Though rare, occasionally ovarian tumors can be squamous
tumor. cell carcinoma. Average age at presentation is 56 years. 353
Diseases of Ovary

Fig. 48.7: Borderline serous tumor of the ovary. Papillary structures Fig. 48.8: Micropapillary serous carcinoma. Note thick central stalk
studded with serous cells and showing minimum nuclear stratification and long but fine papillae all around this stalk. Dr Anurag Mehta (Rajiv
and atypia. Dr Anurag Mehta (Rajiv Gandhi CRIC) Gandhi CRIC)
Section 12

Fig. 48.9: Serous carcinoma. Note nuclear stratification and high grade Fig. 48.10: The invading edge of a serous carcinoma characterized by
nuclear atypia. Dr Anurag Mehta (Rajiv Gandhi CRIC) stromal edema. Dr Anurag Mehta (Rajiv Gandhi CRIC)

Fig. 48.11: Papillary serous cystadenoma Fig. 48.12: Mucinous cystadenocarcinoma (10x)
Dr Anurag Mehta (Rajiv Gandhi CRIC) Dr Yadav, RML Hospital

Prognosis depends upon stage of disease and is similar to tumors. Approximately, 5–10% of epithelial ovarian tumors
other epithelial ovarian tumors. have presence of more than one histological type.
Mixed Tumors Undifferentiated Carcinoma
When there is presence of more than one histological type of When ovarian tumors are so poorly differentiated that the
354 tumor cells in ovarian tumors, these are labeled as mixed cell type identification becomes difficult, such tumors are
 Chapter 48
Fig. 48.13: Mucinous cystadenocarcinoma (40x) Fig. 48.14: Mucinous cystadenoma
Dr Yadav, RML Hospital

Ovarian Malignancy
Fig. 48.15: High dry, H&E view highlighting the intracellular mucin. Fig. 48.16: High dry, H&E view highlighting the intracellular mucin.
Dr Anurag Mehta (Rajiv Gandhi CRIC) Dr Anurag Mehta (Rajiv Gandhi CRIC)

STAGING OF OVARIAN CARCINOMA (FIGO,1998)

Staging of ovarian carcinoma is a surgical staging. Exact
extent of disease is best made out after exploratory
laparatomy. Although a number of imaging studies such as
Ultrasound, CT scan abdomen and pelvis or MRI abdomen
and pelvis are performed but best estimate of spread of
disease is possible by exploratory laparotomy. Upper gastro-
intestinal endoscopy and colonoscopy help in excluding
primary in GIT.
For the purpose of uniform reporting and comparison of
data, FIGO staging (1998) for ovarian carcinoma is universally
followed (Table 48.3).

CLINICAL FEATURES
Epithelial ovarian tumors mostly present late. In
approximately 80% of the cases disease tends to be stage
III or IV at the time of diagnosis. Presenting symptoms of
ovarian carcinoma tend to be in the form of vague abdominal
Fig. 48.17: A maze of glands without any intervening stroma in a case discomfort, flatulence, etc. making early diagnosis difficult.
of well-differentiated endometrioid carcinoma of Ovary—H&E, 200X
Often patients are seen by general physician,
Dr Anurag Mehta (Rajiv Gandhi CRIC)
gastroenterologist or psychiatrist before a diagnosis is made.

labeled as undifferentiated carcinoma. Small cell carcinoma Symptoms

belongs to this category of ovarian tumor and is usually 1. Gastrointestinal Symptoms: Nausea, vomiting, dyspepsia,
associated with poor prognosis. distention of abdomen after meals, constipation are the 355
 Table 48.3: FIGO staging for ovarian carcinoma (1998) cases of ovarian carcinoma. Often tense ascites may be
the only physical sign.
Stage I : Growth limited to the ovaries
2. Abdominal Mass: Large size mucinous and serous tumors
IA : Growth limited to one ovary, no ascites present containing
malignant cell, no tumor on external surface, capsule intact.
can present as abdominal masses arising from pelvis
IB : Growth limited to both ovaries, no ascites present and occupying lower abdomen.
containing malignant cells, no tumor on external surface, 3. Adnexal Mass: On pelvic examination presence of bilateral,
capsule intact. fixed, variegated consistency mass with nodules in pouch
IC* : Tumor either stage IA or IB but with tumor on surface of one of Douglas is a common sign.
or both ovaries with capsule ruptured, with ascites containing 4. Pleural Effusion: Presence of bilateral or unilateral effusion
malignant cells or with positive peritoneal washing. is a finding in patients with advanced disease.
Stage II : Growth involving one or both ovaries with pelvic 5. Unilateral or bilateral edema feet.
extension 6. Hepatomegaly
Diseases of Ovary

IIA : Extension and/or metastases to uterus and/or tubes. 7. Supraclavicular lymph node, umbilical nodule, inguinal
IIB : Extension to other pelvic organs
lymph nodes.
IIC* : Tumor either stage IIA or IIB but with tumor on surface of one/
both ovaries, with capsule(s) ruptured, with ascites present
containing malignant cells or positive peritoneal cytology. Investigations
Stage III : Tumor involving one or both ovaries with Ultrasonography
histologically confirmed peritoneal implants outside Abdominal and transvaginal ultrasounds are most commonly
pelvis and/or positive retroperitoneal or inguinal used imaging methods in suspected cases of ovarian
lymph nodes; superficial liver metastasis; tumor limited carcinoma. Presence of a unilateral or bilateral ovarian masses
to true pelvis but with histologically proven malignant larger than 5 cm in size, with solid components, with thick
extension to small bowel and omentum.
septa and associated ascites almost clinches the diagnosis.
IIIA : Disease limited to true pelvis, negative nodes but
Ultrasonography with color Doppler imaging: Transvaginal
Section 12

histologically confirmed microscopic seedlings on

peritoneal surfaces, or histologically proven extension to ultrasound combined with color Doppler study may enhance
small bowel or mesentry. accuracy of ultrasound to differentiate benign from malignant
IIIB : Tumors of one or both ovaries with histologically ovarian masses. Neovascularization, reduced pulsality index
confirmed implants negative nodes, peritoneal metastasis (PI) are signs of malignant change (Fig. 57.65).
to abdominal organs not exceeding 2 cm in size.
IIIC : Peritoneal metastasis beyond the pelvis >2 cm in diameter, CA-125
and/or positive retroperitoneal/inguinal lymph nodes.
CA-125 is a glycoprotein found elevated in ovarian carcinoma.
Stage IV : Growth involving one or both ovaries with distant
Levels higher than 35 U/ml are considered abnormal.
metastasis. If pleural effusion is present, it should be
positive for malignant cells, parenchymatous liver
However, a number of benign pelvic pathologies such as
metastasis. pelvic endometriosis, pelvic inflammatory disease, fibroids,
abdominal tuberculosis, etc. are also associated with raised
* In order to evaluate the prognostic impact of the different criteria
for allotting cases to stage IC or IIC, knowing if rupture of the levels of CA-125. When levels of CA-125 are higher than
capsule was spontaneous or caused by the surgeon is of value. 96U/ml in the presence of adnexal mass, there is a greater
Also of value is knowing if the source of malignant cells detected likelihood of presence of ovarian malignancy. In
was peritoneal washings or ascites. postmenopausal women raised CA-125 levels in the presence
of adnexal mass mandates early surgical exploration.
commonest presenting symptoms. However, these Currently serial estimation of CA-125 during follow up of
symptoms being non-specific often do not alert the a proven case of Epithelial Ovarian Cancer (EOC) are
physician to make a diagnosis. considered highly reliable in predicting recurrence of disease.
2. Abdominal Distention: Rapidly developing ascites leads to
distention of abdomen. Large size mucinous tumors can CT Scan and MRI
also be responsible for abdominal distention. These two imaging procedures are not considered necessary
3. Urinary Symptoms: Frequency of micturition, oliguria, in the preoperative work. However, when performed they
difficulty in passing urine and retention of urine can be may provide additional information about liver metastasis,
some of the presenting symptoms. lymph node enlargement and extra pelvic spread of disease
4. Irregular Vaginal Bleeding, Postmenopausal Bleeding (Figs 58.10 to 58.12 and 58.29).
pervaginally: These symptoms can be attributed to
hormone production by tumor, stromal hyperplasia in SURGERY
ovary or metastasis to endometrium. To know exact stage of disease and to achieve maximum
5. Pelvic/Leg Vein Thrombosis: Occasionally ovarian tumors debulking almost all cases of ovarian malignancy are
present as leg vein/pelvic vein thrombosis and are subjected to surgery. Surgery carried out in a case of ovarian
diagnosed while being investigated for this symptom. malignancy is labeled as debulking surgery as one tries to
6. Acute Abdomen: Torsion of a pedunculated ovarian tumor, remove as much on tumor as possible. Those who cannot be
rupture of a cystic tumor or hemorrhage in a tumor can operated on account of poor surgical risk or very advanced
result in acute abdomen. disease are treated with chemotherapy after confirming
7. Diagnosed during pregnancy either by clinical diagnosis by ascitic tap or fine needle aspiration cytology or
examination or ultrasonography. true cut biopsy from pelvic tumor.

Physical Signs Steps of Surgical Staging

1. Ascites: Ascites is present in 60–75% cases of ovarian 1. Midline vertical abdominal incision is given
356 carcinoma. This is the most common physical finding in 2. Ascitic fluid/Peritoneal washing for cytology is taken
 3. Careful exploration of pelvis and abdomen to know extent Laparoscopy for Second Look Procedure
of disease. This approach has been tried but in view of possibility of
4. Removal of affected ovary/ovaries intact. adhesions it is no longer a popular technique of second look
5. Performing total abdominal hysterectomy and bilateral procedure.
salpingo-oophorectomy in those with bilateral ovarian
involvement. Those with unilateral ovarian tumor who Surgery for Recurrences
have completed family or have a strong family history of In great majority of cases recurrences tend to be wide spread
ovarian carcinoma should also undergo same procedure. precluding any meaningful role. However, if isolated tumor
6. Performing infracolic omentectomy. masses are noted at the time of recurrence, then a second
7. Peritoneal biopsy samples from various sites in abdomen. laparotomy can be undertaken. Most cases of recurrence
8. Biopsy from adhesions or other suspicious areas. are better managed with salvage chemotherapy.
9. Pelvic and para-aortic lymph node sampling.

Chapter 48
10. Careful assessment of residual disease at various sites CHEMOTHERAPY FOR EPITHELIAL OVARIAN CANCER
in abdomen and pelvis. Epithelial ovarian cancer (EOC) is the second common
gynecological cancer among women in India. Its incidence
Postoperative Care
varies from 4.5–5.5 per 100,000 women in India. Compared to
Adequate replacement of blood and plasma ensures complete west, incidence in India is low. At Institute Rotary Cancer
recovery after surgery. It is not uncommon to encounter Hospital, between 1991 and 2000, 815 patients with a diagnosis
reduced urinary output in those subjects who had marked of ovarian tumor were managed, of these 83% were epithelial,

Ovarian Malignancy
ascites. Replacing plasma volume with fresh frozen plasma 9.5% germ cell, 3.2% sex cord stromal , 3.2% metastatic to
and human albumin ensures good urinary output. Some of ovary with primary elsewhere and 1% had other categories
the cases with significant residual disease tend to have rapidly of tumor (Table 48.1).
accumulating ascites in postoperative period. Slow return of Before planning for chemotherapy for a patient with EOC,
bowel activity and paralytic ileus are not uncommon following it is important to know detailed operative findings so as to
extensive surgery. decide pathological stage, amount of residual disease and
Further Treatment histological type. Postoperative CT scan of abdomen and
pelvis and serum CA-125 levels are helpful in judging
Almost all patients with epithelial ovarian cancer require
response to chemotherapy. Proper assessment of any
postoperative chemotheraphy. Only unilateral, well
associated co-morbid conditions, e.g. diabetes mellitus,
encapsulated stage IA, well-differentiated tumors in young
ischemic heart disease is very important to reduce chemo-
patients are kept on follow-up without giving chemotherapy.
therapy induced toxicity. (Shimizu and Coworker 1998).
Currently use of paclitaxel (Taxol) and carboplatin for six
Following is the list of necessary investigations required
cycles is the standard of care in chemotherapy for epithelial
prior to Chemotherapy: (Table 48.4).
ovarian malignancies. Chemotherapy is usually started 2–3
weeks after surgery when patient has made satisfactory Chemotherapy for Early Stage Disease (Stages 1 and 2)
recovery. (ssee chapter 40 for detail).
Patients with stage I and II are considered as early stage
Interval Debulking Surgery disease, though many investigators consider only stage I as
Occasionally, one may come across a case of ovarian cancer early stage. Even in early stage disease histologic subtype
where only biopsy was possible at the time of primary surgery. and tumor differentiation (grade) have important bearing
In such cases surgery can be undertaken after 3–6 cycles of on the prognosis. Patients with stage IA and IB disease with
chemotherapy. Such a surgical procedure is called as Interval grade I-II differentiation are considered to have low risk
Debulking Surgery. Available reports suggest that such an disease and are at a low risk of recurrence after surgery.
approach can be associated with longer disease free survival. The exceptions are—clear cell carcinoma and high grade
tumors (grade III) which have unfavorable prognosis and
Second Look Surgery are considered as high risk disease. There is now consensus
In the past all cases of ovarian carcinoma who had been that women with low risk disease can be kept on close follow
treated with optimal debulking surgery followed by up after surgery without any postoperative chemotherapy.
chemotherapy were subjected to a repeat laparotomy to be Patients with high risk disease, i.e. stage IA, IB with high grade
sure that no more disease remained. Such a surgical tumor or clear cell histology and those with stage IC
procedure was called as Second Look Laparotomy. Current (irrespective of grade) should receive adjuvant chemotherapy.
opinion does not favor such a surgical procedure as a routine It is widely accepted that early stage tumors that breach the
in the management of ovarian cancer because of better
diagnostic amenities (including PET-CT).
Table 48.4: Investigations
Steps of Second Look Laparotomy • Hemogram
• Urine routine and microscopic
1. Vertical midline incision • Liver and renal function tests
2. Peritoneal washings from pouch of Douglas, both paracolic • Chest X-ray P/A View
gutters and subdiaphragmatic area. • Details of the operative findings + Extent and location of residual
3. Careful inspection and palpation of all peritoneal surfaces disease
including subdiaphragmatic surface, bowel, liver, para- • Histopathology and Grade of the tumor
aortic and pelvic lymph nodes. • CT scan of abdomen and pelvis
4. Multiple random biopsies from pouch of Douglas, • Serum CA-125
• Echocardiography or MUGA scan (for women above age of 45
peritoneum, mesentry of small bowel, under-surface of
years or earlier if indicated)
diaphragm and any other suspicious looking area.
357
 capsule, or ruptured at surgery, or those associated with Table 48.5: Response criterias
positive washings or ascites that contain malignant cells have
a worse prognosis. Complete response: Disappearance of disease on clinical and
Choice of chemotherapy in early stage disease has been radiological examination along with
normalization of CA-125 lasting for 4
a subject of debate in past, but now most investigators agree
weeks.
that 4 to 6 cycles of paclitaxel and platinum (either cisplatin or Partial response: >=50 % reduction in the maximum diameter
carboplatin) should be given. In the past , for patients with of a single measurable lesion, in case of
stage IA and B , high grade disease, we have used single multiple lesions >=50% decrease in sum of
agent oral melphalan 0.2 mg/kg/day for 5 days every 4 weeks the products of the perpendicular diameters
for 9 months. But after the reports of development of of the multiple lesions.
secondary leukemia following melphalan in 5–7% of patients Progressive disease: Greater than 25% increase in the size of
at 5 years, we have abandoned this practice. General the target lesion or in case of several target
Diseases of Ovary

lesions, a greater than 25% increase in sum

guidelines for the management of early stage are given in
of the products of the perpendicular
(Table 48.7). For patients with stage II disease, it is our practice diameters of these lesions or the
to give 6 cycles of adjuvant chemotherapy using paclitaxel appearance of any new lesion. The new
plus carboplatin. appearance of pleural effusion or ascites is
considered as progressive disease.
Advanced Disease
For patients with advanced EOC, initial cytoreductive surgery
is considered the gold standard. All such patients should Inj Paclitaxel 135 mg/m2 IV 24 hours day 1
receive postoperative chemotherapy. In early 1990’s, all such infusion
patients used to be treated with cisplatin, and Inj cisplatin 75 mg/m2 IV day 2
cyclophosphamide +/– adriamycin. McGuire et al (1996) for 3 weekly × 6 cycles
Section 12

the Gynecologiy Oncology Group in a randomized study OR

compared cisplatin and cyclophosphamide vs paclitaxel and Inj Paclitaxel 175 mg/m2 IV 3 hours day 1
cisplatin. Paclitaxel + platinum combination was superior (in infusion
terms of clinical response rates, pathological complete Inj Carboplatin (AUC 5–6) IV 2 hour day 2
response rate, overall and progression free survival) to infusion
cisplatin + cyclophosphamide. Subsequently, similar results 3 weekly × 6 cycles
were reported in the Intergroup trial. These results were Cisplatin can be replaced by carboplatin. Dose of
true both for patients with optimal (residual disease ≤1 cm) carboplatin is calculated by Calvert’s formula.
and suboptimal debulked (residual disease >1 cm) after Calvert’s formula = (GFR +25) AUC 6 .
surgery. Therefore, currently, paclitaxel + platinum (cisplatin Cockcroft-Gault formula for GFR
or carboplatin) is the preferred chemotherapy regimen as a (140-age) × body wt in kg
first line therapy. Our practice is to give at least 6 cycles of = × 0.85
chemotherapy and/or 2 cycles after achievement of 72 × serum creatinine (mg%)
complete response (CR) to all such patients after initial Both cisplatin and carboplatin have been shown to have
debulking surgery. Patients are assessed for response to equivalent activity. However, carboplatin causes significantly
chemotherapy at the end of 3rd cycle with repeat clinical less nausea/vomiting, and is less nephrotoxic, neurotoxic
examination, serum CA-125 and CT scan of abdomen and and ototoxic than cisplatin (Table 48.6) and is thus preferred
pelvis. Those who achieve complete response(CR) receive 2 over cisplatinum for treatment of advanced epithelial ovarian
more cycles of same chemotherapy. For patients with good cancer.
partial response , we repeat assessment at the end of 6 Thrombocytopenia can be a major toxicity with the use
cycles and give 2 more cycles in complete responders. of carboplatin. Therefore, dose of carboplatin must be
Response criterias are given in Table 48.5. calculated carefully as above. For new patients, area under
About 80% of patients respond to chemotherapy, clinical curve is taken as 6 (upper limit) and for patients with recurrent
complete response is seen in half of them. When these disease and previously treated with platinum compounds,
patients are subjected to second look laparotomy, about 20– AUC as 4–5.
30% are found to be in pathological CR. Patients with evidence
of persistent/progressive disease are advised re-exploration. Neoadjuvant Chemotherapy
With above approach, 5-year survival is 30 to 55% for patients In many patients with advanced EOC, optimum debulking
who have nil or minimal residual disease (<1 cm) after initial may not be possible. Rather, aggressive surgery may be
surgery. On the contrary, 5-year overall survival is only 10– associated with considerable intra- and postoperative
20% for patients with gross residual disease (>1cm) inspite of morbidity, e.g. hemorrhage, shock, fistula formation, prolonged
6 cycles of chemotherapy. Thus, amount of residual disease ICU stay and infections with mortality in 2–3% of patients.
after initial debulking surgery is one of most important Patients with poor performance status, and those with lesions
prognostic factor.
Rate of fall of serum CA-125 is a useful guide to judge Table 48.6: Comparison of cisplatin and carboplatin
response to chemotherapy. Most patients who respond
demonstrate 50% or higher decrease in serum CA-125 levels Toxicity Cisplatin Carboplatin
following 2 cycles of chemotherapy (Table 48.5). Nausea/vomiting +++ +
Nephrotoxicity ++ -
Chemotherapy Regimen Neuropathy ++ -
Thrombocytopenia - +/++
Commonly used chemotherapy regimens are given below.
Ototoxicity + -
358 Paclitaxel + platin combination
involving diaphragm, base of small bowel mesentery, liver once a year life long. On each visit, a detailed physical
parenchyma, retroperitoneal nodes and upper abdominal examination including pelvic examination is done. Serum
structures (e.g. stomach and splenic hilum) are often CA-125 is repeated every 3 months during first 3 years, then
unresectable. Benefit of initial surgery in such patients with 6 monthly till 5 years then yearly. Chest X-ray, CT scan or US
gross residual disease is not obvious. CT scan of abdomen abdomen and pelvis every 6 months (or earlier if indicated).
and pelvis could be of help in identifying such patients prior to
surgery. Recurrent Disease
A number of investigators in small retrospective studies Management of relapse EOC is a challenging task. Most
have reported use of neoadjuvant chemotherapy (primary) patients who relapsed have abdominopelvic disease.
in patients deemed inoperable. This approach of using 3–4 Uncommon sites of relapse include- liver, chest (pleural
cycles of primary chemotherapy followed by surgery results effusion), spleen, lymph nodes, CNS or skin. The risk of relapse
in reduction in size of tumor with optimal cytoreduction in is proportional to initial stage of disease (Table 48.8).

Chapter 48
60–90% of patients. Operative morbidity is reduced with Treatment of relapse depends upon a number of factors such
decreased blood loss, decreased ICU stay and decreased as treatment-free interval from last chemotherapy, response
postoperative hospital stay. Overall and progression free to prior chemotherapy, number of metastatic sites and
survival of such patients is comparable to those treated with performance status. Treatment-free interval is the most
conventional approach of debulking surgery (with gross important predictor of response to salvage chemotherapy.
residual disease) followed by chemotherapy. Patients who relapse after a long period have a high
probability of response to second line chemotherapy. On
Immunotherapy

Ovarian Malignancy
the contrary, patients relapsing within 6 months of last
The use of monoclonal antibodies (mAbs) is based on the chemotherapy are generally resistant and unlikely to
idea selectively targeting tumor cells that express tumor- achieve meaningful response to same or similar drugs. Drugs
associated antigens. Angiogenesis is an all reactive target. such as topotecan, oral etoposide, gemcitabine, liposomal
The humanized form of Au61, bevacizumab inhibits the doxorubicin have been reported to result in response rates
growth of ovarian cancer and ascites formation and enhances of 15–28% in the setting of refractory disease. However, the
the efficacy of cysplatin in vivo. It avoids cytotoxic side effects duration of response is generally short <6 months. Patients
on normal tissues and are well tolerated. Epidermal growth who relapse with localized disease after a long treatment-
factor targeted therapy with trastuzumab and cetuximab. free interval can be benefited with debulking surgery followed
CA–125 targetted therapy by oregovomab (murine mab by chemotherapy. Patients with visceral relapse should
B43.13) binds specifically to CA–125 antigen. MuCl targetted receive systemic chemotherapy.
therapy by transmembrane glycoprotein. They may be
another agent for treatment of ovarian cancer (Seiji et al., Treatment of Patients with Raised CA-125
2010) Gene therapy is under research. Many patients have elevated serum CA-125 without clinical
or radiological evidence of relapse. Policy at IRCH for all
Guideline for Follow-up such patients is to repeat serum CA–125 after 2–3 weeks to
At IRCH cases of EOC who have been treated with surgery rule out laboratory error. If it is still elevated then carefully
and chemotherapy are asked to come for follow up every 4 observe the patient over next few weeks with repeat serum
to 6 weeks during the first year; every 3 months during the CA–125 at 2–3 weeks interval. The median time from first
2nd and 3rd year, every 6 months during 4–5th year then increase in CA–125 value to clinical/radiological evidence of
relapse may vary from 6 weeks to 6 months. At present there
Table 48.7: Guidelines for treatment of epithelial ovarian cancer is no data to recommend chemotherapy in patients with
isolated CA–125 elevation. Patients with slow increase (<20%
Stage Treatment 5-year Survival 5-year increase from base line value) are advised close follow up
Approach Literature Survival only. Patients with rapid rise of CA–125 are reviewed carefully
at IRCH for symptoms/ clinical and radiological disease. Patient having
Stage I Low Risk Surgery alone 92% 86% any of above are advised salvage chemotherapy. Best
Stage IA, IB therapeutic approach in such a situation is still not clear. Options
Well or modera- varies from oral hormones (tamoxifen) to single agent oral
tely differentiated etoposide (VP-16) or single agent platinum based therapy to
Stage I High risk Surgery IA-88% 77% combination chemotherapy.
A, and B, high followed by IB–82%
CONCLUSION
grade/ Clear cell adjuvant chemo-
histology/IC therapy (4–6 Significant progress has taken place in the management of
cycles) epithelial ovarian cancer during the past decade. Most
Stage II Surgery followed 63–70% 57% patients with low risk EOC can be cured with surgery alone
by adjuvant chemo- today. Patients with high risk disease or those with advanced
therapy (6 cycles) disease, should receive adjuvant chemotherapy to reduce
Stage III Surgery followed Optimum 18%
by adjuvant chemo- debulking = Table 48.8: Risk of recurrence
therapy (6 cycles) 30–55%
Suboptimal FIGO Stage Risk of Relapse (%)
= 10–20% I 10–23
Stage IV Surgery followed 12–17% 15% II 20–40
by chemotherapy III 30 – 80
(6 cycles) IV >80
359
 the risk of recurrence. Paclitaxel and platinum based chemo- Table 48.10: Tumor markers in MOGCT
therapy is the standard combination for such patients. High
relapse rates despite initial high response rates to Histology subtype B-hCG AFP Other
chemotherapy reflects the development of acquired Dysgerminoma * – LDH, CA-125
resistance to chemotherapy. Many new approaches e.g. Endodermal sinus – +
reversal of drug resistance, intraperitoneal chemotherapy, Tumor
monoclonal antibody/gene therapy are currently under Choriocarcinoma + –
investigations. Immature teratoma +/– +/– LDH, CA-125
Embryonal carcinoma +/– +
MALIGNANT OVARIAN GERM CELL TUMORS (MOGCT) Normal levels Half-life
B-hCG 0–10 miu/ml 18–24 hrs
Germ cell tumors malignent ovarian are rapidly growing
AFP 0–5 ng/ml 5–7 days
tumors and occur commonly in girls and young women.
Diseases of Ovary

Prognosis of patients with GCT of ovary has improved AFP - alfa fetoprotein, β-hCG beta human chorionic gonadotropin
significantly over past two decades as a result of the * -10% of patients with dysgerminoma may have elevated serum β-
introduction of cisplatin based chemotherapy after initial hCG which is usually less than 100 miu/ml. Higher values
surgery. Following conservative surgery most patients can precludes pure dysgerminoma.
anticipate normal menstruation and a reasonable probability
of having normal offsprings. Patients with metastatic dysgerminoma have elevated serum
LDH but negative serum AFP and β-hCG. β-HCG may be
Incidence
elevated in less than 10% of patients with dysgerminoma and
Malignant GCT of ovary accounts for 1% of all the malignant is usually less than 100 mIU/ml. If β-hCG is significantly
tumors in young females and 3 to 6% of all ovarian tumors. elevated , diagnosis of mixed GCT should be considered. Fine
The incidence is higher, almost 9% to 15% in developing needle aspiration cytology/biopsy is not useful for the initial
Section 12

countries and in Japan. At our institute, MOGCT constitutes diagnosis of these tumors. However, it may be useful in
9% of all ovarian tumors. The median age of onset is 20–22 confirming the suspected relapse, in a known case of MOGCT.
years. Approximately, one fifth of these cases occur before Radiological studies of the upper and lower intestinal tract
menarche. At AIIMS, we have seen 85 patients of MOGCT are not routinely recommended unless the patient is having
over 12 years period (1988-1999); 5.9% of patients were below symptoms related to the intestinal tract.
10 years of age, 43.4% were between 11–20 years, 35.4% were FIGO staging similar to epithelial ovarian cancer is
between 21 and 30 years and 13.1% were between 31 and 40 followed for MOGCT. In a study at AIIMS , 42(49.5%) had
years. Clinical presentation of these patients is shown in (Table stage I-II, 30(35.3%) stage III and 13(15.3%) patients had
48.9). stage IV disease at diagnosis.
Diagnostic Work Up and Staging Surgery (Figs 48.27 and 48.28)
Although ovarian GCTs are rare, it is important to consider Initial treatment approach for such young patients is surgery
this diagnosis in all young patients suspected of having an which establishes the diagnosis and initiates therapy. The
ovarian tumor/pelvic mass. Initial evaluation includes— type of primary surgery depends upon the extent of disease.
detailed physical examination, hemogram, liver and renal Bilateral ovarian involvement in absence of advanced
function tests, chest X-ray, ultrasound or CT scan of abdomen disease is rare except in dysgerminoma. Therefore,
and pelvis to determine the disease extent. Serum markers unilateral salpingo-oophorectomy with preservation of
namely serum AFP, serum β-hCG, and serum LDH (Table contralateral normal ovary and uterus can be performed
48.10) are important in the diagnosis and subsequent in most patients, thus preserving fertility. If contralateral
management and should be done in all patients suspected of ovary appears grossly normal, it should be left undisturbed.
having MOGCT . Dysgerminoma (Figs 48.18 to 46.21) is the If the coontralateral ovary appears abnormal, biopsy or
most common subtype (50%), followed by immature teratoma, cystectomy should be performed. At our institute, many of
endodermal sinus tumor (Figs 48.22 and 48.23) and mixed GCT. such patients are referred after surgery done outside
Embryona carcinoma (3.5%). Mature cystic teratoma (Figs 48.24 without having adequate staging biopsies. For such patients,
and 48.25) and choriocarcinoma (Fig. 48.26) (1.2%) are unless bulky residual disease is present, based on physical
uncommon subtypes. Serum LDH is not specific to MOGCT, examination and imaging studies, it is our policy to proceed
but when raised, it is useful in the monitoring treatment of with chemotherapy as soon as possible rather than to resort
MOGCT patients negative for serum AFP and β-hCG e.g. to re-exploration for the purpose of gaining more precise
staging information. If gonadal dysgenesis is confirmed,
the risk of tumor (usually gonadoblastoma or dysgerminoma)
Table 48.9: Clinical presentation : experience
at AIIMS (n = 85) in the contralateral ovary is high enough to warrant bilateral
oophorectomy. In such cases, the uterus should be left ‘in
Duration of symptoms
Median 4 months
situ’ for future embryo transfer.
Range; 10 days to 36 months
Symptoms: n (%) Chemotherapy
Abdominal pain 70(82.4) Because of the rarity of MOGCT, randomized studies have
Abdominal +/-Pelvic lump 75(88.2) not been performed. Most of the lessons learnt from
Acute abdomen 14(16.5) chemotherapy trials in testicular GCT have been applied to
Menstrual abnormalities 17(20.0) the MOGCT and these have now been validated in smaller
Ascitis 15(17.6)
studies in MOGCT. A combination of bleomycin, etoposide
Fever 17(20.0)
Dyspnea 3(3.5) and cisplatin (BEP) is used widely (Table 48.11). Hitchins et al
360 at Charring Cross Hospital-London, have developed—POMB-
 Chapter 48
Fig. 48.18: Dysgerminoma: Hyaline stroma dividing the tumor into Fig. 48.19: Dysgerminoma: Tumor cells are large and possess distinct cell
incomplete lobules. Dr Anurag Mehta (Rajiv Gandhi CRIC) membrane. Nuclei are large and nucleoli are pink and prominent (H&E, x 200

Ovarian Malignancy
X). Dr Anurag Mehta (Rajiv Gandhi CRIC)

Fig. 48.20: Dysgerminoma with lymphoid stroma Fig. 48.21: H&E, 400X demonstrates sharp cell borders and prominent
Dr Anurag Mehta (Rajiv Gandhi CRIC) nucleoli in a vesicular nucleus of dysgerminoma Dr Anurag Mehta
(Rajiv Gandhi CRIC)

Fig. 48.22: Endodermal sinus tumor Dr Yadav, RML Hospital Fig. 48.23: Endodermal sinus tumor 1 (40x) Dr Yadav, RML Hospital

ACE, an alternative regimen. In this regimen, relatively treatments as short as possible to minimize the risk of drug
nonmyelosuppressive POMB (cisplatinum, vincristine, resistance. They reported an overall survival of 83% at 12
methotrexate and bleomycin) is alternated with more years follow-up among 58 patients of stage II–IV, non-
myelosuppressive, ACE (actinomycin-D, cyclophosphamide dysgerminomatous OGCT. There were no deaths beyond
and etoposide) keeping the treatment interval between the 3rd year of entry into the study. 361
Diseases of Ovary

Fig. 48.24: Mature cystic teratoma (4x) Fig. 48.25: Mature cystic teratoma (10x)
Dr Yadav, RML Hospital Dr Yadav, RML Hospital
Section 12

Fig. 48.26: Choriocarcinoma of the ovary. Note large areas of Fig. 48.27: Malignant ovarian tumor (Gross)
hemorrhage and necrosis, besides the tumor tissue Rt Lower corner.
Dr Anurag Mehta (Rajiv Gandhi CRIC)
Table 48.11: Chemotherapeutic regimens for MOGCT
BEP Inj. Cisplatin 20 mg/m2 IV day 1–5
Inj. Bleomycin 10 mg/m2 IV day 1–3
Inj. VP-16 (etoposide) 100 mg/m2 IV day 1–5
Q 3 weeks, 3 – 4 cycles
POMB-ACE
PO MB
Day1 Vincristine 1 mg/m2 (Max 2 mg) IV bolus
Methotrexate 300 mg/m2 IV infusion
Day 2 Bleomycin 15 mg IV infusion over 24 hours
Folinic acid 15 mg at 24, 36, 48, 60 hours after
methotrexate
Day 3 Cisplatin 120 mg/m2 IV infusion over 12 hours
ACE
Day1 Etoposide 100 mg/m2 IV infusion
Actinomycin –D 0.5 mg IV bolus
Day 2 Etoposide 100 mg/m2 IV infusion
Actinomycin –D 0.5 mg IV bolus
Day 3 Etoposide 100 mg/m2 IV infusion
Actinomycin –D 0.5 mg IV bolus
Cyclophosphamide 500 mg/m2 in 250 ml NS over
Fig. 48.28: Malignant ovarian tumor (Gross) with normal uterus 30 minutes.

William et al., (1994) for the GOG have reported the results Chemotherapy for Germ Cell Tumors
of adjuvant chemotherapy with BEP regimen; 93 patients with other than Dysgerminoma
nondysgerminomatous MOGCTs with nil residual disease Our policy is to give 3 cycles of adjuvant BEP chemotherapy
(stage I–III) received 3 cycles of BEP. At a median follow up of to all patients with stage I,II and completely resected stage
362 38.6 months, 91 patients were alive and disease-free. III disease. The only exception is stage I, grade-I immature
teratoma (Table 48.12) patients who are followed up after Table 48.13: Malignant germ cell tumors of ovary:
surgery without adjuvant chemotherapy. Patients on adjuvant Treatment guidelines
chemotherapy are followed up for any recurrence with
periodical check up, ultrasound scan of abdomen and pelvis Stage Histology Residual Disease Treatment
and serum marker studies. I to III Non dysgerminoma Nil or ≤1 Cm BEP: 3 cycles
Patients with advanced disease, i.e. incompletely resected (Endodermal sinus
stage III and IV disease receive 4 cycles of BEP followed by Tumor Mixed
assessment. Patients found to have complete response (CR) GCT, Embryonal ,
(no clinical, biochemical or radiological evidence of disease) Choriocarcinoma)
are advised regular follow up. Patients with normal marker III to IV Any of above ≥1 cm BEP: 4 cycles
studies (who had elevated serum AFP +/- HCG at diagnosis) IA, Immature teratoma Nil Observation
but with evidence of residual lesion of <3 cm size on imaging grade I

Chapter 48
are advised 2 more cycles of chemotherapy and then follow- IA, grade Immature teratoma Nil or ≤1 cm BEP: 3 cycles
up. Patients with elevated markers with gross residual tumor II-III, and
on clinical and radiological studies are advised laparotomy IB –III
for debulking surgery. Those found to have evidence of disease III –IV Immature teratoma ≥1Cm BEP: 4 cycles
on histopathology are advised salvage chemotherapy. IA Dysgerminoma Nil Observation
Patients with evidence of mature teratoma or fibrosis are IB to III Dysgerminoma* Nil or ≤1 cm BEP: 3 cycles
advised follow-up after excision of the mass. Any Dysgerminoma ≥1 Cm BEP: 4 cycles

Ovarian Malignancy
stage
Dysgerminoma Patients who have completed family and not willing for
The initial management of these patients is resection of the chemotherapy can be considered for radiotherapy.
tumor and biopsy of any suspicious lesion in the contralateral
ovary to rule out involvement. Similar to seminoma in males, who relapse after PVB or BEP have responded to VAC
dysgerminoma is radiosensitive and have higher propensity chemotherapy.
for retroperitoneal lymph node involvement. Till recently,
most patients with early stage dysgerminoma have been Follow-Up
treated with postoperative radiotherapy. However, since Similar to patients with epithelial ovarian cancer, we follow
pelvic radiotherapy is likely to be associated with ovarian these patients in outpatients clinic once in 4–6 weeks during the
failure and sterility , the concept of observation after first year, 2–3 monthly during the second year and every 6
complete resection of stage IA disease has been developed. months during the 3rd year and then once in a year indefinitely.
Such patients will require careful follow up as in 15–25% of On each visit a detailed physical examination is done. Serum
patients tumor will recur after unilateral oophorectomy. If markers are repeated once in 2–3 months during first 2 years
regular follow up cannot be ensured, it is better to treat them then once in 6 months till 5 years. US scan of abdomen and
with 3 cycles of adjuvant BEP chemotherapy, if fertility is to be pelvis is repeated once in 6 months till 3 years then once a
preserved or with adjuvant radiotherapy for those who have year till 5 years. The risk of relapse after 3 years is rare.
completed their family. Treatment guidelines are given below
(Table 48.13). Reproductive Functions
Preservation of fertility in these young patients is an important
Treatment of Relapse
issue. A number of studies have reported successful outcome,
About 10 – 20% of patients with advanced GCT of ovary i.e. normal fertility following chemotherapy in these young
relapse after achieving CR. Most relapses occur within two patients in whom preservation of contralateral ovary and
years of treatment and late relapses are rare. Patients who uterus was carried out. In our study, all 17 patients who had an
have relapsed after prior treatment with radiotherapy or intact contralateral ovary, tube and uterus have resumed
VAC (vincristine, actinomycin-D and cyclophosphamide) menstruation. Thirteen patients who attempted pregnancy
regimen may respond to cisplatin based combination. succeeded and have delivered 17 healthy babies, although one
Patients relapsing after PVB or BEP may respond to patient had a spontaneous abortion and another had vesicular
ifosphamide based chemotherapy with CR rate of 25 –30%. mole. These and similar observations by other investigators
Some patients with platinum resistant/ refractory disease support the view that likelihood of retaining fertility after
may even respond to high dose chemotherapy supported chemotherapy is reasonably good.
with autologous bone marrow/peripheral blood stem cell
transplantation. Occasional patient with immature teratoma BIBLIOGRAPHY
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Section 12

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364
 Section 13 Diseases of Vulva

49 Dermatoses of Vulva

Vibhu Mehdirata

Vulval dermatoses Vulva constitutes an area of the body 5. Bullous and erosive diseases (autoimmune bullous
which is accessible for diagnosis and treatment to multiple diseases, Behcet’s disease)
disciplines namely, gynecology, dermatology, family physician, 6. Granulomatous conditions (Hidradenitis Suppurativa,
etc. The overlapping nature of the above disorders is also Crohn’s Disease)
true as regards the extension of the disease process from the 7. Drug Eruptions (Fixed drug eruption, Erythema multiforme)
skin to the internal genital organs and vice versa. Thus, the 8. Aphthae.
importance of a thorough clinical examination of the vulval
Benign Tumors
skin and the internal genitilia is inseparable, in order to institute
optimum treatment. • Epidermal cyst
• Vestibular cysts
THE UNIQUENESS OF THE VULVAR DERMATOSES • Hidradenoma papilliferum
1. Majority are treatable, curable (only a few of them). • Syringoma
2. The scaling dermatoses’ lack their classical morphology. • Bartholin gland duct cyst.
Scales are absent. Premalignant and Malignant Conditions
3. Warm and moist environment of vulva predisposes to 1. Paget’s disease
certain infective and allergic/irritant dermatoses. 2. oon’s vulvitis
4. The vulva is an easily scar—prone area with resultant 3. Erythroplasia of ueyrat
narrowing of the introitus. 4. Squamous cell carcinoma.
5. The vulvovaginal syndromes generate considerable
amount of depression, anxiety and fear in the mind. Miscellaneous
6. There may not be a good correlation between the 1. Vulvodynia
intensity of the subjective complaints and the objective 2. Vulval fissures.
clinical findings. Minor changes in the texture also should Following is a brief overview of common conditions of
not be overlooked. the vulva where predominantly vulva alone is affected
Based on the etiology of the dermatoses, vulval dermatoses characteristically.
can be classified as under—
Pruritus Vulvae
Venereal Is a nonspecific symptom where the patient (usually in the
Major STDs Syphilis, Chancroid, Granuloma inguinale, reproductive age gp. 20–50 yrs) is disturbed by moderate to
lymphogranuloma venereum, herpesgenitalis, gonorrhea. intense pruritus over the vulva which may be provoked by
friction, sweating, chafing and an exposure to irritants like
Non-venereal soap, hot water, etc. The symptom of itching is present
Infections without an organic cause, although a sincere search for
1. Bacterial-folliculitis, cutaneous tuberculosis. vulvovaginal infections, infestations, vulvar neoplasms
2. Viral-condyloma acuminata (warts), Molluscum should be made to rule out the local causes and diabetes,
contagiosum. anxiety, depression needs to be identified. Application of
3. east-candidal vulvovaginitis. topical steroids along with oral histamines would help in the
4. Fungal-Tinea corporis. amelioration of the symptoms. Using cotton under garments
and washing the perineum with lactic acid solution helps.
Eczematous
1. Allergic contact dermatitis Lichen Simplex Chronicus (Localized
2. Irritant contact dermatitis Neurodermatitis) (Fig. 49.1)
3. Lichen simplex chronicus. It is a reaction pattern of the vulvar skin to chronic itching
and scratching of the vulva and the initial stimulus to itch
Involvement of Vulva Secondary to Other Dermatoses may be a local infection (candidal, fungal) or contact
1. Psoriasis dermatitis which leads onto a chronic cycle of itch-scratch
2. Lichen planus resulting in a change in the texture of the vulvar skin,
3. Lichen sclerosus et atrophicus becoming thick, hyperpigmented and with accentuation of
4. Vitiligo the skin markings (lichenification) (Fig. 49.5). Moderately potent
Diseases of Vulva

Fig. 49.1: Shows lichenification of the vulva Fig. 49.3: Showing erythematous papillomatous growth
of vulval warts
topical steroids with oral anti-histamines help to improve mm) and may be larger in the immune compromised patients
the condition. over the vulva. Larger lesions show central umbilication or
surrounding inflammation. Treatment is by extirpation of the
Candidal Vulvovaginitis (Fig. 49.2) lesions and chemical cautery with 30–50 trichloroacetic acid.
Section 13

The symptoms are—vulvar pruritus and curdy white vaginal

discharge with erythema of the vulvar skin, labia majora Contact Dermatitis (Fig. 49.5)
and minora. Spread to the genitocrural area shows well- Presents with erythema, vesiculation, oozing and crusting of
demarcated erythema with a scaling or papulovesicular the vulva following exposure to irritants like iodine/dettol,
border. Treatment consists of oral fluconazole 150 mg. Single etc. or to the agents like dyes in clothing, hair removing
dose and simultaneous treatment of the sexual partner as creams, rubber, fragrances lubricants, sanitary towel, etc.
well. Local pessaries containing fluco. Treatment consitutes removal of the offending agent and
application of topical steroids
Bacterial Vaginosis
Is an ecological disturbance in the normal bacterial flora of Herpes Genitalis (Fig. 36)
the vagina with reduced lactobacilli and overgrowth of Is a sexually transmitted disease and can manifest as
gardnerella vaginalis, mobiluncus sp. etc. Doxycyclin 100 mg multiple, grouped vesicles on erythematous base which
twice a day for 7 days will usually suffice. rupture to form shallow erosions with polycyclic margins
over the vulva, vagina, endocervix associated with burning
Condyloma Acuminata (Fig. 49.3) and itching. Pain is severe in primary forms.
The human papilloma virus infections causing the genital warts Treatment is with oral acyclovir/famciclovir or
by the HPV 6, 11, 16 and 18. It may cause uncommon locally valacyclovir in the primary and recurrent episodes.
aggressive, nonmetastasizing verrucous carcinomas.
(Bushchke Lowenstein Tumor). Lichen Planus (Fig. 49.6)
Is characterized by the presence of violaceous or pink,
Molluscum Contagiosum (Fig. 49.4) (Fig. 36) flat topped papules or white reticulate plaques over the vulva
Is a minor sexually transmitted disease caused by PO group and vagina. There may be an erosive variant of lichen planus.
of virus. There are small pearly papules of size (5 mm-1.5 Clinical clues should be sought in the oral cavity, wrist,

366 Fig. 49.2: Erythema of the vulva with curdy white vaginal discharge Fig. 49.4: Shows flesh colored pearly papules
over the vulva of molluscum contagiosum
 Chapter 49
Fig. 49.5: Shows erythematous papules and lichenification Fig. 49.7: Lichen sclerosus shows depigmented skin
of the vulva, groins with scarring of the vulva

Dermatoses of Vulva
Fig. 49.6: Linchen planus shows multiple flat topped, violaceous Fig. 49.8: H/P Lichen sclerosus vulva Dr RB Yadav (RML Hospital)
papules over the vulva

nails, etc. Active therapy with potent topical steroid is and mild itching. Classical plagues of psoriasis should be
indicated. located at other site. A moderately potent topical
corticosteroid is used to control itching and erythema.
Lichen Sclerosus (Fig. 49.7 and 49.8)
Is the most common cause of vulval dystrophy. The disease Fox Fordyce Disease
presents as erythematous and itchy, sore skin over the vulva Disease of apocrine glands of the vulva resulting from a
which later becomes ivory white and atrophic, later causing blockage of the apocrine sweat ducts. Clinically is seen at
shrinkage of the clitoris and labia minora. Usual age of onset is puberty in the form of itchy, flesh colored dry, shiny papules on
either prepubertal or late onset around 45–60 yrs. There is a 5 the labia. Responds to topical retinoids or topical corticosteroids.
incidence of malignant transformation in the long standing cases.
Leukoplakia vulva (Figs 49.9 A and B) is white discoloration Herpes Zoster of the Vulva (Fig. 49.12)
of valva. It is a benign condition and is not premalignant. It Caused by the varicella zoster virus and is a reactivation
needs no treatment. of the latent virus in the dorsal root ganglion of the
lumbosacral nerves. It is a rare site. Presents as multiple
Vitiligo (Fig. 49.10) grouped, vesiculobullous lesions over erythematous base
Is an acquired disorder of pigmentation which is in a segmental distribution. May be associated with
characterized by loss of vulval pigment with similar extreme neuralgic pain. Oral antivirals acyclovir, tames
depigmented macules elsewhere like oral cavity, lips, hands clover or valaciclovir with analgesics would help in
and feet. It is asymptomatic and the texture of the vulval relieving the symptoms.
skin remains unaltered.
Vulvar Lymphedema (Fig. 49.13)
Flexural Psoriasis (Fig. 49.11) This could be secondary to the obstruction of lymphatics
Is a variant of psoriasis wherein well-defined erythematous due to either infections, (bacterial, viral, sexually transmitted
to bright red areas appear over the labia majora and groins diseases), post-surgery, radiation, lymphoma or local tumors.
without scaling or with little scaling. There may be soreness Genital tuberculosis scrofuloderma involving the inguinal
367
Diseases of Vulva

Fig. 49.9A and B: Leukoplakia vulva, Dr RB Yadav (RML Hospital)

Section 13

Fig. 49.10: Vitiligo depigmentation of the vulvar skin Fig. 49.11: Flexural psoriasis shows erythematous
scaly plaques over vulva

Fig. 49.12: Herpes Zoster showing grouped vesicles over Fig. 49.13: Shows lymphoedematous enlargement of labia majora
erythematous base in a segmental distribution secondary to lymphatic scarring by TB of inguinal lymph nodes

group. Of lymph nodes may also cause swelling of vulva due slough over the labia majora and the vulva with fever and
to lymphatic obstruction. other associated constitutional symptoms. Needs to be
diffrentially diagnosed from Herpes genitalis. The ulcers may
Behcet’s Disease cause scarring of the vulva. Treatment is with systemic
368 Presents as large, painful, deep punched out ulcers with steroids.
 50 Other Benign Conditions of Vulva

Sudha Salhan, Moni Tuteja

Although vulva only comprises a small amount of the body Raised Lesions
surface area (1%), it has surprisingly large number of diseases • Nevi
and ailments. Many inflammatory dermatological diseases that • Bartholin gland cysts/abscess
affect hair bearing skin elsewhere on the body may also occur • Urethral caruncle
on the vulva. So vulvitis may be encountered in psoriasis, ec- • Incisional cyst.
zema, allergic dermatitis, etc. The vulva is prone to skin infec-
tions because it is consistently exposed to secretions and mois- Tumors
ture. Nonspecific vulvitis is particularly likely to occur in blood • Benign
dyscrasias, uremia, diabetes mellitus, malnutrition and avita- • Papillary hidrodgenous
minosis. • Condyloma accuminata
Classification of benign conditions of vulva. • Fibromyoma
• Lipoma.
DEVELOPMENTAL
• Imperforate hymen Developmental Defects
• Vulvovaginal cyst Imperforate hymen/Intact hymen
• Intersex. This can be diagnosed at birth but sometimes the diagnosis
is not made until in her teen years. It is a thin membrane that
INFECTIONS completely covers the opening of a young girls vagina.
• Candida Menstrual blood cannot flow out resulting in hematocolpos
• Trichomonas (blood collection is the vagina) resulting in abdominal pain/
• Bacterial vaginosis backache.
• Herpes Treatment: Surgery to remove extra hyminal tissue and create
• Tinea cruris a normal sized vaginal/opening hymen and stitching the four
• Sexually transmitted diseases ends to the vulvar opening to prevent closure is mostly done.
• Chronic infections, e.g. tuberculosis. But a crucial incision is mostly given in this bulging imperforate.
ALLERGIC Congenital Anomalies of the External Genitalia
Contact dermatosis. In rare cases of sexually ambiguous external genitalia varies
from minimum degree of abnormality from normal female to
SYSTEMIC DISEASES the extreme of male external genitalia. In female
• Psoriasis pseudohermaphroditism (XX chromosome) both labia unite in
• Lichen planus the center hiding vulva. They may be detected at birth anytime
• Seborrheic dermatitis near menarche age (see chapter 28).
• Fox Fordyce disease The goal of treatment is to restore the external genitalia to
• Pemphigus the gender of rearing. In cases who are reared as female the
• Stevens-Johnson syndrome procedures include reduction of the size of the clitoris, cerving
• Hepatitis aout labia minora and make vaginal opening communicate at
• Uremia vulva. Acquired vulval stenosis may be due to burns (from
• Autoimmune disease fluids or electric) trauma, chronic, dystrophic vulval disease.
• Blood dyscrasia The making space at intoritus is the aim of the surgery to
• Diabetes mellitus be done (vulvovaginoplasty).
EPITHELIAL DISORDERS Vulval Infections
Dystrophies Seen in reproductive age group are mostly as follows:
• Lichen sclerosis • Boils
• Squmous hyperplasia • Candidia vulvitis
• Vulvar vestibulitis • Pediculosis pubis
 • Ring worm (Taenia curis) There can be life-threatening HSV encephalitis. It may be
• Herpes genitalis asymptomatic in between. Transmission to the newborn during
• Warts delivery—This danger is more in first or primary episode during
• Infection of the Bartholin gland later half of pregnancy. It is mostly not seen in recurrent cases.
• Elephantiasis Hence, if there are active lesions at the time of delivery, cesarean
• Intertrigo (Tuberculosis). section is safer for the child. Treatment of neonate is essential
Boils at pubis or labia majora are due to infection of hair (also see chapter 36).
follicles. Clipping of hair short and attention of hygiene will Diagnosis—By typical vesicles or ulcers discharge may
relieve most patients. If it does not regress, a course of local contain antibodies.
antiseptic solution or topical antibiotic (soframycin, etc.) will
help. Otherwise a course of ampicllin or erythromycin is needed. Syphilis
Infection of sebaceous or apocrine glands may appear as It is a highly contagious STD caused by spirochete Treponema
Diseases of Vulva

boils (Fig. 50.1). pallidum.

Candidial Vulvitis: It is seen as redness around vulva and
it causes itching. The patient is usually suffering from diabetes Chancroid
mellitus. Controlling the blood sugar level is essential (Figs 41.10 Causative agent: Hemophilus ducreyi symptoms—multiple,
and 49.2). painful ulcers.
Peticulosis Pubis: This is caused by lice, eggs of lice are Granuloma Inguinale: It is caused by calymmatobacterium
seen at the margin of the hairline; Radical hygienic measure as granulomatis. The lesions are painless papules or ulcers with
needed—Clipping the hair short, meticulous cleaning of vulva rolled borders and a friable base.
and the whole body is necessary. Use of anti-lice drugs may be
needed. All clothings are to be disinfected. Sexual partner is to Lymphogranuloma Venereum
Section 13

be similarly treated to prevent recurrence. It is caused by Chlamydia trachomatis L1,L2,L3

Ring Worm of the vulva may be transmitted by hands from There is erosion of skin forming a primary lesion fibrosis.
similar lesion from other body parts during itching. Treatment Phase 2 involves inguinal lymphadenitis. Phase 3 involves
of all sites is needed to prevent recurrence. fibrin. It is a destruction chronic unheated infection. It can cause
Herpes Genitalis: It is caused by Herpes simplex virus type proctocolitis and bowel stricture, stenosis of the urethra and
I and II (HSVI and HSVII). It starts as small vesicles in the vulval vagina.
and perineal area. It is very painful. The vesicle may rupture Tuberculosis of the vulva may be confused with malignancy.
and produce small ulcers on labia, vaginal serosa and perineum Biopsy proves the diagnosis. Standard antitubercular treatment
bodes inguinal lymph may be enlarged. There is thin vaginal (Chapter 36) will cure.
discharge. Urine passing on ulcers causa intense irritation, hence
catheterization of urinary bladder may be needed. Malaise and Elephantiasis
fever is also seen. It is mostly sexually transmitted. HSV2 If vulva may be a part of filarial infection and posttubercular.
infection is usually recurrent. The ulcers at the perineum and Epidermoid cyst requires excision and histopathology test.
vulva increases the risk of acquiring other STS hence advise Infection of Bartholin Gland. The causative organism can
use of condoms. Primary infection of HSV-2 causes mother to be any pyogenic organism, e.g. gonorrhea, Esch. coli, Staphylococcus,
child transmission. Viral cultures take a week. DNA Streptococcus, etc.
amplification (PCR) is quicker HSV, can also cause severe The duct gets dilated after obstruction and may get filled
keratoconjuctivitis with corneal ulceration. It is a chronic illness. with mucin secretion of the gland forming Bartholin cyst. These
After first attack it becomes dormant causing recurrence at a later cysts are mostly sterile. (But if it gets infected, it is called
date. Reactivation from sacral ganglia causes recurrence. The Bartholin abscess). Its cyst is to be examined for malignancy.
ulcers at the perineum and vulva increase the risk of acquiring Before 40 years of age the treatment is marsupialization. An
other STS, hence advise use of condoms. Primary infection of incision is made towards the vagina and hymenal ring under
HSV-2 causes mother to child transmission. Viral cultures take a local anesthesia. The edges are sutured back to leave an open
week. DNA amplification (PCR) can also be done. HSV-1 can space. Epithelization occurs in due course of time.
also cause severe keratoconjuctivitis with corneal ulceration.
Bartholin cyst: It occurs as a swelling at either side of entrance
of vagina caused by chronic inflammation blocking Bartholin
gland duct (Fig. 50.2).
Bartholin gland occurs on either side of vagina at 4 or 8
o’clock position posterolaterally which secretes lubricating fluid
during sexual arousal.
It can be acute/chronic infection.
Acutely presents as tense, hot, tender abscess.
Chronically presents as a non-tender cyst occupies the
posterior labrum.
Treatment: Marsupialization.
Bartholin Abscess: Infection of duct or cyst leads to abscess
formation.
Treatment: It immediately relieves with drainage of pus.
• Unruptured abscess managed by marsupialization with
broad spectrum antibiotics, e.g. ceftriaxone I/M single dose
with probenecid 1 gm by mouth in a single dose.
370 Fig. 50.1: Valva boils • Metronidazole 500 mg BD x 7 days.
 • Skin is typically white/off white with focal lesion. It is caused
by chronic vulval irritation causing thickening of skin.
• It is associated with lots of autoimmune disorders.
Symptoms: Pruritus
Diagnosed by biopsy—shows hyperkeratosis. Colposcopy with
acetic acid application may reveal a thickened epithelium.
Treatment: It consists of twice daily steroids for 3 weeks then
once daily treatment until symptoms disappear. Patient should
also decrease exposure to vulval irritants for examples
perfumes, dyed toilet paper.

Raised Lesions

Chapter 50
Boils are seen on the mons and labia majora.
Sebaceous cyst: It can occur anywhere in the vulva. Small
lumps of variable size that develop from blocked sebaceous
glands. They tend to be round, cystic nodules. Identified by
punctum marking the blocked opening of the gland.
Fig. 50.2: Bartholin cyst Infection of the vulva in children may lead to sticking
together of labia majora (Fig. 50.4). The two labia are separated.

Other Benign Conditions of Vulva

Intertrigo The morther is instructed about hygiene. Local estrogen cream
is needed for some days.
Vulva is seen at the creases of the tuberculous vulvo vaginitis
may be caused by sitting on infected sputum. It can be blood Urethral caruncle: Bright red, polypoid growth that protrudes
borne. Biopsy will clinch the diagnosis (Figs 50.3 and 49.13). from the urethral meatus (Fig. 50.5).
Most cause no symptoms.
EPITHELIAL LESIONS These occur commonly in postmenopausal women.
Atrophy occurs as a normal consequence of decrease in estrogen
secretion after menopause. Labia becomes flatter and skin hangs
loosely due to loss of subcutaneous fat.
Epithelium is pale, smooth and thin.
Introitus narrows.

Symptoms
• Pruritis
• Soreness
• Dyspareunia.
Treatment: Administration of estrogen and progesterones.

Dystrophies
Lichen Sclerosis (see chapter 49).

Squamous Cell Hyperplasia

• Common benign disorders which can look similar to other
white vulvar lesions including condyloma, VIN and
carcinoma. Fig. 50.4: Valval agglutination

Fig. 50.3: TB vulva Fig. 50.5: Urethral caruncle 371

 Symptoms Tumors
• Dysuria Benign Condition of the Vulva
• Bleeding in urine (Hematuria) Papillary Hidradenoma—develops from the apocrine glands
• Irritation and is similar to intraductal papilloma in the breast.
• Painful micturition It presents a sharply circumscribed nodule with a tendency
• Dyspareunia. to ulcerate.
Causes: It is caused by redundancy of the mucosa, combined It occurs on labia majora/interlabial folds.
with laxity of periurethral fascia, Aggravated by increase Diagnosis by biopsy—tubular ducts lined by single/
in intraabdomen pressure and lack of estrogen. It double layer of non-ciliated columnar cells with a layer
originates from the post lip of urethra. It looks like a bed of of flattened ‘myoepithelial cells’—characteristic of sweat
granulation tissue covered by either squmous/ transitional glands.
Diseases of Vulva

epithelium. Fibroma of vulva (Fig. 50.7 ). Excision is the treatment.

Treatment: Warm sitz bath Lipoma of the vulva is rarely seen. Excision is required for
• Topical estrogen cream and topical anti-inflammatory cure (Fig 50.8).
drugs.
• Surgical excision—cystourethroscopy should be done to Condyloma Acuminatum (Figs 50.9 and 49.3)
rule out urinary tract pathologies. Wart like verucous lesions move multiple frequency and often
coalesce and involve peirneal, vulvar and perianal regions as
Vulvodynia: It is pain at the vulva. Besides infection, ulcers
well as vagina and cervix. It is caused by HPV-6,11 mostly
injuries to be treated according to the cause the most facing
sexually transmitted. They are papular or macular, may occur
cause in vulvar vestibulitis.
singly or in bunches. They may cause itching but are painless.
Vulvar vestibulitis: It is defined as severe pain on vestibular touch They can be seen at perineal area, perianal area, rarely seen in
Section 13

on attempted vagina entry, tenderness to pressure localized to vagina and cervix.

the vulvar. Vestibule and physical finding limiting to minimal
degree of vulvar erythema.
Etiology: It occurs mostly in premenopausal women. The etiology
is not known. Sexual abuse history must be elicited whether this
pain is primary or recently developed. An element of depression
is seen because of the symptoms.
Management: Look for any treatable causes like inflammations
education, counseling and support are essential. Support of the
family, especially husband is essential for cure. Look for irritants,
e.g. tight panties, etc. and ask her to avoid them. The more mild
soaps must replace the currently used one. May try non- irritant
ointments during sexual activity (vegetable oils, etc.) she is asked
to apply 5% lignocaine ointment 20 minutes before sexual
intercourse. Pain or vulvo dynia may improve by itself by passage
of time without any definitive treatment (as the above measures).
This is seen more in younger patients. If nothing cures then
surgery may be resorted to; limited surgery is advised.
Vestibulectomy and advancement plasty is the operation of
choice, use of dilators and molds is started 6 weeks after operation
Fig. 50.7: Fibromyoma vulva
edema of vulva (Fig. 50.6).

372 Fig. 50.6: Edema of vulva Fig. 50.8: Lipoma vulva

 hyperkeratosis and most specifically nuclear atypia koilocytosis.
Treatment: 1. Local application of imiquimod on the warts
three times per week for 16 weeks rinse with soap and water
6–10 hours after application.
2. Local application of podophylline twice a way for 3 days
no treatment for 4 days repeat this cycle four times.
3. Trichloracetic acid locally can be applied. If it does not
cure, and the lesion is too big surgical excision is advised. On
urethral warts can apply 5 fluorouracil locally.

Paget’s Disease
It produces lesions that are white or red. However, eczematoid

Chapter 50
erythematous lesions are more common. The common
symptoms is pruritis. It is associated with malignancies of vulva
and in other sites such as breast colon. Biopsy is mandatory.
Treatment wide local excision. Recurrence is common.

BIBLIOGRAPHY
1. Alizai NK, Thomas DF, Lilford RJ, et al: Feminizing genitoplasty

Other Benign Conditions of Vulva

for congenital adrenal hyperplasia. What happens at puberty. J Urol
1999;161:1588.
2. Crouch NS, Criyhoton SM. Minimal surgical intervention in the
Fig. 50.9: Condyloma acuminatum management of intersex conditions. J Pediatr Endoerinol
2004;17(12):1591.
3. Neill SM. Vulvodynia. Ann Dermatol Venereol 2000; 107:1185.
Histology—tree like proliferation of stratified squmous 4. Traas MA, Rund L, Bekkers M, et al. Surgical treatment for vulvar
epithelium supported by fibrous stroma. Acanth—parakeratosis vestibulitis syndrome. Obst Gyn Survey 2006;2(4):199.

373
 51 Premalignancies and
Malignancies of the Vulva

Sudha Salhan, Payal Chaudhary

PREMALIGNANT CONDITIONS OF THE VULVA cut serpiginous edges. Vulval carcinoma may be associated in
The commonest is vulval intraepithelial neoplasia (VIN) by 1/3rd of the case. On histology examination the picture shows
International Society of Gynecology Pathologists Terminology. large secretory cells (Paget’s cells) which may be arranged in
It arises from the squamous part of the vulva. It is mostly (80%) groups or singly. The cell nuclei are hyperchromatic and
caused by human papilloma virus. HPV infection occurs in polymorphic. Cytoplasm is vaccolated and pale and contains
younger patients. Unifocal HPV negative lesions are seen in mucin. Periodic Acid Shiff (PAS) Strain brings out these details.
older women. Intra-epithelial Melanoma—It is very uncommon. A flat
Predisposing factors include other sexually transmitted lesion with irregular border is usually seen.
infections and smoking, etc. Diagnosis of premalignant condition is by keeping a great
It can be divided histologically into 3 groups depending in suspicious mind and doing a biopsy. Colposcopy may help in
the severity of involvement. The histological abnormalities seen pinpointing the area to be biopsied.
are: Treatment: Pretreatment counseling is essential for follow
• Increased mitotic activities up to detect recurrence and development of cancer early.
• Cellular immaturity Treatment is to be individualized. Depending on patient’s age,
• Nuclear abnormalities. nature and extend of the disease and sexual history. Local excision
It is mostly around introitus. But may spread further to the is needed in VIN but simple vulvectomy is advised in Paget’s
perineum and lower vagina. disease with wide excision till the fascia with 3–4 cm margin. In
VIN I. Shows: Mild dysplasia, lower third of epidermis shows non-hairy part of vulva destruction up to 1 mm to be done and
cytonuclear abnormalities. It is mostly asymptomatic. Red flat lesions in hairy part destruction up to 2 mm can be done. In unifocal
on gross examination are common. superficial lesion skinning vulvectomy in done in extensive lesion
VIN II. It is moderate dysplasia, lower two third of the and can give a skin graft in reproductive active women. CO2
epidermis show cyto-nuclear abnormalities. The lesions may laser treatment is not extensively studied. But if the lesion extends
be hypopigmented. to perineum and anal canals do not use laser. Local 5 - fluorouracil
VIN III. It is severe dysplasia. Whole thickness of the is not much effective.
epidermis show abnormalities. It is also called carcinoma in Follow-up—To start follow-up is done quarterly (3 months)
situ. The nucleus is bigger than in the normal cells. The cells for 2 years by cervical cytology and colposcopy of entire lower
are not orderly arranged. But the basement is intact. It was genital tract. The follow-up later on is to be yearly. In HIV cases
called Bowen’s disease when cells are large (Bowen’s cells) which the follow-up more frequently (6 monthly).
are degenerating.
VIN III can progress to invasive cancer of the vulva in 8–10 VULVAR MALIGNANCY
years. It may be associated with invasive cancer of cervix or vagina. Vulvar cancer is the fourth most common gynecologic cancer
(following cancer of the cervix, uterine corpus and ovary) and
Symptoms and Sign comprises 0.6–5% of malignancies of the female genital tract.
The main complaint is itching of the vulva. The vulva may be Although the rate of invasive vulvar carcinoma has remained
discolored at involved area and may feel thicker on palpation. stable over the past two decades, the incidence of in situ
Also look for immunodeficiency (HIV) in recurrent lesions. disease (vulvar intraepithelial neoplasia) has more than
Diagnosis is done by biopsy preferably colposcopically doubled.
directed.
Non-squamous intraepithelial neoplasia: The lesion is EPIDEMIOLOGY AND RISK FACTORS
moslty “multifocal Paget’s disease of the vulva” and melanoma Vulvar carcinoma is encountered most frequently in
in situ. postmenopausal women. The mean age at diagnosis is 65, but
Second premalignant condition of vulva is Paget’s disease. may be falling.
It is caused by atypical proliferation apocrine glands of the Risk factors for vulvar cancer are not completely understood
vulva. It is mostly seen in postmenopausal women. Twenty but include:
percent may have associated with Bartholin’s gland or sweat • Human papillomavirus (HPV) infection
gland malignancy. Local soreness with moist erythematous area • Cigarette smoking
(white or bright scarlet colored) and itching are the main • Vulvar dystrophy (e.g. lichen sclerosus)
complaints. It feels valvetty with unelevated growth with clear, • Vulvar or cervical intraepithelial neoplasia
• Immunodeficiency syndromes Thus, all vulvar and perianal skin surfaces, as well as the
• A prior history of cervical cancer cervix and vagina, should be evaluated. A synchronous second
• Northern European ancestry. malignancy, most commonly cervical neoplasia, is found in up
Vulvar carcinogenesis is thought to occur by two main to 22 percent of patients with a vulvar malignancy.
pathways, the first related to mucosal HPV infection and the
second related to chronic inflammatory (vulvar dystrophy) or DIAGNOSIS
autoimmune processes. HPV appears to be responsible for Biopsy of gross lesions for histologic evaluation must be
approximately 60 percent of vulvar cancers. Specifically, HPV performed to determine whether a preinvasive or invasive lesion
16 and 33 are the predominant subtypes accounting for 55.5 is present, and the depth and nature of stromal invasion. The
percent of all HPV-related vulvar cancers. biopsy should be taken from the area(s) of the lesion that
The increasing incidence of HPV-related vulvar appears most abnormal with adjacent normal area. If multiple
intraepithelial neoplasia among young women may account for abnormal areas are present, then multiple biopsies should be

Chapter 51
the fall in mean age of diagnosis of vulvar cancer. HPV DNA is taken to “map” all potential sites of vulvar pathology. Pathologic
found more commonly in vulvar cancers of young women who evaluation may not be possible for specimens taken from areas
smoke, as compared to older nonsmokers. Early detection and of extensive necrosis.
treatment of vulvar intraepithelial neoplasia may prevent the If a lesion is not grossly evident, but clinical suspicion is
development of cancer. Leukoplakia vulva itself is no longer high, colposcopic vulvar examination should be undertaken
considered a precancerous condition. A patient with past history using 5 percent acetic acid solution. The concentrated acetic
of cervical cancer needs special vigil because of common acid solution should be applied copiously with prolonged

Premalignancies and Malignancies of the Vulva

etiology (HPV-infection). contact to the keratinized vulvar squamous epithelium. This
allows the cells to fully dehydrate and will define acetowhite
CLINICAL MANIFESTATIONS lesions and their underlying vascular changes. Acetowhite areas
The signs and symptoms of all histological types of vulvar with abnormal vascular patterns should be biopsied.
malignancy are similar.
Differential Diagnosis
Symptoms Differential diagnosis includes:
• Pruritus is a most common complaint. It is especially 1. Tuberculosis of the vulva
prevalent when there is an underlying vulvar dystrophy 2. Epidermal inclusion cysts
(e.g. lichen sclerosus or squamous cell hyperplasia). Thus 3. Vitiligo
biopsy should be taken in patients with lichen sclerosus if 4. Disorders of Bartholin’s gland
there is a suspicious lesion or the lesions are refractory to 5. Seborrheic keratoses
topical therapy. 6. Hidradenomas
• Vulvar bleeding or discharge 7. Lichen sclerosus and other dermatoses
• Dysuria 8. Condyloma acuminata.
• An enlarged lymph node in the groin may be suggestive of If one of these disorders is initially suspected but does not
advanced disease. respond to appropriate treatment, biopsy should be performed.
• Many patients are asymptomatic at the time of diagnosis.
HISTOLOGIC TYPES
Signs Most vulvar cancers are squamous cell carcinomas; other
• A unifocal vulvar plaque—ulcer, or mass (fleshy, nodular, histologies include melanoma, Bartholin gland adenocarcinoma,
or warty) (Fig. 51.1) on the labia majora and less frequently sarcoma, Paget disease, or basal cell carcinoma.
the labia minora, perineum, clitoris, and mons may be
involved. Squamous Cell Carcinoma
• Lesions are multifocal in 5% of cases Over 90% of vulvar malignancies are squamous cell carcinomas.
• In 10% of cases, the lesion is too extensive to determine the There are two subtypes, both of which usually occur on the
actual site of origin. labia or vestibule:
• The keratinizing, differentiated, or simplex type
– More common
– Occurs in older women
– Is not related to HPV infection
– It is associated with vulvar dystrophies such as lichen
sclerosus and, in developing countries, chronic venereal
granulomatous disease.
• The classic, warty, or Bowenoid type
– is predominantly associated with HPV 16, 18, and 33
– younger women
– Risk factors associated with HPV infection include early
age at first intercourse, multiple sexual partners, human
immunodeficiency virus (HIV) infection, and cigarette
smoking. These women tend to present with early stage
disease.
Cervical cancer is also strongly linked to persistent HPV
infections. Moreover, there is evidence that some high grade
vulvar and vaginal intraepithelial neoplasia in a monoclonal
Fig. 51.1: Vulvar carcinoma lesion derived from high grade or malignant cervical disease. 375
 Verrucous Carcinoma of the Bartholin gland in a postmenopausal woman is worrisome
Verrucous carcinoma is a variant of squamous cell cancer that since benign inflammatory disease usually does not occur in
has distinctive features. Although cauliflower-like in this age group. The gland should be biopsied in older (over 40
appearance, it is differentiated from squamous cell carcinoma years of age) women with a mass in this location, even if the
with a verrucous configuration by biopsy of the lesion base, lesion appears cystic or like an abscess. Metastatic disease is
which shows papillary fronds without the central connective common in cancers of Bartholin gland because of the rich
tissue core typical of condylomata acuminata. The lesion grows vascular and lymphatic network in this area.
slowly and rarely metastasizes to lymph nodes, but it may be
locally destructive. Sarcoma
Soft tissue sarcomas (including leiomyosarcomas,
Melanoma rhabdomyosarcomas, liposarcomas, angiosarcomas,
Melanoma is the second most common histology, accounting neurofibrosarcomas, fibrous histiocytomas, and epithelioid
Diseases of Vulva

for approximately 5% of primary vulvar neoplasms and 3–7% sarcomas) constitute 1 to 2 percent of vulvar malignancies. The
of all melanomas in women. Melanoma of the vulva occurs prognosis is generally poor. As with soft tissue sarcomas located
predominantly in postmenopausal white non-hispanic women, elsewhere on the extremities and trunk, high-grade lesions that
at a median age of 68 years (range 10–99 years). In contrast, are larger than 5 cm in diameter, with infiltrating margins and
cutaneous melanomas presenting at other sites often develop a high mitotic rate are those most likely to recur.
before age 45. Vulvar melanoma is usually a pigmented lesion,
but amelanotic lesions also occur. Most arise de novo on the MODE OF SPREAD
clitoris or labia minora, but can also develop within pre-existing Vulvar carcinoma metastasizes by a variety of mechanisms.
junctional or compound nevi. Modes of spread include:
• Direct extension to adjacent structures (e.g. vagina, urethra,
Section 13

Basal Cell Carcinoma clitoris, anus).

Two percent of vulvar cancers are basal cell cancers. They • Lymphatic (Fig. 51.2) embolization to regional lymph nodes
usually affect postmenopausal Caucasian women and may be can occur early in the course of disease, even in patients
locally invasive, although usually nonmetastasizing. The typical with small lesions. The pathway for lymphatic drainage of
appearance is that of a “rodent” ulcer with rolled edges and the vulva, in most women, begins at the superficial inguinal
central ulceration; the lesion may be pigmented or pearly and nodes, followed by drainage to the deep inguinal and
gray. They are often asymptomatic, but pruritus, bleeding, or femoral lymph nodes below the cribriform fascia, and then
pain may occur. Basal cell carcinomas are associated with a high to the pelvic lymphatics. Lateral lesions spread to the
incidence of antecedent or concomitant malignancy elsewhere ipsilateral nodal group; central lesions may metastasize to
in the body. Thus, a thorough search for other primary ipsilateral, contralateral, or both groups of nodes.
malignancies should be performed. • Hematogenous dissemination, which typically occurs late in
the course of the disease, is rare in patients without
Extramammary Paget Disease inguinofemoral lymph node involvement.
Extramammary Paget disease, an intraepithelial
adenocarcinoma, accounts for less than 1 percent of all vulvar PRETREATMENT EVALUATION
malignancies. Most patients are in their 60s and 70s and Vulvar cancer is surgically staged (Table 51.1) based on pathologic
Caucasian. Pruritus is the most common symptom, present evaluation of a vulvar biopsy and inguinofemoral lymph nodes.
in 70% of patients. Vulvar Paget disease is similar in Prior to a complete staging procedure, however, a clinical
appearance to Paget disease of the breast. The lesion has an evaluation helps guide the surgical and medical approach (e.g.,
eczematoid appearance; it is well-demarcated and has slightly choice of surgical incision, use of neoadjuvant chemoradiation).
raised edges and a red background, often dotted with small, A complete pelvic and general physical examination is
pale islands. It is usually multifocal and may occur anywhere performed, with particular attention to measurement of the
on the vulva, mons, perineum/perianal area, or inner thigh. diameter of the primary tumor and palpation for inguinal,
Invasive adenocarcinomas may be present within or beneath axillary, or supraclavicular lymphadenopathy.
the surface lesion. Women with Paget disease of the vulva Always do cervical cytology and colposcopy of the cervix,
should also be evaluated for the possibility of synchronous vagina, and vulva because of the multifocal nature of squamous
neoplasms, as approximately 20–30% of these patients have a intraepithelial lesions in these areas. Screening for other cancers is
noncontiguous carcinoma (e.g. involving breast, rectum, performed according to age-appropriate guidelines. This is
bladder, urethra, cervix, or ovary). particularly important in women with vulvar cancers since some
of these patients have an increased frequency of synchronous
Bartholin Gland Adenocarcinoma epithelial neoplasms.
Although a rare malignancy, most primary adenocarcinomas For women with large tumors (i.e. more than
of the vulva occur in the Bartholin gland. This gland is composed 2 cm) or suspected metastases, an abdominal/pelvic computed
of columnar epithelium; ducts are lined by stratified squamous tomography (CT) may be performed to detect lympha-
epithelium which changes to transitional cell epithelium as the denopathy or other metatastases; additional radiographic and
terminal ducts are reached. Cancers arising in Bartholin gland endoscopic studies are performed, as appropriate.
are most often adenocarcinomas or squamous cell carcinomas, In addition, women should undergo evaluation of medical
but transitional cell carcinomas, adenosquamous, and adenoid status prior to surgery, chemotherapy, or radiation.
cystic carcinomas may also develop. Only the squamous cell
lesions are related to HPV infection. The median age at diagnosis Staging
of Bartholin gland cancer is 57 years. Bartholin gland tumors Staging and primary surgical treatment are typically performed
are usually solid and infiltrate deep into the vulva. Enlargement as a single procedure. Staging takes into account the most
376
 Chapter 51
Premalignancies and Malignancies of the Vulva
Fig. 51.2: Lymphatic drainage of vulval carcinoma

Table 51.1: Staging of vulvar carcinoma (Both International important factors related to prognosis: tumor size, depth of
Federation of Gynecologists and Oncologists - 2009)and TNM invasion, lymph node involvement, and presence of distant
metastases.
Stage TNM Clinical and Pathologic Findings
The International Federation of Gynecology and Obstetrics
I Tumor confined to the vulva (FIGO) 2009 uses a surgical-pathologic staging system for vulvar
IA T1a N0 M0 Lesion 2 cm in size, confined to the vulva cancer based upon findings from the biopsy of the vulvar
or perineum and with Stromal invasion 1.0 lesion(s) and the inguinofemoral lymph nodes. Surgical staging
mm. No nodal metastasis
is preferable because inguinofemoral lymph node status is the
IB T1b N0 M0 Lesion 2 mm in size with stromal invasion
most important predictor of overall prognosis (Salhan S, 2000).
1.0 mm, confined to vulva or perineum
with negative nodes Palpation of the groin is generally inadequate.
II T2–4 N0 M0 Tumor of any size with extension to
adjacent perineal structures (1/3 lower Surgical Alternatives to Radical Vulvectomy
urethra, 1/3 lower vagina, anus) with Historically, all patients with vulvar cancer were staged and
negative nodes treated with radical vulvectomy and en bloc inguinofemoral
III Tumor of any size with or without extension to adjacent lymph node dissection (LND), a procedure associated with high
perineal structures (1/3 lower urethra, 1/3rd lower vagina, rates of survival as well as morbidity. Current approaches
anus) with positive inguino-femoral lymph nodes
individualize treatment so that the most conservative procedure
IIIA T2–4 N1 M0 (i) With one lymph nodes metastasis ( 5
mm) or is used to optimize survival while minimizing perioperative
T2–4 N1 M0 (ii) 1–2 lymph node metastasis(es) morbidity and maximizing long-term psychosexual and
(<5 mm) physical well-being.
IIIB T2–4 N2 M0 (i) with 2 or more lymph nodes metastasis Standard radical vulvectomy consists of removal of
( 5 mm) or the entire vulva down to the level of the deep fascia of the
T2–4 N2–3 M0 (ii) 3 or more node metastasis (<5 mm) thigh, the periosteum of the pubis, and the inferior fascia of the
IIIC T2–4 N3 M0With positive nodes with extra capsular spread urogenital diaphragm. This was traditionally performed
IV Tumor invades other regional (2/3 upper urethra, 2/3rd
through a single incision which circumscribes the labia majora
upper vagina) or distinct structures
IVA T2–4 N2 M0Tumor invades any of the following
and extends to the groins bilaterally to include en bloc inguino-
(i) Upper urethra and/or vaginal mucosa, femoral LND (Butterfly Incision) (Fig. 51.3). Morbidity
bladder mucosa, rectal mucosa, or fixed associated with this procedure includes wound breakdown,
to pelvic bones or psychosexual effects from distortion of the vulva, and
T2–4 N3 M0 (ii) Fixed or ulcerated inguinofemoral lymphedema. Alternative surgical approaches that remove less
lymph nodes of the vulvar and surrounding skin are most commonly
IVB Tany N M1 Any distant metastasis including pelvic lymph nodes. performed (3-incision technique). However, the depth of the
The depth of the invasion is defined as the measurement of the tumor dissection is the same as in standard radical vulvectomy (from
from the epithelial stromal junction of the adjacent most superficial the skin to the urogenital diaphragm). For all types of vulvar
dermal papilla to the deepest point of invasion. excision, a tumor-free margin of at least a 1 cm appears to
T: Primary tumor; N: Regional lymph nodes; M: Distant metastases. decrease the risk of local recurrence.

377
 observational studies for Stage IB disease which meets all
the following requirements:
– Unifocal
– Lateral (>1 cm from the vulvar midline)
– Not located in the anterior portion of the labia minora
(defined anatomically as the area just posterior to the
clitoris) as this area may have contralateral lymph flow.
– No palpable lymphadenopathy in either groin
– No lymph node metastases found at the time of
unilateral LND
• Bilateral LND is performed for Stage II or greater disease
and for Stage IB disease which is central (<1 cm from the
Diseases of Vulva

vulvar midline) or if lymph node metastases are discovered

at unilateral LND. The rate of bilateral groin metastases in
Fig. 51.3: Butterfly (single) incision for radical vulvectomy women with lesions with unilateral lesions with stromal
invasion 3 mm is 2.8 percent or higher.
Radical Local Excision Superficial Versus Deep Lymphadenectomy
In women with stage I or II disease, radical local excision or Inclusion of deep LND is generally preferred.
radical partial vulvectomy (i.e. removal or part or all of the vulva
unilaterally, terminology also includes radical hemivulvectomy Sentinel Node (SLN) Biopsy
and modified radical vulvectomy) compared with radical Sentinel lymph node biopsy (SLNB) is under investigation as
vulvectomy in stage I disease appears to result in similar rates an alternative to inguinofemoral LND. Ideally, this approach
Section 13

of local recurrence though there are no randomized trials will incur less morbidity without compromising detection of
comparing radical local excision to radical vulvectomy. lymph node metastases or increasing the risk of groin
recurrence. There is little margin for error in choosing an
Three-incision Technique (Fig. 51.4)
alternative approach because groin recurrence in vulvar cancer
Radical vulvectomy is performed in women with stage III or is usually fatal.
IV disease by the three-incision technique. This technique allows According to the sentinel lymph node (SLN) hypothesis,
for radical excision of the primary lesion and bilateral groin tumor cells migrate from a primary tumor and colonize in one
node evaluation while retaining skin over the groin. This skin or a few lymph nodes (i.e. the SLN) before involving
bridge decreases risk of postoperative wound breakdown and other lymph nodes. Peritumoral injection of a dye or tracer
lower extremity lymphedema and improves cosmesis. permits identification of a SLN in most patients, and its status
Inguinofemoral Lymphadenectomy accurately predicts the status of the remaining regional nodes.
The concept of lymphatic mapping and SLNB was initially
Inguinofemoral lymph node dissection (LND) (i.e. removal of
developed for penile cancer and has been extensively studied
the superficial inguinal and deep femoral lymph nodes) is
in melanoma and breast cancers. The first area to receive
performed for all stages of disease except stage IA. Pelvic LND
lymphatic drainage from a lateral vulvar lesion is usually the
(i.e. removal of the obturator and iliac nodes) is not required ipsilateral superficial inguinal nodes. At least in theory, if the
for staging. SLN shows no evidence of metastatic involvement, then all other
Morbidity rates are high after inguinofemoral LND, nodes should be negative, rendering complete nodal dissection
including wound infection and breakdown (20–40%) and lower unnecessary.
extremity lymphedema (30–70%). The best candidates for intraoperative lymphatic mapping
Unilateral Versus Bilateral Lymphadenectomy are women with uninfected tumors limited to the lateral vulva,
The choice of approach for LND depends on the size and with no palpable enlarged groin nodes and no history of vulvar
location of the lesion: surgery that could disrupt lymphatic drainage.
• LND is optional for Stage IA disease. Bilateral groin involvement is common in patients with
• Unilateral LND was associated with a <1 percent risk of midline vulvar cancers, even if drainage to the contralateral groin
contralateral groin node metastases in multiple is not observed on lymphoscintigraphy. SLNs should be detected
bilaterally when the lesion is midline; if a SLN is not found on
each side, then a full inguinofemoral LND is required on the side
without the SLN.
Intraoperative lymphatic mapping of SLN is performed
using either of two general methods: peritumoral injection of
isosulfan blue dye or preoperative lymphoscintigraphy using
radiolabeled colloid followed by node detection with an intrao-
perative gamma-detecting probe. Use of a combination of blue
dye and radiolabeled colloid is preferred so as to yield more
accurate results than either test alone.

TREATMENT OF VULVAR SQUAMOUS CELL CANCER

Radical wide excision and selective inguinal LND characterize
the main approach to patients with early stage disease.
Chemoradiation is an alternative to radical vulvectomy with
378 Fig. 51.4: Three incision for radical vulvectomy en bloc inguinofemoral LND for advanced disease.
Early Stage Disease those with stage IVA disease, positive or close margins, and a
Stage I large number of groin nodes).
Stage I disease is subdivided according to depth of stromal Adjuvant RT for Node Positive Patients
invasion; TIB. Patients with stage IA disease have a low risk of Ipsilateral groin and pelvic irradiation are recommended when
groin recurrence and very low rates of groin node metastases, there are two or more microscopically positive groin nodes,
therefore, it is reasonable to omit groin treatment for these one or more macroscopically involved lymph nodes, any
patients. evidence of extracapsular spread, or if only a small number of
• Stage IA—Radical local excision without LND is the lymph nodes were sampled.
treatment of choice in patients with less than 1 mm of Toxicity associated with groin irradiation includes wound
stromal invasion, since inguinofemoral lymph node breakdown, infection, lymphocyst formation, lymphedema,
metastases are rare (<1 percent). and long-term risk of femoral fracture or need for hip

Chapter 51
• Stage IB—For lesions with 31 mm of stromal invasion, the replacement.
risk of inguinofemoral lymph node metastases is 38%. Thus,
all patients with stage IB disease should undergo radical Chemoradiation for Locally Advanced Disease
local excision with inguinofemoral LND. The choice of The success of chemoradiation in the treatment of squamous
unilateral or bilateral LND depends upon the location of cell carcinoma of the anus and cervix inspired adoption of this
the lesion. approach in vulvar carcinoma. Similar chemotherapy regimens,
Stage II mainly infusional 5-FU combined with either Cisplatin or
Mitomycin C, have been employed but there have been no

Premalignancies and Malignancies of the Vulva

For women with stage II disease, the most conservative excision
randomized trials. There is considerable toxicity associated with
technique is used that results in a 1 cm tumor-free margin.
chemoradiation, including skin toxicity (in nearly all patients),
Depending upon the size and location of the lesion, this may
wound breakdown, infection, lymphedema, lymphorrhea,
necessitate radical local excision, partial radical vulvectomy, or
lymphoceles, and death.
the three-incision technique.
• Surgical resection is preferable to chemoradiation for patients
Primary Radiotherapy (RT) with disease that can be managed with radical vulvectomy
Primary radiation therapy (RT) is generally avoided for and bilateral groin node dissection.
management of early stage vulvar cancers because of associated • In patients with extensive primary lesions that would
morbidity. require pelvic exenteration, the complications of
In stage I or II disease, surgery rather than radiation therapy neoadjuvant chemoradiotherapy might outweigh the
(RT) is the preferred mode of therapy for management of the complications of surgery alone.
groin nodes unless the patient is not fit enough to tolerate • Patients with inoperable primary tumors or lymph nodes
surgery. benefit from chemoradiation if a salvage operation can be
performed.
Positive Margins
Chemoradiation is generally accepted as a feasible alternative
There is some evidence for benefit with RT in patients with to radical surgery in selected patients with locally advanced
positive or close (<8 mm) margins after surgery. Re-excision vulvar cancer. If surgery can be performed, we tend to proceed
should be considered for positive or very close margins to avoid with radical resection rather than chemoradiation. However, we
the toxicity associated with RT. offer chemoradiation to:
Adjuvant RT for Node Negative Patients • Patients with anorectal or bladder involvement in an effort
Though, it appears reasonable to consider adjuvant RT to to avoid colostomy and urostomy
patients with high-risk primary tumors with negative nodes. • Patients with disease that is fixed to the bone
There have been few studies addressing the role of adjuvant If residual disease remains, following chemoradiation, then
RT to reduce local or groin recurrence in early stage or node local resection is indicated. For those patients with no gross
negative vulvar cancer. disease and an apparent complete response to chemoradiation,
the need for surgery is unclear.
Advanced Disease: Stage III and IV Intensity-modulated radiation therapy (IMRT) reduces the
Treatment for women with stage III and IV disease is dose to normal tissue and conforms radiation to the target,
individualized depending upon the size and location of the thereby offering the potential for reducing the risk of treatment-
lesion and the lymph node status. related toxicity while maintaining tumor control.
Primary Surgical Resection Palliative Chemotherapy
Women with T1–2 tumors are generally treated with conservative There has been little study of palliative chemotherapy for stage
primary resection, similar to early stage disease. IVB metastatic disease or frail, inoperable patients. Single agents,
Surgical management of extensive T3–T4 disease (tumor such as adriamycin, methotrexate, mitomycin C, bleomycin,
spread to the urethra, anus, bladder, rectum, or pelvic bone) cisplatin, or paclitaxel have shown minimal response of short
requires standard radical vulvectomy with en bloc bilateral duration. Local symptom control with surgery, RT, or
inguinofemoral LND with partial removal of any involved chemotherapy can be entertained.
structures or pelvic exenteration; depending on the extent of Novel agents such as anti-EGFR tyrosine kinase inhibitors,
the resection, colostomy or urethral diversion may be necessary. erlotinib have shown promising results in small series.
Lymphadenectomy may not be possible when nodes are fixed
to the femoral vessels or other vital structures. Rotational skin PROGNOSIS
graft was successfully applied in one such case. 1. The presence of inguinofemoral node metastases is the most
It is suggested that postoperative RT to the vulva be important prognostic factor for survival in patients with
administered for patients with high-risk of local recurrence (i.e. vulvar cancer. Reported five-year survival ranges from 379
 70–93% for patients with negative nodes to 25–41% for those depth of invasion and lymphovascular involvement are poor
with positive nodes. Other prognostic factors include. prognostic markers.
2. Stage (which encompasses size and depth of invasion). The roles of RT and chemotherapy (topical and systemic) in
3. Capillary lymphatic space invasion. the treatment of Paget disease of the vulva are not well-defined,
4. Older age. but may be an option for some patients.
Long-term follow-up is indicated because of the high-risk
Follow-up of recurrence and the increased risk of noncontiguous
After receiving primary treatment, follow up should be done carcinoma. Paget disease is associated with underlying invasive
at least twice yearly for five years with visual inspection and adenocarcinomas 4–17% of the time and another 20–30% of
palpation of the vulva, skin bridge, and inguinal nodes. Vulvar patients will have or will develop an adenocarcinoma at another
colposcopy and biopsy are indicated, if abnormalities are nonvulvar location. The vulva should be inspected annually
noted. with a low threshold for biopsy. Screening and surveillance for
Diseases of Vulva

It has been seen that the majority of relapses occur in the tumors at other sites (breast, lung, colorectum, gastric, pancreas,
first year. and ovary) should be considered.
Sexual dysfunction and alterations in body image are
common aftereffects and should be addressed during follow- Bartholin Gland Adenocarcinoma
up visits. The traditional approach to therapy is radical vulvectomy with
bilateral groin and pelvic LND. Less radical excisions, such as
Recurrent Disease radical local excision or partial vulvectomy with ipsilateral
Treatment recommendations for patients with recurrent vulvar inguinal LND, also appear to be effective. The lesions are
cancer take into account patient performance status, prior typically deep within the vulva so extensive deep dissection is
treatment modalities received, and sites of recurrence. generally required.
Section 13

• Vulvar cancer recurrences are classified as local, inguinal, Surgical margins are frequently microscopically positive
or distant. and require postoperative RT to reduce the incidence of local
• Local perineal recurrences can often be treated successfully recurrence. If ipsilateral groin nodes are involved, pelvic and
by re-excision whereas inguinal recurrences have been bilateral groin radiation may decrease the frequency of regional
associated with a much worse prognosis. recurrence. Primary chemoradiotherapy or brachytherapy are
• RT may be added to surgery or chemotherapy, or used as a therapeutic options that may allow sparing of rectal function
sole modality in patients with recurrent vulvar cancer. or obviate the need for surgery entirely in women with primary
• Salvage chemotherapy can be considered for patients with carcinoma of the Bartholin gland.
distant metastases.
Verrucous Carcinoma
TREATMENT OF OTHER HISTOLOGIES Radical local excision is usually adequate, as verrucous
Vulvar Melanoma Carcinoma carcinoma in locally invasive but rarely metastasizes. Suspicious
lym0ph nodes should be biopsied; if positive, then
Radical vulvectomy followed by radiotherapy is the treatment
inguinofemoral LND is indicated. RT is contraindicated because
depending upon the stage of the tumor.
it can induce anaplastic transformation and increase the
Basal Cell Carcinoma likelihood of metastases. Recurrences are treated surgically.
Basal cell carcinomas are locally aggressive but rarely BIBLIOGRAPHY
metastasize. Therefore, radical local excision without LND is
1. Baltzer J. Daignostic and therapeutic dilemas in vulvar carcinoma.
adequate. Eir J Gynecol onchol 2004;25(4):405.
Sarcoma of the Vulva 2. Beller U, Mainsonnenve P, Benedet JL, et al. Carcinoma of the vulva.
Int J Gynecol Obstet Gynecol 2003;83:17-26.
Wide local excision is the standard approach to treatment of 3. FIGO Committee of Gynaecologic Oncology, Revised FIGO Staging
most vulvar sarcomas. Lymphatic metastases are uncommon. for carcinoma of the vulva, cervix and endometrium. International
J Gynecol Obstet 2009;105:103.
Paget Disease of the Vulva
4. Salhan S. Clinicopathological profile of carcinoma of the valva. Eur
Treatment consists of wide local excision or vulvectomy, J Gynecol Onchol 2000;2(25):205-08.
depending upon the extent of disease. Radical excision in not 5. Tyring SK. Vulvar squamous cell carcinoma: Guidelines for early
required, but a 2 cm tumor-free margin is preferred. Greater diagnosis and treatment. Am J Obstet Gynecol 2003;189(3):317-23.

380
 Section 14 MTP and Contraception

52 The Medical Termination of

Pregnancy (MTP) and Safe Abortion

Sudha Salhan, Sangeeta Kaul

To reduce maternal morbidity arising due to illegal abortions Place: No termination of pregnancy shall be made in accordance
the Indian Parliament liberalized the pre-existing abortion law with this Act at the place other than constitute a place where
in 1971. The Medical Termination of Pregnancy Bill was passed pregnancy may be terminated by this Act is (section 4)
by both the Houses of Parliament and assent of the President a. A hospital established by government, or
of India was taken on 10 August 1971. It came on the statute b. A place for the time being approved for the purpose of this
Book as The Medical Termination of Pregnancy Act 1 1. In Act by government or a District level committee constituted
2002, Indian Government added rules and regulations they are by the government with the Chief Medical Officer or District
called The Medical Termination of Pregnancy (Amendment) Health Officer as the chairperson of the said committee.
Act 2002 (64 of 2002) and the delegated legislation provisions Punishment: Whoever terminates any pregnancy in a place
(Amendment Act) 2004 (94 of 2005). This act is extended to the other than that mentioned in section 4, shall be punishable
whole Indian except the state of ammu and Kashmir. with rigorous imprisonment for a term 2 years.
The MTP act is defined under: Any person being owner of a place which is not approved under
• Definitions 4(b) shall be punishable with rigorous imprisonment for a term
• Clauses up to three years.
• Place Owner in relation to place means any person who is
• Person administrative head or otherwise and responsible for the
• Consent and Counseling working or maintenance of a place where the pregnancy is
• Forms. terminated under this Act.
Definitions: Abortion means medical termination of pregnancy. Approval of a place: After the application in form (A) by
Guardian is a person having the care of a person below 16 the owner, inspection by the Chief Medical Officer of the District
years of age or a person who is incapable of giving consent due is done. The facts are verified by the MTP committee and
to mental illness or mental retardation. recognition is given in Form B. Cancellation or suspension of
Medical termination of pregnancy means a medical certificate of the facilities specified in Rule 4 are not being
procedure to terminate a pregnancy in accordance with this properly maintained and MTP at such place cannot be made
Act. Methods of abortion shall mean either medical methods of safe and hygienic condition. The owner can do the corrective
abortion (through the use of medication) or surgical abortion’ measure and apply for fresh certificate of approval within a
means termination of pregnancy through surgical procedures. period of sixty days from the date of such order.

Legal clauses where MTP can be done are: REQUIREMENT OF THE PLACE (MTP RULES 2003)
1. Where the continuation of pregnancy would involve a risk
For first trimester under (b) (up to 12 weeks of pregnancy) the
to the life of the pregnant woman or of grave injury to her
place must have
physical or mental health or Pregnancy caused by rape is
1. A gynecology examination /labor table
terminated on humanitarian causes.
2. Resuscitation equipment
2. There is a substantial risk that if the child were born it would
3. Equipment for sterilization of instruments
suffer from severe physical or mental abnormalities.
4. Drugs and parental fluid
3. Failure of any contraceptive device or method used by any
5. Back up facilities for treatment of shock
woman or her partner. The anguish caused by such
6. Facilities for transport.
pregnancy may be presumed to constitute a grave injury to
the mental health of the pregnant woman. Account may be In case of termination of early pregnancy up to 7 weeks using
taken of the pregnant women’s actual or reasonable mifepristone (RU-486) and misoprostol (medical abortion)
foreseeable environment. service provider the registered medical practitioner (RMP) must
Prenatal determination of sex shall not constitute an have access to a place approved under section 4 of the MTP
indication for seeking medical termination of any under this Act, 1971 and read with MTP (Amendment)Act, 2002 and rule
act. 5 of the MTP rules. For this purpose of access the service
MTP can be done up to 20 weeks of pregnancy only. The provider should display a certificate to this effect from the
opinion formed in good faith by one registered medical owner of the approved place where the patient can be transfered
practitioner where the length of the pregnancy does not in case of emergency.
exceed twelve weeks. Not less than two registered medical In case of second trimester (i.e. 13–20 weeks) of pregnancy
practitioner’s option is required if pregnancy exceeds twelve 1. An operation table and instruments for performing
weeks but does not exceed twenty weeks needs MTP. abdominal or gynecological surgery.
 2. Anesthetic equipment, resuscitation equipment and Form I—Every registered medical practitioner who
sterilization equipment. terminates any pregnancy shall within 3 hrs certify the
3. Drugs and parental fluid for emergency use, notified by termination in Form 1 giving name, qualification and address
the government of India from time to time. of the service provider by whom the pregnancy was terminated
Person: A registered service provider with one or and the date and place of the MTP is given with the signature.
more of the following experience or training in gynecology and Form II is a monthly statement sent by head of the hospital/
obstetrics. owner of the approved place to the chief medical officer of the state.
a. In case of a medical practitioner, who was registered in a Form III—Every head of the hospital or owner of the
State Medical Registrar immediately before the approved place shall maintain a register in form III for recording
commencement of the Act, experience in the practice of details of the admission of women for the termination of their
gynecology and obstetrics for a period of not less than 3 years. pregnancies and keep such register for a period of years for
b. In the case of medical practitioner, who is registered in a the end of the calendar year it relates to. Start a new register at
MTP and Contraception

State Medical Register after the commencement of the Act. the commencement of each calendar year. The serial number of
i. If he/she has completed six months of house surgery in each year must be specified like 6/ 2003, 6/ 2004. The admission
gynecology and obstetrics; or register is kept as a secret document and the name and other
ii. Unless he had experience in any period of not less than particulars of the pregnant woman shall not be disclosed to
one year in the practice of obstetric and gynecology: any person.
c. If he/she has assisted a registered medical practitioner in
the performance of twenty five cases of MTP of which at Keeping Record
least 5 have been performed independently in a hospital or An admission register is to be maintained under the following
institute approved for training by the Government. 14 headings:
d. A registered practitioner who held a postgraduate degree 1. S.No.
or diploma in gynecology and obstetrics. (Only with MD/ 2. Date of admission
MS or DGO degree) MTP from 12–20 weeks is permissible. 3. Name of the patient
No suit or other legal proceeding shall lie against any doctor of 4. Wife/daughter of
Section 14

the above category or any damage caused or likely to be caused 5. Age

by anything, which is in good faith done, intended to be done, 6. Religion
under this Act. 7. Address
Punishment: The termination of pregnancy by a person who 8. Duration of pregnancy
is not a registered medical practitioner under this Act, shall be 9. Reason on which pregnancy is terminated
an offence punishable with rigorous imprisonment for a term 10. Date of termination of pregnancy
which shall not be less than two years but which may extend to 11. Date of discharge of patient
seven years. 12. Results and remarks
Trainings are organized by state health authority in 13. Name of Registered Medical Practitioner (s) by whom the
recognized hospitals, and a certificate of training is issued after opionion is formed
completion of the trainings. 14. Name of Registered Medical Practitioner (s) by whom
Under MTP regulation 2003 the recognized medical pregnancy is terminated.
practitioner who terminates the pregnancy, has to give The content of this register is kept secret it is to be destroyed on
information of the number of MTP performed. It to the the expiry of five years from the date of the last entry in the
appropriate authority (e.g. CMO incharge of the state) but he/ Register.
she is prohibited to disclose the information and the personal
details of the patient unless specific in the regulation. SAFE ABORTION
Consent: No pregnancy shall be terminated except with the Unwanted pregnancies are the main reason behind medical
written consent of the pregnant woman. But in cases of termination of pregnancy. Sometimes, even when induced
pregnancy before the age of sixteen years or pregnancy in abortions are legal, services may be insufficient to meet the
mentally ill person require the consent in writing of her demand or are inadequately distributed. Alternatively, women
guardian. The consent is given in Form C. may be unaware of their availability.
Similarly, when contraception is unavailable or inaccessible
Preabortion Counseling there will inevitably be a large number of unwanted
• Privacy and confidentiality is to be maintained pregnancies. Furthermore, even if services are available and
• Develop a rapport with the patient accessible, a proportion of unwanted pregnancies do arise as a
• Make her sit comfortably result of contraceptive failure.
• Identify the reason for termination When abortion is performed by qualified persons with the
• Discuss complications correct technique under hygienic condition it is a very safe
• Help her choose appropriate methods of termination. For operation. It involves minimum risk (e.g. the death rate for
example, in the first trimester abortion she can opt for abortions in the USA is 0.6 per 100,000 procedures, making it
medical or surgical methods as safe as an injection of penicillin). According to WHO safe
• Give advise for contraception. abortion is defined as abortion provided through approved
Forms: An application for the approval of the place for MTP facilities and/or persons . In India, when the MTP Act was passed,
is done in Form A. The approval certificate is given in Form B. it was assumed that unsafe abortions would disappear and so
This approval is to be displaced prominently in the place where the morbidity (14 of total MMR) and mortality associated with
MTP is done for everyone to see Form C is for consent. Under unsafe abortion would be prevented but statistics from our
MTP regulation 2003 the following formes are filled. country are very disturbing in the case of abortions.
All details including identity of the person undergoing MTP • Nearly 15 millions abortions are estimated to be taking place
382 are kept secret. Privacy is to be maintained. in our country every year.
• Of these, nearly 10 million women risk their lives by 6. Examination of cardiovascular respiratory and other systems
approaching quacks or untrained abortion providers. 7. ounseling: Counseling by the doctor or a compassionate
• 15,000–20,000 women die from complications arising out counselor is invaluable. The patient should be told about
of illegal abortion each year. the procedure, its common complications, how to suspect
There may be 10–11 illegal abortions for each legal one. For them and when she suspects them to report to the doctor.
safer abortions selection of cases is very important. Induced The patient should also be warned that the procedure can
abortions should be classified as low-risk and high-risk fail, it can remain incomplete and can have late reproductive
abortions. repercussions (e.g. in primigravida there is a risk of infection
Low risk: MTPs can be performed by trained MBBS doctors. introduced into the genital tract due to the procedure
Low risk abortions include MTP to be performed on– leading to infertility). The maternal mortality and morbidity
1. Normal healthy multigravida women depends on the period of gestation. It is the least between
7–8 weeks of gestation. It rises by 15–30 for each week.

Chapter 51
2. Pregnancy up to 8 weeks
3. Without any uterine scar, anomaly, or tumor Complications of late abortions are 10 times higher than
(All these criteria should be fulfilled). early pregnancy. She should be informed that repeated
MTPs for unwanted pregnancy is dangerous. MTP is not a
High-risk abortions should be performed on women in tertiary birth control mesure at all. It results in morbidity and
health facility hospital under supervision of consultants. An mortality. Birth control measures are far safer. She should
abortion is considered high risk if the following risk factors are receive information about various methods of contraception
present suggesting that more expertise is needed to deal with and must be made to understand the importance of using
these cases.

Premalignancies and Malignancies of the Vulva

the one that suits her best, as soon as possible.
1. Adolescent girls Many adolescents have a very tight 8. After counseling: ta e written consent
internal os. An incomplete abortion 9. Selection of method: According to the period of gestation the
may result or a cervical tear may method of MTP is individualized. For example suction
develop. evacuation is not advisable in a pregnancy of or below 6
2. Previous Previous uterine scar, previous wks as it may miss the gestational sac. Up to 45 days of
obstetrics MRP amenorrhea MR or medical methods can be used. Up to 8
History weeks of gestation a trained MBBS doctor can use Manual
3. Genital Bicornuate uterus, septate Vacuum Aspiration (MVA).
malformation uterus, extreme flexion of uterus. 10. Signature of the Medical Officer must also be put and the
4. Uterine fibroids They may distort the uterine cavity valid indication written.
5. Medical diseases Severe anemia, heart disease, genital 11. Inj toxoid 0.5 ml I/M is given if not previously immunized
infection and other complicated against tetanus.
medical diseases
Second trimester abortions cannot be totally avoided because
6. Physical When the patient cannot be
of the following reasons:
handicap made to lie in a lithotomy position
1. Teenagers, unmarried women, widows delay in seeking
7. Late abortion Between 9 and 20 weeks of gestation
help. Proper counseling and education may encourage them
8. Primigravida Cervix will not be favorable.
to seek early help.
But all high-risk factors may not be detected in advance. 2. Late detection of fetal anomalies
Uterine anomalies may not be diagnosed till the procedure is 3. Intrauterine fetal death
performed or even later. However, many of these high risk 4. Women staying far away from abortion services.
factors may need ultrasound facilities and special instruments
and techniques. PRECAUTIONS
Proper preoperative checkup, operative competence and It is emphasized that morbidity, immediate and remote will be
follow-up are essential for prevention of complications. kept to a minimum if:
1. ervix is adequately dilated without trauma before attempting
PREOPERATIVE WORK-UP to remove the fetus and gestational tissue. In late first
This includes the following: trimester abortion, sometimes if the cervix is firm and
1. Diagnosis and assessment of the case: All cases must be difficulty in dilatation is anticipated, as in primigravida,
diagnosed and assessed individually. Diagnosis of hygroscopic dilators are used to minimize trauma to cervix.
intrauterine pregnancy is essential. Improper diagnosis can Usually after 4–6 hours or overnight, the laminaria will
miss an ectopic pregnancy, which may lead to maternal have swollen and thereby would have dilated the cervix
morbidity and mortality. Therefore, an MTP should not be sufficiently to allow easier mechanical dilatation. The same
performed without a proper diagnosis. effects can be achieved by the prior use of cervical softener
2. terine size: Must know exact uterine size. Prostaglandin (common is mesoprostones).
3. ule out local infection If bacteria vaginosis is found the 2. emoval of the pregnancy is accomplished without perforation of
woman should be treated with metronidazole to reduce the the uterus. Perforation of uterus depends on the skill of the
rate of postoperative infection. Vaginal application of 2 surgeon and position of the uterus. Hence per vaginal
clindamycin cream for 3 days or cotrimazole pessary for examination before commencing the procedure is a must.
3–6 days reduces postabortion pelvic infection four-fold Retroverted uterus perforates more often. Uterine
compared with placebo. perforation only occurs when any instrument is introduced
4. emoglobin urine routine and microscopic examination are to into the uterus. It rarely occurs on the down stroke of the
be done before. curette. Manipulation should be carried out with the thumb
5. Blood group: Treatment of D-negative woman after abortion and forefingers only.
with anti-D immunoglobulin is recommended because 5 The frequency of occurrence of uterine perforation is
of D-negative women become sensitized after an abortion. 0.1–0.28 . If it occurs or is suspected, keep the patient under 383
 observation for 24 hours in case of strong suspicion. If actual Vaginally/sublingually/orally 48 hours later. Patient is given a
diagnosis of injury to the gut or omentum is made or if home prescription. Ultrasound is performed at the end to
hemorrhage is seen—perform a laparotomy immediately. confirm complete abortion. Complete abortion rates of 90 to
3. All pregnancy tissue is removed. Both MR and MVA should 95 are reported with this method. If mifepristone 600 mg alone
be assessed for completeness. It is recommended that the is used for medical abortion a complete abortion rates of 60-
syringe contents are placed in a clear plastic container and 80 are achieved.
examined with back lighting. The product is put in a strainer Contraindications: Confirmed or suspected ectopic pregnancy,
or gauze piece. intrauterine device in situ, chronic systemic corticosteroid
Tap water is used to wash the tissue held in a strainer. administration, adrenal failure, known coagulaopathy, allergy
The tissue is immersed in clear water. Placenta is to mifepristone inherited porphyria, severe asthmatic patients.
macroscopically soft and fluffy, feathery and villous.
A magnifying lens or colposcope provides visualization. Side Effects: Nausea, vomiting, abnorminal pain, chills,
MTP and Contraception

If there is doubt microscopic examination will show excessive vaginal bleeding, incomplete abortion, shivering and
placental villi. Retained products may encourage infection fever. Mobious syndrome and limb defects have occurred in
and hemorrhage. infants of women who have taken misoprostol during the first
4. Inj ethergin is given after the completion of the procedure. trimester and continued the pregnancy.

FOLLOW-UP Methotrexate with Misoprostol

echanism of action Methotrexate blocks dihydrofolate
We advise
reductase, an enzyme involved in producing thymidine during
1. Abstinence for 2 weeks
deoxyribonucleic acid synthesis. It acts primarily on
2. Follow up after 2 weeks or earlier, if
cytotrophoblast. It stops the process of implantation rather than
• Acute pain in lower abdomen
weakening the implantation site.
• Rise in temperature
• Persistent pain for more than 7 days Procedure: In pregnancy up to nine weeks, oral methotrexate
• Heavy/persistent fresh bleeding (50 mg) or intramuscular methotrexate (75 mg) followed by
Section 14

• Persistent pregnancy symptoms. mesoprostol (800 mcg) intravaginally achieves abortion rate of
90–90 .
HOW TO MAKE INDUCED ABORTIONS SAFE?
Prevention Prevention of unwanted pregnancies is the best Misoprostol
prophylaxis for unsafe abortions. Therefore, there is a need to Misoprostol alone for abortion in pregnancy up to nine weeks
promote safe and effective methods of contraception. has complete abortion rate of 88–90 but has unacceptable rates
Unprotected intercourse or contraceptive accidents do occur of side effects, e.g. nausea, vomiting severe abdominal pain.
all over the world. The prevention of unwanted pregnancies
Surgical Methods of Termination of Pregnancy
must always be given the highest priority and all attempts
should be made to eliminate the need for abortion. There is an Ist trimester (up to 12 weeks)
urgent need to promote emergency contraception in the country. 1. Manual vacuum aspiration
The judicious use of emergency contraception may reduce the 2. Electrical vacuum aspiration
need for abortion in many cases and thus reduce impairment 3. Dilatation and evacuation.
of reproductive health in women. Women who wish to terminate Anesthesia
their pregnancies should have ready access to reliable
Local anesthesia (paracervical block)
information, compassionate counseling and in parallel, services
eneral anesthesia
for the prevention of unwanted pregnancy and management
• Conventional with controlled ventilation (ETT/LMA)
of complications.
• Total intravenous anesthesia
METHODS OF MEDICAL TERMINATION • Monitored anesthesia care.
OF PREGNANCY
MANUAL VACUUM ASPIRATION (MVA)
Medical abortion refers to early pregnancy termination using
medication without primary surgical intervention. It is useful Introduction
when a patient desires to avoid a surgical procedure. Manual Vacuum Aspiration (MVA) is one of the surgical
First Trimester (up to 12 weeks). methods of vacuum aspiration of the uterine contents through
a plastic cannula attached to a vacuum source. In this method
Mifepristone with Prostaglandin Analogues the vacuum is created by using a hand activated aspirator. MVA
is a modification of the earlier used Menstrual Regulation (MR)
echanism of action Mifepristone has antiprogesterone action.
method. The mechanism of action of MVA is that the vacuum
It causes decidual breakdown by blockade of uterine
extracts the entire contents of the uterus without damaging the
progesterone recepotors and leads to detachment of blastocyst
lining of the uterus. The tissue separation of the uterine contents
which decreases hCG production. This causes a decrease in
occurs at a natural plane of cleavage. As the tissue separates
progesterone secretion from corpus luteum which further
easily vacuum aspiration generally avoids damaging the basalis
accentuates decidual breakdown. It also causes cervical
and muscularis layers of the endometrium.
softening and expulsion of detached blastocyst. Mesoprostol is
i. Uses of MVA: The Manual Vacuum Aspiration method has
given 48 hours after to expel the products of conception.
the following main uses:
Procedure: It is an out-patient procedure. In pregnancy up to 9 • Termination of early pregnancy
weeks mifepristone 200 mg–600 mg is given orally followed by • Postabortion care
misoprostol 400–800 mcg. – Inevitable abortion
384
 – Incomplete abortion • Adopter
– Infected/Septic abortion • O-ring
– Missed abortion • Silicone for lubricating the O-ring
– Anembryonic pregnancy • Flexible cannulae.
– Hydatidiform mole 1. MVA syringe: This is a 60 cc syringe made of high density
– Retained placental products polypropylene, with a capacity to hold a vacuum of 26
– Failed medical abortion inches of Hg (equivalent to the electric vacuum aspiration
• Endometrial biopsy. method.) The syringe consists of a barrel with calibrations.
The syringe serves as the source of vacuum to pull the
ii. Advantages of MVA:
contents of the uterus through the cannula into the barrel
1. It is a simple and portable technique for safe and
of the syringe.
effective termination of early pregnancy 2. Locking valves: The syringe is equipped with locking valve

Chapter 51
2. It can be performed without anesthesia in case of very system, which can have double locking system (Double
early pregnancy termination. valve syringe) or single locking valve system (Single valve
3. It is an out-patient procedure syringe) along with the valve liner. The locking system fits
4. It is one of the safe and effective methods of termi-nation into the tip of the barrel of the syringe.
of pregnancy up to 10 weeks of gestation. 3. Plunger: The plunger has handle with arms that snap out
5. The complication rates with this procedure are very low. when the plunger is pulled back. The plunger has a circular
6. It is easy to inspect the aspirate for products of conception slot on the bush for the O-ring.
as the tissue remains more or less intact.

Premalignancies and Malignancies of the Vulva

4. Collar stud: The collar stop holds and locks the plunger
7. It is not dependant on availability of electricity. inside the syringe when fully pulled back out of the barrel.
iii. Disadvantages of MVA: 5. Adopter: The adopters help to connect the cannula to the
1. The MVA instrument has a number of parts which can barrel. The adopters are color coded according to the size
get spoiled easily if they are not maintained properly. of the cannulae.
2. In cases of termination of pregnancies beyond 10–12 weeks, 6. O-ring: The O-ring is placed in the circular slot of the
there are chances of incomplete evacuation. plunger bush. The O-ring helps in creating an effective
vacuum which is sustained for a longer time.
iv. Contraindications for MVA use:
7. Silicone for lubricating the O-ring: The silicone is used
1. History of bleeding disorder
for lubricating the syringe and this helps in proper creation
2. Suspicion of prior uterine perforation
of vacuum.
3. Severe anemia
8. Flexible cannulae: Flexible plastic (Karman’s) cannulae are
4. Hemodynamic instability due to cardiac disease,
attached to the barrel. They are made of high quality state
hemorrhage or septic shock.
of art latex free material. The single valve syringe can
5. Uterine fibroid
accomodate cannulae of three sizes: 4 mm, 5 mm and 6 mm.
6. Any prior surgery in which the uterine cavity has been
The double valve syringe has the advantage of
entered.
accommodating cannulae of different sizes 4–12 mms. The
v. MVA it: (Figs 2.1 to 2. ) cannulae have dots which help in assessing the uterine
The MVA kit has several parts: length. Each cannula has two opposing, offset apertures for
• MVA syringe maximum aspiration effectiveness.
• Locking valves Recent modification easy grip cannulae eliminates the need
• Plunger handle for adopters, the wings for easy insertion and removal. They
• Collar stop can be reused after steam autoclaving or boiling.

Fig. 52.1: MVA syringe and cannulae 385

MTP and Contraception

Fig. 52.2: Lubricating the syringe

Section 14

Fig. 52.3: Adopter of cannula of MVA Fig. 52.4: Syringes and cannulae (together from MVA system)

vi. MVA procedure: (See the video attached with the book) 9. Attach the prepared syringe ( vacuum created in the syringe)
The preliminary steps in MVA procedure are: to the cannula, holding the end of the cannula in one hand
• Take a detailed clinical history. Note down the LMP. and the syringe in the other. Make sure that the cannula
• Perform general physical examination. does not move forward into the uterus when it is attached
• Notice how she feels. to the syringe.
• Place the patient in the lithotomy position and cover 10. Push the cannula slowly into the uterine cavity until it
her with a clean cloth. touches the fundus. Note the uterine depth by the dots
• Explain the procedure to her. visible on the cannula, then withdraw the cannula slightly.
• Use appropriate type of pain management in order to 11. Release the pinch valve(s) on the syringe to transfer the
decrease discomfort and pain. vacuum through the cannula to the uterus. Bloody tissue
• Follow infection prevention protocols. and bubbles should begin to flow through the cannula into
Steps of the MVA procedure: the syringe.
1. Create the vacuum in the syringe and keep it ready (Fig.
52.5).
2. Evaluate the uterus by bimanual examination
3. Insert the Cusco’s speculum to expose the cervix
4. Inspect the cervix for dilatation and signs of infection,
trauma or laceration.
5. Swab the cervical and vaginal areas with an antiseptic
solution twice.
6. Stabilize the cervix with a vulsellum and gently apply
traction to straighten the cervical canal.
7. Administer paracervical block if needed (if pregnancy is
more than six weeks duration)
8. Introduce the cannula gently through the cervix into the
uterine cavity past the internal os. The cannula serves the
purpose of the cervical dilator also. Rotating the cannula with
gentle pressure often helps ease insertion (Figs 52.6 to 52.8).
386 Fig. 52.5: Creating vacuum in new MVA syringe
 c. She has received information about the follow.
up care and recovery.
d. She has been counseled and informed about her
return to fertility and contraception.
vii. Precautions to be taken during MVA procedure:
1. Determine exact uterine size and position
2. Use appropriate sized cannula. (Cannula of incorrect size
may result in the damage to cervix, loss of suction or
retained tissue). Proper selection of cannula is important.
If the uterine size is 5–7 weeks, use 4–6 mm cannula. If
the uterine size is 8–9 weeks, use 7–8 mm cannula.

Chapter 51
3. Cervical dilatation is necessary when the cervical canal
will not allow passage of a cannula appropriate to the
uterine size. (In case of pregnancies beyond 9weeks,
cervical dilatation with prostaglandins is indicated).
Fig. 52.6: Introducing cannula
Inadequate dilatation leads to retained products of
conception with MVA.
4. Insert cannula carefully and not forcefully as forceful
movements may damage the cervix or uterus.

Premalignancies and Malignancies of the Vulva

5. Meticulous attention to sterilization of equipment, along
with use of no-touch technique is essential.
6. A vigilant eye should be kept in case of excessive blood
loss and look out for the uterine perforation.
7. Inspection of material is essential to assess the gestation
age of the aspirated tissue.
8. The signs of completion of procedure are:
• There is pinkish foam in the cannula
• No more tissue is seen passing through the cannula
• A gritty sensation is felt
• The uterus grips the cannula and it is difficult to
move it.
Fig. 52.7: Cannula introduced
viii. Practical issues during MVA procedure:
• Loss of vacuum: The MVA syringe may lose suction if:
– Syringe is full
– Cannula has come out of the external os
– Cannula is not properly attached
– Cannula is too small
– O-ring is not properly placed in the plunger
– Uterine perforation has occurred
• Syringe becomes full:
– The contents of the syringe have to be
emptied into a container
– Vacuum has to be re-established and the
syringe has to be reconnected
– Another prepared syringe can be used
Fig. 52.8: Performing evacuation
• Cannula has been withdrawn from the external os:
– Cannula has to be reinserted
12. Evacuate the contents of the uterus by moving the cannula – The cannula has to be detached from the
gently and slowly back and forth within the uterine cavity, syringe
rotating the syringe as well. – Vacuum has to be re-established, syringe
13. Check for signs of completion. has to be reconnected and procedure can
14. Detach the syringe and remove all instruments be resumed
15. Inspect aspirated tissue by placing them in a sieve or gauge • Tissue clogs the cannula’s aperture:
pie. – The cannula has to be slowly withdrawn
16. Monitor patient’s recovery up to the external os. The release of air will
a. Take vital signs while the patient is still on the cause the tissue to pass through to the syringe
table. – Reinsert the cannula in the uterus and then
b. Allow the patient to rest comfortably where her detach the syringe to recreate vacuum and
recovery can be monitored. resume the procedure.
c. Check bleeding at least once before discharge. ix. Complications of MVA procedure: MVA procedure is a
d. Check to see that cramping has subsided. simple and safe procedure but is not free from usual
17. Patient should be discharged when complications like:
a. Her vital signs are normal • Missing an ectopic pregnancy
b. She can walk without assistance • Uterine/Cervical perforation 387
 • Hemorrhage provides a high level of safety and maximum participation
• Incomplete evacuation by the woman, minimum physiologic disturbance that
• Hypotension allows the uterus to contract firmly and rapid recovery. The
• Acute hematometra paracervical block affects the nerve fibers that are richly
• Pelvic infection distributed around the cervix and the cervical canal and,
• Air embolism. therefore, minimizes the cervical pain from stretching,
x. Post MVA counseling: After the MVA procedure it is dilatation or movement of the cannula in the cervix.
essential to provide the woman with some valuable
information that will help her resolve problems. Suction Evacuation/Electrical Vacuum Aspiration
• The patient needs to know that she should expect some Outdoor Procedure (Table 52.1)
uterine cramping and bleeding Steps
• Her normal menstrual period should begin within 4–8 1. After initial evaluation, counseling, written consent and
MTP and Contraception

weeks tetanus prophylaxis and bladder evacuation the patient is

• She should take medications as prescribed placed in lithotomy position
• She should not have sex or put anything into the vagina 2. Parts cleaned and draped
until a few days after the bleeding stops 3. Vaginal examination is done
• She could become pregnant before her next period is 4. Posterior vaginal speculum is introduced and held by an
expected hence assistant
Contraception can prevent or delay pregnancy, if she 5. Anterior lip of the cervix is held by a tenaculum and painted
so desires twice with iodine.
• She should schedule a follow-up visit 6. The cervix is dilated with smaller size graduated metal
• She should seek medical attention if she experiences dilators up to one size less than that of the suction cannula.
prolonged cramping, excessive bleeding, severe pain, 7. Appropriate suction Karman (Fig. 52.9) cannula is to be
fever, chills, malaise or fainting. connected to the suction apparatus by a thick rubber and
xi. Infection prevention and instrument processing: The steps plastic tubing.
Section 14

of infection prevention are as follows: 8. The cannula is then introduced into the uterus the tip is to
1. Decontamination: All soiled instruments are soaked in be placed in the middle of the uterine cavity.
0.5 Chlorine solution for 10 minutes before cleaning. 9. Pressure is raised to 600 mm mercury by suction machine
2. Cleaning: The syringe and its parts along with the (Fig. 52.10).
cannulae have to be washed in water with a detergent 10. The cannula is moved up and down and rotated within the
or soap. The syringes and cannulae have also to be uterine cavity with the pressure on.
scrubbed with a soft brush and cleaned thoroughly with End point of suction is detected by
clean water. • No more material is being sucked out
3. Sterilization or high level disinfection: The syringe and • Gripping of the cannula
the cannulae have to be soaked in 2 Glutaraldehyde • Grating sensation
or 0.5 Chlorine solution for 30 minutes—High-level • Appearance of bubbles in the cannula
disinfection or 10 hours for Sterilization. (For preparing • The vaccum should be broken before withdrawing the
Chlorine solution, sterile/ boiled water should be used.) cannulae
In case the cannulae and syringe can be autoclaved, that • Curette the uterine cavity by a blunt curette at the end of
would be a highly acceptable method of sterilization. suction.
4. Storage of MVA kit: The instruments are stored in omplication Uterine perforation, retained produces infection.
sterile or high level disinfected containers. • Dilatation and evacuation
xii. Paracervical block: During the MVA procedure cervical – Outdoor procedure. It is done when both MVA and
dilatation might be very painful and so a paracervical block suction equipment are not available.

Table 2.1: Comparison between manual vacuum aspiration

(MVA) and electrical vacuum aspiration (EVA)

anual acuum Aspiration ( A) Electrical acuum Aspiration (E A)

Portable and economical Heavy, expensive, noisy apparatus

Not dependent on electricity Electricity dependent
More suited for rural settings More suited for urban settings
Takes one second to create 26 (660 mm) Hg vacuum Takes 1–1.5 min to create 26 of Hg vacuum
Rotation possible to 360 degrees because of easy maneuverability Rotation possible on either side 180 degrees only because of kinking
Precreated vacuum gets transferred into the uterine cavity of tubing
Pre created transfer of vacuum helps to find cleavage between the Vacuum is created gradually in the uterine cavity
sac and the endometrial lining. This allows sac to get sucked into the
aperture of the cannula enmass causing minimum bleeding Since vacuum takes time to reach 26 of Hg not possible to create
In case of uterine perforation, the vacuum drops to less than 10 mm cleaving easily and therefore, material comes in pieces causing more
of Hg, and therefore, prevents suckling in mesentery or intestines bleeding.
Cannula acts as dilator causing minimum discomfort and pain In case of perforation the vacuum creation continues endangering
Relatively newer technique, not many are conversant. pulling out mesentery or intestines if plugged into the aperture of
cannula.
Metal dilators to be used which cause pain and damage the os.
Established technique for nearly two decades, most are conversant.
388
 MEDICAL METHOD
Extra Amniotic Instillation of 0.1% Ethacrydine Lactate
Procedure This is done transcervically through a number 16
folley catheter, which is passed vaginally above the internal os
between the membranes and myometrium and the balloon is
inflated with 10 ml saline. Success rate is similar to intra-
amniotic saline instillation but it is less hazardous.
echanism of action Stripping the membranes causes the
liberation of prostaglandin from the decidua. Also dilation of
Fig. 52.9: Karman cannula
the cervix by the catheter.

Chapter 51
Prostaglandins
1. Misoprostol (200 mcg) vaginally/orally/sublingually every
4 hourly
2. 15 methyl PGF2a (carboprost tromethamine) 250 mcg 3
hourly for a maximum of 10 injections.
Complications

Premalignancies and Malignancies of the Vulva

Intense nausea, vomiting, fever, uterine pain, diarrhea,
incomplete abortion.

Oxytocin
Oxytocin can be administered in intravenous drip along with
any of the above methods to aid the process of abortion.
It is usually not profer because of many combiceisam.
Surgical Method: Hysterotomy is an operative procedure
of extracting the products of conception from the uterus before
20 weeks by cutting through the anterior wall of the uterus. It
Fig. 52.10: Suction machine is used when other methods of termination have failed or
contraindicated (as in placenta praevia). Usually the lower
segment incision is preferred.
Steps
1. Patient is placed in lithotomy position Intrauterine Instillation of Hypertonic Solutions
2. Parts cleaned and draped Intra-amniotic instillation of hypertonic saline (20 ) through
3. Vaginal examination is done abdominal route. It is usually not performed because of many
4. Posted vaginal speculum is introduced and held by an existent combinations.
5. Anterior lip of the cervix is held at a tenaculum painted
twice with iodine solution. SUMMARY
6. The cervix is dilated with smaller size graduated metal Hence proper selection, counseling, preoperative examination,
dilators up to one size less than that of the suction cannula. and taking proper precautions, as mentioned earlier, are a must
7. Ovum forceps is introduced and products of conception to provide safe abortion services.
(POC’s) evacuated out, curette the uterine cavity with a In conclusion, induced abortions by qualified and trained
flushing curette. doctors are reasonably safe. Efforts must be made to make them
End point Grating sedation, no more material evacuated out. SAFER.
ethods Medical methods of early pregnancy termination
BIBLIOGRAPHY
(Mifepristone and Misoprostone) are available. If judiciously
1. Commercial’s the Medical Termination of Pregnancy Act (1971).
used, it can make safe abortion in early weeks. Newer Manual
Commercial Law Publishers (India) Pvt. Ltd. Delhi 2008.
Vacuum Aspiration (MVA) syringes are now available and it
2. Comprehensive Abortion Care Training and Service Delivery
would certainly help in areas with no power supply or erratic Guidelines. Min. of Health and FW, GoI 2010.
supply. High risk abortions should be performed at those centers 3. Saxena P, Salhan S, Sarda N, Sublingual versus vaginal route of
where backup service is available in case of complications or mesoprostol for cervical ripening prior to surgical termination of
failure to terminate pregnancy. first trimester abortions. Eur Obstet Gynecol Reprod Biol
Second trimester termination of pregnancy (13–20 weeks) 2006;125(1):109.
can be done by medical or surgical methods. 4. The Gazette of India Extraordinary Part II New Delhi 2003.

389
 53 Contraception

Sudha Salhan

Contraception is prevention of pregnancy. It contributes to better METHODS OF CONTRACEPTION

maternal health besides simply reducing the population growth. They can be broadly divided into spacing (temporary) methods
It helps increase intervals between children. There is reduction and permanent methods.
in obstetrics morbidities and mortalities, both by child birth
and induced unsafe abortions. There are fewer multiparity and Spacing Methods include
high-risk pregnancies. Contraception is a big step towards
1. Natural methods
emancipation of the women. By increasing gap between two
2. Barrier methods
children there is investment in the health of the children, as
a. Condom—Male and female
they get more individed care. Un-wantedness has a long-term
b. Occlusive caps and diaphragm
impact on the child’ health so a child must be born when he or
c. Spermicides-tablets, cream, sponges, films
she is wanted.
3. Intrauterine device
Many family planning methods have non- contraceptive
a. Lippes loop
health benefits also, e.g. oral contraceptives are also used to
b. Copper T devices-250,380A
treat AUB and hence curb anemia. Condom prevents ATD
c. Multiload
including HIV/AIDS. Many cancers like ovarian, and
d. Frameless devices
endometrial cancers are prevented by oral contraceptives. The
e. Hormonal IUCD like mirena
constant morbid fear of pregnancy is no longer there, thus
4. Oral contraceptive
reducing her stress and she can chanalize her energies towards
better household management, personal development and a. Combined oral contraceptive
community welfare. b. Progesterone only pill
c. Triphasic pill
DEFINITIONS d. Centchroman
e. Combined nonestrogen progestogen pill
WHO defines family planning as a way of living and thinking
f. Male Pill
that is adopted voluntarily upon the basis of individuals and
5. Injectable contraceptive
couples in order to promote health and welfare of the family
a. Depot-medroxyprogesterone acetate(DMPA)
and thus contribute effectively to the social development of a
b. Norethisterone enanthate (NET-EN)
country. It is now considered a human right.
c. Cyclofem
Eligible couple—currently married couple wherein the wife is in d. Mesigyna
the reproductive age (15–45 yrs.) there are 150/180 such couples e. Male injectable contraceptives
per 1000 population in India. 6. Implants
ouple protection rate Defined as the percent of the eligible a. Norplant
couples effectively protected against unwanted child birth by b. Implanon
one or the other methods of contraception. 7. Vaginal rings
8. Transdermal patches
Pearl Index The pregnancy rate per 100 women years (HWY)
9. a. Injection of chemicals in fallopion tubes and vas deference
Pregnancy rate per HWY =
b. Insertion of devices in fallopion tubes and vasdeference
Total accidental pregnancy 10. Contraceptive vaccine
× 12 11. Emergency contraception.
Total months of exposure to unintended pregnancy
Permanent Methods
otal Fertility ate ( F ) The average number of child a woman 1. Female sterilization
would have 2. Male sterilization.
ontraceptive prevalence rate ( P ) Proportion of population Counseling is crucial while prescribing family planning
practicing contraception at some defined point of time methods. The client is given relevant knowledge of methods of
among the number of married women of reproductive age contraception. It will help the couple make choice and ensure
group. Every 2.4% point increase in contraceptive prevalence to follow it. Counseling helps in longer use of a method of
is associated with a one point decline in the birth rate. CPR in contraception. For any method to be effective, very good
India is 45%. counseling in an essential prerequisite.
TEMPORARY OR SPACING METHODS Rhythm Method or Calendar Method
By temporary family planning method we space between two This method avoids sexual intercourse during fertile phase. This
births. If she delivers at short intervals her health suffers. The is also called ‘Periodic abstinence’ or ‘fertility awareness based
health of last born also suffers a lot. Hence, if all children are method’ or safe period method.
born at least 3 years apart, 3–4 million deaths under 5 years can As is known that ovulation occurs 14 ± 2 days before next
be prevented. It provides better life. There is small size of the period. The ‘Safe Period’ (Ogino-Kanus theory) depends on the
family, hence family income per person becomes more, i.e. length of the cycle. An ovum can be fertilized within 24 hours
prosperity of the family. That means better health, food, of ovulation. A sperm can fertilize the ovum within 3 days
education and family ties. The community can provide (WHO). Natural family planning method is based on the
employment to the youth thus harnessing their potential in assumption that if coitus can be avoided during the fertile or
welfare work rather than destruction. unsafe period there will be no conception.
When discontinue the fertility will return after a reasonable With a 28 ± 2 days cycle the safe period days are

Chapter 53
gap of time. They are also used when either partner is ill or (i) the menstrual flow days(4–6 days), (ii) 3 days after menses
unfit for safe pregnancy and delivery. Pregnancy can be and (iii) 9 days before periods. If the period is short, the safe
temporally postponed when the couple is not financially, period days are less and if it is longer than 28 days cycle the
mentally and physically able to support a child, e.g. too early safe period days are more.
marriage, extramarital or premarital sex, etc. To be more accurate a record of 6 cycles are made. The
longest and shortest cycles are to be noted. By subtracting 18
Natural Methods of Contraception from her shortest period she can know her first day of fertile

Contraception
Natural methods of contraception No method is 100% efficient. period. By subtracting 11 from the longest period she can
There are some side effects in all methods except natural calculate the last fertile day. For example in a 26–32 day cycles
methods. 26–18 = 8th day is first fertile day. 32–11, i.e. 21st day is the last
Natural family planning methods (NPF) are defined by WHO fertile day. Thus from 8th to 21st day no sexual intercourse is to
as methods of planning or preventing pregnancy by be done to avoid pregnancy.
observations of natural symptoms and signs of fertile or infertile Disadvantages It is not applicable in irregular cycle.
phase of menstrual cycle like temperature chart, etc. This is Sometimes ovulation can occur with sexual intercourse.
practiced with abstinence during fertile period without use of
any drugs and device. Efficacy The failure rate of this method is 10 per 100 women
No drug or device is used. No money is spent. Privacy is years. But if the fertile period is not strictly avoided then
maintained. There is no side effect as no outside agency (drugs, pregnancy rate increases.
devices, etc.) is involved. Basal Body Temperature (BBT) Methods (Fig. 53.1)
We must know the date of ovulation.
After ovulation progesterone levels rises and this increases
The methods are as follows:
0.5–0.8°F or 0.2–0.4°C of body temperature. There may
a. ithdrawal and coitus interrupts method By this no sperms
sometimes be a visible drop (0.2°F) before this rise.
are deposited in the vagina. It is one of the oldest family
Everyday the woman records her oral temperature (keeping
planning methods. Here during the process of sexual act
the thermometer for 3–5 min under the tongue) as soon as she
the male partner withdraws his organ from the vagina and
awakes in the morning, before getting out of the bed or taking
discharges the ejaculate outside the female genitalia.
any fluids or food and before washing, etc. Special
Advantage thermometers with 36–38°C marking are easier to read. The
temperature is recorded on temperature chart, special BBT
No expense is involved. No harm is done. No infection.
charts are also available.
Disadvantage Three days after the rise of temperature the couple is
Great motivation and self-control is needed in the male partner. allowed to have sexual contact. In between if sex is to be
Psychological effect on both the partners is seen in some couples. practiced then barrier methods can be used.

Efficacy Failure rate 6.7 per 100 women years. Disadvantage Sometimes the temperature rises slowly for
b. oitus intercurtis The coitus performed in between the several days. The rise may occur twice. During fever and other
thighs of the female. illness the records is not helpful.
c. oitus reservatus ( arezza)—there is no movement during Standard Day Method (SDM)
the act hence ejaculate does not occur. It is a fertility awareness method developed at the Institute for
d. oitus saxonicus The act continues till ejaculation then male Reproductive Health Georgetown University. This identifies
perineum is stroked thereby the spermatozoas go into days 8 through 19 of the menstrual cycle (cycle of 26–32 days)
urinary bladder instead of coming out. as the ‘fertile window.’ Avoid unprotective sexual contract
e. Extra vaginal sex—oral and anal sex. during these days. One year failure rate is 4.8%.
Other Natural family planning method—include the following ethod of use This is a beaded circle. (Fig. 53.2) Each bead
methods: represents a day of the menstrual cycle. On first day she put
f. Rhythm method the black ring on the red bead. She moves it forward one bead
g. Basal body temperature (BBT) method each day in a clockwise direction. When the block ring is on
h. Standard day method any of the brown beads pregnancy is very unlikely when the
i. Cervical mucous method ring is on white beads she should avoid unprotected intercourse.
j. Symptothermal method
k. Lactational amenorrhea method Cervical Mucus (Billing’s) Method
l. Commercial ovulation detection (do it yourself methods) This method includes recognizing the changes occurring the
coming up. cervical mucous in different stages of the menstrual cycle. The 391
MTP and Contraception

Fig. 53.1: Days of menstrual cycle

cervical is opaque, sticking, scanty and thick in pre-ovulatory Disadvantage If there is vaginal infection, the discharge will not
period of the cycle. Just before and at the time of ovulation the follow the normal physiological process. Cervical surgery will
cervical mucus becomes clear, copious and can be stretched also modify the normal observations.
easily between the fingers. During these days the sex is to be A simple Modified Mucus Method (MMM) is advocated
avoided (Fig. 53.3). by Dorai Raj but is not found to be superior to Billing’s method.
She is instructed to wash her hands with soap and water. Failure rate is 3 pregnancies per 100 women years.
Wipe dry them. She can collect the discharge at vaginal outlet
Symptothermal Method
by a finger inserted in the vagina and the discharge collected is
Section 14

wiped on paper. The stickiness, consistency and amount is This is a combined method using BBT, Billing’s method and
observed daily and carefully recorded. other factors of ovulation like midcycle pain, spotting or
bleeding in midcycle and breast tenderness. The woman can
also feel the cervix by clean hands inserted in the vagina. The
cervix becomes soft and os is slightly open during ovulation.
There is a special chart (symptothermal chart deviced by WHO
(1993). Failure rate is 2 pregnancies per 100 woman years.
Failure rate of natural family planning method—If these
methods are used with precision the failure rate can be as small
as 1–9 per 100 woman years.
Lactational Amenorrhea Method (LAM) (Fig. 53.4)
There are certain prerequisitions to ensure the optimum results.
1. The child is exclusively breastfed i.e. breastfeeding both
during day and night. No other feed, even water is given to
the child.
2. There is amenorrhea.
3. The baby is less than months of age.
If any of these 3 conditions is not fulfilled, another family
planning method is to be started.
Fig. 53.2: Standard day method Advantage This is a very good temporary method.

392 Fig. 53.3: Cervical mucus method Fig. 53.4: Lactating mother
 Besides family planning baby’s health is taken care of in • There is no increased risk of chromosomal or congenital
the form of adequate nutrition of mother’s milk. This prevents abnormalities (Bonnar 1984).
from life-threatening conditions like diarrhea, pneumonia, etc. Disadvantages
• Help to develop mother and child bonding • If not used correctly the failure rate increases
• This can be started immediately after birth • More failure rate than other methods of contraception
• No effect of weight and smoking status of the mother • There is no protection against sexually transmitted diseases
• No other precaution is to be taken to prevent pregnancy including HIV/AIDS.
during intercourse. • Non cooperation of the husband will not bring out the
• No cost is engaged for using family planning method desired level of results.
• Mother is protected from PPH and subinvolution of uterus,
cancer of the breast, etc. Wounds heal faster in these women Barrier Methods
• Psychological support to both mother and the child

Chapter 53
These methods achieve avoidance of pregnancy by preventing
• No hormonal and other side effect. the sperm and ovum to come together.
Disadvantages No protection from STD including HIV/AIDS The methods used are:
for both mother and the child (if the mother is HIV positive) a. Condoms both male and female
• Frequent breastfeeding may be difficult for working women. b. Spermicides, occulusive vaginal devices
c. Vaginal diaphragm
Mechanism of Action d. Cervical caps
• Prolactin levels fall immediately after delivery. If the mother e. Vault cap

Contraception
is not exclusively breastfeeding this level is not high enough f. Vinule cap.
to produce anovulation and amenorrhea. By 10–15 weeks
postpartum the ovulation and menstruation is resumed. But Condoms
if the woman is exclusively breastfeeding, she maintains Male condoms are used for a long time. It is made of fine latex
high blood levels of prolactin which inhibits LH and also rubber of various colors. The precise use is important to prevent
prevent the effect of FSH and LH on ovaries. Hence very failures. Hence good counseling and instructions for correct
little estrogen and progesterone are produced preventing use on a essential model.
ovulation and menstruation. Government hospitals have ‘Nirodh’ available free of cost
In these women, amenorrhea may lasts for 5–9 months and at family planning clinics. It can be purchased from chemist
anovulation upto 6–10 mths. shops, grocery shops, pan shops and by vending machines.
This method is effective up to 6 months after childbirth. Instructions for use
Because after 6 months the child is initiated to other feeds • Put on the condom on erect penis before touching the vagina
(weaned) and hence prolactin levels start coming down. • The pack is held at its edge and opened by tearing from
Hence after 6 months LAM is to be supplement with other ribbed edge.
FP methods. • Holding of condom—rolled rim is facing up away from penis.
Efficacy – 2 pregnancies/100 women years. • Pull the foreskin back if the penis is uncircumcised.
Commercial Ovulation Detection Kits • Put the condom on tip of the penis.
• Now unroll the condom towards the base of the penis. If it
Do it yourself methods—Recently a number of ‘do it yourself’
is difficult to unroll then discard this condom and use a
kits are available ‘ovastick, ovoquick, first response, Q test,
new one.
Quidell, persona, etc. They consist of disposable test sticks to
• No lubricant with oil is to be used. It will damage the
be dipped in women’s urine and then reading the level of
condom and hence cause failure. But can use water or water
estrone—3-glucuronide (E-3-G) indicating start of fertile period
based lubricants like spermicides, etc.
and Peuteinzing luteinizing hormone (LH) which indicate
• After ejacuation hold the rim of condom at the base of the
ovulation. Thus the couple can predict ovulation. This further
penis to prevent slipping off. He may be advised to pull
reduces the abstinence or fertile period. The next step is to
out of vagina before losing the erection.
develop hormone test kit which will accurately predict – Removal—slip off the condom without spilling the
ovulation 4 or 5 days before actual rupture of the follicle. A semen on the vaginal opening
failure rate of 6% has been found after using these kits and – Disposal—cover it with a paper and then dispose off in
planning the sexual act accordingly. a dustbin or can burn or bury it
If natural methods are used with barrier method the efficacy – It is to be used only once
will be higher. – If condom breaks, then immediately insert spermicide
Advantage of NFP methods are many: in the vagina if available. Emergency contraception can
• Menstrual cycle is not altered be used to prevent pregnancy. Immediately washing the
• No financial cost penis and douching the vagina will reduce STD risk.
• No physical side effects of drugs devices or surgery Storage Keep it in a cool dark corner. Handle carefully as finger
• No effect of smoking nails and rings can tear it. See the manufacturing date. Use can
• As cooperation of the husband is required it improves be up to 5 years from manufacturing date.
martial relationship. Return to health facility if
• Can be used by women of any constitution. Thin or fat. • Need more condoms
• There is no resistance from the society and the religion. • Symptoms of STD develop (Sore genitalia, dysuria or
• There is no setback when the supply is cut or erratic discharge)
compared to other methods. • Allergic to condom material
• Privacy is maintained • Condoms break—(for supply of emergency contraception,
• Can be taught to uneducated couples also if not available) 393
 • Any other problem Efficacy When used correctly and consistently 3 pregnancies per
• Advise for other methods. 100 women years (1 in 33).
Advantages The most harmless method of contraception. ontraindication—only severe allergy to latex rubber. Can change
• Can be used soon after childbirth brand or use recent polyurethane condom.
• No hormonal side effects
Female Condom (Reality Condom, Femidon)
• No prescription is required for procurement
• No daily upkeep is needed (Figs 53.5A to E)
• Any age is eligible to use Consists of a soft loose polyurethane sheath (15 cm–7 cm) with
• Easy to obtain from health facility and market 2 flexible rings. One ring covers the vulva and the second one
• Prevent STD including HIV/AIDS covers the cervix internally like a diaphragm. It is introduced
• Can be stopped at any time like a tampon. Inserted before intercourse. It is pre-lubricated
MTP and Contraception

• No previous health check is needed with a silicon based lubricant (dimethicone). It is to be removed
• Making men feel responsible after 8 hours and not more than 24 hours after intercourse. It is
• Use in late pregnancy can prevent amniotic infection. If used disposable like male condom.
for more than 5 years reduces the chances of developing It has the advantage of being a woman—Controlled method
severe cervical dysplasia and cancer cervix and does reverse of family planning and for protection against STD including
dysplasia. HIV/AIDS.
Disadvantages May cause allergy in some Disadvantage It is expensive, supply must be handy.
• Privacy is needed Efficacy—used correctly and consistently 5 pregnancies per 100
• Ready supply must be always available women in a year.
• Man’s cooperation is needed
• Buying may cause embarrassment Spermicides
• Some complain of decrease in sensation These are chemical agents capable of destroying sperms and
• May break during the act. are incorporated with an inert base. They are introduced in
Section 14

Recently polyurethane condoms are also being made. vagina before intercourse. The base may be gelatin, glycarine
Besides other attractions it is less susceptible to deterioration or wax which melt at body temperature. They are to be inserted
during storage. There is also introducing of spermicidal coated 30 minutes before the act. No douching is to be done within 8
condoms (using Nanoxynol 9) it increases the efficacy. hours. Spermicide alone are not very efficient family planning

394 Figs 53.5A to E: Method of inserting female condom

method. They are used with other methods like condom, soap and water and dried. Talcum powder is applied and is
diaphragm, etc. They are marketed in various forms viz. kept in air tight container.
Dispersible tablets (Today tablets), cream, films aerosol, and Advantage
sponge (today sponge) mostly Nanoxynol is the chemical • Harmless
used. Foaming tablets with suppositories utilize a chemical base, • Fitted before and removed after sexual act hence do not
which releases Carbon dioxide (CO 2 ) which helps the interfere in the act
distribution of spermicidal agent throughout the upper vagina. • Women friendly device.
A spermicidal film that can be used vaginally or over the penis.
It is a small sheet of material that dissolves in the vagina and is Disadvantages
used in South Korea, Malaysia, Spain, etc. • Privacy is needed
• Rubber allergy can occur
Advantage It is designed to prolong release of Nanoxynol-9 • If kept longer in the vagina, it can cause infection

Chapter 53
after single vaginal application in polycarbophil base. Best • Does not prevent HIV/AIDS
example of sponge containing 1 gm Nanoxynol-9 to release 125- • May cause UTI
150 mg. It is inserted after wetting with water. Removed 6 hours
after the act of intercourse by pulling its loop attached at the Efficacy 18–28% failure. Decreases to 6% if used with
bottom. It is not to be used during menstrual period and after spermicides.
child birth. Other spermicidal chemicals under trial are zinc
Intrauterine Contraceptive Devices (IUCD)
acetate, Magainin G, Maginin A, etc.
Intrauterine Contraceptive Device (IUCD) is becoming an

Contraception
Advantages increasingly popular method of contraception among women
• Easily available and easy to use of reproductive age worldwide. It has been in use for nearly 40
• No gross medical side effects years. It is effective, safe, convenient and reversible long acting
• Some protection against STD (Not proven yet against HIV) contraceptive method being used by more than 100 million
Disadvantages women in the world. Nearly 40% of these women are in China.
• It is messy and not liked by some IUCD usage in developed countries is about 6%. Recent studies
• Cannot be used alone as efficacy is not good. and literature have confirmed that IUCDs provide very effective,
Efficacy—21% failure rate. When used with condom it gives very safe and long-term protection against pregnancy and the health
good efficacy. risks associated with the method are negligible.
Studies show that nearly 6 out of 10 women use the pill
Vaginal Diaphragm (Fig. 53.6) incorrectly. IUCD generally avoids the problem of incorrect use
It consists of a thin, nearly hemispherical dome shaped rubber hence IUCD is superior to use effectiveness to oral
or latex structure. The pheriphery has metal spring ring. They contraceptives (OCP). Because user has to return to the health
are of different sizes and of two types-coil spring type and flat care facility for discontinuation hence continuation rate is higher
spring type. Not much used now. in IUCD contrast to oral contraceptive which can be
discontinued easily without return visits.
Cervical Cap (Fig. 53.7) In India only 1.8% of married women of reproductive age
They are smaller rubber appliance. They are dome-shaped and use IUCDs.
cover the cervix and remain in place by suction. Different sizes
are available. IUCD use in the National Family Welfare Program of India
IUCDs were first introduced in the form of Lippes Loop in the
Vault Cap National Family Welfare Program of the Government of India
Rubber or plastic cap fitting in the vaginal vault covering the (GOI) in the year 1965. After the results of clinical trials
cervix. No metal spring in the rim is there. conducted by the ICMR in the year 1972, Copper T 200 B was
introduced in the program in 1975. In 1997, ICMR conducted a
Vinule Cap
comparative study between Copper T 200B and 380A based on
It made of rubber with string attached. In women with cystocele, which Copper T 380A was introduced in 2002, replacing IUCD
where diaphragm does not fit, it can be used. 200B in the program. Despite the fact that the government offers
Contraindication: Prolapse of uterus—Vesicovaginal fistula, IUCD services free of cost, it still remains largely underutilized.
recotovaginal fistula.
Motivation and teaching the method of insertion is essential. History of IUCDs
It can be inserted up to 2 hours before intercourse. These devices There are fascinating stories available in history, regarding the
are removed 6–8 hours after intercourse. Do not leave them first use of contraceptive devices in animals and human. To
inside vagina for more than 8 hours. Remove and clean with prevent pregnancy in these animals, Caravans inserted pebbles
into their uteri during long journeys. In 1909, Richter in
Germany described the first genuine IUCD. Between 1928–1930
Granfenberg from Berlin presented three reports on silk star
devices and he is known as the pioneer of IUCD. Ishehama
from Japan used the ohta ring made first of gold and later from
plastic. In early 1960s, Lippes loop and Marguilles spiral made
of biologically inert polyethylene appeared. In the year 1962
population council organized first International Conference on
IUCDs in New York, where Marguilles Rings and Lippes Loop
were presented. In 1964 the second Conference on IUCDs was
held and many devices of different shapes were presented. The
Fig. 53.6: Vaginal diaphragm Fig. 53.7: Cervical cap first medicated devices were developed in 1969 using Copper. 395
 In 1970, a USA company developed a Dalkon shield which had Nova T: They are made up of polyethylene to which barium
a faulty design and caused severe infections, sometimes fatal, sulphate is added. Copper (200 mm2) in seven sleeves – two on
this led to many lawsuits and ultimately led to company’s the arms and five on the stem. The copper wire has a silver core
bankruptcy. and is wrapped around the stem.
The Modern IUCD CuT-38 A, CuT-38 Ag, CuT-38 Slimline (CuT-38 S): It is
The IUCDs development continued and many improvements made up of polyethylene to which barium sulphate is added so
have hence taken place regarding the unpleasant side effects of as to make it visible on X-rays. It has 314 mm2 of copper wire
cramping and bleeding. on its stem; two solid copper sleeves of 33 mm 2 on each
transverse arm. (Hence the name ‘A’) In the CuT-380Ag, the
Different Types of IUCDs wire has a silver core. On the CuT-380S the copper sleeves are
First Generation I Ds Lippes loop, spirals, coils, rings and placed at the ends of the arms and are recessed into the plastic.
MTP and Contraception

bows (Figs 53.8 A and B). The length of vertical stem is 36 mm and that of horizontal
It is an inert device made of polyethylene or other polymers, limb is 32 mm.
available in different shapes and sizes-loops, Multiload 2 , Multiload-3 (MLCu-2 , MLCu-3 ):
The size could be A, B, C and D, D being the largest. Larger Polyethylene with two flexible arms with spurs. MLCu-250 has
the size, greater the antifertility effect and a lower expulsion 250 mm2 of copper wire and MLCu-375 has 375 mm2 of copper
rate but a lower continuation rate due to side-effects like pain wire on the stem. Both are available in three sizes – standard,
and bleeding. short and mini/SL.
Second Generation I Ds hird Generation I Ds These are hormonal Progesterone
Earlier devices: Cu-7, Cu T-200 (Figs 53.9 A to C) releasing contraceptive system.
Newer devices: (Variants of T device)
• Cu T -200B, Cu T -380A (currently provided under the Progestasert: T shaped device made up of ethylene vinyl acetate
National Family Welfare Program), (Fig. 53.10) CuT-380Ag, copolymer. The stem contains a reservoir which has 38 mg of
CuT-380 Slimline progesterone and barium sulphate in silicon oil base. It releases
65 µg of progesterone every 24 hrs.
Section 14

• CuT-220C
• Nova T, Multiload devices (ML-Cu-250, ML-Cu-375). LN 2 (Mirena) (Fig. 3.11): It is a more potent Levonorgestrel
CuT-2 , CuT-2 B, CuT-2 Ag (Fig. 3.1 ): They are made releasing contraceptive system. It is a T- shaped device with a
up of polyethylene to which barium sulphate is added. In copper reservoir in the vertical arm containing a mixture of 52 mg of
T-200 copper wire of 200 mm2 is wrapped around the stem. In levonorgestrel with polydimethylsiloxane. It releases 20 µg of
CuT-200 Ag, the wire has a silver core. The TCu-200B has a ball levonorgestrel everyday.
at the tip of the stem. Other IUCDs
CuT-22 C: They are made up of polyethylene to which barium • CuSAFE-300 IUCD has more flexible plastic and is smaller
sulphate is added. Copper (200 mm2) in seven sleeves—two on than CuT 380-A
the arms and five on the stem. The copper wire has a silver core • Sof-T available only in Switzerland
and is wrapped around the stem. Future I Ds Flexiguard, Gynaefix, Cu-fix, Fibroplant—for
perimenopausal women.

Figs 53.8A and B: (A) Lippes Loop (B) Safety coil

Fig. 53.10: CuT-380A

396 Figs 53.9A to C: (A) CuT-200 (B) Cu -7 (C) Multiload Fig. 53.11: Mirena
Frameless I Ds Several copper cylinders strung together are enerally use the method.
anchored into the uterus. ategory 3 A condition where the theoretical or proven risks
Copper Fix is a new frameless intrauterine contraceptive usually outweigh the advantages of using the method. Use of
device. It is highly effective against pregnancy but has more method not usually recommended unless other more
expulsion rate than Cu T 380A appropriate methods are not available or acceptable.
Approved Life-span of IUCDs ategory A condition which represents an unacceptable health
The inert IUCDs can be used indefinitely. The medicated devices risk if the contraceptive method is used. Method not to be used.
are approved for different lengths of time in different countries. Sometimes a given condition is considered one category
This is called approved life span. The approved life span of for initiating use (i.e., insertion) and another for continuing use.
CuT-380 is 10 years whereas that of CuT-200 is 4 years. That of For example, a woman with PID should not have an IUCD
CuT 380Ag is 4 years and CuT-380S is 2.5 years. CuT-220C has inserted (Category 4) but can continue to use an IUCD already

Chapter 53
an effective span of 3 years and Nova T is estimated to be in place while receiving appropriate treatment (Category 2), if
effective for 5 years. MLCu250 has a life span of 3 years and she so desires.
that of MLCu 375 is 5 years. The approved life span of With eligibility criteria (Modified to Indian use) is presented
Progestasert is 1 year only whereas that of LNG 20 (Mirena) is as a wheel (Figs 53.12 A and B) (2010).
5 years.
Side Effects
Effectiveness The IUCD is an extremely effective method of
Side effects of IUCD are not harmful and in most women these
contraception. The copper bearing IUCD’s, with the largest

Contraception
subside or resolve within a few months after insertion. For
surface area of copper (CuT 380 A and MLCu 375) are the most
effective with failure rates of 0.5 and 0.6 per 100 women years.
Those with smaller surface area of copper (CuT 200 and Cu7)
have intermediate failure rates of 1-3 per 100 women years at
one year. The progesterone releasing IUCD’s are more effective
with a failure rate of 0.2 per 100 women years at one year and
LNG IUCDs are highly effective with a failure rate of 0.1 per
100 women years.
Failure rate of CuT 380 in 1st year is 0.3–0.8% which is
comparable to that of female sterilization.
Mechanism of Action of IUCDs
The copper-bearing IUCDs act 1. primarily by preventing
fertilization as the copper ions alter the uterine and tubal fluid
environment. This fluid contains leukocytes, 2. copper ions,
enzymes, and prostaglandins. Copper is toxic to sperms hence
decreases the sperm motility and function thereby preventing
sperms from reaching the fallopian tubes and fertilizing the
egg. The device produces a local sterile inflammatory reaction
in the endometrium which prevents implantation as it releases
macrophages which engulfs sperms and fertilized ovum.
LNG I Ds Steroid releasing devices induce progestational
changes that result in endometrial gland atrophy and inhibit
further development of the ova. This makes the lining a poor
place for a fertilized egg to implant and grow. They diminish
sperm transport through the cervix to the oviduct by increasing
the thickness of the cervical mucus (this happens with the
hormonal IUCD). The hormones in the LNG IUCD also reduce
menstrual bleeding and cramping.

Medical Eligibility Criteria

The medical eligibility criteria of WHO describes diverse
conditions in which the women can and cannot use different
contraceptive methods including IUCD and aim to ensure an
adequate margin of safety.
Each condition was defined as representing either an
individual’s characteristics (e.g., age, history of pregnancy) or
a known pre-existing medical/pathological condition (e.g.,
diabetes, hypertension). The conditions affecting eligibility for
the use of each contraceptive method were classified under one
of the following four categories:
ategory A condition for which there is no restriction for the
use of the contraceptive method. Use the method.
ategory A condition where the advantages of using the
method generally outweighs the theoretical or proven risks. Figs 53.12A and B: WHO medical eligibility criteria wheel India 2010
397
 continuation proper counseling is essential. Some common to RTI/STI should be clearly brought out. Limited general
symptoms are as follows: physical examination is necessary. Pelvic examination is
enstrual changes There may be increase in uterine bleeding performed to exclude any genital tract infection and to assess
either a prolonged cycle, or heavy menstrual bleeding or for uterine size, shape, position, any adnexal pathology.
intermenstrual spotting during the first few days or months iming of the Insertion
after insertion. These usually subside with symptomatic • IUCD can be inserted anytime during the menstrual cycle
treatment by NSAID agents. provided it can be reasonably ensured that the woman is
Dysmenorrhea or cramps during insertion and for the next not pregnant.
few days which subsides in due time. Sometimes an • It may also be inserted immediately (Postplacental insertion)
antispasmotic or NSAID agent may be necessary. or within 48 hours after delivery by a specially trained
person using special insertion forceps.
Concerns, Myths and Misconceptions Regarding IUCDs
MTP and Contraception

• It can also be inserted more than 4–6 weeks postpartum.

I D and infection (PID) infertility There is minimal risk (less • Concurrently with 1st trimester medical termination of
than 1%), and occurs within the first 3 weeks of insertion, and pregnancy.
after that the risk is same as in a woman not using an IUCD. It • After 1st menstrual period following spontaneous/medical/
needs an accomplice (chlamydia, gonorrhea) to cause infection second trimester abortion provided there is no infection.
The ‘risk’ is not due to IUD itself, but to non-sterile insertion • In a woman in lactational amenorrhea after ruling out
technique. Using recommended infection prevention practices pregnancy.
including loading of CuT in its sterile package (no touch • Within 5 days of unprotected sex as a method of emergency
technique) and smearing cervix twice with povidone iodine contraception where long-term contraception is desired.
before insertion can further minimize the risk. Prophylactic
antibiotics are not recommended for IUD insertion or removal. Advantages of Copper IUCD
I D and ris of ectopic pregnancy The WHO multicentric study It offers long term, highly effective reversible protection against
concluded that the IUCD reduces the risk of ectopic pregnancy pregnancy. It is effective immediately after insertion and can
be used as an emergency contraceptive if inserted within five
Section 14

by preventing pregnancy as IUCDs are so effective at preventing

pregnancy, they also offer excellent protection against ectopic days of the first act of unprotected sexual intercourse. It can be
pregnancy. Women who use copper-bearing IUCDs are 91% replaced, without any gap, as many times as she desires, during
less likely than women using no contraception to have an ectopic her reproductive life. There is no need for daily attention by
pregnancy (Sivin 1991). But when an IUCD user becomes the user or any special attention before sexual intercourse. It is
pregnant the chances of that pregnancy being an ectopic are a one time procedure and is cost effective. Can be used by
very high. lactating women It does not interact with any medicines the
client may be taking. Fertility returns promptly on removal of
I D and ris of expulsion The chances of spontaneous expulsion I D
vary between 2–8%. It is more common in first 3 months and
during menstrual period Factors that increase risk are Technique of Insertion
nulliparity increased menstrual flow after second-trimester
When correct procedure, i.e. ‘No touch techni ue‘ is adopted
abortion.
and the infection prevention precautions are followed, for
I D and ris of perforation The risk of uterine perforation is inserting an IUCD, there is minimum risk of post-insertion
rare. The incidence is less than 1.5/1000 cases. It usually occurs infection, perforation and expulsion. This includes:
during insertion. Serious complications from perforation are • Loading the IUD in the sterile package (Figs 53. 13 A to E).
rare. Surgical intervention is rarely required. • Cleanse the woman’s cervix and vagina thoroughly two
I D and I AIDS The IUCD can generally be used in these times with antiseptics.
conditions provided that the woman is clinically well, with • DO NOT allow the sound or IUD insertion tube to touch
access to adequate care. Additional care/follow-up may be the vaginal walls or blades of the speculum, or pass through
needed because the IUCD provides no protection against HIV the cervical os more than once.
reinfection or other STIs. Be alert for signs/symptoms of pelvic he O F Govt of India recommends the following steps for
infection and other problems. insertion of an I D
Step 1: Prepare the client
Prerequisites of IUCD Insertion
Step 2: Insert the high-level disinfected (or sterile)
ounseling Counseling plays a vital role in increasing the speculum in the vagina.
acceptance of any family planning method. If a client choses an Step 3: Cleanse the cervix and vagina with an appropriate
IUCD it is essential to provide specific information about the antiseptic.
advantages, disadvantages including the side effects and Step 4: Do per vaginum examination. Gently grasp the
possible complications along with their management. The anterior lip of cervix with the high-level disinfected
counseling should also include timing of insertion, the insertion (sterile) vulsellum and apply gentle traction. Apply
procedure, effective life. Post-insertion counseling and follow- povidone iodine twice to cervix.
up counseling should include information regarding the Step 5: Carefully insert the high-level disinfected (or
“warning signs” that necessitate medical attention. sterile) sound.
lient Assessment The objective of client assessment is to Step 6: Gently advance the sound into the uterine cavity,
determine whether an IUCD is an appropriate method for the and stop when a slight resistance is felt.
client. It should be aimed at taking a targeted history and Step 7: Determine the length of the uterus
examination including a complete pelvic examination. General Step 8: Determine the angle/direction of the uterine cavity
history, menstrual and obstetric history, reproductive history and also rule out any obstruction in the cervical
398 including H/O PID, STIs or a high individual risk of exposure canal.
Step 9: Load the IUCD in its sterile package woman’s uterus. This is the withdrawal techni ue
Step10: Apply gentle traction on the cervix with the to minimize perforation.
vulsellum. Step14: Remove the white plunger rod, while holding the
Step 11: Insert the loaded IUCD insertion tube stationary. The plunger should be
Step 12: Gently advance the loaded IUCD into the uterine removed before the insertion tube is pulled out,
cavity, and STOP when the blue length-gauge otherwise the threads may be caught between the
comes in contact with the cervix or slight resistance tube and the plunger resulting in downward dis-
is felt placement or expulsion of the IUCD from the
Step 13: While holding the vulsellum and plunger rod uterus.
stationary (in one hand), withdraw the insertion Step 15: Gently push insertion tube upward again, toward
tube downwards (with your free hand) until it the fundus of the uterus, until a slight resistance is
touches the circular thumb grip of the white felt.This step ensures that the arms of the T are as

Chapter 53
plunger rod. This will release the IUCD in the high as possible in the uterus.

Contraception

Figs 53.13A to E: Steps of loading IUCD with NO TOUCH technique. (A) Partially open package till 1/3rd of flap; (B) Placing white Plunger Rod
into tube; (C) Push the card (Measurement insert) up to seal end of packet; (D) Inserting folded IUCD arms into insertion tube; (E) Cu T-380 A
ready for insertion
399
 Step 16: Use high-level disinfected (or sterile) sharp scissors the device at the fundus. The instruments required are shown
to cut the IUCD strings at 3 to 4 cm of length. in (Fig. 53.14). There is special method of holding copper T
Step 17: Gently remove the vulsellum with open ends and (Fig. 53.15).
place it in 0.5% chlorine solution for 10 minutes for
decontamination. Steps for Mirena Insertion (Figs 53.16 A to E)
Step 18: Examine the woman’s cervix for bleeding. If there 1. Open the package
is bleeding where the vulsellum was attached to 2. Make sure that the slider is in the farthest position away
the cervix, use high-level disinfected (or sterile) from you.
forceps to place a cotton or gauze. 3. Set the upper edge of the flange at the uterine sound measure.
Step 19: Gently remove the speculum and place it in 0.5% 4. Place the IUS arms in a horizontal position
chlorine solution for 10 minutes for decontamination. 5. Poll on the threads to place the IUS in the insertion tub and
Step 20: Allow the woman to rest. fix the threads in the cleft at the end of the shaft.
MTP and Contraception

Just after delivery (postplacental) and immediate 6. Take care not to cover the threads with your hand.
postpartum (within 24 hours of delivery), insertion of copper T 7. Move the inserter gently into uterus until the flange is about
requires a special long instrument (Kelley’s forceps) to place 2 cm from the cervix.
Section 14

Fig. 53.15: Postplacental insertion of CuT

Fig. 53.14: Instruments of postplacental insertion of CuT (Method of catching CuT in Kelley clamp)

Figs 53.16A to E: Pictorial representation of important steps of mirena insertion—

400 (A) Step 5; (B) Step 7; (C) step 8; (D) step 9; (E) step 10
 8. Release the IUS arms by pulling the slider back until it ray, should be done to determine whether the IUCD is still in
reaches the mark. place, is malpositioned, or has been expelled.
9. Push the inserter gently inwards until the flange touches isplaced I D Can be removed from the uterus by IUCD hook
the cervix. (Fig. 53.17).
10. Release the IUS by pulling the slider back all the way. If the IUCD is intrauterine and removal is not easily possible,
11. Remove the inserter from the uterus, cut the threads to leave direct visualization with USG (Fig. 53.18) or hysteroscopy can
about 2 cm outside the cervix. be tried. A forcep may be used to extract IUCD under ultrasonic
Indications for IUCD Removal visualization. If still not successful then hysteroscopic removal
• Personal reasons (or offers no reason at all). The woman can be done.
has a right to discontinue the method at any time, regardless If the IUCD is in the abdominal cavity, it should be removed
of the reason. by operative laparoscopy or laparotomy under general

Chapter 53
• Wants another child provide information on antenatal care, anesthesia as copper can form adhesions in the abdominal
care during pregnancy, labor and delivery. cavity. If an IUCD has partially perforated the myometrium
• IUCD to be replaced both routes, i.e. hysterolaparoscopy may be useful.
• Medical reasons (e.g., pregnancy, heavy menstrual Perforation (Fig. 53.19): Uterine perforations occur very rarely,
bleeding)—ensure that she has undergone the appropriate occur mostly because of poor insertion technique and lack of
assessment to determine whether routine IUCD removal is skill of provider. It may be detected during the insertion
safe for her at this time. procedure or much later after the procedure. Risk is higher in

Contraception
• Starting a different method. case of postabortion or immediate postpartum clients and in
• Menopause clients where the uterine size measures less than cm. If
• Evidence of IUCD displacement. detected during insertion procedure (by sudden loss of
Advantages of ormonal I Ds over opper Bearing Devices 1. It resistance to the uterine sound or IUCD insertion device) stop
is more effective than copper bearing IUCDs. the procedure immediately, and gently remove the instrument/
2. Hormonal IUCDs decrease the amount of bleeding, can be object that may have perforated the uterus and observe. If
used in women with abnormal uterine bleeding and improves perforation has occurred with the assembly unit and the IUCD
hematocrit. 3. It also reduces pain and cramps in dysmenorrhea has not been released, stop the procedure and remove the
and endometerisis. There is a beneficial effect on fibroids. assembly unit and abandon the procedure. If perforation has
occurred with the assembly unit and IUCD has been released
Disadvantages of ormonal I Ds They are very expensive and
may not be affordable for many.
Oligomenorrhea or amenorrhea may not be acceptable to
many women.
Sometimes they can cause irregular bleeding or spotting.
Insertion requires a special technique.

Complications and their Management

Pregnancy with I D Although IUCD is one of the most
effective forms of reversible contraception, failures can occur.
If a client reports of having missed her period and pregnancy
is suspected, confirm pregnancy and rule out ectopic pregnancy.
When ectopic pregnancy has been ruled out, determine whether
the woman wants to continue her pregnancy. If she does not
wish to continue her pregnancy offer MTP if she is within 20
weeks of pregnancy. Remove the IUCD immediately if strings
are visible. If she wishes to continue the pregnancy, advise the
woman that the IUCD may be removed if strings are visible. If Fig. 53.17: Cu-T Removal hook
the IUCD is left in place it can cause second-trimester abortion,
infection, and preterm delivery. Removing the IUCD increases
the risk of abortion only slightly In case IUCD is not removed
or the strings are not visible, closely monitor the pregnancy
and look for expelled IUCD at the time of abortion/delivery.
Pregnancy with IUCD in situ does not increase the risk of
congenital anomalies in the baby.
issing strings Missing, shorter, or longer strings may be due
to IUCD expulsion, malposition or uterine perforation. Strings
that are too short may bother the woman’s partner during sexual
intercourse. In case of a problem of missing strings, rule out
pregnancy. Once pregnancy has been ruled out probe the
cervical canal using HLD (or sterile) long artery forceps to locate
the strings. Gently draw them out. If the strings are not located
in the cervical canal (or cannot be drawn out), use a sound to
check whether the IUCD is in place, being very careful not to
injure the uterus. If the IUCD is still in place, the strings may be
drawn out using a long artery forceps. An ultrasound or an X- Fig. 53.18: USG showing IUCD within Uterus (courtesy- Dr Uppal) 401
 The last has pearl index of 0.09 with newer progesterones,
desogestrel, etc. There is no increase in body weight, no pre-
menstrual symptoms, dysmenorrhea and acne.
echanism of Action of combined oral contraceptive pill.
1. Inhibition of ovulation by suppressing GnRh and in turn
FSH and LH. There is no LH surge and ovulation does not
occur.
2. Change in cervical mucus which becomes thick and viscous
(progesterone effect) impairing sperm passage.
3. Increase fallopian tube peristalsis and making the ovum or
the fertilized ovum to reach earlier to the uterus which is
not prepared to receive it.
MTP and Contraception

4. Alteration of endometrium—There is exhaustion and

atrophy of endometrial glands and thining of endometrium.
Decidua does not form and hence no implantation can occur.
ethod of use is to be explained. Start with first 5 days of
last menstural period. If take at night, less chances of nausea.
Take the pill at the same time of the day will keep the hormone
concentration in blood at optimum level and make her more
Fig. 53.19: USG showing perforation (courtesy Dr Uppal)
compliant.
In event of missed pill
and the threads are visible then try to remove the IUCD by
1. One pill missed, take as soon as you remember and next
applying gentle traction on the thread. Monitor her vital signs.
pill at its usual time
If her vital signs remain stable after 1 hour, check for signs of
2. If started 2 or more days late or missed 2–4 pills during 1–
intra-abdominal bleeding. If there are signs of intra-abdominal
7 days then can continue taking one pill per day and avoid
Section 14

bleeding, hospitalize and provide emergency care. If the

sex or use another method for 7 days.
woman’s vital signs have been stable for 24 hours, she can go
3. Missed any 2–4 pills of last 7 active pills (day 15–21) finish
home.
all active pills in the pack. Do not take last 7(iron tablets or
If perforation is detected late, i.e. missing strings/
inactive pill) and start a new pack.
unexplained or persistent pain/pregnancy confirm the diagnosis
by USG/X-ray. Progesterone Only Pill (POP)
Expulsion Partial or complete IUCD expulsion may go It is useful in lactating mothers (as quality and quantity of milk
unnoticed or there may be symptoms, like irregular bleeding, is not affected by progesterone). They act by thickening of
dyspareunia, abnormal vaginal discharge. Missing or longer cervical mucus decreasing sperm penetration. Affect
IUCD strings and delayed or missed menstrual period are other endometrial maturation preventing implantation of fertilized
possible causes. Expelled IUCD may be seen (complete ovum.
expulsion) or felt/seen in the vaginal canal (partial expulsion). Also interfere with corpus luteal function. There is erratic
suppression of ovulation.
Oral Contraceptive Side effect is staining in between periods.
This is the method under the control of women. They are highly Failure rate of POP is 1.3 pregnancy/100 women per year.
effective and can be taken for long time without any adverse Available in India are:
effects. There is quick return of fertility within 3 months after Cerazette/Zerogen(Desogestrel 0.075 mg per tablet)
discontinuation in 98% of cases. It is freely available at all
government outlets free of cost. But it does not protect from Triphasic Pill
STI including HIV. Triphasic pill (Triquilar). It was developed with the aim of
reducing the total monthly hormone intake while maitaining
Combined Oral Contraceptive the efficacy of monophasic pill. The concentration of
Monophasic Pills: They contain estrogen and progesterone in progestogen varies as follows:
the same amount in 21 tablets. Last 7 pills contain no hormone For first 6 days ethinyl estradiol 0.03 mg LNG 0.05 mg
only iron tablets. They are simple to use, do not interfere in For next 5 days ethinyl estradiol 0.03 mg LNG0.075 mg
sexual act. The monophasic pills contents are as follows: For last 10 days ethinyl estradiol 0.03 mg LNG 0.125 mg
It is not commonly used main disadvantage is break-
Drug Estrogen Progestogen through bleeding.
Mala D Ethinyl Estradiol Norgestrel (0.15 mg) Non contraceptive advantages of oral contraception
(30 µ) 1. Cycle stabilized
(Available in market @Rs.3/pkt) 2. Lesser premenstural tension
Mala N 30 µ Levonorgestrel 0.15 mg
3. Lesser dysmenorrhea
(Available at Govt.
Health Facilities free)
4. Menorrhagia is cured—There is less blood loss and hence
Marvelon 30 µ Desogestrel 1.50 mg anaemia is reduced.
Loestrin 20 µ Norethindrone 1 gm 5. Protection against endometrial cancer. Even shorter
-1/20 use(even one year)reduces the chances up to 50% and the
Crisanta/Yasmin/Rasmin 30 µ Drospirenone 3 mg effect lasts 15 years(by reducing cell division)
Dronis-20 20 µ Drospirenone 3 mg 24/4 days 6. Epithelial ovarian cancer is prevented. This effect is due to
off prevention of ovulation.
402
 7. Protection against benign breast diseases, e.g. • Progesterones—reduce spermatogenesis but also cause loss
fibroadenomous disease, colorectal cancer of libido and potency.
8. Protect against functional ovarian cyst • Long acting adrogens—cause serious metabolic side effects.
9. Protection against pelvic inflammatory disease, • Antiandrogenic drugs like cyproterone acetate and
endometriosis, acne, hirsutism and ectopic pregnancy. flutamide reduce spermatogenesis and causes decreased
10. Third generation progestin increases high density libido and gynecomastia.
lipoprotein/low density lipoprotein ratio. • Under trail is oral Desogestrel 75–300 mg daily with
subcutaneous testosterone pellets, this suppresses
Side Effects Minor ones are:
gonadotropin secretion profoundly, and within 8 weeks
1. Nausea and vomiting (due to estrogenic effect passes off in
some men in 300 mg group are azoospermic. HDL cholestrol
2–3 weeks time) to avoid use the pill at night
does not change.
2. Headache
• Other drug under trial is prolactin. It inhibits

Chapter 53
3. Acne and oily skin
spermatogenesis in dogs. Exact mechanism of action is
4. Menstrual irregularities—Breakthrough bleeding,
under investigation. It may become future “Male Pill.”
hypomenorrhea, amenorrhea
• Nofertil pill-low dose Gossypol
ajor adverse effects • Mifepristone—disable sperms by acting on sperm
• CVS—1. Hypertension (due to water retention by estrogens) membrane
• Vascular effects—Venous thromboembolism • Extract from tripterygium Wilford-triptolide—Is a male pill
– Arterial thromboembolism in China.

Contraception
• Liver—increase cholestasis
• Neoplasia—Increase of hepatocellular adenoma Injectable Contraceptives (Fig. 53.20)
– Increase of risk of breast cancer a. Under injectable contraception, the most popular are
– Increase risk of dysplasia, cancer in situ of cervix and DMPA—150 mg, (Depot Medroxy Progesterone Acetate).
invasive cancer cervix by causing ectopy. Pregnancy rate is 0.04/100 women per year. It is given every
3 months by intramuscular route.
Centchroman
b. 2nd is NET-EN-200 mg is given two months. The salt is
Centchroman(Saheli): It is non-steroidal contraceptive pill Norethindrone enanthate. 1st injection is given within seven
developed by central drug research institute, Lucknow. Its active days of beginning of period (as to be sure that injection is
component is ormeloxifene. (i) Mechanism of action. It has given in non-pregnant period). Immediately after abortion
weak estrogenic and potent anti-estrogenic action. (ii) It slightly and six weeks after delivery. It has been seen to be harmless
increases transport of the zygote through the oviducts, if given early after well-establishment of lactation.
(iii) accelerate blastocyst formation and (iv) to suppres uterine Side effects—is mainly episodes of irregular bleeding.
endometrial proliferation and defective decidualization by Hence proper selection of patients and counseling is
blocking mitosis of the uterine epithelial tissue. All these effects essential. Other side effects—Bone density loss and delayed
combine and create sufficient asynchrony between the return of fertility which are reversible.
developing zygote and endometrial maturation to prevent c. Depo sub provera 104—Has 104 mg of medroxy
implantation. progesterone acetate in 0.65 ml given as subcutaneous
ethod of use (3 mg) First tablet on first day of the cycle then injection is effective for 3 months. It causes fewer side effects,
one tablet twice a week at the same time for 2 months then once such as weight gain. It is available in prefilled syringes.
a week. No side effects of hormonal contraception are there. There d. Now estrogen is added and irregular bleeding of only
is doubtful association of benign ovarian cyst with its use which progesterone injection stops. The combined injectable
is being investigated. Failure rate 1–4/100 women year. contraceptive under trails is Cyclofem—previously called
Any deviation may lead to pregnancy. If period delayed Cycloprovera-DMPA 25 mg and Estradiol cypionate 5 mg.
beyond 15 days, she must consult the physician. Another similar Mesigyna-NE TEN 50 mg + Estradiol velarate 5 mg.
drug which acts on embryogenesis and pre-implantation is Third is Chinese injection No. 1. It has 17 Alpha
under trial. hydroxyprogesterone Caproate 250 mg + estradiol velarate
5 mg. These injections are given every 30 days.
Non-estrogen Combined Pill e. onadotropin releasing hormone antagonist—is
The widely used RU-486 (Mifepristone) delays folliculogenesis particularly useful for women over 35 years of age. A third
and luteinization. This property is under investigation to design generation compound Antide (Nal – Gys G GnRH
a non-estrogen combined pill.
First 15 days-RU 486 (Mifepristone) 5 mg/day is taken, next
13 days- medroxyl progesterone acetate (MPA) 10 mg/day be
used.
It does not inhibit ovulation but retarded endometrial
maturation and hence prevent implantation. Consequence of
long-term therapy is under study. Other antiprogestins under
trail are ZK 98, 734, ZK 78, and 299, HPR 2000.

Male Pills
So far they have not been successful with mala pill. Various
drugs are tried. Progesterone, long acting androgens,
antiandrogenic drugs, halogenated sugar, Gossypol,
Tripterygium—Wilford and prolactin. Fig. 53.20: DMPA and NET-EN injections
403
 antagonist) is developed which is well- tolerated and is of
sufficient potency.
It is under trail for both males and females. It acts by direct
competitive (receptor saturation), inhibition to suppress FSH/
LH secretion. It needs a long-term delivery system to achieve
and sustain higher serum levels (Depo delivery in the form of
intramuscular microsphere or subcutaneous implants is under
trial).
Phase 1 clinical trial of LHRH antagonist implants were
initiated by population council.
Fig. 53.21: Norplant
Non contraceptive benefits of progesterone infections
MTP and Contraception

1. Protect against endometrial cancer

2. Protects against PID
3. Reduces incidence of anemia by reducing blood loss
4. Reduces dysmenorrhea
5. Reduces acute sickle cell crisis
6. Reduces ovarian cysts
7. Decreases pain associated with ovulation.
ale injectable contraceptive
They are under trial.
• They are testosterone enanthate weekly, testosterone
buciclate 3 monthly. Supresses FSH and hence prevents
testosterone production.
• Inhibin and Prolactin injections are also under trial. Inhibin
Fig. 53.22: Implanon
Section 14

is peptide hormone found in gonads. It only suppresses

the release of FSH from pituitary and thus could prevent sperm
d. Now Biodergradable Implants are under trial are,
production without affecting production of testosterone.
Capronor, Norethindrone pellet and Microspheres. These
Prolactin injection suppresses spermatogenesis in dogs. It
implants deliver progestin from a carrier to be inserted and
promises to be the future male contraceptive injection.
do not need to be removed and may cost less to manufacture.
• WHO recently completed a study which clearly
demonstrated that long-acting androgen, when given by Capronor has levonorgestrel. It provides effective contraception
injection can cause severe oligospermia without loss of for one and a half year.
libido and these testosterone induced changes are reversible Pellet contains norethindrone enanthate with cholesterol in four
on cessation of treatment. pellets, each size of a grain of rice. It provides highly effective
• In one study Intranasal norethisterone was administered contraception for one year.
daily—Number of sperms was considerably reduced. These
changes are reversible on discontinuation of drug. Microspheres consist of a biodegradable copolymer similar to
• Inj. Testosterone undecanoate combined testosterone and one used in synthetic absorbable surgical suture and steroid
progesterone preparation for contraceptive effect by hormone. They utilize ortho pH new progestin- Norgestimate
augmentary suppression of gonadotropins which is less androgenic. A large clinical trial of 90 days
• Combined etonogestrel implant with testosterone norethindrone enanthate microsphere system is currently under
(Implanon rod with testosterone pellets) trial.
• Combination of cyproterone acetate with testosterone. LHR antagonist pellet is under trial.

Implants Contraceptive Vaginal Rings (Figs 53.23A and B)

a. Norplant (Fig. 53.21) is a first generation implant system. It Offer an easy option for administration of contraceptive steroid
is a subdermal implant containing Levonorgestrel with which is under control of women. It delivers effective
non-biodegradable silicon capsules. It gives 5 years of contraceptive dosage of steroid into the circulation by
effective and convenient contraception. Insertion and absorption through the vaginal epithelium. Phase III trials are
removal is by a minor operation under local anesthesia. yielding good results. It avoids the necessity of remembering
Pregnancy rate is less than 1/100 women year. Although
irregular bleeding is commonly reported by users, it is a
very effective method. The rate of ectopic pregnancy is very
low. There is no incidence of neoplastic and cardiovascular
disease. It was extensively tried in Safdarjung Hospital as
an ICMR study.
b. Norplant-2 or adelle which consist of two silastine covered
rods releasing levonogestrel its use is up to 5 years.
c. Implanon (Fig. 53.22) which consists of ethylene vinyl ace-
tate (EVA) containing 68 mg in one rod releasing 3 etono-
gestrel—both b and c have a contraceptive efficacy of 3 years
are classed as 2nd generation implant systems. It is being
used in Safdarjung Hospital as an ICMR study. Figs 53.23A and B: Contraceptive vaginal rings
404
to ingest a pill daily and it bypasses liver. Gives more uniform are as follows:
hormone levels. 1. Tubal blocking plug
They are made of non-toxic silicone (dimethyl polysiloxane). 2. Essure (flexible microinsert)
The release of hormones is proportionate to their surface area 3. Crafts ceramic plug
and inversely proportional to the thickness of the outer wall. 4. Hossemian polyethylene plug
Four designs are there of which shell is most common. The 5. Preformed silicone plug
vaginal ring (used for 3 months) is levonorgestrel which is 6. Nylon intratual device-Hamou
released at the rate of 20 microgm per day. Other is combined 7. Silicone rubber
or estrogen and progesterone vaginal rings (used for 3 weeks). 8. CuT with silastic ball at tip of the arm
Chemical released is ethinyl estradiol (15 µg) and etonogestrel 9. Quinacrine injection.
– 0.12 µg. Most commonly practiced is Essure (Figs 53.24A and B)—
It is non-incisional alternative to tubal ligation. A soft flexible

Chapter 53
Transdermal Patches microinsert is placed in each fallopian tube through
Three-level patch (inner layer removed on insertion, 2nd layer hysteroscope. It can be inserted after exclusion of pregnancy
is medicated layer, 3rd layer protective polyester layer. and on any day of her cycle. It is taken as permanent method of
A patch is 20 cm in size. During first 3 weeks of the cycle one contraception because removal needs surgery and there are no
patch is applied every week and then one week is patch free. results yet on future functioning of tubes. The patient must use
Areas used are lower abdomen, buttocks upper torso, upper outer alternative contraception until a hysterosalpingogram (HSG),
arm but not on breasts (mostly non-hairy area). (New patch is (which is performed 3 months postmicroinsert placement),

Contraception
applied to a different area of skin on the same day of week as demonstrates satisfactory micro-insert location and tubal
previous patch.). When to start first patch started on any day occlusion. During this time frame, she should use another
after excluding pregnancy within first 5 days of period, contraceptive.
postpartum, postaborted and a backup contraceptive for 7 days. It does not protect against STI/HIV. Use some other
If patch gets detached apply within 24 hrs. At same body contraceptive method for first 3 months the period in which in
location and use backup method for 7 days. growth of tissue results in tubal obstruction. One year failure
Skin irritation can be seen. Other side effects are same as rate 0.2.
oral contraceptive pill. Not effective in obese patients (more uinacrine pellets or injection at the fallopian opening went
than 198 lbs). Does not protect against STI/HIV. Perfect use gives into disrepute for improper selection of patients but has re-
0.3% failure rate. emerged (Sokal and associates 2008).
Intrafallopian and intra vas deferens injection varios drugs
are tried. Intravasal Contraceptive Device (IVCD)
These are under trial like intratubal contraceptive devices.
Male Intra-vas Contraceptive Devices Researchers are trying to put some foreign body in the vas
Reversible inhibition of sperm under guidance (RISUG). This deferens in males to produce temporary blockage leading to
method is developed in India (Trans vas deferens). contraception. The methods under trials are:
RISUG—Styrene maleic anhydride (5 mg) intravasal • Thick nylon thread
injection coats the vas with a clear polymer gel with negative • Vas valves
and positive electric charge. Sperm cells also have a charge, so • Bayeux
the differential charge from the gel ruptures the cell membrane • Brigid end tube valves
as it passes through the vas. Stopping sperm in their track before • Reversible intravasal occlusive device-RIQD.
they can even start their journey to the egg.
RISUG does not affect the surrounding tissues because they Contraceptive Vaccine (CV)
have no charge. It is long-lasting contraceptive method. A single If we want success in population control, active immunization
injection is effective for at least 10 years. is the procedure of choice for this large scale family planning
program in our country. Keeping in mind immunization against
Insertion of Devices and Drugs in polio and other diseases the contraceptive vaccine holds many
Fallopian Tubes and Vas Deferens attractive attributes, conforms long-term effective reversible
These are under trial. (i) Temporary plugging of fallopian tubes protection against pregnancy, follow a single or a couple
is done through hysteroscope. Various methods under research (booster) of injections. (i) no side effects of drugs which are

Figs 53.24A and B: (A) Essure in situ; (B) Diagrammatic 405

 seen with other methods of contraception. (ii) no device (IUCD) recommended practice is to seek assurance that a woman has
or implant to be inserted, (iii) effective even if the client has no not been sexually exposed at the time of insertion, IUDs have
active involvement after immunization (e.g. taking oral drugs been deliberately inserted, on an experimental basis,
or injectable) (iv) it covers many clients in a shorter period of immediately after unprotected intercourse, when a woman
time, (v) inexpensive, (vi) acceptable thus fulfilling properties might become pregnant, so as to prevent or interrupt the
of an ideal contraceptive. implantation of a fertilized ovum in the uterus. This procedure
The active immunization depends on generation of an showed no morbidity.
immune response directly against the target antigens in the
reproductive tract. In contraceptive vaccine three types of Oral Emergency Contraceptive
antigen are targeted in 3 different stages of development of a. The most commonly used drug is Norgestrel
human reproduction cycle. They are: 1.5 mg as single dose taken as early as possible after
1. Gamete production unprotected exposure. It will prevent pregnancy up to 120
MTP and Contraception

2. Gamete function hrs for that unprotected act. Various mechanisms of action
3. Gamete outcome. depending on the phase of cycle are:
The research was started by Dr G P Talwar in Indian Institute • Inhibition or delay of ovulation beyond the sperm
of Immunology Delhi. survival period when taken before ovulation
The vaccines so far tested are: • Thickening of cervical mucous preventing sperm
• β-hCG linked with TT movement
• β-hCG linked with DPT • Endometrium development is altered preventing
• β-hCG linked with LH implantation of fertilized ovum due to altered hormonal
• Vaccine against LHRH (Luteinizing Hormone Releasing pattern
Hormone). • Fallopian tube mobility is altered hence alters the
Other immunologic methods under trial are: transport of sperm, ovum and fertilized ovum
a. Induction of mucosal immunity in the genital tract along oral • It may cause absent or subnormal LH surge hence
vaccine It appears that uterus does not have a significant ovulation dysfunction
Section 14

scretory IGA defence system, but is permeable to systemic • Corpus luteal function is impaired.
immunoglobulins. Hence this site can be manipulated by Hence there is action on ovulation, fertilization (affecting
systemic oral vaccine. The local genital tract (cervix + vagina) sperm mobility) and implantation of fertilized ovum.
has strong local secretory immunity and thus local Other drugs used for emergency contraception are:
immunity can be induced at these sites. Therefore, in both b. High dose estrogen—they produce high incidence of side
females and males, a primary oral immunization followed effects especially vomiting.
by repeated local (vaginal or rectal) boosters by self- c. Yuzpe regimen used 50 µg ethinyl estradiol and 0.5 mg
administered suppositories at regular intervals would norgestrel (in 1972) 2 tablets twice 12 hours apart and it
appear to have best chance of being successful. Hence, a will protect up to 72 hrs.Though side effects were less but
contraceptive vaccine will find its way into family planning they were still there.
practice in near future. d. Can use 4 tablets of combined oc pill (30 mg ethinyl estradiol
b. Intrauterine neem oil instillation A local cell mediated immune and 0.030 mg norgestrel) twice at an interval of 12 hours.
response against conception develops when Neem seed oil e. Mifepristone (RU 486)—anti-progestogen 10 mg dose as
was instilled into the uterine cavity—it generated cytokines soon as possible. It is anti-implantation in action. Menstrual
which kill spermatozoa or the embryo and thus prevent disturbances are seen.
pregnancy. f. Danazol 400 mg twice at an interval of 12 hours. It is
Trial was done in a few patients in our department also. luteolytic in action.
Thus with more choice of contraceptive methods with g. Centchroman—Two 50 mg tablets given twice at 12 hours
less and less complications, doctors can have a method of gap within 72 hours of unprotected act. It is still under trial
choice for different individuals as far as possible and thus for this indication.
help reduce population explosion. h. Ulipristal—an orally active synthetic progesterone receptor
modulator. It inhibits or delays ovulation. The dose 30 mg
Emergency Contraception (Morning after
stat.
Pill or Postcoital Contraceptive)
E-Pill is available free of cost by Govt. of India as an
Unintended pregnancy has many social, personal and financial emergency contraceptive (Fig. 53.25).
consequences besides dangerous to health. Emergency Advantages of EC pills: Reduce unintended pregnancies
contraception provides a second chance of protection against prevent induced abortion and hence improve the health and
unwanted pregnancy for women who experience contraceptive well-being of women in reproductive age group.
failure (e.g. condom ruptures) or do not use a method as well
as for women who experience unplanned intercourse including Intrauterine Contraceptive Devices
coerced sex or rape. There are methods available for emergency Copper-containing IUD can be used as an effective postcoital
contraception to intercept pregnancy at ovulation, fertilization contraceptive if insertion of Copper T is performed within 5
or implementation depending upon the time of unprotective days of unprotected intercourse. It has been reported as a highly
sexual act. successful method for postcoital CC (98% effective). The
The two primary methods of Emergency Contraception are: incidence of ectopic pregnancy does not change and EC does
• Postcoital use of drugs not impair future fertility. Copper T is effective following even
• Insertion of an intrauterine device (IUD) multiple coital exposures during a short interval and when delay
Both can significantly reduce a woman’s chance of becoming is beyond 72 hours, making hormonal methods ineffective.
pregnant (75% and 99% respectively). The possibility of IUD as IUD is particularly suitable for women who would like to
406 EC is being explored from 1976. Though the usual and continue using it as a regular CC. In young multiparous women
 Laparoscopic Sterilization
• With MTP
• With surgical procedures—Manchester repair and VVF
repair
• Alone as interval surgical procedure.
Laparoscopic sterilization should not be concurrently done
with second trimester abortion or in the postpartum period. In
these cases male sterilization or mini laparotomy procedure is
allowed by the Govt. of India. This is because fallopian tubes
being larger get torn more often and recanalize easily (failure).
Eligibility Criteria for Female Sterilization (Case Selection)

Chapter 53
(Government of India, Ministry of Health and Family Welfare)
• The patient should be married (including ever married).
• Age above 22 years and below 49 years. Husband should
be below 60 years.
Fig. 53.25: E-Pill • The couple should have at least one child more than 1 year
of age. Unless sterilization in medically indicated.
or women with multiple sex partners, there is the risk of PID. • The client or her spouse must not have undergone

Contraception
Sometimes, irregular bleeding associated with IUD insertion sterilization in the past (not applicable in cases of failure of
may mask symptoms of early pregnancy. previous sterilization).
Advantages • The client must be in a sound state of mind so as to
• Pregnancy rate is <1% understand the full implications of sterilization.
• Continued CC • Mentally ill clients must be certified by a psychiatrist and
• Subsequent intercourses protected. consent should be given by the legal guardian spouse
regarding the soundness of the client’s state of mind.
Disadvantages
• Infrastructure and training required WHO Medical Criteria
• After checking and ruling out PID.
For female sterilization
A longer efficacy time frame (Coitus intervention interval)
of up to 1 week is to be highlighted as well as the possibility of ontraindications There are no absolute contraindications for
continued contraception. performing sterilization operation. However, caution (C), delay
(D) and special (S)
PERMANENT METHOD OF CONTRACEPTION • Known to have or suspected to have pregnancy (wanted)
• Active pelvic infections (pelvic peritonitis)
Female Sterilization • Acute systemic infection
Female sterilization is the most common permanent method of • Active liver disease
contraception in India amounting to one fourth of the whole • Skin infection at the operation site
world. As many as 2439 female sterilization operations were • Sexually transmitted disease (STD) infection
performed in Safdarjung Hospital during 2005 compared to 270 • Severe anemia (less than 8 gm/dl)
vasectomy (male sterilization). • Acute respiratory disease
Female sterilization was first performed in 1823 in London • Current cardiovascular or coronary heart disease
by Dr J Blundell. By 1950 and 1960, it was initiated in several • Malignant trophoblastic disease
countries. Since 1970 it has rapidly grown. According to WHO • Any other temporary operative risk
(1994) data 202 million total (female and male) saterilization • Any psychiatric condition that may impair decision-making.
are done world wide with 163 million women sterilization. It Following pregnancy conditions to be treated and resolved
can be performed per abdominally (minilaparotomy or before operation
laparoscopically) and per vaginally. • Puerperal sepsis
Methods Per Abdomen • Prolonged rupture of membrane (24 hrs or more)
• Pregnancy with persistent hypertension
1. After a postpartum or puerperal waiting period of 24 hours
• APH and PPH
for rest after delivery the operation can be performed up to
• Severe trauma to the genital tract
7 days after parturition.
• Postpartum psychosis
2. With cesarean section—when there is indication to do
• Unhealthy newborn/stillbirth
cesarean section. Ligation itself is not an indication for
• Recent septic abortion
cesarean section.
• Severe postabortal hemorrhage.
3. With MTP or evacuation of incomplete abortion in the same
setting. Delay should be at least 6 weeks after delivery or abortion.
4. With gynecological operations of Manchester repair, Conditions where reference to center with facilities for
vesicovaginal fistula (VVF) repair. general anesthesia and other medical support is mandatory.
5. Interval sterilization (in between two pregnancies) Conditions increasing anesthetic risk are:
preferably at least 6 weeks after delivery and beyond. Do it • Post cardiovascular disease
within 7–10 days of onset of menstrual period to prevent • Chronic respiratory problem
any chances of pregnancy. • Hypertension (BP>160/100 mmHg)
• Hyperthyroidism
Vaginal Sterilization • Diabetes with vascular disease
Vaginal sterilization as such alone or with Manchester repair • Moderate anemia (>7–10 gmdl) 407
or MTP. • Severe chronic liver disease.
 In these conditions experienced medical staff are required part is cleaned and draped. The abdomen is opened by a
to perform the procedure. subumbilical incision. The size of incision depends on the
Conditions that increase surgical difficulties and risk uterine size. In postpartum sterilization, the uterine size is big
• Endometriosis and the incision is given below the height of uterus (3–4 cm)
• Past pelvic infection but in interval ligation it is 2.5 cm above the symphsis pubis.
• Past complicated abdominal or pelvic surgery The tube is identified, always look for the fimbrial end. Use
• Marked obesity number 1 chromic catgut.
• Umbilical hernia In modified Pomeroy use one zero plain catgut. A loop is
• Coagulation disorders. made about 4 cm lateral to the fundus and ligated twice by
catgut. The loop above the ligature is cut and the surgeon should
Counseling look for any hemorrhage. Repeat the procedure on the other
Counseling in a language understood well by the client is very side. The abdomen closed in layers. Cut tubes are sent of
MTP and Contraception

important in helping her make an informed and voluntary histopathological examination (Figs 53.26 A and B).
decision about her fertility. She must be informed of all available After the catgut is absorbed the ends retract and hence the
methods of family planning and made aware that for all tube cannot recanalize spontaneously. The failure rate is
practical purpose this operation is a permanent one. 1:300:400.
She must make an informed decision for sterilization
Minilaparotomy
voluntary.
Side effects and potential complications of surgery are also This can be done under general anesthesia or local anesthesia
told in clear, balanced way. (0.5% lignocaine) and sedation. The patient empties her urinary
Information given about sterilization: bladder. Cleaning and draping is done. Local anesthesia is given.
• It is a safe and simple procedure A uterine elevator is passed from the vagina.
• It is a permanent procedure that has a small risk of A 2.5 cm incision is given midway between the pubic
complications requiring further treatment symphysis and the umbilicus.
• It does not affect sexual pleasure, ability to perform normal In interval ligation the incision is given above the symphysis
Section 14

day-to-day function pubis. The abdomen is opened.

• It has a small chance of failure, even if performed under Identification of the tube is very important. It is caught with
optimum circumstances Babcock’s forceps and the fimbrial end is identified. It is always
• Sterilization does not give protection against reproductive safely to be away from the cornua. Both tubes are ligated and
tract infection RTI/STD including HIV/AIDS cut one by one. Usually modified Pomeroy’s technique (Figs
• She is told that a reversal of this surgery is possible but the 53.27 A to G) is used in Safdarjung Hospital. Other methods of
reversal involves a major surgery and its success cannot be female sterilization by laparotomy are:
guaranteed Irving method Ligating and burying the proximal tubal end in
• She is encouraged to ask questions to clarify doubts the serosa of the posterior uterine wall (Figs 53.28 A to D).
• She is told that she has the option of deciding against the
procedure without sacrificing her right to other reproductive
health services
• It is not compulsory or binding. It is voluntary. It is not
taken when the woman is sedated or under stress. A printed
consent form is provided by the Government. The husband’s
consent is not essential.
Preoperatively Clinical assessment and screening of client is done.
Prior to surgery, medical history, physical examination and
blood test for hemoglobin and urine analysis for sugar and
albumin are carried out. Tetanus toxoid is given (if not
previously immunized). Informed written consent is taken. The
hemoglobin must be 8 gms or more. (Govt. of India manual on
standards for female and male sterilization service 2006).
ho can perform Female sterilization by minilaparotomy. This
operation can be performed by a trained MBBS doctor.
Laparoscopic sterilization can be performed by a gynecologist
(DGO/MD/MS) or a surgeon with an MS degree and who is
trained in laparoscopy.
Premedication/Anesthesia/Analgesia-Tablet alprazolam
(0.25–0.50 mg) or tablets Diazepam (5–10 mg) a night before is
given. An IV line is secured. General or spinal anesthesia is
given in postpartum sterilization.
Techniques of Operation
The surgeon must see that enough tube is left for recanalization
(if need arises) and ligation is not carried out too close to the
cornua. The following methods are mostly used.
Pomeroy’s method The patient is kept fasting overnight. She is
408 given sedation. Local, spinal or general anesthesia is given. The Figs 53.26A and B: Modified Pomeroy’s technique
 Chapter 53
Contraception

Figs 53.27 A to F: Female sterilization (by modified Pomeroy’s technique)

chida method The medical tied end of the fallopian tubes is Fimbriectomy
retracted into the mesosalpinx after tying and cutting it. The fimbrial ends are cut and tied.
Par land method The tube is tied at two ends after making a Advantages of Female Sterilization
window in an avascular portion of the mesosalpinx and cut in A safe, effective, convenient method.
between (Figs 53.29 A to C). Can be performed by a junior doctor at primary health
centers or camps after proper treaining.
oagulation methods
Complications are mostly minor. When performed
• Bipolar coagulation
according to accepted medical standards. (Govt. of India
• Unipolar coagulation.
Manual 2006).
Bipolar Cautery Method (Fig. 53.30) No special equipment or training is needed (compared to
Here the tube is cauterized by electric cautery at 2 points. laparoscopic sterilization).
409
 Can be performed soon after childbirth, abortion or as
interval sterilization.
It is once only procedures. There is no need for long term
contraceptive supplies.
1.8% major and 14% of minor complication are reported (WHO
1982, ICMR 1982) (Table 53.1).

Table 3.1: Showing complications of female sterilization

Immediate complications Complications depend on
Anesthesia hazard Anesthesia use
Bowel and bladder injuries Route (abd. and vag)
MTP and Contraception

Tube and ovaries injuries Age

Broad ligament injuries Place of operation
Hematoma at incision site Selection of patient
Uterine perforation Technique.
Fig. 53.27G: Female sterilization (Final result)
Section 14

Figs 53.28A to D: Irving method

410 Figs 53.29A to C: Parkland method Fig. 53.30: Bipolar cautery method
 ound infection This is the most common complication.
Sometimes hematoma formation and subsequent infection can
occur. Intraperitoneal hemorrhage, bowel and bladder injuries
are rarely seen. Ectopic pregnancy is an uncommon compli-
cation. Female sterilization does not protect against STD
including HIV/AIDS.
Postoperative care—The client is monitored.
Drawbac s
• Infection of wound can occur.
• The scar is larger.
Vaginal Tubal Ligation Fig. 53.32: Falopes ring method

Chapter 53
This method was in vogue in the 1970’s. But because of a greater
risk of infection it is not commonly used. It can be combined
with MTP and gynecologic pelvic correction operations
(Manchester Repair). It can be done as an interval procedure.
After anesthesia the patient is put in a lithotomy position.
The part is cleaned and draped. The posterior lip of the cervix
is caught with a vulsellum and colpotomy is done.

Contraception
The tubes are ligated and cut one after the other. In both
abdominal and vaginal ligation analgesic ligation intercourse
is to be avoided for at least 3 weeks. Postoperative complications
depend on the method of sterilization.
Laparoscopic Tubal Ligation
It is performed at a place where facilities for laparotomy are
present (Figs 53.31 to 53.34).
Abdomen is entered by an incision at the lower margin of Fig. 53.33: Falope’s ring applied on the fallopian tube
umbilicus. Pneumoperitoneum is created by Viress needle by
introducing carbondioxide gas (gets absorbed easily). The
incision is slowly enlarged. Trochar is inserted. Laparoscope is
inserted. Fallopian tube is recognized by fimbrial end
(manipulation done prevaginally by an assistant having uterine
sound in the uterus). The tube is pulled in the laparoscope and
fallop’s ring are slipped on it. The other fallopian tube is
similarly ligated. The tubes are seen blanched (look white)
because the blood supply is blocked by the ring. The
laparoscope is removed. Excess gas is removed. Remove trochar
and stitch. Monthly report of sterilization is sent to CMO
incharge incentive is given by Govt. of India for undergoing
sterilization. Union Govt. has published standards and quality

Fig. 53.34: Spring clip method

assurance manuals so that any neglect can be pin pointed. Govt.

has started family planning insurance scheme (from December
2005 onwards) to settle claims of complications including
failures.

Male Sterilization
Vasectomy is the surgical procedure for permanent
contraception in males. It is a safe procedure and does not
interfere with physical and sexual capacities of the person. The
vase deferens is cut and tied. It can be reversed surgically. It is
performed by two methods. Traditional vasectomy and non-
scalpal vasectomy.
Preoperative counseling of the couple is essential. If he is on
aspirin he is asked to stop for at least 10 days. The scrotum is
shaved. Written consent is taken and injection Tetanus Toxoid
is given.
Traditional vasectomy: Local anesthesia is given in the scrotal
area or two incisions are made on either side. Vas deferens is
Fig. 53.31: Instruments for laparoscopic ligation pulled out via them. It is clamped, cut and tied. Skin stitches 411
 are closed by one zero chromic catgut suture. Bandage is applied 6. IUCD reference manual for medical officers. FP Div. of Min of IT
and scrotal support is given. Cut vas is sent for histopathology. and FW, GOI 2007.
7. Morston C Clelaend the effect of contraception on obstetrics
Non-scalpal vasectomy: The vas deferens is palpated under outcomes. Geneva WHO document 2003.
the skin, held in place with a clamp. The overlying skin is 8. Naz RK, Gupta SK, Gupta JC, et al. Recent advances in contraceptive
anesthetized by xylocaine injection. A tiny hole is made in the vaccine development: a mini review. Human Reproduction
scrotum by a special artery forceps. This hole is stretched by 2005;20(12):327.
artery forceps vasa deferentia are pulled out clamped, cut and 9. Pinto E. Velasquez C. Introducing the standard days method in
tied. No skin stitches are required. Complications are much less CEMPLAP programme interim operations research report
CEMOLAF IRH 2003.
in this procedure. Both procedures are day time outpatient
10. Quality assurance manual for sterilization services. Research
surgery. It is absolutely safe. studies and standard division. Ministry of Health and Family
Patient is instructed to avoid strenuous exercises and sexual Welfare Govt. of India Book 2006.
MTP and Contraception

intercourse. Scrotal support is applied for a few days. Other 11. Reference Manual for minilep tubectomy. FP Div. Min. of Health
contraceptive methods are to be used for 12–16 weeks. Semen and FW, GOI, November 2009.
test is done thrice in 3 months. Once the semen test shows 12. Smith RD. Comtempory hysteroscopic method for female
azospermia no other contraceptive method is required. sterilization. Int. J. Gynae. Obst 2010;108:79.
13. Sokal DC, Hieu DT, Loan ND, et al. Safety of quinacrine
Complications: Infection of the operation site centraceptive pellets – results from 10 year follow-up in Vietnam.
• Hematoma formation. Contraception 2008;78:67.
14. Standards for female and male sterilization services Research
BIBLIOGRAPHY studies and standard division Ministry of Health and Family
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Section 14

3. C HB, Devoto L, Durand M, et al. Mechanism of action of hormonal Committees on Obstetrics and Gynaecology. Second report on
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412
 The Preconception (PC) and Prenatal
54 Diagnostic Techniques (PNDT) (Prohibition of
Sex Selection) Act

Sudha Salhan

ADVERSE CHILD SEX RATIO IN INDIA and male bias in enumeration of population. Easy availability
Sex ratio (number of females per thousand males) is one of the of the sex determination tests and abortion services may also
most important indicator used for study of population be proving to be catalyst in the process, which may be further
characteristics. Declining trend in sex ratio has been a matter of stimulated by preconception sex selection facilities.
concern for all in the country. Sex ratio in India has declined Sex determination techniques have been in use in India since
over the century from 972 in 1901 to 927 in 1991. The sex ratio 1975 primarily for the determination of genetic abnormalities.
has since gone up to 933 in 2001 (Fig. 54.1). The sociocultural However, these techniques were widely misused to determine
practices in India are predominantly biased against females. the sex of the fetus and subsequent induced abortions if the
In contrast, the child sex ratio for the age group of 0-6 years fetus was found to be female.
in 2001 is 927 girls per thousand boys against 945 recorded in Approximately, 2000 females feticide occur per day in India
1991 census. The encouraging trend in the sex ratio during 1991– more so in urban areas. To curb this practice and in order to
2001 was marred by the decline of 18 points in the sex ratio of check female feticide, the prenatal diagnostic techniques
children aged 6 years or below (Fig. 54.2). (Regulation and Prevention of Misuse) Act, 1994, was brought
The census 2001 figures further reveal that the child sex into operation from 1st Jan 1996. The prenatal diangositc
ratio is comparatively lower in the affluent regions, i.e. Punjab techniques (regulation and prevention of misuse) act 1994 has
(798), Haryana (819), Chandigarh (845), Delhi (868), Gujarat since been amended to make it more comprehensive. The
(883) and Himachal Pradesh (896). State/UT wise sex ratio and amended Act and rules came into force with effect from 14th
child sex ratio as per 1991 and 2001 census is also dismal. feb. 2003 and the PNDT Act has been renamed “2003
Some of the reasons commonly put forward to explain the Preconception and prenatal diagnostic techniques (PCPNDT)
consistently low levels of sex ratio are son preference, neglect (Prohibition of sex selection) Act 1994 to make it more
of the girl child resulting in higher mortality at younger age, comprehensive. The Act to provide for the prohibition of sex
female infanticide, female feticide, higher maternal mortality selection, before (preconception) and after conception (Prenatal)
and for regulation of prenatal diagnostic techniques. The
purpose of detecting genetic abnormalities or metabolic
disorders or chromosomal abnormalities or certain congenital
malformations or sex-linked disorders and for the prevention
of their misuse for sex determination leading to female feticide
and for matters connected therewith or incidental thereto. This
Act extends to whole of India except the state of Jammu and
Kashmir. It is both prohibitory and regulatory in nature and its
violation is a punishable offence.
The technique of preconception sex selection has been
brought within the ambit of this act so as to preempt the use of
such technologies, which significantly contribute to the
declining sex ratio. Use of ultrasound machines has also been
brought within the purview of this act more explicity so as to
curb their misuse for detection and disclosure of sex of the fetus
leading to female feticide.
Preconceptional Prenatal diagnostic procedures include all
gynecological or obstetric or medical procedures such as
ultrasonography, fetoscopy, taking or removing samples of
amniotic fluid, chorionic villi sampling, embryo, blood or any
other tissue or fluid of a man or a woman before or after
conception, for being sent to a (genetic laboratory or genetic
clinic) for conducting any type of analysis or preconception and
prenatal diagnostic test for selection of sex before or after
conception.
‘Prenatal diagnostic test’ means ultrasonography or any test
Fig. 54.1: Child sex ratio (0–6 yrs) in states of India. Source: Censes or analysis of amniotic fluid, chorionic villi, blood or any tissue
2001 office of the Registrar General of India or fluid of a pregnant woman or conceptus conducted to detect
MTP and Contraception

Fig. 54.2: Sex ratio in India over the years

genetic or metabolic disorders or chromosomal abnormalities authorities are empowered with the powers of civil court for
or congenital anomalies or hemoglobinopathies or sex linked search, seizure and sealing the machines, equipments and
diseased. records of the violators of law including sealing of premises
Sex selection includes any procedure, technique, test or and commissioning of witness. Sensitization of AA through
administration or prescription or provision of anything for the training and workshop. It has been made mandatory to maintain
purpose of ensuring or increasing the probability that an embryo proper records in respect of the use of the ultrasound machines
will be of a particular sex. It is determination of the sex of unborn and other equipments capable of detection of sex of the fetus
child and eliminate it, if found to be a female. and also in respect of test and procedures that may lead to
Three types of clinics are considered in this act all to be preconception selection of sex. The sale of ultrasound machines
Section 14

registered with the District Medical officers. has been regulated through laying down the condition of sale
1. Genetic counseling center only to the bodies registered under the Act. Manufacturers of
2. Genetic laboratory u/s machines are required to send report to the AA giving details
3. Genetic clinic (ultrasound clinic/imaging center). of clinics and doctors to whom they sold u/s machines.
Genetic Counseling Center (CGC) Punishment Under the Act
A geneticist, a gynecologist or a pediatrician who has 6 months The punishments prescribed are imprisonment up to 3 years
experience or 4 weeks training in genetic counseling or a medical and fine up to ` 10,000.
geneticists can run this clinic. Equipments include educational For any subsequent offences, he/she may be imprisoned up to
charts, models, etc. Space must be adequate. A medical geneticist 5 years and fined up to ` 50,000 to 100,000.
possesses a degree or a diploma in genetic science. The name of the registered medical practitioner is reported
Genetic Laboratory by the appropriate authority to the state medical council
Genetic laboratories with the prescribed equipments are needed. concerned for taking necessary action including suspension of
A degree or diploma holder of medical laboratory course and the registration if the charges are framed by the court and till
medical genetics with at least one year experience in the field the case is disposed off. Govt. of India is contemplating a longer
of sex selection and prenatal diagnostic techniques or has jail sentence along with higher monitoring penalty up to 1 lakh.
experience of not less than 2 years in any of these fields after Ministry of Health and Family Welfare has taken a number
obtaining any one of the medical qualification recognized under of steps for the implementation of the Act. The major steps taken
the Indian Medical Council Act 1956 or a postgraduate degree are as follows:
in biological sciences. Chorionic biopsy, amniotic fluid • Meeting of the Central Supervisory Board (CSB): Meeting of
aspiration umbilical blood aspiration, and tissues of the fetus the central supervisory board of PC and PNDT act are being
extraction and analysis. held regularly every six months under the Chairmanship
of Union Minister of Health and Family Welfare.
Genetic Clinic (Ultrasound Clinic and Imaging Center) • Sensitization through members of Parliament: An amount of Rs. 5
A registered dedicated ultrasound machine and a sonologist. lac each has been given to 126 members of Parliament (Lok
Ministry of Health, Govt of India is planning to bring in a Sabha and Rajya Sabha) from states of Chandigarh, Delhi,
mandatory clause in this law to only allow gynecologists Gujarat, Haryana, Himachal Pradesh, Punjab and Rajasthan
obstetricians and radiologists with a postgraduate qualification to create public awarness on sex selection and declining sex
to use ultrasound machine. ratio by organizing exhibition, seminars, workshops, training/
The central supervisory board (CSB) constituted under the orientation programs for PRIs, SGHS, Public meetings, debates,
chairmanship of Minister of health and Family Welfare has been essay competitions, nukkad nataks, stage shows, etc.
further empowered for monitoring the implementation of the • On 2.10.07 on the occasion of the Birth Anniversary of the
Act. State level supervisory board in the line of the CSB Father of the Nation Mahatma Gandhi, a signature
constituted at the center has been introduced for monitoring campaign was launched to generate awareness regarding
and reviewing the implementation of the act in states/UTs. The the evils of female feticide.
state/UT level appropriate authority (AA) has been made a • Medical Audit of all the ultrasound clinics in the country,
multi-member body for better implementation and monitoring so as to catch the violators of the Act by scrutinizing “Form
of the Act at the state district/subdistrict level. More stringent F’ filled in respect of all pregnant women by the clinics.
punishments are prescribed under the act so as to serve as a • Changing appropriate authorities—In place of Chief
414 deterrent for minimizing violations of the act. Appropriate Medical Officer/District Health Officer, now District
 Collectors/District Magistrates have been placed as district iii. The pregnant woman has been exposed to potentially
appropriate authorities to streng then the implementation teratogenic agents such as drugs, radiation, infection or
of the act the ground level. chemicals.
• Proposed amendments to PC and PNDT Act iv. The pregnant woman or her spouse has a family history of
• Funding to the state through RCH-II mental retardation or physical deformities such as,
• Inclusion of the issue under NRHM spasticity, or any other genital disease.
• Constitution of National Inspection and Monitoring v. Any other conditions as may be specified by the central
Committee (NMC) supervisory board.
• Consitution of National Support and Monitoring (NSMC) Written consent of the pregnant woman is taken and all
• Meeting with the manufacturers of ultrasound machines known side effects of the procedure are explained to her. Sex of
• Sensitizing and training of judiciary and setting up the baby is not to be told to the pregnant woman or her relative
designated courts to hear cases of violation of the act for or any other person. A board telling that “detection of sex is

Chapter 54
faster conviction rates illegal and punishable and in this clinic sex determination is
• Annual report on implementation of the PNDT Act (Fig. not done” is displayed prominently at the clinic.
54.3) shows number of cases of violation of the Act Registration of genetic counseling centers, genetic
• Designated toll free number 1800110500 for complaints. laboratories and genetic clinic is done as follows:
• Frequently asked questions are framed 1. An application for registration shall be made to the appropriate
• Awareness Generation—It is nevertheless, recognizes that authority in duplicate in Form A with an affidavit that the (i)
mere legislation is not enough to deal with this problem that center/laboratory/or clinic will not conduct any test for sex

The Preconception (PC) and Prenatal Diagnostic Techniques (PNDT)

has roots in social behavior and prejudices. Various activities determination, (ii) will display prominently a notice that they
have been undertaken to create awareness against the practice do not conduct any technique, test or procedure, etc. by whatever
of prenatal determination of sex and female feticide through name called, for detection of sex of the fetus or for selection of
radio, television and print media units. Workshops and sex before or after conception, (iii) An application fees.
seminars are also organized through voluntary organization 2. The appropriate authority acknowledges the receipt.
at state/regional/district/block levels to create awareness 3. The appropriate authority inspects the venue, see the
against the social evil. Cooperation has also been sought from requirement and present the application with the findings
religious/spiritual leaders as well as medical fraternity to curb before the advisory committee.
this practice. The Govt. of India has launched ‘Save the Girl a. If all is within prescribed requirement registration is
Child Campaign’ with a view to lessen son preference by granted on Form B.
highlighting achievements of young girls. b. If all requirements are not fulfilled the application is
No prenatal diagnostic techniques shall be conducted except rejected on Form C citing the deficiencies. After fulfilling
for detection of all the requirement he/she can reapply within 90 days.
a. Chromosomal abnormalities The certificate of registration is non-transferable. If the
b. Genetic metabolic diseases owner is changed the certificate must be surrendered. The new
c. Hemoglobinopathies owner will apply a fresh registration. Any addition or deletion
d. Sex-linked genital disease of the instruments, etc. (like ultrasound machine) or employee
e. Congenital anomalies (as sonologist) must be informed. Registration is for 5 years.
f. Any other abnormalities or diseases as may be specified by Then it is to be renewed. Minimum requirements are specific
the Central Supervisory Board. for all 3 types of centers.
No prenatal diagnostic techniques shall be conducted unless Maintenance of records
the person qualifies to do so is satisfied for reasons to be recorded Genetic counseling center will fill the record in Form D.
in writing that any of the following conditions are fulfilled: Genetic laboratory will fill form E. Genetic clinic keeps the
i. Age of the pregnant woman is above thirty five years record in form F. Consent of the patient is taken in form G in
ii. The pregnant woman has undergone 2 or more spontaneous her language. A declaration, by the person conducting the
abortions or fetal loss. procedure, is given that sex of the fetus is neither detected
nor disclosed. The patient also declares that she does not want
to know the sex of her foetus. Form H is a permanent record
to be maintained as a register in the custody of the appropriate
authority.
All filled forms to be sent to the AA.
Cancellation of Suspension of Registration—AA of its own
or on a complaint by anyone can issue a show cause notice as
to why its registration should not be cancelled or suspended
for breach of any provision of the PCPNDT Act or the rules.
Appeal may be put by the center is reply.

BIBLIOGRAPHY
1. Handbook on Preconception and Prenetal Diagnostic Techniques
Act, 1994 and Rules with Amendments. Ministry of Health and
FW G01 2006.
2. Preconception and Prenatal Diagnostic Technique Act – A user’s
guide to be law, compiled by lawyers collective; Universal Law
Publishing Co. Pvt. Ltd. Delhi 2004;p.17.
Fig. 54.3: Chart: Percentage distribution of ongoing cases of violation 3. The Bare Act. Commercial Law Publishers (India) Pvt. Ltd. Delhi
under PC and PNDT act by the type of violation (as on March, 2006) 2007. 415
 Section 15 Imaging Modalities in Gynecology

55 Role of X-Ray in Gynecology

Puneet Singh Kocher, Sudha Salhan

-ray has a place in diagnostic parafrenia of a gynecologist.

Commonly used procedures are given below.

PLAIN RADIOGRAPH
The role of plain radiograph in current gynecological practice
is limited. However, it is clearly important to be able to recognize
features of gynecological disease on plain films.
A normal female pelvis shows the following features (Fig. 55.1).
1. The uterus of ventricular shape indenting the ovoid of
bladder.
2. A radiolucent cleavage plane between the bladder and the
uterus due to fat.
3. Cresentric shadow of levator ani and fan shaped shadow
of sacrospinous ligament sometimes be seen.
4. Gas and feces in the sigmoid colon and rectum.
Knowledge of the normal features is important to identify Fig. 55.2: Large left ovarian dermoid indenting the bladder shadow.
the abnormalities. Note the tooth inside the dermoid
I. Large masses result in displacement of the bladder or bowel
shadows (Fig. 55.2). dermoid cyst can be easily detected if calcifications are
II. Pelvic infections may obscure the fat planes between pelvic present. Sometimes a typical radiographic finding of
organs so as to produce a homogeneous shadow. Dermoid cyst, fat floating’ sign appears (corresponding
Pelvic calcification may be visible on plain -ray. Various to the fat-fluid level’ on the USG and CT features); this
causes of which include: radiographic sign is a horizontal line between soft
1. Fibroids They are seen usually as coarse popcorn type tissues of different opacities. It is caused by sebaceous
calcification. Rarely there is a peripheral rim of fluid floating over serous and over intra cystic debris.
calcification (Fig. 55.3). Fat fluid level and or presence of teeth is pathognomonic
2. Dermoid cyst (Fig. 55.4): This is the commonest ovarian of dermoid cyst.
mass to calcify. At plain radiography of the abdomen, 3. Other ovarian masses—Cystadenomas carcinoma,
fibromas.
4. Pseudomyxoma peritonei—From rupture of mucinous
tumor.
5. Fallopian tube calcifications rare should suggest
tuberculosis (Fig. 55.5).
6. Uterine endometrial calcification from chronic
endometritis.
7. Urinary calculi (Figs 55.6 and 55.7).
iii. A plain radiograph of the pelvis is also obtained to confirm
proper placement of intrauterine sources of irradiation (Fig.
55.8).
iv. To look for bone destruction which may be caused in
condition known as
• Osteitis pubis occurs in pregnancy/ after childbirth.
• By direct invasion by pelvic tumor.
v. A plain abdominal -ray to look for misplaced IUCD (Fig.
55.9) that cannot be found on USG. If the IUCD is misplaced,
there can be the following possibilities.
• Device in situ (in the uterus)
• There is unrecognized expulsion
• There is perforation of the uterus and the devise has
Fig. 55.1: Normal female pelvis migrated in the abdominal cavity (Fig. 55.10).
 Chapter 55
Role of X-Ray in Gynecology
Fig. 55.3: Showing calcified fibroid Fig. 55.6: Renal calculi

Fig. 55.4: Dermoid cyst Fig. 55.7: Bladder calculi

Fig. 55.5: Calcification ring (? Tubercular) Fig. 55.8: Proper placement of intrauterine source of irradiation 417
Imaging Modalities in Gynecology

Fig. 55.9: Displaced copper T Fig. 55.10: Displaced Lippes loop

If the device is detected in the cavity, clinically using ix. Free fluid in the peritoneal cavity (Ascites) will result in
IUCD removal hook but is not removal under local generalized homogeneous haziness and cause displacement
anesthesia, then we do plain radiography and if uterus of bowel loops bulging of flanks and obliteration of
is clinically believed to be empty then we do abdominal extraperitoneal fat lines (Fig. 55.12).
and pelvic radiography with an intrauterine marker.
A uterine sound or another IUCD is passed into the uterine CHEST RADIOGRAPHS
cavity and two radiographs of the lower abdomen and 1. Pulmonary tuberculosis (Fig. 55.13)
pelvis are obtained, (anteroposterior and lateral views). (evaluation of infertility)
Thus the IUCD can be localized in three dimensions. If the 2. Pulmonary metastasis (Fig. 55.14)
Section 15

IUCD is found to be closely related to the sound on both the (ovarian choriocarcinoma or uterine carcinoma)
plates, it is in the uterine cavity. If it is away from the sound 3. Pleural effusion (Fig. 55.15)
in any of the plates, it is said to be outside the uterine cavity. (ovarian or uterine carcinoma)
vi. To assess bowel dilatation in postoperative patients. 4. Gas under the diaphragm (early postoperative period of
vii. To exclude bowel obstruction as a cause of abdominal laparoscopy or perforation of an organ).
distension in patients with advanced ovarian cancer. CONTRAST STUDIES
iii. A pneumoperitoneum (Fig. 55.11) can be detected which
may be the result of Hysterosalpingography (HSG)
• Abdominal surgery It is the most commonly used screening test to evaluate uterus,
• CO2 hysteroscopy cervix and fallopian tubes. It is an accurate means of assessing
• Tubal insufflation with gas to test for tubal patency or the uterine cavity (congenital abnormalities) bands and tubal
after laparoscopy. patency. The main current indications for HSG are infertility,

418 Fig. 55.11: Air in the peritoneum cavity Fig. 55.12: Showing ascities
 Chapter 55
Fig. 55.13: Showing pulmonary tuberculosis Fig. 55.14: Pulmonary metastasis

Role of X-Ray in Gynecology

Fig. 55.15: Pleural effusion Fig. 55.16: Air below the Rt diaphragm doom

recurrent miscarriage, congenital abnormalities. Less common hree spot films are taken. First during the early filling phase
indications include checking the efficacy of tubal sterilization (to ensure small filling defects are not obliterated by contrast),
and assessment of tubes prior to attempted reversal of second during early tubal filling before the isthmic portions are
sterilization. It is an out-patient procedure. observed by contrast and the third after complete filling of the
tubes to demonstrate free peritoneal spill (Figs 55.17A and B).
Technique Additional oblique views help to demonstrate the position of
The procedure is performed in the first half of menstrual cycle, the uterus and any fibroids.
following cessation of bleeding. The patient is asked to refrain Inadequate distension of the uterus (due to cervical reflux)
from unprotected intercourse from the date of her period until and tubal spasm can give rise to a false positive diagnosis of
the investigation (to be certain there is no risk of pregnancy). corneal occlusion. This can be prevented by avoiding rough
Routine use of antibiotics is controversial. RCOG manipulation of the cervix and allowing time for spasm to get
recommends that all women under 35 years of age undergoing relieved. Gentle traction in the uterus and change in position of
uterine instrumentation should receive prophylactic antibiotics. the patient can also help. Bilateral tubal block (Figs 55.18 to
They suggested antibiotics regimen comprising of metro- 55.20) can be seen multiple defects.
nidazole 1 gm at the time of procedure plus doxycycline 100 Delayed films will help distinguish contrast flowing into a
mg twice daily for 7 days. large hydrosalpinges (Fig. 55.21) from contrast spilling into the
Routine use of analgesia is not required. Patient is given peritoneum secondary to loculated spillage.
injection Buscopan ampoules intramuscularly or tablet orally
hr before the procedure to prevent tubal spasm. Complication of HSG
With the patient in lithotomy position the cervix is exposed • Pain—Due to uterotubal distension or peritoneal spill. It is
with a vaginal speculum and the anterior lip of cervix is held minimized by slow injection of contrast and the use of
with a vulsellum. Cervix is cleaned twice with iodine solution. isosmolar contrast agents.
The cannula is put at the external os and is rotated clockwise so • Infection—It is rare, but more frequent in patients with past
that its tip advances in the cervical canal and the cannula gets history of pelvic inflammatory disease and hydrosalpinx.
fixed in the cervix. Once the cannula is in place, water soluble • Vasovaginal reactions—It occurs usually from manipulation
contrast is injected slowely under fluoroscopic control until the of the cervix or inflation of a balloon in the cervical canal.
uterine cavity is distended, the tubes filled and contrast is seen • Venous intravasation—It is of no clinical significance
to spill freely from the distal ends of the tubes (Fig. 55.16). but can make interpretation of the images difficult. It occurs 419
Imaging Modalities in Gynecology

Fig. 55.18: Bilateral block is a hysterosalpingograph

and filling defect in the body of the uterus
Section 15

Figs 55.17A and B: (A) Hysterosalpingogram; (B) Showing a normal

hysterosalpingogram

more commonly in the presence of fibroids or tubal Fig. 55.19: Bilateral tubal block (cornual)
obstruction.
• Allergic reaction to contrasts media does occur very rarely. • Polys/endometrial hyperplasia
• Intrauterine adhesion, caused by dilatation and curettage
Congenital Uterine Abnormalities (D C), tuberculosis or following exposure to diethylestradiol
The uterus develops by fusion of the paired Mullerian duct (DES).
systems. Complete or partial failure of fusion is estimated to • Pregnancy.
occur in 3–4 of the general population (Figs 55.22 A to F). The effect of fibroids on an HSG depends on their position
Minor degrees of abnormalities are of no clinical within the uterus. Subserosal fibroids may cause displacement
significance; however, there is an increased incidence of of the cavity and may or may not cause distortion. Submucous
recurrent miscarriage in patients with a septate uterus, so fibroids appear as polypoid filling defects within the uterine
differentiation from separate uterus requires further cavity, indistinguishable from the endometriae polyps. Early
investigation. filling films are necessary to demonstrate small fibroids and
Truly unicornuate uteri are rarely seen, (Figs 55.23A and B) so oblique news are helpful in confirming their exact location.
if an apparently unicornuate uterus is demonstrated on HSG care Multiple small filling defects causing an irregular lobulated
should be taken to look for a rudimentary horn by diagnostic outline to the uterine cavity are also seen with endometrial
laparoscopy or MRI or second cervix. hypoplasia, for example in patients with Turner’s syndrome.
Bicornuate uterus can have single uterus (Figs 55.24 to 55.26) • Intrauterine synechiae adhesions cause linear
or double uterus (Fig. 55.27). Arcuate uterus (Fig. 55.28) is to be shaped filing defects that are not obliterated by increasing
differentiated from subseptate uterus by laparoscopy along with amounts of contrast they are associated with recurrent
hysteroscopy. miscarriage. If extensive, they can completely obliterate the
Other uterine abnormalities due to filling defects in the uterine cavity, causing.
uterus are caused by: Asherman’s syndrome Asherman’s syndrome is amenorrhea
420 • Fibroids due to intrauterine synechiae,usually caused by dialation and
 Chapter 55
Fig. 55.20: Hysterosalpingograph showing multiple Fig. 55.21: Hysterosalpingograph showing hydrosalpinges
defects in the uterine cavity

Role of X-Ray in Gynecology

Figs 55.22A to F: Different types of congenital uterine abnormalities

Figs 55.23A and B: Unicornuate uterus

curettage for postpartum hemorrhage or retained products endometritis due to tuberculosis. Genital tuberculosis
of conception. Rarely it follows a normal pregnancy. primarily affects the fallopian tubes and 50 of patients with
• Intrauterine adhesions (Fig. 55.29) and small irregularly tubal disease will have a uterine abnormality. Tubal
shaped cavities are also seen in patients with chronic tuberculosis leads to a rigid abnormal tube with occlusion 421
Imaging Modalities in Gynecology

Fig. 55.24: Showing bicornis unicollis uterus Fig. 55.25: Showing bicornuate uterus
on a hysterosalpingograph on hysterosalpingograph
Section 15

Fig. 55.26: Bicornuate uterus Fig. 55.27: Showing bicornis bicollis uterus
on hysterosalpingograph

Fig. 55.28: Showing arcuate uterus on hysterosalpingograph Fig. 55.29: Intrauterine adhesions seen
on hysterosalpingograph
in the isthmus. The ends are frequently clubbed and there of contrast from the cavity of the uterus to the myometrium,
are diverticula like projections from the tubal surface Tubal usually is assocated with an enlarged uterus.
calcifications can be seen.
• A small irregular shaped cavity, water constrictions around Intravenous Pyelography (IVP)
the body is also associated with intrauterine exposure to The main indications for (IVP) are the clarification of structural
DES, a drug that was used from 1940 to 1960 to treat recurrent renal and uterine abnormalities, especially those of the collecting
miscarriage. It resulted in a range of genital abnormalities in system, typically prior to surgical intervention. In cases
the daughters of the treated mothers and is associated with of congential uterine abnormalities the renal abnormalities
increased incidence of subferlitiy ectopic pregnancy and are associated. It is also done in the work-up of cervical cancer.
pregnancy loss, as well as increased incidence of clear cell A nonionic water soluble contrast medium with an iodine
carcinoma of vagina. content of 300 mg/ml is injected in a dose of approx. 2 ml/kg to a
Adenomyosis (endometriosis interna) is a rare cause of maximum of 50 ml. 3–4 hrs. Overnight fasting, and bowel
422 subfertility, it can be recognized by deverticula like projections preparation is required prior to injection. It is provided to obtain
a plain film of the kidneys, ureter and bladder (KUB) before
contrast medium injection so as not to overlook calculi. An
immediate film is not usually required. A film about 10–15 min
after injection is sufficient to demonstrate normal pelvic anatomy,
although delayed images will be required, if there is collecting
system dilatation. A further radiograph at about 20–30 min (after
bladder emptying) is helpful in determining drainage from the
collecting system. In the presence of upper tract dilatation, further
delayed films will be required to completely display anatomy
(Fig. 55.30) is showing hydronephrotic changes.

BARIUM ENEMA

Chapter 55
Detection of bowel involvement in:
1. Endometriosis
2. Ovarian carcinoma (Fig. 55.31)
3. Rectovaginal fistula (Fig. 55.32).

Role of Radiotracers
Radiotracers (e.g. TC99m-DTPA-Dimethyl triamine penta

Role of X-Ray in Gynecology

acetate, TC-99m-EC-Ethylene dicystein, and TC-99m-MAG3-

Fig. 55.32: Rectovaginal fistula

Methyl acetate triglycine, etc.) are administered intravenously

and then their concentration detected by gamma camera. The
usefulness in gynecology is seen in cases of ureteric injury
during surgery. By DTPA/MAG 3 and renal scan (DMSA) site
of urine leak can be detected. These radiotracer pass the
glomeruli and reach the ureters. The radiotracer accumulates
at the injury site (of ureter or urinary bladder) and guides in
opening of abdomen and repairing the leak. If the ureter is
inadvertently included in a stitch and thus tied the radiotracer
accumulates above the block and the site can be picked up by
gamma camera.
In infertility: For detection of patency of the fallopian tubes
radionuclide hysterosalpingo-scintigraphy is done by injectiong
5–10 mCi sulfur colloid into the uterus. Radiotracers are
detected at the fibrial end. Compared to conventional HSG
radiation exposure is much less in this procedure.
Postmenopausal: Osteoporosis can be detected by bone scan
Fig. 55.30: IVP showing cancer hydronephrotic changes (as is done to find secondaries in the skeleton). It is very sensitive
test.
To differentiate benign from malignant lesions of female
genital tract tumors TC–99 MIBI is used. In malignancy fixed
focal uptake is seen. Bone metastases have grave prognosis. To
detect these metastasis whole body skeletal scintigraphy is very
sensitive. For bone to be seen 10–30mCi technetium labeled
methylene diphosphate (TC-99m-MDP) is used. At the site of
osteoblastic activity they show as hotspot. It is also useful in
monitoring the response of treatment.
Benign lesions have more diffuse and less concentration of
radiotracer distribution.
For ovarian cancer monoclonal antibody imaging can be
used. In I–III satumomab pendetide is used.

BIBLIOGRAPHY
1. Ali N, an H, Van Trappen, et al. Radioimmunoscintigraphy with Tc-
99-M labeled SM3 in differentiating malignant from benign adnexal
masses. B OG 2003;110:508.
2. Tian , hang , iao L, et al. A prospective study of Tc-99m MIBI in
Fig. 55.31: Barium enema showing compression of sigmoid colon by the differential diagnosis of pelvic masses in female patients. Clin.
ovarian carcinoma Nucl Med 2000;26:614. 423
 56 Ultrasound (USG) in Gynecology

Rajesh Uppal

Ultrasound (US) has been the widely available since 1980’s Transabdominal US Transvaginal US
and has become the standard of imaging in gynecology. Both
trans-abdominal and transvaginal techniques have evolved 3–5 MH 3 7–12 MH 3
Full bladder Empty bladder
over the years making ultrasound an integral part of
Gives a wider view of Gives a focused view of
examination. Color Doppler and 3D evaluation are other pelvic uterus, ovaries.
additional tools used in ultrasound imaging (Fig. 56.1). Structures remote from Large uterus may be
Various techniques used in ultrasound are: the vagina seen easily incompletely evaluated.
Resolution is relatively Excellent resolution of uterus
Transabdominal
poor varies among all imaging technique.
Transvaginal
Color Doppler
Uterus (Figs 56.2A and B)
Power Doppler
3D Uterus consists of two parts:
Sonohysteroscopy. 1. Body or corpus
2. Cervix.
Transvaginal US (TVS) and transabdominal US
Isthmus is the zone at interval or, separating the cervix
examinations are complementary and often are combined
from the corpus.
in a patient. Transabdominal US is performed first as a full
bladder and then transvaginal US is done on an empty Fallopian tubes emerge from the lateral aspects; will the
bladder. However, in virgins and unwilling patients only fundus superior to the tubers.
transabdominal scanning is performed. Sometimes Uterine size undergoes changes throughout the age of
transperineal US is done in them. the subjects.
Table below is showing comparison of transabdominal Corpus Size Endometrium
US with transvaginal US.
cervix
ratio
Prepubertal 1:2 2–44 cm
Nulliparous 1:1 6–85 cm Cyclical changes
Multiparous 2:1 8–10.5 cm Cyclical changes
Postmenopausal 3.5–7.5 cm <8 mm is asymptomatic
and in bleeding cases and
>5 mm warrants for
further evaluation.
The myometrium makes up most of the uterus and can
be divided into three layers:
1. Outer layer (superficial to arterial vessels)
2. Intermediate layer major part of myometrium
3. Inner layer hypoechoic layer around the endometrium
Endometrium is a thin echogenic layer which changes
with the menstrual cycle.
1. Menstrual phase thin echogenic
2. Early proliferative (D5-10)—thick echogenic
3. Late proliferative (D10-15)—thick, hypoechoic functional
layer.
4. Secretory phase (D15–28)—thick isoechoic functional layer.

Endometrial Thickness
Proliferative 4–8 mm
Peri-ovulatory 6–10 mm
Secretory 7–14 mm
Fig. 56.1: Ultrasound machine
 Chapter 56
Figs 56.2A and B: (A) Normal uterus; (B) Transvaginal 3D USG

Ultrasound (USG) in Gynecology

US is used to measure endometrial thickness in the Uterus
management of infertility and postmenopausal bleeding. Congenital anomalies can be seen
Ovaries Agenesis
• Ovaries are ellipsoid Unicornuate with or without rudimentary horn. More
• Location is variable difficult to diagnose on ultrasound especially where no
• Ovarian size is variable, changes will be age and rudimentary horn is seen.
menstrual cycle. Uterus didelphys—Two uterine with separate cervix.
Time period Size of ovaries Bicornuate uterus—Single cervix (Figs 56.3A and B).
Premenarchal 3.0 ml Fungal part is concave with a cleft of more than 1 cm.
Menstruating subjects 10 ml Septate—Fundal part is flat or indented less than 1 cm.
Postmenopausal 5.8 ml Arcuate—Slight indentation internally.
Cyclical Changes Imperforate hymen, vaginal septum, vaginal adhesion.
Can cause collection to appear within the uterus and vagina:
Day 5–7 Multiple follicles seen
hydrometra and hydrocolpos.
Day 8–12 Few dominant follicles
Day 12–15 Dominant follicle glows at 2–3 mm/day. Acquired lesions and fibrosis can also cause collections,
Maximum of approx. 20 mm more approx. called hematometra and hematocolpos.
24 hours before Follicle decreases in size with or Adenomyosis diffuse changes (Figs 56.4A and B)
ovulation without echogenic debris. • globular shape of uterus
Corpus luteum Cystic area of 20–30 mm involutes to form
• abnormal heterogeneous myometrium
corpus albicans (seen as a white spot).
Areas of increased and decreased echogenicity with
US is used for follicular monitoring in the management coarsening of echomorphology.
of infertility. Hypervascularity in the lesion

Figs 56.3A and B: Bicornuate uterus-3D USG 425

Imaging Modalities in Gynecology

Figs 56.4A and B: Adenomyosis

Focal adenomyosis presents a diagnostic challenge • Shadowing may or may not be seen
Differential includes fibroid. • Calcification
• Rarely cystic change.
Adenomyosis Fibroid
Often generalized change outlines Focal change Arteriovenous Malformations (Figs 56.6 A and B)
of uterus smooth It is a communication between arterial and venous channels
Lesions poorly defined Lobulated
without a capillary bed. Mostly iatrogenic, secondary to
Vascularity is diffusely increased Well-defined
Minimal effect on serosa or Peripheral instrumentation.
endometrium increase Gray scale changes are minimal with small cystic areas
which show a dramatic filling up on color Doppler.
Fibroids (Figs 56.5 A and B)
Section 15

It is the most common neoplasm of the uterus. Can be Endometrium

differentiated into intramucosal, submucosal, subserosal, Endometrium morphology during reproductive age
intracavitary, exophytic or pedunculated. is a function of menstrual cycle and varies with time of
Sonographically, varied appearance is seen. Focal study and with pregnancy, abortion and retained
fibroids are usually heterogeneous but mostly hypoechoic. products.
Large fibroids degenerate with varying morphology. Hyperplasia polyps and malignant changes are the other
Calcification may be seen in large fibroids. “Whorled” changes which become more important after menopause.
appearance is a classical feature. Morphological features often overlap and a definite
Transvaginal study is limited in large fibroids. appearance may not be available.

Feature Hyperplasia
• Variable morphology Differently thick and echogenic endometrium with well-
• Hypoehoic or heterogeneous mass defined margins. Cyst may or may not be seen. Non-specific
• Distortion of outer contour morphology.

426 Figs 56.5A and B: Fibroid uterus

 Chapter 56
Figs 56.6A and B: Arteriovenous malformation

Ultrasound (USG) in Gynecology

Polyp In a known case of endometrial cancer, intact subendo-
Diffuse or located, single or multiple, polyps are seen as metrial halo (The inner layer of the myometrium) indicates
echogenic modules projecting within the lumen. Easily seen in superficial invasion. Loss of halo indicates deeper invasion.
presence of fluid. However, non-specific morphology.
Gestational Trophoblastic Neoplasm
Endometrial Carcinoma (Figs 56.7A and B) Typical features of complete mole are (Fig. 56.8):
It is the most common presentation is postmenopausal bleeding, • Uterine country filled with heterogeneous mass
although only 10% of cases with postmenopausal bleeding will • “Snow with anechoic spaces form” like appearance
have endometrial carcinoma. In a case with postmenopausal • No fetal development
bleeding thickened endometrium should be considered • High velocity low resistance flow in the issue
cancer unless proved otherwise. • Theca-lutein cysts in ovaries
Lesion may be well-defined uniformly echogenic or • In invasive mole, myometrial involvement is seen
irregular, diffuse and heterogeneous. Irregularity and • Presence of some fetal landmarks in partial moles
heterogenicity favors malignancy. (Fig. 25.4).
80% of complete and about 30% of partial moles
Abnormal Uterine Bleeding: Postmenopausal are confidently diagnosed on ultrasound, rest of the cases
TVS in postmenopausal bleeding has been extensively used. may be missed.
A distinct endometrial echo less than 4 mm is used to exclude Approximately, 10% cases diagnosed as molar pregnancy
patients who require endometrial sampling. A high negative are non-molar hydropic changes on histology.
predictive value for endometrial echo less than 4 mm (almost
99%) excludes cancer. Ovarian Pathology
Thickness measured should be baseline to baseline Morphology of the ovarian lesion has a strong correlation
excluding any third in the human. with the diagnosis.
In asymptomatic postmenopausal patients, endo-metrial Absence of solid components and absence of
thickness of unto 8 mm is doubtful and investigated further. irregularities in an adenexal mass suggests benign lesion

Figs 56.7A and B: Endometrial carcinoma 427

 Two forms have been recognized:
Diffuse—small nodules.
Only fixity of the pelvic organs may be seen. Often no
findings are seen on ultrasound.
Focal endometriomas
Focal masses of variable echopattern.
Cysts with variable solid areas, uni or multi-located.
Presence of diffuse, low level echoes in a cyst is highly
suggestive of endometriomas (Fig. 56.10).
Appearances can be minimized by hemorrhagic ovarian
cyst.
Imaging Modalities in Gynecology

Lesions with Specific Morphology

Dermoid cyst (mature cystic teratoma) (Figs 56.11A and B).
Presence of adipose tissue and hair within the cyst is
diagnostic of terotoma.

Endometriomas
Typical lesions have a homogeoneous low level echopattern.
Fig. 56.8: H mole Nodularity in the wall can confuse the diagnosis with other tumors.

(Figs 56.9A and B). Irregularity in cyst wall, outline or in the Parametrial Cysts
echogenicity suggests a malignant potential. Cysts with thin walls and no solid contents in the pelvis
The larger and more complex the solid are, greater in separate from the ovaries.
the risk of malignancy.
Papillary projections are strong indications of malignancy.

Functional Cysts
Follicular, corpus and theca-lutein cysts are most common
ovarian findings.
Section 15

Follicular cysts result from follicles that fail to rupture,

and hence can only be diagnosed when more than 2.5 mm in
size. Completely anechoic with thin walls, they tend to resolve
spontaneously.
Corpus luteal cysts are larger with thicker walls and
created outlines. Often show a ring of vascularity.
Hemorrhage in a corpus luteal cyst is initially seen as a
homogeneous low level pattern, but after organization it is
seen as a reticular pattern with no vascular flow. These lesions
resolve over a period of 6–12 weeks.

Endometriosis
Involves the pelvis: The ovary, tubes, broad ligament and cul-
de-sac is affected.
Fig. 56.10: Ovarian endometriosis

428 Figs 56.9A and B: Ovarian Cysts

 Chapter 56
Figs 56.11A and B: Dermoid cyst

Ultrasound (USG) in Gynecology

Hydrosalpinx Typically features include (Fig. 56.13):
Fluid filled sausage shaped cystic lesions, in complete septae, • Typically in size (ovarian volume of >9 cm2)
cogwheel morphology. • Increase stroma (area >5.5 cm2)
• Multiple follicles (>10 follicles).
Ovarian Tumors (Figs 56.12A and B)
Ovarian tumors present as adenexal masses. Well-defined Ectopic Pregnancy (Fig. 56.14)
ovarian lesions are more likely to be benign, lesions will be • Heteroechoic adnexal mass
irregular walls thick, irregular septae and neural or nodules • Empty uterine cavity
factors are considered to be malignant. • Doppler shows vascular ring around lesion.
Serous cyst adenomas are large, thin walled unilocular • UPT+
cystic masses with or without septations.
Serous cystadenocarcinoma are large and are Sonohysterograph and Sonosalpingography
multilocular, cystic masses with multiple papillary projectors. A TVS is done to see the pelvic organs. A Sim’s speculum is
Mucinous cystadenomas are cystic masses often filling inserted pervaginum, cervix is caught by a tenaculum.
the abdomen. Multiple thin septae with low level echos may Cervix is cleaned with iodine twice. A 2 mm thick 20 cm long
be seen. flexible catheter is inserted into the uterine cavity after
Mucinous cystadenocarcinoma are large, multiloculated saline is passed through it (to prevent air) can insert Foley’s
cyst areas with papillary projectors with echogenic material. catheter also. Remove speculum and inject normal saline
filled syringe is attached to the catheter. TVS probe is
Solid Ovarian Tumors visualizing the uterine cavity and fallopian tubes while saline
Fibroma and fibroadenoma are similar to pedunculated fibroids: is being injected.
solid, round, smooth outline homogeneous morphology.
Hysterocontrast Sonography (HyCoSy)
Polycystic Ovarian Syndrome (PCOS) Performed by inserting a small ballooon catheter through
Part of metabolic syndrome, PCOS presents a wide spectrum the cervix into the uterine cavity. TVS is performed while
of ovarian morphology. the USG contrast agent (Ectovist) is injected via a catheter.

Figs 56.12A and B: Ovarian malignancy 429

Imaging Modalities in Gynecology

Fig. 56.13: Polycystic ovarian disease Fig. 56.14: Ectopic pregnancy

Tubal patency is confirmed when contrast is seen to flow • Removal of POCs

along both fallopian tubes and along ovaries. • HyCoSy
Sonohysterography, sonosalpingography and HyCoSy are • US guided injection of methotrexate in ectopic pregnancy.
used to evaluate abnormal uterine bleeding, infertility, Color Doppler, power Doppler and 3D ultrasonography
monitoring in tamoxifen users and unextractable IUCD, etc. are discussed in chapter 57.

USG Guided Procedures BIBLIOGRAPHY

• Fluid/pus aspiration (from an ovarian cyst) 1. Lovsin R and Tomazevic T. Hysterosalpingography contrast
• FNAC/Biopsy sonography for infertility investigation. Int J Gyn Obs 2010;108(1):70.
Section 15

430
 57 Color Doppler and 3D Ultrasound
in Gynecology

Ashok Khurana

The techniques of color Doppler studies and three and time, or alternatively, image based software may be built
dimensional ultrasound are established as a yardstick of into the 3D package. The freehand method may be used on-
pathophysiology and morbid anatomy. This chapter line where the ultrasound unit manages all functions, or, off-
discusses the state of the art and science of these techniques line where the analog video output is fed into a workstation.
in gynecology. Most units currently in vogue are automated 3D probes.
These are unit specific, more accurate and easy to use. When
TECHNICAL CONSIDERATIONS these units are employed, an area of interest is chosen in
Three technical advances have greatly influenced the the real time 2D image and the size and depth are outlined.
widespread use of ultrasound in gynecological disease. These A speed of acquisition is then selected and the acquisition
include variable and high frequency transvaginal activated. The slower the speed of acquisition the higher the
transducers, power Doppler technology and 3D (Three- resolution. The closer the plane of acquisition to the plane of
dimensional) and D (Real-time 3D) techniques. study, the better the resolution. The machine automatically
Higher transducer frequencies improve resolution. The receives and stores data from the region of interest and
trade-off is, however, decreased depth of penetration. Newer displays it in an orthogonal format (Figs 57.1 A and B).
transducers combine frequencies as high as 15 MHz with a In conventional ultrasound, the endometrium is visualized
multifrequency option of low (about 5 MHz) and mid frequency, as a variably thick, linear or ovoid structure in longitudinal,
thereby allowing combinations of high resolution and depth transverse and oblique plane. The shape of the cavity is difficult
penetration by using keys and knobs on the console. to assess, as is the coronal plane. With 3D, the entire extent of
In conventional color Doppler, where flow information the endometrium can be shown, including the corpus, fundus,
represents flow direction, mean velocity and range of cervix and cornual areas. Coronal, sagittal and transverse
velocities, power Doppler is a technique that assesses planes can be simultaneously displayed to permit more
amplitude or energy. Information displayed represents exhaustive viewing (Figs 57.2 A and B). The images may be
reflected (scatter) information from clumps of red blood cells automatically zoomed in or out (Fig. 57.3). Once acquired, the
within the sampled vessel. The greater the clump density, volume data can be reviewed by first rotating the planes to
the higher the amplitude of the signal and, therefore, the obtain standard anatomic orientations and then scrolling
brighter the color coding. The technique is known by several through the entire data to locate and characterize lesions,
names, including power Doppler, power angiography, color both focal and diffuse. In experienced hands the exercise takes
Doppler energy, color amplitude imaging and amplitude- no more than three to ten minutes. Once identified in any one
mode color Doppler ultrasound. Mathematically speaking, plane, the lesion can be marked by a center point, and this
the signal represents the area under the power spectral center point is automatically displayed in all three orthogonal
curve. The technique, enhances low flow sensitivity and this planes. The evaluation is enhanced by using volume measure-
makes it an excellent method for detecting slow flow vessels ments, niche mode studies (Fig. 57.4), power Doppler studies
and areas of omnidirectional vessels. A gain of 10–15 dB is (Fig. 57.5) and a retrospective review of stored data frequently
achieved without interference by noise. This method of required in gynecologic 3D studies. The entire acquired data
detecting flow information has consequently emerged as can be transmitted electronically to obtain second opinions,
the method of choice for studying parenchymal flow in normal facilitate remote conferencing with experts, and can be
and pathological areas in the pelvis. Although the information efficiently stored for review and recall.
display lacks directional information, it can be obtained from The sagittal plane is selected for volume measurements
any image by a spectral Doppler waveform study. As power and the other two planes for ensuring that the entire
Doppler is less angle dependent, tortuous vessels are more pathology is included in the measured area. Surface
completely demonstrated. rendering permits contoural evaluation. Niche mode studies
In this era of rapidly evolving technology, three permit a virtual tour of the entire lesion and surrounding
dimensional (3D) and real-time four-dimensional ultrasound tissue along with evaluation of vascular morphology. 3D
(4D) are emerging as necessary tools in the assessment of power Doppler permits an unsurpassed view of vascularity
the pelvic viscera. As for other anatomical regions, freehand and permits quantification of neovascularization. 3D saline
or automated devices may be used to acquire volume data infusion sonohysterography enhances the sensitivity in
for 3D evaluation of the endometrium. In the freehand method select situations. Real time 3D (4D) is useful in saline infusion
the transducer is manually moved through the region of sonohysterography for storing data sets, excluding the need
interest and a position sensor registers the slice in space for re-instillation, permitting multiplanar analysis and
Imaging Modalities in Gynecology
Section 15

Figs 57.1A and B: 3D units sweep through the region of interest and store the entire information in computer memory. Knobs on the keyboard
are employed to reconstruct any desired plane. One of the most useful and commonly employed display formats is the display in three
orthogonal planes: longitudinal, transverse and coronal. The coronal view is difficult to obtain on 2D scans and remarkably easy to visualize
with 3D

allowing magnification of stored data during re-evaluation. 2D transvaginal scanning is a sensitive screening tool
In patients who have not been sexually active, 3D data for developmental uterine malformations but lac s specificity
acquisition is done via the rectum. and is markedly operator dependent. Often a minimal and
3D data is basically a sum total of 2D data sets, and, as a usually clinically innocuous duality, such as an arcuate uterus,
logical consequence, a 3D study does not replace a 2D study. may display two endometrial stripes in an axial section
It, in fact, extends the wealth of information obtainable from through the fundus. The markers for uterine duality
an ultrasound scan. (bicornuate) in conventional ultrasound include a double
endometrial echo complex, a wide transverse uterine
CONGENITAL UTERINE MALFORMATIONS diameter, and rarely, a distinctive complete uterine duality.
Precise delineation of the type and extent of the anomaly is It is becoming increasingly apparent that precise anatomical
important to assess the need for surgical correction and the information can be obtained without the need for radiation,
432 technique of correction. contrast material or surgical intervention by 3D.
 Chapter 57
Color Doppler and 3D Ultrasound in Gynecology

Figs 57.2A and B: (A) 3D rendered displays show the entire configuration of the cavity including the tubal ostia, corpus and cervix. Note the convex
contour of the uterine cavity and the subtle concavity of the fundal aspect of the cavity. These features exclude any uterine duality or septations. The
hypoechoic zone around the cavity is a normal feature and is important to delineate because it loses definition in adenomyosis, endometritis and
neoplastic conditions. All three rendered images show a normal uterus. Note how the triangular configuration can differ within the normal population.
Rendered images can be obtained even in a thin endometrium; (B) While rotating orthogonal planes to render the endometrium in the region of the ostia,
the cavity may show hypoechoic artifacts (<<) which represent areas of myometrium. This can be confirmed by referring to the orientation of the
plane of interest in the selected plane of imaging (the longitudinal selected plane in this case) and should not be mistaken for focal endometrial lesions

It is, preferable to obtain the 3D data set in a longitudinal orientation, an additional acquisition in the coronal plane
sweep. In patients who have not been sexually active, data may be useful. Surface rendering may be required in some
may be obtained by a transrectal scan. It is imperative to cases to assess the fundal contour. 3D acquisition of Saline
obtain one 3D data set in the power Doppler mode in order Infusion Sonohysterography yields excellent details of global
to display a vascular guidemap to the congenitally malformed uterine anatomy. In the presence of concurrent uterine
uterus as this has a bearing on management protocols. In a pathology such as fibroids and polyps in the anomalous
uterine duality where the horns have a largely horizontal uterus, however, 3D sonohysterography is a useful problem 433
Imaging Modalities in Gynecology

Fig. 57.3: 3D acquisition can be obtained simultaneously in gray scale and color Doppler/power Doppler modes.
These may be zoomed in for better visualization

frequently unable to identify the subtle findings of a unicornuate

Section 15

uterus. 3D rendered images reveal a banana shaped relatively

narrow uterus with or without a rudimentary horn (Figs 57.8 A
and B). Multiplanar imaging helps to confirm a single
cornual angle. Class III refers to a didelphys uterus, which is a
result of complete non-fusion of the Mullerian ducts. The
two horns are usually fully developed and two cervices are
present (Figs 57.9 and 57.10). There may be an associated
transverse vaginal septum (Figs 57.11 A to D) causing
hematocolpos. All these features can be evaluated with ease
and accuracy with 3D techniques. The cervices are very close
to each other but the canals are distinct. Class IV is a bicornuate
uterus. The central myometrium may extend to the internal os
(bicornuate unicollis) (Fig. 57.12) or the external os (bicornuate
bicollis) (Fig. 57.13). The horns are typically low normal or small
in size. A 3D orthogonal plane study with coronal reformatting
is the method of choice for evaluating these uteri. A midsagittal
Fig. 57.4: Niche mode studies permit a biplanar scrolling through indentation of 10 mm or more is evident in the bicornuate uterus.
acquired data. These are useful for enhancing accuracy of identifying
Class V is a septate uterus. The septum may be shallow
and localizing lesions
(subseptate) (Fig. 57.14) or extensive (down to the external os)
(Fig. 57.15), fibrous, muscular or mixed. The septate uterus may
solving modality. uantification of developmental uterine be associated with a septate cervix, a septate vagina or both.
anomalies is possible (Fig. 57.6). The tubal ostia are Coronal plane analysis is necessary for assessing this condition
delineated in the coronal plane and a line drawn through and differentiating it from a bicornuate uterus. Recognition of
them. The midpoint of this line is extended to the inferiormost this condition is imperative because obstetric outcomes greatly
point of indentation of the uterine cavity or the extent of the improve with hysteroscopic metroplasty in appropriately
septum (distance F). The other measurement taken is the selected cases. With bicornuate and didelphys uteri, the
vertical extent of the uterine cavity (distance C). These approach has to be an abdominal one. In recent years, 3D
distances are reliably reproducible and the ratio F/F C can criteria have helped greatly in patient selection. Poor obstetric
be obtained. It is the vertical height of the residual uterine outcomes and the accurate information obtained by 3D now
cavity, which is considerably shorter, and the degree of justify septal resection by a hysteroscopic method as soon as
distortion that is considerably greater, in women with they are diagnosed.
recurrent pregnancy losses (Fig. 57.7). The arcuate uterus comes in class VI of the AFS
AFS Class I includes uterine agenesis and hypoplasia. 3D classification. The cavity is single but demonstrates a
studies are useful for calculating uterine size and assessing convexity towards the cavity. Class VII of the classification
434 canalization. Class II is a unicornuate uterus. 2D ultrasound is refers to the T-shaped uterine cavity (Fig. 57.16).
 Chapter 57
Color Doppler and 3D Ultrasound in Gynecology
Fig. 57.5: Gray scale and power Doppler 3D acquisitions may be displayed in a tomographic sectional format akin to CT and MR.
This format permits excellent localization and identification of pathological lesions and vascular signals

Fig. 57.6: Mullerian anomalies can be quantified. A horizontal line is Fig. 57.7: 3D rendered coronal image of a subseptate uterus. The
drawn between the two ostia. F represents distance of the depth of length of the septum is considerably longer than the length of the
the septum from this line. C represents the vertical extent of the residual cavity and indicates relatively poor prognosis
residual cavity and has a bearing on prognosis 435
Imaging Modalities in Gynecology

Figs 57.8A and B: Elongated narrow uterus with no cornual angle: unicornuate uterus
Section 15

Fig. 57.9: 3D rendered coronal image of a uterus didelphys. Fig. 57.10: Uterus didelphys. The uterine cavity is well-defined on either
The two horns and two cervices are clearly evident side. The cervices were poorly defined even on 3D scans. Examination
under anesthesia and cervical dilatation confirmed a narrow spiral cervix
on either side

FOCAL ENDOMETRIAL LESIONS flow in fibroid polyps is secondary to degeneration,

inflammation and very rarely consequent to a sarcomatous
Polyp
change. Adenomyomatous polyps show a typical spoke-
Saline infusion sonohysterography enhances the sensitivity wheel appearance with a central large vessel and radiating
of identifying polyps. 3D techniques with their inherent smaller vessels (Figs 57.20 A and B). uantific Indices such
increased contrast resolution have reduced the need for as peak systolic velocity, diastolic velocity, systolic diastolic
sonohysterography. Saline infusion sonohysterography can ratios, resistive index, pulsatility index, time to peak velocity
be combined with 3D to increase the sensitivity of both and 3D vascular indices are not reliable predictors of the
techniques. 3D also increases the possibility of identifying histopathology of these focal endometrial lesions.
multiple polyps and multiple endometrial lesions (Figs 57.17
A and B). Power Doppler studies are useful to assess the Endometrial Abnormalities
origin and vascular pattern of polyps. 3D Power Doppler can Small echogenic vascular foci in the endometrium, either
help differentiate fibroid polyps from endometrial polyps solitary or in a clump are often trophoblastic remnants. These
and adenomyomatous polyps. Endometrial polyps typically demonstrate low impedance flow (Fig. 57.21) and a final
show a solitary feeding vessel (Figs 57.18 A to C). Fibroid diagnosis can only be made with correlation with clinical
436 polyps often show only peripheral flow (Fig. 57.19). Central events and serum beta hCG levels. The differential diagnosis
 Chapter 57
Color Doppler and 3D Ultrasound in Gynecology
Figs 57.11A to D : (A) Evaluation of a patient of primary amenorrhea who has never been sexually active. The transabdominal scan reveals
a didelphys uterus with possibly two vaginas; (B) There is a right hematocolpos seen on a transrectal scan; (C) This also reveals a normal left
horn, cervix and vagina; (D) 3D rendering confirms a dual vagina with a right hematocolpos

Fig. 57.12: 2D transvaginal scan showing two uterine cavities Fig. 57.14: 3D rendered image in the coronal plane revealing a
shallow fundal muscular septum and a longer fibrous septum

Fig. 57.13: 3D rendered image of a bicornuate uterus Fig. 57.15: 3D rendered image showing a subseptate uterus with
with two cervices an extensive separation of the two horns 437
 Dichotomous branching of a feeder vessel is a strong marker
of a malignant mass. Other markers for endometrial
malignancy include dilated, saccular, tortuous vessels and
arteriovenous anastomoses. The shaggy surface of
malignant masses is easier to identify in the presence of
endometrial fluid collections with 3D techniques (Fig. 57.23)
and with saline infusion sonohysterography.

INTRAUTERINE DEVICES
The type of device can be readily identified only by 3D
rendering. This technique also improves delineation of
abnormal migration of a device. Medicated devices are often
Imaging Modalities in Gynecology

less echogenic than copper loaded devices. It must be

remembered that once a device has migrated beyond the
myometrium and into the peritoneum or bowel, it is very
difficult to identify with ultrasound.

ENDOMETRIAL FLUID COLLECTIONS

Fig. 57.16: 3D rendered image of a T-shaped uterus. The vertical
limb of the cavity is remarkably long
These are thin-walled and clear. Any focal thickening or
vascularization of the endometrium associated with free fluid
in the cavity warrants histopathological sampling.
includes a degenerated submucous fibroid and focal endo- Echogenicity within fluid contained in the uterine cavity may
metritis. represent menstrual debris, inflammatory debris, blood or
Malignant endometrial lesions in the endometrium are pus. Only a gross examination and microscopy can reveal
difficult to characterize when they are small. Larger lesions the pathological basis in these situations. Adhesive bands can
are poorly marginated, variably vascular and when invasive, be seen as echogenic or trilaminar variably thick structures
obscure the endometrial-myometrial interface. Focal that traverse the uterine cavity. These are largely missed on
increased echogenicity, diffuse increased echogenicity and routine 2D scans but well-delineated with 3D saline infusion
diffuse inhomogeneity (Figs 57.22A to I) increase the sonohysterography (Figs 57.24 A to F). Failure to sharply
predictability of pathologic findings. In addition, these delineate the endometrial contour should raise the suspicion
Section 15

findings, even in an endometrium which is thinner that the for adhesive bands. Sensitivity for detecting adhesions is
cutoff values of normal postmenopausal endometrium, are best in the secretory phase of the menstrual cycle.
indicators for inclusion in the group for invasive endometrial
sampling. Aggressive evaluation for a malignancy must be ENDOMETRIAL RECEPTIVITY
made if there is a focal increased echogenicity or a diffuse The parameters that have been studied include endometrial
inhomogeneity even in a thin endometrium. thickness, endometrial volume, endometrial ultrasound

Fig. 57.17A: 3D orthogonal displays help to identify multiplicity of polyps

438
 interest and reflects the number of vessels in the volume
being studied. FI is the flow index and is the ratio of the sum of
color intensities to the number of color voxels inside the volume
being interrogated. It reflects the amount of blood flow. VFI is
the vascularization flow index and is the ratio of the sum of
color intensities to the total number of voxels inside the volume
of interest. This reflects vessel presence and blood flow.
Endometrial and subendometrial VI/FI/VFI is significantly
lower in stimulated cycles than in natural cycles. Smoking is
associated with significantly lower VI and VFI. Patients who
become pregnant have a significantly lower Resistive Index
(RI) of subendometrial vessels: 0.53 compared to 0.64 /– 0.04

Chapter 57
Fig. 57.17B: When lesions in the endometrium are concurrent such as
polyps, congenital uterine malformations and fibroids, the ultrasound
image may be dramatic or confused. MR is useful in such situations.
This 3D rendering shows a subseptate uterus with submucous fibroids

Color Doppler and 3D Ultrasound in Gynecology

and polyps

morphology, subendometrial peristalsis, endometrial and

subendometrial vascularization, subendometrial
vascularization, myometrial echogenicity, myometrial power
Doppler, spectral analysis of uterine artery flow velocity
waveforms and perifollicular vascularization.
Endometrial thickness below 6–8 mm (Fig. 57.25) is rarely
associated with conception. Increase in endometrial
thickness above this level, however, does not enhance
implantation rates and there is no difference in the mean
endometrial thickness in patients who become pregnant and
those who do not become pregnant in ART cycles. The
minimum endometrial volume (Fig. 57.26) associated with
pregnancy is 1.59 mL as calculated by three-dimensional
ultrasound. This is calculated using a manual or semi-
automated planimetry and automated software called
(VOCAL) Virtual Organ Computer Aided Analysis.
Endometrial layering into a triple layer is associated with
good implantation rates(Fig. 57.27). Conversely, a
homogeneous or a heterogeneous (Fig. 57.28) endometrium
in the proliferative and midcycle phases is associated with
poor outcomes. Premature echogenic transformation of the
endometrium (Fig. 57.29), a consequence of progesterone
action, if observed on the day of hCG administration or on
the day of ovum pick-up, is associated with poor implantation
rates.
Less than three peristaltic contractions of the
subendometrial myometrium over a 2 minute interval on
the day of hCG administration are associated with poor
implantation rates.
By far the best correlation with implantation rates are
being observed with power Doppler and three dimensional
(3D) power Doppler studies (Fig. 57.30). Ultrasound delineation
and quantification of endometrial and subendometrial angio-
genesis is emerging as a reliable and reproducible indicator
of endometrial receptivity. Basic static 3D and Virtual organ
Computer Aided Analysis (VOCAL) and 3D shell imaging have
been used to assess and quantify endometrial and
subendometrial vascularization. The vascularization index Figs 57.18A to C: (A) Dichotomous branching of a feeder vessel should
raise a strong suspicion for a malignant histopathology; (B) Coronal
(VI), flow index (FI) and Vascularization flow index of
reconstructed images are useful to identify feeding vessels; (C)
endometrial and subendometrial vessels increase during the Tomographic ultrasound imaging is a 3D technique that permits sectional
proliferative phase, peaks 3 days prior to ovulation and imaging in parallel planes. This is useful for identifying the number and
decrease to a nadir 5 days postovulation. VI is the ratio of location of polyps. Gray scale and power Doppler intensities can be
color voxels to the total number of voxels inside the volume of displayed simultaneously 439
Imaging Modalities in Gynecology

Fig. 57.19: Fibroid polyps often show only peripheral flow. Central
flow secondary to degeneration, inflammation or sarcomatous change
may also be evident
Section 15

Fig. 57.21: The widespread use of medication to terminate early

intrauterine pregnancies is not always successful. Focal echogenic areas
with intense neovascularity seen in the cavity of such patients often
show a characteristic trophoblastic signal with a low impedance pattern.
The differential diagnosis includes focal endometritis and a degenerated
endometrial polyp

logically better reflector of cyclical uterine neovascularization.

Pregnant patients show considerably lower RI and pulsatility
index (PI) values compared with the nonpregnant group,
5–6 days after ET. The chance for pregnancy is almost zero if
the PI is more than 3.019 (Fig. 57.32) on the day of hCG
administration.
Inner zone vascularization (Fig. 57.33) of the endometrium
observed on the day of hCG administration or on the day of
embryo transfer is associated with higher pregnancy rates.
uantification can be done using the power Doppler area
technique which measures the vascularized area in any one
endometrial plane or with VOCAL which involves a 3D
acquisition followed by semi-automated planimetry.
Figs 57.20A and B: (A) Adenomyomatous polyps show a typical Preretrieval hCG does not enhance endometrial PI although
spoke-wheel appearance with a central large vessel and radiating more embryos are generated. Interestingly, impedance in
smaller vessels; (B) Central flow in adenomyomatous polyps of the
the uterine and spiral arteries does not show any significant
endometrium may not always have a spoke-wheel appearance. In
these situations central vessels are randomly distributed and have no
difference between normal pregnancies, missed abortions
specific pattern and anembryonic pregnancies.
Ovarian antral follicle number, ovarian volume (Fig.
in pregnant and non-pregnant patients respectively. 57.34), and ovarian stromal blood flow 3D quantification and
Nondetectable subendometrial artery flow (Fig. 57.31) is not perifollicular vascularization (Fig. 57.35) correlate well with
associated with a lower implantation rate. embryo quality and fertilization rates but do not have a direct
Uterine artery flow velocity waveforms show a correlation with endometrial receptivity.
remarkably good correlation with endometrial receptivity
and implantation rates. These should be recorded and FIBROIDS
measured from the segments of the artery near the cornual Fibroids are the most frequently encountered pathological
aspect of the uterus. This downstream location compared to finding on ultrasound. These may be submucous (Figs 57.36
440 the upstream location of the same artery near the cervix is a A to D) and abutting the endometrium, interstitial (Figs 57.37
 Chapter 57
Figs 57.22A and B: (A) 15 mm thick, inhomogeneous endometrium with a poorly differentiated endometrial/ myometrial interface of the posterior
wall suggesting a strong possibility of an endometrial cancer; (B) Same case as in figure 22A showing dilated and tortuous feeder vessels

Color Doppler and 3D Ultrasound in Gynecology

Fig. 57.22C: Same patient as in figure 22A and 22B showing markedly abnormal caliber vessels when analyzed with 3D Tomographic
Ultrasound Imaging studies. Histopathology confirmed a poorly differentiated endometrial carcinoma

Figs 57.22D and E: (D) Thick, inhomogeneously echogenic, poorly marginated endometrium, strongly suspicious of a neoplastic process; (E)
Color Doppler study of the same case as in Figure 24D. Vascular lakes and dichotomous branching evident in the endometrium strongly suggest
a malignant lesion
441
Imaging Modalities in Gynecology
Section 15

Figs 57.22F to I: (F) Spectral Doppler of the same patient as in Figure 24D. The flow velocity waveform shows a low impedance flow. Although
low impedance flows with a PI of less than 0.40 have been reported to have a strong association with endometrial cancers, wider experience
suggests that spectral Doppler studies correlate poorly with histopathology and that vascular morphology is more specific; (G) Thin inhomogeneous
endometrium in a postmenopausal patient with bleeding. Traditionally an endometrium of less than 4 mm has been regarded as benign.
However, adding the parameter of texture enhances the accuracy of prediction of malignant neoplasia in the endometrium. This was a poorly
differentiated endometrial carcinoma; (H) Focal thickening in a postmenopausal patient with bleeding. Arrows indicate the area where a
hysteroscopic biopsy confirmed an adenocarcinoma; (I) Focal increased echogenicity in an otherwise thin endometrium in a patient with
postmenopausal bleeding. Any loss of inhomogeneity of the endometrium, irrespective of thickness, warrants a hysteroscopic sampling. This
was confirmed to be a well-differentiated adenocarcinoma of the endometrium

Fig. 57.23: Transvaginal scan showing an endometrial fluid collection Fig. 57.24A: Saline infusion sonohysterography excludes synechial
with echogenic areas within it. It is difficult to differentiate whether bands within this endometrium
this corresponds to debris or a mass

A and B) and entirely in the myometrium or subserous calcification may be seen in fibroid post degeneration. The
(Fig. 57.38) and largely extending beyond the surface number and location of fibroids is best assessed with 3D
extent of the uterus. Most fibroids are hypoechoic, but studies (Figs 57.40 to 57.42). Fibroids are frequently multiple.
hyperechoic and isoechoic types are not uncommon. Not infrequently, fibroids are large and a transabdominal
Fat within a fibroid renders it markedly echogenic and transvaginal approach may be necessary for adequate
442 (Fig. 57.39). Calcification of the rim or random coarse delineation.
 Chapter 57
Color Doppler and 3D Ultrasound in Gynecology
Fig. 57.24B: 3D rendering of an endometrium showing multiple fluid loculi confirming adhesive bands in a chronic
inflammation of the endometrium

Figs 57.24C and D: (C) 3D rendering of an endometrium that showed no abnormality on 2D studies. Amputation of the endometrium is evident
at the left cornu. Histopathology confirmed tubercular synechial bands; (D) 2D evaluation of an endometrium in a patient with secondary
amenorrhea. No abnormality is evident

ADENOMYOSIS
The findings on ultrasound include focal or generalized
myometrial thickening, diffuse or focal speckling, myometrial
cysts and an obscured endometrial-myometrial junction (Figs
57.43 A to E). Myometrial thickening may be diffuse and
present as an enlarged, globular uterus with a markedly
increased transverse diameter or a differential thickening
of the posterior wall and occasionally a differential thickening
of the anterior wall. Sometimes, the process is focal and
presents as a globular myometrial mass mimicking a fibroid.
Differentiation is possible with the use of 3D Power Doppler
which demonstrates the classical spoke wheel pattern of an
adenomyoma (Fig. 57.44). This consists of a central vascular
pool with radiating vessels and rim vascularization.

FALLOPIAN TUBES
Fig. 57.24E: 3D rendering and orthogonal plane evaluation Healthy tubes are not visualized with routine transvaginal
suggesting synechial bands in the endometrium. scans. The interstitial part of the tubes is evident as an 443
Imaging Modalities in Gynecology

Fig. 57.24F: 3D Tomographic Ultrasound Imaging studies in the same case as in figure 24e reveal a markedly
interrupted endometrium confirming extensive synechiae in the cavity.
Section 15

Fig. 57.25: Proliferative phase endometrium which has achieved a Fig. 57.26: Three dimensional volume measurement of the endometrium.
thickness of only 7 mm at the time of follicular maturation. Endometrial Using branded software called Virtual Organ Computer Aided Analysis
thickness is measured in the region of maximum anteroposterior extent (VOCAL) the outline of the endometrium is traced through an acquired
in the subfundal area and should include the anterior and posterior volume. The machine automatically calculates endometrial volume and
layer. Such an endometrial thickness is almost never receptive to displays it as shown in the bottom right hand picture. The other three
implantation frames show an orthogonal multiplanar display of the endometrium.
The minimum volume associated with implantation is 1.59 ml
echogenic line extending towards the cornu from the cavity.
Dilated tubes may be visualized depending on the extent, loculi may be seen with inflammatory and endometriotic
echogenicity and status of surrounding structures. Free fluid lesions (Figs 57.47 A to C). Adhesive bands may be seen
in the pelvis permits complete visualization of the tubes which traversing the pelvis if free fluid is present (Fig. 57.48). A
are seen as echogenic curvilinear structures engulfing the possibility of ectopic pregnancy must always be borne in mind
ovaries. Non-specific pelvic inflammatory disease and its for almost all tubal enlargements. The spectrum of findings
sequelae result in a thin walled, uni- or multilocular, largely in an ectopic pregnancy varies from no findings to the
avascular hydrosalpinx with clear contents (Figs 57.45 A to demonstration of a live embryo in an extra-uterine location.
D). Suppuration is echogenic and intensely vascular (Figs In the absence of the latter, the findings include a non-specific,
57.46 A and B). Tubercular lesions may present as any of the variably echoic, variably vascular mass, probe tenderness
morphological types mentioned above. Endometriotic lesions and a cystic core surrounded by vascular solid echoes (Figs
are echogenic, variably thick walled and poorly vascular. 57.49 A to C). 3D scans are particularly useful for delineating
444 They may undergo secondary suppuration. Peritoneal fluid adnexal organ relationships and for differentiating the tubal
 Chapter 57
Fig. 57.27: Triple layered endometrium 10–11 mm thick. Note the Fig. 57.28: A homogeneously echogenic endometrium or a
hypoechoic anterior and posterior layer between the echogenic lines heterogeneous echogenicity of the endometrium in a proliferative phase

Color Doppler and 3D Ultrasound in Gynecology

of the triple layer. This shows no speckling and such an endometrium of the cycle reflects a disordered hormonal milieu or an endometritis
is highly conducive to implantation during the nidation window and is associated with a poor reproductive outcome consequent
through failure of implantation

Fig. 57.30: Proliferation of spiral arteries and their subsequent growth

into the endometrium is reflected as morphologic and quantitative
increases in endometrial vascularity when imaged by power Doppler.
This is seen in the late proliferative and periovulatory phases. The
Fig. 57.29: Increase progesterone subsequent to an LH surge results in deeper the vascularization into the endometrium, the better the
intracellular changes in the endometrium. On ultrasound, this is seen as endometrial receptivity. 3D multiplanar studies with appropriate rendering
increased echogenicity of the endometrium. Premature echogenic afford an accurate delineation and quantification of angiogenesis in
transformation of the endometrium is associated with poor implantation the endometrium. The illustration shows endometrial neovascularization
rates. It is termed premature if it is observed on the day of hCG in the longitudinal, axial and coronal planes along with the morphological
administration or the day of ovum pick-up rendering of endometrial vessels

and ovarian components of the clinical tubo-ovarian mass Peritoneal telangiectasia is a phenomenon associated with
(Figs 57.50 A to E). pelvic endometriosis. Dilated tortuous vessels are evident
Solid tubal masses may rarely be adenocarcinomas. in the pelvic peritoneum (Fig. 57.53). These show arterial
These are echogenic, variably vascular and are almost flow velocity waveforms on duplex Doppler studies.
always rude surprises at surgery or pathology Ovarian vein thrombosis is an acute clinical event and
may be identified with an enlarged, hypoechoic, avascular
VASCULAR DISEASE IN THE PELVIS ovary. Not infrequently the ultrasound shows no significant
Arterial congestion in the pelvis may be physiological in the findings.
menstrual phase. When evident in other phases it is a marker Ovarian torsion remains an ultrasound enigma even
for pelvic inflammation or endometriosis (Figs 57.51 A to D). today. Although it usually involves an enlarged ovary or
Venous congestion is now a well-recognized pathological tube, this can occur in a normal sized ovary as well. The
process in the pelvis and is consequential to loss of valvular latter phenomenon is usually seen in children and
function in the veins. This is seen as persistently full adnexal adolescents. Since the ovary receives a dual supply from
veins or veins showing short forward flow phases (Fig. 57.52). the ovarian and tubal arteries, and since torsion can vary 445
Imaging Modalities in Gynecology

Figs 57.33A and B: Frame A shows vascularization into the midzone

of the endometrium. Frame B s hows extensive endometrial
vascularization up to the cavity

Fig. 57.31: W hen subendometrial flow is not detectable in the

proliferative phase, this does not imply a lower implantation rate.
Intraendometrial vascularization can proceed rapidly even after hCG
administration. This endometrium shows absent intraendometrial and
subendometrial flow
Section 15

Fig. 57.34: Ovarian volume using three dimensional acquisition

techniques and three dimensional quantification software is more
accurate than 2D methods. However, volumes correlate well with
embryo quality and fertilization rates but not with endometrial receptivity

Fig. 57.32: In the late proliferative phase of the cycle and particularly
by the time of the LH trigger extensive myometrial and endometrial
vascularization result in a lowered impedance flow through the uterine
arteries. The quantification of flow should be done in the cornual
areas of the uterus and signals should be obtained from the terminal
portions of the uterine artery after it has given off the tubal branch and
turned medially. This lowered impedance persists for 5–6 days after
embryo transfer. A pulsatility index of greater than 3.019 is almost
never associated with successful implantation

from a few degrees to complete strangulation, the ultrasound Fig. 57.35: Follicular maturation is accompanied by perifollicular
picture can vary from a situation of no findings to a plethora neovascularization. This can be recognized by the appearance of
occasional perifollicular vascular signals when the follicle reaches
of non-specific findings. These include an enlarged,
12–14 mm in size, which then progress to 50–100% of perifollicular
hypoechoic, tender ovary, variably deprived vascularity and vascularization as the cycle progresses. This phenomenon correlates
a displacement of follicles to the periphery. Some cases of well with parameters of oocyte quality such as the levels of follicular
adnexal torsion reveal a pedicle sign. This refers to a spiral fluid estradiol, pH, follicular fluid pO2 and absence of oocyte aneuploidy.
course of the adnexal vasculature as it courses towards the This neoangiogenes is, however, does not c orrelate well with
ovary. Arteriovenous fistula (Fig. 17.1) may be cause of AUB. endometrial receptivity
446
 Chapter 57
Color Doppler and 3D Ultrasound in Gynecology
Figs 57.36A to D: (A) Transvaginal scan showing an ovoid hypoechoic
lesion rising from the posterior wall and lying largely within the cavity.
This is the classical finding in a submucous fibroid; (B) 3D rendering of
a fibroid confirming that it is entirely a submucous lesion; (C) Isoechoic
ovoid lesion in the cavity arising from the posterior wall. If gain settings
are incorrect such lesions may be completely obscured; (D) 3D
rendering of a fibroid showing a two-third submucous component
and a one-third interstitial component

Figs 57.37A and B: (A) Interstitial fibroids are located entirely within
the myometrium and have no cavity component and no myometrial
surface component; (B) 3D rendering of an interstitial fibroid confirming
that there is no submucous or subserous fibroid 447
Imaging Modalities in Gynecology

Fig. 57.38: Subserous fibroids are located largely in the outer Fig. 57.39: Fat within a fibroid is part of a degenerative process
surface of the uterus and is highly echogenic
Section 15

Fig. 57.40: Multiple fibroids are often difficult to localize on 2D transabdominal and transvaginal scans. 3D rendering demonstrates with
great clarity the exact location of these fibroids and the extent of cavity components

Figs 57.41A and B: (A) Interstitial fibroids with a possible submucous

component. 3D rendering clarifies the location as shown in figure
41B; (B) Same patient as in Figure 41A. 3D rendering shows a largely
448 interstitial fibroid with a minimal submucous component. The other
fibroid is not evident in this plane
 Chapter 57
Color Doppler and 3D Ultrasound in Gynecology
Figs 57.42A to C: (A) Interstitial fibroid
with a doubtful cavity component. 3D
studies showed a better delineation
and are shown in figure 42A and
figure 42C; (B) 3D rendering shows
the same fibroid as in figure 42A. The
cavity is mildly displaced but the fibroid
has no cavity component; (C)
Tomographic Ultrasound Imaging
demonstrates a lesion in multiple
parallel planes. This makes it a useful
modality f or a more ac curate
delineation of the location of fibroids
as shown in this entirely interstitial
fibroid

Figs 57.43A and B: (A) Transvaginal scan showing a longitudinal section of an adenomyotic uterus with a diffuse thickening of the posterior
myometrium and a diffuse myometrial speckling; (B) Longitudinal and transverse transvaginal scans of a uterus showing a globular enlargement
with a coarse speckling of the myometrium. These are features of adenomyosis

FUNCTIONAL OVARIAN CYSTS These are conventionally referred to as cysts if the maximum
Although referred to as functional cysts, these lesions are diameter exceeds 50 mm. Smaller lesions are termed cystic
truly dysfunctional cysts. Transabdominal scans may areas. All these lesions are unilocular and thin walled. Wall
completely miss smaller functional cysts (Fig. 57.54 A to N). thickness never exceeds 3 mm. These are largely devoid of 449
Imaging Modalities in Gynecology

Fig. 57.44: Focal subendometrial les ion. Dif ferentiating this

adenomyoma from a fibroid is possible with power Doppler studies.
These reveal central vascularity with a spoke wheel radial pattern
characteristic of an adenomyoma. Fibroids usually show only peripheral
flow. Central flow in a fibroid is usually secondary to degeneration
Section 15

Figs 57.43C to E: (C) In some cases of adenomyosis, myometrial

thickening may be in the anterior wall only. Images show this feature
along with a diffuse echogenic speckling of the entire myometrium;
(D) Myometrial cyst. This is a feature of adenomyosis. These are thin-
walled, clear fluid spaces that show cyclical variation and probe
tenderness; (E) Adenomyotic changes when confined to a limited Figs 57.45A and B: (A) A hydrosalpinx is most frequently seen on
globular area of the uterus constitute an adenomyoma. These are ultrasound as an extra-ovarian fluid lesion which may be unilocular or
usually hypoechoic but may have echogenic and cystic foci multilocular. This is thin-walled, clear and variably vascular. Vascularity
depends on the extent of acute inflammatory changes. A hydrosalpinx
any internal echoes except some luteal cysts which may often takes on a retort shape. It is necessary to delineate the ovary
have occasional fine internal echoes. The vast majority of separate from the fluid lesion in order to clarify whether the lesion is
functional cysts are avascular. Some luteal cysts may show ovarian or extra-ovarian; (B) A classical tubo-ovarian mass consists of a
occasional vascular signals. These have a high impedance fluid ovary surrounded by a fluid filled tube. Scan shows a lobulated fluid
arterial spectral pattern or may be venous in origin. lesion in the ovary draped by a hydrosalpinx which is thin-walled and
Secondary changes of hemorrhage, infection or torsion may clear. See also figure 45C
occur occasionally rendering these cystic areas variably
echogenic and differentiation then from an endometrioma, previous abscesses, endometriosis or surgery are identical
abscess or solid neoplastic lesion is not always possible. in appearance to functional cysts. These remain largely
Serial re-evaluation should always be carried out in the unchanged throughout the menstrual cycle. Care should be
immediate postmenstrual phase as these lesions tend to taken to differentiate between cysts of ovarian and
450 grow larger during the menstrual cycle. Residual cysts from paraovarian origin during transvaginal scanning.
 Chapter 57
Figs 57.45C and D: (C) Same patient as in Figure 45B. 3D rendering

Color Doppler and 3D Ultrasound in Gynecology

reveals a variably echogenic ovary surrounded by a multilocular
hydrosalpinx. The texture of the walls of these lesions is best studied
by 3D; (D) The SonoAVC software provided by one vendor
automatically delineates fluid loculi with a color signal. This helps to
highlight fluid collections anywhere in the body and can be used to
delineate a hydrosalpinx as well

Figs 57.46A and B: (A) A pyosalpinx or a tubercular salpinx are usually variably echogenic and thick walled. A pyosalpinx is usually vascular.
Power Doppler studies confirm hyperemia in the walls of the hydrosalpinx; (B) Acute pyosalpinx showing a marked thickening of the walls and
extensive echogenic debris within the tube

POLYCYSTIC OVARIES Doppler indices correlate well with fertility outcomes but are
Ultrasound morphology is one of the diagnostic features of not consistent diagnostic criteria.
polycystic ovaries.
The Rotterdam ultrasound criteria for diagnosis include ENDOMETRIOSIS
at least one of the following: an ovarian volume of greater Small lesions in the pelvic peritoneum are difficult to identify
than 10 cm 3 and the demonstration of 12 or more follicles on ultrasound and are often missed. The endometrioma is a
2–9 mm across (Figs 57.55 A to D). If even one of the follicles focal fluid lesion of hemorrhage and is seen as a relatively
exceeds 10 mm the study is to be repeated when the ovaries thick walled (1–3 mm) variably echoic cystic area (Figs 57.58
are quiescent. Strict application of these criteria in day-to- A to L). The echoes may be fixed or mobile. A fluid-fluid level
day practice would miss a large number of polycystic ovaries. may be apparent. Mural nodules should raise a suspicion of
This is because the ultrasound morphology is influenced by an endometrioid carcinoma. The lesion is unilocular and
several factors including transducer resolution, patient frequently multiple. There is no apparent vascularity,
habitus, treatment status, associated hypothyroidism, although tortuous vessels may course the ovarian surface.
hyperprolactinemia and incipient coexistent premature Telangiectatic vessels may be evident in the peritoneum on
ovarian failure. The expanded ultrasound criteria in literature power Doppler studies. Some lesions may be septated. The
include stromal hyperplasia assessed subjectively, increased morphology is similar for ovarian, tubal and peritoneal
stromal echogenicity assessed subjectively, stromal lesions, although peritoneal lesions are generally smaller.
hyperemia assessed with power Doppler studies and The ovaries are frequently prolapsed into the pouch of
peripheral, central or random distribution of excessive Douglas and adherent to each other. Fixity of the uterus,
number of follicles (Figs 57.56 and 57.57). 2D and 3D power ovaries and bowel is also frequent and can be demonstrated 451
Imaging Modalities in Gynecology
Section 15

Figs 57.49A to C: (A) An ectopic pregnancy must always be considered

in the differential diagnosis of an adnexal mass in the absence of an
intrauterine gestational sac. The figure shows a live ectopic in the
Figs 57.47A to C: (A) Hemorrhagic ovarian cyst surrounded by free adnexa. The corpus luteum in the ovary is seen adjacent to the ectopic
fluid in the pelvis. Such fluid may be loculated or free; (B) Echogenic pregnancy; (B) Most ectopic pregnancies present as an extra-ovarian
free fluid seen in the pelvis; (C) Fluid loculi in the pelvis may form after anembryonic gestational sac and free fluid in the pelvis; (C) Some
surgery or an infective process. These are referred to as inclusion ectopic pregnancies present as a non-specific solid adnexal mass.
cysts. These are variable in shape and usually avascular. The wall is The differential diagnosis includes exudative and hemorrhagic lesions
thin and the contents are clear

by transvaginal transducer probing. Hypoechoic lesions in

the peritoneum are useful additional markers but need a
sensitized observer for documentation. Free fluid is a
frequent finding in the pelvis and this may be anechoic or
echogenic. Endometriotic lesions being hormone dependent
are largest in the premenstrual phase of the cycle. MRI may
be useful in identifying and characterizing atypical appearing
endometriomas because of its unique ability to identify iron
in hemorrhagic lesions.
Infertile patients will benefit from minimally invasive
surgery rather than ultrasound guided drainage. Recurrent
symptomatic endometriosis in the non-infertile patient may
Fig. 57.48: Free fluid enhances the delineation of adhesive bands in respond to repeated aspiration and instillation of
the peritoneum methotrexate into the drained endometrioma.
452
 Chapter 57
Figs 57.50A and B: (A) Transvaginal scan showing a hypoechoic right ovary and a tubular fluid loculus in the right adnexal. Further evaluation
using 3D studies yielded information as shown in figures 50B, C; (B) 3D reconstruction of the same patient as in figure 50A, the tubular
structure is suggestive of a shaggy hydrosalpinx enveloping a corrugated ovarian surface

Color Doppler and 3D Ultrasound in Gynecology

Fig. 57.50C: 3D Tomographic ultrasound imaging of the same patient as in figure 50A and 50B. Sequential sections show a distinct
hydrosalpinx enveloping an ovary, one edge of which shows echogenic debris, confirming acute salpingo-oophoritis

Figs 57.50D and E: (D) Transvaginal scan showing multiple hypoechoic

and clear fluid loculation in the left adnexa. It is not possible to delineate
the ovary from the tube; (E) 3D reconstruction showing a distinct
hydrosalpinx enveloping a globular ovary 453
Imaging Modalities in Gynecology
Section 15

Figs 57.51A to D: (A) Endometriotic ovary showing extensive vascularity around it. Spectral Doppler features are showing in figure 51B; (B)
Same patient as in figure 51A. Spectral Doppler evaluation of a perilesional signal reveals a low impedance arterial signal. Findings indicate
secondary pelvic arterial congestion; (C) Adenomyotic uterus showing markedly hyperemic arcuate arteries. Persistence of these signals
beyond the menstrual phase confirms arterial congestion. Findings were confirmed at laparoscopy and histopathology. Arterial congestion
concurs with patient symptomatology. See also figure 51D; (D) Same patient as in figure 51C. Arterial congestion is evident adjacent to the
endometriotic ovary

Fig. 57.53: Dilated tortuous vessel in the pelvic peritoneum: peritoneal

telangiectasia adjacent to an ovarian endometrioma
Fig. 57.52: All abnormal vessels in the pelvis should be assessed with
spectral Doppler. Vascular signals in this patient show venous flow
with short forward flow phases. This finding is pathognomic of primary a variable, mixed echogenicity (Figs 57.60A to E). Sebaceous
venous congestion material has a speckled fluid pattern. Teeth are seen as
echogenic foci with distal acoustic shadowing. Hair is seen
as heterogeneously echogenic material. Dermoids may be
DERMOID CYSTS multiple and bilateral (10–20 ). Demonstration of a vascular
They are notorious for being missed on ultrasound because pedicle is not infrequent. Small dermoids may be seen in
they are isoechoic with surrounding bowel. Small dermoids normal sized ovaries. Solid components of dermoids have
454 are uniformly echogenic (Fig. 57.59). Larger dermoids show also added to the notoriety of dermoids by upsetting systems
 Chapter 57
Figs 57.54A and B: (A) Transabdominal scan revealing a largely normal right adnexa. Decreased resolution, compression by a full bladder and
reverberation artifacts usually interfere with the accurate identification of pelvic pathology as reveal further in figure 54B; (B) Transvaginal scan of
the same patient as in figure 54A. There is a 28 mm thin-walled clear cystic area in the right ovary. This was completely missed in the
transabdominal scan

Color Doppler and 3D Ultrasound in Gynecology

Figs 57.54C and D: (C) 28 mm thin-walled cystic area in the right ovary. This is unilocular and shows occasional fine internal echoes. Dysfunctional cysts
of luteal origin often show this characteristic; (D) Thin-walled unilocular cystic area showing a focus of indentation and echogenic specks. These usually
represent the ovarian hilum and are best evaluated with 3D studies to assess the echogenic area

Fig. 57.54E: Same patient as in figure 54D.

3D Tomographic sections confirm a single
foc us of indentation and ec hogenic
specks. See figure 54F

of malignant and benign scoring. CT and MRI can be useful improve outcomes. Neoplastic ovarian masses have a wide
to confirm fat in a dermoid. pathological spectrum and vary in appearance from simple,
thin walled, unilocular, avascular cysts to completely solid
NEOPLASTIC OVARIAN LESIONS masses. Advances in transducer technology, color Doppler,
One of the main aims of gynecological ultrasound is early power Doppler and 3D studies have greatly enhanced the
identification of malignant ovarian masses in order to accuracy of histological prediction of benign and malignant 455
Imaging Modalities in Gynecology

Figs 57.54F and G: (F) 3D rendering of the same patient as in figure 54D.
Indentation at the ovarian hilum is confirmed by this method; (G) Power
Doppler studies are useful for characterizing thin-walled, clear unilocular
cysts. Follicular cysts and residual cysts such as this one show no flow.
Luteal cysts show arterial signals of variable impedance, but never of very
low impedance (Resistive Index of usually greater than 0.40 favors a
benign diagnosis)
Section 15

Figs 57.54H and I: (H) Cystic corpora lutea and luteal cysts often show rim vascularity. Flow velocity waveforms show a moderate impedance
flow with a resistance of 0.40 to 0.60. See figure 54I; (I) Flow velocity waveforms from a luteal cyst showing a low impedance flow velocity
waveform with a resistive index of 0.52

Figs 57.54J and K: (J) Chronic benign cystic lesions often show fine,
mobile internal echoes with swirling. There are no fixed wall echoes.
These lesions are usually avascular and can often be handled by
serial surveillance; (K) Same patient as in figure 54J. 3D rendering
456 reveals a thin wll and numerous mobile internal echoes
 Chapter 57
Fig. 57.54L: 3D Tomographic sequence

Color Doppler and 3D Ultrasound in Gynecology

images of the same patient as in figure
54J and 54K. There are no mural
nodules of fixed echoes confirming a
larger likelihood of a benign lesion

Figs 57.54M and N: (M) Chronic benign cystic lesions often have a
flaccid shape and a corrugated appearance as shown in this
transvaginal 3D rendering; (N) Ovaries showing two thin-walled cystic
areas, one clear and one with fine internal echoes and rim vascularity.
Histopathology of this specimen which was removed revealed one
follicular cyst and one luteal cyst. Color flow mapping also excludes
significant torsion

adnexal lesions. The criteria for a diagnosis of a malignant may also be echogenic. Vascular mural nodules and vascular
mass include grey scale observations of a solid mass, a cystic septations are strongly suspicious of malignancy. Ovarian
mass with solid areas, focal or diffusely thick walls or fibromas show marked beam attenuation. Metastatic ovarian
septations, mural nodules and heterogeneous internal lesions may be uniformly echogenic.
echoes. Pelvic and para-aortic lymph nodes enlargement, The literature is fraught with scoring systems for
ascites, suprarenal and liver metastases and (Fig. 57.61). malignancy but the evolving multitude of these systems
Pleural effusions can be elucidated by transabdominal underscores their inadequacy.
ultrasound. Color flow and 3D vascular reconstruction criteria
include abnormal calibration of vessels, dichotomous ULTRASOUND IN UROGYNECOLOGY
branches, elongation, coiling, aneurysms, vascular lakes, Whereas, magnetic resonance imaging (MRI) has been the
arteriovenous anastamoses and veno-venous anastomoses modality for visualizing the endopelvic fascia, in recent years
(Figs 57.62 to 57.66). Low Resistive and Pulsatility Indices are 3D ultrasound sectional images are replacing MRI because
inadequately wide-range to be reliable. Serial evaluation of an equivalent resolution (Figs 57.67 and 57.68) and the
using 3D power Doppler quantification are also proving useful added advantage of ease of utility and the ability for vascular
for following up patients on treatment, particularly those on display. Anatomical atrophy of the endopelvic fascia, change
anti-neoangiogenesis agents. in the configuration of the vagina (Fig. 57.69) and paucity of
Mucinous masses are often mildly echogenic. Serous vasculature (Fig. 57.70) can be documented with amazing
tumors are usually anechoic but blood within serous tumors clarity and reproducibility. Vascular response to perineal 457
Imaging Modalities in Gynecology

Fig. 57.55D: Scanning technique is important for delineating polycystic

ovaries. 4 views of the same ovary are shown in this figure. Failure to
scan the ovary from left to right and superior to inferior results in a
suboptimal display of follicular number and distribution
Section 15

C
Figs 57.55A to C: (A) Polycystic ovaries are classically those which
show a volume exceeding 10 cm3 and 12 or more follicles 2–9 mm Figs 57.56A to C: (A) Ovarian stromal volume and vascularity correlate
across. These strict criteria will exclude a large number of polycystic well with fertility outcomes but are not diagnostic criteria. Polycystic
ovaries because the condition is influenced by associated endocrine ovary showing a subjective stromal hyperplasia and mild stromal
disorders, treatment status and equipment resolution; (B) Polycystic hyperemia on power Doppler studies; (B) Polycystic ovary showing
ovary showing a peripheral and central distribution of follicles. The mild stromal hyperplasia and moderate stromal hyperemia. Hyperplasia
older criterion for only peripheral distribution of follicles is no longer and hyperemia are subjectively assessed. Hyperemia can also be
458 followed; (C) Polycystic ovary showing the variant of largely central objectively evaluated with 3D criteria but these remain to be established;
location of numerous follicles (C) Intense stromal hyperemia in a polycystic ovary
 Chapter 57
Color Doppler and 3D Ultrasound in Gynecology
Figs 57.57A to E: (A) Polycystic ovary showing multiple peripherally
located abundant follicles and excessive stroma. Figure 57B shows
further evaluation of this ovary; (B) Same case as in Figure 57A. A 3D
acquisition has been made of the entire ovary and displayed in three
orthogonal planes. Frame D shows a 3D inversion mode rendering.
Using this method, follicles are highlighted and the stroma blacked out.
This improves the appreciation of the number and distribution of follicles;
(C) The calculation of follicle number can be automated using
proprietary 3D software. In this technique, the ovary is chosen as the
region of interest and the appropriate software choice key is activated
on the equipment console. The software automatically assesses the
size and number of follicles and allots a different color to each follicle.
Frame D shows a color coded display of the polycystic ovary shown
in section planes A, B and C; (D) Same patient as in figure 57A showing
a 3D graphic display of the contralateral ovary; (E) Automated report
of follicular size and number of the same patient as in figure 57A. The
report shows color coding of each follicle, the three dimensions of
each follicle and the mean diameter of each follicle

exercises and local estrogen application (Fig. 57.71) can be INFERTILITY

demonstrated by serial scans done 6 weeks to 12 weeks The uterus and ovaries are some of the only adult tissues in
apart. Transanal and transrectal side-firing linear transducers which angiogenesis occurs as a routine process. The changes
now offer detailed delineation of the anal and urethral in vascularity and concurrent alterations in blood flow can
sphincters and sphincter mechanisms and in the future are be identified and quantified using color Doppler imaging.
likely to find increased application. 3D provides objective Recently available 3D techniques are being increasingly
evaluation of outcomes from urethral bulking agent therapy studied to augment current imaging protocols in patients
and helps in assessing failure and the need for re-injection. undergoing fertility evaluations.
Tension free vaginal tape slings are highly echogenic and Most recent studies conclude that if the uterine artery
can be assessed by 3D ultrasound. Mechanical compression Pulsatility Index as observed on the day of hCG
of the urethra by the tape is evident as a reduction in the gap administration or on the day of embryo transfer is greater
between the tape and the symphysis pubis. than 3.0, then the chances of pregnancy are practically nil. 459
Imaging Modalities in Gynecology

Figs 57.58A to E: (A) Ovarian endometriosis usually consists of

Section 15

echogenic, variably fluid lesions which may be unilocular or multilocular

and are often surrounded by peripheral cystic loculi on the ovarian
surface. Wall thickness rarely exceeds 3 mm and vascularity is poor
or absent; (B) Recurrent hemorrhage into endometriotic lesions in the
ovary is the rule and this manifests as marked variations in the
echogenicity of the contents as shown in this ovary; (C) Multilocular
endometriosis of the ovary; (D) Two endometriomas in an ovary. One
lesion has a homogeneous ground glass echogenicity and the other
one is heterogeneous in echo pattern. This pattern can often be
mistaken for a dermoid. Clues to the presence of endometriosis include
evidence of free and loculated endometriotic fluid in the peritoneum
and the clinical features; (E) Associated peritoneal disease with ovarian
endometriomas may or may not be evident on ultrasound scans. The
figure shows extensive variably echoic peritoneal loculi alongwith
variably echoic intra-ovarian fluid loculi

Figs 57.58F and G: (F) 3D reconstruction of the same case as in

figure 58E. Note the demonstration of coalescing extra-ovarian fluid
loculi; (G) Long standing endometriomas may demonstrate intralesional
460 calcification. These may then also masquerade as dermoids
 Chapter 57
Color Doppler and 3D Ultrasound in Gynecology
Figs 57.58K and L: (K) 3D rendering of endometriotic adnexal showing
telangiectatic ves sels ; (L) Power Doppler studies showing a
teleangiectatic vessel adjacent to an ovarian endometrioma. Note the
distinction between normal ovarian tissue and the endometrioma

Figs 57.58H to J: (H) The figure shows endometriotic adnexal lesions

where it is difficult to identify which is the tubal component and which
is the ovarian component. Such distinctions can occasionally only be
made at surgery; (I) Endometriotic ovaries can show normal ovulation.
This transvaginal scan shows a small corpus hemorrhagicum and a
large endometrioma in the same ovary; (J) Ovaries are often prolapsed
into the pouch of Douglas in endometriosis. This scan shows the
“kissing sign” which refers to ovaries that adherent to each other in
the pouch of Douglas. Note the adherent bowel in the same location.
Transvaginal probe manipulation is an excellent technique for
demonstrating abnormal adherence of pelvic viscera

Additionally, endometrial thickness and morphology are by

themselves inadequate to predict outcomes. Endometrial
vascularization assessed by power Doppler has been divided
into four categories: subendometrial, basal layer, mid zone
and inner layer, and, cavity vascularization. The deeper the
vascularization noted, the better the outcome. uantification
of the intra-endometrial power Doppler area (EPDA) Fig. 57.59: Polycystic ovaries are common and not infrequently show
correlates well with reproductive outcome. Women with an concurrent pathology. This figure shows an echogenic dermoid in a
EPDA of 5 mm 2 achieve a significantly higher pregnancy polycystic ovary 461
Imaging Modalities in Gynecology
Section 15

Figs 57.60A to E: (A) Dermoids show a variable, mixed echogenicity and are often isoechoic with surrounding bowel making the
margins difficult to define; (B) Very intensely echogenic foci are common in dermoids and reflect calcification, hair or congealed sebum;
(C) Dermoid cyst showing echogenic foci with subtle distal acoustic shadowing suggesting bones or teeth. Note the poor definition of the
posterior aspect of the lesion because of distal acoustic shadowing; (D) At body temperature, sebum is usually liquid. In dermoids this is seen
as a cystic or hypoechoic space rather than echogenic components; (E) Color flow mapping and power Doppler studies help exclude a twisted
dermoid

rate. The measurement of EPDA might serve as a method to

evaluate the specific effects of the therapies.
Vascular perfusion of maturing follicles has been graded
on the percentage of follicular circumference seen to be
vascularized using power Doppler techniques (Grade 1 25 ,
Grade 2 50 , Grade 3 75 and Grade 4 75 ). Mean
follicular diameter, oocyte retrieval rate, number of mature
oocytes recovered and fertilization rates are all higher and
triploidy rates significantly lower from follicles with 50
vascularity. The Peak Systolic Velocity (PSV) is an excellent
parameter to assess the chances of obtaining mature
oocytes and high grade preimplantation embryos. The
chances of producing a Grade I or II embryo is 75 if the
PSV is 10 cm/second. Interestingly, during the ovulatory
process there are prominent changes in the regional blood
flow of the follicle with a marked increase in flow to the base
of the follicle and a concommitant decrease of blood flow to
the apex. These changes may be essential for the release of
a mature oocyte.
Fig. 57.61: Transvaginal scan showing multiple enlarged lymph nodes
adjacent to the inferior vena cava. Note the Motheaten appearance of
Patients with a PSV of 10 cm/second in ovarian stromal
the lymph nodes. Lymph nodes are common in simple acute conditions arteries after pituitary suppression yield significantly higher
as well as in pelvic infections and may reflect neoplastic disease as mature oocytes and achieve a higher clinical pregnancy rate.
462 well Ovarian stromal Pulsatility Index, Resistive Index and
 Chapter 57
Color Doppler and 3D Ultrasound in Gynecology
Figs 57.62A to D: (A) Solid ovarian lesions as seen in this ovary are not necessarily malignant and the 2D morphology needs to be
supplemented with color and 3D color criteria for histologic characterization; (B) Echogenic cystic lesions with thin septations are usually
benign hemorrhagic lesions. Occasionally, however, these may be pathologic surprises and should be assessed with power and color Doppler
to confirm a benign pattern; (C) Cyctic lesions with thick septations and mural nodules are highly suspicious for malignancy on 2D criteria alone;
(D) Shaggy lesions with echogenic fluid contents usually indicate old benign hemorrhagic lesions or mucinous neoplasm. The latter are often
avascular and difficult to characterize. Magnetic Resonance Imaging is sensitive to iron content of lesions and helps to differentiate hemorrhagic
lesions from those that do not contain blood

Fig. 57.63: All solid lesions should be assessed with power Doppler.
The presence of vascularity within a solid lesion confirms the presence
of tissue and excludes fluid. This is a useful criterion for a neoplastic
lesion. Occasionally, benign granulation tissue such as within an
abscess may mimic this finding. A clinical perspective is therefore
useful in the interpretation of these findings

Figs 57.64A and B: (A) Spectral Doppler is often misleading in characterizing adnexal lesions. This is so because vessels in the periphery of
the lesion are usually host vessels and may not show low impedance characteristics. Intratumoral vessels are low impedance circuits
because tumor neoangiogenesis usually gives rise to vessels that lack muscle in their walls; (B) Classical low impedance flow in the center of
a malignant mass. Some workers quantify cut-offs at a resistive index of 0.40 and others at 0.33. Specific figures should be disregarded and 463
emphasis laid on morphology as detailed in the text
Imaging Modalities in Gynecology

Figs 57.64A and B: (A) Spectral Doppler is often misleading in characterizing adnexal lesions. This is so because vessels in the periphery of
the lesion are usually host vessels and may not show low impedance characteristics. Intratumoral vessels are low impedance circuits
because tumor neoangiogenesis usually gives rise to vessels that lack muscle in their walls; (B) Classical low impedance flow in the center of
a malignant mass. Some workers quantify cut-offs at a resistive index of 0.40 and others at 0.33. Specific figures should be disregarded and
emphasis laid on morphology as detailed in the text
Section 15

Fig. 57.65A: Markedly tortuous vessels with extensive coiling in a mucinous cystadenocarcinoma

Figs 57.65B and C: (B) Cluster of abnormal vess els showing bizarre sizes. These f eatures indicate a malignant lesion;
(C) Small cystic lesions throwing up a surprise on 3D power Doppler. The 3D rendering shows a bizarre branching pattern suggesting
malignancy which was confirmed after surgery
464
 Chapter 57
Figs 57.65D and E: (D) Central spoke-wheel pattern in a solid adnexal mass seen on 3D rendered studies. Surgical pathology confirmed a
malignant fibroma; (E) Unilocular cystic lesions showing a thick vascular wall on 3D studies. The 3D rendering shows arteriovenous anastomosis.
Surgery confirmed a serous cystadenocarcinoma

Color Doppler and 3D Ultrasound in Gynecology

Fig. 57.66: Benign vessel showing one branch at a time. Note the Fig. 57.67: Three-Dimensional (3D) images of the endopelvic fascia
regular decrease in the size of this feeder vessel as it goes towards showing the region in three orthogonal planes and one rendered
the center of the solid lesion. Surgery confirmed a benign fibroma plane. The top left image shows (from top to bottom) the urethra,
vagina and rectum in the midline and the fibromuscular tissue laterally.
The rendered image (bottom right) shows the urethra flanked by the
endopelvic fascia

Fig. 57.68: 3D Tomographic Ultrasound Imaging (TUI). Currently available

3D transducers acquire information in sweeps across the region of
interest. Each signal thus acquired can be rendered in an infinite
number of planes. TUI allows a choice of plane direction and thickness Fig. 57.69: Complete loss of anatomical delineation of the vagina,
in much the same format as CT or MRI. Note the exquisite soft tissue rectum and endopelvic fascia in postmenopausal atrophy in a patient
detail of the urethra, vagina, rectum and endopelvic fascia. The vagina with incontinence. The difference is striking when the plane displayed
has an H-shaped configuration as evident in sections 1–4 in the top right area is compared with its counterpart in Figure 57.67 465
Imaging Modalities in Gynecology

Fig. 57.70: 3D Tomographic Ultrasound Imaging with gray scale and Fig. 57.71: 3D Tomographic Ultrasound Imaging with 2D and power
power Doppler information. Note the scanty vascular signals seen in Doppler information in a patient on perineal exercises and local estrogen
the top right image and the complete absence of vascular signals in cream application. Note the increased vascular signals in the top right
the other orthogonal planes frame when compared with Figure 57.69

Systolic/ Diastolic ratio of ovarian stromal arteries during 12 . Delisle M-F, Villeneuve M, Boulvain M. Measurement of
ovulation induction correlates with the chances of developing endometrial thickness with transvaginal ultrasonography: is it
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13 . Dietz HP, Wilson PD. The iris effect’: how two-dimensional and
0.48, more than two thirds of patients will develop a pleural
three-dimensional ultrasound can help us understand anti-
effusion. Over one half of patients with a Pulsatility Index incontinence procedures. Ultrasound Obstet Gynecol 2004;
0.75 and a Systolic/ Diastolic ratio 1.92 develop pleural 23(3):267-71.
effusions.
Section 15

14 . Epstein E, Valentin L. Rebleeding and endometrial growth in

women with postmenopausal bleeding and endometrial thickness
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467
 58 Computed Tomography (CT) and Magnetic
Resonance Imaging (MRI) in Gynecology

Parveen Gulati, Peeyush Pandit, Sudha Salhan

COMPUTED TOMOGRAPHY (CT) (FIG. 58.1) In slice by slice method the table top supporting the
It is an imaging technology—display of the anatomy in thin patient comes to a stop for each section. In spiral or helical
slices of the body developed from multiple -ray absorption CT the patient is transported continuously through the
measurements (Figs 58.2 A and B). Internal structure of any scanner, data are collected continuously. The advantage of
object reconstructed from multiple projections of the object. spiral CT are significant reduction of scan time ever a single
The density of the tissue is shown in an accuracy far greater breath hold can scan one whole organ.
than by the conventional -ray. No gaps in the image or overlap due to inconsistent
A ray projection by an -ray source made to move in a breathing.
translate route then there are detectors (it can be mobile or Better reconstruction and a possibility of image data are
stationary) the intensity of beam monitored by small collected in a continuous spiral as opposed to discrete section
detectors before entering the body to yield the value of the blocks.
incident intensity (Fig. 58.3). After passing through the body Fetal movements produce artifacts and diagnosis is not
the beam is detected by a scintillation crystal, which is possible. Besides CT exposes the fetus to radiation hence
collimated to receive those protons not scattered or CT has little role in obstetrics.
absorbed. The transmitted intensity (I) is recorded and stored The image is filtered. The CT scanner reconstructs the
in computer memory. image of each set of exposure. The resulting images are
The -ray tube and detector system moved continuously displayed on a television monitor, photographs of images
across the patient, making 160 multiple measurements in are used for permanent record and basic data can be stored
translation. At the end of each translation the -ray tube and on an optical disc or on magnetic tape.
detector system are rotated one degree and the translation CT is usually performed in an axial plane. But it is possible
is repeated. It required 5 min. to scan, in 1st generation in any desired plane, e.g. coronal or sagittal.
scanners.
In recent times multiple -ray detectors scanning period
reduced to 18 seconds. The widening of -ray angle next
progress in 3rd generation. Scanners producing a scan in
1–10 sec stationary detectors are fourth generation. In
modified th generation -ray beam is moved electronically
instead of mechanically.
• The scanned electronic beam has little mass, so used to
scan rapidly, time 0.02 sec/slice up to 17 slices/sec. There
are two methods of CT scanning, slice by slice known as
conventional CT and volume ac uisition-spiral or helical CT.

Fig. 58.1: CT machine Figs 58.2A and B: Principle of CT

 Morbidity and mortality associated with iodinated
contrast agents.
Although CT is useful in the later stages of pelvic
malignancy it has limited utility in characterizing early stage
disease

MAGNETIC RESONANCE IMAGING (MRI)

(FIGs 58.4 AND 58.5)
The patient is placed in the external magnetic field of the
MRI magnet. Hydrogen nuclei (proton) in the water body
and lipids molecules normally oriented randomly-affected
by this external field and undergo a net alignment parallel to

Chapter 58
the field when subjected to a brief period of the radio
frequency (RF) energy.
The hydrogen nuclei in the patient’s tissues absorb the
RF and alter their orientation. As the hydrogen (protons)
realign (relax) induce a radio signal although very weak, can
be detected and localized by the coils placed around the
patient. The strength of the signal depends not only on proton

Computed Tomography and Magnetic Resonance Imaging in Gynecology

density but also on two relaxation times T1 and T2 produce
mixed a (both T1 and T2) called balanced images.
Absorbed RF is later released by nuclei- emitted energy
measured by(received) an external RF antenna (coil). These
are standard body coil (BC) and new circularly polarized
body array coil (BAC). The later help to provide superior

Fig. 58.3: Principle of CT

Contrast agents in CT are ionizing and non-ionizing the

former are cheaper but have more side effects. Non-ionizing
contrasts are costly but give less side effects.
Ionizing contrast agents are iodinated (Diatrizoic acid-
urografin, fucithalamic acid, salts of ioxaglic acid-Hexabrix).
Non-ionic—contrast agents are Monomer iohexol
(omnipaque) iopamidol (iopamiro) Ioversol (opliraq), etc
Diamer—Iotrol, Iotrolan (Isovist), etc.
Oral and rectal constrast in GIT, IV contrast enhancement
of blood vessels and visceral, fast data acquisitions and high
spastic resolution.

Disadvantage of CT
Use of ionizing radiation, degradation of image quality by
body habitus or metallic hip prosthesis. Fig. 58.4: MRI machine

Fig. 58.5: Diagram of an MRI machine. The patient lies within a strong magnet (usually a cylindrical magnet). The radiofrequency transmitter coils
send radiowaves into the patient and the same coils receive signals from within the patient. The intensity and source of these signals can be
calculated and displayed as on image 469
 image. Endorectal surface coil (ECMR) is helpful in carcinoma • CT staging is more accurate that clinical staging
cervix. techniques demonstrating locally advanced disease and
Contrast enhancement depends alteration T1 and T2 staging of poorly differentiated cancers that have a high
relaxivity parameters. T1 relaxation agents—paramagnetic propensity for lymphatic and peritoneal metastases.
substances most commonly used are Gadoteridol Gel-HP- • CT-guided biopsy to confirm metastatic spread
DO2A other 2 are Gd-DTPA and Gd-DTPA-BMA. of disease to the peritoneal cavity or retroperitoneum.
T2 relaxation agents used are SPIO-Ferrite particle as in • Before performing CT, it is essential to exclude the
Magnetite (F 3O4), SPIO, USPIO possibility of pregnancy because ionizing radiations are
used.
Advantages of MRI
• CT can detect benign ovarian tumor e.g. dermoid and
Super spastial and tissue contrast resolution. endometriosis (Figs 58.7 to 58.12).
No use of ionizing radiation and can be used in pregnancy.
Imaging Modalities in Gynecology

Multiplaner capability and fast (breath holding and breath MRI IN GYNECOLOGY
independent) technique.
• Is useful in evaluating–Mullerian Anomalies
MRI is the technique of choice in patients allergic to
• Both benign and malignant conditions of the pelvis for
iodinated IV contrast media or impaired renal function.
diagnosis and staging.
Disadvantage of MRI • MRI shown to be superior to CT in work up of-uterine and
Higher cost However, it limits or eliminates further tests and cervical cancer and recently reported to be useful in the
or surgery-further cost is slashed. evaluation of ovarian cancer also.
• Aids in the differentiation of radiation fibrosis from
CONTRAINDICATIONS recurrent tumor.
• CT in patients with pacemaker, neural stimulator, choclear • The accuracy of MRI assessment of lymph node invasion
implant,vasclips, etc. is similar to that of CT; both rely on size criteria to detect
• Some feel clostrophobic-stop test. lymphadenopathy.
There is limited availability of MRI units all over the country. • MR guided biopsies are gaining wider clinical acceptance

CT IN GYNECOLOGY CONGENITAL ANOMALIES

• CT is the most commonly used primary imaging • MRI has proven to be an accurate and non-invasive
investigation for evaluating the extent of gynecologic means of evaluating patients with congenital anomalies,
malignancy and, detection of persistent and recurrent allowing both precise classification and demonstration
Section 15

pelvic tumors (Fig. 58.6). of associated complications (Figs 58.13 to 58.17).

Fig. 58.6: CT direct axial and reconstructed coronal CT scan of a 30 yrs old female patient showing well-defined complex lesion with fat,
fluid and soft tissue density component in the right iliac fossa—Right Ovarian Dermoid

Fig. 58.7: Axial CT scan showing cystic lesions in bilateral ovaries with few of them showing hemorrhagic contents with bilateral
470 hydrosalpinx—Endometriosis
 Chapter 58
Computed Tomography and Magnetic Resonance Imaging in Gynecology
Fig. 58.8: CT sagittal reconstructed contrast enhanced CT images showing soft tissue mass in the cervix with
distended endometrial cavity due to hematopyometra

Fig. 58.9: CT axial scans in a follow-up case of carcinoma cervix Fig. 58.10: CT postcontrast axial CT images showing a soft tissue
reveal pyometra with irregular heterogeneous thickening with lobulated mass in the left adnexal region with focal area of omental thickening—
margins involving the cervix and vagina with obliteration of surrounding Mitotic ovarian lesion
fat planes with loss of fat plane with recto-sigmoid and posterior wall
of bladder wall

Pelvic Pain and differentiate from leiomyomas. While helical CT

• U/S is first line diagnostic modality. In dificult cases MRI demonstrates intraluminal, intramural and extraluminal
and CT are used in confusing finding. structure of uterus, as well as providing superior opacification
• Lesions of endometriosis 1 cm routinely demonstrated and of vascular structures, the concomitant ionizing radiation
MRI is the single best technique to diagnose adenomyosis precludes its routine use in the evaluation of CPP. 471
Imaging Modalities in Gynecology

Fig. 58.11: CT Contrast enhanced axial scans with coronal reformatted

images showing a heterogeneous soft tissue mass with solid as well
as cystic component in the pelvis completely obliterating the normal Fig. 58.13: MRI Sagittal T2 weighted images showing hypoplastic
anatomy. There is associated free fluid with thickened omentum and uterus. The endometrial cavity can hardly be appreciated. The
small soft tissue deposits—Ca ovary with omental cake cervicovaginal canal also appears hypoplastic
Section 15

Fig. 58.12: Fig.20 CT contrast enhanced axial scans in a follow-up case of Ca Ovary reveal a cystic lesion with a small eccentric solid
component near the splenic hilum (metastasis) with retro caval as well as para-aortic nodes. There is associated thickening of the terminal
ileum with soft tissue stranding in the adjacent fat. Note also mode of incisional hernia, distended small bowel loops with air fluid levels cavity
including the pouch of Douglas extending to the abdominal cavity. The mass shows multiple septae of varying thickness within between areas
of soft tissue thickening. Some of the cysts also show soft tissue component. The mass shows heterogeneous hyperintense signal on T2
(coronal images) and heterogeneous low intense signal on T1 (axial images) images with septae showing iso to low intense signal.There are
also small areas of hyperintense signal on T1 images suggestive of small areas of hemorrhage.

BENIGN UTERINE CONDITIONS—LEIOMYOMA Endometrial Polyp

• In addition to detection, MRI allows for clinically • While MRI is diagnostic it is rarely employed because of
pertinent, anatomically precise classification of high cost.
leiomyomas—important for selecting appropriate uterine • Endometrioma
artery embolization candidates.
Cervical Incompetence
• MRI may be useful to monitor the success of trans
catheter uterine artery embolization and assess its • MRI findings are as follows:
durability (Fig. 58.18). – Shortening of endo cervcial canal (less than 3 cm).
– Widening of the internal cervical os (greater than 4 mm).
LEIOMYOMA – Asymmetric widening of the endocervical or absence
• While contour deformity is the commonest sign of a of the low signal intensity cervical stroma.
leiomyoma uterus, calcification is the most specific – When one or more of these findings are present,
finding for a leiomyoma on CT. should be suspected.
– Beingn ovarian tumor, e.g. dermoid.
Adenomyosis
• On the T1-weighted MRI image, high signal intensity foci can Endometrial Carcinoma
be detected. These foci are felt to represent endometrial High quality pelvic CT in endometrial carcinoma requires
472 rests and/or small punctuate hemorrhages (Fig. 58.19). good bowel opacification. Oral and rectal contrast agents
 Chapter 58
Computed Tomography and Magnetic Resonance Imaging in Gynecology
Fig. 58.14: MRI Sagittal T2 (A and B) and axial T2 (C) and Axial T1 Fig. 58.15: MRI sagittal, coronal and axial T2 weighted images and
weighted images showing the three components of uterus— axial T1 weighted images showing bicornuate uterus. Note is made of
endometrium, junctional zone, myometrium. Axial scans show the a single cervix
normal ovary with multiple small follicles

Fig. 58.16: MRI coronal T2 weighted images showing an arcuate Fig. 58.17: MRI axial and coronal T2 weighted images showing arcuate
uterus with a heart shaped endometrial cavity uterus with an oblique septum in the cervicovaginal canal

coupled with IV contrast medium is mandatory. The latter • Endorectal surface coil in MRI can be used.
serves to enhance normal myometrium and delineate
Endometrial Carcinoma-staging (Figs 58.20 to 58.22)
endometrial and myometrial tumor.
• Routine use of dynamic IV contrast enhancement is • CT is widely used for the staging of endometrial cancer.
necessary for state-of the-art MR evaluation of Its greatest clinical impact is in confirming parametrial
endometrial carcinoma, very small tumor necrosis, and sidewall extension in stage III tumor and in detecting
stromal and cervical invasion. pelvic lymphadenopathy
• Dynamic contrast MRI highly efficacious
473
Imaging Modalities in Gynecology

Fig. 58.18: MRI coronal T2, Axial T2 (Top) and Axial T1 and STIR (Bottom) Fig. 58.19: MRI axial T2, T1 , FATSAT and sagittal FATSAT images
images showing large uterus with a heterogeneous mass showing low showing focal thickening of the posterior junctional zone with ill-defined
intense signal on T1 as well as T2 and heterogeneous low with mildly margins suggestive of focal adenomyosis
hyperintense signal on STIR images suggestive of large uterine fibroid
Section 15

Fig. 58.20: MRI sagittal T2, axial T1,T2 images showing distended Fig. 58.21: MRI axial T2 weighted images showing bulky uterus with a large
endometrial cavity with a soft tissue almost completely filling the cavity heterogeneous soft tissue mass filling the endometrial cavity showing
with focal invas ion of the superfic ial, about 50% myometrium mildly hyperintense signal on T2 images. The mass shows full thickness
endometrial carcinoma-late stage infiltration of the myometrium

Uterine Sarcomas • The extra uterine manifestation of GTD are on CT.

MRI can provide accurate preoperative assessment of Adnexal findings bilateral ovarian enlargement by
uterine size and degree of involvement.Uterine sarcomas multilocular, theca lutein cysts. Locoregional spread is—
commonly metastasize to the lung, chest CT should be enhancing soft-tissue density in the parametria and/or
considered for staging purposes. obliteration pelvic fat or muscle plans.

Gestational Trophoblastic Disease Carcinoma of the Cervix

• Uterine enlargement is the most common CT feature of. • Typically, CT findings include enlargement of the cervix-
IV contrast medium-uterine enhancement hetero- administration of IV, contrast medium, low attenuation
474 geneous, and focal enlargement or irregular hypodense areas may be seen within the tumor are a function of
regions within the myometrium. tumor necrosis/ulceration and/or inherent differences in
 Chapter 58
Computed Tomography and Magnetic Resonance Imaging in Gynecology
Fig. 58.22: MRI axial T1 (on the left) and axial T2 (on right) weighted Fig. 58.24: MRI axial T2 ( top ) and FATSAT (bottom) images showing a
images showing distended endometrial cavity filled with an ill defined soft tissue mass arising from the posterior lip of cervix showing mildly
heterogeneous signal intensity soft tissue lesion showing hyperintense signal on both the sequences. The mass shows bilateral
heterogeneously hyperintense signal on T2W and iso to hypointense parametrial extension. Pelvic walls are normal. The fat plane between
signal with areas of hyperintense signal on T1W images. There are thin the mass and the anterior wall of rectum is preserved—CA CX
tubular areas of flow void suggestive of increased vascularity. There
are areas of cysts/necrosis/subacute bleed within the lesion—GTN

Fig. 58.23: MRI sagittal T2, axial T1, T2 and FATSAT images showing Fig. 58.25: MRI axial T2 and T1 ( top ) and FATSAT axial and sagittal T2
a soft tissue involving the cervix with left parametrial infiltration (bottom) images showing a soft tissue mass arising from the anterior lip
of cervix showing mildly hyperintense signal on T2 and low intense
signal on T1 images. The mass shows right parametrial extension.
the attenuation between tumor and normal cervical Pelvic walls are normal. There is focal area of loss of fat plane between
tissue. The cervix and parametrium may be problematic. the mass and the posterior wall of bladder. The lesion is extending to the
Obstruction of the endocervical canal can result in uterine lower uterine segment and there is associated pyometra with fluid
level—CA CX
enlargement with a fluid filled endometrial cavity.
• MRI is useful for preoperative staging and findings
corresponds to histopathologic features, e.g. Ca or • MRI is superior to US or conventional CT for delineation
benign. of tumor, assessment of tumor dimensions and extent of 475
Imaging Modalities in Gynecology

Fig. 58.26: MRI sagittal T2 (A and B) and axial T2 (C) and axial T1 Fig. 58.28: MRI sagittal and axial T2 weighted, T1 axial and FATSAT
weighted images showing an irregular heterogeneous soft tissue images through the pelvis showing an oval well-defined mass in the
mass in the cervix infiltrating into the left parametrium. There is no anterior pelvic wall showing heterogeneous iso to low intense signal
involvement of rectum or bladder. There are enlarged internal iliac on T1 and heterogeneous peripheral iso and central hyperintense
nodes bilaterally signal on T2 and FATSAT images suggestive of a soft tissue mass
with central necrosis, turned out to be dermoid tumor
organs, and identify fistulous tracts. MR imaging staging
Section 15

when available is invaluable for identifying important

prognostic factors and optimizing treatment strategies.

Pelvic Varices
• Varices show on CT (and MRI) as serpiginous structures
that enhance following administration of contrast
medium.

Pelvic Inflammatory Disease

On CT, an adnexal abscess - soft-tissue mass with central
areas of low attenuation. MRI adnexal abscess- nonspecific.
CT is the choice for defining abscesses and to identify a
possible access route if percutaneous drainage is considered,
exclude the possibility of other intra-abdominal fluid
collections.

Contraception
• Intrauterine contraception
• CT may accurately depict the presence of the device
within the pelvic cavity. IUCDs can be safely imaged
with MRI and their presence does not create artefects
that impede image interpretation.
Fig. 58.27: MRI benign ovarian tumor
ADNEXA
disease due to superior soft tissue contrast between
tumor and normal tissue, ability to define the tumor in Benign Ovarian Conditions (Figs 58.27 to 58.31)
orthogonal planes. Tumor signal intensity usually greater • Endometriomas hyperintense on T1 and heterogeneously
than normal low signal intensity found in fibrocervical hyperintense on T2 MRI. The use of fat suppression
stroma and necrosis. increases the conspicuity of endometriosis. Endometriomas
1 cm seen (Figs 58.32 to 58.34). MRI noninvasive
Carcinoma of the Cervix Staging (Figs 58.23 to 58.26) techniques minitor treatment response, and help select
• T2 weighted MRI more clearly delinates cervical carcinoma for hormone therapy.
and is preferred for evaluation of the lymph nodes. Dynamic • MRI diagnoses dermoid cysts and simple cyst. But real
gadolinium-enhanced T1 weighted imaging help identify strength of MRI is its ability to characterize adnexal
476 smaller tumors, detect or confirm invasion of the adjacent lesions especially in the case of US indeterminate masses.
 Chapter 58
Computed Tomography and Magnetic Resonance Imaging in Gynecology
Fig. 58.29: MRI coronal T2 and axial T1 weighted MR images of pelvis showing a large heterogeneous multiseptate mass likely to be arising
from the right ovary filling the pelvic

Fig. 58.30: MRI coronal T2, axial T1 and T2 and sagittal FATSAT images Fig. 58.31: MRI coronal T2 (left row), axial T1 (middle row) and Axial T1
showing bilateral complex adnexal masses with heterogeneous iso, FATSAT (right row) images showing a large well-defined lobulated complex
low and hyperintense signal on all the sequences. Areas showing soft tissue mass lesion which shows heterogeneous texture with
hyperintense signal on T1 weighted images showed suppression on heterogeneously hyperintense signal with internal areas of iso to low
FATSAT images—Bilateral ovarian dermoid intense signal on T2W images and heterogeneously hyperintense signal
with internal hypointense areas on T1W images. The component of the
lesion showing hyperintense signal on both T2W and T1W images shows
suppression of the bright signal on fat suppressed images is suggestive
Malignant Ovarian Conditions of fatty component. The focal areas of signal alteration seen within the
CT-study for the preoperative evaluation ovarian carcinoma, lesion appearing as hypointense signal on all pulse sequences are
determining the extent of cyto reductive surgery to suggestive of calcification/ossification—Dermoid
optimizing subsequent chemotherapeutic response. The
stomach and colon should be carefully examined as potential
primary tumor sites. Occasionally, it is not possible to Staging
determine whether the origin of a pelvic mass is ovarian or CT and MR Imaging are adjunct to surgical staging and
uterine on CT. are becoming a valuable tool in the detection of non- 477
Imaging Modalities in Gynecology

Fig. 58.32: MRI T1 is the longitudinal/spin lattice relaxation time. T2 is the

transverse/spin relaxation time. T1 weighted image-contrast between
Fig. 58.33: MRI axial scan showing a hemorrhagic cyst in the ovary
tissues is due mainly to their T1 relaxation properties. In T2 weighted
showing hyperintense signal on TI (b) and T1 FATSAT sequence.
image the contrast T2 relaxation properties. Some sequences Axial T2,
Multiple small follicles are seen at the periphery
T1 and FATSAT images showing bilateral complex adnexal masses with
heterogeneous iso, low and hyperintense signal on all the sequences.
Areas showing hyperintense signal on T1 weighted images showed no
suppression on FATSAT image—Bilateral adnexal endometrioma
Section 15

resectable disease. Furthermore, cross sectional imaging

is useful in the detection of intra heptic and intra splenic
metastases, the presence of which may alter staging and
therapy. Additionally, MRI and CT also provide a
noninvasive mechanism to monitor treatment response.

CARCINOMA OF THE VULVA

CT and MRI are usually performed for staging of vulvar
carcinoma.

Complications of Hysterectomy
• Deep venous thrombosis—MRI may detect thrombi in
pelvic veins which are not imagined by venography.

Stress Incontinence
• Kinematic MRI
• Using fast sequences, kinematic MRI can be applied to
evaluate the urethra, bladder and adjacent muscular and
ligamentous structures in near real-time. Despite the fact
that little experience is available for this diagnostic
method of evaluation so far, it can be especially helpful
in selected cases.

BIBLIOGRAPHY
Fig. 58.34: MRI axial T2, T1 and axial T2 FATSAT and T1 FATSAT. 1 . Medeiros LR, Freitas LB, Rosa DD, et al. Accuracy of MRI in
Weighted images showing multiloculated complex cystic lesions with ovarian tumor. A systematic quantitative review. An . Obstet
homorrhagic components in bilateral adnexal region—Endometriosis Gynecol 2011;204(67):1-10.

478
 59 Positron Emission Tomography (PET)
in Gynecology

Sudha Salhan

Positron Emission Tomography (PET) is a diagnostic imaging

technique.
The metabolic signal activity of multiplying cancer cell is
detected by PET scan. If it is combined with CT (gives
anatomical details of the malignant tumor), the information
gained is a superimposed picture of both giving details, e.g.
precise staging which is very helpful in treatment. It gives
more information about extend of the disease in gynecological
cancers. The dye nowadays used in PET-CT is mostly fluorine-
18 fluoro-2-deoxy-o-glucose radionucleotide. Fast multiplying
malignant cells show accumulation of F-18 which acts as a
marker for sugar metabolism. Rapidly growing cancer cells
take up the fluorodeoxy glucose (FDG) of F-18 and seen in
the picture obtained. Most studies have been done in cervical
cancer. It is highly sensitive and specific in detecting lymph
node metastasis.
It also helps in mid-course monitoring of treatment. Fig. 59.1: PET machine
Seeing the response the treatment can be continued or
modified in between, unlike CT alone where the response because it is costly and has no proven benefit in overall
can only be inferred at the end of the treatment used in survival rate.
monitoring therapy. It avoids over and under therapy usage False negative occurs in
in recurrence detection. Its greatest benefit is in potential • Small lesions
candidates for exenteration surgery. In cases of recurrence • Low metabolic rate tumors are not visible, viz.
malignant tumor of cervix, ovary and uterus. PET is useful. It – Low malignant lymphomas
can replace second look laparotomy in ovarian malignancy. It – Low malignant sarcomas
is also used to detect metastasis. It is used for detection of – Border line tumors.
recurrence or metastasis in tubal malignancies. It is not Its role in vaginal and vulval cancer is under investigation.
superior for initial staging. (It is also useful to detect Newer PET Agents—As FDG is excreted in urine it causes
inflammatory plaques in atheroma). It can be used in uterine diagnosis confusion in pelvic region. It can also concentrate in
carcinoma in gynecology. inflammatory tissue causing diagnostic dilemma. Hence, newer
radiotracers are under research, e.g. 11-C methionine, 11-C
Shortcomings choline, 11-C acetate, Cu ATSM, etc.
It has a limited value in early diagnosis of gynecological
tumors. BIBLIOGRAPHY
It can be confusing in inflammations especially tuberculosis. 1 . Kumar R, Alavi A. PET imaging in gynaecologic malignancies.
It is not a screening method. False positive is also seen Radiol Clin North A 2004;42:1155.
in premenopausal women (ovaries with late follicles and 2 . Pandit-Taskar N. Onchology imaging in gynaecologic
early luteal phase). It is not to be used as routine follow-up malignancies. J Nucl Med 2005;46:1847.
 Section 16 Operation Theater Activities

60 Asepsis and Antisepsis in

Operation Theater (OT)

HP Anand, Sudha Salhan

Asepsis and antisepsis in the operation theater are a very Instruments

crital compenents of patient care. Most of the postoperative The surgical instruments come in close contact with the
infections have their origin in the intraoperative period. A proper surgical wound and could be a potential source of infection, if
operative technique with meticulous attention to details of not sterilized before use and is not handled properly.
the operation theater protocols goes a long way in preventing They are best sterilized using steam sterilization through
this morbidity in patients who are undergoing elective and autoclaving after decontamination in bleech solution and
emergency surgery. flushing with water.
However, some of the equipments especially plastics
NEED FOR ASEPSIS IN OT
and rubber may not withstand autoclaving and may need to
The operation theater (OT) is a place where one is be treated with ethylene oxide or gamma radiations to make
deliberately cutting open the protective barrier of skin during them sterile. Some of the modern sterilizers use the nascent
a surgical procedure creating a potential portal for infection. oxygen produced from H 2 O2 for sterilization of delicate
Further, at the end of procedure one will be leaving behind equipments like endoscopes.
foreign bodies in the form of suture materials and some Various chemicals like glutaraldehyde, lysol, carbolic acid
devitalized tissue creating a stage for setting up an infection. have been used as disinfectant, to disinfect the instrument
In this scenario any implantation of a potential infective by soaking them overnight.
organism in these tissues will trigger the onset of a well- In an emergency, instruments can be sterilized by
established infection, resulting in postoperative morbidity. flaming, i.e. by pouring alcohol over them and setting it
Sometimes even mortality may occur. aflame, for a fast and quick sterilization.
The possible source of this infection could be from
1. Environment The Patient
2. Instruments The patient herself can be a source of infection for her
3. Patient surgical wound. The micro-organisms normally inhabiting
4. Medical Personnel.

Environment
The environment of the OT can contaminate the surgical
wound.
This includes–
• Air
• Immobile structures like the walls, OT tables, etc.
The floor and walls of the OT must be wet mopped rather
than swept. Door handles and other surfaces which are
frequently touched, to be cleaned by wet antiseptic solution. Fig. 60.1: Fixed air asepticizer
The air in the operation theater can be kept free of
contamination by maintaining a laminar flow under positive
pressure. Further, using air aseptisizer and UV lamps, the
air in the operation theatre can be made germ free. Air
asepticizer and ultraviolet equipment can be fixed (Fig. 60.1)
or mobile (Fig. 60.2). The fixed ones are equipped with an
ultraviolet source UV 30L90 which emits radiation in the
germicidal band at a wavelength of 2537 . The mobile device
disinfects and deodorize rooms up to 100 m 3 in operation
theater. A fan coupled to an electric heating element (2 Kw)
blows warm air over one evaporation unit where one 500 ml
container has bactericidal solution.
Atomizers and vaporizers can create plasma of an
antiseptic material (e.g. formalin) which percolates through
the nooks and corners of immobile structures of the OT
sterilizing/disinfecting them. Fig. 60.2: Mobile air asepticizer
her skin or the vaginal flora can contaminate the surgical Droplet Infection
wound. Wearing a mask will prevent the droplets from spilling onto
Shaving causes cuts which invite infection. Clipping of the operative site as well as in the OT environment. The
the hairs over the operative site and a thorough scrubbing mask should be made of sufficiently impervious material to
bath on the day prior to surgery may mechanically reduce prevent droplet infection but still comfortable to breathe in.
the bacterial load from these sites. It should cover the nose and mouth completely and should be
Vaginal preparations in the form of antiseptic douche, in position all the time when the person is inside the OT area.
painting with antiseptic solutions or placement of vaginal
Provision of a nose clip built into the mask will help maintaining
pessaries overnight may protect the surgical wound from
the mask in the proper position over the nose and mouth.
contamination by the vaginal flora.
Whenever, there is a possibility of accidental Falling Hair
encroachment into the bowel during surgery, (e.g. dense A cap over the head will prevent the hairs from falling onto

Chapter 60
adhesions or in ovarian malignancy), a thorough bowel the operative field. Caps should be sufficiently large to cover
preparation in the form of a high cleansing enema or a bowel the head completely without any part of the hair projecting
wash using polyethylene glycol may help in preventing out. Long hair needs bunching up to be kept under the cap.
surgical infection.
Finally on the OT table a routine protocol of skin/vaginal Sweat and Body Contamination
cleaning with antiseptic solutions—savlon, dry swab— The other possible point of contamination of surgical wound
iodine—spirit in that order is to be done. Start from the is from the body sweat of the surgical team. The sterile gown
proposed incision site and go laterally (Fig. 60.3). Never come

Asepsis and Antisepsis in Operation Theater (OT)

worn will be impervious to bacteria as long as it remains dry.
bac from farthest point to the operation site. In case of the A plastic apron worn underneath will ensure this. It should
abdominal surgery clear the umbilicus last of all. In case of be made certain that the front of the plastic apron is dry
iodine sqeeze the solution from the swab and do the cleaning. before putting on the sterile gown.
Never let it trickle behind the abdomen, it will form painful
burns. Take care to wipe out the iodine solution with the The Surgical Scrub (Figs 60.4 to 60.17)
spirit. Now drape the surgical area with sterile drapes. This • Handwashing is the simplest and a very important way
also helps in prevention of surgical infection. to control infection.
The purpose of surgical hand scrub is to:
Medical Personnel • Remove debris and transient microorganisms from the
The operating team could be a source of infection through nails, hands, and forearms
a. Clothes • Reduce the resident microbial count to a minimum, and
b. Droplet infection • Inhibit rapid rebound growth of micro-organisms.
c. Falling hair (Infected areas of the hands are given in Figure 62.3).
d. Sweat and body contamination
e . Hands. Techniques
The operation theater personnel must maintain personal The nails must be cut short. There must not be cuts or wounds
hygiene. They must take a thorough bath and wear clean on the hands. Remove all jewelery (rings, watch, bracelets, etc).
clothes before coming to the operation theater. The basic principle of the scrub is to wash the hands
thoroughly. Wash from the clean area (the hand) to a less
Clothes
clean area (the arm). The approach to scrub should be
By adhering to the following protocol regarding the clothes systematic and effective to ensure proper cleansing. While
in which the OT personnel enter the OT, the postoperative scrubing remember each finger has four surfaces and not
infection can be minimized to a great extent. just two. The scrubbing should be through and systematic and
• Never to enter the OT in a street wear each sequence of scrub and wash should last from three to five
• Never to go out into the wards with OT wear minutes. The sequence should be repeated two to three times.
• The OT dress should be made up of materials, which will
Rubbing with a brush is going into disfavor as it may
not carry static electricity (hence the dust and bacteria
produce microscopic or macroscopic cuts which may end up
along with) and are preferably of cotton
harboring infection. The procedure for the timed five minute
• It must be clean
scrub consists of:
• Change footwear before entering the OT room.

Fig. 60.3: Infected areas of the hands Fig. 60.4: Proper cleaning of nail 481
Operation Theater Activities
Section 16

Figs 60.5A and B: Palm to palm Figs 60.7A and B: (A) Interplace fingers of right hand over left.
Change hands and repeat; (B) Rotational rubbing backwards

Fig. 60.6: Right palm over left dorsum and left palm Fig. 60.8: Rotational rubbing
over right dorsum

482 Figs 60.9A and B: Clean thumb

 Chapter 60
Figs 60.10A and B: (A) Back of finger to opposing palm with fingers interlocked; (B) W ashing off soap with water

Asepsis and Antisepsis in Operation Theater (OT)

Fig. 60.11: Rub both wrists in a rotating manner.
Rinse and dry thoroughly Fig. 60.12: Back of fingers

Fig. 60.13: Front of fingers Fig. 60.14: Final rinse with water

Fig. 60.15: Position of hand in final rinse Fig. 60.16: Position of arm after final rinse 483
 • Repeat the process on the other hand and arm, keeping
hands above elbows at all times. If the hand touches
anything at any time, the scrub must be lengthened by
one minute for the area that has been contaminated.
• Rinse hands and arms by passing them through the water
in one direction only, from fingertips to elbow. Do not move
the arm back and forth through the water.
• Repeat the whole sequence two to three times.
• Proceed to the operating room holding hands above
elbows.
• If the hands and arms are grossly soiled, the scrub time
should be lengthened. However, vigorous scrubbing that
Operation Theater Activities

causes the skin to become abraded should be avoided.

Once in the operating room, hands and arms should be
dried using a sterile towel with aseptic technique from hands
down to elbow viz. hands first and elbow last and discard the
towel (protocol). ou are now ready to don your gown and
Fig. 60.17: Position before wearing gown
sterile gloves.

Wearing of Surgical Gowns (Figs 60.18A to D)

• Wash hands and arms with anitmicrobial soap. • The hands are wiped clean with a sterile towel, and the
Excessively hot water is harder on the skin, it dries the plastic apron is wiped dry with sterile towel by the
skin, and is too uncomfortable to wash with for the circulating nurse.
recommended period of time. However, because cold • The sterile gowns are provided with their outside surface
water prevents soap from lathering properly, soil and folded in, exposing the inside surface for handling
germs may not be washed away. Hence, proper • The arms are slid into the sleeves of the gown touching
temperature is essential. only its inner part. The scrub nurse or an assistant secures
• Clean subungual areas with a nail file. the gown from behind. Always keep the hands high or
Section 16

• Start timing. Scrub each side of each finger, between the docked in front. Do not touch any part of the gown.
fingers, and the back and front of the hand for two
minutes. Wearing of Surgical Gloves (Figs 60.19A to H)
• Proceed to scrub the arms, keeping the hand higher than • The principle is that the outside of the sterile gloves which
the arm at all times. This prevents bacteria-laden soap come in direct contact with the surgical wound is never
and water from contaminating the hands. touched with bare ungloved hands.
• Wash each side of the arm above the elbow for one • First one glove is worn holding the inside of its cuff with
minute. the other hand.

484 Figs 60.18A to D: Serial photographs, demonstrating the proper technique of wearing a sterile gown
 Chapter 60
Asepsis and Antisepsis in Operation Theater (OT)

Figs 60.19A to H: Figure showing method of wearing gloves (A,B,C) Ungloved hand touching the inside of the sterile glove; (D,E) Gloved
hand touching the outside of the sterile glove. In both hands are with gloves can now do final adjustment of the gloves over the gown cuff;
(F,G,H) Serial photographs demonstrating the wearing of sterile gloves the are hands not touching the outside of the gloves

• Now the gloved hand holds the out side of the second PROPHYLACTIC ANTIBIOTICS
glove and manipulates it onto the hand. Antibiotics cannot substitute for the aseptic precautions and
• At this point the surgeons hand are totally dedicated to complete hemostasis and gentle handling of tissues by the
the patient use and he cannot use it for his own use, till surgeon but are still required for clean contaminated and
the procedure is completed or till he/she is willing to go contaminated cases.
through the whole rituals of scrubbing and wearing of The choice of antibiotic should be based on sensitivity
gown and gloves again. studies and the hospital policy. These should be given as a
One can conclude that by strict adherence to such basic single dose approximately 1–2 hours prior to beginning the
protocols one can considerably reduce the infection in surgery and may be repeated if the operation lasts more
surgical patients, making the surgical procedures safe. than 3 hours or if blood loss is more than 1500 ml. 485
 61 Preoperative Care

Sunita Malik, Pawan Nayyar

Studies of perioperative morbidity reportedly show that • Evaluate and optimize patient health status
preoperative conditions and perioperative optimizing of • Facilitate the planning of anesthesia
care are significant predictors of postoperative morbidity. • Reduce patient’s anxiety through education
Less severe manifestations of adverse preoperative • To return the patient to desirable functioning as quickly
conditions are associated with lower preoperative morbidity as possible
and mortality. Preoperative and preprocedure assessment • Obtain informed consent.
must be accomplished by the anesthesiologist by taking a Preoperative preparation includes interventions dictated
thorough history and to determine the extent of consultation by findings on diagnostic work up, preoperative health and
with the primary care physician that is needed, to judge optimal the nature of planned operation.
health and the potential for improvement of the preoperative
status. Preoperative Evaluation
Understanding the context the environmental, sociological, Preoperative evaluation strives to answer three questions: is
ethical and team concept, and the economical influences of the patient in optimal health? Can or should the patient’s physical
preoperative care is almost as important as the technical or mental condition be improved before surgery? Does the
knowledge upon which the practice of preoperative care rests. patient have any health problems or use any medications that
Reduction in expenditure by selectivity in ordering tests and could unexpectedly influence peri-operative events?
using education and information tools to increase efficacy to Preoperative evaluation is intrinsically valuable and
shorten the length of stay, to reduce the rate of cancellations interacting with the patient in this way is an enjoyable and
and to increase patient satisfaction are part and parcel of productive part of the practice of anesthesia and can continue
preoperative planning. In addition, preoperative assessment to make anesthsia a specialty integral to and valuable for
can uncover hidden condition that could cause problems both the health of a nation and of the individual patient. Inadequate
during and after surgery. By anticipating the problems the preoperative assessment is at present one of the top three
anesthesiologist plans therapy intended to prevent or minimize causes of lawsuits against anesthesiologists.
the effects of such problems. Uncovering patient factors that increase the risk of
Furthermore, a negative history and physical examination anesthesia, the anesthesiologist needs to know to ensure
can lead to decreased resource utilization for healthy patients that his or her patient is asymptomatic from the standpoint
and for those with co-morbid conditions but without risk factors of anesthesia risk.
requiring high intensity care. In addition, preoperative Preopertive evaluation: It consists of various steps as
evaluation gives practitioners confidence that they will not be follows:
surprised by unexpected patient conditions and gives patients • Complete history
confidence that the health care system is responding to their • Thorough physical examination
individual conditions and is focused on their well-being in the • Laboratory testing
preoperative period and beyond. • Imaging procedures
There are dramatic benefits of instituting a functional • Consultation with other specialties besides anesthetist if
preoperative clinic that goes through the stages of efficient required.
patient evaluation, appropriate test selection and effective
prerequisite education of the patient and that is organized in History
such a way that patient satisfaction is increased. The initial diagnostic workup is concerned chiefly with
The aim of the surgeon is to have the patient in good determining the cause of the presenting complaints. It should
condition at the operation table, do the surgery keeping the include all the aspects on the patient’s menstrual cycle and
ailment in mind, supervise the post- operative period so that abnormalities of bleeding pattern. Diagnostic laparoscopy
the recovery is eventless. For the first aim preoperative for testing the tubal patency and hysteroscopy are to be
care is required. avoided during the menstrual period. Also take obstetric
Preoperative care implies preoperative evaluation and history, and history of personal habits, urological and
preparation for surgical operation. Aims of preoperative care gastrointestinal problems and other medical diseases (see
are to: chapter 4 on history taking and examination of a Gynecology
• Decrease surgical morbidity patient). History of current medications being taken, allergy
• Increase the quality but decrease the cost of post- and reaction to antibiotics and other agents should be
operative care prominently displayed on the chart. Any addiction (e.g.
• Minimise expensive, delays and cancellation on the day smoking) must be known. History of previous surgery and
of surgery. any complications, if known, is helpful.
Examination Imaging Procedures
Physical examination includes overall assessment of general A chest radiograph should be obtained in all cases. Ultra-
health which includes: sonography, computerized tomography, magnetic resonance
• BP assessment, checking of peripheral pulses imaging, barium studies may be done as and when indicated
• Weight and height measurement to help in the diagnosis as well as to know the extent of disease.
• Temperature recording
• Thyroid and neck examination Consultation
• Breast examination Medicine, cardiology, respiratory medicine, endocrinology,
• Neurologic and orthopedic assessment urology, psychiatry and surgery departments may be
• Psychiatric evaluation in a patient with history of consulted as and when required to treat the ailment before
significant mental disorders or whose complaint on hand. In elective surgery, try to correct the deficiencies, e.g.
examination of abdomen and pelvis appears to have a anemia and stabilize the patient. Get the preanesthetic check

Chapter 61
psychoneurotic basis. up done before admission.
• Rectal examination should be done along with pelvic In addition to good surgical skills and techniques, the
examination in most of the gynecology cases outcome of pelvic surgery depends on several factors. These
• A Pap smear should be taken in women over 30 years of age factors include:
• In a teenage patient look for evidence of abnormal sexual • Age of patient
development, growth of hair on face, chest, abdomen, • Nutritional status
extremities, back and pubis. • Immune competence

Preoperative Care
• Critical evaluation of cardiac and pulmonary function in • Certain drugs
elderly patients is a must. • Pulmonary dysfunction
• Adequacy of circulating volume needs to be evaluated • Other medical diseases
and can be determined by looking at neck veins in supine • Obesity.
position, erect position, testes for orthostatic changes in Based on these factors the gynecological patient may be
BP and pulse. divided into 3 separate categories as follows:
• A hemoglobin of 8 gm/dl is physiologically safe for oxygen a. Uncomplicated gynecologic pathology
delivery but inadequate in patients with decreased b. Complicated gynecologic pathology
cardiac output or a surgery where blood loss is expected. c. Uncomplicated/complicated gynecolgic patho-logy with
In such cases blood replacement strategies may include: a medical/surgical problem.
1. Store the patient’s own blood in the weeks prior to
operation in the blood bank to allow autologous blood Age
transfusion, e.g. in genital prolapse. Operative risk should be judged on the basis of physiologic
2. Directed—donor blood storage rather than chronologic age and an elderly patient should
3. Phlebotomy and hemodilution immediate preoperative not be denied surgery because of age alone. Comprehensive
and subsequent reinfusion not a common procedure. evaluation requires tests for cardiac, pulmonary and renal
reserve; occult cancer even in presence of minor gastro-
Laboratory Tests intestinal complaints.
Once the decision for operation is taken in the out-patient They require smaller doses of narcotics, preanesthetic
department (OPD) (in elective surgery) the laboratory tests and anesthetic drugs.
can be performed there itself. This prevents the discomfort
of being admitted in the hospital for investigations alone and Nutritional Status
saves hospital indoor resources for other needy patients. This assessment is very important in cases of malignancy
as mortality and infection rate is higher in women with weight
Routine Tests
loss of >20%. Dietary history and tests for serum albumin of
• Hematocrit in all patients more than 6 months of age. <3 gm/dl and serum transferin of <150 mg/dl are important
• Bleeding time/clotting time if any such disorder is for this.
suspected and if BT, CT is found deranged, may do platelet Obesity on the other hand has its own hazards, there are
count, prothrombin time and partial thromboplastin time. more chances of hypertension, more risk of thromb-
• Urine routine examination in all cases and culture oembolism, difficulty in surgery. A controlled preoperative
sensitivity in cases with urologic symptoms. weight loss is often beneficial before elective procedure.
• Pregnancy test in all sexually active women of
reproductive age and using no contraception. Drugs
• STD testing, (chlamydia, gonococcus, syphilis, hepatitis, HIV) Certain drugs may reduce the patient’s resistance to infection
• White blood cell count in cases of suspected or evident by interfering with host defence mechanism, e.g.
pelvic infection. • Cortico-steroids
• Electrocardiogram (ECG) • Cytotoxic drugs
• Blood group. • Prolonged antibiotic therapy
Inall cases more than 65 yrs • Irradiation
All these may result in fungal infection. Renal failure,
• Blood urea nitrogen
lymphomas, leukemias, uncontrolled diabetes mellitus and
• Blood glucose
aplastic anemia result in immune compromise and higher
• Kidney function tests and liver function tests should be
infection rate.
done if impairment is suspected as each organ plays a
Medical disorders like cardiac disease, hypertension,
major role in clearance of various anesthetic agents both
thyroid disorder are considered high-risk from anesthesia
pre- and intraoperatively
point of view. All these should be under control. 487
• Serum electrolytes.
 Immune competence: The assessment of immune system situations, sometimes, this consent may not be available. In
should be done in cases of elderly, malnourished women, such cases two doctors can give a written opinion in good
those suffering from cancer, severe trauma or burns, or faith that the operation is necessary to save the patient.
AIDS by doing the following tests: Every effort should be made to obtain adequate consultation
• Total leukocyte count and careful documentation should be done in the case-file to
• CD4 cell count avoid legal hassles later on.
• Neutrophil chemotaxis
Preoperative Medication/Procedures
• Measurement of specific lymphocyte population.
For minor procedures like endometrial aspiration, cervical • Depending upon the type of surgery certain drugs may
biopsy, etc. a general examination, hemoglobin estimation be given to achieve better results, e.g. gonadotropin
and routine urine examination and an injection of tetanus releasing hormone agonist in the 3 months before
toxoid (if indicated) are all that is required. surgery may be beneficial in hysteroscopic resection of
Operation Theater Activities

For major surgery the patient is to be admitted at least myoma or endome-trium and to improve anemia in
one day prior to the surgery. This is for reassessment of the dysfunctional uterine bleeding.
patient, and making the patient, doctors, ward staff to get • Use of preoperative vaginal estrogen cream, starting 4–6
used to each other. This causes less anxiety. weeks before prolapse surgery in postmenopausal woman
to thicken the vaginal mucosa and control uropathogens.
The Rule of Threes • Diabetic women may be shifted to insulin in consultation
The rule of threes indicates that three aspects of acute with an endocrinologist as it gives better control of sugar
history, three aspects of chronic history and three aspects of levels during and after surgery.
physical examination make a difference to the operative • Those on oral anticoagulants should be shifted to heparin,
outcome. The three aspects of acute history are: preferably low molecular weight heparin.
1. Exercise tolerance. • Oral pills with high estrogen content pose a risk of venous
2. History of present illness and its treatment. thrombosis and embolism, so these should be stopped
3. When the patient last visited her or his primary care 2–4 weeks prior to elective surgery. With the current low
physician. dose oral pills this risk is much decreased. Nevertheless
one should give mechanical venous support such as
The three aspects of chronic history are: elastic stocking or intermittent pneumatic compression
Section 16

1. Medications and indication for their use and allergies. at the time of surgery.
2. Social history including drug, alcohol and tobacco use • In case of chronic smokers, the patient should be
and cessation. encouraged to stop it altogether or abstain for at least 30
3. Family history and history of prior illness and operations. days before an elective operation.
The three aspects of physical examination are: • An overloaded intestinal tract during surgery is potentially
1. Airway hazardous in terms of anesthetic risk. The patient should
2. Cardiovascular be instructed to take light easily digestible meal in the
3. Lung, plus those aspects specific to the patient’s condition previous night and nothing orally for at least six hours prior
or planned proceeding such as a sensory examination if to surgery. If she has to take same medication, e.g.
a regional block is planned. antihypertensive, she should take it with minimum water
Questions also are asked about prior exposure to only. For keeping the rectum empty an enema a night before
anesthetics and subsequent problems. surgery is enough for normal pelvic surgeries. In case the
Sensitive subjects include risk factors for use of illegal surgery involves bowel entry or anticipated injury, the
drugs and for human immunodeficiency virus (HIV) infection. patient should have complete bowel preoperation. She may
be given peglec/colowash a day before surgery with only
Preoperative Preparation liquid diet. The lower colon should be cleansed by a
Meticulous preoperative preparation is mandatory in elective preoperative enema. When vaginal surgery is to be
gynecologic surgery to obtain optimum results as time is not performed (e.g. vaginal hysterectomy) an antibiotic vaginal
as limited in elective case as it is sufficient to permit the pessary put in the vagina previous night may be sufficient.
principles of good surgical preparation to be followed. The • Preparation of the operation area—Pubic hair are to be
various factors to be considered in preoperative preparation cut short or gently shaved. The abdomen area need not
are as follows: be shaved.
• An adequate night’s rest before surgery is very importance
Informed Consent and one may have to sometimes give a mild sedative.
It is the gynecologist’s responsibility to inform the patient • Preoperative sensitivity testing of antibiotics to be given
and next of kin about the type of surgery and why the during surgery is performed. An injection of tetanus toxoid
operation is needed, its risks and possible consequences in 0.5 ml is given a day before surgery unless the patient is
her own language in simple words as it helps the patient in fully immunized against tetanus.
understanding the procedure and building rapport and
cooperation in the recovery period. The potential need for Hospital Environment
blood should be stressed and blood should be kept ready in Postoperative wound healing depends not only on meticulous
the blood bank. surgery and complete hemostasis but also on asepsis and
The patient and her legal guardian should sign the case- antisepsis of the hospital environment, instruments and
sheet authorizing a major or minor operation. A separate personnel.
anesthesia consent is also required. Therapeutic abortions Key points for optimum surgical outcome in preoperative
and operations that may adversely affect the sexual or care are:
childbearing function should usually be undertaken with the
488 concurrence in writing of the marital partner. In emergency
• Careful history taking
• Thorough physical examination
• Relevant laboratory tests • Postoperative management
• Interdisciplinary consultation in high risk cases – Pain control
• Correction of nutritional status, anemia or any other – Intensive care
medical illness – Postoperative ventilation
• Informed consent – Hemodynamic monitoring.
• Control of hospital environment
• Asepsis and antisepsis Routine Preoperative Anesthesia Evaluation
• Prophylactic antibiotics. • History
– Current problem
Preanesthetic Evaluation – Other known problems
The preoperative meeting between the anesthesiologist and – Medication history
Allergies

Chapter 61
patient has six specific purposes:
Drug intolerances
1. To obtain pertinent information about the patient’s medical
Present therapy
history and physical and mental conditions, in order to
– Prescription
determine which tests and consultations are needed. – Non-prescription
2. Guided by patient choice and the risk factors uncovered by Nontherapeutic
the medical history to choose the care plans to be followed.
Alcohol
3. To obtain informed consent
Tobacco
4. To educate the patient about anesthesia, perioperative

Preoperative Care
care, and pain treatments in the hope of reducing anxiety Illicit drug use
and facilitating recovery. – Previous anesthetics, operations, and, if applicable,
obstetric history and pain history
5. To make perioperative care more efficient and less
– Family history
expensive.
– Review of organ systems
6. To utilize the operative experience to motivate the patient
General (including activity level)
to more optimal health and thereby improve
Respiratory
perioperative and/or long term outcome.
Cardiovascular
Recovery occurs more quickly when the anesthesiologist Renal
allays the patients concern, informs the patient about what Gastrointestinal
is to come and plans postoperative pain therapy with the Hematological
patient (Tables 61.1 and 61.2) Neurological
Endocrine
The Anesthetic Plan
Psychiatric
• Premedication Musculoskeletal
• Type of anesthesia Dermatological
– General – Last oral intake
Airway management • Physical examination
Induction – Vital signs
Maintenance – Airway
Muscle relaxation – Heart
– Regional
– Lungs
Technique
– Extremities
Agents
– Mounted anesthesia care – Neurological evaluation
Supplemental oxygen • Laboratory evaluation
Sedation • ASA classification.
• Intraoperative management Table 63.2: Estimated energy requirements for various activities
– Monitoring
Metabolic equivalents Actions
– Positioning (MET)
– Fluid management
1 MET Can you take care of yourself?
– Special techniques Can you eat, dress, and use the toilet?
Can you walk in doors around the house?
Table 61.1: Preoperative physical status classification of patients Can you walk a block or two on level ground at 2-3
according to the American society of Anesthesiologists (ASA). mph (3.2 to 4.8 km/hr)?
Class Definition 4 METS Can you climb a flight of stairs or walk up a hill?
Can you walk on level ground at 4 mph (6.4 km/hr)?
P1 A-Normal healthy patient
Can you run a short distance?
P2 A patient with mild systemic disease (no functional limitation)
Can you do heavy work around the house such as
P3 A patient with severe systemic disease (some functional
scrubbing floors or
limitation)
moving heavy furniture?
P4 A patient with severe systemic disease that is constant risk
Can you participate in moderate recreational activities
to life (functionally incapable)
such as golfing, bowling, dancing, table tennis, or
P5 A moribund patient who is not expected to demote without
throwing a baseball or football?
the operation.
10 METS Can you participate in strenuous sports such as
P6 A brain-dead patient whose organs are being removed for
swimming, tennis, football, basketball or skiing?
donor purposes.
E If the procedure is an emergency, the physical status is
followed by ‘E’
Adapted from the Duke Activity Status Index and the American
Heart Association standards.
489
 62 Intraoperative and Anesthesia
Complications during Gynecology Surgery

Sudha Salhan, Sonia Ghuman, Meenakshi, PK Verma

Even with conscientious preparation and appropriate care and emergency requirements are fulfilled. Pulse oxymeter
by experienced surgeons and anesthetists, unexpected should be available. Allergies should be excluded the amount
difficulties may be encountered during any surgery leading of blood likely to be lost during surgery should be estimated.
to damage to adjacent structures with potentially serious Time out—Seven steps include knowing all team members,
consequences. The recognition of unexpected trauma at the confirmation of correct patient, site and procedure by
time of surgery is as important as is knowledge of appropriate surgeon, anesthetist and nurse. Surgeon gives approximate
repair procedures. Correction of surgical damage at the time operation duration, rough anticipated blood loss. Anesthetist
is usually preferable to interval surgery. All surgeons should takes any patient as specific concern. The nursing team
know their limitations and readily seek advice and help from confirms the standard of sterility. Any prophylactic antibiotic
others, either their seniors within the specialty or those in is given.
another surgical specialty. Patients should be advised Sign out phase has four points. Recording of procedure
preoperatively of well-recognized complications associated and correct count, proper labeling of specimen and any
with the operation they are about to undergo appraised after equipment problem. Proper handing over to the next health
the operation of any complications sustained, what treatment care provider(s) is essential. If major surgery is contemplated,
was given and any likely long-term implications thereof. the urinary bladder is catheterized by simple rubber catheter
WHO has initiated ‘Safe Surgery Saves lives’ initiative to (Fig. 62.1) or Foley’s indwelling catheter (Fig. 62.2).
reduce the number of surgical deaths across the world. A After anesthesia the patient is cleaned with antiseptic
surgical safety 18-point checklist is published and has proved solution in our hospital, we first clean with savalon (Fig 62.3)
to result in marked improvement in surgical outcome (Wtto with dry cotton or gauze we wipe it off. Then we paint the
2009). This checklist works in the same fashion as the checklists abdomen with iodine solution starting with incision site and
used by Pilots before flight. This helps to follow safety steps moving away in subsequent strokes. Finally the methyl
for each and every surgery. The list is divided into 3 distinct alcohol coat is applied. The operating area may be covered
phases. Sign in (before induction of anesthesia, Time out by sterile, disposable covering (Fig 62.4). Finally sterile draps
(period after induction and before incision of the skin), and cover whole of the ventral surface of the patient.
Sign out (period during or immediately after wound closure Hysterectomy, whether abdominal or vaginal is the most
but before the patient is removed from the operation room common gynecological surgery done the world over. Other
itself). major gynecology surgeries include oncology surgery:
Sign in—Has seven critical safety steps: Confirm patient’ Wertheim’s hysterectomy for cervical cancer, radical
identity, type of procedure, site of procedure and consent. hysterectomy and bilateral salpingo-oophorectomy with
Anesthetist confirms the fitness for surgery and that lymph node dissection for carcinoma of the endometrium,
equipment for airway and breathing system (oxygen and carcinoma of the vagina and vulva. With increasing use of
inhalation agents), suction, drugs and devices are available laparoscope, more and more number of procedures, both

Fig. 62.1: Red rubber catheter Fig. 62.2: Foley’s indwelling catheter
diagnostic and operative are being carried out through the because of the laceration of the deep pelvic veins can vary
laparoscope. Over a period of time, many advances and in magnitude from trivial to life-threatening. Pelvic veins may
refinements in techniques have been made. However, at be fragile, tortuous, hidden from view and sometimes not
times, significant complications and morbidity still do occur. available to ligation. Placing clamps and sutures blindly should
Anesthetic accidents, hemorrhage, injuries to ureter and bladder, never be attempted nor should (electrocoagulation) of a
bowel injuries, infections, postoperative pulmonary emboli and laceration in a large vein be done lest it results in an even
wound infections are common surgical risks. The larger hole that may be even more difficult to manage. Digital
intraoperative complications during gynecology surgery, both pressure is the best choice in such cases as it prevents further
open and laparoscopic, will be discussed here at length. tearing and trauma to the veins and also takes advantage of
the fact that the pressure in the pelvic veins is low.
HEMORRHAGE Arterial bleeding on the other hand is easier to control.
Despite adequate technical skills and careful dissection, These vessels have thick walls and are not easily torn further.

Chapter 62
serious hemorrhage can suddenly occur, especially during Blood spurting from the vessel leads to its easy identification.
dissection of the lateral pelvic walls and around the sacrum. It is best to apply pressure pack to tamponade the bleeding
Hemorrhage in the pelvis is a difficult problem to manage. It and then slowly remove the pack, visualize, catch and ligate
may be arterial or venous in origin. Hemorrhage that occurs the individual vessels. Mass ligatures should be avoided.
The use of surgical clips may be helpful.
Bleeding from the peritoneal edges may be controlled
with pressure, application of topical agents such as thrombin

Intraoperative and Anesthesia Complications during Gynecology Surgery

or collagen, or cautery or with Bovie or argon beam laser.
Major vascular injuries (MVI) like aortic injury still occur in
laparoscopic surgery. The incidence of MVI reported in the
literature is 0.05%, but the true incidence is difficult to estimate
because data are not always comparable and there is a
possibility of under-reporting. The mortality rates (8–17%) are
high. No technique or instrumentation is completely safe;
therefore, a high level of alertness must be maintained at all
times and precautions must be adopted to avoid major
complications. Small ooz can be covered by surgical,
interceed, etc. which prevent adhesions also. (Fig. 62.5).

URETERAL INJURIES
Any gynecological procedure, including laparoscopy can
result in ureteric injuries. About 75% of the ureteric injuries
result from gynecological procedures of which 3/4th occur
during abdominal procedure and ¼ th during vaginal
procedures. The highest incidence (1–2%) is reported with
extensive abdominal surgeries for invasive cervical
carcinoma. Incidence is higher for abdominal hystere-
ctomy(1–2%) than with vaginal (0.1%).The incidence with
adnexal surgery is below 0.1%. Ureteric injury may also occur
during surgery for removal of a TO mass, extensive pelvic
Fig. 62.3: Technique of cleaning and painting the abdomen endometriosis, leiomyomas (especially extending to the broad
(1) Nipple to mid thigh ligament) and during para-aortic lymph node sampling (during
(2) Laterally up to mid axillary line radical surgeries).
(3) Center to periphery: (max time spent at clearing
umbilicus) A peri-incisional area Various types of injuries to the ureter include:
(4) Perineum: A perianal area in the end. • Crushing from misapplication of a clamp
• Ligation with suture
• Ureteric transection (partial or complete)
• Angulation with secondary obstruction (either partial or
complete)

Fig. 62.4: Sterile covering of abdomen Fig. 62.5: Interceed 491

 • Ischemia that occurs from stripping the ureteric wall of using continuous or interrupted 3–0 absorbable suture. If
its blood supply (blood supply from a network of vessels). the lumen is involved, it is safer to close the defect in two
• Resection of a segment of the ureter layers. The defect should be closed in a direction perpendi-
• Injury during laparoscopy. Ureteric injuries with the cular to the intestinal lumen. If a large area is involved,
laparoscope have been reported in recent years with resection and anastomosis may be required. The transverse
increasing frequency. Injuries have been reported during colon, usually being well outside the operative site is rarely
laparoscopic treatment of endometriosis using both injured. However, the descending colon and the rectosigmoid
electrocoagulation and lasers. The ureters are also at are intimately involved with the pelvic structures and are at
risk of injury with laparoscopic ablation of uterosacral significant risk of injury. Injuries not involving the mucosa
ligaments, adhesiolysis and even during laparoscopic may be repaired in single layer using continuous 3–0
sterilization procedures using electrocoagulation. absorbable suture. If the mucosa is involved, it may be
Ureteral injury has also been reported during application repaired if the colon has been adequately prepared or a
Operation Theater Activities

of the linear stapler across uterine arteries and cardinal diverting colostomy may be required to protect the repaired
ligaments during laparoscopic assisted hysterectomy site from fecal contamination.
(LAVH).
These injuries are easily missed. Always be vigilant to COMPLICATIONS DURING LAPAROSCOPIC SURGERY
prevent or recognize this serious and troublesome Laparoscopic surgery has become a surgical discipline in its
complication. own right. Like any other surgical technique it does involve a
The most common anatomic sites of ureteral injury are: risk of complications. The risk is related to the complexity of
1. At the base of the broad ligament, where the ureter the surgical procedure. The set up phase for laparoscopy
crosses beneath the uterine vessels must never be considered lightly. The part played by the
2. When it passes through the ureteric tunnel in the cardinal surgeon’s experience cannot be over-emphasized in
ligament and turns anteriorly and medially to enter the preventing intra-operative complications, especially
bladder. involving complex procedures and more so in promptly
3. In the intramural portion of the ureter that traverses the recognizing complications if they occur, and managing them
bladder wall. in a skillful manner (Table 62.1).
4. At or below the infundibulopelvic ligament. The incidence of laparoscopic complication is 1.1–5.2%
in minor procedures and 2.5–6% in major ones.
Section 16

5. Along the course of the ureter on the lateral pelvic wall

just above the uterosacral ligament. The main complications that occur during laparoscopic
6. Vaginal fornices surgery include:
7. Over the iliac vessels while doing lymph node dissection. 1. Respiratory complication
Most of the ureteric injuries occur in the lower one third, 2. Prenumoperitoneal complications
as reported in most studies. For ureteric injuries occurring 3. Injuries
at the level of the ureteric tunnel or lower, the most effective a. Bowel injury
method of repair is to re-implant the ureter into the bladder. b. Bladder injury
c. Vascular injury
Locations at which the Reason for risk d. Diathermy damage
ureter is at risk 4. Gas embolism.
Pelvic brim Lies very close to ovarian vessels Table 62.1: Procedures performed and complication rates following
Ovarian fossa May adhere to any ovarian mass each procedure (for major and advanced operative laparoscopy only)
Ureteric tunnel Lies immediately inferior to uterine result of a multi-centric study in seven top French centers for
artery gynecologic laparoscopic surgery
Anterior to vagina May not be mobilized during
Indications Complications
at entry into bladder bladder dissection
Major operative laparoscopies
Major adhesiolysis 22 (3)/2665
BLADDER INJURY Conservative treatment for ectopic 2/1468
The bladder is vulnerable to injury because of its close pregnancy
Salpingectomy 9/1909
anatomic relationship with the uterus and upper vagina.
Distal tuboplasty 6/1675
Injury commonly occurs during the dissection of the bladder Benign ovarian cyst (cystectomy or 17 (7)/3908
off the cervix and upper vagina, though it may also occur adnexectomy)
during opening of the peritoneum. Unless there is Pelvic inflammatory disease 2/6 92
involvement of the trigone, a bladder laceration is easily Endometriosis 3/1894
repaired. A one or two layered closure with a small caliber Uterine suspension 0/3 91
braided suture such as 3–0 polyglycolic is adequate. After Polycystic ovary 2/ 20
Total 63/14622
bladder injury, the bladder should be continuously drained
Advanced operative laparoscopies
postoperatively for at least 7–10 days. Drainage should be
done until gross hematuria clears, which may occur as early Myomectomy 2/4 78
Hysterectomy for benign pathology 24/1798
as 48 hours. If the bladder trigone is involved, a surgeon
Lymphadenectomy 2/3 20
trained in urological repair should be consulted. Urinary stress incontinence 18/389
Genital prolapse 2/ 53
BOWEL INJURY Deep endometriosis 7/1 74
Small bowel injuries are the most common intestinal injuries Hysterectomy for malignant pathology 1/ 84
in gynecological surgery. If the defect is small, involving the Others 4/1 43
Total 60/3439
492 muscularis or the serosa, it may be repaired in single layer
 The incidence of complications in laparoscopic surgery measure should be adopted to aspirate gas from the
is closely related to the experience of the surgeon. venous side.
Safety tests done at the end of the surgical procedure
Respiratory Compromise
help in identifying any injury to the viscera that may have
i. The use of steep Trendelenburg position and the distension gone unnoticed at the time of surgery. Intraoperative
of the abdomen may both reduce excursion of the diagnosis of the injury and timely management helps in reducing
diaphragm reducing effective ventilation. the severity of complications and medicolegal actions. The
ii. CO2 (used by the surgeon) can be absorbed particularly surgeon should be aware of visceral injury in every case of
during prolonged operations. Endotracheal intubation extensive adhesiolysis. Injection of dye into the bladder and
and positive pressure ventilation along with monitoring insufflation of air into the rectum may help to identify small
of end tidal CO 2 (EtCO 2) and pulse oximetry (SpO 2 ) injuries and should be performed routinely in such cases.
reduces the risk of hypercarbia to a minimum.

Chapter 62
COMPLICATIONS OF ANESTHESIA
Pneumoperitoneum
Anesthesia word is derived from Greek language and means
Induction of pneumoperitoneum can cause the following
loss of sensation. Since the first successful anesthesia by
complications:
Morton on 16th October 1846 with Ether, anesthesiology has
i. Extraperitoneal emphysema (2% cases). If the Veress
opened up undreamt of avenues to operative medicine and
needle is not introduced into the peritoneal cavity.
has spared men and women a great deal of pain and torture.
The diagnosis is made by palpation of crepitus caused
A wealth of experience may have assisted in diminishing
by bubbles of CO2 under the skin. If it is recognized early

Intraoperative and Anesthesia Complications during Gynecology Surgery

the risks involved in anesthesia but it will never be possible
the gas may be allowed to escape and the needle
to abolish them entirely because these risks are inherent in
reintroduced through the same or another site.
the anesthetic state itself.
ii. Mediastinal emphysema: The gas may extend from a
correctly induced pneumoperitoneum into the Types of Anesthesia
mediastinum and create mediastinal emphysema.
There are three main types of anesthesia used in gynecology
Extensive emphysema may cause cardiac embar-
surgery, namely:
rassment and there will be loss of dullness to percussion
• General Anesthesia
over the precordium.The laparoscopy must be
• Regional Anesthesia
abandoned and evacuate as much gas as possible.
• Local Anesthesia.
iii. Pneumothorax: This may result from insertion of Veress
needle into the pleural cavity. Whenever a high site of Complications of General Anesthesia
insertion is chosen the needle should be directed away Data from perioperative deaths represents a combination
from the diaphragm and the standard protocols of of anesthetic and surgical factors and is difficult to analyze.
aspiration and fluid tests should be employed. But according to a confidential enquiry into perioperative
Pneumothorax should be suspected if there is difficulty deaths in 1987,very few deaths actually occur as a direct
in ventilating the patient. The procedure should be result of general anesthesia, which is about 0.0007% .
abandoned and the gas should be allowed to escape. As far as anesthesia related morbidity is concerned the
Keep the patient under close observation. Occasionally data suggest that up to 2% of intensive care admissions at
assisted ventilation and insertion of an intercostal tube any one time are related to anesthetic problems.
may be required. Various complications arise during and after general
The incidence of bowel damage during laparoscopic anesthesia; the major ones are listed below:
surgery is 0.5%. Blind insertion of Veress needle and trocar • Anaphylaxis
may lead to perforation of intra-abdominal and retro- • Nausea and vomiting
peritoneal structures. The transverse colon is the most • Aspiration of gastric contents
common segment perforated during insertion of veress • Laryngeal/bronchial spasm
needle or trocar. The bowel is rarely damaged unless it is • Damage to teeth
adherent to the anterior abdominal wall or has reduced • Cardiovascular collapse
mobility. Patients with previous abdominal surgery or past • Respiratory depression
intra-abdominal sepsis are the high risk groups. Laparoscopic • Aspiration pneumonitis
surgery carries a lower rate of bladder damage~1% • Hypothermia
when compared with open surgery (1–2%) except during • Hypoxic brain damage
colposuspension(4%). Bladder emptying by catheterization • Nerve injuries
or voiding prior to surgery greatly decreases the risk of • Awareness during anesthesia
bladder injury. • Embolism-air/thrombus
iv. Urinary bladder and blood vessel injuries—may also occur • Headache, backache
due to improper insertion of Veress needle. The editor • Idiosyncratic reaction
has seen an aortic injury in laparoscopy sterilization. • Death.
v. Gas embolism: Accidental continuous intravascular
insufflation of gas may lead to massive gas embolism or Important Complications of General Anesthesia
even death. But it is quite uncommon as the gas used Anaphylaxis
(CO2) is highly soluble and is rapidly reabsorbed and it The severity of anaphylactic reactions may vary from simple
has been seen that up to 400 ml of gas may be intravasated rash and urticaria to bronchospasm, hypotension and
without producing changes in ECG. Gas embolism should angioedema. A careful preanesthetic assessment helps to
be prevented by routine use of the aspiration test. The avoid anaphylaxis, which can occur to any anesthetic agent
patient should be turned to the left lateral position and and in all types of anesthesia. 493
 Patients with prior history of allergy to anesthetic agents • Total spinal or high spinal block
should be further investigated, which may require a • Direct nerve damage
provocation/skin testing and a referral to an immunologist • Damage to spinal cord
to determine the exact cause. • Spinal infections, meningitis
• Hematoma of spinal cord
Aspiration of Gastric Contents
• Anaphylaxis
Unconsciousness and reflex depression of coordinated • Urinary retention.
defense mechanisms deprive the body of its protective
reflexes, which can lead to either aspiration or laryngeal/ Postdural Puncture Headache (PDPH)
bronchial spasm. It is quite common and results from CSF leak from puncture
Aspiration of stomach contents is common as they reach site. The patient complains of headache (which is throbbing
the pharynx either by active vomiting or by passive in nature), photophobia, dizziness and vomiting.
Operation Theater Activities

regurgitation. Especially dangerous is the aspiration of Incidence of PDPH can be reduced by using finer gauge
gastric acid (with pH below 2.5) into the air passages. This needles or using pencil tipped needles (Sprotte type or
phenomenon was first described by Mendelson. Mendelson’s Whitacre type). PDPH is treated with analgesia and adequate
syndrome—to avoid this, patients must be kept empty stomach hydration. Occasionally, epidural blood patch (20–30 ml of
for 6–8 hrs for elective surgeries. Further, the patient should patient’s own blood) may be required to seal the site of
be positioned on a tilt-table and a well-functioning suction meningeal tear. Epidural blood patch treats headache within
pump should be available during anesthesia. minutes of injection.
Laryngospasm and Bronchospasm Hypotension
Foreign bodies entering trachea (even endotracheal tubes) Approximately, 1/3rd of patients suffer from hypotension
during lighter planes of anesthesia may cause laryngospasm after an intrathecal anesthetic. The definition of hypotension
or bronchospasm. The tendency to bronchospasm is varies but a fall of 25–30% from a preoperative blood pressure
especially increased in patients with asthma and chronic is generally considered a cut-off for treatment. The cause of
obstructive pulmonary disease—COPD (emphysema and hypotension is thoracolumbar sympathectomy produced by
chronic bronchitis). the local anesthetic solution, which causes a fall in systemic
Aspiration laryngo/bronchospasm can cause severe vascular resistance and increases venous pooling.
Section 16

impairment of ventilation with a low pO2 and high pCO2 levels Hypotension usually responds to treatment with intravenous
in alveolar air and blood so there is always a risk of death. fluids. Occasionally, vasopressors (ephedrine 3–6 mg
Damage to Teeth boluses)may be required to treat severe hypotension.
During laryngoscopy damage to teeth can occur and it is High Block or Total Spinal Block
one of the commonest cause of claims made against
Sometimes spinal anesthesia may extend above T4 levels,
anesthetists in the West. So during the preanesthesia check-
which is referred to as high spinal block resulting in bradycardia
up one must examine the teeth. The tooth most commonly
and hypotension. Aggressive management with appropriate
affected is the upper left incisor.
chronotropic and vasoconstrictor drugs along with
Peripheral Nerve Damage intravenous fluids should be done. A total spinal anesthesia
The commonly encountered cause is the exaggerated occurs in cases where a large volume/dose of local anesthetic
positions for prolonged periods of time resulting in nerve is accidentally injected into the subarachnoid space instead
compression. The nerves commonly affected are ulnar and of the epidural space. In such cases respiratory insufficiency
common peroneal nerves. Less often the brachial plexus occurs, therefore, these patients should be intubated and
may be affected. mechanically ventilated.
The severity of nerve damage varies and may take long
to recover. Therefore, both the anesthetists and the surgeon Complications of Local Anesthesia (LA)
should be aware of this potential complication and extreme • Pain
postures for lengthy periods during surgery should be • Bleeding and hematoma
avoided. If nerve damage occurs, then the patient should be • Nerve injury
followed up and further investigations such as electro- • Infection
myography may be required. • Ischemic necrosis
• Allergic reactions
Complications of Laparoscopy • Systemic toxicity.
Complications directly attributable to the general anesthetics 1. Allergic reactions: True allergic reactions due to LA are
are no different from those which may occur when any other rare. However, adverse reactions (e.g. local anesthetic
type of surgery is performed. But some features of overdose, fainting) are common.
laparoscopic surgery predispose to specific anesthetic 2. Systemic toxicity: It results from one of the following two
complications like respiratory compromise, extraperitoneal causes—accidental intravascular injection or admini-
emphysema, etc. stration of excessive dose.
The toxic effects are primarily directed at the central
Complications of Regional Anesthesia nervous system (CNS) and cardiovascular system (CVS)
Regional anesthesia is associated with less serious with CVS being considerably more resistant.
complications and less mortality when compared with general CNS toxicity—the toxic effects on CNS are concentration
anesthesia.The important complications are as follows: dependent. Low concentrations produces sedation whereas
• Postdural puncture headache (PDPH) higher concentrations produce seizures. When seizures
494 • Hypotension and bradycardia occur hypoxia, hypercarbia and acidosis develop rapidly.
Furthermore, these metabolic changes greatly increase the space fluid loss, unreplaced urinary losses or septicemia
toxicity of local anesthetics. Therefore, at the first sign of with vasodilatation and capillary leakage.
toxicity oxygen must be given immediately. However, if the Whatever is the cause prompt diagnosis and treatment is
seizure activity interferes with ventilation or is prolonged, important because prolonged hypotension can result in
anticonvulsant drug therapy is indicated along with mechanical hypoperfusion of vital organs leading to ischemic changes.
ventilation. Rapid and short acting benzodiazepenes like Try to restore intravascular volume by means of I/V fluids
midazolam can be given to control seizure activity followed and if not corrected use vasopressors (dopamine).
by barbiturates (thiopentone).
The best treatment for toxic reactions is prevention. Hypertension: It is often due to pain, hypercapnia, hypoxemia,
1. Never administer excessive doses of local anesthetics urinary retention or excessive I/V fluid volume. These
2. Use meticulous technique and utilize the test doses etiologies need to be ruled out. Severe hypertension can
whenever possible lead to left ventricular failure, myocardial ischemia or

Chapter 62
3. One must have knowledge of highest recommended dysrhythmias. It may also precipitate pulmonary edema or
doses of local anesthetics (Table 62.2). cerebral hemorrhage.
If toxic reactions occur, early detection and prompt Beta blocking drugs like labetalol and esmolol are effective
support of ventilation and circulation is necessary. in treatment of hypertension in recovery rooms.
Labetalol is an alfa and beta-blocking drug given in 5 mg
Postanesthetic Care
increments and effect is apparent in several minutes. Esmolol
Recovery from anesthesia is usually smooth and uneventful. is an ultra-short acting beta blocker so it can be given as an

Intraoperative and Anesthesia Complications during Gynecology Surgery

However, it can be a life-threatening experience for some infusion of 25–300 micro-grams/kg/min.
patients, which can be managed only by skilled medical and
nursing personnel. In the recovery room there are patients Dysrhythmias: The most common dysrhythmias are sinus
waking up from routine surgery, patients recovering from tachycardia, sinus bradycardia, ventricular premature beats,
regional anesthesia and critically-ill postoperative patients. ventricular tachycardia and supraventricular tachydys-
Therefore, facilities and staff must be experienced and rhythmias. Factors predisposing to the development of
flexible to give care for all these patients. postoperative dysrhythmias are electrolyte imbalance
The most common postoperative complications are especially hypocalemia-hypoxia, hypercarbia, metabolic
nausea and vomiting, airway complications needing support, alkalosis/acidosis and pre-existing heart disease.
hypotension, dysrhythmias, hypertension, altered mental Dysrhythmias appearing in the recovery room rarely require
status, major cardiac event and need to rule out myocardial long term treatment.
Before discharge or transfer to the ward a patient who
infarction in that order.
has undergone anesthesia should meet certain criteria. A
Nausea and vomiting: It is a common complication causing modified Aldrete score is a simple sum of numerical values
patient discomfort and prolonged stay in the recovery room. assigned to activity, respiration, circulation, consciousness and
Serotonin antagonists like ondansetron and granisetron are oxygen saturation; a score of at least 9/10 indicates a patients
useful as first line of drugs. readiness for discharge (Table 62 .3).
Respiratory complications: The major respiratory complications The Postanesthesia Discharge Scoring System modifies
encountered are airway obstruction, hypoxemia, hyper- these required parameters by including assessment of pain,
capnia and aspiration. The most common cause of airway nausea vomiting and surgical bleeding in addition to vital signs
obstruction is pharyngeal obstruction, a combination of and activity (Table 62.4).
backward tilt of the head and anterior displacement of the The anesthesiologist must see the patient again before
mandible is often helpful or else a nasal or oral airway can be being discharged from the recovery room.
inserted. Airway obstruction can be due to laryngeal spasm Table 62.3: Two examples of discharge criteria systems
which can also be relieved by anterior displacement of the
mandible or else by giving 8 to 10 mg of dexamethasone intra- Postanesthesia Recovery Score (Modified Aldrete Score)
venously to reopen the airway. Oxygen by facemask should Activity
be given. When the airway cannot be opened by physical 2 = Moves all extremities voluntarily/on command
means intermittent positive pressure ventilation IPPV with 1 = Moves two extremities
bag and mask and 100% oxygen is indicated. 0 = Unable to move extremities
Respiration
Hypotension: There are many causes of hypotension during 2 = Breathes deeply and coughs freely
recovery phase of anesthesia like decreased ventricular 1 = Dyspneic, shallow or limited breathing
preload, reduced myocardial contractility or a profound 0 = Apneic
reduction in systemic vascular resistance. Circulation
2 = BP+20 mm of preanesthetic level
Decreased ventricular preload is due to intravascular 1 = BP+20-50 mm of preanesthetic level
volume depletion because of blood loss, excessive third 0 = BP+50 mm of preanesthetic level
Consciousness
Table 62.2: Doses of total anesthetic 2 = Fully awake
Agent Concentration-used Highest recommended 1 = Arousable on calling
clinically dose 0 = Not responding
Bupivocaine 0.125–0.5% 2 mg 1kg b.wt.150 mg Oxygen saturation
over 4 hrs. and 400 mg 2 = Spo >92% on room air
over 24 hrs. 1 = Supplemental O req.to maintain Spo 90%
Lignocaine 0.5–2% 3 mg/kg b.w. without 0 = Spo , 92% with O supplementation
oder 7 mg/kg bw with 10=Total score
Score >9 required for discharge or transfer to the ward
adrenalin 495
 Table 62.4: Post-anesthesia discharge scoring system
Vital signs(BP and Pulse)
2 = Within 20% of preoperative baseline
1 = 20–40% of preoperative baseline
0 = >40% of preoperative baseline
Activity
2 = Steady gait, no dizziness
1 = Requires assistance
0 = Unable to ambulate
Nausea and Vomiting
2 = Minimal:treat with PO medications
1 = Moderate:treat with IM medication
0 = Continues:repeated treatment
Operation Theater Activities

Pain
Acceptable to patient;control with PO medications
2 = Yes
1 = No
Surgical Bleeding
2 = Minimal:no dressing change required
1 = Moderate: up to 2 dressing changes
0 = Severe: more than 3 dressing changes
10=Maximum score
Score >9 required for discharge Fig. 62.7: Venepuncture
loosen the fist and remove the tourniquet. Take out the needle
Venesection (Figs 62.6A to C) and press the site with spirit swab for one minute. The swab is
It is required in moribund patients: to be thrown in yellow/red bag.
a. Palpate and locate the saphenous vein For giving intravenous medication, rotate the needle and
b. Infiltrate the skin with local anesthetic syringe by 180° so that the bevel faces opposite to the
c. Make a 2 cm transverse incision operator and then inject the drug. If it is to be given
Section 16

d. Expose the vein continuously either in the infusion pump, or intravenous line,
e . Insert sutures loosely under proximal and distal end of hang the bottle by the tripod drip stand. The exact rate of
the vein and tie distal suture drug therapy or infusion is set and written in the instructions
f. Make a small incision in vein. in the case sheet.
g. Expose the vein and insert cannula If the superficial veins are collapsed then femoral vein
h. Tie upper suture to secure cannula (Figs 62.8A to C) is punctured 1 cm distal to the inguinal
i. Close the wound ligaments. The femoral artery is first felt at the midpoint of
j. Secure cannula with suture. the inguinal ligament and the needle can be introduced
medial to it. Keep all the vials for blood collection, or the
Indications medicine to be given, ready.
• To collect blood
• To inject medications Complications
• To give transfusions/infusions. • Counter puncture and hematoma formation
• Thrombophlebitis
Venepuncture (Fig 62.7) • Extravasation
Sites: Median cubital vein in the cubital fossa is commonly • Inadvertent injection into an artery.
used for collection of blood and giving medications/infusions. • Air embolism if the fluid bottle is empty.
The doctor must wash his/her hands, put on sterile gloves, Central Venous Pressure
clean the skin with spirit. For making the vein prominent tie a
The central venous pressure is the pressure of the blood in
rubber tourniquet proximal to the venepuncture site or ask an
the right atrium or the superior vena cava, where the blood
assistant to compress at that point with a hand. Ask the patient
is returned to the heart from the venous system. Because
to close the fist. Pull the skin at the puncture site and then
the tricuspid valve is opened between the right atrium and
introduce the needle by the side of the vein into the
the right ventricle during diastole (ventricular filling), right
subcutaneous tissues with the bevel facing upwards. The needle
atrial pressure or CV pressure or CVP also represents the
is advanced till it pierces the vein (felt as a characteristic “give
end diastolic pressure in the right ventricle and reflects
in”). As counter puncture can occur as blood comes into the
preload for the right ventricle.
syringe do not push the needle any further. Pull the piston out
and collect the required amount of blood. Ask the patient to Clinical Significance
Central venous pressure is regulated by a balance between
the ability of the heart to pump blood out of the right atrium
and the amount of blood being returned to the heart by the
venous system (venous return). Normal CVP is between 3–12
cm H 2O. Central venous pressure may be elevated under
the following conditions:
• Increased venous return
• Increased intrathoracic pressure
496 Decreased ability of the right heart to move blood. Causes
Figs 62.6A to C: Venesection of decreased central venous pressure include the following:
 Chapter 62
Intraoperative and Anesthesia Complications during Gynecology Surgery
Figs 62.8A to C: Technique of venepuncture of femoral vein

• Inadequate circulating blood volume (hypovolemia)

• Decreased intrathoracic pressure
• Placement of the transducer or zero level of the water
manometer above the patients right artrial level
• Air bubbles or leaks in the pressure line.
Central Venous Pressure Catheters and Insertion Sites
(Fig 62.9)
Central venous pressure catheters (single lumen or
multilumen) are positioned in the superior vena cava via the
subclavian or internal and external jugular and/or antecubital
veins (are rarely via general veins). The internal jugular vein
has become the most popular site because of the ease of
insertion, low risk of pneumothorax and good visibility if
hematomas form in the neck.
Central Venous Pressure Line Site Care
Central venous pressure catheters should be inserted under
aseptic conditions. Migration of bacteria from the skin surface
along the subcutaneous tract to the blood stream has been
found to be the primary mechanism in the pathogenesis of
catheter-related septicemia. A dry and sterile dressing should
be applied over the insertion site. The dressing should be
assessed every 2–4 hrs and as necessary and should be
replaced when it becomes damp, loosened, or soiled and
when inspection of the site is necessary.
Central Venous Pressure Monitoring
Central venous pressure may be obtained using transducer
system or a water manometer. Water manometer measures Figs 62.9A to C: Femoral vein puncture
pressure in centimeters of water whereas a transducer
shows pressure in mm of mercury (mm Hg). – X-ray verification of the tip of the catheter (if possible)
For measuring CVP using a water manometer system, • Position the bed so that the patient is supine with the head of
proceed in steps, as described below: the bed flat or elevated no more than 60°
• Wash hands • Locate the atrial reference point. It is at the mid-chest
• Confirm the position of CVP catheter: For confirmation, level at the fourth intercostals space
look for the following: • Use a carpenters level or spirit level to match the zero
– Free-flowing intravenous fluid level of the manometer with the atrial reference point
– Ability to easily aspirate a blood sample from the • Turn the water manometer stopcock open to the IV
CVP catheter fluid bag and open the IV tubing roller clamp water
– A rapidly falling water column when the pressure is manometer
obtained • Close the roller clamp on the IV tubing. Turn the water
– Oscillations at the top of the water column accruing manometer stopcock open to the patient 497
with respiration • Measure the CVP at end expiration
 • Turn the water manometer stopcock open to the IV fluid ACIDEMIA
bag and to the patient Acidemia refers to an arterial pH below 7.35.
• Wash hands.
ALKALEMIA
Central Venous Pressure Line Removal
Alkalemia refers to an arterial pH above 7.45.
Central venous catheters are removed when therapy is
completed, or a mechanical malfunction has occurred, or the ACIDOSIS
catheter has become occluded or malpositioned or the patient
A physiologic process that, occurring alone, leads to an
has developed a catheter-related infection. While removing
acidemia. Common clinical causes include low-perfusion
the CVP line, following steps should be followed:
states (metabolic acidosis) and hypoventilation (respiratory
• Remove gloves, clean the area with alcohol or povidone-
acidosis).
iodine.
Operation Theater Activities

• Ensure that the head of the bed is flat, remove the pillow ALKALOSIS
and have the patient turn his/her head away from the
A physiologic process that, occurring alone, leads to an
catheter.
alkalemia common clinical causes include diuretic therapy
• Carefully cut the suture and pull the sutures through the
(metabolic alkalosis) and hyperventilation (respiratory
skin.
alkalosis).
• Grasp the catherter with the dominant hand and slowly
withdraw the catheter. With the non- dominant hand, quickly BUFFERS
apply pressure over the puncture site with a sterile gauge.
A buffer is defined as a compound which opposes changes in
• Maintain pressure for 2–5 min until hemostasis has been
[H+]. Physiological buffers consist of a weak acid in equilibrium
achieved. Apply an occlusive, sterile dressing over the site.
with its conjugate base:
Arterial Blood Gas (ABG) analysis is a singe most useful
laboratory test as it can be safely and easily obtained and
Acid Conjugate base– + H+
furnishes rapid and accurate information on how well the
lungs and kidneys are working. Moreover, because it is not Ka = ([H+] × [Conjugate base–])/[acid]
possible to predict the partial pressures of oxygen (PaO 2) where Ka is the dissociation constant. H + added to this
and carbon dioxide (PaCO2) in the arterial blood reliably using system will combine with the conjugate base to form the
Section 16

physical signs of cyanosis and depth of breathing, the ABG undissociated acid (lowering the [H +]. If [H +] falls, the acid
provides the most important way of making a diagnostic will dissociate to generate more H+. The body’s main buffer
assessment of the nature, progression, and severity of a systems are (i) Intracellular (protein, phosphate, and
respiratory disturbance. hemoglobin) and (ii) Extracellular (bicarbonate).
It is important to have a clear understanding of what is
meant by the commonly used terms in blood gas analysis STANDARD BICARBONATE
and acid-base balance. This is the bicarbonate concentration of plasma that has
been fully equilibrated with a normal PaCO 2 at standard
PARTIAL PRESSURE temperature and pressure and thus reflects only non-
The pressure of any gas is the sum total of the molecules in respiratory (i.e. metabolic) effects. Normal value 21–27
the gas colliding with the walls of the container. If the gas is mmol/L.
a mixture (such as air), then the total pressure is the sum of
all the individual gas pressures. The pressure of individual ACTUAL BICARBONATE
gas is known as its partial pressure. When a gases mixture is This is the concentration of bicarbonate measured in a
in contact with a liquid, some of the gases will dissolve in the sample without any corrections as mentioned for standard
liquid and the volume that dissolves depends on the partial bicarbonate. Therefore, the actual bicarbonate reflects the
pressure of the individual gas forcing the molecules into the contribution of both the respiratory and metabolic
liquid and the ease of the individual gas molecules to get into components of the body’s acid-base balance and not the
the liquid (that is, its solubility). In time, provided the gas and metabolic component in isolation of HCO 3– will fall with
solution are left undisturbed, an equilibrium will develop respiratory alkalosis. Normal value 21–28 mmol/L.
whereby the number of molecules of gas leaving the liquid
will equal the number entering the liquid. At this point the BASE EXCESS
partial pressure of each individual gas within the liquid will be Base excess is defined as the titrable base to [H +] of 40
equal to the partial pressure of the same gas in contact with nmol/L and a PaCO2 of 40 mm Hg at 37°C. It represents the
the liquid. Partial pressures are measured in either mmHg or deviation from normal of the buffering capacity of the body.
kPa. Normal PaO2 value: over 90 mm Hg on room air; normal A deficiency of buffer base or negative base excess
PaCO2 value: 35–45 mm Hg. implies a non-respiratory (metabolic) acidosis; a positive
base excess implies metabolic alkalosis. Base excess
pH SCALE (negative or positive) takes into account all the buffers in
The concentration of hydrogen ions in the blood is in the the blood sample and is therefore considered a more
order of 40 nanomole/liter (nmol/L). Dealing with such very accurate assessment of the metabolic component of the
small numbers is obviously difficult. Consequently in 1909 patient’s acid-base status. Normal base excess value ± 2
the pH scale was developed to express the concentration of mmol/L.
hydrogen ions in a more convenient way. The normal pH of an
arterial blood sample is between 7.36 and 7.44, and this is ARTERIAL BLOOD GAS SAMPLING:
equivalent to a hydrogen ion concentration of 44–36 nmol/L CLINICAL CONSIDERATIONS
498 respectively; 6.8–7.8 is the pH range usually considered While taking an arteria blood gas sample, the following points
compatible with life. should be considered:
• Is ABG machine working and has it been calibrated? body has had no time to compensate completely for the
• Date and time of sample alteration in hydrogen ion concentration, the altered pH will
• Fraction of oxygen in inspired air (FiO2) indicate the primary acid-base problem. Nevertheless, a
• Ventilatory status normal pH does not exclude an underlying acid-base
• Heparin: A heparinized syringe (to prevent the sample disturbance. It may be within the normal range either
from clotting) is used to take an ABG sample. PaCO2 and because of full compensation by the body for a single acid-
[HCO3–] show an inverse relationship to the volume of base disturbance or because of the presence of more than
heparin used, especially if the volume is greater than one acid-base disturbances with equal but opposite effects
10% of the sample volume. Heparin 5000 IU/mL is acidic on pH.
and may influence [H+] reading Knowing the patient’s clinical history and examination,
• Air bubbles greater than 0.5–1% of the sample volume one may have an idea about which of these options is true.
will introduce error To confirm, however, one needs to go to the next step.

Chapter 62
• Any sample that cannot be measured in less than 10
minutes must be sealed, packed in ice and measured Step 2: Look at the PaCO2 and HCO3–
within 1 hour. In a patient with acidemia, an increase in PaCO 2 level
indicates primary respiratory acidosis and a decrease in
INTERPRETATION OF A BLOOD GAS SAMPLE bicarbonate level indicates primary metabolic acidosis.
Before attempting to interpret, it is useful to take a moment Similarly, in a patient with alkalemia, a decrease in the PaCO2
to confirm whether the sample represents arterial blood. level indicates primary respiratory alkalosis and an increase

Intraoperative and Anesthesia Complications during Gynecology Surgery

The interpretation of ABG should always be based on the in the level of bicarbonate suggests primary metabolic
background of clinical history and physical examination of alkalosis.
the patient. While interpreting, it is advisable to proceed in However, there may be situations where, for example,
steps (Table 62.5). pH is low and the PaCO 2, standard bicarbonate, and base
excess concentrations are all high. The most likely reason
Step 1: Is there an Acidemia or Alkalemia? for this is a respiratory acidosis that has persisted long
A pH less than 7.35 denotes acidemia and more than 7.45 enough to enable some metabolic compensation to occur
denotes alkalemia. In most of the acute situations, when the or it could be because of primary respiratory acidosis and
combined primary metabolic alkalosis.
Table 62.5: 1° Primary interpretation of bloodgas sample As one observes from the above table, there are more
than one possible causes for the changes in pH, PaCO 2,
pH PaCO 2 Standard Likely causes
bicarbonate and base excess.
HCO 3 and
base excess
Step 3: Compare with the Expected Changes
Low High Low Acidemia due to combined
1°respiratory and metabolic
To clarify the matter, one needs to quantify the changes in
acidosis. PaCO2, actual bicarbonate, and base excess and compare
Low Low Low Acidemia due to either a 1° these with the expected changes appropriate for a single
metabolic acidosis with acid-base disturbances.
incomplete respiratory
compensation or a 1° metabolic Expected Changes
acidosis with a 1° respiratory
alkalosis. • Acute respiratory acidosis: A 10 mm Hg rise in PaCO 2
High Low High Alkalemia due to a combined 1° produces 1.0 mmol/L rise in actual bicarbonate
respiratory and metabolic • Chronic respiratory acidosis: A 10 mm Hg rise in PaCO 2
alkalosis produces 3.5-4.0 mmol/L rise in actual bicarbonate.
High Low Low Alkalemia due to either a 1° • Acute respiratory alkalosis: A 10 mm Hg fall in PaCO 2
respiratory alkalosis with
produces 2.0 mmol/L fall in actual bicarbonate
incomplete metabolic
compensation or a 1° respiratory • Chronic respiratory alkalosis: A 10 mm Hg fall in PaCO 2
alkalosis with a 1° metabolic produces 5.0 mmol/L fall in actual bicarbonate chronic.
acidosis. • Metabolic acidosis: A 1.0 mmol/l fall in actual bicarbonate
High High High Alkalemia due to either a 1° produces a 1.0–1.3 mm Hg fall in PaCO2.
metabolic alkalosis with • Metabolic alkalosis: A 1.0 mmol/L rise in actual bicarbonate
incomplete respiratory
compensation or a 1° metabolic
produces a 0.6 mm Hg rise in PaCO2.
alkalosis with a 1° respiratory When the observed values lie beyond the expected range
acidosis. of changes, as derived by calculation, then the patient
Normal High High Combined respiratory acidosis probably has more than one acid-base disturbance.
and metabolic alkalosis that are
cancelling out each other’s pH Step 4: Look at the PaO2 and FiO2
changes. Both can be 1°
disturbance or one could be Finally one needs to look at the PaO2 value. This is important
completely compensating for the because a failure to take up oxygen can lead to hypoxia,
other. which, in turn, can give rise to metabolic acidosis because
Normal L o w Low Combined respiratory alkalosis hypoxia promotes anaerobic metabolism and excessive
and metabolic acidosis that are production of lactic acid. However, simply looking at PaO2 is
cancelling out each other’s pH
not enough, it should be evaluated with reference to the
changes. Both can be 1°
disturbances or one could be inspired concentration of oxygen (FiO2). By knowing the FiO2,
completely compensating for the it is possible to have a rough idea of what the PaO2 should be
other. if patient is ventilating normally. A difference between the 499
 inspired oxygen concentration and the PaO 2 of greater than 9 . Hines R, Barash PG, Watrous G, et al: Complications occurring
75 mm Hg would imply that there is a defect in the uptake of in post-anaesthesia care unit: a survey. Anaesth Analg
oxygen. For example, an inspired oxygen of 50% will have a 1992;74:503.
10 . Hoffman J, Westendorff C, Reinert S. Evaluation of dental injury
partial pressure of 50 × 760/100 = 380 mm Hg (that is, half the
following endotracheal intubation using the period test technique.
normal atmospheric pressure). This would mean the expected Dent Traumatol 2005;21(5):263-8(abstract).
PaO2 would be at least 380–75 = 305 mm Hg. 11 . Kroigaard M, Garvey LH, Menne T, et al. Allergic Reactions in
anaesthesia: Are suspected causes confirmed on subsequent
Step 5: Integrate the Clinical Findings and ABG Data testing? Br J Epub 2005; 95(4)468-71. Epub 2005 Aug 12(abstract).
Finally, it is important to integrate the clinical findings and 12 . Kuczkowski KM. Post-dural puncture headache in obstetric
ABG data to efficiently manage the patient. Simply using the patients–an old problem. New solutions: Minerva Anaestesiol
ABG data result in isolation increases the chances of missing 2004;70(12):23-30(abstract).
13 . Masterson BJ. Ureteral injuries.In: Manual of Gynecologic
a co-existing acid base disturbance.
Operation Theater Activities

Survey. 2nd edn. New York:Springer-Verlag;1986.pp.339-49.

14 . Mendelson CL: The aspiration of stomach contents into the lungs
BIBLIOGRAPHY
during obstetric anaesthesia. Amer J Obstet Gynaec 1946;52:191-
1 . Atkin head AR. Injuries associated with anesthesia. A global 20 5.
perspective; Br J Aneasth. Epub 2005;95(1):95-109. 15 . Mitchell GW, MasseyFM. Bleeding 3 hours following vaginal
2 . Borgeat A; Neurologic deficit after peripheral nerve block: what hysterectomy.In : Nichols DH, (Ed). Clinical Problems, Injuries
to do? Minerva Anaestesiol 2005;71(6):353-5 (abstract). and Complications of Gynecologic Surgery. Baltimore: Williams
3 . Butter worth J. Physiology of spinal anaesthesia: What are the & Wilkins;1988.pp.151-3.
implications for management? Reg Anaesth Pain Med 16 . Petri E. Current opinion in Obstetrics and Gynecology 1999;
1998;23:370-3. 11(5):495-8.
4 . Chung F, Chan VW, Ong D: A post-anaesthetic discharge scoring 17 . Randall L, Carpenter and David C, Mackey. Local anaesthetic
system for home readiness after ambulatory surgery. J Clin chapter 17 page 430 in clinical anaesthesia 3rd edition by Paul G
Anaesth 1995;7:500. Barash, et al.
5 . Complications of Gynecological Surgery. Krisher S and Richard 18 . Review: The Obstetrician and Gynecologist 2004;6:203-8.
J. Surgical complications of diagnostic and operative 19 . Roviaro GC Varoli F, Saguatti L, Vergani C, Maciocco, M, Scarduelli
gynecological laparoscopy: a series of 29966 cases. Human A. Department of Surgery S Giuseppe Hospital Fbf, A.Fa.R,
Reproduction 1998;(13);867-72. University of Milan, 12 Via San Vittore, 20123 Milan, Italy.
6 . Fehrman H. Surgical management of life-threatening obstetric 20 . Thomas W Feeley, Alex Macario; The postanaesthesia care unit.
Section 16

and gynecologic haemorrhage. Acta Obstet Gynecol Scand Chapter 71 in Millers Anaesthesia 6th Edn.
1988;67:125. 21 . World Health organization (2009a). Surgical safety checklist
7 . Harris W. Early complications of abdominal and vaginal (1st edn). Retrieved Feb. 16, 2009 from http://www.WHO. int/
hysterectomy. Obstet Gynecol Survey 1995;50:795. patientsafety/safesurg/tool_resources/SSSL_checklist_final/
8 . Haynes AB, Weiser TG, Berry W, et al. The surgical safety June09.pdf.
checklist to reduce morbidity and mortality in a global population. 22 . WHO (2009b) World Alliance for patient safety. Retrieved Feb.
The New Engl J of Med 2009;306(5):491. 16, 2009 from http://www.int/patientsafety/en/.

500
 63 Postoperative Care and Complications

Renuka Sinha, Sushma Suri, Sudha Salhan

Care of the patient following surgery is as important as pre- hemoglobin level is below 8 gm%. Above this oral iron
and intraoperative care. Good postoperative care leads to therapy is advised. Transfusion of platelets or fresh frozen
reduction in morbidity, leading to shorter stay in hospital plasma is based on the clinical situation and laboratory value.
and better patient satisfaction. Prevention and early Additional fluid is required in the following conditions:
recognition of postoperative complications is the essence of
High fluid loss through drain
good clinical practice. A long abdominal operation—1 L loss/hour
Early mobilization and appropriate physiotherapy are Pyrexia—15% extra/1degree Celsius rise of temperature
important in preventing complications and early recovery. Loss into the third space, e.g. ascites, pleural effusion, debulking of
ovarian tumor
POSTOPERATIVE CARE Pelvic drain—lymph node dissection
Colostomy—3–4 liters/24 hours.
Suitable Environment
The postoperative room should provide minimum access to Postoperative Feeding
relatives. It should provide privacy to the patient but still be Early feeding is recommended to reduce the risk of infection
observed closely by skilled nursing staff. The nursing staff and average length of stay. Once the bowel sounds return
should be trained in postoperative care and available round feeding is allowed. After manipulation of the bowel during
the clock. A physiotherapist and a dietician should be available surgery, normal peristaltic activity of the small bowel returns
daily. in about 16 hours.
Fluid Replacement Postoperative Analgesia
Postoperative intravenous fluid therapy is not needed for Control of pain is required to provide subjective comfort and
the majority of minor and intermediate procedures. However, to blunt autonomic and somatic reflex responses to pain. It
an indwelling number 18 cannula is to be put. A patient should not be neglected. The degree of pain following surgery
undergoing day care procedures can take oral fluids soon is subjective and individual drug requirement for pain relief
after recovery from the anesthesia. may vary. The requirement is greater in tobacco and other
Intravenous fluid replacement is required to replace blood drug addicts.
and fluid loss after major abdominal or vaginal surgery. Fluid
balance is essential to ensure adequate healing and exclude Effects of Inadequate Analgesia
postoperative hypovolemia caused by an unanticipated 1. Impairs oxygenation
hemorrhage. IV fluids are needed to allow for a period of 2. Promotes shallow breathing
decreased oral intake postoperatively as a result of recovery 3. Prolongs hospitalization
from anesthesia. The average patient requires 2.5–3 liters of 4. Decreased mobility of the patient.
fluid per 24 hours and at least 75–100 mEq of sodium per day Patients undergoing day care surgery should be given
and 60 mEq of potassium per day. Requirement of fluid is oral analgesics to be taken at home after discharge from the
dependent on room temperature and output. (urine, drain, hospital.
vomits, etc.). Cell death and mild renal acidosis maintains the Infiltration of incision sites with marcaine is effective.
postoperative potassium level for first 24 hours. However, Epidural analgesia may be given to patients with extended
potassium loss is increased by postoperative persistent surgery. Opioids are given in the post-operative period.
vomiting. In some cases like ruptured ectopic pregnancy the Sedation may be given as per the requirement of the patient.
patient may be dehydrated preoperatively. Oral osmotically Non-steroidal analgesics are useful once the acute pain
active preoperative bowel preparation will lead to substantially is over. Diclofenac, ibuprofen and ketoprofen may be given
increased fluid loss. orally or by a rectal suppository.
Analgesia can also be administered in the form of patient
Blood Transfusion controlled analgesia (PCA) by IV pumps. The patient presses
The risk and benefits of blood transfusion should be a button when he/she feels the need of analgesia. Other
considered carefully in each case. One unit of packed red methods of postoperative pain relief include cold massage
blood cells raises the hemoglobin level by 1 g/dl and raises or compresses. Interferential current therapy (IFC) is a
the hematocrit by 3%. Blood transfusion is required if the deeper form of transcutaneous electrical nerve stimulation
 (TENS) and it acts by increasing cerebrospinal fluid levels of 3. Tertiary intention or delayed primary closure is used to manage
betaendorphins and by counter-irritation. It uses a high wounds that are too contaminated for primary closure
frequency (4000 Hz) carrier waveform which penetrates the but appear clean and well-vascularized after 4–5 days of
skin deeper and over a larger area than normal TENS. IFC dressing and observation.
gives less discomfort. It is administered three times a day Local blood supply, temperature of wound environment,
for 15 minutes. It is contraindicated in pregant women and presence of infection, foreign body, hematoma, local tissue
patient with a pacemaker. trauma and technique and suture material used in wound
closure are important factors affecting wound healing. The
Management of Drains other systemic factors are nutritional status of the patient,
Drains inserted to monitor hemorrhage or discharge (Fig. diabetes mellitus, smoking and use of steroids and
64.9) can be usually safely removed after 24 hours, if loss is chemotherapeutic agents.
minimal. If a drain is placed in an abscess cavity a large bore The dressing is not to be disturbed unless wet or at times
Operation Theater Activities

drain without suction is appropriate. It allows drainage of for removing of stiches. Do not touch the wound with dirty
viscid material and minimum trauma to surrounding tissues hands. Remove sutures by 6–8 days depending on the type
as a result of suction. of incision and site (abdomen 7 days, perineum 5–7 days)
Suction drains are used in removing lymphatic fluid after (earlier with transverse abdominal incision than with vertical).
Wertheim’s hysterectomy, lymph node dissection and inguinal The patient must take a bath. For prevention of surgical site
lymph node removal along with vulvectomy (Fig. 73.9). infection do not remove hair at incision site unless necessary
and that too should be done just at the time of operation.
Management of Urinary Catheters Preoperative antiseptic preparation and impervious covering
Indwelling catheterization is used at the time of major pelvic (Fig. 62.4) to be used. Prophylactic antibiotics should be given
surgery. It is needed to reduce the risk of bladder damage at at the time of making the incision. Follow aseptic precautious
the time of surgery and for patient comfort in the acute phase during the operation.
of recovery. It predisposes to urinary tract infection and
may partially delay mobilization of the patient. Hence, we POSTOPERATIVE COMPLICATIONS
must unlearn the habit of keeping in-dwelling catheter in Postoperative complications should be distinguished from
uncomplicated vaginal/abdominal surgeries. The catheter the inevitable consequences of an operation, e.g. post-
should be removed once the operation is over; extended anesthetic drowsiness, incision scar. Complications can
Section 16

bladder catheterization for 7–10 days is needed only if the largely be avoided if appropriate prophylactic measures are
bladder has been opened during surgery or in repair of VVF. used, and if sufficient care is taken during the procedure
Following bladder neck surgery it is better to use a suprapubic itself. A high level of awareness of possible complications in
catheter. Radical hysterectomy may impair the sensation of the postoperative period goes a long way in early detection
a full bladder and contractility and result in a poor urinary and timely management. Postoperative complications may
stream. There is also extensive dissection. It causes high either be general or specific to the type of surgery
volume of residual urine. Use of indwelling catheter is undertaken, and should be managed with the patient’s history
indicated here. It is kept in situ till residual urine output is in mind. The majority of potential postoperative complication
less than 100 ml. Also carry out microscopic examination of associated with gynecological surgery are common to other
urine for red blood cells. If there is hematuria (even surgical procedures and represent the complicated response
microscopic) in radical hysterectomy the catheter is not of the body to the stresses imposed by the surgery. In
removed for at least 7 days. Repair of stress incontinence addition there are other complications associated with the
and in cases of bladder suspension indwelling catheter is to specific operation itself. Because of the considerable
be kept for longer period. advances in anesthetic and surgical technique, in addition to
postoperative management, surgery has become safer and
Mobilization and Physiotherapy thus operations are being carried out on people who would
Early ambulation reduces muscle loss through inactivity. A have been previously considered unsuitable.
reduction of 12 hours in the onset of mobilization makes a
remarkable difference. Risk of thromboembolism is General Postoperative Complications
decreased. It also prevents respiratory infection. A skilled Delayed Recovery
physiotherapist can teach toe movement exercises on day 1 Most patients regain consciousness within 15 minutes of transfer
and pranayam type of exercise on the next day. to the recovery room, following general anesthesia.
In case of a delay beyond 30 minutes, look for a specific
Wound Care cause. It may be related to the anesthetic drug used. It may
Proper hemostasis is important for proper wound healing. be also due to increased sensitivity to the drug in elderly
There should be minimum pressure on the wound with self- patients, thin patient or hypothyroidism. It may be due to
retaining retractors. Close the wound properly, avoid extra decreased drug metabolism in hypothermia, hepatic
tension and assure good apposition of the wound edges. disorder, metabolic acidosis, hypoglycemia and cerebral
There are three types of wound healing. damage. Rapid transfusion of cold IV fluids can be another
1. Primary intention: This type of healing takes place in the factor.
healed clean cut surgical wound, which is closed at the The complications can be Immediate, Early or Late.
end of operative procedure with minimal dead tissue.
2. Secondary intention or spontaneous healing occurs when a Immediate Complications
large wound is left open and allowed to close by • Primary hemorrhage: Either starting during surgery or
epithelization and contraction because of significant loss following postoperative increase in blood pressure.
or destruction of tissue preventing apposition of edges. Tachycardia and pallor may alert the surgeon to the
502
 possibility of hemorrhage. Hemorrhage may be obvious Fever after 5 days
or occult. There may be soakage of dressing or increased • DVT
vaginal bleeding . It needs immediate replacement of • Specific complications related to surgery, e.g. septic
blood loss and may require return to theater to re-explore abortion.
the wound. In case of occult bleeding, time lapse may
After the first week
occur. There may be distension of the abdomen at a later
stage. • Wound infection
Ultrasonography may confirm collection of blood in • Distant sites of infection, e.g. UTI
the peritoneal cavity after abdominal or vaginal surgery. • DVT, pulmonary embolus.
It needs exploration and achievement of hemostasis.
Hemorrhage
• Basal Atelectasis: Minor lung collapse
• Shock: It can be due to blood loss, acute myocardial Hemorrhage in the immediate postoperative phase

Chapter 63
infarction, pulmonary embolism or septicemia (in last is primary. Delayed hemorrhage is known as secondary
emergency cases). hemorrhage. The rate of hemorrhage will determine when
• Low urinary output: The average urine output is 30 ml/ the patient exhibits sign of volume loss. A fit person can
hour, if there is inadequate urine output then find the compensate for decreased intravascular volume by
cause which could be either pre renal, i.e. inadequate tachycardia and peripheral vasoconstriction. In case of severe
fluid replacement or post renal, i.e. inadvertent injury to hemorrhage the compensatory capacity is lost and there are
ureter. signs of hypovolemic shock. Patients who were anemic in the
preoperative phase go into hypovolemic shock early as there

Postoperative Care and Complications

• Early Complications (after 24 hours)
is no time for compensatory mechanisms. In such cases even
– Acute confusion: Exclude dehydration and sepsis
a small volume of hemorrhage may be disastrous. The early
– Nausea and vomiting: Analgesia or anesthetic agent
signs of hemorrhage are rising pulse rate, cold hands and feet
related
and a feeling of coldness. The patient becomes restless,
– Paralytic ileus
confused and complains of severe thirst. It may be
– Fever (see below)
accompanied by diminution of urine output. If it goes
– Secondary hemorrhage: often as a result of infection
undetected at this stage or a massive hemorrhage occurs,
– Pneumonia
there is a rapid fall of blood pressure. Patients with pre-existing
– Wound or anastomosis dehiscence
anemia or cardiovascular disease decompensate with small
– Deep vein thrombosis (DVT)
amount of hemorrhage earlier and in unpredictable manner.
– Acute urinary retention
The normal clinical monitoring by pulse rate, BP and respiratory
– Urinary tract infection
recording is adequate for most gynecological cases. For high
– Postoperative wound infection
risk cases hourly measurement of urinary output is a good
– Bowel obstruction due to fibrinous adhesions
indicator, provided that adequate hydration has been
– Wound dehisence.
maintained. Central venous pressure monitoring may be
Late Complications required in older women or women with cardiac or renal
• Incisional hernia disease to avoid fluid overload.
• Persistent sinus • Following transfusion of large volumes of blood
• Recurrence of reason for surgery, e.g. malignancy hemorrhage may be exacerbated by consumption
• Neuralgic pain. coagulopathy. It may also be due to preoperative
anticoagulants or an unrecognized bleeding diathesis.
Postoperative Fever: It is usually seen on: • Perform clotting screen (BT, CT at the bedside) specific
Day 0–2 tests and platelet count, ensure good IV access and insert
• Mild fever (T<38 °C) a CVP catheter. Give protamine sulfate if heparin has been
– Reaction to tissue damage and necrosis at operation used. Order cross-matched blood. If clotting screen is
site abnormal, give FFP or platelet concentrates as the results
– Reaction to pyrogen in IV-fluid/blood indicate. Consider surgical re-exploration at all times.
– Hematoma • Late postoperative hemorrhage occurs several days
• Persistent fever (T>38 °C) after surgery and is usually due to infection damaging
– Atelectasis: The collapsed lung may become vessels at the operation site. Treat the infection and
secondarily infected. consider conservative measures.
– Specific infections related to the surgery, e.g. UTI,
Pelvic Hematoma
– Blood transfusion or drug reaction
Pelvic hematoma may occur following vaginal hysterectomy
Fever on days 3–5 and is seen at the vault. It manifests as pyrexia and can be
• Bronchopneumonia confirmed by ultrasound. It is self-limiting and usually either
• Sepsis resolves or results in discharge via the vaginal vault in the
• Wound infection second week following surgery. Surgical drainage is needed
• Drip site infection/phlebitis if there is persisting pelvic pain or systemic upset with pyrexia
• Abscess formation. (colpotomy)
Hence, assess the wound if there is redness and pain send Abdominal wound hematoma is self-limiting. It causes
the discharge for culture and sensitivity and dress the wound. discomfort, pain and spreading bruising.
If the wound is healthy auscultate the lungs to exclude
pneumonia or atelectasis. If the chest is clear look for Infection
thrombophlebitis. If none, ask for urinary complaints and send • Infectious complications are the main causes of
urine for culture and sensitivity. Treat according to the cause. postoperative morbidity in abdominal surgery. 503
 • Wound infection: The commonest form is superficial Pulmonary Embolism
wound infection occurring within the first week presenting • Classically presents with sudden dyspnea and
as localized pain, redness and slight discharge usually cardiovascular collapse with pleuritic chest pain, pleural
caused by skin staphylococci. Routine use of prophylactic rub and hemoptysis. However, smaller pulmonary
antibiotics reduces it. embolisms is more common and present with confusion,
• Cellulitis and abscesses: usually occur after bowel related breathlessness and chest pain.
surgery. Mostly present within the first week but can be • Diagnosis is by ventilation/perfusion scanning and/or
seen as late as the third postoperative week, even after pulmonary angiography or dynamic CT.
leaving the hospital. Patient presents with pyrexia and • Management: IV heparin or SC low molecular weight
spreading cellulitis or abscess. Cellulitis is treated with heparin for 5 days plus oral warfarin.
antibiotics. Abscess requires suture removal and probing
of the wound but deeper abscesses may require surgical Common Urinary Problems
Operation Theater Activities

re-exploration. The wound is left open in both cases to • Urinary retention: This common immediate post-
heal by secondary intention. operative complication that can often be dealt with
• Gas gangrene is uncommon and life-threatening. conservatively with adequate analgesia. If this fails, the
• Wound sinus is a late infectious complication from a deep patient may need catheterization.
chronic abscess that can occur after apparently normal • UTI: This is very common, especially in women, and may
healing. It usually needs re-exploration to remove non- not present with typical symptoms. Treat with antibiotics
absorbable suture or mesh, which is often the underlying and adequate fluid intake.
cause. Acute renal failure: May be caused by antibiotics, obstructive
jaundice and surgery to the aorta. It often occurs due to
Thromboembolic Disease
episode of severe or prolonged hypotension. It presents as
• This is major cause of death after surgery. DVT is very low urine output with adequate hydration. Mild cases may
commonly related to the grade of surgery. be treated with fluid restriction until tubular function recovers.
• Many cases are silent but present as swelling of the leg, In severe cases may need hemofiltration or dialysis while
tenderness of calf muscles and increased warmth with function gradually recovers over weeks or months.
calf pain on passive dorsiflexion of foot.
Diagnosis is by venography or Doppler ultrasound. Cardiac Complications
Section 16

Elective surgery should be delayed for 6 months following

Respiratory Complications
myocardial infarction. Patients with chest pain post-
• These occur in up to 15% of surgeries under general operatively should be investigated with serial cardiac
anesthetic and major surgery and include: enzymes and ECG. Women with pulmonary edema or a new
• Atelectasis (alveolar collapse): cardiac murmur should be investigated for myocardial
– It is caused when airways become obstructed, usually infarction. It needs a cardiology reference but thrombolytic
by bronchial secretions. Most cases are mild and may therapy is contraindicated within 5 days of surgery.
go unnoticed.
– Symptoms are slow recovery from operations, pallor, Wound Dehiscence and Incisional Hernia
poor color, mild tachypnea, tachycardia and low- Disordered Wound Healing (Fig 63.1)
grade fever.
Most wounds heal without complications and healing is not
– Prevention is by pre-and postoperative physiotherapy.
impaired in the elderly unless there are specific adverse
– In severe cases, positive pressure ventilation may
factors or complications. Factors which may affect healing
be required.
rate are:
• Pneumonia: Requires antibiotics, physiotherapy.
• Poor blood supply
• Aspiration pneumonitis
• Excess suture tension
– Sterile inflammation of the lungs from inhaling gastric
• Long term steroids
contents.
– Presents with history of vomiting or regurgitation with
rapid onset of breathlessness and wheezing. Non-
starved patient undergoing emergency surgery are
particularly at risk.
– May help avoid this by crash induction technique and
use of oral antacids or metoclopramide.
– Mortality is nearly 50% and requires urgent
treatment with bronchial suction, positive pressure
ventilation, prophylactic antibiotics and IV steroids.
• Acute respiratory distress syndrome(ARDS)
– Rapid, shallow breathing, severe hypoxemia with
scattered crepitations but no cough, chest pains or
hemoptysis, appearing 24–48 hours after surgery.
– Occurs in many conditions where there is direct or
systemic insult to the lung, e.g. multiple traumas with
shock.
– Requires intensive care with mechanical ventilation
with positive-end pressure.
504 Fig. 63.1: Wound infection
• Diabetes mellitus include injuries due to falls from trolley, damage to diseased
• Immunosuppressive therapy bones and joints during positioning, nerve palsies, diathermy
• Radiotherapy burns.
• Severe rheumatoid disease
Complications Related to Gastrointestinal Tract
• Malnutrition and vitamin deficiency.
In case of an infected wound, take a swab for culture and • Delayed return of function
sensitivity of the causative organism and dress with antiseptic – Temporary disruption of peristalsis: may complain of
precautions using EuSOL (boric acid with bleaching powers nausea, anorexia and vomiting and usually appears
releases nascent chlorine. It helps in separating slough), with the re-introduction of fluids. Often described as
hydrogen peroxide (releases nascent oxygen destroying ileus.
anaerobic organism, produces heat and frothing to bring out – More prolonged extensive form with vomiting and
debris), honey (bacteriocidal and dehydrating agent). intolerance to oral intake called adynamic obstruction

Chapter 63
and needs to be distinguished from mechanical
Abdominal Wound Dehiscence obstruction. If involves large bowel usually described
(Wound Disruption, Burst Abdomen) as pseudo-obstruction. Diagnosed by instant barium
It affects about 2% of mid-line laparotomy incision. enema caused by conservative treatment.
It is a serious complication with mortality of up to 3%. It • Early mechanical obstruction: May be caused by twisted
may be due to failure of the wound closure technique or or trapped loop of bowel or adhesions occurring
postoperative cough or infection. It usually occurs between approximately 1 week after surgery. May settle with
7 and 10 days postoperatively. It is often preceded by nasogastric aspiration plus IV fluids or progress and

Postoperative Care and Complications

serosanguinous discharge from wound. It can be partial (only requires surgery.
some layers separate or complete or total (all abdominal • Late mechanical obstruction: Adhesions can organize
layers are separated with or without protrusion of viscera). and persist commonly causing isolated episodes of small
Partial dehiscence repair can be delayed till complete bowel obstruction months or years after surgery. Treat
resolution of infection is established. as for the early form.
It should be assumed that the defect involves the whole • Anastomotic leakage or breakdown: Small leaks are
of the wound. Initial management includes opiate analgesia common causing small localized abscesses with delayed
and protecting the eviscerated organs with moist sterile recovery of bowel function. They usually resolve with IV
dressing to wound, fluid resuscitation and early return to the fluids and delayed oral intake but may need surgery.
theater for resuture under anesthesia. Burst abdomen • Major breakdown causes generalized peritonitis and
without evisceration is best managed by urgent resuturing. progressive sepsis needing surgery for peritoneal toilet
If there is evisceration it is a surgical emergency and this and antibiotics. Local abscess can develop into a fistula.
requires an immediate closure.
BIBLIOGRAPHY
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It occurs in 10–15% of abdominal wounds usually appearing for 24 hours after hysterectomy? Am J Ob hy 2003;189:435.
within the first year but can be delayed by up to 15 years 2 . Harkki-Siren P, Sjoberg J, Toivonen J, Tiitinen A. Clinical
after surgery. Risk factors include obesity, distension and poor outcome and tissue trauma after laparosocopic and abdominal
muscle tone, wound infection and multiple use of the same hysterectomy. Acta Obstet Gynecol Scand 2000;79:866-71.
incision site. It presents as a bulge in abdominal wall close to 3 . Loft A, Anderson TF, Bronnum Hansen H, Roepstroff C, Madsen
M. Early postoperative mortality following hysterectomy. A
the previous wound. It is usually asymptomatic but there
Danish population based study 1977-1981. Br J Obstet Gynaecol
may be pain, especially if strangulation occurs. It tends to 1991;98:147-54.
enlarge over time and causes inconvenience. 4 . Melissa Calvin. Cutaneous wound repair: biopsy of wound
Management: It is done by surgical repair where there is healing. http://www.medscape.com/viewarticle/407502_2(1 to
pain, strangulation or inconvenience. 16). Accessed June 5, 2008.
5 . Michael Read, M. James, The obstetricians and gynecologists
Vault Prolapse: It can occur after vaginal/abdominal 2002;4:(1).
hysterectomy. Management is by surgery. 6 . Pherson KMC, Metcalfe MA, Herbert A. Severe complications
for hysterectomy; the VALUE study. Br J Obstet Gynaecol
Surgical Injury
2004;111:688-94.
There is also a risk of injury while being transported and 7 . Santra S, Orgil DP. Mechanism of action of vacuum assisted
handled in the theater under general anesthetic. These closure device. Plast Recon Surgery 2008;112:3.

505
 64 Sutures and Needles

Nivedita Sarda, Sudha Salhan

At the end of a surgical procedure the cut edges of the tissue can all play a role in the surgeon’s choice of the most
have to be sutured together in the same sequence as they appropriate knot configuration. They must try to tie the most
were cut. The goals of wound closure include obliteration of secure knot possible for prevention of complication.
dead space, maintenance of hemostasis, even distribution Skillful wound closure requires not only knowledge of
of tension along deep suture lines, maintenance of tensile proper surgical techniques but also knowledge of the
strength across the wound until tissue tensile strength is physical characteristics and properties of the suture and
adequate, approximation and eversion of the epithelial needle.
portion of the closure.
Methods for mechanical wound closure include staples, Ideal Suture Characteristics
tape, adhesive, and sutures. Each method has specific The ideal suture has the following characteristics:
indications, advantages and disadvantages, and special • Sterile
considerations. • All-purpose (composed of material that can be used in
Stapes are metallic devices, being insert. They donot invoke any surgical procedure)
inflammatory and foreign body reaction. (Fig. 64.1) • Causes minimal tissue injury or tissue reaction (i.e., non-
Sutures are the cheapest and most widely used material electrolytic, noncapillary, nonallergenic, noncarcinogenic)
for wound closure and permit primary wound healing. • Easy to handle
Tissues are held in proximity until enough healing occurs to • Holds securely when knotted (i.e., no fraying or cutting)
withstand stress without mechanical support. Suture material • High tensile strength
is a foreign body implanted into human tissues; it elicits a • Favorable absorption profile
foreign body tissue reaction. During wound closure, a sterile • Resistant to infection.
field with complete hemostasis and meticulous aseptic Unfortunately, at the present time, no single material can
technique are critical to minimize the risk of wound infection. provide all of these characteristics. In different situations
Other complications of wound healing, such as hypertrophic and with differences in tissue composition throughout the
scars (Kelord), wide scars, and wound dehiscence, may result body, the requirements for adequate wound closure require
from factors in the patient (e.g. nutritional status), incorrect different suture characteristics.
suture selection, or technique that results in excessive tension Since no such ideal suture exists which can be universally
across the wound. (see chapter 63). used in all tissues, the surgeon should be very careful in choosing
Knot security must never be taken for granted Suture the correct suture type depending on the wound type and the
material, suture gauge, and the operative circumstances tissue under consideration.

OTHER SUTURE CHARACTERISTICS

• Absorbable it is the progressive loss of mass and/or
volume of suture material
• Tensile strength is the measure of a material or tissue’s
abilitiy to resist deformation and breakage
• Memory: It is the inherent capability of suture to return
to or maintain its original gross shape
• Knot strength is the amount of force necessary to cause
a knot to slip(related to the coefficient of static friction
and plasticity of a given material)
• Elasticity is the measure of the ability of the material to
regain its original form and length after deformation
• Plasticity is the measure of the ability to deform without
breaking and to maintain a new form after relief of the
deforming force
• Pliability is the ease of handling of suture material; ability
Fig. 64.1: Staple removal
to secure knot.
Suture Size crushing or crimping of this suture can nick or weaken the
Suture Size refers to the diameter of the suture strand and is suture and lead to undesirable and premature suture failure.
denoted as zeroes. The sizes progressively larger than 0 are Thus the suture material should never be crushed or damaged
numbered in increasing numerical order, i.e. 1, 2, etc. Size with a needle holder artery forceps or other instruments.
smaller than zero are numbered as 1–0 to 10–0. The more Multifilament suture is composed of several filaments
zeroes characterizing a suture size, the smaller the resultant twisted or braided together. These materials are less stiff
strand diameter (e.g., 4–0 or 0000 is thicker than 5–0 or 00000). but have a higher coefficient of friction. Multifilament suture
The thinner the suture, the less is the tensile strength of the generally has greater tensile strength and better pliability
strand. and flexibility than monofilament suture. This type of suture
handles and ties well. Multifilament materials have increased
Guide to Select Suture Size capillarity, hence absorption of fluid may act as a tract for
the introduction of pathogens.

Chapter 64
Peritoneum 2–0 or 3–0
Muscles 1–0 or 1
Absorbable Versus Nonabsorbable Sutures
Rectus sheath 1–0 or 1
Subcutaneous fat 3– 0 Absorbable sutures provide temporary wound support, until
Small bowel 2–0 or 3–0 the wound heals well enough to withstand normal stress.
Urinary bladder 4–0 or 5–0 Absorption occurs by enzymatic degradation in natural
Ligaments 1–0 or 1 materials and by hydrolysis in synthetic materials.
Ovarian surgery 2–0 or 3–0 Hydrolysis causes less tissue reaction than enzymatic
Tuboplasty 5–0 to 10–0

Sutures and Needles

degradation. The first stage of absorption has a linear rate,
lasting for several days to weeks. The second stage is
CLASSIFICATION OF SUTURES characterized by loss of suture mass and overlaps the first
Based on their rate of absorption by body tissue sutures are stage. Loss of suture mass occurs as a result of leukocytic
initially classified as either absorbable or non-absorbable. cellular responses that remove cellular debris and suture
Sutures that undergo rapid degradation in tissues, losing material from the line of tissue approximation. Chemical
their tensile strength within 60 days, are considered absorbable treatments, such as chromic salts, lengthen the absorption time.
sutures. Accelerated absorption may occur in patients with fever,
Sutures that generally maintain their tensile strength for infection, or protein deficiency and may lead to an
longer than 60 days are non absorbable sutures. excessively rapid decline in tensile strength. Accelerated
Both absorbable and non-absorbable sutures may be absorption also may occur in a body cavity that is moist or
made either from a natural or synthetic material, and may be filled with fluid
further classified as monofilament or multifilament depending Absorbable sutures do not require removal.
on the number of strands they are made up of sutures may Nonabsorbable sutures elicit a tissue reaction that results
be coated with agents that improve handling characteristics, in encapsulation of the suture material by fibroblasts.
e.g. chromic coating of catgut. Nonabsorbable sutures are commonly used in percutaneous
Special coatings allow sutures to pass more easily skin closure and are removed after sufficient healing has
through tissues (less coefficient of friction) and also improve occurred. Healing typically occurs in 6–8 days in an otherwise
handling characteristics. Sutures also may be colored with healthy patient. Nonabsorbable sutures also have internal use;
dye to increase visibility. in these situations, the sutures become permanently
encapsulated in tissue.
Natural Versus Synthetic Sutures
Types of Absorbable Sutures
Natural sutures can be made of collagen from intestines of
mammals (sheep in catgut) while synthetic sutures are made These sutures are prepared either from the collagen of
of polymers. Tissue reaction and suture antigenicity lead to healthy mammals or from synthetic polymers. Some are
inflammatory reactions, especially with natural materials. absorbed rapidly, while others are treated (e.g. chronic
Synthetic nonabsorbable sutures elicit the least tissue reaction. catgut) or chemically structured to lengthen absorption time.
Natural sutures are economic and are easy to handle and They may also be impregnated or coated with agents that
knot. Synthetic sutures are more expensive but have more improve their handling properties, and colored with an FDA
strength and have a predictable absorption. approved dye to increase visibility in tissue.
1. Natural Absorbable Sutures
Monofilament Versus Multifilament Sutures
Collagen: This comes from the submucosa of sheep
Monofilament suture is made of a single strand. This structure intestine (catgut) or the serosa of beef intestine. They
is relatively more resistant to harboring microorganisms are monofilamental.
and ties relatively more easily when compared with • Surgical catgut, plain: Tensile strength is maintained
multifilament suture. Less resistance to passage through for 7–10 days postimplantation (variable with
tissue occurs than with multifilament suture. Great care must individual patient characteristics). Absorption is
be taken in handling and tying monofilament suture because complete within 70 days. This type of suture is used

Monofilament sutures Multifilament sutures

Advantages Disadvantages Advantages Disadvantages
Smooth surface Handling and knotting Strength Bacterial harbors
Less tissue trauma Ends/Knot burial Soft and pliable Capillary action
No bacterial harbors stretch Good handling Tissue trauma
No capillarity Good knotting 507
 for (i) repairing rapidly healing tissues that require • Poliglecaprone 25 (Monocryl): Is a monofilament
minimal support, (ii) ligating superficial blood vessels, suture that is a copolymer of glycolide and
and (iii) suturing subcutaneous fatty tissue. (iv) It is E-caprolactone. The suture has superior pliability,
ideal for tubal ligation by Pomeroy’s technique as it is leading to easy handling and tying. Tensile strength
absorbed quickly and allows the tubal ends to fall apart. is high initially, 50–60% at 7 days, and is lost at 21
• Surgical catgut, fast-absorbing: This type of suture is days. Absorption is complete at 91–119 days.
indicated for epidermal use (required only for 5–7 Poliglecaprone sutures are used for subcuticular
days) and is not recommended for internal use. closure and soft tissue approximations and ligations.
• Surgical catgut, chromic (treated with chromium salt): • Polydioxanone (PDS II): This is a polyester
The process alters the coloration of the surgical gut monofilament suture made of dioxanone. This suture
from yellowish tan to brown. Chromic catgut sutures provides extended wound support and elicits only a
minimize tissue irritation, causing less reaction than slight tissue reaction. Tensile strength is 70% at 14
Operation Theater Activities

plain surgical catgut during the early stages of wound days and 25% at 42 days. Wound support remains for
healing. The absorption rate is slowed by chromium up to 6 weeks. Absorption is minimal for the first 90
salt (90 days). It causes tissue reaction due to the days and essentially complete within 6 months. This
noncollagenous material present in these sutures. material has a low affinity for microorganisms (like
Tensile strength may be retained for 10 to 14 days, other monofilament). PDS II suture is used for soft
with some measurable strength remaining for up to tissue approximation, especially in pediatric,
21 days. It is ideal for suturing serosal , visceral, cardiovascular, gynecologic, ophthalmic, plastic, and
vaginal tissues. They should not be used for skin digestive (colonic) situations. Another similar suture
suturing since inflammatory response may cause material is made from polytrimethylene carbonate
scarring and also may be a nidus of infection. Catgut is (Maxon). This material has a similar tensile strength
not an ideal suture for infected tissues since their tensile and absorption profile.
strength will be lost due to rapid degradation by
proteolytic enzymes released by inflammatory cells. Types of Nonabsorbable Sutures
2. Synthetic Absorbable Sutures: Chemical polymers are Classificationof Nonabsorbable sutures
absorbed by hydrolysis and cause a lesser degree of • Class I—Silk or synthetic fibers of monofilament, twisted,
tissue reaction following placement. or braided construction
Section 16

• Polyglactin 910 (Vicryl) (Fig. 64.2): This synthetic suture • Class II—Cotton or linen fibers or coated natural or
is a braided multifilament suture coated with a synthetic fibers
copolymer of lactide and glycolide (polyglactin 370). • Class III—Metal wire of monofilament or multifilament
The water-repelling quality of lactide slows loss of 1. Natural Nonabsorbable Sutures
tensile strength, and the bulkiness of lactide leads to • Surgical silk: This suture is made of raw silk spun by
rapid absorption of suture mass once tensile strength silkworms. The suture may be coated with beeswax or
is lost. The suture is also coated with calcium stearate, silicone. Many surgeons consider silk suture the
which permits easy tissue passage, precise knot standard of performance (superior handling
placement, and smooth tie-down. Tensile strength is characteristics). Although classified as a nonabsorbable
approximately 65% at 14 days postimplantation. material, silk suture becomes absorbed by proteolysis
Absorption is minimal for 40 days and complete in and is often undetectable in the wound site by 2 years.
56–70 days. These sutures cause only minimal tissue Tensile strength decreases with moisture absorption
reaction and may be used in the presence of infection. and is lost by 1 year. The problem with silk suture is the
Vicryl sutures are used in soft tissue approximation acute inflammatory reaction triggered by this material.
and vessel ligation. Host reaction leads to encapsulation by fibrous
• Dexon II is made from polyglycolic acid and coated connective tissue.
with polycaprolate. This material has a similar tensile • Surgical cotton: This is made of twisted, long, staple
strength and absorption profile as polyglactin. cotton fibers. Tensile strength is 50% in 6 months and
30–40% by 2 years. Surgical cotton is nonabsorbable
and becomes encapsulated within body tissues.
• Surgical steel: This is made of stainless steel (iron-
chromium-nickel-molybdenum alloy) as a
monofilament and twisted multifilament. Surgical
steel demonstrates high tensile strength with little
loss over time and low tissue reactivity. The material
also holds knots well. Surgical steel suture is used
primarily in orthopedic, neurosurgical, and thoracic
applications.
2. Synthetic Nonabsorbable Sutures
• Nylon: This is a polyamide polymer suture material
available in monofilament (Ethilon/Dermalon) and
braided (Nurolon/Surgilon) forms. The elasticity of
this material makes it useful in retention and skin
closure. Nylon is quite pliable, especially when moist.
The braided forms are coated with silicone. Nylon
Fig. 64.2: Vicryl suture has good handling characteristics, although
508 its memory tends to return the material to its original
 straight form. Nylon has 81% tensile strength at 1 sutures; thus, monofilament sutures are generally preferable
year, 72% at 2 years, and 66% at 11 years. The material in potentially contaminated tissues. Use the thinnest inert
is stronger than silk suture and elicits minimal acute monofilament suture materials, such as nylon or poly-
inflammatory reaction. Nylon is hydrolyzed slowly, propylene, in this setting.
remaining suture material is stable at 2 years, due to Optimal suture size (thickness) is generally the smallest
gradual encapsulation by fibrous connective tissue. necessary to achieve the desired tension-free closure. If
• Polybutester (Novofil): This monofilament suture is wound tension is high, thinner-diameter sutures may actually
made of a copolymer of polyglycol terephthalate and injure tissues by cutting through them. Therefore, closely
polytrimethylene terephthalate. This material is very match the tensile strength of the suture and tissue.
elastic and has a very low coefficient of friction. These
properties are ideal for surface closure, permitting NEEDLES
adequate tissue approximation while allowing for Needles are required to carry the suture material during the

Chapter 64
tissue edema and detumescence. Polybutester does process of surgical wound closure.
not lose tensile strength or become absorbed. Wound closure and healing is affected by the initial tissue
• Polyester fiber (Mersilene/Dacron [uncoated] and injury caused by needle penetration and subsequent suture
Ethibond/Ti-cron [coated]): This suture material is passage. Needle selection, surface characteristics of the suture
formed from polyester, a polymer of polyethylene (e.g. coefficient of friction), and suture-coating materials
terephthalate. The multifilament braided suture also selected for wound closure are important factors that must
comes coated with polybutilate (Ethibond) or silicone be considered by the surgeon.

Sutures and Needles

(Ti-cron). The coating reduces friction for ease of
tissue passage and improved suture pliability and Ideal Surgical Needle Characteristics
tie-down. The suture elicits minimal tissue • High-quality stainless steel
reaction and lasts indefinitely in the body. Polyester • Smallest diameter possible
fiber sutures are stronger than natural fibers and do • Stable in the grasp of the needle holder
not weaken with moistening. The material provides • Capable of implanting suture material through tissue with
precise consistent suture tension and retains tensile minimal trauma
strength. This suture is commonly used for vessel • Sharp enough to penetrate tissue with minimal resistance
anastomosis and the placement of prosthetic • Sterile and corrosion-resistant to prevent introduction of
materials. Mersilone tape is used in Shirodkars microorganisms or foreign materials into the wound.
Abdominal sling operation for prolapse of uterus.
• Polypropylene (Prolene): This monofilament suture Needle Performance Characteristics and Definitions
is an isostatic crystalline stereoisomer of a linear • Strength: Resistance to deformation during repeated
propylene polymer, permitting little or no saturation. passes through tissue (Increased needle strength results
The material does not adhere to tissues and is useful in decreased tissue trauma)
as a pull-out suture (e.g. subcuticular closure). – Ultimate moment: Measure of maximum strength
Polypropylene also holds knots better than other determined by bending the needle to 90°
monofilament synthetic materials. This material is – Surgical-yield moment: Amount of angular deformation
biologically inert and elicits minimal tissue reaction. that can occur before permanent needle deformation
Prolene is not subject to degradation or weakening occurs.
and maintains tensile strength for up to 2 years. This • Ductility: Resistance (of a needle) to breakage under a
material is useful in contaminated and infected given amount of deformation/bending
wounds, minimizing later sinus formation and suture • Sharpness: Measure of the ability of the needle to
extrusion. penetrate tissue (Factors affecting sharpness include the
angle of the point and the taper ratio, i.e. ratio of taper
Choice of Suture Material length to needle diameter)
Much of the process regarding suture selection depends • Clamping moment: Stability of a needle in a
on surgeon training and preference. A wide variety of suture needle holder, determined by measuring the interaction
materials are available for each surgical location and of the needle body with the jaws of the needle holder.
surgical requirement. Generally, the surgeon selects the
thinnest suture that adequately holds the healing wound Parts of a Needle
edges. The tensile strength of the suture should never Point
exceed the tensile strength of the tissue. As the wound This portion of the needle extends from the tip to the
heals, the relative loss of suture strength over time should maximum cross-section of the body. It can be sharp or blunt
be slower than the gain of tissue tensile strength. (Fig. 64.3).
Certain general principles can be applied to suture
selection. Sutures are no longer needed when a wound has Body
reached maximum strength. Therefore, consider nonabs- This part of the needle incorporates the majority of the
orbable suture in skin, fascia, and tendons (slowly healing needle length. The body of the needle is important for
tissues), while mucosal wounds (rapidly healing tissues) may interaction with the needle holder and the ability to transmit
be closed with absorbable sutures. the penetrating force to the point. The needle factors affecting
Because the presence of foreign bodies in contaminated this interaction include needle diameter and radius, body
tissues may facilitate infection, special consideration of suture geometry, and stainless steel alloy. These components
selection in these locations, such as a contaminated post- determine the needle-bending moment, ultimate moment,
traumatic wound, is imperative. Multifilament sutures are surgical-yield moment, and needle ductility.
more likely to harbor contaminants than monofilament The needle can be either swaged on non-swaged. 509
 Figs 64.5A to C: Points of a needle

The sharpness is determined by taper ratio (8–12:1) and

Operation Theater Activities

tip angle (20–35°). The needle is sharper if it has a higher

Fig. 64.3: Needle parts
taper ratio and lower tip angle. The taper-point needle is
used for easily penetrated tissues (e.g. subcutaneous
Swaged Needle
layers, dura, peritoneum, abdominal viscera) and
(Atraumatic needle) (Fig. 64.4 A) minimizes potential tearing of fascia.
The suture attachment end creates a single, continuous 2. Blunt-point: This type of needle dissects friable tissue
unit of suture and needle. The swage may be designed to rather than cuts it. The point is rounded and blunt, ideal
permit easy release of the needle and suture material hence for suturing the liver and kidneys. Additionally, blunt
less tissue trauma needles are being developed for more conventional uses
• Channel swage: A needle is created with a channel into in an effort to reduce needle stick injuries (for soft tissue).
which the suture is introduced, and the channel is crimped 3. Cutting: The needle has at least 2 opposing cutting edges
over the suture to secure it into place. The diameter of (the point is usually triangular). This type is designed for
the channel swage is greater than the diameter of the penetration through dense, irregular, and relatively thick
needle body. tissues. The point cuts a pathway through tissue and is
• Drill swage: Material is removed from the needle end ideal for skin sutures. Sharpness is due to the cutting
(sometimes with a laser), and the needle is crimped over edges.
Section 16

the suture. The diameter of the drill swage is less than • Conventional cutting Fig. 64.4B: This type of needle has
the diameter of the needle body. 3 cutting edges (triangular cross-section that changes
Nonswaged Needle (Fig. 64.4 B): Alternatively, the suture may to a flattened body). The third cutting edge is on the
be passed through an eye, similar to that found in a sewing inner, concave curvature.
needle. In a closed-eye configuration, the shape may be • Reverse cutting: The third cutting edge is on the outer
round, oblong, or square. In a French (split or spring) eye, a convex curvature of the needle. The needles are
slit is in the end of the needle with ridges that catch and hold designed for tissue that is tough to penetrate (e.g.
the suture in place. skin, tendon sheaths, oral mucosa). Reverse-cutting
Several disadvantages are associated with the use of a needles are also beneficial in cosmetic and
nonswaged needle. Tissue passage of a double strand of ophthalmic surgery, causing minimal trauma.
suture leads to more tissue trauma. In a swaged needle, the • Side-cutting (spatula): These needles are flat on the
suture is less likely to become unthreaded prematurely. Also, top and bottom surfaces to reduce tissue injury. The
decreased handling helps maintain suture integrity. Swaged needles allow maximum ease of penetration and
sutures are not subject to suture fraying or damage due to control as they pass between and through tissue
sharp corners in the eye of eyed needles. layers. Side-cutting needles were designed initially
for ophthalmic procedures.
Point Types (Figs 64.5A to C) Needle shapes: Needles are basically either straight or curved
1. Taper-point (round needle): This type of needle penetrates (Fig. 64.6).
and passes through tissues by stretching without cutting. • Straight: This body type is used to suture easily accessible
A tip at the point flattens to an oval/rectangular shape. tissue that can be manipulated directly by hand. The
straight-body needle is also useful in microsurgery for
nerve and vessel repair. Examples of straight-body
needles include the Keith needle, which is a straight
cutting needle used for skin closure of abdominal wounds,
and the Bunnell needle, which is used for tendon/GI tract
repair.
• Curved: The needle has a predictable path through tissue
and requires less space for maneuvering than a straight
needle. The semicircular path is the optimal course for
sutures through tissue and provides an even distribution
of tension. Body curvature commonly is a quarter-circle,
three-eighths–circle, half circle, or five-eighths–circle. The
three-eighths–circle is used most commonly for skin
closure. The half-circle circle was designed for confined
spaces, and more manipulation by the surgeon is
required (i.e. increased wrist motion is required). Quarter
510 Figs 64.4A and B: (A) Swaged needle; (B) Eyed needle
circle for microvascular anesthesinosis.
 Fig. 64.8: Mesh

Chapter 64
Sutures and Needles
Fig. 64.6 Needle shapes

• Other body types are compound curved and half curved

needles.
• Length of needles varies from 2–6 mm. Fig. 64.9: Corrugated and malecot drain

NEEDLE-HOLDER (FIGS 64.7A AND B) must be appropriate to the needle size to hold it securely and
The needle should be held in the needle holder approximately prevent rocking, turning, and twisting.
1/3rd to ½ distance from the sewaged end, never hold the The needle-holder handle must be appropriate for the depth
needle at the sewaged end which is the weakest part of the needed for placement of the suture. The difference between
needle. the length of the handle and the jaw creates a mechanical
The stability of the needle within the needle holder affects advantage for exerting force through the needle point.
needle control and performance. The jaws of the needle holder The needle-holder clamping moment is the force applied
to a suture needle by a needle holder. The jaws of the needle
holder contact a curved needle at 1 point on the outer curvature
and 2 points along the inner curvature.

Mesh (Fig. 64.8)

Meshes are made synthetic elastic material used to
strengthen anatomical structure (e.g. used in hernia repair,
implants for urogynecology. They have excellent
biocompatibility, high maternal purity, minimal shrinkage
aging resistance.

Drains
Drains are used before closing to make way for collected
fluids (blood, serous discharge, lymph) so that the surfaces
come together. Different types of drains are used, e.g.
corrugated drain, malecot drain, etc. (Fig. 64.9).

Dressing
After stitching the wound a sterile dressing is applied. It
maintains the wound warm and to retain moisture which is
most conducive to healing. The dressing must absorb any
superficial bleeding or inflammatory exudates. It protects
healing tissue from trauma and bacterial contamination. The
sutures are prevented from entangling in clothing or other
objects because of the dressing. Pressure dressing is applied
where there is a chance of hematoma formation.
Dressing can be simple sterile gauze dressing or synthetic
dressing (used in superficial burns or at the site of split
Figs 64.7A and B: (A) Method of grasping the needle with needle 511
holder; (B) Needle holder thickness skin graft donor site, etc.).
 65 Minor Procedures

Sushma Suri, S Prateek, P Chowdhury, Harsha Gaikwad, P Muley, Sabri, HP Anand, Sudha Salhan

Minor procedures have a very important role in the • Dilatation and curettage (D andC)
management (diagnostic and therapeutic) of gynecological • Fractional curettage
conditions. The preliminary preparation is given in • Manual vacuum aspiration (MVA) and suction evacuation
preoperative care chapter. Minor procedures include some (For MTP)
surgical operations and some procedures. Surgical procedure • Dilatation and evacuation
causes pain and for its mitigation, sedation or local or general • Only dilatation.
anesthesia may be required, depending on the amount of It is contraindicated in cases of known allergy to lignocaine.
handling. It is not possible to give detail of these measures.
However, the following main points may be kept in mind: Paracervical Block
• Informed written consent Paracervical anesthesia blocks the Frankenhouser ganglion
• Sedation lying just posteriorly to the cervicouterine junction.
• Local anesthesia: In minor procedures done per vaginally Paracervical block makes cervical dilation pain free.
the main methods used are infiltration or spray.
Paracervical block anesthesia and Pudendal block Requirements
anesthesia is useful in minor procedures of vulval vaginal 1. Sponge holder
and cervical region. 2. Sim’s speculum
• General anesthesia is also required in some cases. 3. Anterior vaginal wall retractor
Reassurance and proper explanation of the procedure go a 4. Tenaculum
long way in allaying the anxiety and apprehension of the client. 5. 22 G needle
6. 10–20 ml syringes
SEDATION 7. Injection lignocaine 0.5% without adrenal.
The following drugs can be given as preoperative, Procedure (Fig. 65.1)
intraoperative sedation:
1. Bladder is evacuated (ask patient to pass urine).
Pethidine 25 mg and Promethazine 12.5 mg or
2. Patient put in lithotomy position on the operation table.
Pentazocine 15 mg and Promethazine 12.5 mg.
3. Do aseptic ritual of cleaning and draping.
Repeat dose, if required during operation Pethidine 10
4. Posterior vaginal wall is retracted with Sim’s speculum.
mg IV or Pentazocine 5 mg IV. However, if needed, tablet
5. Anterior vaginal wall is retracted with anterior vaginal
Alprazolam (0.25 to 0.50 mg) or tablet Diazepam (5 to 10 mg)
wall retractor.
can be given right before the operation.
6. Clean the cervix twice with iodine solution.
Anesthesia/Analgesia: Local anesthesia is the preferred
7. One ml of 0.5% lignocaine solution is injected into anterior
choice for minor operations.
lip where we are going to hold the cervix by tenaculum.
LOCAL ANESTHESIA 8. Anterior lip of cervix held with tenaculum or sponge
Skin sensitivity testing for local anesthesia agent (lignocaine) holder (in case of pregnant patient).
has no established predictive value for anaphylactic reaction.
Therefore, it is not mandatory to perform a skin sensitivity test
prior to infiltration of lignocaine.
The following are the requirements for the administration
of local anesthesia:
1. An IV line is to be secured before the start of the procedure.
2. Lignocaine without adrenaline is the local anesthetic that
is to be infiltrated when the patient is on the operation
table. The maximum dosage is 3 mg per kg body weight.
3. Client must be monitored and attended to after the
administration of the drug.
4. Communication must be maintained with the client
throughout the procedure.
Paracervical block and pudendal anesthesia is required in
most of the minor procedures requiring dilatation of the
cervix, viz. Fig. 65.1: Paracervical block
 9. Normal 5 cm, 22 or 24 G needle is attached to • 10–20 ml syringe
10–20 ml syringe and 10 ml of 0.5% lignocaine is loaded. • Injection lignocaine without adrenaline.
10. Slight traction is applied on tenaculum to help identify Thirty to forty ml of 0.5% lignocaine without adrenaline is used
the area between the smooth cervical epithelium and as the anesthetic agent for the block. The aim is to infiltrate
the vaginal tissue. This is the site for insertion of the about 15–20 ml of this solution around the pudendal nerve as
needle around the cervix. it passes through the lesser sciatic notch around the ischial
11. Insert the needle just under the epithelium. Injections are spine. The procedure is carried out using sterile technique.
given at 2 and 10 o’clock position or 4 and 8 o’clock some Two approaches are described:
authors advised 3 and 9 o’clock position injection. 1. Transperineal
12. After inserting the needle aspirate to be sure that no vessel 2. Transvaginal.
has been penetrated. If the blood come into syringe, then The patient lies in the lithotomy position. In the trans-
remove the needle and recheck at another position and perineal approach (Fig. 65.2A). Paint and drap. Raise a weal

Chapter 65
try again. Never inject if blood is aspirated, it can lead to with the local anesthetic solution half-way between the
convulsions and even death. fourchette and the ischial tuberosity. Then the needle with
13. Inject 2 ml of lignocane just under the epithelium and do loaded 10 ml syringe pierces.
not go deeper than 3 mm. When correctly placed swelling Two fingers are placed in the vagina, guide the needle tip
and blanching of the tissue can be noted. towards ischial spines. The tip is slightly carried beyond the
14. Wait for 2–5 minutes then pinch the cervix with forceps to sacrospinous ligament and after confirming it is not in a vessel
check the effect of anesthesia. (by aspiration), about 10–15 ml of the lignocaine solution is

Minor Procedures
Complications: It provides a high level of safety and has injected. The same procedure is repeated on the other side.
very few complications mostly due to toxic effects of local In the transvaginal procedure (Fig. 65.2B) a special
anesthesia due to inadvertent injection into the blood vessel. pudendal needle guide (trumpet) or the Kobacks needle (as
(Systemic side effects). it prevent vaginal injury) is inserted (if available) in the vagina
with the corresponding side index finger of the surgeon in the
Toxic Effects of Lignocaine vagina advanced towards the medial and posterior of the
1. Hypersensitivity or anaphylactic response ischial spine. The needle inserted through this guide pierces
2. Twitching of muscles the vaginal mucosa and sacrospinous ligament to get into
3. Convulsions the exact position. Rest of the procedure is same as above.
4. Severe hypotension
5. Bradycardia
6. Cardiovascular collapse
7. Respiratory collapse.
Management
If sign and symptoms develop, do the following:
1. Ask somebody to call anesthetist and ask for assistant
doctor-check airway and breathing.
2. Put IV access
3. Start oxygen
4. Control convulsion by injection Diazepam or Thiopentone
slowly IV
5. Immediate intubation may be needed
6. Artificial ventilation may be required and maintain with
100% oxygen and relaxation
7. If cardiovascular collapse occurs, then vasopressors and
IV fluid are indicated.
The support of respiration and cardiovascular activity will
be required to be maintained for the duration of action of the
drug for lignocaine it is 45 minutes. The maximum cumulative
safe dose for adult is
0.5%, 1% lidocaine 4 mg/kg
0.5%, 1% lidocaine + Adrenaline 7 mg/kg.
Other complications include: Parametrial hematoma and
laceration of vaginal mucosa.

Pudendal Block Anesthesia

The pudental nerve gives sensory innervation of the lower
vagina, vulva and the perineum. It provides motor branches
to the perineal muscles and the external anal sphincter. The
nerve is to be blocked before it divides into its terminal
branches.
Requirements
• Sponge holder Figs 65.2A and B: Pudendal block. (A) Transperineal approach;
• 22 Gauze needle (B) Transvaginal approach 513
 At the end of the block, wait for a few minutes before Endometrial Sampling
starting, for the anesthetic effect to take place. Endometrial Sampling is an office procedure for obtaining
The side effects are the same as paracervical block endometrial tissue which has been shown to be adequate for
besides retropsoas and subgluteal abscess. evaluation of endometrium and are indicated when pathology
The requirement of General anesthesia is determined by is global rather than focal (e.g. infertility abnormal uterine
the surgeon and the anesthesia. bleeding). If the endometrial generalized sampling is done
Commonly used minor procedures are given below: for infertility or abnormal uterine bleeding then just
premenstrual (or even first day of the period) is the ideal time
Pap Smear to know about ovulation and even detection and tuberculosis,
Papanicolaou test is a screening method to detect etc. The tissue obtained is sent for histopathology and
premalignant and malignant lesion in the cervix. It may also tubercular culture.
detect infection and abnormality in the endocervix and Endometrial sampling offers a number of advantages to
Operation Theater Activities

endometrium. D and C:
• It is performed in the office, rather than in an operating
Procedure
room.
• The client lies in dorsal position on the examination table. • It can be done with minimal to no cervical dilation.
• Labia is parted apart, Cusco’s self-retaining speculum is • Anesthesia is generally not required.
introduced without any lubricant or jelly Prophylactic antibiotics are not necessary.
• Squamocolumnar junction of cervix is scraped with Ayre’s
spatula (with longer end inside the cervical os-rotated Indications
through 360° twice) (Fig. 65.3) Indications for endometrial sampling include:
• This scraping is spread on a glass slide and is fixed by 1. Infertility
dipping in jar (containing 95% ethanol and either in the 2. Abnormal uterine bleeding
ratio of 1:1) or by cytospray 3. Chronic pelvic pain.
• While taking a Pap smear, be careful that the patient is
not menstruating, and Contraindications
• There should be no douching or use of vaginal cream for 1. The only major contraindication is viable and desired
at least 24 hours. intrauterine pregnancy.
Section 16

2. Bleeding diathesis is a relative contraindication, since

Newer Techniques bleeding may be excessive in such patients.
Liquid Based Cytology 3. In the presence of acute vaginal, cervical, or pelvic
In this cell, sample is collected with endocervical brush and infection, the procedure should be deferred, if possible,
Ayre’s spatula (or broom can also be used). until the infection has been treated.
This sample is rinsed in a vial containing liquid 4. Women with true cervical stenosis, they generally require
preservative. With this technique 80–90% of cells are general or regional anesthesia and mechanical cervical
transferred to a liquid medium, compared from conventional dilation and it is better to perform D and C in them.
Pap smear in which 10–20% of cells are retrieved on glass 5. Cervical cancer, if obstructing the endocervical canal,
slide. also is a contraindication as heavy bleeding or perforation
Moreover, it eliminates the risk of air drying. may occur.
Cells are retrieved by passing the liquid through the filter Many devices are used to get endometrial sample. A
which traps large epithelial cells and separates them from strip of endometrium is removed with thin Sharman’s curette
blood and small inflammatory cells. It improves the (Fig. 65.4) or NOVOK’s curette. They are thin tubular blunt
sensitivity to 80%. ended curettes with a cutting edge.
• With the patient in the lithotomy position (after emptying
AUTOPAPAS SCREENING the urinary bladder) perform a bimanual examination
It uses automated microscopy coupled with a special digital paying particular attention to the size, shape, and
camera. This system scans the slide and uses computer orientation (anteverted or retroverted) of the uterus.
imaging technique to analyze each field of view on the slide. • Insert Sim’s speculum and visualize the cervix.
Computer algorithms are used to rank each slide on the basis • Clean the cervix twice with antiseptic solution (e.g.,
of probability that the sample may contain an abnormality. The povidone-iodine).
selected slides are then reviewed by cytotechnologist or Anterior vaginal wall retractor visualizes the cervix (Fig.
cytopathologist. 65.5). Anterior lip of the cervix is caught by a tenaculum or a
vulsellum (Figs 65.6 A and B). Pass uterine sound to know
the length of the uterine cavity and its position. Now pass
the endometrial curette and remove one or more strips of

514 Fig. 65.3: Ayre’s spatula Fig. 65.4: Endometrial curette

 Table 65.1: Comparison of cytology classification system

Bethesda system (III) Dysplasia/CIN system Papanicolaou system

Within normal limit Normal I
Infection (organism should Inflammatory atypia II
be specified)
Squamous cell abnormalities Squamous Atypia HPV atypia II R
Atypical squamous cell of - Exclude LSIL
undetermined (ASCUS) - Exclude HSIL
significance
Exclude high grade lesion (ASCH)
Low grade squamous CIN I (mild dysplasia) III
intraepithelial lesion (LSIL)

Chapter 65
High grade squmous CIN 2 (moderate dysplasia) IV
intraepithelial lesion CIN 3 (severe dysplasia)
CIS (CA in situ)
Squamous cell carcinoma Squamous cell CA V

is constructed of flexible polypropylene with an outer sheath

measuring 3.1 mm in diameter with a 2.4 mm distal side port,

Minor Procedures
through which the endometrial sample is obtained. The
flexibility of the Pipelle allows the cannula to conform to
the contour of the uterus and minimizes cramping. In a
typical procedure, 5–15% of the endometrial surface area is
sampled.

Procedure
• The Pipelle can often be inserted avoiding contaminating
the tip (by touching vulva, vagina, etc.) without the aid of
a vulsellum.
• Using steady and moderate pressure, slowly insert the
sampling device (with the piston in) through the external
cervical os and onto the uterine fundus. Stop when
resistance is met.
Fig. 65.5: Visualizing cervix • If the device cannot pass through the cervix, attach a
vulsellum(if not already in place) and use a series of
the endometrium. The tissues so obtained are taken out with small (1–4 mm) Hegar dilators to gently dilate the cervical
a stillette or a needle or flushed down partly in formalin canal.
solution for histopathology examination and partly into saline • Use the device to document the depth of the uterus (most
solution for microbacterium tuberculosis culture. biopsy catheters are calibrated). Average uterine length
All used instruments to be decontaminated by placing is 6–8 cm.
into the bleech solution for 10 minutes. Then rinse them with • Stabilize the sheath with one hand and pull the piston out
water and send for sterilization Decontaminate the gloves. as far as possible to create suction.
Before washing and sterilization, decontaminate the blood • Rotate the sheath 360° while withdrawing the distal port
soiled linen. from the fundus to the internal os. The entire uterine
Pipelle Device cavity can generally be sampled with at least four
complete back and forth passes from fundus to internal os.
The Pipelle endometrial sampling device is a popular method
for sampling the endometrial lining. The disposable device

515
Figs 65.6A and B: Catching anterior lip of cervix
 Do not let the sheath come outside of the external os or a vasovagal episode. Cramping can be managed with
you will lose the negative pressure. NSAIDs, although persistent cramping is unusual.
• Remove the device when the entire cavity has been
sampled and the catheter is visibly filled with tissue. Endocervical Curettage (ECC)
• Expel the specimen into the formalin container by pushing The scraping of the mucous membrane of the cervical canal
the piston into the sheath, thereby discharging the using a curette or a cytobrush (Figs 65.8 and 65.9).
specimen into the fixative. If there appears to be insufficient
Indication
tissue for diagnosis, perform a second pass of the catheter.
The same catheter may be used if it has not touched the 1. Abnormal pap smear
formalin 2. In predicting the cervical involvement in the uterine
• Remove the instruments. Most bleeding can be controlled malignancy and predicting advanced FIGO staging.
with pressure via cotton swabs or a sponge stick. 3. Unsatisfactory colposcopy
Operation Theater Activities

• Decontaminate all used instruments, gloves and blood 4. LSIL and HSIL when conservative and ablative treatment
soiled linen. is planned respectively.
5. First step of fractional curettage operation.
Vabra Aspirator and Karman Cannula
Special Cases
The Vabra aspirator and Karman cannula are also used.
1. Postmenopausal patient benefit from an endocervical
Vabra: The Vabra aspirator is available as a 4 mm disposable curettage since their squamocolumnar junction tends to
plastic or a 2 or 3 mm stainless device. The aspiration procedure be high in endocervical canal.
is similar to that described above for the Pipelle device, except 2. Patient with positive endocervical margin in cone
suction is initiated via an external vacuum pump. The tissue specimen have followed by examination with Pap smear
sample is placed in formalin solution for histopathology and in and cytobrush.
normal saline for culture.
It has specificity of 75% and sensitivity of 55%.
Karman: The Karman cannula comes in diameters of 4–6 mm Procedure: It is minor OT procedure with no anesthesia
and is made of flexible plastic with two ports at the distal end. required. Postvaginal wall is retracted with Sim’s speculum
The procedure is similar to that described above for the and ant cervical lip caught with a tenaculum or a vulsellum
Pipelle device, except a syringe is connected to the disposable after cleaning twice with iodine.
Section 16

cannula provides suction. An external vacuum pump can A cytobrush is used to take endocervical specimen with 2
also be used (Fig. 65.7). complete rotations. The specimen is fixed on a slide with
An advantage of the Vabra and Karman systems is that cytospray. An endocervical curette can also curette out the
they yield a large tissue sample, comparable to dilation and tissue which is fixed in formalin solution (Fig. 65.6).
curettage. The disadvantage is that the larger cannulas are
less comfortable for the patient than the Pipelle system because Dilatation of Cervix (Fig. 65.10)
they are less flexible and generally mandate use of a vulsellum, It is the most common minor gynecological procedure.
cervical dilation, and analgesia. Indications can be gynecological or obstetrics. Indications
Side Effects and Complications of cervical dilatation in gynecology–
The most common side effect is cramping, which subsides 1. First step in
rapidly after the procedure is completed. Cramping tends to a. Dilatation and curettage
be more severe with the Vabra device then the Pipelle b. Drainage of pyometra
because the former is more rigid, the suction is greater, and c. Intrauterine insertion of radiotherapy
larger samples are removed. Vasovagal reactions are not
uncommon; the occurrence can be reduced by allowing the
patient to eat and drink before the procedure and by
minimizing pain through use of analgesics and, if necessary,
local anesthesia.
Rare complications include excessive uterine bleeding
(especially with undiagnosed coagulopathies), uterine
perforation (risk 0.1–1.3 percent), pelvic infection, and
bacteremia (including sepsis and endocarditis).
Postprocedure Care
The women should remain in a semirecumbent position for
several minutes after the procedure to reduce the chance of Fig. 65.8: Endocervical curette

516 Fig. 65.7: Karman’s cannula Fig. 65.9: ECC brush

 Dilatation and Curettage (D and C) (Figs 65.11 and 65.12)
Previously the gold standard for endometrial sampling was
dilatation and curettage. It is a blind procedure and
assessment can’t be done whether the lesions have been
missed. It involves sharp curetting all the walls of uterine
cavity in systematic manner after dilatation of the cervix.
But now it may be replaced by endometrial biopsy
endometrial aspiration and hysteroscopy directed biopsy (Fig.
65.10, Instrument tray).
D and C can be elective, when done in premenstrual period
to know the hormonal status (infertility and abnormal uterine
bleeding) and any gross pathology or emergency operation,

Chapter 65
when the patient is bleeding profusely to removal of the
endometrium that will stop bleeding.
Send the tissue obtained for histopathology and
tuberculosis culture.
Fig. 65.10: Dilatation of the cervix (insertion of dilator)
Dilatation and Evacuation
The operation consists of dilatation of the cervix and
d. Hysteroscopy

Minor Procedures
evacuation of the products of conception from the uterine
e . Before cervical amputation in Fothergill operation in cavity in a pregnant patient.
obstetrics.
Indication of the Cervical Dilatation Indications
a. Before evacuation of missed or incomplete abortion • Incomplete abortion
b. Before suction evacuation in MTP or of a moral pregnancy • Inevitable abortion
c. Dilatation of cervix per abdominally during cesarean
section when the cervix is closed.
d. Diagnose of incompetent cervix.
Procedure: After passing urine patient lies on the operation
table in lithotomy position. Part is cleaned and draped. Per
vaginal examination is done. Sim’s speculum retracts
posterior vaginal wall. Anterior vaginal wall is retracted by
anterior vaginal wall retractor. Cervix is visualized. Anterior
lip of cervix. Caught by a vulsellum (a pregnant cervix by a
sponge forceps) Cervix is swabbed by povidone iodine twice.
Give local anesthesia and wait for it to start acting. In a non-
pregnant uterus uterine sound is passed to know the size
and position of the uterus.
Now gradually dilate the cervix by increasing number of
Hager ’s or other metal dilators. The vulsellum is firmly
gripped and the dilater is passed just beyond the internal os.
A pregnant uterus can be dilated by Karman’s cannulae of
increasing diameters.
Complications
1. Perforation of uterus if the dilator goes beyond internal
os.
2. Cervical tears if the cervix is forcefully dilated. Fig. 65.11: D and C instruments

Fractional Curettage
The minor procedure is used in the diagnosis of endometrial
cancer, “Fractional curettage” plays a major role in making
diagnosis. Some other methods are less traumatic (e.g.
hysteroscopic directed biopsy) and more accurate. After
cleaning and draping to a pervaginal examination.
It is done under anesthesia. After cleaning and draping do
a peravaginal examination first ECC and Pap are performed.
Introduce Sim’s speculum and see cervix after insertion of
anterior vaginal wall retractor. Catch hold of another lip of
cervix. Twice swab the cervix with iodine solution. Insert uterine
sound. After the dilation of cervix, curettage is taken from
fundus, both anterior and posterior wall, isthmus and lower
part of the uterus and the specimen are placed in different
formalin solution and sent for histopathology examination
(HPE) after labeling. Fig. 65.12: D and C curette inserted in uterus 517
 • Missed abortion In the second stage, further dilatation by metal or Karman
• Hydatidiform mole in the process of expulsion. dilator is done and evacuation of uterus is carried out.
• Medical termination of pregnancy (1st trimester). Evacuation may be possible in incomplete abortion with
Anesthesia—either general or local anesthesia, with sedation. only mesoprostone, as is seen in one study in our hospital.

Procedure Complications
Patient is put in lithotomy position after voiding urine. The • Excessive hemorrhage
part of perineum along with lower abdomen and thighs are • Cervical laceration
cleaned first with savlon, then iodine and finally spirit. The • Uterine perforation
cleaning is started from the part to be operated and then go • Late complications—pelvic inflammation, infertility,
laterally. Do not clean with strokes from clean part to unclean cervical incompetence, uterine synechiae.
part and back to clean part. Now drape with autoclaved, cut Instruction at discharge: If everything is normal, to report after
Operation Theater Activities

perineal sheet. 6 weeks for collecting histopathology report. Investigations

• Procedure is done under aseptic conditions, bimanual to find the cause of miscarriage may then be carried out.
examination is performed to access the size and position Report immediately if there is excessive vomiting, pain, fever
of the uterus and any findings in the fornices. or bleeding.
• Posterior vaginal wall is retracted by Sim’s speculum. • Take medicines as prescribed.
• Cervix is visualized with the use of anterior vaginal wall • Avoid sex till next period, which may start after 1 month
retract or and it is twice painted by povidine iodine. to 6 weeks.
Anterior lip of cervix is grasped by sponge holding
forceps (in gravid uterus) with tenaculum in early Suction Evacuation (Figs 65.13 and 65.14)
pregnancy (Do not pass uterine sound). It is a procedure in which the products of conception are
• The cervix is dilated gently up to the desired extent by sucked out from the uterus with the help of a cannula fitted
the graduated metal dilators or Karman cannulas. The to a suction apparatus (Fig. 65.15) or manual aspiration
tip of the dilator should go just beyond internal os and syringe (MVA syringe). (Fig. 52.1).
the cervix should be dilated enough to admit the index
Indications
finger of the operator easily.
• Closed ovum forceps is passed into the uterine cavity. • MTP (1st trimester)
Section 16

The blades of the ovum forceps are opened and detached • Inevitable abortion
pieces of product of conception are grasped with the • Recent incomplete abortion
blades, close the blades and remove them. The ovum • Hydatidiform mole.
forceps may be rotated through a right angle before
Procedure
withdrawing it from the uterine cavity. This ensures better
grasp on the material held with the forceps. The ovum • The steps follwed are the same as adopted for D and E.
forceps may have to be passed many times in the uterine The procedure may be performed under IV sedation
cavity. supplemented with paracervical block.
• When all the products of conception have been removed,
a blunt curette is passed into the uterine cavity and gentle
scrapping of all the walls of the uterus is done till the typical
grating sensation is felt.
• Injection Methergin 0.2 mg is to be administered
intravenously during the procedure. Remove sponge
holding forceps/tenaculum.
• The Sim’s speculum is removed and with the two fingers
in the anterior fornix and the other hand on the abdomen,
the uterus is massaged to expel any clots left in the uterus.
A final bimanual examination is done.
• After being satisfied that the uterus is remaining firm
and the bleeding is minimal, the vagina and the perineum
are toileted dried and a sterile vulval pad is placed.
• The products of conception or the material obtained is
sent for histopathological examination. (Sometimes we Fig. 65.13: Introduction of cannula (Suction)
diagnosed even choriocarcinoma as experience.
• Prophylactic antibiotics may be given after the operation.
Postoperative orders include:
• Nil orally for 2 hours
• Half-hourly pulse/BP/respiration check for first 2 hours.
• Observe the pad.
• Antibiotics—mostly ampicillin is given but if patient
comes with incomplete abortion metrogyl may be added.
• Mala N is given to regulate the pituitary-ovarian axis for
three months.
In some cases, this procedure is done in two stages, in first
stage, cervix is only dilated by either tents or intravaginal
518 prostaglandin E2 pessary or gel or mesoprostone tablets. Fig. 65.14: Cannula connected to suction
 vertically in the vagina to try to identify the level of the fistulae.
Then the bladder is filled with diluted methylene blue swab
dye around 150–200 ml. The patient is instructed to walk
around, climb stairs over a period of 15– 20 minutes.
The swabs are then examined
1. Lower swab → Wet and Stained
→ Urethrovaginal fistulae
2. Lower and middle swab → Wet and Stained
→ Vesicovaginal fistula
3. Upper swab → Wet and not stained
→ Ureterovaginal fistula
4. If upper one is wet but not stained then probable

Chapter 65
diagnosis will be uretrovaginal fistalae which can be
confirmed by double dye test in this phenazopyridine (an
orange dye) or tablet pyridium is given orally. Orange
staining of urine will occur in ureteric fistula. Also can
give indigo carmine injection parenterally and see blue
dye on the upper most swab which was unstained initially.
Fig. 65.15: Suction machine
Vulvar Biopsy

Minor Procedures
• The cervix is dilated with graduated metal dilators or
Karman’s cannula (in MVA) up to one size less than that Indication
of suction cannula. 1. One or more vulvar biopsies is indicated if the lesion is
• The appropriate suction cannula is fitted to the suction clinically suspicious for malignancy (asymmetry, border
apparatus or MVA syringes. The cannula placed in the irregularity, color variation, rapid change, bleeding, non-
mid uterine cavity. healing).
• The pressure of the suction is raised from 400–600 mm Hg. 2. Biopsy should also be performed if a benign looking lesion
The cannula is moved up and down and rotated within the does not resolve after standard therapy.
uterine cavity. The suction bottle is inspected for the products
Relative Contraindication
of conception and blood loss.
• The end point of suction is denoted by 1. Bleeding diathesis
– No more material is being suctioned out 2. Recent (<3 weeks) chemical destruction attempt on the
– Gripping of the cannula by the contracting smaller lesion.
size uterus Anesthesia
– Grating sensation
Local anesthesia (infiltration or topical) should be used for
– Appearance of the bubbles in the cannula.
vulvar biopsies. The site can be infiltrated with 1% lidocaine
• The vacuum connection should be broken before
with or without epinephrine.
withdrawing the cannula down through the cervical canal
to prevent injury to the internal os. Procedure
• The procedure is completed as described above for D
• Vulvar biopsies can usually be performed in the office.
and E.
• The indications and procedure for the biopsy should be
Complications discussed with the patient, and informed consent obtained.
• Excessive hemorrhage. But it is much less than in D and E. • Tetanus toxoid injection is given if not previously
• Cervical laceration immunized for tetanus.
• Uterine perforation. • After proper positioning on the examination table, the
selected site is cleaned with a cleansing solution and
Late Complications draped.
Pelvic inflammation, infertility, cervical incompetence,
Different types of biopsies are taken.
uterine synechiae.
1. Shave biopsy: A shave biopsy removes the top layer of the
Three-Swab Test skin and is used when the lesion is small. Shave biopsy
may be performed if the suspected lesion is confined to
A fistula is defined as abnormal communication between 2
the epidermis. It should not be used when melanoma is
epithelial surface. In the relation to gynecology urinary tract
suspected.
fistula connect genital tract (vagina, uterus or perineum) to
2. Punch biopsy: It can be performed by Keye’s biopsy punch
urinary tract (bladder, ureters).
(Fig. 65.16) or punch biopsy forceps (Fig. 65.17). Punch
Indications biopsy is indicated when the pathologic process is dermal
Three-swab test is indicated for small fistulae that cannot be or in the subcutaneous fat. A punch biopsy removes a
visualized on examination and to exclude multiple fistulae. small (2–6 mm), circular piece of skin tissue and is used
Contraindications allergy to the dye. when all skin layers need to be examined. More than one
punch biopsy may be necessary to adequately sample a
Dye used large, heterogeneous lesion and repeat biopsies may be
1. Diluted methyline blue necessary if the clinical and pathologic findings do not
2. Phenazopyridine (orange dye). correlate. The biopsies are obtained from the thickest
Procedure: This test is done in operation theatre without region of the lesion and from any ulcerated areas
anesthesia Foley’s catheterization is done. Place three swabs including a portion of healthy skin. 519
 Fig. 65.16: Punch biopsy forceps (Keye’s)
Operation Theater Activities

Fig. 65.18: Excision biopsy

Fig. 65.17: Punch biopsy forceps

Section 16

• Incisional biopsy: Incisional biopsy is performed when

the ulceration is large but only a portion of the lesion
is to be biopsied and the sample should include on
edge of healthy portion of the ulcer.
• Excisional biopsy (Figs 65.18 and 65.19): Excisional biopsy
to remove the entire lesion. It can be done when the
lesion is less than one centimeter in size. Atypical- Fig. 65.19: Stitching after excision biopsy
appearing pigmented lesions are completely excised
to ensure accurate depth assessment. • Lesions that are ulcerated, bleeding, nonhealing, rapidly
The number of biopsies that need to be taken depends changing, and/or asymmetric should also raise concern
upon the size and location of the lesions, their for malignancy, and biopsy is indicated.
appearance, and the age of the patient. • Two to three random incisional biopsies are sufficient to
The biopsy tissue is to be sent for hiostopathology. establish a diagnosis of vulvar intraepithelial neoplasia
Hemostasis is usually achieved with pressure or (VIN) among women under age 50 with multifocal lesions
electrocautery. If bleeding is not controlled or the and no ulceration.
defect is large, then the biopsy site is closed with an
absorbable suture. A small wound that is not bleeding Complication (Rare)
can be allowed to heal by secondary intention. • Infection
After the procedure, the patient should be instructed • Bleeding/hematoma/ecchymosis
to keep the site clean and dry. • Hypopigmentation
• Pain
Certain Pertinent Points to Remember • Scar
• Vulvar malignancy commonly presents with multifocal • Recurrence.
lesions, so multiple biopsies (including of cervix and
vagina—in suspicious looking) are indicated if the Postprocedure Care
concern for invasive cancer is high. • Wash the area twice a day with soap and water
• Biopsy under colposcopic guidance is useful for diagnosis • Apply antibiotic ointment after each cleansing
of intraepithelial neoplasia, carcinoma, or flat warts and • Use aceta aminophen or ibuprofen for discomfort
is performed after applying a gauze saturated with 3 to 5 • Use ice pack, sitz bath
percent acetic acid to the vulvar skin for 5 to 10 minutes. • Avoid intercourse until discomfort is over.
• There is an increased incidence of microinvasive
carcinoma in unifocal lesions in women over age 50, thus Bartholin Cyst and Bartholin Abscess
a biopsy should be performed in all lesions that have no Cysts that are disfiguring or symptomatic can be treated by
known diagnosis to exclude invasive disease. the techniques illustrated below.
• The risk of invasive disease is highest when a slight a. Incision and drainage: Incision and drainage may be
ulceration accompanies the lesion; excision is mandatory performed with or without packing. The cyst should be
520 in these patients. incised at or behind the hymenal ring to prevent vulvar
 scarring. However, this procedure is not recommended Imperforate Hymen
alone since there is a tendency for cysts to recur because It is a congenital abnormality. As the patients are teenage a
outflow is obstructed when the incised tissue edges general anesthesia is preferred. Patient lies on the table in
reapproximate. lithotomy position. The part is cleaned and draped. A crucial
b. Marsupialization (Figs 65.20 and 65.21): Marsupialization incision (12°C–6°C and second from 9°C–3°C) is given. The
refers to a simple procedure for Bartholin duct abscess. A pent up menstrual blood comes out as dark tarry fluid. Four
linear incision is given on the abscess behind the hymenal points of the incision are stitched to the hymenal ring to the
ring. The proximal duct wall is then everted onto the prevent closure. A clean pad is given. After anesthesia effect
introital mucosa with interrupted sutures, thus creating a is over she is enouraged to walk around to facilitate draining
fenestration for egress of glandular secretions. This the old menstrual blood. Do not do suction.
procedure can often be performed with local anesthesia.
c. Sclerotherapy: Silver nitrate sticks can be inserted into Vaginal Septum

Chapter 65
the cyst cavity to necrotize the cyst wall. After incision It is also a congenital abnormality (chapter 41). If the septum
and drainage, a crystalloid silver nitrate stick 0.5 cm in is at the junction of upper two third and lower third of vagina.
length and diameter is placed deep into the cavity. Mild General anesthesia is given. After painting and draping
burning sensation may be felt. After 3–4 hours, the patient the urinary bladder is catheterized. The transverse incision
is called for follow-up and the vulva is cleansed to reveal given carefully to prevent injury to the urethra or rectum.
the incision site and any necrotized tissue with the The pent up menstrual blood comes out. The cut ends of
remaining silver nitrate particles is removed. the vaginal septum are undercut, advanced and drawn down.

Minor Procedures
d. Excision: Excision of the entire Bartholin’s gland and duct It is stitched to the edge of the lowest part of the vaginal
is the definitive procedure for both cysts and abscesses. arifice.
It is usually considered after other methods have
repetitively failed because it is not an office procedure Cervical Biopsy
and has higher morbidity, including excessive bleeding, A cervical biopsy involves the removal of a small amount of
hematoma formation, cellulitis, and dyspareunia. Send tissue from the cervix for histopathological diagnosis.
the tissue obtained for histopathology.
Indications
• Abnormal Pap smear and suspicious looking cervix.
• Exophytic or ulcerative growth in cervix.
• Follow-up in cases of cancer of the cervix after a radio-
therapy course.

Types of Cervical Biopsy

a. Punch biopsy
b. Wedge biopsy
c. Loop biopsy
d. Cone biopsy.
Punch Biopsy: A cervical biopsy is performed with the women
lying on her back, after the patient emptied her bladder. Explain
the procedure to the patient and take written consent. Cusco
self-retaining speculum is introduced in the vagina to enlarge
the opening of the vagina.
If the mass is obvious then direct punch biopsy is taken.
If not, then colposcopy direct biopsy after, application of 3 or
5% acetic acid is performed. Accuracy with punch biopsy is
Fig. 65.20: Marsupialization of Bartholin cyst (incision)
84–90%. Normal area is included in the biopsy. To allow the
cervix to heal for 1 week after biopsy avoid.
• Douching
• Sexual intercourse
• Using tampons.

Contraindication
Severe anemia should be treated first otherwise patient may
collapse as one of the complications is hemorrhage.
Wedge Biopsy: It provides substantial tissue for reporting as
sometimes punch biopsy fails to prove a lesion in suspicious
looking area in cervix by holding with Ellis tissue forceps and
cutting with a scalpel including normal looking area.
Indications are same as punch biopsy except exophytic
ulcerative growth in cervix.

Procedure
A wedge is taken from the function of abnormal area and
Fig. 65.21: Completion of marsupialization adjacent normal area of the cervix.
521
 Complications consent. Extent of cervical lesions are marked with Lugol’s
• Bleeding iodine.
• Sepsis. Descending cervical vessels are ligated at 3’o clock and
Contraindication 9’o clock position and canal is dilated upon no. 8 with Hegar
Frank growth. dilator cone is out by (i) scalpal, (ii) electrosurgery, (iii) laser.
Scalpal conization circular: After putting into lithotomy
Loop Biopsy: Diathermy loop is used both as a diagnostic and
position and the perineum and vagina are cleaned. Drape
therapeutic for the cervical lesions. It provides a substantial
the perineum. Put Sim’s speculum, visualize the cervix and
amount of sample from the affected area of the cervix.
paint with 3–5% acetic acid or Lugol’s iodine. Anterior lip of
Indications cervix is suerficially grasped with vulsellum (do not include
Same as for punch biopsy. transformation zone in the grasp). A demarcation silk suture
is placed at 12 o’clock position to know the site of lesion by
Operation Theater Activities

Advantages the pathologist. Initial dilatation is needed.

• Preferred in younger women Incision is given over ectocervix and depth of cone
• Where minimal tissue is sacrified depends on the site of the lesion. It is present in cetocervix,
• More likely to tell about micro invasion. a shallow cone is removed. A deep cone is removed if the
lesion present in endocervix.
Procedure The tissue obtained is sent for histology examination.
Done in minor OT under local anesthesia. Under colposcopy (ii) Laser conization: Infrastructure expert surgeon is
guidance loop used to remove abnormal or suspicious area required. It is performed under anesthesis in well-equipped
from transformation zone. Multiple loop biopsies can also be operation theater.
taken. Size of the loop depends upon the size of abnormal area. (iii) Loop electrosurgical procedures (LEEP). Also called
Complications large loop excision of transformation zone (LLETZ). Very
thin loop shaped wire is used of different sizes (Figs 65.22
Bleeding.
and 65.23). The loop is guided through cervix from one side
Cone biopsy: It is Gold Standard Method for evaluating to the other using cutting current. Ferric subsulfate paste is
abnormal Pap smear (Fig. 44.7). The exocervix is excised like applied to the cone after obtaining hemostasis.
a cone cervix. Abstinence is advised for 6 weeks and patient is kept
Section 16

Cervix is infiltrated with anesthetic agent. Colposcopically admitted for a week for observation.
appropriate loop is selected.
The loop is allowed to guide through cervix from one side Complications
to the other using cutting current. After hemostasis is • Hemorrhage may be due to inadequate hemostasis
obtained with ball electrode also apply ferric subsulfate paste during cone biopsy or due to secondary infection
to the cone bed. After excision endocervical curettage done. • Cervical stenosis
Postoperative advise after cone biopsy • Infection
• Avoid sexual contact for 4 weeks • Preterm labor if done during pregnancy.
• No vaginal application should be done.
• Don’t sit in water (tube bath or swimming) for 4 weeks.
Follow-up visit is after 6 weeks to look for healing and
patency of cervical canal. Pap smear is to be taken after four
months.

Complications
Bleeding during operation
Postoperative bleeding is due to inadequate hemostasis
during cone biopsy. Secondary bleeding may be seen after
7–10 days due to erosion of blood vessels during healing. Fig. 65.22: Loop of different size for LLETZ
Uterine perforation may occur in postmenopausal cases.
Infection: Antibiotics may be used in selected high risk
cases to prevent infection.
Late complication: Stenosis of cervix can be seen.
Indications
• When microinvasion is suspected on cytology
• Unsatisfactory colposcopy
• As a diagnostic and therapeutic for SIL
• Adenocarcinoma in situ or ECC positive.
Contraindications
• Frank growth
• Pregnancy

Procedure
It is done under regional or general anesthesia after
adequate blood arrangement and well-informed, written Fig. 65.23: Fibroid polyp
522
Polypectomy Placental Polyp: When bits of placenta is left and remains
Definition: Polyp is pedunculated growth arising from uterine attached in case of incomplete abortion or childbirth. It gets
corpus or cervix. organized into a blood clot.
Main types are mucous polyp and fibroid polyp and – It is single, sessile but non-capsulated and is called
placental polyp. placental polyp.
Diagnosis is made on speculum examination. It is removed by D and C with small blunt curette and
Fibroid Polyp: It results from expulsion of submucous sent for histopathology examination.
fibroid from its bed to the uterine cavity, thereafter into vagina. Transvaginal ultrasound-guided polypectomy: A new
device has been manufactured (Safe T choice) , which allows
Polypectomy:
attachment of a transvaginal ultrasound probe to a specially
a. Intravaginal polyp with a thin pedicle: The polyp is grasped
adapted cervical tenaculum. This affords the capacity to
by Lane’s tissue forceps or sponge forceps for traction
monitor intrauterine surgical procedures without the need

Chapter 65
(Figs 65.24 and 65.25). The polyp is twisted till (Figs 65.26
for hysteroscopy.
and 65.27) the pedice becomes very thin it is secured by
Tissue obtained after polypectomy is to be sent for
an artery forceps at its base cut and ligated above forceps
histopathology.
by chromic catgut. Excess of pedicle below ligature is
excised. D and C is done for exploration of uterine cavity. Cryocautery
b. Big intravaginal polyp Where pedicle cannot be reached.
Cryocautery of cervix means that outer layers of cells of
On cleansing polyp with betadine under Sims’ speculum,
cervix are frozen using a special flat tip instrument.
lower pole is grasped by Lane’s forceps. Circular incision is

Minor Procedures
made on lower part of polyp, fibroid is enucleated piecemeal Indications
(morcellement) followed by twisting the pedicle and placing • Vaginal discharge or bleeding caused by cervical ectropion
the ligature at base of pedicle followed by excision of • Chronic inflammation of cervix
redundant part and performing D and C in the end. • Abnormal Pap smear
c. Intrauterine Polyp diagnosed by hysterography or TVS • Preinvasive cervical neoplasia (CIN)
is removed by hysteroscopic procedure. • Warts.

Fig. 65.24: Polypectomy Fig. 65.26: Twisting the polyp

Fig. 65.25: Polyp caught by vulsellum Fig. 65.27: Twisting the polyp 523
 In CIN, it should meet the following criteria
• Satisfactory colposcopic examination with complete
visualization of transformation zone.
• Lesion identified and fully visualized
• Biopsy consistent with cytology
• Invasive carcinoma ruled out by biopsy
• Negative ECC.
Contraindications
Unsatisfactory colposcopy
• Lesion not fully visible or extending beyond the range of
cryotherapy probe.
Operation Theater Activities

• Colposcopically directed biopsy not consistent with Fig. 65.30: Cryocautery probe in position
cytology
• Biopsy consistent with or suspicious for invasive carcinoma After freezing for 3 minutes. It is allowed for a few
• Diagnosis of glandular epithelial dysplasia or adeno- minutes (generally 5 min.) again followed by freezing till the
carcinoma in still not ruled out. whole area is covered.
Prerequisites Complication
• Patient should not be pregnant • Cramping pain—It is relived itself in a day
• Patient should be free of vaginal and cervical infection • Profuse vaginal discharge—It is generally seen for 2–3
• It should not be done prior to or during periods. weeks and patient is asked to have abstinence during
this time.
Procedure • Spotting
Patient should take some painkiller 2 hours prior to procedure. • Cervical stenosis. It is a rare complication
She is laid down in dorsal lithotomy position and cuscos Pap smear is done 3 months after the treatment and
speculum is introduced. repeated every 6 months till 2 years after which it is done yearly.
Cryoprobe (Fig. 65.28) which is attached to a machine is
held on the cervix. The machine has the following components: USE OF ELECTRICAL ENERGY IN GYNECOLOGICAL
Section 16

1. Gas cylinder containing CO2/N2O (Fig. 65.29) SURGERY (FIGS 65.31 AND 65.32)
2. Green gun. Passage of the normal domestic electricity at a low frequency
Green gun holds the cryoprobe it is put in place (Fig. 65. of 60 Hz/sec through human tissue will stimulate muscle
30) and decreases the temp to –95°C. So, there occurs cell activity and cardiac systole. If the same AC current is passed
destruction by dehydration, crystallation, denaturation of at a very high frequency of 500–3500 kHz/sec through human
membrane proteins and vascular stasis. tissue it produces the desired surgical effects. The
electrosurgical units used in surgery does the job of
generating a very high frequency alternating current to
produce the surgical effects.
The passage of this high frequency current through the
human tissue resistance will generate heat which is
responsible for all the tissue reactions and surgical effects
(coagulation, cutting, etc.).
The HF electrical energy can be used in two main forms:
1. Monopolar
2. Bipolar.

Monopolar Mode
Fig. 65.28: Probe of different sizes
In this mode the HF current enters the tissue through a small
size active electrode causing maximum surgical effect (heat

524 Fig. 65.29: Cryocautery Fig. 65.31: Elecctrosurgical unit

 continuously monitor the tissue effects which facilitate the
optimal delivery of the electrical energy to tissue with less
side effects.

Electrocautery
1. It is used for cautery of the cervix (Nabothian follicles,
etc.)
2. In all surgical procedures to coagulate and cut
3. For LLT

Colpotomy (Fig. 65.33)

Definition

Chapter 65
Colpotomy (also known as vaginotomy) is a procedure by
which a deliberate incision is made in the vagina. (Mostly
posterior vaginal wall).
Purpose
A colpotomy is performed (i) to visualize pelvic structures
(ii) to perform surgery on the fallopian tubes or ovaries

Minor Procedures
(iii) drain pelvic abscess.
(iv) Role of Colpotomy in Major Gynecological Surgery
• Many gynecological surgeries require a colpotomy as a
Figs 65.32A and B: Electrocautery part of the surgical procedure. It is performed whenever
the surgeon needs to access the vagina. It is required in
burn at the contact point and return through tissue of lower following surgeries:
resistance to the passive patient plate which has a much • Tubal sterilization—Through colpotomy incision
wider area of contact and hence less tissue resistance and sterilization can be done vaginally. It is done along with
minimal heating to complete the circuit. modified Manchester and Shirodkar operation also.
The monopolar mode can work either with a cutting effect • Removal of pelvic cysts and masses—In one sitting,
or a coagulation effect. patient may undergo a laparoscopy cystectomy followed
a. Cutting effect: Here the HF current is delivered by a colpotomy for vaginal extraction of cyst or mass.
continuously to the tissue with a steady low voltage. This • Removal of Myoma—Myomas are fibroid tumors
causes a rapid heating effect resulting in vaporization of sometimes removed vaginally by colpotomy.
water molecules causing disruption of tissues and • Hysterectomy surgery—In laparoscopic hysterectomy,
achieving a surgical cut. uterus can be vaginally delivered out through colpotomy
b. Coagulation effect: The HF current is delivered to tissue incision.
in an intermittent fashion with a much higher voltage. (v) As a step in vaginal hysterectomy.
This causes slow heating resulting in gradual drying of
Procedure
tissues. The protein coagulum and the retracting
dehydrated cells induce hemostasis. Coagulation may • The procedure is explained to the patient and written,
result in desiccation or fulguration. informed consent taken. Tetanus vaccination is ensured.
i. Desiccation: The electrode will be in contact with the The patient is taken into the operation theater. She is
tissue and there will be gradual desiccation of the asked to pass urine and to lie in the lithotomy position.
tissues with coagulation of proteins resulting in An antiseptic solution, such as chlorhexidine, is applied
coagulation of blood vessels.
ii. Fulguration: The electrode is held at a distance and
the intermittent current delivered at a higher voltage
so that the currents spark off onto the tissues resulting
in superficial charring and necrosis.

Bipolar Mode
The HF current is passed through a small amount of tissue
held between two small electrodes in close proximity, so that
only the tissue between the two electrodes is subjected to
the surgical effect. Thus the tissue effect is well-controlled
and predictable and is restricted to only tissues between the
two electrodes. This mode of electrosurgical usage does not
need a passive patient plate.
Bipolar mode with vessel sealing technology (Ligasure, Ligaseal):
Here along with the HF current passing through tissue
between the two tips/blades of a forceps, an element of
mechanical compression is also applied to the tissues. So
during the coagulation processes the tissue elements are
fused into a proteinaceous gel resulting in actual sealing of
vessels even up to 7 mm size. The electrosurgical generator Fig. 65.33: Colpotomy 525
 to the skin of the perineum. Perineum is draped. Pain Risks
management depends on the surgery that is needed for There is always some risk of puncturing any growth, cyst or
the colpotomy and may require local, regional or general ectopic pregnancy that exists. The needle should not be
anesthesia. The cervix is exposed by Sim’s speculum and inserted too far.
anterior vaginal wall by anterior vaginal wall retractor
cervix is visualized. Posterior lip of the cervix is caught Results
by a tenaculum or vulsellum. • No fluid in cul-de-sac or small amount of clear fluid—
• Vagina below the cervix is grasped between two Allis Normal
forceps. The middle part of vagina is cut by a pair of • Fluid present—Send for culture to rule out infection
scissors. The incision is made as large as necessary for • If non-clotting blood—Ruptured ectopic (immediate
the requirement of overall surgery. Throughout the laparotomy)
procedure vital sign and blood loss are monitored. • If clotted blood—May have punctured vein or artery.
Operation Theater Activities

After draining pelvis abscess or postoperative fluid in POD Remove it and reinsert.
by colpotomy: A drain is put so that the drainage of pus
continues. On second or third day when pus discharge stops, Uterine Artery Embolism (UAE) (Fig. 65.35)
the drain is removed. Pus is to be sent for culture and It is minimally invasive angiographic procedure which is
sensitivity at the time of operation. relatively new in the medical armamentation. In recent era
of preserving the uterus has helped growth of this procedure.
Complications
The uterine vessels are occluded leading to ischemia and
• Bleeding hence shrinkage of growth or stoppage of bleeding.
• Infection Indications: UAE is used for quite a few indications
• Reaction to the anesthetic agent. mentioned below.
Normal Results 1. Uterine leiomyoma and adenomyosis: The usual treatment of
symptomatic fibroids is surgery, viz. hysterectomy or
Colpotomy results are considered normal when the incision
myomectomy. But being a major operation it may have
performed allows the surgeon to meet the goal of the overall
morbidity, long period of convalescence and loss of the
surgical protocol. Colpotomy morbidity rates are not
uterus (in some cases). Hormones can also be prescribed
reported.
in a particular group of patients but they are to be taken
Section 16

Culdocentesis (Fig. 65.34) religiously for prolonged period of time. Considering the
development of sarcoma to be less than one percent
This procedure is done when patients have pain in the lower
UAE is the treatment of choice in certain category of
abdomen and pelvis, and other tests suggest there is fluid
cases. The fibroid thrive on its blood supply, if it is blocked
(pus or blood) in the cul-de-sac. It may also be done when
there is shrinkage of its size and thus relief of symptoms.
the clinician suspects a ruptured ectopic pregnancy or
2. Arteriovenous malformations of the uterine arteries. This
ovarian cyst.
leads to intractable dysfunctional uterine bleeding which
The procedure is explained to the patient and a written
can be cured by hysterectomy or UAE (Fig. 17.1).
informed consent of the patient is taken. Ask her to lie in
3. Locally eroding advance cancer cervix which is bleeding.
lithotomy position after passing urine. Perineum is cleaned
4. As a palliative measure to prevent exagulation.
and draped, cervix is exposed by either Sim’s posterior
5. Situations where immediate surgery is not fesible but
vaginal wall speculum or Cusco’s bivalve speculum. Posterior
bleeding is to be stopped.
lip of the cervix is caught by a tenaculum or vulsellum. A long
6. Postpartum hemorrhage (PPH)—Intractable PPH may
needle or spinal needle with 20 ml syringe is introduced in
require UAE.
POD just below the posterior lip of cervix and aspiration is
This procedure can also be performed by laparoscope.
done.

526 Fig. 65.34: Culdocentesis Fig. 65.35: Uterine artery embolism

Preoperative Assessment and Investigations • DUB resistance to medical treatment and uterine size
The diagnosis must be certain. Sarcomatous changes to be less than 10 weeks
reasonably excluded. Ultrasound is advised. Any infection is • Endometrial carcinoma, atypical hyperplasia should be
excluded by clinical examination. ruled out by endometrial sampling or hysteroscopic
Contrast enhanced MRI may give more details and may directed biopsy
be used, when affordable. Endometrial biopsy is done to • It is not recommended for patients who are high risk for
exclude endometrial hyperplasia and malignancy. The carcinoma endometrium
interventional radiologist must also meet the patient before • It should be avoided in presence of gross infection of
hand to gain confidence. uterus or salpingitis, etc.

Contraindications Pretreatment
• Doubt of sarcoma not cleared. All patients are pretreated for atrophy of endometrium (to

Chapter 65
• Pedunculated submucosal fibroid as may disintegrate less than 3 mm) so that less endometrial thickness is to be
and lie free in the pelvis causing peritoneal irritation, ablated by Danazol, (200-600 mg/day for 3 months)
infection and even bowel adhesions. progesterone OC pill or progesterone can be used, or GnRh
• Pelvic inflammation depot for 4-6 weeks. This atrophy results in reduction in
• Any associated pelvic mass operation time, decreased bleeding and less amount of fluid
• Immunosuppressed patient requirement through the hysterscope. Performing the
• Allergic to contrast media procedure immediately after the period is over (3-10 days)

Minor Procedures
• Patient with coagulopathies also has thinned endometrium. Some perform a D and C before
• Pregnancy. the procedure to get the endometrium for histopathology
examination and thinning of endometrial layer.
Procedure
It is mostly done under sedation. Local anesthetic agent is Counseling
infiltrated on both groins and an antiemetic is given. Femoral Patient should be informed about the following:
arteries on both sides are catheterized percutaneously. • Rationale of procedure
Contrast pelvic angiography by digital fluoroscopy is done. • Anticipated discomfort, potential risk and medical and
Amount of blood flowing to the tumor is assessed. Now surgical alternatives
multiple small emboli of polyvinyl alcohol particles (PVA 500– • Therapeutic success and failure
710µg in diameter) are injected till there is arterial blushing. • Risks of damage to the intestines or the urinary tract, if
The end point is no distil flow is seen in the uterine arteries. happens then subsequent need of laparotomy.
Patient is discharged within 24 hrs. • Risk of failure consent for major surgery to be taken.
Complication Advantages
From injection side–hematoma (rarely) • Short hospital stay
Infection is sometimes seen which may become serious • Early convalescence, less pain, fewer complications
(called postembolization syndrome). compared to hysterectomy
Other minor nonspecific complications like malaise, fever, • Can be used in high risk patients unfit for surgery (morbid
etc. obesity, previous abdominal surgery) especially the
Rarely there is serious infections requiring immediate second generation methods.
hysterectomy.
Disadvantages
Follow-up after 3 months. See by ultrasound the size of
fibroid and compare. • Menorrhagia may recur in up to 23% of patients and may
In other indications also same procedure is used. require further surgery in the form of repeat ablation or
hysterectomy
Methods of Endometrial Ablation We have done hysterectomies in TCRE done in other
Over recent years a number of techniques of endometrial hospitals and our TCRE patients may have landed up
ablation have emerged. The goal of endometrial ablation is with other surgeons
to destroy (mostly by heat) the visible endometrium including • Success rate varies with the duration of follow-up and
myometrium to a depth of 1–2 mm. When the endometrium definition of success. For some patients amenorrhea is the
sloughs regeneration is prevented because neither basal goal for others normalization of menses is the objectives
nor spiral arterioles survive the 100°C heat exposure. Over • Costly equipments
a period of 6–8 weeks, the uterine wall scars and shrink. • In Nd:YAG laser the whole OT should be made laser proof.
A preoperative shrinkage of endometrium with Failure: About 20% of patients fail to respond and need
progesterone or GnRH Agonists, etc. enhance the results. surgery.
The criteria for an ideal endometrial ablation technique: Depending on the method used it is called first generation
• It should be effective and safe technique or second generation technique.
• Easy to learn Various methods of endometrial ablation so far are:
• Quick to perform 1. Cryosurgery—which can lead to pyometra, hence
• Painless abandoned.
• Suitable for local anesthetic 2. Chemical agents were harmful hence dropped.
• Suitable for office use 3. Ionizing radiation—Not used because of many
• Applicable to a wide population. shortcomings, these 3 methods are not used now.

The main selection criteria for ablation are: First generation endometrial ablation techniques: These mostly
use hysteroscope A continued fluid installation is used. In
• The patient should not be desirous of fertility 527
 these methods resection and ablation of the endometrium is 3. Another technique is versapoint system using bipolar
done by electrical endometrial resection. Loop or ablation electrodes. In this saline is used as distending medium,
by roller ball or laser. avoiding ammonia toxicity of glycerine medium.
In transcervical resection of endometrium (TCRE) loop More recently a long hysteroscopic ball electrode has
and roller ball are used through the hysteroscope. been used.
1. The loop (with passage of current) shaves off up to 7 mm 4. ELA—Endometrial laser ablation using Nd: YAG
endometrial strips (resection). Continuous fluid (mostly (Neodymium Yttrium, Aluminium, Garnet ) laser at a power
glycerine) stream flushed off the removed endometrium level of 30–60W. Through the hysteroscope. A conical
and cleared the field for visualization. The endometrium sculptured fiber is used (1 mm laser fiber or 1 mm ball of
is sent for histological examination (Fig. 65.36). sculpted fiber) is used it causes coagulation at 60–70°C and
2. Roller ball endometrial ablation is considered easier. It is photo evaporation at 100°C all these required great skill.
also used through the hysteroscope and the electric
Operation Theater Activities

energy is delivered through a ball electrode instead of Second Generation Methods of Endometrial Ablation
through a loop. This dispenses the current over a wider These were developed to reduce complications and need
area. It is systematically rolled over the entire for lesser skills. They mostly use no distenion media the
endometrium destroying endometrium to 4–5 mm depth. treatment is quicker and local anesthesia suffices.
It can fit in the cornua also. As the endometrium gets Here hysteroscope is not used.
burnt it is not available for histopathological examination
1. Uterine balloon system. It employs a uterine balloon
(Fig. 65.37).
(made of latex or silicon) to expose the endometrium to
A combination of two above methods using ball electrode
85°C–87°C temperature for 10–15 min using the circulation
for the uterine fundus and 2 cornua and loop resection
of hot saline. This is a simple procedure and is done under
for endometrium in remaining uterus is also used.
local anesthesia (Figs 65.38 A to C).
Section 16

Fig. 65.36: Loops for TCRE Fig. 65.37: Roller ball for TCRE

Figs 65.38A to C: Balloon system

528
 2. Circulating hot saline heated to 90°C directly through a
catheter in the uterine cavity.
3. Radio frequency induced endometrial ablation (RAFEA)
is still under assessment. In this technique electromagnetic
waves are used in the electrosurgical device—heat is
generated by the rapidly oscillating charged particles in
tissue directly around the intrauterine abnormality.
Complications encountered in RAFEA:
• VVF burns
• Rectal bleeding
• Interference with anesthetic monitoring
• It is suitable only for regular uterus, which exclude

Chapter 65
many patients.
4. The latest technique microwave ablation (MEA) and is
giving good results. But it is a blind procedure. Microwaes
at 9.2 GHz are used reaching 70°C–80°C.
5. Endometrial cryoablation is improved on now. The device
uses a disposable probe with a surface temperature as
low a minus 100°C to minus 120°C by pressurized gas. It

Minor Procedures
is inserted in the uterus under ultrasound guidance. The
freeze and thaw cycles of 5–7 minutes is used in the
procedure CARMEN is another cryoablative device
under research.
6. Novasure endometrial ablation—The whole uterine Fig. 65.39: NovaSure endometrial ablation
cavity is covered after the electrode array expands to
conform to the contour of each patient’s uterine cavity. A
and death. Young women are more prone as their endogenous
small amount of CO2 is used to assess the cavity integrity.
progesterone inhibits the enzyme Na, K ATPase.
The bipolar radio frequency energy is delivered till the
Hyperosmolarity can cause pulmonary edema.
dessication and coagulation of the endometrium is
Glycerin has the disadvantage of being metabolized into
complete, the electrode array is retracted for easy
ammonia by the liver. Excessive intravasation of glycerin
removal (Figs 65.39 and 65.40).
may lead to hyperammonemia encephalopathy which may
Other methods under research are:
cause transient blindness, muscle aches and memory loss.
7. Endometrial laser interstitial thermal therapy
To prevent all these complication lowest intrauterine
8. Photodynamic therapy
pressure necessary to produce clear fluid of view should be
9. Vestable multi-electrode balloon
used.
10. Hydrothermablator
Prompt recognition and proper treatment of overload is
11. MRI guided focused u/s (MRgFus).
to be done.
Complications are mostly known of the first generation Uterine perforation either by electrode or laser fiber is much
methods. more serious than perforation by mechanical devices.
The complications can be studied by dividing into several (Dilator or curette) because greater damage of the
categories. surrounding structure occurs by thermal energy. Maximum
Media: The potential side effect of fluid absorption with damage can be seen after 2 days –2 weeks. If a perforation
hysteroscopic techniques are ever present and it may lead occurs laparoscopy should be undertaken. If there is
to mild electrolyte disturbance to even pulmonary edema blanching on the serosa of the uterus abdominal exploration
and encephalopathy. should usually be the next step. If the bowel injured bowel
Hyponatremia may cause cerebral edema, leading to resection with adequate margin is needed. Injuries more
increase intracranial pressure, herniation of the brain stem common during learning phase of the surgeon.

Fig. 65.40: NovaSure endometrial ablation in uterus 529

 Hematometra can be prevented by leaving intact the lining
of the isthmus and the endocervical canal.
Air and gas emboli although uncommon, but can occur
whenever uterine vessels are opened during surgery. It can
lead to cardiac arrest.
Anesthesia complications (with IV injection or overdose
of anesthetic drug) include allergy, neurologic effect, impair
myocardial conduction.
Injuries to operating personnel. In TCRE activated loop
may cause burn of surgeon’s glove, if punctured. Nd: YAG
laser necessitates use of laser proof goggles by all the OT
staff otherwise irreversible retinal damage and permanent
Operation Theater Activities

blindness may occur.

Covering of all glass windows with laser proof barrier.
Interlock system that will switch off the laser if any door is
opened.
Special skill is required for these techniques. So training
is important.
Most serious complications happen because of operative
error. Majority are due to inexperience and are usually
avoidable. Injuries are most common during the learning
curve. 55% of uterine perforations occur during the first 15
ablations. Case reports are available describing injuries to
the bladder, bowel and major blood vessels when the learning
Fig. 65.41: Colposcope
physician was not under direct supervision. In expert hands
these injuries are not common. Advantages of Colposcopy: It is a non-invasive, painless,
During postoperative period, operative complications acceptable procedure, guides to locate the site of biopsy,
should be arrived by exclusive diagnosis. Any patient not
Section 16

improves accuracy of early diagnosis, reduces over-

recovering according to the usual pattern, i.e. worsening treatment, avoid over-cut and is a tool of long-term use.
postoperative pain, fever, nausea, distension and free
intraperitoneal air are the signal of bowel injury. Limitations: It is an expensive equipment operated by
Diminished urinary output, fever, distension suggest qualified person, hence training is required. It is difficult to
bladder or ureteral trauma. observe pathological epithelium in the cervical canal and
Falling BP and rapid thready pulse, with or without needs standardization so cannot be used as screening tool.
distension should raise concern of a vascular problem and Precautions: Patient should be advised not to have intercourse
third space hemorrhage. or vaginal douche for last 24 hrs, no vaginal pessary or
Cases involving injury recognized at the time of surgery ointment in preceding two days, urinary bladder should be
and correctly managed in timely fashion do not usually empty for colposcopy and preferable time for procedure is
become medicolegal problems. mid menstrual cycle.
In conclusion I want to say that TCRE and ELA require
Required Instruments, Chemicals and Other Accessories: These
extensive training to reduce the chances of complications.
are examination table, self-retaining vaginal speculum.
MRgFus—[MRI with IV gadolinium on a 1.5T magnet is
Vaginal sidewall retractors, cervical hook, endocervical
kept in position to exclude adenomyosis and other suspicious
retractor (Fig. 65.42), endocervical curette, punch biopsy
lesions. Ultrasound waves are directed to the tissue to cause
forceps, electrosurgical loop/cryoprobe, cotton swabs, Ayre’s
coagulation necrosis.
spatula, endocervical brush, tampons, glass slides, HPV DNA
Colposcopy testing kit and chemicals (Normal saline, 3% and 5% acetic
acid, Lugol’s Iodine, 10% formalin, Cytospray).
Colposcopy consists of examining the illuminated cervix and
lower genital tract at a magnification; intermediate between Method of Colposcopic Examination: Introduce the speculum,
naked eye and light microscopy with an optical instrument Sim’s observe of the color, thickness and status of cervix.
the ‘Colposcope.’ Clean the mucus with normal saline swab to observe the
First account of Colposcopy was published in 1925 by Dr original cervical vessels, pathological area, surface figure
Hans Hinelmann. His original belief was that the earliest and the edge. Put cotton swab dipped in 3% acetic acid for 30
cancer of the cervix must occur as a dot, a minute ulcer or a seconds and observe the color change. Note the color change
tumor which could be recognized by means of suitable
magnification and illumination. For this he designed a
microscope using strong source of light which he called a
colposcope (Fig. 65.41).
Indications for Colposcopy: Common indications of
colposcopy are abnormal Pap smear, unhealthy cervix, H/o
postcoital bleeding, persistent vaginal discharge, localization
of lesion for biopsy in treatment of low as well as high grade
intraepithelial abnormalities), post-treatment follow-up and
HPV positive cases. Fig. 65.42: Endocervical retractor
530
of epithelium after 1–2 mts. Acid response disappears in 3 • Large complex lesion
mts. compare with original image • Wide inter-capillary distance
• Severe changes with canal involvement.
Steps of Colposcopy
Unaided Colposcopy: Pap smear and smear for HPV DNA to Methods of Recording of Colposcopic Findings
be taken first if not taken before. Cervix is cleaned with normal 1. Diagrammatic Representation: Recording of data is essential
saline to make the tissues transparent. Unaided colposcopy for good colposcopy (Fig. 65.43).
first delineates the gross lesions so that vascular details can Hammond’s Graph of Cervix: The whole cervix is divided into
be made out. Documentation by diagram and photography 4 circular divisions A, B, C and D and 12 equal parts in
in a prescribed form is to be done at this stage. Intercapillary clockwise fashion. In this graph colposcopic finding can be
distance is measured by micrometer or after taking simply drawn on the graph. Diagnosis and specific lesion
colpophotograph at 8X.

Chapter 65
can be designated by checking the appropriate square.
Inspection through Green Filter helps in studying angio- Odell’s Diagram: Exact sites of biopsy to be marked.
architecture.
Colpo-photography
Inspection following Application of 3% Acetic Acid: Acetic acid
is applied on the cervix by a cotton swab for better Colposcopic Classification (IFCPC 1990): International
visualization of glandular mucosa and metaplastic epithelium Federaion of Cervical Pathology and Colposcopy.
which makes metaplastic, dysplastic and malignant changes Normal Coloposcopic Findings
in glandular mucosa and pathological squamous epithelium

Minor Procedures
• Original squamous epithelium (OSE)
white. It is mucolytic and produces surface changes because
• Columnar epithelium (CE)
of coagulation of cell protein after an interval of one minute.
• Transformation zone (TZ).
The action of acetic acid fades away in 1–2 minutes, so
repeated application may be necessary for the proper Abnormal Colposcopic Findings
visualization and detection of pathological lesions. Within and outside the transformation zone (e.g. ectocervix,
Inspection following Lugol’s Iodine: Lugol’s Iodine is made vagina), Acetowhite epithelium appears flat, micropapillary
up of potassium iodide 4 gms. Crystalline iodine 2 gms and or micro convoluted.
distilled water 100 ml. when applied over the cervix and • Punctation
vagina with the help of a cotton swab, it stains the glycogen • Mosiac
mahogany brown. Staining is superficial and fades off in • Leukoplakia
8–10 minutes. Iodine does not stain columnar epithelium, • Iodine negative epithelium
immature metaplastic epithelium, regenerating squamous • Atypical vessels.
epithelium after surgical trauma, intra-epithelial neoplasia Suspect Invasive Cancer
and invasive carcinoma, as these do not contain glycogen.
Unsatisfactory Colposcopy
Few colposcopists do not consider iodine application, an
• Squamocolumnar junction not visible
essential step in colposcopy, as it destroys all the minute
• Severe inflammation or severe atrophy
details that are necessary for precise diagnosis. It also
• Cervix not visible.
interferes in picking up the abnormal areas within a lesion
requiring biopsy. Miscellaneous Findings
• Non-acetowhite micropapillary surface
Examination of vagina: While withdrawing the speculum, the
• Exophytic condyloma
vault of vagina should be carefully examined for evidence of
• Inflammation
vaginitis, leukoplakia and any growth.
• Atrophy
Colpophotography: Documentation of lesions is necessary • Ulcer
for precise case recording, serial follow-up, comparison and • Other.
consultative reports, demonstration and teaching purpose
and for publication and research. Colposcopy of Premalignant and Malignant Lesions of Cervix
Colposcopically Directed Biopsy: Cervical punch biopsy is Premalignant Lesions of Cervix: Neoplastic lesions are
taken from the areas of maximum abnormalities and is sent multifocal, appear in Transformation Zone (TZ) usually.
for histopathological examination. Colposcopy is useful in achieving directed biopsies from
abnormal area and histopathological provides final diagnoses.
Grading of Colposcopic Findings
Grade I: Flat, acetowhite epithelium, regular pattern of fine
caliber vessels CIN 1 , HPV.
Grade II: Flat but whiter acetowhite epithelium, irregular
pattern of vessels often coarse. Can be seen from CIN I to
carcinoma-in situ.
Grade III: Acetowhite epithelium with irregular surface contour
and irregular coarse and coiled vessels. These generally
indicate carcinoma-in situ or early invasive carcinoma.

Colposcopic Features Suggestive of Invasion

• Atypical vessels
• Irregular, raised nodular surface Fig. 65.43: Graphic record of cervical lesion 531
 Features of acetowhite epithelium assessed in colposcopic grading: 4. Barbara F Atkinson. Atlas of Diagnostic Cytopathology.
These include maximum whiteness reached, rapidity of 5. Burghardt E, Pickel H, Girardi F. Colposcopy—Cervical
development of maximum whiteness, length of retention of Pathology. Textbook and atlas. New York: Thieme; 1998.pp.
203-16.
whiteness and sharpness of outline.
6. Campion MJ, Sedlacek TV. Colposcopy in pregnancy. Obstet
Differential Diagnosis of Acetowhite Epithelium Gynecol Clin North Am 1993;20(1):153-63.
7. Copper KG, Parkin DE, Garratt AM, et al. A randomised
• Cervical intraepithelial neoplasia (CIN) comparison of medical and hysteroscopic management in women,
• Human papilloma virus (HPV) infection consulting a gynaecologist for treatment of heavy menstrual
• Combined CIN and HPV loss. Br J obstet Gynecol 1997;104:1350.
• Immature squamous metaplasia 8. Duleba AJ, Heppard MC, Soderstrom RM, et al. A randomized
• Healing/regenerating epithelium study comparing endometrial cyroablation and rollerball
• Congenital transformation zone electroablation for treatment of dysfunctional uterine bleeding. J
Operation Theater Activities

• Inflammation Am Assoc Gynecol Laparose 2003;10:17-26.

9. Gallinat A: An impedance controlled system for Endocrine
• Adenocarcinoma, CGIN (Cervical glandular intraepithelial
ablation. Five-Year follow-up of 107 patients. J Reprod Med
neoplasia) 2007;52(6):467.
• Invasive squamous cell carcinoma. 10. Gu M, Lin F. Efficacy of cone biopsy of the uterine cervix during
Vascular pattern seen in abnormal epithelium: These can be frozen section for evaluation of cervical intraepithelial neoplasm
punctations, mosaics (fine or coarse) and atypical vessels Grade e. Am J clin. Patholol 2004;122:383.
11. Gu M, Lin F. Efficacy of cone biopsy of the uterine cervix during
which can be corkscrew, irregular caliber, irregular branching.
frozen section for the evaluation of cervical intraepithelial
Other features of abnormal epithelium: neoplasm gr 3. Am J Clin Pathol 2004;122:383.
12. Lipscomb GH, Roberts RA, Givens VM, et al. A trial that compares
Intercapillary distance: In normal cases it is 50–200 microns, Monsel’s paste with ball electrode for hemostasis after loop
average being 100 microns. Value of 200 is Abnormal and electrosurgical excision procedure Am J Obstet Gynecol
450–500 microns is diagnostic of CIN-3. 2006;194:1591.
Color tone: Abnormal epithelium appears much darker, 13. Lipscomb GH, Roberts RA, Givens VM, et al. A trial that compares
there are sharp line of demarcation and after acetic acid Monsel’s paste with ball electrode for hemostasis after loop
application abnormal epithelium appears very white. electrosurgical excision procedure. Am J Obstet Gynecol
Surface contour: Uneven, raised and exophytic growth 2006;194:1591.
Section 16

14. Nichols CM, Gill EJ. Thermal ballon endometrial ablation for
pattern.
management of acute uterine haemorrhage. Obstet Gynecol
To conclude colposcopy is a great asset in diagnosing 2002;100:1092.
preinvasive lesions in hands of trained gynecologist. 15. Overton C, Hargreaves J, Maresh M. A national survey of the
complications of endometrial destruction for menstrual disorders:
BIBLIOGRAPHY the MISTLETOE study J Obstet Gynecol 1997;104:1351.
1. A simplified and cost-effective approach. J Lower Genital tract 16. Wright Jr TC, Cox JT, Massad LS, Twiggs LB, Wilkinson EJ,
Dis 1998;2(2):67-70. for the 2001 ASCCP-sponsored Consensus Conference.
2. Baldauf J, Dreyfus M, Ritter J. Benefits and risks of directed biopsy Consensus Guidelines for the Management of Women with
in pregnancy. J Lower Genital Tract Dis 1997;1(4):214-20. Cervical Cytological Abnormalities and Cervical Cancer
3. Barbara S Apgar, Gregory L Brotzman, Mark Spitzer. Precursors. Part I: Cytological abnormalities. JAMA 2002;
Colposcopy – Principles and Practice 2002. 287(18):2120-9.

532
 Section 17 Major Operation

66 Perineal Tears

Sunita Singhal, Sudha Salhan

INTRODUCTION – 3a: Less than 50% of External Anal Sphincter

The overall risk of obstetric anal sphincter injury is 1% of all (EAS)thickness torn (Fig. 66.1)
vaginal deliveries. Obstetric perineals depending on their – 3b: More than 50% of EAS thickness torn
depth lacerations are classified as first to fourth degree. A – 3c: Both EAS and Internal Anal Sphincter (IAS) torn
rectal examination is helpful in determining the extent of (Figs 66.2 to 66.4)
injury and ensuring that a third- or fourth-degree laceration • Fourth degree: Injury to perineum involving the anal
is not overlooked. sphincter complex (EAS and IAS) and anal mucosa
• If there is any doubt about the grade of third-degree
PREDISPOSING FACTORS tear, it is advisable to classify it to the higher degree
Risk factors for perineal-degree tears have been identified rather than lower degree.
in a number of retrospective studies. Taking an overall risk of
1% of vaginal deliveries, the following factors are associated REPAIR OF FIRST AND SECOND DEGREE TEARS
with an increased risk of a perineal tear in big babies (>4 kg), All women having a vaginal delivery with evidence of genital
primi pt. face or tract trauma should be examined systematically to assess
• birth weight over 4 kg the severity of damage before attempting to suture.
• persistent occipitoposterior position Repair of the tear should be done in and by proper
• epidural analgesia visualization in good light, requisite surgical instruments and
• prolonged second stage suture material should be available, Adequate analgesia
• shoulder dystocia should be used.
• midline episiotomy • Many first degree tears may close spontaneously. Before
• instrumental delivery. suturing explain the need for procedure to the woman
and obtain necessary consent. Place the patient in a
CLASSIFICATION lithotomy position. Apply antiseptic solution to area
The following classification, described by Sultan, has been around the tear. Local infiltration with lignocaine should
adopted by many be done beneath the vaginal mucosa, the skin of the
• First degree: Injury to perineal skin,vaginal mucosa and perineum and deeply into the perineal muscle using about
connective tissue. 10 ml 0.5% lignocaine solution : Ensure that no vessel has
• Second degree: Injury to perineum involving vaginal been penetrated. Pudendal block may also be used. By
mucosa, connective tissue and perineal muscles but not placing a gloved finger in the anus and gently lift the
involving the anal sphincter. finger and identify the sphincter. If the sphincter is not
• Third degree: Injury to perineum involving the anal injured, proceed with repair.
sphincter complex, i.e. complete transaction of oval Repair the vaginal mucosa using a continuous unlocked 2–0
sphincter or 3–0 polyglactin 910 suture.

Fig. 66.1: Perineal tear 3C Fig. 66.2: Perineal tear 3C

Major Operation

Fig. 66.3: Perineal tear 3C Fig. 66.4: Perineal tear 3C

Start the repair about 1 cm beyond the apex of the vaginal superficial perineal muscles is recommended to prevent
tear. Continue the suture to the level of the mucocutaneous knot migration to the skin.
junction at the opening of the vagina, bring together the cut • Women should be warned of the possibility of knot
Section 17

edges of the vaginal opening. migration to the perineal surface, with long-acting and
If the apex is too far into the vagina to be seen, the non-absorbable suture materials.
anchoring suture is placed at the most distally visible area of
laceration, and traction is applied on the suture to bring the TECHNIQUE
apex into view. The running suture can be locked for Two methods are used overlap method or end to end method.
hemostasis, if needed. Currently, there is no evidence to show that overlap
Next the perineal muscles are sutured using interrupted method is superior to end to end method (Fig. 66.5).
2–0 suture. If the tear is deep, a second layer stitcing is done. For repair of the external anal sphincter, either an
Repair of the skin may be done either by using interrupted overlapping or end-to-end (approximation) method can be
of suturing may be required or subcuticular 2–0 sutures used, with equivalent outcome. Where the IAS can be
starting above downwards. identified, it is advisable to repair separately with interrupted
Finally, perform a rectal examination to ensure that no sutures.
stitches are in the rectum. Repair of a fourth-degree laceration requires approxi-
mation of the rectal mucosa, internal anal sphincter, and
THE MANAGEMENT OF THIRD- AND external anal sphincter.
FOURTH-DEGREE PERINEAL TEARS The apex of the rectal mucosa is identified, (Fig. 66.6) and
The incidence may vary from 0.6–0.9% of vaginal deliveries the mucosa is approximated using closely spaced interrupted
where mediolateral episiotomy is given. Occult damage to or running 3–0 or 4–0 polyglactin 910 sutures. Traditional
anal sphincter anatomy as identified to endoanal USG, may recommendations emphasize that sutures should not
occur in up to 36% of after vaginal delivery. penetrate the complete thickness of the mucosa into the
Repair of third- and fourth-degree tears should be anal canal, to avoid promoting fistula formation. The sutures
conducted in an operating theater, under regional or general are continued to the anal verge (i.e., onto the perineal skin).
anesthesia. The internal anal sphincter is identified as a glistening, white,
The 3rd or fourth degree tear repair should be performed fibrous structure between the rectal mucosa and the external
by experience obstetrical preferably be done in OT with anal sphincter (Fig. 66.7). The sphincter may be retracted
aseptic precautions under General or Regional anesthesia.
Repair in an operating theater will allow the repair to be
performed under aseptic conditions with appropriate
instruments, adequate light and an assistant. Regional or
general anesthesia will allow the anal sphincter to relax,
which is essential to retrieve the retracted torn ends of the
anal sphincter. This also allows the ends of the sphincter to
be brought together without any tension.
Choice of suture materials
• When repair of the EAS muscle is being performed, either
monofilament sutures such as polydiaxanone (PDS) or
modern braided sutures such as polyglactin (Vicryl®)
can be used with equivalent outcome.
• When repair of the IAS muscle is being performed, fine
suture size such as 3–0 PDS and 2–0 Vicryl may cause
less irritation and discomfort.
• When obstetric anal sphincter repairs are being
534 performed, burying of surgical knots beneath the Fig. 66.5: Repair of perineal tear
 Chapter 66
Fig. 66.6: Perineal tear repair Fig. 66.8: Complete repair of perineal tear

Perineal Tears
exercises for 6–12 weeks after obstetric anal sphincter
repair.
• All women who have had obstetric anal sphincter repair
should be reviewed 6–12 weeks postpartum by a
consultant obstetrician and gynecologist.
• If a woman is experiencing incontinence or pain at follow-
up, referral to a specialist gynecologist. If a woman is
experiencing incontinence or pain at follow-up, referral
to a specialist gynecologist or colorectal surgeon for
endoanal ultrasonography and anorectal manometry
should be considered. A small number of women may
require referral to a colorectal surgeon for consideration
of secondary sphincter repair.

CONSEQUENCES OF PERINEAL TRAUMA

Women should be advised that the prognosis following EAS
Fig. 66.7: Stitching of sphincter
repair is good, with 60–80% asymptomatic at 12 months.
laterally, and placement of Allis clamps on the muscle ends Women who are remain symptomatic describe incontinence
facilitates repair. The internal anal sphincter is closed with of flatus or fecal urgency. If available, endoanal USG and
continuous 2–0 polyglactin 910 sutures. anorectal manometry may be performed to assess the
The external anal sphincter appears as a band of skeletal residual damage.
muscle with a fibrous capsule. Traditionally, an end-to-end Trials have reported fewer residual defects, abou
technique is used to bring the ends of the sphincter together 19–36% overall. The clinical relevance of asymptomatic
at each quadrant (12, 3, 6, and 9 o’clock) using interrupted defects demonstrated by ultrasound is currently unclear.
sutures placed through the capsule and muscle. Allis clamps
are placed on each end of the external anal sphincter. We FUTURE DELIVERIES
use 2–0 polydioxanone sulfate (PDS), a delayed absorbable • All women who sustained an obstetric anal sphincter
monofilament suture, to allow the sphincter ends adequate injury in a previous pregnancy 17–24% risk of developing
time to scar together. Recent evidence suggests that end-to- anal incontinence or worsening symptoms with
end repairs have poorer anatomic and functional outcomes subsequent vaginal delivery.
than was previously believed (Fig. 66.8). • All women who have sustained an obstetric anal
An alternative technique is overlapping repair of the external sphincter injury in a previous pregnancy.
anal sphincter. Colorectal surgeons prefer to use this method • There is no evidence to support the role of prophylactic
when they repair the sphincter remote from delivery. episiotomy in subsequent pregnancies.
The perineal muscles, vaginal mucosa, and skin are
repaired using the same techniques described for the repair DELAYED MANAGEMENT
of second-degree lacerations. If women report late, for repair, i.e. beyond 12 hrs, then
delayed primary closure is indicated.
POSTOPERATIVE MANAGEMENT 1 and 2 tears, may be left open 3 and 4 close the rectal
• Analgesics for 24 hrs mucosa with some supporting tissue and approximate the
• The use of broad-spectrum antibiotics is recommended. fascia of anal sphincter with 2 or 3 sutures close the muscle
• The use of postoperative stool softeners and laxatives and vaginal mucosa and perineal skin 6 days later.
like lactulose is recommended to reduce the incidence of In 3rd and fourth degree tear fecal incontinence may
postoperative wound dehiscence for about 7–10 days. result. But many women can develop control of defecation
• Indwelling catheter is generally required for all women. by using other perineal muscles. If incontinence persists,
Physiotherapy should be offered and pelvic-floor reconstructive surgery should be undertaken 3 months after 535
 delivery. Rectovaginal fistula, also requires reconstructive Adequate removal of scar tissue, hence freshening of the
surgery after 3 months. area.
Preoperative preparations is very important correction of
Old Complete Perineal Tear anemia and treatment of infection, should be done.
Is unhealed third degree (complete) obstetrical tear, which Bowel preparation: Fluid and non-residue diet, should be
involves skin, perineal muscle and anal sphincter. It results started 5 days before surgery. Intestinal antiseptics
from non-sutured or non-healed third degree perineal (Neomycin, Metronidazole) may be used 48 hrs prior to
tear. operation. Daily cleansing enema repeated in the morning of
While taking history try to assess the severity of operation. Only liquids 48 hrs prior to surgery. Some surgeons
incontinence by assessment of frequency consistency of prefer to give oral peglec or colowash the night before.
stool and whether it is gas, liquid or solid. Sometimes, there Operation: The most commonly used operation is layered
may be inability to control rectal gas or feces especially repair (Lawson-Tait operation) an H-shaped incision is given
Major Operation

when liquid or flatus only (levator ani act as sphincter, chronic in the skin, with horizontal limb of the H—at the junction of
diarrhea may occur. Inspection will reveal that the perineal the rectum with the vagina and the 2 vertical limbs at the site
body is absent in its lower part and the vaginal epithelium is of the 2 dimples The old dimples are torn, ends of sphincter
continuous with the anal mucosa which is bright red and of which are identified and stay sutures are placed. Dissection
appear in the lower end of the defect. The external anal of the vagina from the rectum is done upward and lateral to
sphincter is only present posteriorly and as indicated by expose the structures of the perineal body.
wrinkling of skin. Gaping anus indicates major defect in the Rectal anal mucosa is closed followed by prerectal fascia
anal sphincter. The torn ends of the retracted sphincter are and then external and sphincter, is sutured. It is then covered
marked by dimple on each side. Perform a rectal examination with levator ani and perineal muscles sutures. Vaginal
by introducing your finger in the anal canal and asking the mucosa is then closed and final perineal skin is approximated.
Section 17

patient to hold herself (contract her pelvic floor muscles) to Vaginal pack is required.
confirm absence of sphincteric control. Postoperative care: Antibiotics are given usually. Clear liquid
The following are fundamental principles essential for or non-residue diet and intestinal antiseptic continued for 3 days.
successful repair. There should be evidence of good blood Removal of the pack after 24 hours. Wash the vulva after
supply to the area. There should be no infection in the tissue. every micturition with antiseptic then dried. Laxatives/stool
Closure of repair should performed without any tension. softners are continued for 7–10 days.

536
 67 Endoscopy in Gynecology

Rahul Manchanda

ENDOSCOPY In 1947, Raoul Palmer of France used the lithotomy

Endoscopy is the examination of the interior of a canal or position and created gaseous distension. He also used a
hollow viscous generally done with a specialized instrument uterine cannula to elevate the uterus.
called an endoscope. Breakthroughs in endoscopy came by introduction of the
Enormous technical advances have taken place since cold light concept by Fourestier, Gladu and Valmiere and
the idea of using reflecting light in deeper body cavities for fibreoptics by Kampany and Hopkins.
diagnostic purpose was first conceived and these have led The works and writings of Palmer (1962), Semm of
to perfection of modern endoscopic techniques. Depending Germany (1974), Gomel (1977) attested to the successful use
on the organ or cavity being visualized, endoscopy might be of laparoscopy as a diagnostic and surgical procedure.
of various types.
Gastroscopy (Stomach), Colonoscopy (Colon), Cystoscopy INTRODUCTION
(Urinary bladder), Laparoscopy, Koloskopie, coelioscopy Laparoscopy is a minimal access procedure allowing
(Abdominal Cavity), Hysteroscopy (uterus), etc. peritoneal visualization, performed through a range of
The introduction of endoscopy in Gynecology has endoscopes to minimize the anatomical and physiological
produced dramatic changes in clinical practice. It is trauma to the patient.
immensely gratifying to know that gynecologists were first The advantages of laparoscopy from an open surgery
practitioners to take advantage of the introduction of cold are—small incision, excellent visualization of operative site,
light systems and the development by Prof H Hopkins of the reduced postoperative pain, shorter hospital stay, early return
rod lens system in 1954. No longer is the diagnosis of pelvic to full activity, cosmetic advantages, less wound complications.
disease dependent on signs and symptoms, limited bio- The disadvantages are—difficulty in stopping bleeding,
chemical investigations and often a laparotomy of uncertain longer operative time, danger of visceral and vascular injury,
value. expensive, specialized equipment, technically difficult and
Laparoscopy is essentially the inspection of the abdominal special training required.
cavity and the pelvic organs by means of a lensed instrument.
It has been known by different names: Koloskopie (Kelling INSTRUMENTS
1901), Ventroscopy (Ott, 1902), Laparothorakoskopie) Laparoscopes
( acobaeus 1910), Organoscopy (Bernheim 1911), The two types of laparoscopes available are—diagnostic and
Peritoneoscopy (Orndoff, 1920), Abdominoscopy (Steiner, operative. They come in variety of sizes from small (5–7
1924) and Lacoelioscopy Gynecologique (Palmer 1947). The mm) to large (8–11 mm).
confusion in nomenclature is illustrated by Frangenheim, Diagnostic laparoscopes are available with different
who refers to the technique as koloskopie, coelioscopie, angles of view, either straight-forward or fore-oblique (45°),
laparoscopy, and peritonioscopy in various publications. the selection being the surgeon’s choice but straight forward
Gynecologic endoscopy refers to the application of this requires less adjustment.
technique for the diagnosis of obscure pelvic diseases in the The degree of magnification varies with the distance of
age of consumer driven medical advances. the laparoscope from the object.

LAPAROSCOPY Pneumoperitoneal Needle and Trocar (Fig. 67.1)

Pneumoperitoneal needle allows the passage of carbon
HISTORY
dioxide after it has pierced the abdominal wall. The two
Laparoscopy also known as peritoneoscopy or coelioscopy needles available are—Touhy and Veress needle, the latter
has seen lot of advancement since the latter part of the one being commonly used.
Twentieth century. Veress needle was designed to reduce the chances of
Earlier between 1910 and 1940, laparoscopy was mainly accidental puncture. It has a spring that allows retraction of
done by physicians. the blunt inner point as it traverses the abdominal wall but
In 1910, acobeus of Sweden induced a pneumoperit- springs out to protect the intra-abdominal structures when it
oneum and introduced a Nitze cystoscope into the peritoneal encounters the decreased pressure of the abdominal cavity.
cavity. In the early 1930s, Kalk of Germany was principally Trocar is available in two models-flapper valve-allowing
responsible for developing laparoscopy into an effective insertion of laparoscope and other instruments without loss
diagnostic and surgical procedure. of gas and trumpet valve-the more traditional one.
 Ancillary Instruments (Figs 67.3 and 67.4)
Probes
Simplest and commonly used is the blunt probe for
visualization and manipulation of the structures. It’s also
used to stabilize the structures atraumatically.
Forceps
Atraumatic grasping tongs and forceps
Large spoon forceps
Large claw or toothed forceps
Punch biopsy forceps.
Major Operation

Scissors
Scissors are commonly used and come in many designs that
include toothed, serrated, micro and hooked.
Fig. 67.1: Pneumoperitoneal needle and trocar Hook scissors are typically used for large tissue
dissection, micro scissors for fine dissection. Serrated
The trocar tip may be pyramidal or cone-shaped, but its
scissors are not used, as they tend to chew through tissues.
important that it should be sharp.
Trocar can be inserted after pneumoperitoneum is Aspirators/Irrigators
created or without insufflation. The latter requires great Aspiration can be regulated mechanically by suction devices
expertise and should be carried out by only skilled and or manually with a large syringe.
trained surgeons.
Section 17

Combined aspiration/irrigation units are available which

make the procedure simple and quick especially in cases of
Gas Insufflators
ectopic pregnancies.
A gas insufflator is used to produce controlled
pneumoperitoneum. The low flow produce is 0.5–1.0 l/min. Morcellators
Laparoscopic procedures are possible only if adequate Morcellation is commonly performed during myomectomy,
pneumoperitoneum is maintained despite multiple oophorectomy, salpingectomy and removal of gestational
instrument changes, multiple puncture site and irrigation. tissue following conservative endoscopic surgery for ectopic
Therefore, its imperative for a high flow insufflator which pregnancy. Pieces of tissue too large to be removed intact
produces at least 4–5 L/min or more. The intraperitoneal from the pelvis may be cut into smaller pieces and removed
pressure is 15–20 mm Hg not more than 25 mm Hg. through the laparoscopic sleeve.

Gas
Carbon dioxide is the commonly used gas as it is absorbed
by the blood stream and excreted by the lungs. The safe
absorption rate is 100 ml/min but if it exceeds can develop
cardiac arrhythmias.
Nitrous oxide can also be used as it causes less peritoneal
irritation and is well-absorbed but the disadvantage is
supports combustion in the presence of methane gas, which
escapes if the bowel is breached.

Lighting
Adequate visualization depends on the quality and power of
light delivered.
The beam of light used is xenon which is transmitted
through fibreoptic cables (Fig. 67.2).
Fig. 67.3: Ancillary instrument of laparoscopy

538 Fig. 67.2: Cable for light source Fig. 67.4: Ancillary laparoscopic instruments
Hemostatic Instruments Anesthesia
The ability to achieve hemostasis depends on instrument The patient is anesthetized using muscle relaxant,
availability, type of proposed surgical procedure and endotracheal intubation and positive respiration. General
physician preference. anesthesia is used.
Electrocoagulation Technique
The modern generators are low voltage, high frequency, Patient is placed in a modified lithotomy position with her
and solid-state units with insulated circuitry. Both unipolar legs flexed to 45° and a Trendelenburg tilt of 15°. A steeper
and bipolar modes are available. tilt may be necessary if loops of bowel prevent easy access
In a unipolar system, the current passes from the of the pelvis. Surgeon cleans abdomen with antiseptic
generator through the instrument to a ground plate and then solution. The assistant cleans the vulva and vagina, bladder
back to the generator. Many instruments can be combined is emptied and a cervical tenaculum is applied to manipulate

Chapter 67
with unipolar electrocautery-scissors, scalpels, point uterus and give surgeon an adequate view.
coagulators. The Veress needle is inserted through umbilicus, because
There is a lateral spread of the current resulting in tissue at this point the thickness of abdomen wall is minimal and
necrosis at a distant site. Tissue damage can be seen 3–4 cm peritoneum is closely adherent to the underlying tissue. It
away from the area of coagulation. inserted into the skin at almost right angles for about a
The bipolar system uses the two insulated jaws of the centimeter before changing the direction to about 45° towards
instrument to carry the current to and from the generator. the anterior part of the pelvis. The position of needle within

Endoscopy in Gynecology
The tissue between the jaw completes the circuit and the the abdominal cavity is checked by aspiration test. Normal
tissue is heated (coagulated) by passage of the current. saline is injected through the needle and then aspirated. If
Bipolar can be dispensed in both a cutting and coagulating the needle lies in the peritoneal cavity, no fluid is withdrawn.
mode. Peripheral damage with bipolar is less extensive than If the needle lies in the abdominal wall clear fluid is withdrawn,
with unipolar. Nevertheless, there is approximately 1–2 cm but if it is in bowel or a blood vessel, the aspirate will be
of coagulation damage around the point coagulated. stained brown or red and the surgeon must decide whether
Thermocoagulation or not to proceed with laparoscopy. With experience the
free side to side mobility of the end of the needle in the
The system coagulates tissue by increasing the temperature
peritoneal cavity is quite characteristic.
through heat convection.
Pneumoperitoneum is produced by insufflating 1–2 liters
Electricity is used to heat the metal inside the instrument
of CO 2/min. When the gas is flowing freely and intra-
that delivers the heat.
abdominal pressure is normal ( 25 mm Hg), the rate of flow
Hemostasis is achieved by heating the tissue to 100–120°C
can be increased to 4–5 liters/min.
as the temperature in the tissue rises slowly; a color change
An incision of 5–1.0 cm in length, depending upon the
to white is seen. It is thought that the denaturing of proteins
diameter of laparoscope, is made downwards from the
and desiccation cause coagulation. Penetrating injury is not
deepest point of the umbilicus and trocar is inserted using
possible but superficial damage is possible.
zig zag path to prevent herniation of omentum. The
Laser abdominal wall is held with the other hand to avoid damage
The laser is a device that produces and amplifies light, to bowel by trocar.
creating intense, coherent electromagnetic energy. A telescope is now inserted and abdominal cavity is
The major types of lasers used are CO 2 , argon, inspected. Second port is made under direct vision, the
532 nm potassium-titanyl-phosphate-garnet (Nd: AG) laser. second trocar is inserted. Most commonly used instruments
The power density determines the laser’s ability to vaporize, are 5 or 7 mm in diameters. Suprapubic sites of access are
excise and coagulate various tissues. The ability of the target the corner stones of accurate visualization and precise
tissue to absorb the beam determines the area of surgery. The trocars are inserted on left and right side
destruction. This restricts the damage to healthy tissue in abdominal wall.
the vicinity of the impact by limiting the time of exposure of At the end of the procedure as much gas as possible is
the beam. expelled through the cannula by pressure on the abdomen
CO2 laser is the most commonly used. The CO 2 has the and clips or sutures are applied to the puncture wounds.
ability to seal off blood flow in vessels up to 0.5 to 2.0 mm.
Indications
Suture The indications of laparoscopy may be considered as either
Suturing has added a new dimension to operative Diagnostic or Operative.
laparoscopy.
Roeder loop is used. Suturing can also be performed Diagnostic Laparoscopy
with a straight needle. A 3 or 5 mm needle holder with a Infertility
spring to keep needle in place is used. Laparoscopy can reveal peritubal adhesions not detected
Staples by HSG. Chromotubation is a part of diagnostic laparoscopy
for infertility evaluation to determine tubal patency (Figs
Staples may be used for large vessel hemostasis. They may
67.5 and 67.6).
be either applied as single clips, which are usually mounted
in a clip applicator, which has a stack of 20 clips available. Its Endometriosis
necessary to skeletonize the vessels before using these clips. Laparoscopy helps to identify the degree or extent of
There are also available laparoscopic staplers which place endometriosis allowing selection of the treatment and also
rows of titanium staples and simultaneously divide the pelvic adhesions (Fig. 67.7).
clamped tissue 539
 Ovulation
Presence of corpus luteum in the ovary during mid cycle
confirms ovulation.

Chronic Pelvic Pain

In patients complaining of chronic pelvic pain not responding
to therapeutic measures laparoscopy is indicated. Often
unsuspected pathologies get revealed like adhesions, tubal
hydrosalpinx, endometriosis, and pelvic congestion. Even
negative finding is valuable to reassure that there is no pelvic
pathology.
Major Operation

Ovarian Disorders
Most reproductive endocrine disorders do not need
laparoscopy. However, polycystic ovarian disease (Fig. 67.8)
not responding to conservative treatment, laparoscopy may
be useful to confirm diagnosis. The operation of ovarian
drilling is performed for improving ovulation induction and
other symptoms of PCODs. Ovarian cysts are removed (Figs
Fig. 67.5: Chromotubation 67.9 to 67.11).
Section 17

Fig. 67.6: Dye in POD Fig. 67.8: Polycystic ovary

540 Fig. 67.7: Endometriosis Fig. 67.9: Ovarian cyst

 Chapter 67
Fig. 67.10: Left functional ovarian cyst

Endoscopy in Gynecology
Fig. 67.11: Ovarian cyst Figs 67.12A and B: (A) Tubal ectopic; (B) Cornual ectopic

Suspected Adnexal Masses Inspection of Pouch of Douglas

Suspected ectopic pregnancy. Often endometriosis is present in this site, so also adhesions
In a patient with abdominal pain and a positive pregnancy to the rectum present. POD can be the site of pelvic abscess.
test, a laparoscope can detect tubal pregnancy even before
Biopsies
it has ruptured (Figs 67.12 A and B).
Operative laparoscopy.
Pelvic Inflammatory Disease and Tuberculosis
Adhesiolysis
In case of PID diagnosis can be confirmed on laparoscopy in
most of cases. Peritoneal fluid or pus can be obtained for Adhesiolysis is sometimes used to obtain correct diagnosis
culture. and help to free out the pelvic organs to correct the anatomy.

Missing IUD Laparoscopic Myomectomy

A missing IUD which escapes into the peritoneal cavity, can Myomectomy is best planned for the younger women
be often retrieved successfully at laparoscopy. desirous of preserving their reproductive function (Figs 67.13
and 67.14).
Pelvic Malignancy
Laparoscopic Assisted Vaginal Hysterectomy (LAVH)
In case of pelvic malignancies like ovarian malignancy, a
laparoscopy is useful in staging and a biopsy from an effected LAVH is performed in benign conditions (myomas, adeno-
area to confirm the type of tumor. Second look. myosis, and chronic Mennorrhagia and DUB, in situ cancer
Laparoscopy is helpful in assessing the presence of of cervix) (Fig. 67.15).
residual tumor. Laparoscopic Sterilization
Uterine Abnormalities Laparoscopic sterilization is the most frequently performed
Laparoscopy reveals uterine abnormalities like– endoscopic procedure.
The presence of Mullerian anomalies like absent uterus, Coagulation: In this method the tubes are identified, and
bicornuate uterus or presence of rudimentary horn. different types of electrocoagulation methods are used like
An enlarged uterus due to fibromyomas or adenomyosis. monopolar, bipolar or thermo-coagulation. The electricity or
Adhesions to uterus and its retroverted fixity. heat is passed through the tube until it bubbles and collapse. 541
 forceps, loop and scissors and therefore is not widely
practiced.
Other indications are:
• Genital prolapse
• Stress urinary incontinence
• Pelvic floor repair
• Dysmenorrhea.
Second look laparoscopy
• Second look laparoscopy helps us to know about the effect
of treatment given for pelvic malignancies and other
pathologies. Second look is the ideal to complete
Major Operation

reconstruction of various abnormalities.

Contraindications
Absolute Bowel obstruction, ileus, peritonitis, intraperitoneal
hemorrhage, diaphragmatic hernia and severe cardiovascular
Fig. 67.13: Laparoscopic view of fibroid uterus disease.
elative Extremes of body weight, inflammatory bowel
disease, the presence of a large abdominal mass and
advanced intrauterine pregnancy.
Section 17

Complications
For a long time, laparoscopy was considered a dangerous
procedure.
Complications can be divided into few major categories:
• Anesthesia related
• Trocar related
• Procedure related
• Instrument related
• Positioning related.
Anesthesia Related Complication
Possible intoxication from absorption of CO 2 gas. Extreme
Trendelenburg and increasing intra-abdominal pressure
Fig. 67.14: Posterior wall fibroid being removed with harmonic scalpel
during laparoscopy may compromise patient.
Trocar Related Injuries
The most common of all the complications in laparoscopy,
has been responsible for more deaths and injuries than
any other category. Injury to major vessels is a real risk at
the insertion of access instruments like Veress needle and
trocars. Types on injuries caused by trocar insertion is as
follows:
Unrecognized bowel injury.
Aorta, inferior vena cava, mesenteric vessel, iliac artery
and vein, gastroduodenal artery, hypogastric artery, omentum
vessel, portal vein.
Procedure Related
Injuries during the surgical maneuvers are also common.
The bladder could be injured during the dissection from
the pubocervical fascia.
Fig. 67.15: Left ovarian ligament being cut during total hysterectomy
Cesarean section and endometriosis could increase
likelihood of this complication.
Injury of small bowel, colonic laceration may occur during
It can then be divided by advancing the sheath of forceps so dissection of adhesions.
that the cutting edge transects the tube or it can be cut with Furthermore, electrosurgery or laser may create
hook scissors. unrecognized thermal lesion which becomes apparent after
Mechanical blockage: In this method the tubes are 48–72 hours with peritonitis. When frank bowel perforation is
clamped with different types of clips or rings. The most present, laparotomy is indicated.
commonly used is falope ring.
Ligation: Sterilization may be achieved by laparoscopic Instrument Related
ligation of tube, a slipknot applied on the tube. This operation Improper use of electrosurgery during a procedure,
involves a three-puncture technique to allow application of unfamiliarity with equipment, and the use of incompatible
542
components contributes to the many injuries. Accidental Surrounding the optics are numerous small diameter
burns of bowel and bladder. incoherent fibreoptic bundles that provide intense cold light
to the operative field.
Patient Related
The use of the video camera attached to the eyepiece
Obesity, chronic obstructive pulmonary disease, diabetes, allows magnification, comfortable operating position,
hypertension, history of deep vein thrombosis, peripheral demonstration of intrauterine findings to trainees and staff
artery disease all complicate surgical and recovery process. as well as allowing permanent photographic or video images.
Patient may develop atelectasis, pulmonary embolism
and cardiac compromise following prolonged laparoscopic Light Generators
surgery. Anemic patient may go into hypovolemic shock.
Three types are available:
Diabetic patient may develop fulminant infections.
1. Tungsten emits orange/yellow tinged light
Careful selection of patients is advised.
2. Metal halide emits a bluish tinge to the field

Chapter 67
Positioning Related 3. enon emits clear, white light and provides best shower
Prolonged Trendelenburg position with increased intra- for video imaging. This light source is used for
abdominal pressure may cause CO2 intoxication and acidosis. hysteroscopy.
Pressure points may cause to develop neuropathy, e.g. Peroneal
nerve palsy, foot drop, wrist drop, sciatic pain, brachial nerve
neuropraxia. Deep vein thrombosis may be caused with calf
pressure and stagnation of circulation.

Endoscopy in Gynecology
It is essential that stockings be used with prolonged
laparoscopy.
Other Complications
Other complications include surgical emphysema,
hematoma formation and ureteric injuries, burns, accidental
ligation, puncture injuries of stomach. Hernia at the site of
incision, omentum prolapse at the site of umbilical incision
Fig. 67.16: Diagnostic hysteroscopy
and fistula formation.
Like all surgical procedures, it is important to observe
strict aseptic techniques, postoperative sepsis and infection
are known to occur. Uterine perforation with intrauterine
manipulators are known complication.

HYSTEROSCOPY
History
One of the oldest endoscopic procedures first performed is
hysteroscopy in 1800s.
The technical difficulties of uterine distension, and poor
illumination prevented the procedure becoming useful until
the arrival of fiber optical hysteroscopes in the 1970s. Initially,
the use of diagnostic and operative hysteroscopy remained
the preserve of a few enthusiasts, but by the 1980s the
equipment had reached a point of development whereby
hysteroscopy could be carried out simply. Refinement of
optical and fibreoptic instruments allows excellent visual
documentation.
Fig. 67.17: Operative hysteroscope
INTRODUCTION
Hysteroscopy is an endoscopic procedure using the natural
passage, i.e. the external os to enter the endometrial cavity.
It is a low risk technique permitting the direct assessment
of the endocervical canal and the uterine cavity.
It a is day procedure and the anesthesia required can be
local or general depending on the indication of the procedure.

INSTRUMENTS DIAGNOSTIC INSTRUMENTS (FIG. 67.16)

Telescopes Operative Instruments (Figs 67.17 and 67.18)
Available as 0 — straight on view
30 — fore-oblique view
Parts of a telescope are:
1. eyepiece
2. barrel
3. objective lens. Fig. 67.18: Hysteroscopy instruments 543
 The quality and power of light delivered to the telescope Disadvantages
depends on the remote light generator as well as the • Messy so not used for office hysteroscopy
structural integrity of the connecting fibreoptic light cable. • Clogs the sheath as it has the tendency of drying and
hardening
Sheath • Hyskon reaction, i.e. produces bleeding diathesis
To perform a panoramic hysteroscopy, a sheath is required • When uterine wall is damaged then noncardiogenic
to deliver the distending medium into the uterine cavity. pulmonary edema
Two types of sheaths are: • Rare-idiosyncratic anaphylactic reaction.
1. Diagnostic Low molecular weight media
2. Operative. Normal saline ringer lactate
Diagnostic sheaths are 5 mm in diameter, has easy access,
Readily available plentiful and cheap.
negotiation is safe under vision.
Major Operation

Operative sheaths have greater diameter 7–8 mm and Disadvantages

cervical dilatation is required. • Easy leak out of the uterus
There are 2 operating channels in the operating sheath • Fluid overload
one for the distension medium; and the other for the operating • When mixed with blood obscures the operative field.
instrument insertion. Glycine More commonly used for the urologic electro-surgeries.
Accessory Instruments Disadvantages
• Can cause pulmonary edema, congestive cardiac failure,
They are available as rigid, semi-rigid and flexible.
and water electrolyte imbalance
The rigid ones are heavy duty and are incorporated or
• Ammonia intoxication in impaired hepatic function.
are the part of the sheath.
Section 17

The semi-rigid/flexible ones permit back and forth

ANESTHESIA
movement.
• For diagnostic procedures- Paracervical block with 1
The various instruments are: xylocaine (10–15 ml)
• Grasping forceps Alligator aw Forceps • For operative procedures—general anesthesia or
• Cup Biopsy Forceps regional anesthesia (spinal/epidural).
• Scissors
• Flexible needles. When to be done?
Hysteroscopy is done in postmenstrual period or in the mid
Resectoscopes proliferative phase. The endometrium is thin which facilitates
• Manual – Cutting loop intracavity viewing. Bleeding is absent or less and there is
• Electrical– Monopolar diathermy reduced chance of conception in that phase.
– Bipolar diathermy
• Laser power. TECHNIQUE
The patient is placed in the dorsal lithotomy position and the
Distending Medium position of the uterus confirmed by bimanual examination.
Distension of the uterine cavity is an important pre-requisite The cervix is cleaned and a tenaculum or vulsellum forceps
of hysteroscopy. applied to the anterior lip of cervix. A uterine sound is passed
Two forms: to confirm the axis of the uterus, and the cervix is gently
1. Gas es dilated to 3 or 4 mm. The hysteroscope is connected to the
2. Liquids. distension medium. To provide adequate uterine distension,
the intrauterine pressure needs to be 40–50 mm Hg, and this
Gases may be achieved by hydrostatic pressure whereby the bag
O Gas used for distending media is CO2. A CO2 insufflator of infusion fluid is kept one meter above the patient, or by
is used to deliver the gas at a maximum rate of 100 ml/min. the use of a pressure cuff around the infusion bag. More
The advantage is that it can be used in office hysteroscopy sophisticated pressure rotatory pumps are available and
as it’s not messy. are particularly useful for therapeutic procedures like
endometrial resection or resection of fibroids, where
Disadvantages
continuous flow of fluid is necessary.
• Gas and blood mix producing obscuring bubbling foam
The hysteroscope is passed under direct visual control
• CO2 flattens the endometrium thus obscuring the pathology
through the cervix until the whole uterine cavity and fundus
• Emboli
can be seen well-distended. Each uterine cornu is identified,
• Cannot be used to flush the cavity of debris.
and the cavity carefully inspected for pathological lesions.
Liquids
INDICATIONS
In two forms:
1. High molecular weight—hyskon (32 dextran 70 in dextrose) Diagnostic
2. Low molecular weight—5 dextrose, normal saline, • Menstrual abnormalities—abnormal uterine bleeding,
ringer lactate. menorrhagia, amenorrhea-primary/secondary
igh molecular weight media • Evaluation of the endocervical canal (Fig. 67.19)
• Infertility-recurrent abortions, pre IVF evaluation,
ys on
proximal tube occlusion
Its 32 dextran, 70 in dextrose. It does not mix with blood • Congenital uterine anomalies-uterine septum-complete/
544 and is an excellent media for operative procedures. partial
• Polyp (Fig. 67.20) • Cervical carcinoma
• Postmenopausal bleeding • Uterine bleeding causing poor visibility.
• Endometrial cancer
• To visualize transformation zone with colpo- COMPLICATIONS
microhysteroscopy when colposcopic finding is The complications of hysteroscopy can be divided into:
unsatisfactory 1. Anesthesia related complications-shock due to
• Visualizing cornual opening and fibroid (Figs 67.21 to 67.23). hemorrhage, fluid overload
2. Procedure related complications.
Operative
• Adhesiolysis (Figs 67.24 to 67.26)
• Septum resection
• Submucous myomectomy

Chapter 67
• Polypectomy
• Endometrial biopsy
• Endometrial ablation
• Missed IUCD removal
• Tubal cannulation
• Sterilization—destroying the interstitial portion of the
tubes

Endoscopy in Gynecology
• Bony fragments removal in case of retained products of
conception.

CONTRAINDICATIONS
• Pelvic infections
• Pregnancy Fig. 67.20: Hysteroscopic view of endometrial uterine
polyp in the fundus

Fig. 67.19: Hysteroscopic view of uterine cavity Fig. 67.21: Cornual opening

Fig. 67.22: Cornual opening Fig. 67.23: Fibroid 545

Major Operation

Fig. 67.24: Adhesions in uterine cavity on hysteroscopy Fig. 67.25: Adhesiolysis

8. Injury to intra-abdominal organs

Section 17

9. Thermal injury to intra-abdominal organs due to laser or

electricity.

Late
1. Incompetent os
2. Infection—endometritis, pyometritis
3. Postoperative synechiae
4. Extensive endometrial destruction
5. Non-resolving problem.

NEW DEVELOPMENTS
The sophistication of technology has lead to the advent of
small diameter hysteroscopes—Diameters ranging between
1.0–2.9 mm.
The realization of a new family of continuous flow sheath
with oval profile and a total diameter of 5 mm has given a
new force to hysteroscopy.
Fig. 67.26: Adhesiolysis With these instruments, it is, in fact, possible to perform
operative procedures in the course of diagnostic procedures
Procedure Related Complications without the need for cervical dilatation and anesthesia.
Early Thus, hysteroscopy becoming a real OFFICE
PROCEDURE.
1. Perforation—cervical or uterine
2. Hemorrhage BIBLIOGRAPHY
3. Hyponatremia
1 . Curr Opin Obstet Gynecol 14:381-5.
4. Gas embolism 2 . HAMOU :Hysteroscopy and Microhysteroscopy- Hamou .
5. Fluid overload Ed,CoFeSe, Palmero, (1984).
6. False passage creation 3 . Office Hysteroscopy by Franklin D Loffer MD, OBG N.net
7. Inability to see the operative field Editorial Advisor.

546
 68 Operations of Ovary

Niharika Dhiman, Sudha Salhan

Operations of ovary may be for benign conditions, for Technique

malignancies of the ovary, uterus or cervix, and as a precaution • Ovary is mobilized and the ovarian ligament held with
to prevent development of malignancy commonly performed grasping forceps, and the site for opening the ovary
ovarian operations are given below. selected; preferably on the mesenteric border
• The cyst is punctured and aspirated
Ovarian Cystectomy • Cyst wall stripped from the ovarian tissue
An operation in which ovarian cyst is removed from the • The cyst wall is then placed in a endobag
substance of the ovary either by shelling out or by clean • The ovary need not be sutured unless there is
dissection and in which healthy ovarian tissue is left behind. troublesome bleeding.
Indication
Oophorectomy
Operation of choice when both the ovaries are involved with
Removal of the tumor along with healthy ovarian tissue is
benign neoplasm in young women (size ≥8 cm, symptomatic) called oophorectomy. It is performed for benign cyst (Fig.
Steps 68.1). If paraovarian cyst (Fig. 68.2) if the ovary looks healthy
only the paraovarian cyst is removed by clamping its base
• After opening the abdomen ovary is caught.
as in oophorectomy.
• Elliptical incision is made through the thin cortex at the
base of a benign cyst Indications
• The cyst wall is separated gently using scalpel or by • The tumor is big or complicated by torsion or hemorrhage
scissors and cyst taken out without rupture. and the other ovary is healthy (Figs 68.3 and 68.4)
• The dead space in obliterated using(4–0) absorbable • As a part of hysterectomy with salpingo-oophorectomy.
suture. Ovarian surface is approximated using very fine
interrupted sutures. Steps
• Principles of microsurgery which include gentle tissue • Paired clamps are placed over the infundibulopelvic fold
handling; hemostasis, use of fine and ideally minimally of peritoneum with its contents (Fig. 68.5)
reactive sutures and an effort to ‘bury knots’ should • Medial pair of clamps are applied on the side of uterus to
always be preferred. The cyst removed is sent for include the ovarian ligament and fallopian tube
histopathology examination. • Pedicles are cut in between and the tumor is removed
• Clamps are replaced by transfixing ligatures
Laparoscopic Ovarian Cystectomy • The stump is invaginated by purse stringe stitches to
It plays both diagnostic and therapeutic role. Both laparoscopic prevent adhesions. The ovary removed is sent for
ovarian cystectomy and laparoscopic aspiration. histopathology examination.

Fig. 68.1: Ovarian tumor Fig. 68.2: Paraovarian cyst

Major Operation

Fig. 68.3: Tuisted ovarian cyst

Section 17

Fig. 68.5: Clamping of infundibulopelvic ligament

Oophoropexy (Ovarian Repositioning)

Indications
• Dyspareunia is a case of hysterectomy where pendulous
ovaries hanging in the POD can cause pain
• Infertility surgery—To assist natural ovum pick-up and
to improve access or assisted reproductive technique
• Pelvic radiotherapy—ovaries can be repositioned behind
the liver or paracolic gutter in cases of cancer cervix in a
young patient. Radical hysterectomy is done and ovaries
are left behind. There may be chance of radiotherapy and
hence ovaries are repositioned away from radiation field.
If there is certainty that the diagnosis is benign and
depending upon the experience of the gynecologist many
ovarian cysts may be dealt with laparoscopically.

Fig. 68.4: Tuisted ovarian cyst Paradoxical Oophorectomy

The paradoxical oophorectomy is the removal of severely
pathologic adnexa to improve fertility in patients with strict
Laparoscopic Ovarian Drilling unilateral tubal disease.
This technique is indicated when medical treatment fails to
induce ovulation in PCOS. Prophylactic Oophorectomy
The ovarian drilling technique includes a 5 mm second It is indicated in women who have a high risk of developing
port puncture placed suprapubically through which suction ovarian and breast carcinoma. The protection against
irrigation or grasping of tissue can be inserted. All visible ovarian cancer is excellent and reduces the risk of BRCA
subcapsular follicles are vaporized and a 2–4 mm diameter is related gynecological cancer by 96% in cases of family history.
made randomly in ovarian stroma. However, there remains a risk of developing peritoneal
carcinoma (1%).
Ovarian Biopsy
This is indicated to differentiate between premature ovarian BIBLIOGRAPHY
failure from resistant ovarian syndrome or for the cases of 1 . Berck and Novaks gynaecology 14th Edn. 2006;35:1471-2.
intersexuality. 2 . Telindes’ Operative Gynaecology 10th Edn; 2008.pp. 639-43.

548
 69 Conservative Surgical Methods of
Treatment of Pelvic Organ Prolapse

Sudha Salhan, Shakti Bhan Khanna, HP Anand, Kiran Bala Dass, Kaushiki

If the patient is symptomatic the pelvic organ prolapse is to 5. oshi’s sling

be surgically treated after giving a trial of pelvic muscle 6. Virkud’s sling
exercises, controlling precipitating factors(e.g. malnutrition, 7. Promontofixation.
asthma, obesity, etc.). Before operation correct any pre-
operative medical diseases like anemia and control diabetes VAGINAL PROCEDURES
mellitus, asthma, urinary tract infection and obesity, etc. Also Anterior Colporrhaphy
stop any drug like anticoagulant or corticoid, etc. about a This is the operation for repair of Cystocele (Fig. 69.1). It is
week before operation. Evaculate both in lying down and part of almost all cases of vaginal prolapse surgeries. This
standing position, during straining(with full bladder)and operation when done as stand alone is performed in younger
without straining with empty bladder. Look at strength of patients who have no descent of cervix. The patient is
pelvic muscles and mobility, tenderness and adnexal mass anesthetized. After the patient is put in lithotomy position the
on pervaginal examination. On per-rectal examination, see part is cleaned and draped (Fig. 69.2). Do per vaginal
the external sphincter tone and exclude presence of rectocele examination. The steps of operation include:
or enterocele. The type of operation performed depends upon
a number of factors including assessment of all pelvic defects.
Also take sexual history. Inquire about stress incontinence,
frequency or any other voiding difficulties including urinary
retention. Post-voiding urine volume is to be measured.
Individualize the surgical procedure in each patient after
discussing with her about severity of symptoms, her choice,
presence of other diseases like stress incontinence, any other
pelvic surgery and her age. The endeavor must be to correct
all defects in one sitting only. onservative surgery (preserving
uterus)is done in the following cases of prolapse uterus:
• Preservation of reproductive function is desired
• Patient is refusing for hysterectomy
• Patient is unfit for lengthy operation.
All possible existing pathology should be detected and
treated before operation. Particularly no malignancy should
be present in the preserved uterus. Awaiting surgery the
patient may be prescribed a ring pessary while being worked
up and made fit for operation. Fig. 69.1: Cystocele
The conservative operations of uterovaginal descend as
listed below. They can be performed vaginally and or abdominally.
I. Vaginal Operations
1. Anterior colporrhaphy
2. Posterior colpoperineorrhaphy
3. Manchester Fothergill operation
4. Shirodkar’s modification of Manchester operation
5. LeFort operation
6. Perigee
7. Iliococcygeal vaginal suspension on both sides.
II. Abdominal operations mostly are slings: Slings employed
could be both natural(Rectus sheath) or synthetic.
Synthetic meshes can also be cut to size and requirement
and used. The commonly used procedures are:
1. Shirodkar sling
2. Abdominal cervicopexy(Purandare’s operation)
3. Khanna’s sling
4. Soonawala’s unilateral postsling operation Fig. 69.2: Cleaning the perineum
 1. Vulval stitches applied (Fig. 69.3). Posterior Colpoperineorrhaphy
2. The bladder is catheterized to empty it by metal catheter This operation is done to repair the rectocele. It is mostly a
(Figs 69.4 and 69.5). part of surgery for vaginal prolapse. It reduces the enlarged
3. Anterior lip of cervix is held by vulsellum (Fig. 69.6) introitus, repairs perineal body, enforce pelvic diaphragm,
4. The bladder is sounded (by bladder sound)to know the repair rectocele and enterocele, if any.
extent of cystocele (Fig. 69.7). Preoperatively, the bowel must be empty and perineal
5. A transverse incision is given just above the vulsellum hair clipped short. The patient is anesthetized. She is positioned
holding the anterior lip of the cervix. in lithotomy position. Her perineum is cleaned and draped.
4. This incision is converted into inverted T-shaped incision. Three marker Alli’s forceps (Fig. 69.13) are applied to demarcate
5. The vaginal flaps are separated form underlying bladder the amount of tissue to be removed. Two on the posterior
(Fig. 69.8) termination of labia minora and third on the vaginal wall in the
6. The vesicocervical ligament is cut (Fig. 69.9) midline(according to the extent of the rectocele or enterocele).
Major Operation

7. The bladder is mobilized upwards to expose the The three Allis forceps are united by incision.
uterovesical pouch (Fig. 69.10) The vaginal flap is separated from the underlying
8. The fused pubocervical and vesical fascia is sutured and Denonvillier fascia tissue to make the levators visible (Fig.
pleated in the midline to form a firm support for the 69.14). The pre-rectal fasica and levator ani are stitched in
bladder using a delayed absorbable suture, e.g. Vicryl the midline by lambart sutures using delayed absorbable
(Figs 69.11A and B). sutures (Fig. 69.15). Excess vaginal flap is trimmed off. The
9. The vaginal wound is resutured, after cutting off excess perineal muscles are also sutured in the midline.
vagina tissue (Figs 69.12A to C), by interrupted sutures. The vaginal flaps are stitched together in the midline
Continuous sutures shorten the vagina. Some surgeons (Fig. 69.16).
put vicryl mesh placed under these stitches. If enterocele is present, the whole hernial sac is dissected
Section 17

If the defect is lateral or paravaginal reattachment of the out. The hernia is reduced. Excess peritoneum is excised.
anterior lateral sulcus to obturator internus fascia or arcus Purse string suture is given to obliterate the sac. Both
tendineus fascia or while line is done. It may need reposition uterosacral ligaments are brought together under the
graft to relieve tension. These operations may need peritoneum and attached to the vaginal apex to give support
cystoscopy at the end of the procedure. to vaginal vault.

Fig. 69.3: Vulval stitches are applied Fig. 69.4: Metallic catheter

550 Fig. 69.5: Bladder cetheterization Fig. 69.6: Anterior lip of cervix is held with vulsellum
 Fig. 69.7: Bladder sound

Chapter 69
Fig. 69.10: Bladder is pushed up

Conservative Surgical Methods of Treatment of Pelvic Organ Prolapse

Manchester Fothergill Operation
This operation was originally described by Donald in 1888
and later modified by Fothergill.
Indications are elongation of cervix with minimal cervical
descent in a young patient (Fig. 69.17) or
Fig. 69.8: Vaginal flap separated Cases where the woman wants to retain the uterus in
uterovaginal prolapse.
The patient is preoperatively prepared. After giving
anesthesia she is placed in lithotomy position, cleaned and
draped. Bladder emptied with metal catheter.
Perform pervaginal examination. The first step is dilatation
and curettage. Anterior lip of the cervix is caught with vulsellum.
Uterine sound is passed to know the direction and size of the
uterus. This will give an idea of excess cervical length. The
cervix is dilated up to No.8 Hegar’s dilator. This helps in placing
the Sturmdorf posterior suture for reconstruction of cervix up
following amputation. A thorough uterine curettage is carried
out and tissue obtained is sent for histopathology examination.
This will rule out uterine malignancy, and more important, will
avoid confusion of secondary hemorrhage with a normal
withdrawal bleeding in the postoperative period.
Anterior lip of the cervix is already caught by the
vulsellum forceps. Bladder sound passed to know the extent
Fig. 69.9: Cutting of vesicocervical ligament of the cystocele.

Figs 69.11A and B: Stitching of pubocervical fascia for bladder bed 551
Major Operation

Fig. 69.13: Posterior colpoperineorrhaphy

Section 17

Fig. 69.14: Separation of fascia from vaginal fold

Figs 69.12A to C: Excess vaginal tissue and stitching Fig. 69.15: Stitching of prerectal fascia

Four Allis’s forceps are applied on Fothergill’s points (Fig. separation of vaginal flaps. Anterior dissection is done till
69.18). First below the urethral orifice. Second is behind the the cervix is reached and vesicocervical ligament is exposed.
cervix on the posterior fornix in the midline at the level of As in anterior colporrhaphy the vesicocervical ligament
uterine isthmus. Two lateral points about 1/2 inches from the and lateral bladder pillars are cut and bladder is mobilized
552 external os. All four points are joined by scalpel incision for upwards. Bleeding vessels are ligated. The dissection is
 Chapter 69
Fig. 69.16: Stitching of vaginal flap Fig. 69.17: Prolapse without cystocele

carried out posterior to cervix exposing the cul-de-sac. The stick starts at 3 o’clock position and comes out at 12 o’clock

Conservative Surgical Methods of Treatment of Pelvic Organ Prolapse

sac is opened and transfixed at its highest point. The neck of position. These stitches when tied, cover the anterior lip of
the sac is tied and excised. In this case the uterosacral the cervix.
ligaments are approximated over this in the midline by 2–3 Like cystocele repair the pubocervical fascia is stitched
transfixing sutures. in the midline thus forming a bed for the bladder.
Cardinal ligament on both sides are caught cut and tied Interrupted sutures are placed in the anterior vaginal
and the stitches are left long (Fig. 69.19). flap to close the cuts ends.
The cervix is now amputated at appropriate point Posterior colpoperineorrhaphy is performed.
(Fig. 69.20). After cleaning the operation site put in an indwelling
All bleeding vessels are secured. bladder catheter connect it to urobag Foley’s pack the vagina.
Formation of posterior flap of cervix (Sturmdorf suture). The packing is optional depending on surgeon’s choice. (The
The posterior flap of vagina is pierced at 6 o’ clock position editors do not put vaginal pack)
with a big needle(so that it can pass through the cervix)with omplications Immediate complication is mainly
a long suture. The thread is tied there(making two equal hemorrhage from the cervical stump. Delayed complications
thread lengths). The needle is passed through the cervical including decreased chances of conception, increased
canal posteriorly and brought out at 7–8 o’clock position. The incidence of recurrent second trimester abortion, pre-term
other end of the suture is threaded on a needle and similarly labor and precipitate labor.
passed through the cervical canal posteriorly and brought
out 3–4 o’clock position (Fig. 69.21). Both threads are tied Shirodkar’s Modification of Manchester Operation
together. This covers the posterior lip of the cervix. Shirodkar had serious objections in the way. Manchester
Fothergill suture (Figs A and B) The needle with the Fothergill operation was performed as a conservative
suture enter the vagina at 9 o’clock position. Take a bite of surgery. The main points of the contention were:
cardinal ligament stump, then enter the cervical canal(inside 1. ervix amputation The amputation of the cervix is not
out)and comes out near 12 o’clock position. Another similar necessary for enforcing the support of the uterus. It is
more mutilating and has an adverse effect on fertility.

Fig. 69.18: Four Allis forceps applied Fig. 69.19: Cardinal ligaments are caught 553
Major Operation

Fig. 69.20: Amputation of cervix Fig. 69.21: Formation of sturmdorf suture

Section 17

Figs 69.22A and B: Applying of Fothergill stitch

2. Manchester operation forcefully shortens the cardinal end of the uterosacral ligament cutting the peritoneal along.
uterosacral ligaments by bringing together in front of The strip so obtained is mobilized by blunt dissector to get a
the cervix with the peritoneal layer backing. strip of sufficient length on either side of the uterus.
In his modification, he recommends no amputation of cervix, The peritoneal opening in the POD is closed by 3 stitches
mobilization of uterosacral and cardinal ligaments. Complex (A,B,C) extending from the upper most portion of peritoneum
as a free strip. With their peritoneal backing and attaching at 7,6 and 5 o’clock position and running to the lower most part
them in front of cervix. His method of closure of cul-de-sac, on the post surface up to the cervix at the corresponding point
preventing enterocele also. just above to cut edge of cervix. The postcervix incision is closed
(Fig. 69.23). The two uterosacral cardinal ligament slings are
Procedure brought anteriorly and transfixed to the front of cervix at about
A circular incision is put around the cervix at the level of the level of the internal os. This elevates and anteverts the
internal os. uterus (Fig. 69.24).
Anterior colporrhaphy incision (inverted T-shaped) is Anterior colporrhaphy is completed refixing the vagina
performed and dissection done. mucosa to the anterior lip of cervix.
Posterior dissection is carried out exposing the POD. The Posterior colpoperineorrhaphy is performed as usual.
pouch is opened cutting it parallel to the lower edge of the
LeFort Operation (Partial Colpocleisis)
uterosacral ligament.
Laterally, on either side, the vagina is dissected away The procedure is performed in very aged or debilitated patient
from the cardinal, uterosacral complex as high as possible (not medically unfit to undergo longer surgical procedures)
mobilizing a good part of these ligaments. with major uterovaginal prolapse. The patient is no longer
The uterosacral cardinal complex along with peritoneum engaging in intercourse and there is no uterine pathology,
on its surface is clamped close to the cervix, through the e.g. malignancy. Stress incontinence must also be ruled out. It
was first performed by Neugebauer in 1867 and first published
554 open POD and released from the cervix. A cut of about 1–2
by LeFort in 1877.
cm is made at right angles to this about 2 cm above the lower
 Chapter 69
Conservative Surgical Methods of Treatment of Pelvic Organ Prolapse
Fig. 69.23: Shirodkar modification

If uterus is still present, partial colpocleisis can still be done.

The steps consist of denuding a rectangular area of Fig. 69.24: Shirodkar repair
anterior and posterior wall. Anterior and posterior vaginal
walls are then closed together by interrupted sutures. Thus
uterus and vagina are held up. Channels are left below the
cervix and lateral to the closure to provide drainage of
cervical secretions. Only small portion of vaginal epithelium
near introitus for urethral function is left behind.

Perigee Operation
Anterior repair incision is given. The bladder is dissected as
for laterally towards the ischiopubic rami to facilitate needle
passage. Four points (Fig. 69.25) are marked on the perineum.
Upper ones are at the level of clitoris at the lateral edge of lie
at ischiopublic ramus. The lower points are 3 cm below and
lateral to the upper points. We have two special needles
(Fig. 69.26). The upper needle has superior pink needle handle.
It is passed through the upper point medially. Once the needle Fig. 69.25: Incision of perigee operation
is felt inside the vagina connector’ is attached to its tip and
pulled out. Next lower needle is inserted through the lower
point. Once it reaches the vagina 2 cm from the ischial spine
the connectors’ are attached to the needle tip. Similar
procedure is done on the other side. Finally all four needles
are pulled out along with the mesh ends. The hammock of
the mesh sits below the cystocele in a tension free manner.
The redundant position of the mesh tails are trimmed off.
The anterior vaginal incision is closed with interrupted
stitches. All four points are also closed.
For poster repair by mesh the operation is Apogle
procedure.

ABDOMINAL METHODS
The various surgical techniques using abdominal approach
are mainly sling operations.

Shirodkar’s Posterior Sling Operation

It is one of the earliest sling operations where stress is given
to the strengthening of uterosacral ligaments. In this
technique center of a 5 mm mersilene tape is attached to the
back of the cervix and ends of the tape are carried retro-
peritoneally, roughly in the line of uterosacral ligaments, on Fig. 69.26: Needles of Perigee method
both sides and attached to the transverse ligaments of the
sacral promontory. Since the left loop encircles the iliac muscle on left side, a psoas hitch, and the main loop is
rectosigmoid there is risk of constriction of the part of the passed thorough this. The operation obviously is good with 555
gut. To avoid this a small loop of mersilene is anchored to the its sound bony point of attachment and backward pull of
 cervix. However, it is difficult to perform especially the left abdominally, by laparoscopy or by vaginal and laparoscopic
part of it with its looping the loop technique. The venous approach together.
plexus at the promontory can be really bothersome. Since In 1972, during Maternal Mortality Conference in Bombay,
the mersilene tape from the back of the cervix does not Brig SD Khanna showed a film on his posterior sling operation
proceed directly to the sacral promontory, but in a curvilinear for nulliparous prolapse. The abdomen is opened by a small
fashion, it has an inherent slack in it. It has also been noted suprapubic pfannenstiel incision. Uterus is pulled up with the
that with the passage of time due to the gravitational pull of help of Shirodkar’s uterus holding forceps. The center of a 10
the cervix, the loop tends to travel medially and straighten cm long and of 3 mm width mersilene tape is attached to the
out with resulting descent of cervix by an inch or so . Other supravaginal portion of cervix posteriorly by three 1–0 silk
side effects could be an injury to the uterus, major vessels, sutures avoiding the uterine vessels. A small nick is given in
genitor-femoral nerve leading to the spasm in the psoas front of the anterior superior iliac spine into the inguinal
muscle and pain in the left leg. ligament. A uterine packing forceps is guided through this
Major Operation

cut medially across the iliac fossa retroperitoneally and then

Purandare’s Sling Operation (Abdominocervicopexy) along the folds of broad ligament to the lateral aspect of the
(Figs 69.27 to 69.32) back of the cervix where the tape is fixed. A nick is made in
In this operation strips of fascia from anterior rectus sheath the peritoneum at that level and the end of the tape is pulled in
are raised and taken into the abdomen roughly in line with the by the tip of the uterine packing forceps which is gently withdrawn
route of the round ligaments and fixed on the anterior surface in front of anterior-superior iliac spine. Same procedure is
of the supravaginal portion of the cervix. This procedure has applied on the other side. The requisite pull is applied on both
many disadvantages. The procedure is technically faulty. ends of the tape to pull the cervix up and to keep the uterus in
There is no bony attachment and the tissue used is weak. The midline in anteverted position. The abdomen is closed. The two
cervix is pulled anteriorly and the incidence of big enteroceles ends of the tape are sutured to the lateral ends of inguinal
Section 17

in such patients is high. There is interference with vaginal ligament near anterior superior iliac spine. Number 3–0 black
delivery and if the LSCS has to be performed, this sling has to silk sutures are used and care is taken to bury the knots deeper
be incised. There is also high recurrence rate. than inguinal ligament and, not subcutaneously.
The rational of this sling is to strengthen the cardinal
Khanna’s Sling Operation (Fig. 69.33) ligament and, therefore, this not only elevates the uterus but
Khanna’s Sling Operation can be performed for nulliparous also maintains anteversion. This technique is fairly easy to
prolapse vault prolapse. The procedure can be done perform, has no risk of bowel obstruction and can be

Fig. 69.27: Purandare’s sling operation. Abdominal incision Fig. 69.28: Dissection to locate rectus muscle

556
Fig. 69.29: Making a strip of rectus muscle Fig. 69.30: Bring the rectal strip anterior
 Chapter 69
Fig. 69.31: Rectus sheet brought anterior Fig. 69.32: Rectal strips tied in front of cervix

Conservative Surgical Methods of Treatment of Pelvic Organ Prolapse

performed laparoscopically. However, not all genital prolapses paresthesia of varying degrees was-felt on the anterior
are suitable for this operation. Those patients of nulliparous aspect of thigh in 4 patients post operatively, which became
prolapse who do not have too much of cervical elongation all right in a couple of weeks. The lateral cutaneous nerve of
should be treated by this method. During labor there is no thigh has a course, invariably about 1 cm medial to anterior
problem in cervical dilatation and if LSCS is to be performed, superior iliac spine and probably in these four patients the
it can be done easily without excising the tape. Chances of nerve was injured at some stage of the operation while
recurrence are minimal. putting in the forceps or suturing the tape to the inguinal
Having personally performed the Khanna’s Sling operation ligament. The most gratifying feature even after years of
(by Shakti Bhan Khanna) for nulliparous prolapse for last two follow-up in these patients has been the central high up fixed
decades with good results, the importance of vertical vault with adequate length of vagina.
suspension of cardinal ligaments as a support to cervix and
upper vagina was evident. In the operations of abdominal Soonawala’s Unilateral Posterior Sling Operation (Fig. 69.34)
sacral colpopexy, McCalls culdoplasty and most of the other Abdomen is opened by pfannenstiel incision. Peritoneum over
operations performed for the vault prolapse, the stress has S1 vertebra is incised to visualize the anterior longitudinal
been laid on strengthening the uterosacral ligaments. ligament. Number 1 prolene loop on a large atraumatic needle
A total of 37 patients have been operated upon by is used. The loop is anchored to the longitudinal ligament and
Khanna’s Sling operation in the last 15 years. Out of 16 patients then the needle is passed retroperitoneally along the right
of vault prolapse, three patients had anterior colporrhaphy uterosacral ligament to the isthmus of the cervix posteriorly
and posterior colpoperineorrhaphy and two patients had taking a bite through it. The needle is retraced back
retropubic paravaginal repair of cystocele done along with retroperitoneally to the area of 1st sacral vertebra. The two
sling operation. Abdominal hysterectomy for uterovaginal ends of the loop are tied pulling the cervix back and upwards
prolapse with prophylactic Khanna’s Sling operation for vault towards the sacrum. For second and third degree uterine
prolapse was done in 21 patients. In three patients, the sling prolapse the procedure is most satisfying. It does not cause
was put in laparoscopically. problem in labor neither does it injure the bowel.
Material used was 3 mm wide Mersilene tape in most of
the patients synthetic mesh of polyglycolic acid also can be Joshi’s Sling Operation (Fig. 69.35)
used with non-absorbable sutures. The mesh can be rolled Through a Cherney incision, the uterus is suspended to the
into a small tape with the help of sutures. pectineal ligament on both sides with mersilene tape. Using
Dragging pain in lower abdomen was felt by 4 patients a stout curved Mayo needle a 30 cm long 5 mm width
for a few days postoperatively. Appropriate counseling was mersilene tape is anchored to the mid-point of isthmus
done as a remedial measure for this complaint. Bilateral anteriorly. Number o’ silk sutures are applied on either side
to fix the tape to the uterus. A long artery forceps is applied
retro-pubically from lateral end of the round ligament,
medially subperitoneally up to the lateral edge of the uterus
and the lateral end of the tape is grasped and pulled to the
retropubic space. Same procedure is applied on the other
side. The lateral ends of the tape are passed through the
adequate thickness of pectineal ligament by cervical Mayo
needle, extra anchorage number,’0’ silk sutures. Adequate
anteflexion and elevation of the uterus is obtained without
any compressive effect on any organ. The weight of the
uterus is shared by two strong ligamentous anchoring points
via mersilene tapes which has good tensile strength. Most
patients deliver vaginally and LSCS is done at higher level to
avoid accidental incision of tape. There are minimal chances
Fig. 69.33: Khanna’s posterior sling operation of recurrence. 557
Major Operation

Fig. 69.34: Soonawala’s unilateral posterior sling operation Fig. 69.35: Joshi’s sling operation

Virkud’s Sling Operation (Fig. 69.36) RECENT ADVANCES IN SURGICAL

In this operation one end of 30 cm long mersilene tape is MANAGEMENT OF POP
attached to the sacral promontory posteriorly with two strong Tape and Mesh
linen stay sutures. The tape is passed subperitoneally on the
With the concept of POP being the hernia of the pelvic floor
right side of the pelvic wall, then through the right broad
the use of prosthetic material in an effort to reduce
ligament and fixed to the posterior surface of isthmus of the
recurrence of prolapse as for the correction of abdominal
uterus with 20 Barbour linen stay sutures. The tape is then
wall hernia has been reported in a number of studies. The
Section 17

passed through the left broad ligament up to the internal

material used has been monofilament polypropylene mesh.
inguinal ring where it is passed through transversalis fascia
The prosthetic grafts may be autologous, synthetic, allografts
and guided medially at linea semilunaris between the rectus
or xenograft. The synthetic grafts are supposed to have less
muscle and the sheath where it is sutured with 20 Barbour
postoperative morbidity than the autologous grafts. These
linen stay sutures to the rectus sheath. The left uterosacral
grafts have been used in the recurrence of POP when the
ligament is plicated in order to correct the dextrorotation of
pelvic floor fascia is too attenuated for repair. At present
the uterus. It also maintains anteversion of the uterus. This
monofilament polypropylene mesh is used more often with
sling provides both static and dynamic support. There is no
less complications of infection, rejection or mesh erosion.
tendency to enterocele formation, bowel injury or obstruction
For anterior compartment repair tension free vaginal tape
and no difficulty in performing subsequent LSCS.
(TVT), trans obturator tape (TOT) and vaginal para vaginal
repair is done by these prosthetic grafts. Total vaginal mesh
Promontofixation
(TVM) is a new technique to use one piece of mesh for
In this procedure the cervix/vaginal vault (posthysterectomy) is urogenital prolapse and repair of cystocele and rectocele.
suspended from sacral promontory using a synthetic mesh. The Perigee and Apogee is another modification of mesh to
The procedure can be carried out through open laparotomy correct anterior compartment, posterior compartment and
and through laparoscopic robotic technique also. enterocele defects. The results are encouraging but still long-
Peritoneum from sacral promontory and cervix/vault is term follow-up is needed to know about the complications
cut and mobilized on the right side of the rectosigmoid so and success rates.
that the strings of synthetic mesh can be buried extra- esh Abdominal Sacrocolpoperineopexy Replace normal
peritoneally. A string of synthetic mesh is cut into the vaginal suspensory ligaments and to augment or replace
appropriate size and shape one end of the strip is fixed to the posterior fibromuscular plane with mersilene mesh or
anterior vertebral ligament at the sacral promontory. The dermograph that runs from the sacrum to the perineal body.
other end is fixed to the cervix either anteriorly through holes This operation is performed through abdomen or done
in the broad ligament in an avascular area just above the abdominoperineally.
insertion of uterosacral ligaments to the cervix or posterior Abdominal Sacral Colpopexy—Posteriorly the mesh is
surface of the cervix. The strip of this mesh can be extended attached to the anterior longitudinal ligament of the sacrum.
down between the vagina and rectum to correct a coexisting
rectocele. Similarly, it may be extended down between vagina Laparoscopic Approach
and bladder to correct a coexisting cystocele. The various operations done laparoscopically are
sacrocolpopexy, uterosacral suspension, sacrospinous
fixation, paravaginal repair, Burch colposuspension and
Khanna’s Sling operation for vault prolapse. The procedures
are carried out through a standard three-post laparoscopy
with the vaginal vault elevated using a probe, vaginal
elevator, vaginal packing or swab on ring forceps. The steps
of the operation are same as in the abdominal method.
Laparoscopic approach has less pain, shorter hospital stay
and less scarring. The success rate of this approach is 100
at 1 year to 95 at 5 years.

Robotic Surgery
Sacrocolpopexy is done by robotic surgery also.
558 Fig. 69.36: Virkud’s sling operation
 70 Hysterectomy

Sudha Salhan, Rani Jain, MD Goswami

Hysterectomy (from Greek Womb ) is the surgical removal diseases, use of blood transfusion, antibiotics and better
of the uterus, usually performed by the gynecologists. anesthetic techniques, mortality reduced to 1–2 per 1000.
Hysterectomy is the operation in which the uterus is There are three types of abdominal hysterectomy.
removed surgically. Total hysterectomy means that the
uterus is removed along with the cervix. Subtotal hyster- Partial or Subtotal or Supra-cervical Hysterectomy
ectomy leaves behind a part or whole of cervix. This refers to a procedure in which the cervix is left in place
Hysterectomy is one of the most common surgical as a Stump while the body of uterus is removed. This type
procedures in women. Laparoscopic hysterectomies have of hysterectomy may be done if difficulties arise during
recently been performed with some frequency, however, surgery, making removal of the cervix difficult (Fig. 70.1).
abdominal hysterectomy still remains the most common An emergency subtotal hysterectomy may be done in
choice by the gynecologists. Most surgeons may prefer to women with uncontrolled uterine bleeding following delivery
use techniques that they had learned as residents while and it may not be possible to identify the point where the
others use recently introduced devices for abdominal cervix ends and the vagina begins. These women should
hysterectomy. have regular screening for cervical cancer by Pap smear.
The operation can be performed by the following The disadvantage is that the patient may continue to have
methods: menstrual bleeding as the retained cervix may have a small
remaining portion of the uterus. Initially, surgeons preferred
TYPES OF HYSTERECTOMY to leave the cervix behind, as they believed that it would not
• Abdominal hysterectomy interfere with sexual satisfaction. But studies have
• Vaginal hysterectomy demonstrated that sexual satisfaction is the same in women
• Vaginal hysterectomy in absence of uterine descent with or without a cervix after hysterectomy.
(Non-descend vaginal hysterectomy) The laparoscopic supracervical hysterectomy is
• Laparoscopic assisted vaginal hysterectomy performed like the laparoscopic assisted vaginal
• Hysterectomy by robotic surgery. hysterectomy (LAVH) procedure and cautery is used to
History: Earlier abdominal hysterectomy was performed for divide the cervix at the cervical stump and the uterine tissue
large ovarian cysts or leiomyomas which were misdiagnosed is removed through laparoscopic tools. Recovery is very
as large ovarian cysts. The first recorded operation is by quick and the postoperative pain is also less.
Langenbeck who removed the uterus in 1825 for the
advanced cervical cancer, in just seven minutes but the Total Abdominal Hysterectomy
patient died within hours. This is the most common type of hysterectomy performed in
Charles from Manchester did abdominal hysterectomy in general practice. It involves removal of the uterus including
two patients for leiomyomas in 1843, however, both these
patients died of hemorrhage. It was Health who recognized
and ligated the uterine arteries to prevent hemorrhage.
Bellinger did the first planned abdominal hysterectomy in
1846 in Carolina, USA but the patient died.
Walter Burham performed the first successful abdominal
hysterectomy in 1853 for leiomyoma though unplanned, but
the patient survived. Koeberle in France, in 1864, introduced
clamping of the vascular pedicle to control hemorrhage. In
1888, Mary Amadna of USA did first successful total abdominal
hysterectomy, although the body of uterus was removed
separately by the abdominal route and the cervix delivered
vaginally.
The initial mortality was quite high. However, it was
reduced from 6 in 1889–1906 to less than 1 in 1909. Later Fig. 70.1: Partial or sub-total hysterectomy
on, with the recognition and treatment of associated medical (removal of the body of the uterus only)
 the cervix with or without removal of one or both ovaries and endometriosis which do not respond to conservative
fallopian tubes at the same time (Fig. 70.2). management with antibiotics and anti-inflammatory drugs
The literature supports that the reduction in nocturia and or hormones, the uterus may be removed. However, young
stress incontinence and the improvement in bladder capacity women who would like to attempt pregnancy through in vitro
are similar in subtotal and total hysterectomy. Also, there is fertilization (IVF) technique should be advised the option of
no difference in the frequency of bowel symptoms and uterus conservation. Certain ectopic pregnancies like
measures of sexual function across these two groups. cervical, interstitial or abdominal pregnancy where the
placenta cannot be removed without the removal of uterus
Radical Hysterectomy and in patients with repeated tubal pregnancy that have
This procedure involves more extensive surgery than total destroyed both the fallopian tubes.
abdominal hysterectomy because it also includes removing Neoplastic diseases
tissues surrounding the uterus and removal of the upper 1/3 a. Cervical intraepithelial neoplasia.
Major Operation

of the vagina. It is commonly performed for early cervical b. Early invasive cervical cancer stage IA, IB and II A can
cancer. Pelvic lymphadenectomy and omentectomy are done be treated with radical hysterectomy. Primary surgery is
if uterine or ovarian malignancy is suspected (Fig. 70.3). indicated in young women to preserve the function of
normal ovaries.
Indications of Hysterectomy
c. Endometrial adenocarcinoma and sarcoma of
Benign conditions of uterine origin endometrium and myometria.
a. Abnormal uterine bleeding It is defined as excessive bleeding d. Fallopian tube neoplasm.
per vagina (menorrhagia), and irregular uterine bleeding e . Ovarian neoplasm.
or spotting that occurs at times other than during the f. Trophoblastic disease—in cases of persistent elevated
expected menstrual bleeding (metrorrhagia) or frequent human chronic gonadotropin (hCG) titre after
Section 17

bleeding (polymenorrhea), defined as bleeding that lasts chemotherapy.

longer than seven days. Metrorrhagia and menorrhagia g. Malignant diseases of other adjacent pelvic organs,
are generally treated first with medications or other hysterectomy is indicated if it is technically difficult to
surgical alternatives like endometrial ablation or resection. remove the other adjacent organs without removal of
However, abnormal uterine bleeding that does not respond the uterus.
to the conservative treatment with a reasonable trial, may
require hysterectomy. Obstetric indications:
b. terine leiomyoma Fibroids are benign growths of uterine a. Uncontrollable postpartum hemorrhage (PPH).
musculature that may or may not cause symptoms or b. Irreparable uterine rupture.
require removal. The patients with small and asym- c. Uterine inversion.
ptomatic myomas may be followed with periodic pelvic d. Ectopic pregnancy of interstitial, cervical or abdominal
examination. New myomas do not appear after origin and certain cases of septic abortion.
menopause and rather existing ones shrink in size. Miscellaneous causes:
Sometimes large myomas especially subserous types a. Intersex disorders like true hermaphrodites, gonadal
may be asymptomatic and removal may be recomm- dysgenesis and persistent Mullerian syndrome, all of
ended based on size alone. which have been assigned a male sex. Rarely, patients
c. Adenomyosis A symmetrical enlargement of the uterus in with congenital adrenal hyperplasia with significant
the anteroposterior dimensions may indicate the virilization and reared as male, also need hysterectomy,
diagnosis of adenomyosis. Symptoms like dysmen- with removal of adjoining adenexa.
orrhea, tenderness and menorrhagia may be treated b. Mentally challenged children who are unable to take care
with hormones before resorting to hysterectomy. of themselves (after consulting the constitution board).
Benign diseases of the tubes and ovaries, in which the uterus c. Single episode of postmenopausal bleeding. It should be
is not primarily involved. In cases of chronic inflammatory investigated because of atrophic vaginitis, cervical polyp
diseases with bilateral tubo-ovarian abscessess and pelvic or uretheral caruncle rather than neoplasia of genital
system.

Fig. 70.2: Total hysterectomy (removal of uterus, Fig. 70.3: Radical hysterectomy (removal of uterus, cervix, upper
560 cervix, upper third of vagina) third of vagina, and both the ovaries and the fallopian tubes)
d. Abnormal Pap smear: Laparoscopy, endometrial biopsy and first generation cephalosporium 1 gm is given 1 hr before
cervical biopsy should be done to rule out malignancy. procedure. Prophylactic antibiotics have been documented
Mild to moderate cervical dysplasia should be treated to reduce postoperative infections.
by cauterization, cryosurgery or conization rather than Cleaning vagina with betadine reduces local vaginal
resorting to hysterectomy. infection and vault infection postoperatively. Shaving of pubic
hair, clinical is unnecessary clipping of hairs can be done.
Preparation for Hysterectomy Suturing labia causes more harm and discomfort to patient
Treating gynecologist should explain to the patient about the postoperatively covering anus is must during procedure with
indication of hysterectomy in a language that the patient drap or with towel.
best understands. They should be informed about the
physical and sexual effects of surgery. The risks, benefits Abdominal Hysterectomy
and side effects must also be explained. Also the need for Procedure

Chapter 70
estrogen replacement therapy (ERT) should be discussed. The objective of abdominal hysterectomy is to remove
ounger women in whom the ovaries have been uterus through abdominal incision without unnecessary blood
removed may need ERT to avoid hot flushes, night sweats, loss without injury to the tissues and adjacent organs,
and loss of bone density. The women in whom the ovaries maintaining normal anatomy and to avoid postoperative
are retained, ERT may be needed at a later date if the ovaries dysfunction.
stop functioning earlier than expected. Abdominal hysterectomy should be performed in a
Women who have attained menopause generally do not hospital with adequate infrastructure facilities. Patients are

Hysterectomy
require ERT after hysterectomy. given general/spinal anesthesia of pain. The bladder is
Women should have the following tests before surgery: emptied and pelvic examination is performed under
i. Complete pelvic examination including manually anesthesia to evaluate and reconfirm the pelvic pathology.
examining the ovaries and uterus. Useful information is obtained about size, location and
ii. Up-to-date Pap smear. mobility of pelvic tumor and their proximity to adjacent
iii. Pelvic ultrasonography. organs such as bladder and rectum. The choice of incision
iv. Decision regarding whether or not to remove the ovaries can be made from findings on pelvic examination under
v. Complete blood count and an attempt to correct anemia, anesthesia.
if any exists. Blood urea, blood sugar and serum There are two primary types of incisions in an abdominal
electrolytes. surgery. They include:
vi. Sampling of the lining of endometrium (endometrial A vertical incision is given from below the umbilicus to
biopsy) to rule out cancer or precancerous conditions of just above public bone and the crease horizontal incision
the uterus. (Pfannenstiel incision) which runs across the abdomen an
vii. -ray chest, ECG. inch or so above the pubic bone (Figs 70.4A and B).
Preanesthetic clearance from the anesthetist is needed in After the incision is made, the upper abdomen is explored
elective hysterectomy. Adequate blood is booked before for any abnormality or lymph node enlargement. The
hand. operation begins with the identification of the round ligaments.
The round ligaments are followed medially—they are grasped
Preoperative with a curved clamp near the uterine cornu, cut and ligated,
Ultrasonography gives size of uterus and weight by formula lateral to the clamp.
length x width x anterioposterior width × 0.52. Normal weight The anterior leaf of the broad ligament is opened and
of uterus is 75–125 gm, maximum by weight NDVH can be incised up to the reflection of the bladder peritoneum on the
done up to 580 gm. uterus and the posterior leaf of the broad ligament is pushed
Preoperatively routine give soft purgatives Tab diazepam forward, thus making a window in the broad ligament. If
(valium) 2.5 mg is given night before surgery. Single dose of tubes and ovaries are to be spared, the utero-ovarian

Figs 70.4A and B: Showing the types of skin incisions (A and B) for performing abdominal hysterectomy 561
 ligaments are clamped as close to the uterus as possible so below the cervix. Further dissection and mobilization of the
that blood supply of mesosalpinx and mesovarium are not base of bladder anteriorly and rectum posteriorly can be
interfered with, the incision and ligature is made. If tubes and accomplished, if required.
ovaries are to be removed with the uterus, the infundibulopelvic The fibers of pubovesicocervical fascia are dissected
ligament portion of the broad ligament is clamped (Fig. 70.5), cut away from the cervix and reflected laterally off the anterior
and transfixed. Ureters should be located before putting this surface of the cervix and upper vagina. The whitish fascial
clamp. Same procedure is carried out on the opposite side. plane of the vagina comes into view.
The midline reflection of the bladder peritoneum onto The dissection of the remaining portion of the uterosacral
the uterus is freed by incising the peritoneum from the point ligament is carried out by placing straight clamps inside the
where each round ligament is cut and extended medially rectovaginal space posteriorly and inside the cut edges of the
and inferiorly towards the midportion of lower uterus pubovesicocervical fascia anteriorly. Each clamp is replaced
segment where the incisions meet in the middle. Now the by delayed absorbable suture ligature (Fig. 70.7). The uterus
Major Operation

bladder is separated from the lower uterus segment and the is removed (Fig. 70.8).
upper cervix by blunt dissection and complete mobilization The anterior and posterior wall of the vagina may be
of the bladder is done but if it is adherent then it should be clamped together at each lateral vaginal angle or the uterus
surgically released with scissors (sharp dissection). may be removed by a circumferential incision in the vagina
The posterior leaf of broad ligament is incised on either close to the cervix, ensuring that the entire cervix has been
side down to the point of origin of the uterosacral ligament removed with the uterus.
behind the cervix. Now the uterine vessels are exposed and As anterior, posterior and lateral angles of the vagina
skeletonized, triply clamped and cut. To avoid ureteric injury, are opened, straight clamps are placed to secure the vaginal
it is always advisable to palpate the lower portion of the margins. The lateral vaginal angle clamps are replaced with
pelvic ureters as they course beneath the uterine arteries transfixation sutures. Some surgeons place sutures for tight
Section 17

lateral to the interior os, passing medially and anteriorly closure of the vaginal vault while others use open cuff
through the base of broad ligament to enter the trigone of techniques for allowing better extraperitoneal drainage.
the bladder. When the vaginal vault is left open, the incidence of cuff
The lowest clamp is placed initially at the level of internal cellulitis, abscess and hematoma formation is reduced. After
os at right angles to the lower uterine segment. The upper the vaginal angle clamps have been replaced with
clamp prevents the backflow from the uterus and lower two transfixation sutures, the free margins of the vagina is reefed
clamps doubly occlude the uterine vessels. with continuous locking sutures.
The uterine vessels are triply ligated because if only one Because of the possibility of the vaginal vault prolapse
clamp is used and the tissue slips out of ligature and retracts, or enterocoele in subsequent years after hysterectomy,
the uterines vessels may be caught again and attempt to vaginal vault must be supported well. Reperitonization is
clamp retracted vessels may result in injury to the ureter completed by suturing the bladder peritoneum to the cul-de-
(Fig. 70.6). sac peritoneum or can be left without reperitoni-zation
Further clamp is placed between the uterine vessel and ensuring complete hemostasis before closing the abdomen.
side of the uterus which includes the uppermost part of the The abdomen is closed in layers (some surgeons do not
uterosacral ligament. This is cut and transfixed. The uterus stitch the abdominal peritoneum).
is pulled forward and upward to expose the uterosacral
ligament posteriorly. Now the uterosacral ligaments are Recovery after Surgery
clamped, cut and transfixed with particular care to avoid Patient is kept nil orally for 24 hours. IV fluids are administered
injury to the pelvic portion of ureter. Continued sharp and during first two days, allowing gradual oral feed
blunt dissection posteriorly and inferiorly in the midline subsequently.
between the ligated uterosacral ligament will develop a plane Antibiotics and analgesics are given by IV injection at
between the cervix and vagina anteriorly and the anterior the time of incision. Catheterization is done for the period of
rectal wall posteriorly. operation only. Patients are encouraged to resume their
At this point, the dissection of the bladder base away normal daily activities as soon as possible. Mobility is
from the anterior vaginal wall should be completed with particularly important since it helps to prevent chest and
traction on the uterus placing two index fingers opposed DVT complications.

Fig. 70.5: Divison of the infundibular ligament between clamps Fig. 70.6: Uterine arteries being triply clamped
562
 Chapter 70
Fig. 70.7: The lateral vaginal angle being dissected out Fig. 70.8: Postoperative specimen following total hysterectomy
(the uterus, the cervix)

Hysterectomy
To minimize stress of the healing tissues, patients are • Cervix flushed with vault
asked to avoid lifting heavy weights for four to six weeks • Adnexal pathology
after surgery. Vaginal intercourse, tampons and douching • Very limited vaginal space
are not recommended for the same time period to allow • Severely restricted uterine mobility.
complete healing. Any woman with a history of abnormal
Pap smear is recommended to have annual Pap smear PREOPERATIVE PREPARATION
examination for the remainder of her lifetime. Vaginal hysterectomies were already being performed in
the 19th century. The first was by Langerbeck in 1813, since
COMPLICATIONS OF ABDOMINAL HYSTERECTOMY then many modifications and variations have been reported.
Hysterectomy poses some risks with major and minor Schautaz (1890) gave a boost to vaginal surgery treating
complications. However, most women are free from carcinoma cervix by vaginal route. The current technique of
complications of hysterectomy. Incidence of major vagina hysterectomy has evolved from a variety of
complications is approximately 5 and these include: operations. Heaney first reported in 1934 the correct
1. Excessive blood loss requiring blood transfusion – 11.9 technique of vaginal hysterectomy by putting clamps in
2. Bowel injury—0.6 various ligaments supporting uterus and tying them before
3. Bladder injury—0.6 taking out the uterus 1940 was the year when Telende
4. Pulmonary embolism—0.6 performed vaginal hysterectomy.
5. Hematoma at surgical site—1 The first operative procedure of endoscopic hysterectomy
6. Injury to the ureter—1.7 unilateral or bilateral, partial or was done by Kurth Semm in 1984 of Germany. He derived
complete. Tear or obstruction may happen occasionally clamping and coagulating uterine supports per abdomen
specially in difficult dissection, malignant adhesions, through small holes and removing uterus per vaginal. The
endometriosis and in women with lot of pelvic fat, etc. procedure required great skill, training, and is costly.
7. Deep vein thrombosis—pelvic surgery increases risk of Vaginal hysterectomy by itself became popular in late
developing blood clots in the large veins of leg or lung. 1988 and early 90s. Even in non-prolapsed uterus cases with
Medication (low dose heparin) may be given to some uterine indication this non-descend vaginal hysterectomy was
women to prevent blood clots. performed. It was done by various surgeons for DUB, small
fibroid and other gynecological non-malignant conditions.
The Minor complication includes: In the coming days, it will certainly emerge as the
1. Hematoma not needing surgical drainage operations of choice. The abdominal approach will only be
2. Incisional wound infection: low grade fever which is resorted to when vaginal surgery is contraindicated the pride
common after hysterectomy is not always caused by and the excellence of Gynecological surgeon should be in
infection and usually resolves without treatment. the vaginal operation. But it needs experience.
However, high and persistent fever may signal an In prospective randomized study no difference between
infection—6.8 . vaginal hysterectomy and LAVH was found with respect to
3. Fever—3 estimated blood loss, complications, hospital stay and period
4. Heavy blood loss not requiring transfusion—1 of convalescence. In comparison the cost of LAVH was
5. Vaginal vault granulation—0.1 considerably high. It seems that laparoscopically vaginal
6. Vaginal vault prolapse—0.6 hysterectomy should be replaced by the vaginal
7. Incisional hernia—1.1 hysterectomy rather than abdominal hysterectomy when
there are contraindi-cations for laparoscopic hysterectomy.
A AL YS R C O Y There are less contraindications for vaginal hysterectomy
When the uterus is removed vaginally— and operation can be performed with nulliparity and big
Absolute contraindications for vaginal hysterectomy uterus even up to the size of 20 weeks and 500 gm by weight.
• Uterus 20 wks size Given choice most women would choose vaginal
• Previous VVF or RVF repair hysterectomy which is the gold standard for surgically 563
 removal of uterus. Although size beyond 14–16 weeks of to prevent them coming in the way at the time of operation
gestational is often regarded as relative contraindication for urinary bladder is catheterized with a metal catheter
non-descent vaginal hysterectomy. Size alone is rarely a (smeared with xylocaine jelly at the tip). Anterior lip of cervix
deciding factor restricted morbidity of uterus, transverse is caught (Fig. 70.10). Bladder sound is passed to know the
enlargement of uterus previous uterine surgery like LSCS extend of cystocele (Fig. 70.11). Two allis forceps are placed
or myomectomy and PID are few cases which need extra at the angles. A circumscribed incision is given at a level
precautions and expertise. below the bladder descend limit or isthmus level. Some
surgeons give inverted T incision.
Operation Procedure
Vaginal hysterectomy has been recommended for treatment Definition of the Vesicovaginal Space
for benign conditions. Therefore, endometrial malignancies • Blunt dissection with gauze wrapped around the finger, or
should be excluded before starting operations. If diagnostic with cutting edges of the scalpel sharp dissection is done
Major Operation

curettage not been done earlier hysteroscopy at least be and the vaginal fascia is separated from the vesical fascia
done to rule out malignancy. almost as far laterally as the inferior ramus of the pubic
Investigations routine and specific as per patient bone. If the correct layer is reached, the separation may be
condition are done for surgery and anesthesia as in total completely bloodless.
abdominal hysterectomy (TAH). Ultrasound is done prior to
surgery to know exact size and locations of enlargement of Mobilization of Bladder
uterus. CT and MRI are not mandatory. • The cervix is pulled down by one of the assistants by
Do painting and then sterile drapping of the vulva and its volsellum forceps. The bladder is drawn up. The
surrounding areas up to midthigh and umbilicus after the vesicocervical ligament is cut with the Mayo’s scissors,
patient is anesthetized on the operation table and put in the convexity of the curves of the blades of the scissors
Section 17

lithotomy position. A per vagina under anesthesia will give being directed towards the bladder. On each side the
update position. Labial stitches (Fig. 70.9) are given with silk bladder pillar is also divided (Fig. 70.12).

Fig. 70.9: Labial stitches

Fig. 70.11: Bladder sounding

564 Fig. 70.10: Anterior lip caught by vulsellum Fig. 70.12: Bladder mobilization
Exposure of Vesicocervical Space
• After the vesicocervical ligament has been divided a clear
space known as vesicocervical space is exposed with
gauge dissection and the lateral extension of the bladder
are thoroughly separated from the lateral border of
uterus. The bladder is now separated from the cervix
with a retractor and the peritoneum of the uterovesical
pouch exposed.

Opening the Uterovesical Pouch

• The peritoneum of uterovesical pouch is divided with
Mayo’s scissors to expose the peritoneal cavity. The

Chapter 70
peritoneum is divided on each side as far laterally as
possible (Fig. 70.13).

Opening the Pouch of Douglas

• The assistant now pulls the cervix upwards and forwards
with vulsellum holding the posterior lip. The anterior
incision is extended posteriorly and completed as

Hysterectomy
circumcision of cervix. The surgeon displays the pouch of
Douglas by exerting traction on the vaginal flap of the
posterior fornix in downward direction. The peritoneum of
pouch of Douglas POD is now opened and the incision
extended laterally or both sides. An assistant passes a
Sim’s speculum into the pouch and pulls the rectum
backwards (Figs 70.14 A and B).

Clamping and Section of the Pedicles

• The uterosacral ligaments are now identified by the
surgeon’s fingers and secured from within the pouch of
Douglas by a clamp. They are then cut and ligated by
transfixation sutures using No.1 vicryl (Figs 70.15 A to C).
• Now we proceed from below upwards along the tissues of
the broad ligaments by clamping, cutting and ligating. Both
the uterine vessels are ligated before proceeding further Figs 70.14A and B: Opening of pouch of Douglas
upwards (Figs 70.16 A to C). It is advisable that the tip of
the clamp securing the uterine pedicles should engage
• At this point, when only the ovarian and round ligaments
the peritoneum on front and back of broad ligament, so
are attached to the uterus, (Fig. 70.17), it can be delivered
that the chance of not including a tributary in the ligature
extremely through the pouch of Douglas or alternatively
is reduced.
through the uterovesical pouch.
• Now the ovarian and round ligament pedicles are
clamped (Figs 70.18 A and B) either together or separately
and cut and transfixed (Fig. 70.19). The uterus is now
removed (Fig. 70.20).
A culdoplasty is recommended by some gynecologic
surgeons to decrease the subsequent risk of enterocele
formation and the potential for development of vaginal vault
prolapse.
McCalls Culdoplasty—An absorbable suture is placed
through the full thickness of the posterior vaginal wall at the
apex of what will be the vaginal vault. The suture is then passed
through the left uterosacral ligament pedicle, the posterior
peritoneum, and the right uterosacral ligament and completed
by passing the suture from the inside to the outside at the
same point that it was begun. The suture is then tied, which
approximates the uterosacral ligaments and posterior
peritoneum.
Moschcowitz type repair—It is done by closing the cul-
de-sac and bringing the uterosacral cardinal complex
together in the midline.
It is not necessary to use a vaginal pack or leave a bladder
catheter in place.
• Internal McCall sutures-depending on the size of
Fig. 70.13: Opening the uterovesical pouch enterocele, one to three internal McCalls sutures are 565
Major Operation
Section 17

Figs 70.16A to C: Uterine artery clamping

Figs 70.15A to C: Clamping of uterosacral ligaments • External McCall sutures: Now 1–2 internal McCall sutures
can be applied using 1–0 vicryl. It is applied cephalad to
applied. The surgeon depresses the sigmoid colon to the the internal McCalls. The suture is passed through the
patient’s right using left index and middle finger. Vicryl 10 posterior vaginal wall, then the left pararectal fascia,
sutures are placed deeply in left pararectal fascia which continued across the front of sigmoid colon to the right
is continued across the front of the sigmoid colon and pararectal fascia and then brought out through the vagina.
then in right pararectal fascia. These sutures are tagged These sutures are also tagged and tied after completion
566 to be tied after completion of anterior colporrhaphy. of anterior colporhorphy (Fig. 70.21).
 Chapter 70
Fig. 70.19: Uterine clamps

Fig. 70.17: Uterus attached with ovarian and round ligament

Hysterectomy
Fig. 70.20: Uterus after vaginal hysterectomy

Fig. 70.21: McCalls sutures

Anterior Colporrhaphy
• Buttressing sutures are taken through the vaginal adventia
and muscularis starting from one side. These sutures are
now tied in the midline.
• Now excess vaginal mucosa is excised (Figs 70.22A
Figs 70.18A and B: Ovarian and round ligament clamped and B) (too much vaginal mucosa must not be excised)
as it will result in narrowing of vaginal diameter and cause
dyspareunia). The vaginal mucosa is now closed by
Reperitonization interrupted sutures (prevent shortening of the vagina).
• Reperitonization sutures are applied cephalad to both
the Mccalls sutures. Posterior Colpoperineorrhaphy
• The anterior peritoneum is grasped with Ally’s forceps. • Ally’s clamps are placed at the mucocutaneous junction
The reperitonization suture is passed through the above just over the posterior termination of labium minus. The
and then through the peritoneum cephalad to McCalls width of incision is decided by placing 2 fingers in introitus
sutures picking up the peritoneum over uterosacral and and assessing the caliber of introitus. So as to avoid undue
cardinal ligaments. The purse string suture is now tied. constriction of the introitus postoperatively.
567
Major Operation

Figs 70.22A and B: Anterior colporrhaphy

• A midline incision is made extending upwards up to

Section 17

the third Allis clamp which is placed as described above

(Fig. 70.23).
• The vaginal epithelium is separated from the underlying
rectovaginal septum by blunt or sharp dissection (Fig.
70.24). Dissection depth is till the level the ischial spines
are reached. Series of side to side stitches are taken in
vaginal muscularis. The stitches are tied in the midline
(Fig. 70.25). A recent concept is that tears in the Denon
villier’s fascia (rectovaginal septum) and not the cause
of rectocele. Repair is, therefore, done by appropriate
reunion by interrupted stitches to restitute the normal
rectovaginal septum).

Enterocele Repair
• To be more comfortable, the table is placed in slight
Trendelenburg position to prevent the intestines from
prolapsing into the operative field. The peritoneum of
Fig. 70.23: Posterior colporrhaphy the posterior cul-de-sac is mobilized off the anterior
surface of the rectum and lower sigmoid and excess
• The mucocutaneous junction between the two Allis peritoneum is excised. The excess sac is excised and
clamps is excised. purse string sutures are given to obliterate the sac.
• A third Allis is placed in thevaginal wall in the midline Levator muscles are caught by Allis forceps (Figs 70.26A
usually about 5 cm above the vaginal orifice but this might and B)
differ depending on the size of the posterior vaginal wall • Levator plication is done by ligating its medial most fibers
prolapse. in the midline by sutures.

568
Fig. 70.24: Posterior colpoperineorrhaphy Fig. 70.25: Posterior colporrhaphy
• Vaginal mucosa is closed after cutting off excess tissue. begins to elongate, to aid exposure of the incisional plane and
Perineal muscles are brought together and tied. The skin to decrease blood loss. Care should be taken not to remove a
of the perineum is closed (Fig. 70.27). small core of tissue, but to remove a significant volume of the
central portion of the uterus. The overall result is an elongation
Always maintain hemostasis.
of the uterus.
• Vaginal packing is done (Not done by the editor)
Wedge morcellation is accomplished by removal of V-
• Foley’s catheterization is performed and kept overnight.
shaped tissue pieces, and is most commonly used for
ANCILLARY PROCEDURES FOR COMPLICATED CASES removal of anterior or posterior myomas or when a broad
ligament myoma is encountered. Using a tenaculum, the
Examination is under anesthesia is a must for any
posterior fundus is grasped and a V-type incision is made
gynecological surgery and the same for non-descend Vaginal
with a knife. A second tenaculum is attached to the piece of
Hysterectomy (NDVH).
tissue that is to be removed and the incision is completed. It

Chapter 70
Uterine Morcellation is important not to extend the incision into the broad ligament
or through the anterior portion of the uterine fundus. It is
Uterine morcellation refers to the piecemeal removal of a
often possible to perform a myomectomy for removal of an
large, often myomatous uterus. It is not recommended in
intact myoma; this greatly reduces the overall size of the uterus.
women with uterine cancer.
After securing uterine vessels—uterine hemisection (Fig.
Several methods have been described, including
70.12) or bivalving can be performed. The uterus is split in the
hemisection (bivalving), wedge/V-type incision, or
midline beginning at the cervix. One side of the uterus is then
intramyometrial coring/Lash procedure. The latter two

Hysterectomy
removed, followed by removal of the opposite side. If the uterus
techniques are most commonly used, generally in
is still too large to remove after it has been bisected, the uterine
combination. The operation is done up to uterine vasculature
half can be further morcellated. This method is most appropriate
ligated and the peritoneal cavity entered either posteriorly
for a fundal or midline myoma.
or anteriorly before beginning any type of morcellation.
The use of uterine morcellation to remove the enlarged
Intramyometrial coring is best suited for the diffusely
uterus transvaginally is a safe and effective procedure and
enlarged uterine fundus. Coring generally begins with a
morbidity is less than that encountered at the time of
circumferential incision into the lower uterine segment just
abdominal hysterectomy.
above the cervix. The incision is continued circumferentially
and cephalad in a slightly enlarging diameter. Constant Hemisection
traction should be maintained on the cervix as the uterus
The one half of the uterus is left inside the pelvis by pushing
uterus into the wound in the vagina after putting a marker at
the cervix with Alli’s forceps. The other half of the uterus is
delivered outside and its fundal structures are clamped, cut
and tied. Same procedure is done after pulling down other
half. Complete hemostasis is assured by seeing pelvic
ligatures and fundal structure ligatures.
Uterine volume may be reduced preoperatively by
administration of a gonadotropin—releasing hormone
agonist as a possible alternative to morcellation (3 months
before operation).

Poor Uterine Descensus

Sometimes the degree of uterine mobility that was anticipated
based upon office examination is not present at the examination
under anesthesia or after the procedure is begun. The surgeon
must decide whether to proceed with a vaginal approach or to
stop and convert the procedure to an abdominal approach lack

Figs 70.26A and B: Posterior colporrhaphy Fig. 70.27: Completed procedure 569
 of descent resulting from extensive adhesive disease usually from vaginal to abdominal can be done at any time if difficulty
requires an abdominal incision or packing the vagina and arises. Surgeon should never hesitate to open abdomen or
accessing the pelvis by means of laparoscopy. changing procedure from vaginal to abdominal if any time
Many surgeons infiltrate the vaginal wall with a mixture difficulty is encountered.
of 1: 200000 or 1: 100000 concentration of xylocaine adrenaline
solution but many reported given incision at proper place CORNUAL FIBROID
hardly require this procedure so far as bleeding/oozing of Bissection procedure is followed after uterine artery ligation
vessels concerned. Non descent cervix pose little problem on both sides (after Mackenrodt’s and uterolsacral ligaments
in completing this incision all around, the incision can be have been tied). Bisection of uterus is done on non-fibroid
given from 2 o’clock to 10’o clock and then 4’o clock to 8’o side first. The incision is carried spirally towards non-fibroid
clock positions. The reflection of vaginal flap anteriorly and side and uterine half is delivered first and then space is
posteriorly exposes the anterior and posterior peritoneal. created and fibroid side is delivered later. If fibroid is
Major Operation

Identifying anterior peritoneum by loose and glistening approachable through the cavity, enucleation of the fibroid
surface with convexity downward. Cutting on opening free is done prior to putting clamps on fundal structures and
fluid small in amount comes out. The opening is secured by completing the procedure.
right angle laden’s retractor angles are widen with fingers
stretching laterally on both sides. BIG UTERUS WITH MULTIPLE FIBROIDS
The uterine fundal structures are brought in view by Bissection of the uterus is done after ligation of vessels and
applying traction downwards and laterally on contralateral ligaments. Fibroids are enucleated manually or with the help
side. The fundal structures are clamped, cut, and tied on of a myoma screw and uterus is delivered after myomectomy.
both sides (Fig. 70.13). Uterosacral ligaments are secured Coring of big adenomyotic uterus is started from isthmic
for further doing culdoplasty by McCaul’s technique. Other level longitudinally upwards and uterus size is reduced before
Section 17

ligaments which have been secured are inspected for delivering the uterus.
bleeding and so are uterine vessels. Some surgeons prefer
to bring down fundus through cul-de-sac before putting Complications of Surgery
clamps on broad ligaments and fundal structures. Uterus 1. Retention of urine—Incidence of retention is much lower
can be delivered anteriorly or posteriorly through incisions after NDVH than after vaginal hysterectomy done for
in anterior and posterior pouch and it causes no problem if prolapse.
uterus is of normal size. Bisecting uterus (Fig. 70.14) is done 2. Pyrexia—Presence of pyrexia may indicate urinary tract
after ligation of uterine vessels. infection and should be investigated for the same.
Ovaries are inspected and palpated if not removed. 3. Vault Sepsis
Culdoplasty is done by taking sutures from posterior 4. Postoperative collapse—Patient should be re-examined
vaginal wall inwards from one angle of opened vaginal vault in OT for retraction of uterine vessels and bleeding or
and then taking a bite from uterosacral ligament on one slippage of ligature.
side, taking another bite from pelvic peritoneum followed by 5. Fistula formation—Blood stained urine or leaking during
from uterosacral ligament of other side and taking final bite intraoperative procedure. A dye test should be performed
from inside out to vaginal wall parallel to the first suture. with catheter to find out bladder injury and repair should
Both ends are held together for tying and are tied after be done immediately.
finishing suturing of vaginal vault at end of all procedures. 6. Hemorrhage—It can be intraoperative or postoperative.
This procedure will prevent future vault prolapse. Postoperative hemorrhage is primary due to bleeding from
Vault of vagina is sutured with number 1–0 catgut after vessels due to infection or may be secondary if occurs
completing inspection of all ligatures in transverse manner. after 24 hrs.
Some surgeons do not put pack at all. Catheter and vaginal
packing are removed after 24 hrs. Mobilization of the patient Late Complications
is started on 2nd day onwards and oral ingestion is allowed. 1. Secondary hemorrhage and vault dehiscence.
Patient can be discharged on 3rd day if there is no fever or 2. Thromboembolic complication particularly patients of
any other complication. diabetes and hypertension. Patient should be treated with
thromboembolic prophylaxis with heparin.
VAGINAL HYSTERECTOMY IN SPECIAL CIRCUMSTANCES 3. Dyspareunia.
NDVH with Previous Scar of Myomectomy and LSCS 4. Vault prolapse, if vault is not supported properly.
Cesarean section distorts the anatomy by reducing the Vaginal hysterectomy is a state of art procedure for the
vesicouterine space between the scar and urinary bladder. gynecologist.
In this circumstance, dissection done more towards the
uterine surface keeps the bladder further away and OPERATIVE PROCEDURE
peritoneum can be then identified separately. The surgical technique is dependent upon the pathologic
Injury to bladder at this stage almost always will be above conditions or anatomic variations encountered.
the trigon area of bladder. A gush of fresh urine flowing
indicates the injury to bladder which can be identified by Initial Steps
injecting the dye (Methylene blue) through catheter per Patient positioning in dorsal lithotomy is critical to obtain
urethra. Injury site is isolated and dissection continued. optimal exposure. When adequate anesthesia is attained,
Bladder injury repair can be done by Vicryl no. 3–0 in two a bimanual pelvic examination is performed to confirm
layers. After finishing and completing hysterectomy. Bladder the findings, to assess uterine mobility and descent, and to
is drained for 10–14 days (in these cases of bladder injury). confirm that no unsuspected adnexal pathology is found. A
Reflection of peritoneum and bladder is done very final decision can be made at this time to proceed with a
570 carefully and under direct vision. Changing of procedure vaginal or abdominal approach.
 The patient is painted the vulva and draped. A metal Vasopressin (10 to 20 units in 50 ml saline) or lidocaine
bladder catheter may be inserted and bladder is emptied (0.5 ) is injected into the cervical, paracervical, and
(although some surgeons believe that a distended bladder submucosal tissues by some surgeons to help identify tissue
helps with recognition of a bladder injury and thus do not use planes and reduce blood loss. However, vasoconstrictive
a catheter). A weighted speculum is placed into the posterior agents are not required.
vagina, a Deaver or right angle retractor is positioned Prior to vault closure anterior and posterior vaginal wall
anterior to the cervix and then the anterior and posterior lips defects are repaired as per patients requirement.
of the cervix are grasped with a single- or double-toothed Closure: The vaginal epithelium is reapproximated in
tenaculum or a rostellum. either a vertical or horizontal manner using either a
continuous suture or a series of interrupted sutures. The
Laparoscopic Assisted Vaginal Hysterectomy sutures are placed through the entire thickness of the vaginal
A simple classification of the above is as follows: epithelium, making certain that the bladder is not entered.

Chapter 70
• Laparoscopy with vaginal hysterectomy The peritoneum can be incorporated into these sutures, but
• Laparoscopic assisted vaginal hysterectomy with or this is not necessary. Whether the cuff is closed vertically or
without bilateral oophorectomy horizontally does not affect postoperative morbidity or
• Laparoscopic supracervical (subtotal) hysterectomy vaginal depth.
• Laparoscopic total hysterectomy with or without bilateral
oophorectomy. POSTOPERATIVE CARE
By definition, if uterine vessels are ligated transvaginally, It is not generally necessary to leave a bladder catheter

Hysterectomy
the procedure is described as laparoscopically assisted in place postoperatively and even if a catheter is used, it should
vaginal hysterectomy. be removed no later than the morning following surgery.
If the uterine vessels are coagulated, or stapled or ligated Intravenous fluids are generally administered for the
through the laparoscopic, the operation is a laparoscopic first 24 hours to ensure that the patient remains well hydrated,
hysterectomy . especially if she experiences any nausea or vomiting. Early
feeding of a regular diet can stimulate the bowel. And thus
Preop one can begin with clear liquids and can rapidly advance to a
• Nill per oral from previous night regular diet.
• Enema is given previous night and morning of surgery Adequate control of postoperative pain is necessary.
• Preop antibiotic is given. Patient-controlled analgesia can be utilized, either epidural
or intravenous, or an opioid pain medication can be given
Steps of Vaginal Hysterectomy as an intravenous or intramuscular injection. Oral or per
• Position: Lithotomy position rectal analgesics are usually adequate on the first
• Procedure: Parts are cleaned and draped postoperative day.
• Labial sutures with silk are applied for proper exposure The woman is encouraged to resume her normal daily
• Bladder emptied activities as quickly as is comfortable. Walking and stair
• A careful pelvic examination is done climbing are encouraged; tub baths or showers are
• Sims speculum is introduced permissible. She should avoid lifting any heavy weight for
• Cervix is held with a tenaculum and traction is applied four to six weeks after surgery to minimize stress on the
and cervix is delivered out of the vagina. healing fascia. Vaginal intercourse is also discouraged during
this period to allow the vaginal cuff to heal completely. Driving
Inspection should be avoided until full mobility returns and opioid
• On inspection, 3 grooves can be distinguished in the analgesia is no longer required.
anterior vaginal wall—
1. A small groove immediately above the external Complications
urethral meatus- submeatal sulcus. The most common complications are urinary, bowel and
2. About 4 cm above this level lies a second sulcus known bladder injuries, hemorrhage, and infection. Viral compli-
as transverse vaginal sulcus which corresponds to cation late in a vaginal hysterectomy is 1–3 .
the upper border of posturethral ligament.
3. Near the cervix a third sulcus can be distinguished UROLOGIC ISSUES
best referred to as the bladder sulcus which indicates Urinary Incontinence
the upper limit of the relation of the bladder to the Hysterectomy may result in damage to the nerve supply or
anterior vaginal wall. supportive tissues of the pelvic floor which may lead
• In cystocele, the prolapse of the vaginal wall is restricted to subsequent urinary incontinence; however, this is
to the space between the transverse vaginal sulcus and controversial.
bladder sulcus.
Ureteral Injury
Anterior Vaginal Incision The ureter can sometimes be visualized and/or palpated
• A circumferential incision is made at the cervicovaginal during vaginal hysterectomy. The best way to avoid ureteral
junction (below the lower limit of bladder i.e. below the injury is to place all clamps close to the uterus and keep the
bladder sulcus). A middle incision is made from the above bladder out of the operative field, which displaces the ureters
incision and subsequently extended upwards till the level away from the operative field. If an injury is suspected,
of the submeatal sulcus. cystoscopic evaluation is especially helpful during vaginal
• Alternatively, the vaginal may be incised as an inverted hysterectomy or else retro grade instillation of methylene
V shaped incision. blue can be performed. Ureteral injuries are rare.
571
 Bladder Injury bleeding will tamponade and stop, forming a hematoma that
Bladder injuries occur in 1–2 of cases. The bladder is most will eventually reabsorb. The risk of this approach is that the
commonly perforated during entry into the anterior cul-de- hematoma will become infected, necessitating surgery if
sac. A one- or two-layer running closure with a small caliber antibiotic therapy is not successful.
absorbable suture (e.g. 3–0) is adequate, if the bladder has not Another option is to perform an abdominal exploration
been irradiated. ethylene blue can be instilled into the bladder while the patient is stable and in good condition. This approach
to confirm the adequacy of the repair, and the ureteral orifices brings the added morbidity of a second anesthesia and an
observed cystoscopically to ensure they have not been abdominal incision, but avoids the possibility of her condition
compromised. The bladder should be drained until gross deteriorating with continued delay or the possibility of a pelvic
hematuria has cleared and for a minimum of three to four abscess later. General anesthesia should be administered
days, or until a cystogram confirms bladder healing. and the vaginal operative site explored. Consideration may
be given to laparoscopy, as this may allow identification and
Major Operation

Bowel Injury control of the bleeding site without the need for laparotomy.
Bowel injuries are uncommon; the incidence is 0.4 .
Infection
Colonic Injury Febrile morbidity occurs in approximately 15 of women.
The ascending and descending colon and rectum can be This rate can be reduced substantially with use of
injured during either abdominal or vaginal hysterectomy, the prophylactic antibiotics. Infection after vaginal hysterectomy
transverse colon is rarely damaged since it is well out of the can be classified as vaginal cuff cellulitis, pelvic cellulitis,
operative field. Repair is similar to that described above for pelvic abscess, and infected pelvic hematoma; pelvic
the small bowel. However, if the bowel has not been cleansed infection occurs in 4 of cases. Pelvic cellulitis is an infection
preoperatively and the injury is larger than 5.0 cm, a diverting of the soft tissues of the pelvis and usually begins about the
Section 17

colostomy may be rarely considered, especially if there is third day after surgery. Although some degree of cuff cellulitis
gross spillage of bowel contents. probably occurs after every hysterectomy, antibiotics are
not required unless the fever persists.
Hemorrhage Regardless of the type of infection, treatment is initiated with
Blood loss averages 300 ml. Significant arterial bleeding is broad-spectrum intravenous antibiotic therapy, which should be
usually from the uterine arteries or the ovarian vessels near continued for 24–48 hours after the resolution of fever and
the insertion of the infundibulopelvic ligaments and occurs symptoms. Oral antibiotics after parenteral therapy are not
in less than 1 of cases. Blindly clamping or mass ligature necessary. If the patient does not respond to parenteral antibiotic
placement in bleeding areas should always be avoided, as therapy or the pelvic examination findings are uncertain, an
one risks unnecessary ureteral or bowel injury. It is best to ultrasound may be helpful. In addition, the vaginal cuff should be
apply a pressure pack to tamponade the bleeding and then opened using a Kelly clamp or uterine dressing forceps and
slowly remove the pack to visualize, isolate, and individually allowed to drain.
clamp the bleeding vessels. The use of surgical clips may be
helpful. Venous bleeding is often more bothersome than Urinary Retention
arterial bleeding, but can usually be controlled with pressure It is the only postoperative complication that is higher in
and/or suture ligation. Bleeding from peritoneal edges or patients undergoing vaginal hysterectomy compared to
denuded surfaces may be cauterized or topical hemostatic those undergoing abdominal hysterectomy. It usually results
agents can be applied. from pain or bladder atony. The bladder can be drained until
If a vascular pedicle is lost during a vaginal hysterectomy the patient is able to void.
and efforts at visualization from below are unsuccessful,
blind clamping or suturing is ill advised. Laparoscopy can be Fallopian Tube Prolapse
used to identify and control the bleeding site, with laparotomy Prolapse of the fallopian tube is an uncommon postoperative
reserved for bleeding inaccessible to laparoscopic techniques complication often confused with granulation tissue at the
or beyond the skill of the surgeon. vaginal apex. Development of a hematoma or abscess at the
Early and late postoperative hemorrhages occur in 2 of vaginal apex is a predisposing factor. If the tissue at the top of
cases. Early postoperative hemorrhage after vaginal hyster- the vaginal cuff does not respond to conservative treatment,
ectomy may present as bleeding from the vagina or as such as silver nitrate application or cryotherapy, a biopsy of the
deteriorating vital signs, falling hematocrit level, and flank or area is warranted to determine if it is tubal epithelium. Treatment
abdominal pain. The first presentation usually represents is surgical; the surrounding vaginal epithelium is opened and
bleeding from the vaginal cuff or one of the pedicles, while the widely undermined, and the tube is resected. Laparoscopic
latter presentation may represent retroperitoneal hemorrhage. and vaginal approaches may be used.
These two situations are approached differently in evaluation Acute management involves wrapping the bowel in moist
and treatment, but both involve prompt stabilization of vital saline soaked towels, administering intravenous fluids and
signs, fluid and blood product replacement, and constant broad spectrum antibiotics, and immediate laparotomy with
surveillance of the patient’s condition. The patient should be inspection and replacement of the mesentery and small
taken promptly to the examining room where the operative bowel. Any necrotic vaginal epithelium, or bowel, should be
site is viewed and the vaginal cuff inspected. Bleeding from the resected, and the vaginal cuff should be closed.
vaginal cuff can usually be sutured in the examination room.
Bleeding arising from above the cuff should be evaluated Life after Hysterectomy
in the operating room. Physical examination typically reveals After hysterectomy, most women report relief of symptoms,
tenderness and dullness in the flank and abdominal improved quality of life, no adverse effect on sexual function,
distension. If the patient’s condition stabilizes rapidly with and satisfaction with their surgery.
572 intravenous fluids, she can be transfused and followed with Women’s response to hysterectomy show that most
serial hematocrits and vital signs. In many instances, the women are very satisfied with their results. Most reported
improvement in symptoms directly related to the removal life saving measure. Thus, a detailed assessment of the
of the uterus, including pain and vaginal bleeding. The sexual severity of menstrual complaints, pelvic pain and
functions, interest in sex and dyspareunia also improved in premenstrual symptoms should be done to assess the need
most women. However, this improvement was dependent for hysterectomy. Hence, detailed information on
upon several factors, including the age of women at the time hysterectomy, its alternatives, both medical and surgical,
of surgery and the reason for surgery. Some women have allows patients to evaluate the benefits and risks of any
feelings of anxiety or depression after surgery including a treatment against the severity of the symptoms as
feeling of incomplete woman. perceived by them. Such an informed choice can help
If both the ovaries were needed to be removed in a prevent against emotional trauma.
premenopausal woman, then she enters the menopause b. Psychological evaluation: The emotional state of the
abruptly. This results in more severe symptomatology than patient after the decision of hysterectomy may identity
she would otherwise experience due to naturally going into the those with the unstable or neurotic personality.

Chapter 70
menopause. These symptoms included; hot flushes, night Assessment of the patient’s mental status with inquiry of
sweats, vaginal dryness, mood swings and decreased sex drive. their personal or family psychiatry history should be
routinely taken.
Psychological Impact c. Psychosexual counseling: The attitude towards the decision
Hysterectomy has long been repeatedly linked with determines the psychological outcome, hence the patient
psychological issues, anxiety and other sensitive responses should be able to understand the need for the treatment.
with patient’s sociocultural make up. Literature does not cite An opportunity to freely discuss their concerns, clarify

Hysterectomy
definitively whether a hysterectomy leads today to a mood misconceptions and sharing of experience of other
disorder or rather an improvement of mood. patients in a support group can be beneficial in dealing
A positive or negative impact on the patient’s well-being with fears, anxities and uncertainties.
is a subjective perception. Therefore, it is advisable to explain d. Psychosexual counseling of the partner further lends
the patient the indication of surgery, assess psychological support and reassurance to the patient.
readiness, physical and social preparedness for surgery and Thus, in summary, the operation of abdominal
issues relating to gender as understood by the patient. A hysterectomy is quite common and safe procedure to be
reduction in pain, an understanding of correct treatment performed in experienced hands. The procedure of
received and freedom from the ongoing illness give a positive abdominal hysterectomy, however, should not be misused
impact and an improvement in quality of mood. However, for sake of ease of operation as compared to the vaginal
the negative impact related with post-hysterectomy hysterectomy which is comparatively a difficult procedure
conditions is diversely researched, especially the development to perform. Abdominal hysterectomy should be performed
or recurrence of a depressive episode (incidence being reported only for the definite pathological indications, justifying
as 30–70 ). The reason attributed to this may be the loss of the need. Clinical guidelines need to be developed so that
uterus, which creates an emotional crisis with concerns over the woman undergoes most appropriate route of
loss of feminizing end of reproductive potential with the hysterectomy, that is cost-effective and meets the standard
diminished sexuality and stress. These factors are exacerbated of quality care.
as perceived with over sensitivity under purview of sociocultural
variables. In the Indian scenario, womanhood, motherhood BIBLIOGRAPHY
and beauty are synonymously understood, hence issues with 1 . Diker RC, Greenspan R, Strauss LT, et al. Complications of
reproductive ability and cosmetic reasons due to scarring are abdominal and vaginal hysterectomy among women of
reproductive age in the United States. The Collaborative Review
further highlighted in the Indian setup.
of Sterilization. Am Obstet Gynecol 1982;144:841-6.
However, the risk of developing a psychiatric illness can 2 . ohn D. Thompson, Hysterectomy; Operative Gynaecology;
be dealt with by addressing the risk factors. The prospective 1992. pp.663-738.
studies did not support the influence of party, marital status 3 . Kovac SR. Guidelines to determine the route of hysterectomy.
and socioeconomic background. A higher rate of depression Obstet Gynecol 1995;85:18-23.
was noted in younger patients only in a prospective study. 4 . Kovac SR. Decision-directed hysterectomy: a possible approach
Others suggest that older women are more prone to post- to improve medical and economic outcomes. Int Gynaecol
operative complications that may result in depression. The Obstet 2000;71(2):159-69.
5 . Kovac SR. Hysterectomy outcomes in Patient with Similar
factors that increase the risk of developing depression are:
Indications. Obstet Gynecol 2000;95:787-93.
a. Patients with limited education who had misconceptions 6 . McCracken G, Hunter D, Morgan D, et al. Comparison of
regarding the role of uterus and were secretive about laparoscopic-assisted vaginal hysterectomy. Total abdominal
their fears and anxieties. hysterectomy and vaginal hysterectomy. Ulster Med 2006;75:54-8.
b. Cultural influences which emphasize reproductive 7 . uerleu D, Cosson M, Paramentier D, et al. The impact of
abilities and attach traditional roles to women. laparoscopic surgery on vaginal hysterectomy. Gynecol Endosc
c. A hysterectomy performed as an emergency is commonly 1993;2:89-91.
seen to be associated with anger and depression as these 8 . Richardson RE, Bournas N, Magos A. Is laparoscopic
hysterectomy a waste of time Lancet 1995;345:36-41.
women do not get time to psychologically adjust to the
9 . Saini , Kuczynski E, Gretz III HF, Scott Sills E. Supracervical
intervention. hysterectomy versus total abdominal hysterectomy: perceived
d. Nervous and over anxious patients unable to cope with effects on sexual function. BMC Women’s Health 2002;2:1-7.
stress, are particularly vulnerable to depression both 9 . Ryan MM, Dennerstein L, Pepperell R. Psychological aspects of
before and after hysterectomy. hysterectomy: a prospective study. Br Psychol 1989;154:516-22.
10 . Thakar R. Ayers S, Clarkson P, et al. Outcomes after total versus
Preventive Measures subtotal abdominal hysterectomy. N Engl Med 2002;347:1318-24.
a. Careful case selection: Hysterectomy is usually 11 . G Cha, HK HO, H Chen. Abdominal Hysterectomy: indications
performed to improve the quality of life rather than as a and complications. Singapore Med 1993;34:337-40. 573
 71 Microsurgery in Gynecology

Rekha Bharti, Sudha Salhan

DEFINITION 2. It gives limited depth of field and small field of view as

Microsurgery is defined as surgery under magnification. microscope can only be directed vertically downwards.
Delicate tissue handling and use of fine sutures is the hallmark 3. With use of microscope, lesions below ovaries, tubes and
of microsurgery. The use of specialized instruments allows uterus could not be accessed.
precise tissue dissection and minimizes tissue trauma. The use of laparoscopic microsurgery could overcome the above
Microsurgery was introduced in the field of infertility to limitations. The varied angle approach of the telescope allows
improve conception rates. multiple angles of view as well as ability to look underneath
Initially, operating optical glasses or magnifying loops organs for continuous microsurgery.
which allowed moderate magnification were used by surgeons.
However, in the modern era; the use of the operating microscope ADVANTAGES OF LAPAROSCOPIC
has produced better surgical results as it allows magnification TUBAL ANASTOMOSIS
from 2–30 folds. 1. All microsurgical principles like magnification, gentle tissue
The basic principles of microsurgery include: handling, hemostasis, irrigation and lavage are well-
1. Delicate handling of tissues to minimize tissue trauma. maintained.
2. Frequent intraoperative irrigation with heparinized ringer 2. This technique avoids tissue trauma associated with packing
lactate solution to prevent tissue drying. and retractors.
3. Use of electrical or laser energy to control bleeding and 3. Adhesion formation is minimal
enhance visualization, achieving pinpoint hemostasis. 4. Cosmetically better
4. Complete excision of the abnormal tissue till healthy tissue 5. Recovery is faster
is encountered. 6. Pregnancy rates are comparable with the open technique.
5. Correct alignment and approximation of tissue planes. Around 25–30% of subfertile women have tubal damage and
6. Preventing foreign body contamination with glove powder. quiet a few of them seek tubal reconstruction for fertility
Performing thorough pelvic lavage at the end of the enhancement. It is a single step procedure as compare to IVF
procedure to remove blood clots or debris. where multiple sittings may be required.
7. At the time of closing the abdomen, isotonic fluid is flooded
to prevent adhesions. INDICATIONS OF MICROSURGERY
These techniques are equally applicable to both laparotomy 1. Reversal of tubal sterilization.
and laparoscopy access. 2. Mid-tubal block secondary to pathology.
3. Tubal occlusion secondary to ectopic pregnancy.
EVOLUTION OF MICROSURGERY 4. Failed previous macrosurgical sterilization reversal.
Microscopy was first introduced by Holmgren in 1921 for 5. Salpingitis isthmica nodosa.
otosclerosis. It was quickly adopted by ophthalmology, 6. Failed tubal ligation for cornual block.
microvascular surgery and neurosurgery. In gynecology, this
Laparoscopic microsurgery is preferable to open microscopy
technique was first used for infertility in the late 1960s, by
for all but tubal re-anastomosis.
Swolin. He used magnification and delicate instruments for
procedures like adhesiolysis and neosalpingostomy. CONTRAINDICATIONS TO TUBAL MICROSURGERY
In mid 1970, Winston and Gomel, separately published their
1. Age 40 years
first series of microsurgical reversal of sterilization and tubal
2. Decreased ovarian reserve or ovarian failure
reconstruction for pathological occlusion of fallopian tube. The
3. Tubal infertility not amenable to tubal reconstruction
pregnancy rates in their series were superior to previous
4. Extensive tubal damage
macrosurgical procedures.
5. Hydrosalpinx with a diameter of more than 3 cm
The first human laparoscopic microsurgical tubal anasto-
6. Inadequate proximal or distal tubal segment for
mosis was performed in February 1992 using 7–0 and 8–0 nylon.
reanastomosis
7. Projected tubal length of less than 3 cm after the
LIMITATIONS OF MICROSURGERY BY LAPAROTOMY
reconstruction procedure
1. During laparotomy retraction and bowel packing causes 8. Extensive pelvic/peritubal adhesions
tissue trauma and postoperative adhesion formation.
 9. Abnormal uterine cavity
10. Any contraindication to pregnancy or surgery
11. Severe male factor infertility or male sterility.

EQUIPMENTS FOR CONVENTIONAL

MICROSURGERY (FIGS 71.1 AND 71.2)
1. Microscope
2. Needle driver
3. Scissors
4. Curved forceps
5. Straight forceps.

Chapter 71
Microsurgery in Gynecology
Fig. 71.2: Microsurgery instruments

EQUIPMENTS FOR LAPAROSCOPIC MICROSURGERY

1. Three-chip camera with digital enhancement
2. High resolution monitor
3. Cardiac titanium needles
4. Koh ultramicro series instruments.
Special Features of Microsurgical Instruments are:
1. Terminal serrations of the jaw so that fine sutures don’t get
crushed.
2. Special handle design for maximum transmission of hand
movements to the instrument tip.
3. 130° angle between handle and shaft of the instruments
provides better movements.

SURGICAL STEPS IN MICROSURGERY(FIGS 71.3 AND 71.4)

1. The proximal segment of the tube is distended by
Fig. 71.1: Operating microscope transcervical chromotubation to know the exact site of block.
2. The pathological segment is excised till healthy tissue is
reached and free spillage of dye is seen. Care is taken to cut

Fig. 71.3: Steps of tubal recanalization 575

 5. The first stitch is taken at 6 o’clock position and knot is
kept outside the lumen. Further stitches are taken at 9, 12
and 3 o’clock positions.
6. Throughout the procedure irrigation with heparinized
ringer lactate solution is done to avoid drying due to
exposure to air and operating lights.
7. Bleeding points are exposed by a jet of irrigating solution
instead of swabbing. Hemostasis is achieved with
electrocautery.
The technique of tuboplasty is an important determinant of its
success.
Major Operation

BIBLIOGRAPHY
1. Balen AH. Tubal Infertility and Fibroids;chapter 11,Infertility in
Practice, 3rd Edn; 2008.pp.239-57.
2. Jindal P, Gill BK, Gupta S. Reversal of tubal ligation under 4x
magnification. J Obstet Gynecol India 2005;55(5):448-50.
Fig. 71.4: Recanalization in progress 3. Jain M, Jain P, Garg R, Triapthi FM. Microsurgical tubal
recanalization: A hope for the hopeless, Indian Journal of plastic
surgery 2003;36(2):66-70.
the tube at a right angle to its long axis and not to extend 4. Jain N. Laparoscopic Surgery; Gynaecological Endoscopic surgery:
incision beyond the mesosalpinx. A nylon thread is passed Current Concepts by Desai SV and Joseph K; 2002.pp.38-42.
Section 17

through. 5. Tubal and Uterine Surgery, Fertility: Assessment and treatment for
people with fertility problems; Clinical Guideline National
3. Mesosalpinx is sutured first, using 6–0 polypropylene. This
Collaborating Centre for Women’s and Children’s Health
will help in bringing the tubal ends closer for better Commissioned by the National Institute for Clinical Excellence
alignment and approximation. 2004;8(1):70.
4. The tubal ends are anastomosed in two layers. The first layer 6. Zaveri K, Hinduza I, Role of Microsurgery in Infertility
is mucosal-muscularis and second layer is musculo-serosal. Management. The Infertility Manual by Rao 2004;2:228-36.

576
 72 Myomectomy

Sudha Salhan, Shweta Rajani

Definition 9. Hormonal suppression by GnRH analogues may be given

Myomectomy is the enucleation of myomata from the uterus in selected cases preoperatively to reduce the size of
leaving behind a potentially functional organ capable of myomas.
future reproduction. 10. Ultrasound for mapping of fibroids.

Indications Types of Myomectomy

1. Fibroids causing infertility. • Abdominal
2. Recurrent pregnancy wastage due to fibroid. • Vaginal
3. Other symptoms such as menorrhagia, metrorrhagia, • Hysteroscopic
etc. in women too young for hysterectomy. • Laparoscopic
4. Fibroids with complications such as torsion of a subserous • Robotic.
pedunculated fibroid, infection in a submucous fibroid
polyp, etc. Abdominal Myomectomy
Principles of Abdominal Myomectomy
Contraindications • Perioperative antimicrobial prophylaxis is given
1. Suspicion of malignancy. • Adequate exposure and thus an adequate incision is required
2. Suspected sarcomatous change in the fibroid. • Minimize blood loss.
3. Active pelvic inflammatory disease (PID). This is achieved by:
4. Severe anemia (In such cases, the patient’s hemoglobin a. Occlusion of the uterine and ovarian vessels using
should be built up and only then should she be operated). Bonney’s myomectomy clamp, tourniquet or use of
5. Diffuse adenomyosis. ring forceps on ovarian vessels.
6. Numerous leiomyomas/multiple leiomyomatosis. If all b. Local injection of vasoconstrictive agents such as
these myomas are removed rendering the uterus a mere vasopressin into superficial myometrium and serosa.
mass of multiple growths so that some myomas will c. Use of hypotensive anesthesia.
definitely be left behind at Myomectomy and necessitate
hysterectomy later. • Minimum number of incisions to be given to minimize
7. Other factors contributing to infertility being untreated, postoperative adhesions. Many myomas can be removed
e.g. both fallopian tubes irreparably damaged/husband from the same incision by tunneling, etc.
proved infertile, etc. With advent of in vitro fertilization, a. Site of uterine incision—preferably anterior, in the
these factors should be taken into account judiciously. midline. Avoid incisions on posterior uterine wall.
b. Remove as many fibroids as possible by “tunneling
Prerequisites Prior to Myomectomy incisions” through primary incision.
1. Build up hemoglobin. c. Avoid entry into endometrial cavity. If entered it must
2. Treat associated PID. be mentioned in the discharge slip as it has a bearing
3. Cervical exfoliative cytology (Pap smear) is done to rule in future pregnancy management.
out malignancy. d. Dissection of proper plane between fibroid and the
4. In cases of infertility, other factors such as male factor (semen pseudocapsule.
analysis), tubal factor (HSG), etc. have been ruled out. e . Avoid damage to the interstitial portion of the fallopian
5. All other conditions possibly responsible for the patient’s tube.
complaints have been excluded. • Closure of defect:
6. Adequate blood compatible with patient’s blood be kept a. Obliterate all dead spaces.
ready. b. Closure of serosa with baseball sutures with fine
7. Explain prognosis. Take consent for hysterectomy telling delayed absorbable material.
her the circumstances in which after multiple • Adhesion prevention is done by the following measures:
myomectomies the uterus left behind may be of no a. Keep the operative field moist using heparinized
physiological use and hence may need removal. The risks Ringer Lactate.
should be explained preoperatively after assuring our b. Gentle handling of tissues.
effort to save the uterus. c. Use fine instruments.
8. In some cases, hysteroscopy or hysterosalpingography may d. Sutures on serosal surface using fine nonreactive
be done to detect a fibroid encroaching the uterine cavity. material.
 e . Use of adhesion barriers like Interceed (Fig. 62.7), or Vaginal Myomectomy
put omentum if posterior uterine incisions are given. • Submucous pedunculated myoma can be removed
f. Flooding the operative field with normal saline before vaginally
closing the abdomen. • A moderate-sized fibroid can be removed by grasping the
• Postoperative: Avoid conception for at least 3 months fibroid with an Allis/Sponge forceps and twisting it off
• Morcellation is needed if tumor is large
Basic Technique/Steps • If it has a pedicle pull the fibroid, catch hold of its pedicle by
• The operation is performed under general/regional Kocher’s forceps, cut the pedicle and stitch it.
anesthesia
• Peroperative assessment: The uterus is palpated for Hysteroscopic Myomectomy
assessment of size, number and location of fibroids and It is indicated in cases of symptomatic submucous fibroids,
feasibility of myomectomy is determined. The uterine usually not greater than 4 cm in diameter and with less than
Major Operation

incisions best for each case are also decided 50% intramural component that is largely bulging into the
• The abdomen usually opened by infraumbilical vertical endometrial cavity.
incision
• Bonney’s myomectomy clamp is applied at the level of Complications
isthmus uteri. Sponge holding forceps applied on each 1. Perforation
infundibulopelvic ligament 2. Hemorrhage
• Minimum number of uterine incisions, preferably anterior 3. Infection
are given
4. Water intoxication.
• Myoma screw (Fig. 45.12) can be used
• All incisions are deepened till the pseudocapsule is cut, and Laparoscopic Myomectomy
Section 17

leiomyomas enucleated and shelled out (Figs 72.1 A and B).

Indication
• The hemostatic clamp should be released for 5 minutes
every 20 minutes for circulation of metabolites Intramural or subserous fibroids, usually less than 10 cm in size.
• Adequate hemostasis is achieved in the bed of leiomyoma Steps:
• Enucleation cavities are occluded and dead space is 1. Excision of fibroid
obliterated 2. Retrieval of fibroid from
• The serosa closed with “baseball sutures.” • Trocar site
• Morcellation
Complications
• By posterior colpotomy
Intraoperative • By minilap incision.
• Hemorrhage and the need for blood transfusion 3. Closure
• 2% risk of conversion to hysterectomy
• Damage to surrounding structures (ureter, bladder) Advantages
• Collection of hematoma in the layers of myometrium 1. Better cosmetically.
due to inadequate closure of enucleation cavities 2. Earlier recovery of patient, early ambulation, lesser
• Injury to interstitial portion of fallopian tubes. hospital stay.

Postoperative Disadvantages
• Febrile morbidity 1. Proper repair of uterine wall is difficult, so increased risk
• Infection. of rupture in subsequent pregnancy.
2. Increased expertise and infrastructure required.
Delayed
• Recurrence ( 10% in 5 years, 30% on 10 years) Robotic Myomectomy
• Omental or bowel adhesions to the scar It is less painful and there is less bleeding (see chapter 77 on
• Intrauterine synechiae where uterine cavity has been opened Robotic surgery).
• Rupture of the uterine scar in a subsequent pregnancy.

578
Figs 72.1A and B: Enclosing a myoma
 73 Radical Surgeries in Gynecology

Sudha Salhan, Banashree Das, HP Anand

Radical surgeries are done for malignancies. 1. Patents with FIGO stage 1A2-11A cervical cancer, who
Radical surgery involves removing the organ involved are medically fit enough to tolerate the aggressive
along with the draining lymph nodes, fascia, fat, etc. and a surgery and wish to avoid the long-term adverse effects
margin or normal tissue. of radiation therapy.
The main radical operations described in this chapter are: 2. oung patients who desire ovarian preservation and
• Radical hysterectomy retention of a functional, non-irradiated vagina.
• Radical vulvectomy 3. Patients who have relative or absolute contraindication
• Radical vaginectomy to radiotherapy, e.g. pelvic irradiation, previous history
• Exenterations. of pelvic abscess.
4. In cases who had recurrence after radiotherapy
RADICAL HYSTERECTOMY especially where the tumor is very small and centrally
Cervical cancer is the most common cancer of the female located.
genital tract in our country. If diagnosed in the early stages 5. In cases of cancer of the upper vagina.
it can be treated equally efficiently by both surgery and 6. Endometrial cancer which has spread to the lower uterine
radiotherapy. Establishing a radiotherapy unit is costly and segment or cervix.
cannot be available at every nook and corner of our vast
country. However, trained surgeons who can perform a Contraindications
radical hysterectomy can be available far more early. Besides, 1. Patients who refuse surgical treatment.
radiotherapy has its inherent long-term complications. 2. Medically unfit for surgery.
History: The first radical hysterectomy for cancer cervix was 3. Patient belonging to some religions who prohibit blood
performed at ohn Hopkins Hospital in 1895 by Dr Clark. Dr transfusion ( ehovah’s witness).
Wertheim an Austrian gynecologist developed radical total 4. In cases where lymph nodes seem to be involved which
hysterectomy with removal of the pelvic lymph nodes and will need postoperative radiotherapy. They come under
the parametrium in 1898, about 112 years ago He reported relative contraindication.
the outcome of his first 270 patients in 1905. The operative
Preoperative Work up Examination
mortality rate was 18 and the major morbidity rate was 31 .
In the meantime Schauta described his technique of radical General examination is performed to find out any medical
vaginal hysterectomy in 1901. He reported a lower operative disease so as to control them before the operation (e.g.
morbidity rate than the abdominal approach. Because the anemia, hypertension, diabetes mellitus).
surgical mode of treatment had high morbidity and Examination under anesthesia, physical examination
mortalities radiation therapy became the favored approach of the cervical growth to find the exact size of the tumor
in the early and middle 20th century. and presence of parametrial extension is important for
Meigs repopularized the surgical treatment in 1949. He clinical staging. Look for common sites of metastasis
developed a modified Wertheim operation in which he by examining the abdomen and supraclavicular lymph node.
removed all pelvic lymph nodes. (The Wertheim-Clark-plus Examine vagina, vulva and urethra closely for any suspicious
Taussig technique). lession. Per rectal examination is done for assessing the
In mid- and late-20th century there was improvement in size of the tumor, involvement of parametrium and rectal
anesthetic drugs and techniques. Blood transfusion became mucosa.
available, antibiotics and intensive care improved. These all Look for unilateral swelling of the leg denoting extension
led to various modification in the procedure of radical of the malignancy to the side walls leading to lymphatic and
hysterectomy besides conservative surgeries (e.g. conization venous obstruction.
and trachelectomy, etc). Cystoscopy
Indication for Radical Hysterectomy Examination of the interior of the urinary bladder is important
to detect extension of malignancy directly from the cervical
Proper selection of the patients according to indication will
lession. Bullous edema of the bladder does not make the
go a long way in improving the outcome of the operation and
tumor of higher stage. However, bullous edema signifies
the well-being of the patients. The following are the main
lymphatic obstruction of nearby tissue by tumor.
indications for performing radical hysterectomy:
 Barium enema is done to find disease outside the cervix. Boundaries of para-rectal space are:
• Anterior—cardinal ligament
Proctoscopy
• Posteriorly—sacrum
It is performed to know about the extension of cancer of the • Laterally—internal iliac (hypogastric) artery
cervix into the rectal mucosa. • Medially—rectum.
Colposcopy The next step is dissection of the bladder flap down on the
It is important in cases of endocervical carcinoma. vagina to look for the adhesions denoting spread. Broad
IVP is used to identify hydroureter and hydrone-phrosis. ligament is opened by clamping, cutting and ligating the
Sometimes double ureters can be identified besides a pelvic round ligament as laterally as possible (Figs 73.1 to 73.3).
kidney. Ureter is visualized. Now clamp, cut and ligate the
infundibulopelvic ligament (Fig. 73.4). If ovary is to be preserved
CT
Major Operation

then they are left (squamous cell carcinoma cervix has 0.5
It is not recommended by FIGO as an essential investigation. incidence of ovarian speread and adenocarcinoma has 1.5
But it is useful in evaluating the urinary tract, liver, bone and metastasis in the ovaries).
lymph nodes. Lymph nodes along with lymphatics and fat are dissected
MRI enbloc (if possible) (Fig. 73.5). External iliac lymph node when
traced towards the inguinal ligament may come across
It is also not made mandatory by FIGO, but it helps to find
Cloquet’s lymph node. Internal iliac and inter iliac lymph
the tumor size, depth of stromal and vaginal invasion. Extent
nodes are dissected. Psoas muscles with ileofemoral nerve
of node involvement is also brought out clearly. MRI is useful
can be seen. Common iliac lymph nodes are dissected and
in pregnant patients with cancer cervix as other modalities
para-aortic lymph nodes are palpated. If they are enlarged
(IVP, CT), etc. are contraindicated.
Section 17

they need to be removed. At the base between the internal

PET (Positron Emission Tomography) and external vessel (forming to sides of the triangle), the
It is not advised for primary work up of the tumor. obturator lymph nodes are palpated and removed. Ureter is
See that adequate amount of blood is available before followed to the ureteric canal in the cardinal ligament
starting the operation.
Technique
At the table, when patient is under anesthesia, a repeat per
vaginal and per rectal examination is performed to know the
current status of the growth. Tight Vaginal Packing is done
by a gauze soaked in mercury (mercurochrome) or
iodine(they kill any exfoliating malignant cells) and the tail of
the pack is kept long with a forceps attached to the end
hanging by the side of the operation table. Urinary bladder
is catheterized by indwelling Foley’s catheter the balloon of
which is inflated by 5 ml normal saline. The abdomen is
cleaned and draped.
Incision
Infraumbilical vertical incision is preferred, because it can
be extended cranially when required for para-aortic lymph
node dissection. Besides, this incision causes least
hemorrhage. Muscle cutting transverse incisions are used
by some surgeons. Some surgeons do lymphadenectomy Fig. 73.1: Clamping of round ligament
before opening the abdominal peritoneum. Lymphadene-
ctomy is done and the tissues removed are sent for frozen
section examination. If the lymph nodes are positive for
malignant deposits the case is considered as inoperable. If
the lymph nodes are negative then the surgeon opens the
peritoneum and does a radical hysterectomy. This is possible
in institutions where frozen section facilities are available.
Otherwise, the abdominal peritoneum is opened. Exploration
of the abdomen is done meticulously guage the extent of the
disease. The peritoneum over the anterior and posterior
surface of the cervix is inspected and palpated for any
thickness and adherence to the underlying vagina (signifying
spread). Paravesical and pararectal spaces are opened for
better palpaton of the parametrium.
Boundaries of paravesical space are:
• Anteriorly—pubic symphysis
• Posteriorly—cardinal ligament
• Laterally—obturator internus muscle
• and Medially—obliterated umbilical arteries
580 Fig. 73.2: Cutting of round ligament
 Chapter 73
Fig. 73.3: Opening of broad ligament Fig. 73.4: Ligation of infundibulopelvic ligament

Radical Surgeries in Gynecology

Fig. 73.5: Lymph node dissection Fig. 73.6: Ureteric dissection

(Fig. 73.6). Its roof (ureteric canal) contains uterine vessels (clamped, cut tied at the attachment to the sacrum) cardinal
which are clamped, cut and tied by angle clamp. The ureter ligament (up to the pelvic side walls) uterine artery at its
can now be traced to its entrance into the urinary bladder. origin from the internal iliac artery are removed.
Posterior dissection is done after clamping, cutting and
securing the uterosacral ligament. Multiple lateral to median Postoperative Care
clamps are applied on the parametrium as far as possible till Patient is allowed to sit up as soon as possible. Pulmonary
the vagina is reached. The vagina is clamped by 90 angled physiotherapy is started early. The drain is removed once
Wertheim’s clamps (Figs 73.7 and 73.8). A 2 cm vaginal cuff no fluid is collected in the container. The catheter in the
around the cervix is mandatory. All bleeding points are urinary bladder is kept for 10 days to 3 weeks depending on
secured. The vault of the vagina is stitched by running the extension of dissection of the urinary bladder is done
mattress stitches to prevent any bleeding from the edges. against the vagina. It prevents bladder distension and
An inflated Foley’s catheter is placed on the vault (as a drain) damage helps healing.
and connected to a slow suction container (Fig. 73.9). (Though
newer reports without a suction drain are also coming up). Complications
The abdomen is closed. Excessive bleeding may occur. Injury to surrounding tissues,
Similar operation can be done laparoscopically. The extent viz. ureter, urinary bladder, bowel, blood vessels and nerves
of surgery depends upon the stage of the growth. can occur. Prompt diagnosis and repair is the key to prevent
In stage IAI an extra-fascial hysterectomy is done. One further morbidity. Excessive bleeding is to be controlled and
can perform a cold knife cone biopsy with adequate negative replaced adequately for proper recovery.
margins in cases where future fertility is the issue. Lymph Late complications include wound infection on secondary
nodes metastasis occurs in 0.5–1.5 of cases. hemorrahge and urinary tract infection.
In stage IA2 modified radical or Wertheim’s radical -year survival rate in stage I cancer cervix without lymph
hysterectomy with pelvic lymphadenectomy is chosen. There nodes involvement is 90 . But if lymph nodes are positive
is increased risk of extension beyond the primary lesion. for secondaries the 5 years survival is reduced to 50–60 . It
In stage IIA Type III hysterectomy or Meigs radical is further reduced to 20–45 if aortic lymph nodes are
hysterectomy is done where of the uterosacral ligaments infiltrated by the malignancy. 581
Major Operation

Fig. 73.7: Angled clamp Fig. 73.8: Wertheim’s clamps

iliac lymph nodes). The superficial inguinal lymph nodes are

the primary nodal group of the vulva and are located around
the saphenous, superficial epigastric, and superficial
circumflex iliac veins. These lymph nodes drain through the
Section 17

cribriform fascia to the femoral lymph nodes. Femoral nodes

are mainly located medial to the femoral vein. From here it
drains to the pelvic lymph nodes. The pelvic lymph nodes
are virtually never positive in the absence of inguinofemoral
lymph node metastases. Overall, 20–40 of all patients with
invasive squamous cell carcinoma of the vulva have lymph
node metastases. The survival of patients with invasive
squamous cell carcinoma of the vulva is most closely related
to the pathologic status of the inguinal lymph nodes.
Since Taussig in 1940 and Way in 1948, advocated radical
vulvectomy with bilateral inguinal lymphaden-ectomy
performed by en bloc excision, it has become the standard
therapy. Until the early 1980s, patients with invasive
carcinoma of the vulva were routinely treated with radical
vulvectomy and bilateral inguinofemoral and pelvic
lymphadenectomy.
This operation involves radical removal of the entire
vulva, the mons pubis, the inguinofemoral lymph nodes, and
Fig. 73.9: Closed suction drain often the pelvic lymph nodes (by giving a butterfly incision)
(Fig. 51.3). A large surgical defect is created that is generally
Follow-up is done every 3 months for first 2 years. Then closed under tension with a high subsequent breakdown rate
6 monthly for 5 years then yearly. At each follow-up visit and marked disfigurement. Other potential problems related
elicit a detailed history, do a physical examination, pelvic to the en-bloc radical resection include urinary or fecal
examination and Pap smear. Most of the recurrences are incontinence and vaginal relaxation.
seen in the first 2 years. To overcome the problem of wound complications and
its psychosexual effect, separate incisions for the vulvar and
RADICAL VULVECTOMY inguinal phases of operation has been advocated. After reports
Carcinoma of the vulva is mostly seen in elderly women in by Hacker and colleagues, DiSaia and associates, and others,
6th decade of life. Overall incidence is about 2 of all genital separate incisions for the vulvar and inguinal operation came
malignancies and 0.5 of all female cancer. Because of into increasing use. Separate incision also allows further
increasing life span, incidence of vulval cancer is increasing. modification of two aspects of the operations like unilateral
The predominant histological type of carcinoma vulva is groin lymphade-nectomy, local excision of vulva,
squamous cell carcinoma, which accounts for about 90 of hemivulvectomy, etc.
the tumors in most series. Melanoma is the second most
common histological type, accounting for 5 to 10 of vulvar Operation by Triple Incision
cancers. Other rare tumors are Bartholin carcinoma, basal In this procedure separate incisions are used for vulvectomy
cell carcinoma, verrucous carcinoma, adenocarcinoma, and bilateral lymphadenectomy (Fig. 51.4).
invasive Paget disease, and sarcomas.
Squamous cell carcinoma of the vulva metastasizes Operative Procedure (Figs 73.10 and 73.11)
primarily through the lymphatic system. Draining regional General, epidural, or spinal anesthesia is administered.
lymph nodes include the superficial inguinal lymph nodes, The patient is placed in Allen stirrups with the hips
the deep inguinal femoral lymph nodes, and the pelvic lymph abducted 45° and flexed 45°. This position allows both dissection
582 nodes (external iliac, obturator, internal iliac, and common of vulva and inguinal lymphadenectomy to be done in same
 Chapter 73
Radical Surgeries in Gynecology

Figs 73.10A to H: Steps of radical vulvectomy. (A) Examination prior to surgery; (B) Skin incision in perineum; (C) Deepening of incision;
(D) Incision of vaginal margins; (E) Removal of vulvectomy growth; (F) Closure being performed; (G) Completion of closure; (H) Specimen of
vulvectomy

position. The other option is to put the patient in lithotomy The skin is prepared from the umbilicus to the knee joints.
position first, for the vulvectomy and then to put the patient The patient is examined carefully to identify the limits of
in the supine position for inguinal lymphadenectomy. It is spread and then a marking pen is used to mark where the
helpful to position the patient so that the perineum protrudes skin should be incised, both externally and within the vagina.
over the bottom of the operating table. A pad or cushion Skin incision starts at the midpoint between anus and
may be placed under the sacrum. posterior fourchette extending laterally to include labia 583
Major Operation

Figs 73.11A and B: Closure of groin dissection

majora and labia minora. Superiorly incision is extended to use of a running suture. The specimen is sent for histology
include the clitoris. At least two centimeter of disease free with the orientation marked.
margin should be included in the incision. Fat pad over mons Closure: In most of the cases the wound can be closed
pubis is spared if possible. Incision can be modified according primarily without resorting to special techniques. Care is
Section 17

to the site and size of the disease. The dissection is taken all taken to appose the skin above the urethral meatus to the
the way through the subcutaneous fat to the deep fascia. A residual skin of the mons pubis. Marker sutures may be
urethral catheter is inserted into the bladder. Inner incision inserted to assess the way in which the edges will come
in the vagina is given just above the hymenal attachment together. Closure may be facilitated following resection of
and extent depends on the site of the growth. Inner incision posterior lesions if the residual vagina is mobilized off its
normally excludes the urethral meatus. If there is need for lateral attachments and the rectum posteriorly.
removal of part of the urethra because of the proximity of
the growth then a stay suture should be taken distal to the Groin Node Dissection
part to be removed. Distal one or two centimeter of the urethra Bilateral or unilateral groin dissection is done according to the
can be removed without affecting the function of the external site of the disease to assess nodes for evidence of metastasis,
sphincter. If frozen sections are required to ensure that the which may indicate the need for further therapy, and to help
intended resection margins are clear of tumor, they should reduce the chance of recurrence of further metastasis. The
be taken at this time. They can be cut as small ellipses in the groin nodes are the most important prognostic indicator in
line of the incision. Only biopsies should be sent for frozen squamous cell carcinoma of the vulva. If cancer recurs in a
section, not the vulvectomy specimen. previously undissected groin, the outlook is grim.
The tissues can be separated relatively easily from the
deep fascia and pubic ramus with scalpel or scissors until Operative Procedure for Groin Node Dissection
the intended vaginal resection margin is reached. The patient is placed supine with the legs abducted 30 degrees
Hemorrhage can be reduced by using cutting cautery for and externally rotated. Provided the groin nodes are
dissection and promptly clamping and ligating branches of clinically negative, the groin incision runs 4 cm below and
the pudendal artery and vein encountered posterolaterally. parallel to the inguinal ligament starting 4 cm distal and medial
It is important to avoid damaging the anal sphincter, to the anterior superior iliac spine and ending below the
while at the same time ensuring an adequate margin around superficial inguinal ring. This helps to dissect both upper
a tumor placed posteriorly on the vulva or perineum. A finger oblique and inferior vertical set of superficial inguinal lymph
in the rectum helps to guide the operator under these nodes. If there is concern for groin node metastases, an
circumstances. The posterior margin of the specimen is elliptical skin incision can be made in the same line so that
elevated with forceps, which can be held by the assistants this overlying segment of skin can be excised with the nodes.
while dissection proceeds. If necessary, the anterior third of The incision is taken through the full thickness of the skin
the anal sphincter can be removed with the specimen. and 2–3 mm into the fat. Incision is carried through the
Superiorly, the dissection is carried down toward the Camper ’s fascia. Allis forceps are applied to the dermal
clitoral attachments by sweeping the specimen off the surface of the upper skin incision to provide traction while
periosteum of the pubic bones and the deep fascia until the skin flap is separated by both sharp and blunt dissection.
clitoral attachments are reached. The suspensory ligament The sentinel nodes are present in the fat pad below the
of the clitoris may be clamped, divided, and ligated at this Camper fascia superior to cribriform plate and fascia lata.
point as it is very vascular. The dissection is carried superiorly to the inguinal ligament
The vaginal incision is now made circumferentially, and inferiorly about 2 cm proximal to the opening of Hunter
ensuring that the required margin around the tumor is canal. Laterally the dissection extends to sartorius muscle
maintained. The tip of a scalpel or Kelly forceps is passed and medially to fascia over the adductor longus muscle. The
through the specimen in the midline to isolate the crura. caudal skin flap is now raised and dissection is taken down
They are held with forceps, divided, and ligated with through the subcutaneous fat to the deep fascia of the thigh.
absorbable sutures. The specimen is detached completely Once the deep fascia has been reached, dissection of the
and hemostasis is secured. Venous sinuses around the fatty bundle containing the groin nodes off the deep fascia is
584 urethra and vaginal margin may be difficult to control without performed from lateral to medial. Laterally, the circumflex
iliac vessels need to be electrocauterized, but throughout the obliterated. The drain can be removed once the wound has
dissection care must be taken to control bleeding. healed, and there is no significant draining (Fig. 73.12).
Anteromedially the long saphenous vein (LSV) is identified Completed specimen is shown in (Fig. 73.13).
ascending into the thigh from the medial side. The vein is
ligated and divided at the distal margin of the dissection. Postoperative Care
Following ligation of the LSV the tissues on the medial The patient is kept on bed rest for the first two to three days
and caudal side are dissected from the deep fascia. The of the initial postoperative period. Pneumatic calf
cranial end of the ligated LSV is followed down to the compression, active leg movements, and subcutaneous
saphenofemoral junction. Although the pulsation of the heparin are recommended to minimize the risk of deep
femoral artery is a good landmark for identifying the position venous thrombosis and embolism.
of the femoral vein it is best approached by following down Self-retaining catheter is used to drain the bladder until
the medial side of the cranial end of the LSV. This end of the the patient is ambulatory. The wound is inspected daily to

Chapter 73
LSV is dissected free on all sides and the LSV is ligated, ensure continued healing and to detect early signs of infection.
transfixed, and divided approximately 0.5 to 1 cm from the The perineum is cleansed with sterile saline after the first 48
saphenofemoral junction, taking care not to narrow the femoral hours and dried with a hair dryer. Sitz baths are begun a few
vein. The specimen is removed usually by dividing the days later (Figs 73.14 A and B).
lymphatic tissues entering the femoral canal. At this stage The patient is given a low residue diet for three days,
cribriform fascia is identified and opened. The deep femoral particularly if the anal sphincter or rectum were repaired.
nodes are removed by dissecting the tissue in the anterior and Following this period, stool softeners are prescribed.

Radical Surgeries in Gynecology

medial surfaces of the femoral vein above the lower limit of the Complications—Wound breakdown is a common
fossa ovalis. Any fatty tissue in the femoral canal is excised. complication, though incidence is much less with triple
The skin is closed with staples or interrupted vertical incision. The wound usually heals with conservative
mattress sutures, ensuring that the skin edges are neatly management. If the wound has been closed with skin flaps
apposed and everted. A suction drain with multiple openings and necrosis has occurred, the dead skin should be debrided.
is placed in the wound which is brought out by a separate Hematomas/seromas, although unusual if adequate
stab incision inferior to the lower limit of incision and secured. drainage is maintained, may require evacuation. Signs of
infection should prompt obtaining specimens for culture and
Closure of Groin Dissection instituting antibiotics. Urinary tract infection, thrombo-
The closed slow suction drainage (Fig. 73.9) is applied to allow embolism, and osteitis pubis are additional potential
time for the incision to heal and the underlying space to be complications.

Fig. 73.12: Completed three-incision vulvectomy Fig. 73.13: Completed operation

(Two drains seen)

Figs 73.14A and B: View after stitch removal in radical vulvectomy 585
 Late sequelae include stenosis of the vaginal introitus posterior exenteration can be used. Anoproctectomy is a
and pelvic organ prolapse. more extensive procedure than anovulvectomy. Ano-
vulvectomy with sigmoid colostomy is the most useful
Ancillary Procedures procedure in older women because it is well-tolerated and
Additional procedures, which depend upon the characteristics avoids the need for an extensive laparotomy in addition to
of the primary tumor, may be required to ensure complete the perineal procedure. The operation is performed in two
excision of the carcinoma. stages. First, a sigmoid end colostomy is raised in the left
iliac fossa. Two weeks later, in the perineal phase, the tumor
Wider Margins is excised widely including the anus and lower rectum. The
Extensive areas of skin can be excised with the primary rectum is transected and left opening into the perineal wound.
tumor. The methods available for closure of the resulting It is usually secured to the posterior edge of the residual
defect should be considered when planning the procedure. vagina and to the skin margins. If necessary, the two phases
Major Operation

In the event of being unable to fashion flaps, the defect can may be performed during the same surgery, with the lower
be packed with povidone-iodine soaked gauze and then bowel being irrigated from above to clean away fecal
allowed to granulate, with careful postoperative nursing care. material.
The most widely used supplementary method of closure
is by skin flaps, which may be of the transposition type, such RADICAL VAGINECTOMY
as the rhomboid flap (particularly useful for small posterior
Vaginal Carcinoma
defects), or myocutaneous flaps (e.g. gracilis, rectus
abdominis, and tensor fascia lata) or one of several lotus Therapy
petal flaps. The disease can be treated both by radiotherapy and primary
surgery.
Section 17

Urethral Surgery
Radical Vaginectomy
If the tumor involves the urethra, the distal 1 cm can be
excised without affecting continence. The residual urethral Stage I disease involving the upper two thirds of the vagina
mucosa is included in the closure. can be treated with primary radical surgery.
If any more than the distal 1 cm of the urethra must be
Basic Principles
excised, the patient will require an additional procedure to
prevent urinary incontinence. In some women this will be an A radical vaginectomy includes a radical hysterectomy with
anterior exenteration with formation of neo-bladder. An pelvic lymphadenectomy along with partial or total removal
alternative procedure in the palliative setting is inversion of of vagina with its para-colpos. At least a two inch cancer free
the proximal residual urethra into the bladder. Through a surgical margin below the tumor should be included in the
suprapubic incision the space of Retzius is entered and the dissection. If the growth has extended into the lower third of
upper urethra and bladder neck are exposed. A rubber drain the vagina, a bilateral inguinal node dissection should also
is passed around the urethra, which is mobilized around with be included in the procedure for a complete cure.
the bladder neck, and then transected and transfixed. The
Preoperative Preparation
anterior bladder is opened through a midline incision and
the upper urethra is inverted into the bladder using forceps. This surgery is quite extensive, mutilating and time
The edges of the inverted bladder neck exteriorly are consuming. Adequate preparations should be made with
approximated. The bladder incision is then closed with sufficient blood available for transfusion. Overnight fasting
continuous suture around a suprapubic catheter. with thorough bowel preparation is necessary. Attention
should be paid to fluid and electrolyte balance.
Vaginectomy (Partial or Total)
The extent and site of vaginal involvement will dictate the Anesthesia
amount of surgery required. Involvement of the lower lateral Complete relaxation with prolonged anesthesia can be
wall can be dealt with by resection as necessary. If the tumor achieved with a combination of continuous epidural and
involves the anterior or posterior walls of the vagina, care general anesthesia.
must be taken not to damage the bladder or rectum while
achieving clear margins around the tumor. Involvement of Positioning of the Patient
extensive amounts of the vagina will require removal of the With two teams working together, one from the abdomen
bladder or anorectum, depending upon the site of involvement. and the other from the vaginal end, surgical time can be
reduced to quite an extent, decreasing the surgical morbidity.
Excision of Anus and Distal Rectum
The patient is put in a semi-lithotomy position with the
Several procedures have been described for the excision of thighs partially extended, and the legs in stirrups, so that
tumor involving the anus and rectum. When the lesion just there is an adequate surgical access for both the teams to
encroaches on the anus, or there is a suspicion of this operate simultaneously.
encroachment, the anterior third of the anus and sphincter
can be excised without major impact on continence. The Procedure
external anal sphincter is repaired with interrupted 0 The patient is cleaned and draped with abdominal drapes,
polyglactin sutures. For extra support of the sphincter proper leggings and perineal drapes so that both vagina and
mechanism, the distal limbs of the puborectalis may be abdomen are accessible simultaneously.
plicated together anterior to the anus. The skin can be closed
with rhomboid flaps. Abdominal Part
In many cases, partial resection of the anus would be The abdominal team proceeds to carry out the radical
insufficient and anovulvectomy, anoproctectomy, or hysterectomy with pelvic lymphadenectomy starting with a
586
right para-median incision extending from the symphysis pubis and delineated on either side of the vesico- vaginal space.
to about an inch and a half above the umbilicus encircling the Carrying the dissection lateral to the bladder pillars at their
umbilicus, along the lines described in this chapter. lowest exposed point, leads to the paravesical space, making
the bladder pillar stand out. Bladder pillars are clamped and
Vaginal Part cut controlling any bleeders and taking care not to injure the
The vaginal team starts with a circular vaginal incision, placed ureters in the process.
in the lower 1/3 of the vagina (Figs 73.15 and 73.16). At least
this incision should be 2 inches below the margin of the Posterior Dissection
growth. In growths higher up in the vagina this incision may The posterior cut edge of the vagina is held with two Allis
be placed higher up conserving more of the vagina. forceps. With traction and countertraction, the vaginal fascia
is cut and by the help of sharp and blunt dissection the
Anterior Dissection rectovaginal space is entered in the midline. Dissection is

Chapter 73
The anterior cut edge of the vagina is held with two Allis carried out in the loose areolar tissue of this space cephalad
forceps. With traction and counter-traction, the vaginal fascia till the space opens into the pouch of Douglas which would
is cut and by the help of sharp and blunt dissection the have been already opened by the abdominal team. During
vesicovaginal space is entered in the midline. Dissection is this dissection care should be taken not to injure the rectum
carried out in the loose areolar tissue of this space cephalad or the branches of middle rectal artery which are in close
till the resistance of vesicocervical ligament are met. During proximity to the dissection.
dissection care is taken to control the bleedings from the Retracting the rectum posteriorly will make the rectal

Radical Surgeries in Gynecology

branches of pudendal and vaginal vessels and protect the pillars on either side of this space prominent. Carrying the
bladder from accidental injury. dissection lateral to the rectal pillars at their lowest exposed
The vesicocervical ligament (which is practically point, leads to the pararectal space, making the rectal pillar
avascular) is cut exposing the vesicocervical space already stand out. The rectal pillars are clamped, cut and ligated
dissected by the abdominal route. taking care of any bleeders in it and taking care to avoid
Now by retracting the bladder and the vagina in opposite injury to rectum.
directions in the midline, the bladder pillars are stretched
Completing the Vaginal Dissection
Now at this point the vagina is held in the pelvis by only its
lateral attachment through paracolpos. The paracolpos are
clamped, cut and ligated successively cephalad freeing the
vagina completely and the total specimen of uterus and cervix
and adnexa, with the parametrium, and the vagina with
paracolpos are removed en-masse (Fig. 73.17).
Closure
The cut end of the remaining lower 1/3 of the vagina is
secured with a continuous blanket suture achieving
hemostasis and leaving the vaginal vault open. A Foley’s
catheter is placed in the raw area of pelvis bringing it
out through the vagina for continuous suction drainage.
It is left in place for about a week in the postoperative
period along with continuous bladder catheterization for
14 days.
The space between the bladder and the rectum in the
pelvis will be obliterated over a period of time by the natural
process of healing leaving behind a short vagina.
Fig. 73.15: Radical vaginectomy Postoperative haparin is to be given.
During the follow-up period if the disease is established
to be completely cured the woman may require a plastic
reconstruction of the vagina to promote a better sexual life.

Radiotherapy
This involves the application of adequate tumoricidal dose
of radiation to both the primary growth and the routes of
spread along with the draining lymph nodes.
For growth involving the upper vagina the whole of pelvic
lymph nodes should be included in the treatment field. For
the tumors of the lower vagina the inguinal nodes should be
included in the field. A combination of both intracavitary and
external radiation is used to deliver the optimal tumoricidal
dose to the primary growth and the draining lymphatics and
lymph nodes.
Malignant tumors of the vagina are rare and
standardization of treatment is difficult. Each case requires
Fig. 73.16: Radical vaginectomy individualization in the method of treatment. 587
Major Operation

Fig. 73.18: Anterior exenteration

Fig. 73.17: Complete specimen
Section 17

EXENTERATION
Definitions: Exenteration is an extensive operation in which
all contents of a body cavity are removed. Pelvic
exenteration refers to removal of the pelvic organs and
adjacent structures.
The pelvis contains reproductive organs, bladder and
rectum. Pelvic is exenteration is usually carried out in cases
of extensive malignancies of these organs that do not
respond well to other types of treatments. Exenteration is
done only if there is no less invasive alternative method of
treatment (Chemotherapy, Radiotherapy, etc.) tumor
available.
Pelvic exenteration is also done in tumor recurrences.
All modalities for diagnosis of extent of the disease are
utilized, viz. history, physical examination, IVP, barium meal
and enema, CT, MRI, etc.
Preoperative discussion with the patient is a very
important step. It is a major operation. This radical surgery Fig. 73.19: Posterior exenteration
provides the only hope to eliminate the malignancy and
prevent recurrence. Pelvic exenteration can be Total Pelvic Exenteration
1. Anterior pelvic exenteration.
A widespread malignancy involving all the pelvic organs is the
2. Posterior pelvic exenteration.
indication.
3. Total pelvic exenteration.
In this procedure all pelvic organs are removed, viz.
Anterior Pelvic Exenteration (Fig. 73.18) • Uterus, ovaries, fallopian tube and vagina
In this operation organs placed anteriorly in the pelvis, are • Urinary bladder
removed. The following organs are removed: • Urethra
• Uterus, ovaries, fallopian tube, and vagina • Rectum
• Bladder • Anus
• Urethra. • All support muscles and ligament of these organs.
A new ileal conduit is made to divert the ureters to a pouch A urinary outlet and a fecal outlet are made in the abdomen
made of small intestines, connected to the abdominal wall. and the contents are collected in appropriate bags.
Through a small opening (called stoma’) the urine comes Exenteration is a very extensive operation and is
out and is collected in a bag. The vagina is reconstructed at performed by a team of experts. There is a 30–44
a later date. complication rate and 3–5 mortality in the hands of
seasoned surgeons. Postoperative heparin is given.
Posterior Pelvic Exenteration (Fig. 73.19) Postoperative recovery includes psychological adjustment
The organs placed in the back of the pelvis are removed viz. and major life-style changes.
• Uterus, ovaries, fallopian tubes and vagina
BIBLIOGRAPHY
• Lower part of the bowel.
1 . Campion M . Pre-invasive disease in Berck S, Hacker NF’s.
A colostomy is made connecting the colon to the abdominal Practical gynaecology onchology 4th Edn; 2005.p.265.
588 wall. Feces come out through a stoma and are collected in a 2 . Sevin BG and Koechlie OR. Pelvic exenteration’. Surgical Clinics
of North America 2001;81:771.
colostomy bag.
 74 Vault Prolapse

Banashree Das

DEFINITION a. A feeling of pelvic fullness or pressure or heaviness.

Vaginal vault prolapse refers to a herniation of vaginal apex b. A feeling of something (mass) protruding out of the vagina.
or when the upper portion of the vagina loses its normal c. A pulling or stretching in the groin area or a low backache.
shape and sags or drops down into the vaginal canal or d. Painful intercourse.
outside the introitus. It may occur alone or along with prolapse e. Urinary problems, such as involuntary release of urine
of the bladder or urethra, small intestine or rectum. (Figs (stress incontinence) or a frequent or urgent need to
74.1 A and B). Vault prolapse may occur with or without the urinate, recurrent urinary infections, inability to empty
presence of uterus. the bladder, difficulty in micturition, or the need to digitally
It is more common in multiparous women and rare in reduce the prolapse in order to urinate. Women may give
nulliparous women. In nulliparous women, cause is history that, stress incontinence, which was present before
congenital pelvic tissue weakness, defective innervations, the onset of vault prolapse, has actually got relieved
or unusual trauma. following the onset of vault prolapse, (due to kinking of
urethra). In these patients one will have to take special
INCIDENCE care to treat this condition while treating vault prolapse.
The incidence of vaginal vault prolapses, after hysterectomy f. Difficulty with bowel movements such as constipation or
is as high as 11.6%, when hysterectomy was done for uterine need for manual assistance for evacuation.
prolapse. Whereas the incidence is only 1.8%, when g. The symptoms usually worsen with exertion and ease
hysterectomy was done for causes other than uterine with bed rest.
prolapse. This significant difference clearly indicates that if
the ligaments were too weak to support the uterus, they are RISK FACTORS
often also too weak to support the vaginal vault. As the years The majority of patients with clinically significant prolapse
ago by aging of the population will further increase the will have at least two or more risk factors for the disorder,
number of women affected. But wrongly chosen faulty which cumulatively, over time, contribute to worsening
operative procedures may also be the cause. For example prolapse, as a woman ages. Important risk factors for pelvic
not repairing the enterocele properly or improper vault organ prolapse include, multiparty, operative vaginal
support (in these cases vault prolapse occurs within a year delivery, obesity, advanced age (old age), estrogen
of hysterectomy). deficiency, postoperative or congenital neurogenic
Symptoms: Symptoms depend on severity of the disease. dysfunction of the pelvic floor, or prior pelvic surgery with
The patient may complain of – disruption of natural support, conditions affecting the spinal

Figs 74.1A and B: Vault prolapse. (A) with uterus; (B) Without uterus
 cord or spinal cord injury that causes paralysis of the muscles Complications: It is mostly a safe, simple and effective
of the pelvic floor, connective tissue disorders, chronically operation. The complications that may occur are
increased intra-abdominal pressure (e.g., from strenuous hemorrhage, pudendal nerve injury, rectal or bladder injury,
physical activity or coughing). (See also chapter 29) and recurrent anterior vaginal wall prolapse.

MANAGEMENT OF VAULT PROLAPSE Shirodkar’s Modification of Manchester Operation

Surgical treatment is essential. Patient should be thoroughly This operation is preferred in young patient with apical
examined for presence of cystocele, rectocele, enterocele, prolapse with uterus, associated with cystocele and rectocele
etc. and appropriate operation should be planned accordingly. who wish to conserve the uterus and want to become
Operation will depend on presence or absence of uterus. It pregnant in the future.
will also depend on fitness of the patient for that particular
Major Operation

Procedure: The cervix is pulled by a vulsellum. If a cystocele is

surgery. present, an inverted T incision is given for classical anterior
colporrhaphy. If there is no cystocele a circular incision is
OPERATIONS
given all around the cervix. The bladder is mobilized beyond
Vault prolapse repair can be done vaginally or abdominally. the internal os. A bed is prepared for transfixation of the
Abdominal operations can be endoscopic or by the open uterosacral ligament. A transverse incision over the anterior
methods. In recent years different surgeons are using lip of the cervix is extended posteriorly and the posterior
different material for suspending the vault. But the basic vaginal wall is dissected down to expose the lower end of the
principle is to pull up the vault and fix it to some fixed structure pouch of Douglas (POD). POD is opened and two strong
and make the position of vagina as anatomical as possible. uterosacral ligaments identified. The uterosacral ligament is
Frequently used operations are described below:
Section 17

cut from the cervical attachment, about 3/4th inch in breadth.

Assumed upper border of the ligament is cut for an inch and
TRANSVAGINAL REPAIR
dissected further with a tip of the index finger as laterally as
Transvaginal Sacrospinous Colpopexy possible. The lower border is also cut parallel to the upper
This procedure can be done both for prophylaxis (in case of border. Thus two strips of uterosacral ligament are created on
massive uterovaginal prolapse) and for treatment of vault either side. The medial end of each strip is transfixed with no.
prolapse. 0 silk about an inch lateral to the free edge. The enterocele sac
The patient is put in a dorsal lithotomy position. In case is dissected as high as necessary. Now the highest point of the
of massive uterovaginal prolapse vaginal hysterectomy peritoneum is attached to the cut edge of the posterior surface
should be completed before proceeding for repair of vault of the cervix by taking three delayed absorbable interrupted
prolapse. An inverted V incision given in the perineum and suture. The posterior vaginal wall is stitched back to the cervix.
posterior vaginal wall is separated from the anterior rectal Cystocele enterocele and rectoceles, stress incontinence
wall to enter the rectovaginal space and dissection is carried if present, should be repaired by standard methods. After
out up to apex. The right rectal pillar separates the pushing the uterus up to the desirable level with the help of
rectovaginal space from the right perirectal space. Rectal a dilator in the uterine cavity, both uterosacral ligaments are
pillars have two layers which may be merged together. Ease pulled across the anterior aspect of the cervix at the level of
of exposure of sacrospinous ligament-sacrococcygeal internal os and fixed by non-absorbable suture material. The
muscle complex depends on thickness of the rectal pillar. It anterior vaginal wall is closed. (Figs 69.24 and 69.25)
is easier to penetrate in case of a large rectocele. The right
index finger is introduced into the rectovaginal space, and LeFort Vaginal Colpocleisis
the right ischial spine is palpated, (usually it is at 9 o’clock This operation is reserved for patients who are old and not
position) to note the position and size of sacrospinous desirous of coital function. The prerequisite for this operation
ligament. Penetrate the rectal pillar near the under-surface is that patients should be postmenopausal with an atrophic
of vagina. This can be done by a finger tip. If the pillar is thin uterus and not at a high risk for endometrial cancer. It can be
catch with a hemostatic forceps. A long straight retractor done under local anesthesia.
pushes the rectum to the left side. Another retractor is used to In this operation a rectangular flap is dissected from the
push the cardinal ligament and ureter. Adequate illumination anterior and posterior wall of vagina and raw area are sutured
is necessary. A stitch is taken about 2 cm medial to the ischial together. Vagina is thus obliterated in the midline. This
spine through the substance of the ligament by using non- operation is very simple and can be done under sedation
absorbable suture or delayed absorbable suture (no. 2 vicryl and local anesthesia.
or no. 0 silk). Very fine suture should not be used as it might Sometimes colpectomy or total colpocleisis is the last
cut through the ligament. Use of special needle is not resort when other procedures are inappropriate.
mandatory. The free end should be sewn to the undersurface
of the vagina, but not yet tied. Now the upper part of the Repair by Using Mesh
posterior colporrhaphy is started and upper two inch of the To reduce the recurrence various operations have been
vaginal wall approximated. At this stage, the sacrospinous advocated in recent years by using synthetic monofilament
suture is tied. Traction to the free end will pull the vaginal polypropylene mesh or biological porcine graft to repair the
vault up to the ligament which is then tied. Suture bridge defect in the endopelvic fascia. The basic aim is to make a
should be avoided (only one sided procedure—Right is done). tension free vault suspension by using synthetic materials
Postoperatively the patient may feel a mild pulling to cover the defect in pelvic fascia which helps to maintain
sensation at the buttock without transmission to the thigh. near normal anatomical structure and function of vagina.
But as the edema subsides, pain disappears in days or weeks. Systems that are in use at present are Apogee, Prolift, etc.
590
 Apogee system has a longitudinal mesh with two A suprapubic transverse incision is given in the abdominal
horizontal arms coming out at the upper part. wall. Rectus sheath is exposed. A transverse incision is given
It also includes two specially designed needles, which in the rectus sheath of sufficient length. About ½ inches above
are used to place the mesh in place (Fig. 74.2). The longitudinal the 1st incision another transverse incision is given. A
arm is used to treat rectocele and enterocele and horizontal longitudinal incision is given in the midline and thus two strips
arms are attached to pelvic sidewall muscles near the ischial of rectus sheath are made and both strips are separated till
spine. The posterior vaginal wall is dissected up to the apex. the lateral edge. A non-absorbable stay suture is applied on
Both side walls are dissected to expose the iliococcygeus the medial edge of the each rectus strip. The abdomen is
muscle near the ischial spine. A small incision is made 3 cm opened as usual. The vault of the vagina is identified.
below and lateral to the anus. The corresponding needle is Peritoneum over the vault is incised and is separated from
passed by the side of the pelvic wall and it penetrates the the vaginal vault, taking adequate care not to injure the

Chapter 74
pelvic sidewall muscle near the ischial spines. The horizontal bladder (it will be easier if the vagina was packed tightly
arms at the top of the graft are attached to the needles and before hand). On the right side a curved round ligament
pulled back through the incisions in the buttock. This supports forceps is introduced through the fold of broad ligament along
the top of the vagina at the level of the ischial spines and the the cut edge of round ligament till it reaches the internal
body of the graft repairs the rectocele and enterocele. inguinal ring. A stay suture attached to the strip of the rectus
The “Prolift system” combines graft for repair of sheath is held with the forceps and is pulled out to the vault.
cystocele, enterocele and rectocele. The disadvantage is that The same procedure repeated on the left side. Both strips

Vault Prolapse
in this procedure too, a needle is passed blindly to fix the are stitched to the vaginal vault by using no ‘0’ silk. The
mesh in position with a high chance of injury to nearby peritoneum is closed by using absorbable suture. The
structures in inexperienced hand. abdomen is closed in layers. It is a simple procedure and not
Intraoperative and postoperative complications include mush dissection is required. The main disadvantage is that
rectal injury, bleeding, generalized vaginal or pelvic pain, abdomen needs to be opened and if the vault prolapse is
dyspareunia, infection, extrusion of mesh vaginally or associated with cystocele and rectocele, it cannot be repaired
erosion into the rectum. along with this procedure.
To negate the complications of apogee/prolift system, This procedure also can be used in young patient with an
recently a less invasive procedure is being devised (Figs intact uterus. In those patient after opening the abdomen the
74.3 and 74.4) (Elevate system). The system utilizes a central uterus is pulled back and the uterovesical fold of peritoneum
graft (made of a soft Type I macroporous polypropylene is identified and opened from one round ligament to the
mesh) that is connected to two arms. These arms are placed other. The bladder is pushed down to create a space at the
into the sacrospinous ligaments with a very small self-fixating level of the internal os. By inserting the curved artery forceps
tip that is much less invasive than “hooking” around the entire along the round ligament, the free end of the rectus sheath
ligament. Once the apical arms are in place in the ligaments, strip is pulled to the front of the cervix. Then both strips are
the body of the graft is slid down over the arms and then attached to the anterior surface of the cervix by using no. ‘0’
adjusted into position. Prior to locking the graft in position, the silk sutures. The peritoneum is closed by absorbable suture.
tension is checked and if appropriate, the graft is locked in By using Mersilene
place with small little locking eyelets that are slided down the Procedure is similar to the one using rectus sheath. In
arms. The extra mesh of the arms are cut off, the lateral portion this procedure mersilene tape of desired length is stitched
of the body of the graft sutured to the pelvic sidewall on both to the anterior superior iliac spine. The rest of the procedure
sides and the distal portion attached to the perineal body. is similar to the one using rectus sheath. It is useful for the
patient where rectus sheath is not strong enough to hold on.
ABDOMINAL OPERATION FOR VAULT PROLAPSE
Khanna’s Posterior Sling
Abdominal Sling by Using Rectus Sheath
To overcome the Shirodkar’s and Purandare’s anterior sling
Vault prolapse following hysterectomy can be treated by a
operation, Khanna described a posterior sling operation.
sling made of rectus sheath. This is a simple procedure with
Here 6 mm mersilene tape is used. The center of the tape is
minimum dissection.

Fig. 74.2: Apogee system Fig. 74.3: Elevate graft

591
Major Operation

Fig. 74.4: Elevate graft in place

stitched to the posterior wall of the cervix at the level of the

internal os. The lateral ends are taken out laterally and
retroperitoneally and fixed to the anterior superior iliac spine
with no. ‘0’ silk.
Section 17

Fig. 74.5: Promontofixation

Transperitoneal Sacropexy (Promonto Fixation) (Fig. 74.5)
It can be done with other procedures where the abdomen is
opened. This operation can also be done laparoscopically. In cases of posthysterectomy vault prolapse, the vault is
Different materials are used for sacropexy like mersilene or stretched by using a straight retractor in the vagina or
Teflon tape, proline mesh strips of rectus sheath, etc. packing the vagina prior to laparotomy. The peritoneum over
After opening the abdomen or after introducing an the apex of the vault is separated. Both anterior and posterior
endoscope, if vault prolapse is associated with uterovaginal walls of the upper part of the vaginal vault are dissected.
prolapse then the uterus is pulled backward and the One will have to be careful to avoid injury to the bladder.
uterovesical fold of peritoneum is identified and incised. The Preparation of promontory stitches and opening of the pelvic
bladder is pushed slightly downwards to create a space for peritoneum is the same as described earlier. Two limbs of
attachment of the mesh. Dissection is done laterally on both the mesh are stitched to the anterior and posterior wall at
sides to make a small window around the internal os just the apex of the vaginal vault. The other end is pulled up till
above the uterine vessels. This will be necessary to bring the apex of the vault comes to the desired level and tied to
the two end of the mesh to fix it in front of the uterus later. the stitch taken over the anterior longitudinal ligament.
For fixing the mesh to the sacral promontory the Excess mesh is excised. The peritoneum is closed by
peritoneum in front of the promontory is identified and incised. absorbable suture to keep the mesh retroperitoneal.
The anterior longitudinal ligament identified. Care should be Prevention of Vault Prolapse
taken to avoid injury to the presacral vessels. Two transverse
While doing a vaginal hysterectomy one should look for
sutures are taken through the anterior longitudinal ligaments
strength and length of the uterosacral ligament. If it is long
by using no. 0 silk. The peritoneal incision is extended from
and strong they should be shortened and attached to the
the front of the promontory till the level of right uterosacral
vaginal vault.
ligament and then to the level of left uterosacral ligament.
Wide vaginal vault should be surgically narrowed. Cul-
A 15 cm long and 5 cm in width synthetic mesh (proline or
de-sac should be obliterated and any enterocele sac should
proline and vicryl), is used. One end is split into two by incising
be excised. If strength of uterosacral—cardinal complex is
in the mid line for about 5 cm and a 2 cm circular area is
not satisfactory alternate methods of colpopexy have to be
created by removing part of the mesh just medial to the split
undertaken as a preventive measure.
area to accommodate the body of the uterus.
Now the mesh is placed in the POD and each split end is BIBLIOGRAPHY
brought out anterioly through the window created earlier by
1 . Barrington JW, Edwards G. Posthysterectomy vault prolapse.
the side of uterus. Both the ends are fixed to the anterior wall Int. Urogynecol. U Pelvic Floor Dysfunction 2000;11:241.
of cervix by using no. 0 silk. Uterovesical fold of peritoneum 2 . Cossen M, Rajabelly R, Bogaert E, et al. Laparoscopic
is closed by using no. 00 vicryl. Posteriorly the mesh is fixed sacrocolpopexy-hysterectomy and burch colposusp-ension:
to the uterosacral ligament on both sides. Other ends of the feasibility and short-term complications of procedures. J SLS
mesh are pulled to lift the vault of the vagina to the desired 2002;6:115.
level and now at that level the mesh is fixed to the promontory 3 . Farnswarth BN. Posterior intravaginal sling plasty (infracoccygeal
by tying the stitches already taken through the anterior sacropexy) for severe posthysterectomy vaginal vault prolapse—
a preliminary report on efficiency and safety. Int J Urogynecol
longitudinal ligament. Excess mesh is excised. The
Pelvis.
peritoneum is closed to keep the mesh retroperitoneal. In a 4 . Raj Maheswari N, Gunasekaren G. Transvaginal sacrospinous
patient who has not completed her family, the mesh can be colpopexy for vault prolapse and for marked uterovaginal
fixed only posteriorly. prolaps. J Obstet Gynecol Ind 2004;54:275.

592
 75 Vaginoplasty

BD Hasija, Sudha Salhan

Congenital aplasia of the vagina is a rare entity, its incidence One day prior to the procedure, the thigh from which
being 1:4000 to 1:5000 women. Failure of the vagina to canalize graft is to be taken is prepared. Plastic surgeon’s help may
may be partial or complete. In these cases the uterus is be required for taking the skin graft and necessary
generally rudimentary and non-functional. It is functional in arrangements are made for dermatome blades and sterile
7–8 cases only, when it will be associated with hematometra. rubber foams to construct vaginal mould. This operation is
Vaginal aplasia is encountered in testicular feminizing done under anesthesia.
syndrome and Rokitansky-Kuster-Hauser syndrome (RKH). The first step is pelvic examination to verify the previous
In RKH the uterus is rudimentary with normal ovaries. RKH findings. The patient is positioned for taking skin graft from
may be associated with urinary and genital abnormalities the thigh or hip. Split thickness graft 0.018 inches thick and
(40 ) and skeletal abnormalities of ribs and spines in 20–30 8–9 cm wide, 16–20 cm long will be required to cover the
cases. Secondary sexual characters are normal, however vaginal mould, so two grafts of 8-10 cm in length are taken.
menarche fails to occur and sexual intercourse is not possible The skin of the donor site is prepared with antiseptic solution
due to an absent vagina. In women with testicular feminizing which is washed and then lubricated with mineral oil.
syndrome, while performing a vaginoplasty, surgical removal Assistants steady and stretch the skin tight (Fig. 75.1). Uniform
of the intra-abdominal or inguinal gonads (testes) should be pressure is applied over the dermatome so that a graft of
recommended as these are prone to malignant change in uniform thickness is obtained. The graft should not be very
30 of cases. In cases of congenital absence of the vagina, a thin or have breaks in continuity. The donor site is dressed
new vagina is created between the bladder and rectum. and the dressing is opened 2–3 weeks later. The graft so
Vaginoplasty should be performed when the girl is about obtained is kept between two layers of moist gauze.
to be married and the husband should know that woman will
remain infertile. If vaginoplasty is done earlier, then there Step-2
are chances of re-stenosis of vagina. The patient should know Now the patient is placed in a lithotomy position, the bladder
that her cooperation is necessary for successful outcome as is catheterized and the assistant puts finger in the rectum to
she has to wear the vaginal mould continuously for six months guide the dissection between the bladder and the rectum.
and intermittently for several years. After putting an indwelling catheter in the vagina catch hold
These patients of vaginal aplasia may be selected. The of the labia at 3 places (3, 6, 9, o’clock position) as in (Fig.
methods used for vaginoplasty are: 75.2). Two small openings are seen below the urethral
1. Frank technique, a non-surgical method, or opening. These openings are gradually dilated by increasing
2. Construction of an artificial vagina either by number of Hager’s dilaters (Figs 75.3 A and B), till a midline
a. McIndoe operation or more simple procedure septum is left (Fig. 75.3 C). This septum is cut (Fig. 75.3 D) and
b. William’s vaginoplasty further blunt dissection is done creating the vaginal space.
c. Less common methods are creatsas Vaginoplasty,
Vecchietti’s procedure, Davydov technique, Baldwin’s
intestinal transposition, etc.

Frank’s Dilation
This is a non-surgical procedure where gradual pressure
with progressively increasing dilators is applied over the
Mullerian pit for 15 min twice daily. It takes about 3–6 months
for some length of vagina to form. For some patients it may
be satisfactory but the majority of patients require surgical
procedure eventually.

McIndoe Operation
In this operation, space is created between the bladder
anteriorly and the rectum posteriorly. This space is lined by
split thickness skin graft taken from the patient’s thigh or full
thickness skin graft from the abdomen. Amnion can also be
used for lining this new vagina but it should be HIV and
HbsAg negative. Fig. 75.1: Split skin graft being taken
 This space is dissected until the undersurface of peritoneum Step-3
is reached (Figs 75.3 E to G). This method is very useful in Once space is created, the vaginal mould is fashioned from
dissecting an adequate space without injury to the sterile foam rubber according to length and width of the new
surrounding structures. Complete hemostasis has to be vagina. This rubber mould is covered with two rubber sheath
achieved otherwise bleeding will cause the graft to separate (condoms) and tied with silk at the base and the size of mould
from its bed resulting in failure of the graft to implant in that is tested by inserting it into the new vaginal space. The skin
area and local graft necrosis. graft is applied over this form keeping the outer skin surface
facing the rubber sheath which is slightly darker in color
than other side. The edges of the skin graft are sutured
together over the vaginal mould with fine polyglycotic sutures
Major Operation
Section 17

Fig. 75.2: Exposing the introitus

594 Figs 75.3A to E

 Chapter 75
Figs 75.3F and G

Vaginoplasty
Figs 75.3A to G: Steps in creating neo-vagina

and there should not be any gaps (Figs 75.4A and B). for the original mould in 6 weeks, which is easier to remove
Otherwise granulation tissue will form and lead to and clear than the rubber mould.
contracture. The vaginal mould, covered with skin graft is The patient is asked to use the silicon mould
then fitted into the new vagina. Free edges of graft are not (Fig. 75.5) during the night for further one year. After that it is
sutured to mucosal margins of vaginal introitus to encourage used intermittently until coitus is frequently occurring. If there
drainage. Mould can be held in place by suturing the labia is the slightest difficulty in inserting the mould, the patient
together with two or three non-reactive sutures. Self-retaining should be advised to use the mould continuously again.
catheter or suprapubic catheter is kept for urinary drainage. Antiseptic douches are used if there is residual vaginal
Broad spectrum antibiotics are started 12 hrs before surgery healing and discharge.
and continued for 5 days postoperatively to reduce the omplications The success rate of the operation is 80-100 .
infection in the operative site. In some patients serious complications can occur:
After 7–10 days, the mould is removed and the vaginal 1. Fistula-urethrovaginal, vesicovaginal, and rectovaginal
cavity is irrigated with warm saline solution and inspected. fistula can occur in 4 of cases.
This is done in the operation theater under sedation. The 2. Failure of graft take can occur occasionally which leads
vagina is inspected to determine if the graft has taken to granulation tissue, which will require regrafting after
satisfactory in all areas of the new vagina. A new mould is curettage of granulation tissue.
fashioned and covered with condoms to fit the new vagina. 3. Stenosis and loss of vaginal length.
The vaginal mould should not make too much pressure 4. Sometimes malignancy can occur in the new vagina.
superiorly against the peritoneum of cut-de-sac, otherwise
it will weaker the support and enterocele will result. The William Vulvovaginoplasty
patient is taught to daily remove it and reinsert it after In most cases McIndoe operation is the preferred procedure.
cleaning with povidone iodine. She is advised to do so at the But William’s operation should be considered as the operation
time of urination and defecation. This vaginal mould is to be of choice in patients who may need a supplement to an
worn for a period of 6 weeks. A silicon mould is substituted unsatisfactory McIndoe operation or a supplement to a small

Figs 75.4A and B: Making a vaginal mould 595

 and postoperative pain is less and recovery is fast. The
success rates of operation and repeat operation are high
and there is no need to wear the vaginal mould.
Disadvantage Unusual angle of vaginal canal. A very high
perineum is created. Urine may collect in the pouch following
urination. Urethral meatus if patulous will be further
aggravated by coitus and this technique cannot be used in
poorly developed labia.
Procedure (Fig A) A horse shoe shaped incision is made
in the vulva. It extends across the perineum and up the medial
side of the labia to the level of the external urethral meatus.
Major Operation

Initial mucosal incisions are made as near the hair line as

possible and approximately 4 cm from midline (Fig. 75.6B).
After mobilization, the inner skin margins are sutured
Fig. 75.5: Silicon mould
together with knots inside the vaginal lumen (Fig. 75.6C). A
second layer of sutures approximates subcutaneous fat and
vagina resulting from extensive surgery or radiation therapy. perineal muscles for support (Fig. 75.6D). Finally external
Rarely a patient with solitary kidney low in the pelvis will skin margins are approximated with interrupted sutures (Fig.
require this operation as there is no room for dissection 75.6E). One should be able to insert two fingers into the pouch
adequate vaginal space. for a depth of 3 cm. The indwelling catheter is kept for 7 days.
Advantages of illiam’s Operation It is a simple technique Examinations are avoided for 6 weeks at which the patient is
Section 17

without any serious complications. Postoperative care is easy instructed to use dilators before or after 6 weeks.

Figs 75.6A to E: William’s operation

596
 76 Laser in Gynecology

Sunita Malik, Sujata Das

Since the time of Albert Einstein in 1917, who first described These intermediate energy photons induce molecular
the process of stimulated emission of radiation, lot of vibration and create heat. (Fig. 76.2).
progress has been made over the century in understanding Excited E 2 and E 1 state of electrons laser radiation is
and developing different types of laser and safer delivery released when the electron drops from E2 to E 1 state.
system for perfect clinical application. Now what causes the electrons to go into E 2 state is
LASER is an acronym for Light Amplification by external energy source such as electricity or light which
Stimulated Emission of Radiation. This is often referred to as stimulates the active medium housed in an optically resonant
the light that heals. The common lasers used in gynecology cavity. Electrons that are still in excited or higher orbital
are carbon dioxide (CO 2) (Figs 76.1A and B); Argon KTP energy levels can also be stimulated by bombardment of
(Potassium, Titanyl, Phosphorus); and Nd: YAG (Neodymium: photons so that they undergo identical decay and emit an
Yttrium, Aluminum, Garnet), the names given are based on identical photon. This is called stimulated emission because
the medium that is activated. Each medium produces light one photon has stimulated the production of another photon.
waves of specific wavelength which gives a characteristic
color to the laser beam. Special Characteristics of Laser Light
1. Monochromatic—Uniform wavelength
Principles of Laser 2. Coherent in phase with each other
Laser is a device that produces and amplifies light energy to 3. Collimated—parallel waves
create intense, coherent electromagnetic radiation. X-rays 4. Not carcinogenic.
and gamma rays are another form of ionizing radiations
which result from nuclear destruction. While radiation emitted Measurement of Laser
by laser results from the release of photons that occur when Laser power is measured in watts. Laser energy is measured in
stimulated electrons circling their nuclei return from their Joules.
excited state (E2) to the resting state (E1), (E2 – E1 = photon). 1 J = 1W. sec

Figs 76.1A and B: (A) CO2 laser machine; (B) Sharplan 40 Watts CO2 laser
Major Operation
Section 17

Fig. 76.2: Principle of focusing laser beam

Power density is a measure of penetrating force • Operating system

• Aiming beam.
Watts × 100
Pd (Watts/cm2) = 2 2 Delivery System
Spot diameter (cm)
Tissue Effects Delivery system on the other hand delivers the beam in a
continuous or pulsed or super pulsed mode depending on
The radiant energy of laser beam strikes the tissue which is
the requirement.
rapidly heated and then vaporized, ablated or coagulated
depending upon the power density employed. The tissue CO2 Laser
damage is according to the (i) amount of power (wattage) The CO2 laser is invisible laser beam of infrared light, with a
that is used; (ii) Time—The longer the beam remains focused wavelength of 10,600 nm. This is delivered by articulate arm
on one spot, the more energy is applied to that area. So, to with the help of precisely aligned metallic mirrors. When it
limit the tissue damage, one can move the beam back and leaves the arm, it is in the form of parallel beams which need
forth or select an intermittent timed pulse mode. (iii) spot to be focused to increase the power density of laser. Coupling
size of beam—the smaller the spot size of beam, the more lenses of various focal length are used to focus the beam at
intense is the effect on tissue. (Table 76.1) the end of hand held probe or laproscopy.
Three types of tissue injury may be identified following a
laser wound: Nd: YAG Laser
1. Zone of vaporization This is delivered through optic fibers which are made up of
2. Zone of stromal necrosis quartz. These fibers are flexible, very light and thin. Both
3. Zone of reversible injury. contact and noncontact types of delivery systems are
Besides the power density, other determinants of laser available with this. This type of laser is a good coagulator but
include the degree to which a specific laser is absorbed, not cutter unless used with sapphire tips to increase the
refracted or reflected by impacted tissue, e.g. CO 2 laser is power density.
fully absorbed by water therefore, tissues, being made up
KTP 532 and Argon Lasers
mostly of water, will absorb all the laser energy, boil and
vaporize immediately Argon, KTP and Nd: YAG lasers are Both KTP 532 and Argon lasers are similar in their charac-
not absorbed by water or clear tissues but are fully absorbed teristics and clinical application, delivered through flexible
by pigmented tissue containing hemoglobin so, they are fibers, making them well-suited for endoscopic use. Charac-
employed successfully for coagulation of blood vessels, like teristics of different types of lasers are given in Table 76.2.
to ablate endometrium and vascular tumors.
Advantages of Laser Surgery
Components of Laser Machine 1. Sterile incision
Laser machine consists of body and delivery system. 2. Short surgical time

Laser Body Table 76.1: Tissue effects of different power densities

Laser head and support system.
10–100 Watts/cm 2 Surface heating and coagulation
Laser Head 400–1200 Watts/cm 2 Vaporization and some hemostasis
4000–25,000 Watts/cm 2 Rapid vaporization and less hemostasis
• Pumping system >25,000 Watts/cm 2 Very rapid vaporization with minimal
• Lasing medium hemostasis
598 • Optical cavity
 Table 76.2: Characteristics of different types of lasers

CO 2 Nd: YAG Argon KTP-532

Wavelength (µm) 10 .6 1.064 0.458–0.515 0.532

Visible light No No Yes Yes
Flexible fibers No Yes Yes Yes
Color dependent No Yes Yes Yes
Effects of fluid on beam Strongly absorbed Slightly absorbed Not absorbed Not absorbed
Degree of scatter Minimal Significant Moderate Moderate
Approx. depth of tissue 0.1 4.0 0.5 0.4
destruction (mm)
Cutting capabilities Very good Fair with sapphire tips Fair Fair

Chapter 76
Coagulation capabilities Poor Very good G oo d G oo d

3. Minimal bleeding b. Vagina

4. Very little scarring 4. Ablation of vaginal intraepithelial neoplasia (VAIN)
5. Rapid healing and fast recovery 5. Excision of VAIN in cases where there is suspicion of
6. Less postoperative pain invasion on colposcopy or
7. Requires short or no hospitalization 6. Small lesion at the vaginal apex after hysterectomy

Laser in Gynecology
8. Allows selective destruction of concerned areas. c. Cervix
7. Vaporization of CIN (cervical intraepithelial neoplasia),
Disadvantages of Laser provided the colposcopy is satisfactory
1. Errors of judgment may be dangerous 8. Excision—Laser conization of cervix
2. Optical hazards During Laparotomy with hand held probe or operating micro-
3. Skin hazards scope
4. Fire hazards 9. Vaporization of small myoma
5. Chemical hazards 10. Excision of pedunculated myoma
6. Electrical injuries 11. In ovarian carcinoma with peritoneal spread in
7. No tissue remains for histopathology examination. combination with surgery and chemotherapy
12. In malignancies that have not responded to
Indications of Laser in Gynecology
conventional therapy
The main advantage of lasers over the conventional surgery 13. Recurrent malignancy in previously irradiated areas
is the ability to pass laser beam through endoscopes either or when surgical approach is not possible.
with help of mirrors or flexible optical fibers, thereby making
them well-suited for such procedures. Laser laparoscopy is Safety Concerns
being successfully employed for the following indications: 1. Gynecologist should be certified for the specific type of
• Pelvic adhesiolysis laser rooms.
• Tuboplasty 2. A warning sign ‘Laser in Use’ should be displayed on the
• Neosalpingostomy door of operation room so that the person entering the
• Fulguration/excision of endometriosis room takes necessary precautions.
• Removal of benign tumor like myoma, ovarian cyst 3. Protective glasses for eyes should be available at the
• Salpingo-oophorectomy entrance of the room.
• Treatment of ectopic pregnancy 4. Surgical drapes near the operating field should be fire
• Ovarian drilling retardant and kept wet from time to time.
• Division of uterosacral ligaments 5. Laser machine should be kept on standby mode while
• Presacral neurectomy not in use of surgery.
• Colpopexy and urethropexy 6. Adequate suction should be available to collect all
• Hysterectomy. dissected produced by laser use as intact viral DNA has
been detected which may be carcinogenic.
Laser with Hysteroscopy
7. When using various types of laser wavelengths, it is
• Ablation of endometrium, submucous myoma or polyp important to understand their specific tissue interaction
• Metroplasty to avoid undesired trauma, e.g. injury to a vessel or ureter
• Removal of intrauterine adhesions. may occur while treating superficial endometriosis if Nd:
YAG laser with a deep penetrating power is used instead
Laser with Colposcopy or Operating Microscope
of CO2 laser.
a. Vulva 8. Always check the laser before use as there may be
1. Vulvodynia leakage of laser energy if any of the delicate optical fibers
2. Focal condyloma of recent onset caused by HPV/HSV have broken which may potentially injure the patient and/
3. Very extensive; refractory, neoplastic conditions like or staff at the site of leak.
vulval intraepithelial neoplasia (VIN)

599
 77 Robotic Surgery in Gynecology

Neena Aggarwala

Laparoscopic Surgery console). The unit is located in the same operating room as
It is a welcome innovation of surgery. Laparoscopic surgery the patient. The robotic system is used to assist with a variety
is a minimally invasive approach to surgery. Patients of complex, minimally-invasive laparoscopic operations for
undergoing laparoscopic procedures typically experience less benign and malignant female pelvic conditions. The da Vinci
pain, have fewer instances of infection and recover more system offers all the benefits of laparoscopic surgery along
quickly than those undergoing open surgery. with increased precision and effectiveness.
Robotic surgery is especially useful in the performance
Advantages of Laparoscopic Surgery of –
• Minimally invasive • Tubal ligation and tubal reanastomosis
• Excellent visibility • Endometriois resection
• Easy recovery, less postoperative ileus • Oophorectomy
• Less blood loss • Hysterectomies, both simple and radical
• Minimal tissue damage • Removal of fibroids (myomectomy) while preserving the
• Quick return to activity and work. uterus
• Correction of vaginal prolapse, and sacrocolpopexy
Disadvantages of Laparoscopy • Salpingectomy
• Instrument limitations • For the treatment of uterine and cervix cancers
• 2D vision • Ovarian cystectomy
• Loss of depth perception • Ovarian transposition.
• Restricted degrees of movement
• Restricted spaces How the Robot Works?
• Need for skilled assistant and cameraman As the surgeon manipulates the remote control unit (Fig.
Incisions in traditional and laparoscopy surgery is given 77.2), the motions of the surgeon are translated to the robotic
in (Fig. 77.1). arms. Each robotic arm consists of multiple appendages
connected by joints (Figs 77.3 to 77.6). The “hand” of the
Robotic-assisted Minimally Invasive Surgery robot holds interchangeable surgical instruments that
In the late 1990s, another evolutionary stage in the can be moved in a manner similar to a human wrist. At all
development of surgical technique was achieved with the times, a second surgeon is positioned at the operating table
application of robotics to surgical technology. At the forefront to assist with exchanging the instruments on the robotic
of this new era, Intuitive Surgical introduced the da Vinci® arms.
Surgical System. The daVinci system, approved by the US
FDA for gynecologic surgery in 2005, is one of the newest
technologies available for the treatment of gynecologic
cancer and other benign conditions.

How the Robotic System Works?

The robotic system consists of 2–3 interactive mechanical
arms, a camera arm, a three-dimensional (3D) image
processing system and a remote control unit (surgical

Fig. 77.1: Traditional and laparoscopy surgery Fig. 77.2: Remote control pannel
Wristed Instruments
The da Vinci System features wristed instruments with seven
degrees of freedom, three-dimensional, intuitive visua-
lization and ergonomic comfort. Robotic surgery is an
upgraded form of minimally invasive surgery and is asso-
ciated with major patient benefits. The robotic operation is
more precise than conventional surgery and it allows a
patient to return to normal activities much more quickly.
The reduced use of pain medications after robotic or
laparoscopic surgery, indicating less tissue trauma. A team Fig. 77.4: Remote control and action
of assistants helps the surgeon on the patient by irrigation,
showing structures, etc. (Fig. 77.7). abdomen in order to manually access the inter-abdominal

Chapter 77
organs, including the uterus. It is a suture intensive procedure
Uterine or Vaginal Vault Prolapse and requires precise dissection of tissue planes.
120,000+ cases of uterine and vaginal vault prolapse are
Laparoscopic and da Vinci® Sacrocolpopexy
surgically treated each year in the US Prolapse of any pelvic
(Figs 77.8 A and B)
floor organ occurs when the connective tissues or muscles
within the body cavity are weak and unable to hold the uterus, An anatomically correct procedure done in a minimally
vaginal vault and pelvis in its natural orientation. The invasive manner with less blood loss, correct vaginal

Robotic Surgery in Gynecology

weakening of connective tissues accelerates with age, after orientation, better postoperative sexual satisfaction and
child birth, with weight gain and strenuous physical labor. lesser graft risks.
Women experiencing pelvic organ prolapse typically have For most women, da Vinci Sacrocolpopexy offers
problems with urinary incontinence, vaginal ulceration, numerous potential benefits over a traditional open approach
sexual dysfunction and/or having a bowel movement. because of the hard to reach spaces and lack of formally
trained assistants.
The Treatment: Sacral Colpopexy for Prolapse Other advantages include:
Sacrocolpopexy is a procedure to surgically correct vaginal • Significantly less pain
vault prolapse where mesh is used to hold the vagina in the • Less blood loss and need for transfusions
correct anatomical position. This procedure can also be • Less risk of infection
performed following a hysterectomy to treat uterine • Less scarring
prolapse to provide long-term support of the vagina. • Shorter hospital stay
Sacrocolpopexy has traditionally been performed as an open • Shorter recovery time
surgery. A 15–30 cm horizontal incision is made in the lower • Quicker return to normal activities.

Figs 77.3A and B: Remote control unit guiding the operation Figs 77.5A and B: Movements of remote machine translating into action 601
 Myomectomy (Figs 77.9 A and B)
• Precise dissection
• Layered, suture intensive
• Minimal tissue damage
• Focused area of surgery.

Suturing
Many difficult aspects of laparo-
scopy such as laparoscopic
suturing, are made easier by the
robot through the use of the
3D visualization and increased
Major Operation

instrument maneuverability.
Fig. 77.6: Robotic hand Fig. 77.7: Complete set up of robotic surgery
compared with human hand
Section 17

Figs 77.8A and B: Principles of sacrocolpopexy

Figs 77.9A and B: Myomectomy by robotic surgery

The da Vinci Experience: An Immersive Surgical Experience • Increased precision

• Superior visualization • Enables complex procedure
• Superior instrument dexterity • Besides precision and detail
• Streamlined surgical experience • Remote surgery
• Reduced port site trauma • Complex surgery
602 • Improved cosmesis • Surgeon controlled surgery.
 Section 18 Miscellaneous

78 Breast Diseases

Sunita Singal, Sudha Salhan

The mammary gland is a unique feature of Mammals. In mammary gland and also throughout the nipple and areola
humans, the breast remains a dynamic organ throughout the (Fig. 78.2).
life of a woman. From the neonatal period to puberty,
motherhood and then menopause, the concerns about breast CHANGES AT PUBERTY
problems are common. Women may, therefore, suffer from a The pubertal changes in the breast have been described by
variety of diseases causing anxiety, fear or distress. Tanner and his colleagues as P1 to P5 (see chapter 12 Puberty).
A woman usually approaches a Gynecologist for breast P1 – Prepubertal
related problems. As a primary care provider the Gynecologist P2 – Early development of subareolar bud, widening of
must be able to evaluate the breast and the breast disease by areola with or without a few labial or axillary hair.
taking a thorough medical history, including a history of pain, P3 – Elevation of breast with increase in size of palpable
duration of any lump, discharge, reproductive history, history breast tissue and areola; increase in the dark pubic hair
of hormone intake, and family-history of breast disease. This on mons and axillary hair.
chapter discusses the various aspects of female breast its P4 – Further increase in breast size and areola which
diseases and is intended to provide knowledge to the protrude above the breast level.
Gynecologists to help them arrive at an initial diagnosis and Areolar mound; adult mount of public hair.
refer appropriately. P5 – Adult contour of breast; adult pubic hair with extension
to upper thigh and menarche.
ANATOMY OF BREAST
The mammary gland is a modified sweat gland. It is superficial ROLE OF HORMONES
to the 3 muscles—the pectoralis major, serratus anterior and The breast demonstrates functional changes throughout the
external oblique. The mediolateral borders are from midsternal reproductive life. Prepubertal development is due to the action
to mid-axillary line. Its superoinferior borders extend from the of estrogen secreted by the ovary, the growth hormone and
2nd rib to the 6th intercostal space. adrenal corticoids. For a non-lactating breast to grow; estrogen
The breast is a tuboglandular system and comprises of the (o), progesterone (p), growth hormone, insulin, cortisol,
following parts: thyroxin and prolactin are required.
The mature breast also undergoes changes during each
Skin menstrual cycle under the influence of the predominant
It covers the entire gland. The nipple is in the center of the breast hormones. During the follicular phase the estrogen causes
and is at the level of the fourth intercostal space. The skin ductal proliferation. There is proliferation of the terminal duct
surrounding the nipple is pigmented and is called areola (Fig. structure and increased mitotic activity of the basal epithelial
78.1).

The Parenchyma
The mammary gland consists of 15 to 20 lobes which are
arranged in a radial pattern. Each lobe drains through its own
lactiferous duct which is 2 mm. in diameter. Each lobe is
subdivided into 20–40 lobules. The lobule is the basic structural
unit of the mammary gland. Ten to 100 duct alveoli drain
through ducteoli into one lobulus which is 50 mm in diameter.
Each alveolus is a sac like structure 0.12 mm in diameter, lined
by a single layer of epithelium which is surrounded by the
myoepithelial fibers. The lactiferous ducts converge towards
the nipple and open into it.

The Stroma
The supporting tissue of the mammary gland is partly fibrous
and partly fatty. There are septa in the fibrous stroma which
anchor the skin and the gland to the underlying pectoral fascia.
The fatty stroma is distributed throughout the region of Fig. 78.1: Structure of breast
 Developmental (Congenital) and Functional
Anomalies of the Breast
Underdevelopment of the breast or other developmental
anomalies can be a source of great psychological trauma or
embarrassment to a young woman and this brings them to their
physicians. The following conditions are seen:
Polymastia (Accessory Nipples, Supernumerary Breasts)
Accessory nipples and glandular tissue may arise at
abnormal sites any where along the line from anterior fold of
axilla to the pubic spine (mamillary line as is seen in some
mammals like dogs.
Miscellaneous

The condition may manifest as merely a pigmented area, a

small nipple with or without areola. Occasionally, parenchymal
glandular tissue may underlie the nipple, supernumerary
breasts may respond to normal cyclical hormones and may be
a seat of usual breast disease.
Generally, no treatment is required for mere presence, unless
it becomes a site of disease, e.g. axiallary tail of spence may
become enlarged during lactation.
Fig. 78.2: Anatomy of lactating breast
Section 18

Asymmetry
cells. During the week before menstruation, the breast increases Breast is a paired organ, temporarily inequality in the size may
in size due to congestion and stromal edema. This explains the be seen in 7% of adolescents, which disappears later in life.
slight pain and tenderness in the breast experienced by many Very rarely, aplasia is seen. It is a condition in which one breast
women, premenstrually. fails to develop normally, whereas the other breast is normal in
Pregnancy initiates active development of ducts as well as size. The defect is perhaps regional, as, often the underlying
acini. The breast is composed almost completely of glands with bones and muscles of pectoral area are also underdeveloped.
a small amount of stroma. After the delivery and lactation, these
Hypoplasia (Micromastia) of breasts may occur due to deficiency
changes regress. These changes are caused by estrogens which
of ovarian hormones or due to an intrinsic defect, wherein the
mainly affect the ducts and the progesterone which mainly
gland may be absent. The failure of breast to enlarge at puberty
affects the alveoli. Other hormones required are corticosteroids
may be genetically determined (Turner’s syndrome). Treatment
and prolactin of placental or pituitary origin.
is by diet, physiotherapy, estrogens or plastic surgery.
Though the number of acini are same irrespective of size of
the breast, during menopause the ducts and the gland atrophy Hypertrophy (Macromastia): Abnormal breast size, whether
and in addition, there is shrinkage of inter- and intralobular stroma. developing precociously or at normal puberty, is caused by
either excessive estrogens or abnormal response of mammary
EMBRYOLOGY tissue to estrogens. The breast may weigh from 6 kg to 13 kgs.
In the embryo, the breast first develops at 5 or 6 weeks in The exact cause is difficult to determine but, usually, there is an
ectodermal primitive milk streak, that extends from axila to associated endocrine disturbance.
the groin (mammillary line). At the level of the thorax, the Treatment is breast support and plastic surgery.
proliferating basal cells become nipple bud. During the fifth Gynecomastia is benign enlargement of male breast.
month, the squamous cells enter the nipple bud and proliferate
Amastia (Absence of Breast Although a Nipple may Exist)
into a system of multiple branching in the fat, vascular and
connective tissue. May be due to abnormality of initial epithelial primordium from
A thickened mass of epidermis projects, into the dermis, the tissue of the mammillary line. The duct systems may be
over the regional pectoralis muscle between 16-20 weaks. Solid poorly developed.
outgrowths arise from the thickened mass and grow into the Athelia
surroundings which contain fat, vascular and connective tissue.
No nipple is present.
Canalization occurs in the mass as well as outgrowths. The
proximal end of the each outgrowth form lactiferous ducts. Polythelia
The breast growth pushes the wall of the pit outwards and It is a condition of having more than one nipple on one breast.
it becomes elevated above the surface to form the nipple. Rarely the epithelia of mammillary (milk) line divides to form
In the third trimester, under the influence of sex steroids, 2 or more budding duct systems which are connected to separate
canalization of the epithelial cells as well as outgrowths takes nipples which may lie within a single areola or may form 2
place. At birth, the nipple is fully formed and breast consists of areolas each with its own nipple.
a simple system of ducts without alveoli. At 9–10 years, female
breast begins to enlarge around the nipple. In the next 3–4 years Inverted/Retracted Nipples
acini and the ducts develop. The further development continue These result from a failure of the nipple to elevate above the
till 16–18 yrs. Fat gets deposited to make the breast more chest wall. It is the congenital failure of the epithelial pit to
prominent and round. evert out as a raised tissue. There may be fibrous bands fixing
the base of the nipple to the underlying fascia.
ABNORMAL CONDITIONS OF THE BREASTS Treatment consists of regular manipulation or suction.
Abnormal conditions of the breasts can be congenital or Physiotherapy and wearing special shields is likely to be
604 acquired. effective.
Neonatal Mastitis iii. Galactokinesis (Fig. 78.4)
Occasionally, the breasts of a newborn baby may enlarge and Ejection of milk is a centrally mediated reflex of milk let
the nipple may show a discharge of so-called Witch’s milk. down.
This is due to withdrawal of influence of maternal estrogen Suckling Tactile sensors in areola Afferent sensory
which results in secretion of prolactin from the baby’s neural arc Hypothalamus Oxytocin (Paraventricular
hypothalamus and pituitary. The condition resolves on its own. nucleus and Supra-optic nucleus)
Reassurance of the parents is needed. Emptying of alveolar lumen myoepithelial cells around
alveoli efferent arc
BREAST IN PREGNANCY AND LACTATION There may be a conditioned response to the presence of
In pregnancy, there is a general enlargement of the breast which baby without inducing efferent arc.
may be twice or thrice the previous size. There is more increase Hence oxytocin is for present feed.
in glandular elements, i.e. ductal and lobuloalveolar system iv. Galactopoiesis: Maintenance of lactation depends upon

Chapter 78
frequent suckling by infant which prompts the release of
and lesser increase in stromal elements, i.e. fat or connective
prolactin. Therefore, prolectin is for future feed.
tissue.
There is an increase in vascularity, nodularity, and erectility
ABNORMAL LACTATION
of the nipples.
Failed or Deficient Lactation—The cause may be–
Brown pigmentation of areola occurs. There is formation of
a. Poor development of breast tissue due to genetic or familial
Montgomery tubercles which is a raised pale area of areola,
causes.
representing the non-pigmented openings of sebaceous gland.

Breast Diseases
b. There may be congenital abnormality of nipple, e.g. Retracted
Secretion of fluid may be present.
or depressed or inverted nipple. For this reason, all patients
Physiology of Lactation should have breast examination during antenatal check-ups.
The treatment is reassurance and encouragement. Frequent
The process of lactation is controlled by the complex interaction
suckling, with traction is advised by fingers and by sringe
of metabolic and reproductive hormones. Progesterone,
suction (Fig. 78.5).
estrogen and growth hormone. It may be described to occur in Temporary use of breast pump, nipple shield, may prove
4 stages. helpful.
i. Mammogenesis is a phase of preparation of breasts. c. Sore or cracked nipple is a common problem caused by
There is continued progesterone and estrogen exposure in poor attachment positioning, long gaps between feeding,
the presence of rising level of prolactin. drying agents or failure to dry nipples after feeding.
Corticosteroids are also required. Management is by:
Insulin and thyroxine have a facilitatory role. – Correct positioning and attachment of baby so that
Cellular proliferation, ductal and lobulo – alveolar growth areola + nipple is taken in the mouth (Figs 78.6 and 78.7)
takes place. – Air drying of nipple after breastfeeding should be advised
Alveoli assume secretory characteristics and later begin – If there is severe pain, analgesics may be required
to fill with colostrum. – Anhydrous lanolin preparation locally, may be applied
ii. Lactogenesis (Fig. 78.3): Synthesis and secretion of milk – Last part of the feed is full of fat and can be applied to
from breast alveoli occurs because of high prolactin and the nipples at the end of the feed
precipitous fall in estrogen and progesterone after – Shield is not advisable for such cases
delivery of the placenta. – Treatment of infection of the nipple, if present.
Withdrawal of estrogen and progesterone. d. Psychological—pain, anger, fear, embarrassment, emotional
upsets affect letdown reflex. Counseling is needed for such
Mammary Gland Milk patients.
e. Physiological—Lack of sucking stimulus, abnormality of
Prolaction, glucocorticoids, thyroid hormones, Insulin nipple, ill-health of mother, congenital anomalies of the baby
and growth hormone. (e.g. lips or palate defect).

Fig. 78.3: Prolactin reflex Fig. 78.4: Oxytocin reflex

605
 g. Destruction of anterior pituitary gland, hypothalamus due
to PPH or shock, leads to deficient lactation.
h. Other causes:
– Women who have had augmentation or may be smoking
or had reduction mammaplasty.
– Certain drugs like combined pills, anti-hypertensives,
tranquilizers diminish the quantity of milk.

Management of Lactation Failure

• Supportive methods
• Frequent suckling, adequate rest, nutrition and psychological
support are successful in 70% of the cases
Miscellaneous

• Rubbing mother’s back to stimulate oxytocin reflex (Fig. 78.8).

• Lactaid or nursing supplements are of no help
• Drop and drip method of feeding can be tried
In this method milk is poured on clean nipple and the baby
is made to suckle. By suckling the milk production starts
Fig. 78.5: Treatment of inverted nipple • Drugs are rarely needed
– Metoclopramide 30 mg/day in three divided doses, or
– Domperidone chlorpromazine, may also be tried. But
f. Engorgement of breast—Here the blood supply gets the main stimulus is suckling by the neonate.
Section 18

diminished. Treatment is by encouraging. – Galactogogues special drinks, etc. have also been used.
– Demand feeding/regular emptying of the breast. But of no advantage.
– Heat applied prior to nursing, improves blood supply.
– Oxytocin nasal spray or injection (5 units) may be used. INDUCTED LACTATION
In non-puerperal adopting mothers, there may be a desire to
breastfeed the infant.
• Vigorous breast stimulation every 1 to 3 hours, may be
started many days in advance
• 25 mg chlorpromazine 3 times a day or metoclopramide 10
mg 3 times daily
• Drip and drop method, of feeding should be used initially,
so that suckling stimulus is achieved.
Preparation at least a few weeks in advance, before the
adopted, child is brought home, is always helpful.

SUPPRESSION OF LACTATION
Suppression of lactation is required in cases of death of fetus,
or newborn, HIV or malignancy of mother or if she is taking
anti-cancer drugs. The formation of milk depends on suckling.
If suckling is infrequent, less milk is produced. If there is no
suckling, milk will not be produced.

Fig. 78.6: Correct positioning

606 Fig. 78.7: Good attachment Fig. 78.8: Rubbing a mother back to stimulate oxytocin reflex
 Proper breast support and analgesics are needed if histological appearance called Aberration of Normal
breastfeeding was started. But in case where no breastfeeding Development and Involution (ANDI) (Hughes). This is based
was initiated only breast support will do the job. Do not try to on the fact that most benign disorders of the breast are due to
express milk to see the results. minor aberrations of the normal development, hormones,
involuton, etc. Diagnosis (besides history) require ultrasound
BENIGN CONDITIONS OF BREAST or mammography and Fine Needle Aspiration cytology
Benign conditions of breast include breast pain (mastalgia) (FNAC). The common benign lumps are due to cyclical
benign growths and infections. nodularity or lumpiness, fibroadenomas, breast cysts,
galactocele, traumatic fat necrosis, chronic breast abscess and
Breast Pain (Mastalgia or Mastodynia) tuberculosis of the breast, etc.
The most common complaint regarding breast is pain. It can Nodularity or lumpiness: It can be focal and diffuse and
be associated with benign or rarely malignant diseases of the may be bilateral. It may be cyclical occuring before the start of

Chapter 78
breast. The pain can be cyclical, noncyclical and extramammary. menstural bleeding and relived after the menstrual flow starts.
Further, it may be localized or diffused. Proper history is Histological examination shows benign proliferative changes.
essential. A diary card may help in documenting the timing In some cases, atypia is seen, they may be further investigated
relationship with menstrual cycle. Effect on day to day activity for carcinoma.
(severity), also any medicine used is to be documented. Before the start of menstrual bleeding relieved after the
The cyclical pain is common in patients with median age blood flow starts. Histological examination shows being
35 years and is related to menstrual cycle. During the proliferative changes. In same cases atypias seen and they may

Breast Diseases
reproductive years, it frequently occurs in the luteal phase and be further investigated for carcinoma.
disappears after start of menstrual flow. It is mainly in the upper Treatments give support of the breast. Excision biopsy is
outer quadrant and may radiate to the axilla or the arm. done in suspicious cases.
Nodularity may be felt. It often runs relapsing course. There is Fibroadema These are 2–3 cm in size, rubbery, mobile with
no scientific basis to support the belief that patients with well-defined margin. FNAC will give the diagnosis. General
psychoneurosis suffer more from this disorder. Hormonal measures and support are sufficient, large sized (more than 5
assays have shown an increased level of estrogen and cm) may need simple excision.
diminished progesterone. Abnormality of prostaglandin Breast cysts are mostly seen in peri-menopausal women.
synthesis secondary to deficiency of dietary essential fatty acids Surface is smock and may be tender. They are caused from
have also been observed. Fluid electrolyte imbalance and excess aberration of normal process of involution of the breast.
caffeine is also implemented by some. For treatment simple Diagnosis is made by aspiration under ultrasound guidance.
reassurance is helpful in the 80% of cases. If still not relieved This procedure cures most of the cases. Surgery is indicated if
(in 20%), she is asked to maintain a pain chart for 3 cycles. Drugs the cyst persists after aspiration or rapidly fills.
generally used are primrose oil, Danazol, oral contraceptive Phyllodes tumor is seen in 30–50 years age. The masses are
pills, tamoxifen and bromocriptine, etc. so sharply circumscribed and up to 20 cm in size. The overlying
In cases of non-cyclical mastalgia, nodularity is less marked. ok is in streched, shining and may be ulcerated. Nipple
The pain is constant or intermittent and not associated with discharge is sometimes seen. They are mostly benign but are
menstrual cycle. It is more chronic, unilateral or bilateral. It malignant also. FNAC or excision biopsy shows cellular
occur usually after menopause. The pain may be associated with hypertrophy. Mastectomy is performed on big sized tumors or
cyst. Duct ectasia and periductal mastitis may be present in whose malignancy is seen.
some. These cases may show radiographic abnormality on Uncommon causes of breast lump are:
mammography in the form of coarse ductal calcifications or Fat necrosis following trauma—an ill-defined firm lump is
dilatations. seen. Conservative treatment is advised.
The management should include a thorough evaluation. Galactocele is collection of milk. It is seen in pregnant or
The aim should be to exclude breast cancer in women having lactating women.
nodularity of breast. When no pathology is detected, Granulomatous mastitis look like an abscess but there is no
Reassurance, health education and information, a good breast preceding infection.
support, low caffeine diet, use of NSAID agents generally brings Sclerosing lymphocytic lobulitis is rarely seen in insulin
good response. dependent diabetic patients.
Severe cases may require hormonal treatment with Sebaceous cysts or lipoma of overlying the skin may be
progestins, antiestrogens, prolactin lowering drugs or danazol. seen treated according to the case.
Supplementing the diet with evening primrose oil which is a
source of EFA may be useful. The role of Vitamin E and diuretics Nipple Discharge
is controversial.
Nipple discharge is seen in many conditions. It can be
Extra-mammary pain may be due to chest wall pain,
spontaneous or seen only after expression or massage. It can be
costochondritis, cervical radiculopathy, herpes zoster, shoulder
unilateral or bilateral. The nipple discharge can be from a single
pain, pleural pain, gasteroesophageal reflex and angina, etc.
duct or multiple ducts. The color of the discharge is also
Resssurance and treatment of the cause will help.
significant. The causes of nipple discharge are physiological,
Benign Tumors of Breast or pathological. Physiological discharge of milk is during
lactation only. Rest all discharges are pathological.
If all the patients attending breast clinic about 40 percent
complain of a lump. They start appearing in the second decade Galactorrhea
and peak in the fourth and fifth decade of life. Previously, all It is defined as discharge of milk from breast, remote from
benign breast diseases were called fibrocystic disease. Which pregnancy. It may be primary due to mechanical stimulation or
caused much confusion. Now there is a classification based on stress or secondary due to side effects of drugs. It may be
607
 associated with amenorrhea or infertility and all these patients, performed. An ultrasound and mammography should be the
require further evaluation. There may be normal ovulation and second line of investigation followed by FNAC. Recently a
prolactin levels in 30% of all galactorrhea women. It may be portable scanner based on radiofrequency technology is
primary due to mechanical stimulation or stress or secondary developed which is able to show in a second the presence of
due to side effects of drugs. The etiology may be pituitary tumors—malignant or benign by computer tomography. The
adenoma. basis is electric contrasts between normal and diseased breast
Some antidopaminergic drugs like phenothiazines tissues. While mammography works on density of the breast
chlorpromazing haloperidol, metaclopramidee, etc. can lead to tissue.
hyperprolactinemia or galactorrhea. Other causes may be In India, breast cancer is second only to cancer of the
stimulation of breast pituitary pathways due to chest wall injury, cervix, the number one killer cancer of women. Perhaps
herpes zoster of the chest wall. the most common concern is any abnormal lump felt in
History of discharge may not be forthcoming. It may appear breast. But the majority of diseases with the lump are of benign
Miscellaneous

only on expression. It is bilateral or unilateral is also important. nature.

The color of the discharge is also of significance. A detailed history to uncover or identify possible risk
Most patients with hyper-productive pituitary do not have factors should be done. The patient should be asked as to what
a visible lesion or microadenoma. The treatment targeted to prompted her to visit the physician, a lump, nipple discharge,
eliminate symptomatic galactorrhea and restore ovulation. enlargement or abnormality of skin over breast. Reproductive
Duct ectasia is due to dilatation of the subareolar ducts that history should include age at menarche, parity, age at first
contain inspissated secretions. The discharge is creamy or childbirth (30 years or more), lactation history (since lactation
greenish from multiple ducts. It occurs in women in their fourth has a protective effect) and any history of hormone intake.
and fifth decade. After confirming the diagnosis only Early menarche and late menopause is also important.
Section 18

reassurance is required. Patients with a profuse discharge may Association with OC pill is not clear but use of HRT is
need excision of the major duct. associated with higher risk. Middle age obesity is an important
factor. Alcohol intake increases the incidence of proliferative
Pathological Nipple Discharge benign breast diseases like duct papilloma and atypical
A unilateral blood stained or watery discharge from a hyperplasia which are more prone for development of cancer.
single duct may point to a significant underlying pathology Family history of breast of mother, father and first degree
and is to be referred to the surgeon. The discharge is spread relatives is important, as there is a genetic predisposition
on a slide and sent for cytology. Ultrasound or mammography (BRCA1 and BRCA2, P53 gene mutation, a-EKB-2 or HER-2g
is to be performed. About one-tenth of these patients may new gene).
have underlying intraductal papilloma or cancer. In the Previous history of benign breast disease should also be
former there may be a palpable lump. Carcinoma of the recorded, because about 5% of benign breast disease (BBD) may
breast produces blood-stained discharge investigations lead to carcinoma.
include determination of protein level, thyroid function tests,
X-ray of skull for sella turcica, ultrasound of breast and Screening for Breast Diseases
mammography. Screening strategies for breast cancer are recommended by
various cancer societies and associations, including the
Infections of the breast: They are of the following types:
education of females for breast self-examination (BSE), which
1. Lactational breast abscess
should be encouraged and taught.
2. Non-lactational breast abscess
i. Breast self-examination (BSE) (Figs 78.9 A to F): should
3. Recurrent subareolar sepsis
begin at the age of twenty years. It should be performed
4. Tuberculosis of the breast.
monthly in the follicular phase of menstruation and in
Breast abscess: Breast abscess in a lactating patient is situated postmenopausal woman on the first day of every month.
at the periphery. Pain and redness around the nipple are the Abnormal features on inspection like change in size,
presenting symptoms. These may be greenish discharge. Nipple contour, nipple retraction, visible lumps, skin changes–
may be retraced. Anaerobic organisms are most common cause erythema, dimpling or ecchymosis, or failure of breast to
metronidazole 400 mg bd can be useful. Culture of the pus on fall forward. If any of these is noticed, the physician
drainage (aspiration or incision) will give the drug sensitivity should be consulted by the women.
profile. Smaller abscesses require repeated aspiration, but bigger On palpation, if any swelling is noticed or any discharge
ones are cured by incision drainage. Recurrent subareolar sepsis from the nipple is observed, the doctor should be contacted
or persistent require excision of the affected duct. by the patient.
Tuberculosis of the breast. There is a lump at central or upper ii. Clinical examination should begin at about the age of 40
outer quadrant. Local or systemic manifestation may or may yrs and done annually by the gynecologist. Evaluate the
not be seen. (Cough, fever, loss of weight, etc.) culture of the breast-axilla- and supraclavicular region. Examine areola,
aspirate and histopathology of the biopsy specimen gives the and nipple; first in the sitting position, then with the hands
diagnosis. Six months antitubercular treatment is curative. on hips and then hands above head. Do the check up
Breast cancer is the commonest female malignancy in the quadrant-wise.
developing countries and second commonest in India. In USA, iii. Mammography: The US preventive services task force
the 10-year breast cancer risk is 1 in 69 at the age 40, 1:42, age (USPSTF) has issued new Breast Cancer Screening
50, 1:29 after 50 yrs age. In India about 80,000 new cases of Guidelines (2009). Film mammography is associated with
breast cancer are seen every year. decreased breast cancer mortality rate particularly in
Most women report to physicians because of fear of cancer. women aged 50–74 years. Women aged 50–74 years should
A detailed history and clinical examination should be undergo biennial screening mammography (grade B

608
 Figs 78.9A to F: Self-examination
Chapter 78
Breast Diseases

recommendation). Current evidence do not give any BIBLIOGRAPHY

additional benefit of digital mammography or MRI. In 1. Hughs LE. Classification of benign breast disorders: the ANDI
women who are at a high risk of developing cancer classification. Br Med pul 1991;47:251.
mammography should begin mammography test before the 2. New Breast Cancer Screening guidelines. Ann. intern med
age of 35 years. (Women with one or more first degree 2009;151:716-737,750-2.
relatives who have been diagnosed with premenopausal 3. Rao DN, Dinshaw L KA. Breast cancer incidence, risk factors and
survival rates. Hospital cancer Registry. Tata memorial Hospital,
breast cancer, women with histological risk factors found
Mumbai; 1999.p.6.
at previous biopsy/surgery).

609
 79 Drugs Used in Gynecology

Sudha Salhan, Pikee Saxena

Besides the antibiotics and analgesics and other drugs used Therapeutic Applications
in general medicine the drugs commonly used in Gynecology Hormone Replacement Therapy (HRT) in
are given below. Postmenopausal Women
ESTROGENS In postmenopausal women estrogen levels fall due to cessation
Estrogens are synthesized by the ovary, placenta and in of normal ovarian functions and this may lead to vasomotor
small amounts by the testis and adrenal cortex. Estrogens symptoms (hot flashes, sweating paresthesias), sleep
are of two types: Natural and Synthetic. disturbances, genital atrophy, recurrent UTI, cardiovascular
diseases, lipid changes and osteoporosis. HRT relieves
Natural Estrogens vasomotor symptoms, prevents genital atrophy, maintains
bone density and shows a favorable lipid profile. There is some
The most potent naturally occurring estrogen is estradiol, which
evidence that it may also be useful in preventing Alzheimer’s
is synthesized from cholesterol. Estradiol is metabolized in
disease and colon cancer.
the liver to form estrone and estriol, both of which have mild
Estrogens given alone (called “unopposed estrogens”)
estrogenic activity.
may stimulate endometrial hyperplasia, which might later
Natural estrogens for clinical use are obtained from the urine develop into endometrial cancer. There are also chances of
of pregnant mares. These estrogens are inactive orally and developing breast cancer. The basic principle of estrogen
have a short duration of action due to rapid metabolism in replacement therapy (ERT) is to achieve minimal
the liver. physiological levels of estrogen (45–200 pg), which will relieve
Synthetic Estrogens: To increase the oral effectiveness of the climacteric symptoms and minimize the long-term risks
estrogens, a variety of estradiol and non-steroidal associated with estrogen deficiency on various organs. The
compounds have been synthesized for therapeutic use. minimum possible dose of estrogen, which is easily
acceptable, cost-effective and has minimal side effects, is
Preparation of Estrogens Available in the Market (Table 79.1) prescribed. A woman who still has an intact uterus should
1. Oral: Conjugated estrogens (0.625–1.25 mg) micronized not be prescribed unopposed estrogen therapy alone for
(2 mg) Ethinyl estradiol (0.01–0.05 mg), estradiol valerate prolonged use, because of the high risk of endometrial
(2 mg) and Mestranol (0.05 mg) are available in the form cancer. In these patients progesterone has to be added to
of oral tablets. They cause loss of lean body mass. counteract the stimulatory and carcinogenic effect of
2. Transdermal patch: Contains 25–50 µg or 100 µg of estrogen on the endometrium. When combined with
17 α estradiol. Transdermal matrix patch provides slow, progestogens the therapy is known as estrogen progestogen
sustained release of the hormone and constant blood replacement therapy (EPRT).
levels. The patch is applied to non-hairy skin below the 1. Hormone Replacement Regimens:
waist and replaced every week at different sites. It a. Cyclic regimen: In postmenopausal women who have
not undergone hysterectomy, estrogens are given
bypasses the liver. It also prevents loss of lean body mass.
for 25 days, progestin (MPA) is given for the last
3. Estradiol (25 µg 17 estradiol E 2)-25 vaginal tablets are
10–15 days of estrogen treatment followed by 5–6
inserted vaginally daily for 2 weeks and then twice a week.
days with no treatment. The administration of proge-
4. Intramuscular injection: Esters of estradiol dissolved in oil
stational agent with the estrogen prevents the risk of
are used for intramuscular (IM) injection. Oily
endometrial cancer.
preparations have a longer duration of action.
b. Continuous regimen—Both estrogens and progestogens
5. Topical preparation: Vaginal cream containing dienestrol is
are given daily for 28 days or progestin is added for
also available.
the last 14 days of estrogen treatment.
6. Vaginal ring (silicon), which provides slow release
Estrogen is also used as
(5–10 µg per day) of estradiol, is used for contraception.
2. Contraception: Estrogen is used as oral contraceptive (OC)
7. Implants: Subcutaneous implants of 50 mg and 100 mg of
pills containing a combination of estrogen and
17 β estradiol are available.
progestogen
Table 79.1: Estrogen preparations 3. In urogenital atrophy
4. Turner’s syndrome
Steroidal synthetic estrogens Non-steroidal synthetic estrogens
5. Abnormal uterine bleeding (AUB)
Ethinylestradiol Diethylestradiol
Mestranol Hexestrol, Dienestrol
6. Dysmenorrhea
7. Hypopituitarism in childhood.
PROGESTINS Table 79.2: Preparations of progesterone
The progestins include the naturally occurring hormone
1 . Natural Progesterone
progesterone and a number of synthetic compounds with
Progesterone 25 mg 1M
progestational activity. It is essential for the development of Micronized Progesterone 100 mg oral/vaginal
decidua and to maintain pregnancy. 2 . Pregnane progestins tablet and gel
17 α hydroxy progesterone
Natural Progestin: Progesterone caproate 250 mg IM
Progesterone is produced by the corpus luteum in the later Medroxy progesterone acetate 150,300 mg IM
half of menstrual cycle under the influence of LH. During 3 . 19-nortestosterone derivatives
Norethisterone 5 mg oral
pregnancy the placenta is the main source of progesterone.
200 mg IM
It is also produced by the adrenal gland. Norethynodrel 2.5 mg oral
Natural: Progesterone is rapidly metabolized; and hence

Chapter 79
4 . Gonanes
cannot be given orally. It is effective after intramuscular Desogestrel 0.15 mg oral
injection in oil base. Levonorgestrel 0.25 mg oral, IUD,
implant,
Synthetic Progestins Vaginal ring
A large number of synthetic compounds with progestational Gestodone 0.75 mg oral
activities have been synthesized, which are active after oral 5 . Dydrogesterone 10 mg BD Tablet oral
administration. They have much longer plasma half-lives. Dehydro-9 β,
10 α-progesterone

Drugs Used in Gynecology

Some of these preparations and their dosages are given
in the Table 79.2.
Therapeutic Applications without interruption. These pills are suitable for
women who have hypertension, diabetes mellitus,
The two most frequent uses of progestins are: migraine or valvular heart disease or who smoke
1. As contraceptive either alone or in combination with an and for lactating mothers.
estrogen in oral contraceptive pill. For example or low-dose progestin contains 350 ug of
2. In combination with estrogen for hormone replacement norethindrone or 75 µg of norgestrel.
therapy in postmenopausal woman.
INJECTABLE PREPARATIONS
Other Uses
Injectable preparations for contraception.
• Puberty menorrhagia • Medroxyprogesterone acetate
• AUB 150–400 mg at 3–6 months intervals
• Endometriosis—Norethisterone 5 mg or MPA 10 mg BD • Norethindrone enanthate
for 6–9 months 200 mg at 2–3 months intervals
• Dysmenorrhea • Both estrogen and progesterone—given once a month.
• Premenstrual syndrome
• Secondary amenorrhea INTRAUTERINE INSERT
• Endometrial carcinoma
A levonorgestrel impregnated intrauterine device provides
• Postponement of menstruation
contraceptive action for 3–5 years. It is fully reversible.
• Mood disorders
Besides it makes the periods lighter (for detail see the chapter
• In assisted reproductive technology.
on contraception and AUB).
ORAL CONTRACEPTIVE (OC)
Mechanism of Action of OCs
Oral contraceptives are the most effective, convenient,
a. Inhibition of release of FSH and LH from pituitary.
affordable and reliable hormonal method for contraception.
Therefore, ovulation does not take place.
Oral contraceptive preparations are of two types:
b. Cervical mucus becomes thick so that it becomes hostile
1. Combined pills: These contain combination of estrogen
to sperm penetration.
and progesterone. In combination formulations, the
c. Endometrium becomes hypersecretory and unfavorable
estrogen content varies from 20–50 µg; the majority
for implantation.
contains 30–35 µg and progestogen from 75 µg to 2 mg.
d. Hypermobility of fallopian tubes brings the ovum and
Generally, these pills are administered for 21 days
fertilized zygote earlier to unprepared endometrium.
starting on the 5th day of the menstrual cycle. They are
then restarted from 5th day of withdrawal bleeding. Adverse Reaction of Oral Contraceptives
Monophasic pills—These formulations contain fixed
Non-serious adverse effects include
amounts of estrogen and progestogens.
Nausea, vomiting, headache, migraine, breast discomfort,
a. Biphasic and triphasic pills: In these preparations dose of
weight gain, acne, chloasma, and carbohydrate intolerance
estrogen/progestogens or both components is changed
Serious adverse effects are:
once or twice during the cycle to provide almost the
Leg vein thrombosis, coronary and cerebral thrombosis,
same ratio of hormones that occur during the natural
rise in BP, cervical cancer, benign hepatomas and gallstones.
menstrual cycle. For example–Levonorgestrel (50–75–
125 µg) and Ethinyl estradiol (30–40–30 µg) is a triphasic Contraindications
combination pill. OCs are contraindicated in thromboembolic disease,
b. Progestogen only pills: These do not contain estrogen. hypertension, malignancy of genitals/breast, porphyria,
Progestogen only pills are less effective than diabetes mellitus, obesity, migraine, gall-bladder diseases,
combined pills. They are administered every day uterine leiomyoma. 611
 Drug Interactions of Oral Contraceptives • It inhibits the proliferation of human breast cancer cells
Contraceptive failure may occur if the following drugs are and reduces tumor size.
used concurrently: • It has antiestrogenic action on the uterus.
a. Potent inducers of the hepatic microsomal metabolizing • Has an antiresorptive effect on bone and it decreases
enzymes, such as phenytoin, phenobarbitone, rifampin total cholesterol, LDL and lipoprotein (a) but does not
and anti-HIV drugs. They may increase the metabolism increase HDL and triglycerides.
of estrogens or progestins and diminish the efficacy of Use
oral contraceptives.
Breast Cancer: Tamoxifen is indicated as the hormonal
b. Drugs causing suppression of intestinal microflora, such
treatment of choice for both early and advanced breast
as tetracycline, ampicillin, etc. These drugs interfere with
cancer in women of all ages. Treatment for 5 years with
their enterohepatic circulation resulting in reduced
tamoxifen reduces cancer recurrence by 47–50% and death
efficacy of oral contraceptives.
Miscellaneous

by 26–28%.
With both types of interacting drugs, women should be
This drug is approved by FDA for primary prevention of
advised to use alternative method of contraception or
breast cancer in women at high-risk and as an adjuvant for
increase the dose of oral contraceptives.
the treatment of axillary-node negative breast cancer in
EMERGENCY CONTRACEPTION women after total/segmental mastectomy and breast
Implantation of the fertilized ovum is thought to occur on the irradiation in postmenopausal women with node-positive
6th day after fertilization. This interval between fertilization disease.
and implantation is known as the fertile window. It provides Adverse reactions: Deep vein thrombosis, pulmonary
an opportunity to prevent pregnancy even after fertilization. embolism, hot flashes, vaginal dryness, cataracts, nausea,
Section 18

When treatment is begun within 72 hours, effectiveness is and increased risk of endometrial cancer due to estrogenic
90–98%. Various regimens have been used for emergency activity in the uterus.
contraception:
Raloxifene
1. Estrogen: high dose estrogens are used
Raloxifene is an estrogen agonist in bone exerting an
• Ethinyl estradiol: 5 mg for 5 days
antiresorptive effect and also reduces total cholesterol and
• Diethylstilbestrol: 50 mg for 5 days.
LDL. It does not cause proliferation of the endometrium
2. Estrogen/Progestin combination: Ethinyl estradiol (200 ug) and
• It is rapidly absorbed after oral administration.
norgestrel (2 mg) two tab followed by two more 12 hours later.
• Bioavailability = 2%
3. Levonorgestrel: 0.75 mg twice a day for 1 day or 1.5 mg once.
• Half-life (t1/2) = 28 hrs
4. Levonorgestrel (0.5 mg) with ethinyl estradiol (.05 mg);
• Eliminated primarily in the feces after hepatic glucoron-
two tab stat and two after 12 hrs.
idation.
The high doses of estrogens/progestins used for
emergency contraception produce severe nausea and Dose: 60 mg daily.
vomiting. Other adverse effects include headache, It reduces the risk of newly formed breast cancer by 77%.
dizziness, breast tenderness, abdominal cramps and leg Use: Osteoporosis in postmenopausal women.
cramps. Now they are available without prescription (over It increases BMD and hence reduces chances of fractures.
the counter).
Adverse reactions: Deep vein thrombosis, pulmonary
5. Uripristol—Synthetic progesterone receptor modulator
embolism, hot flashes, leg cramps.
30 mg stat inhibit or delay ovulation 6. Ru 486.
Ormeloxiene—Used in fibroids, adenomyosis,
ANTI-ESTROGENS endometriosis and AuB.
Selective Estrogen Receptor Modulators (SERMs) ANTIPROGESTINS
SERMs have tissue-selective estrogenic activities. Commonly
Mifepristone (Ru 486): Mifepristone was approved by FDA in
used SERMs are tamoxifen, raloxifene and toremifene.
2000 for the termination of pregnancy. It is a derivative of 19-
SERMs are a group of agents that have the ability to bind
norgestin norethindrone and is a potent, competitive
and activate the estrogen receptors whilst exhibiting tissue
antagonist of both progesterone and glucocorticoid.
specific effects distinct from estradiol. These agents work by
Mifepristone binds competitively with the uterine
conformational changes in the estrogen receptor, resulting
progesterone receptors resulting in decidual breakdown (1)
in differential expression of specific estrogen regulated genes
that results in
in different tissues. SERMs have gained attention due to
↓
concerns regarding breast cancer, endometrial hyperplasia
Detachment of the blastocyst
and recent evidence from HERS regarding coronary artery
↓
disease with EPRT. Raloxifene is the first of a benzothiophene
Decreased hCG production
series of anti-estrogens to be labeled a SERM.
↓
The pharmacological goal of these drugs is to produce
Decreased secretion of progesterone from
estrogenic actions in bone, brain, and liver during postmeno-
the corpus luteum
pausal hormone replacement therapy. These drugs have either
↓
no activity or antagonist activity in breast and endometrium
Marked increase in decicual breakdown and termination of
where estrogenic actions are harmful.
pregnancy
Tamoxifen
Endogenous progesterone and blockade of uterine
Tamoxifen has antiestrogenic, estrogenic or mixed activity progesterone receptors result in increased prostaglandin
depending upon the target tissue.
612 levels in the uterus followed by discontinuation of pregnancy.
Mifepristone has a long half-life of 20–40 hrs. It undergoes 3. Fibrocystic breast disease
hepatic metabolism in entero-hepatic circulation and is 4. Gynecomastia
excreted in the feces. 5. Hereditary angioneurotic edema.
Use Cyproterone Acetate
1. This is used in combination with misoprostol for the It is a specific anti-androgen which competes with androgens
termination of early pregnancy (49 days or less). for receptor binding; it is also a potent progestational agent.
2. Postcoital contraception—inhibit ovulation, blocks In combination with ethinyl estradiol it is being marketed as
implantation (by delaying endometrial maturation and an oral contraceptive. This combination is very effective in
regression of the corpus luteum). cases of PCOS having menstrual irregularity with hirsutism,
3. Induction of labor. acne, etc. It does not have much side effect; but is costly.
4. Endometriosis—By antioxidant properly do not allow

Chapter 79
endometrium to proliferate. Use
5. Uterine leiomyomas—12.5 mg daily for 3 months. In hirsutism 50–100 mg is given along with 30 mg
6. Breast cancer—On adding mifepristone 200 mg daily for ethinylestradiol given cyclically for 3 weeks.
more than one year. Tamoxifen causes better growth Side effects can be fatigue, nausea, headache, weight
inhibition. gain, decreased libido or some alteration in the lipid profile.
7. Meningiomas.
8. As a contraceptive 2–10 mg (inhibit ovulation), and Spironolactone
significantly supresses enametrium.

Drugs Used in Gynecology

It is an aldosterone antagonist and in addition, it has specific
9. Ovarian carcinoma—Inhibits the growth of ovarian anti-androgenic effects. This drug competes at the level of
cancer cells by inducing G1 cell cycle arrest and blocking the androgen receptor and also inhibits the 5-α reductase
G1–5 phase without apoptosis. activity and thereby decreases conversion of testosterone
Adverse drug reactions: Nausea, vomiting, abdominal pain, into dihydrotestosterone (DHT), thus lessening hair growth,
vaginal bleeding, headache. acne and sebum production. This is to be administered in 50–
100 mg doses twice daily for 3 months or longer. Its treatment
Contraindications may be accompanied by menstrual irregularities, so com-
• Adrenal insufficiency bining it with oral contraceptives produces better clinical
• Inherited porphyria effect and provides contraception.
• Severe asthma
• Hemorrhagic disorders Use
• Patients receiving glucocorticoid therapy Hirsutism 25–150 mg/day
• Ectopic pregnancy. Adverse Drug Reactions are Mostly Minor
ANDROGENS/ ANTIANDROGENS Menstrual irregularity, diuresis, electrolyte imbalance,
gynecomastia, dizziness and headache.
Danazol
Danazol is an isoxazole derivative of 17 α ethinyl testosterone Flutamide
having mild androgenic and progestational activity. It has Marketed as Flutamide, Protamid, Cytomid 250 mg. It is a
suppressive action on the pituitary gland resulting in inhibition non-steroidal antiandrogen which binds to androgen
of secretion of sex hormones from gonads. receptors and also reduces 5 α reductase activity. The dose
It was introduced in 1971 and has become the main drug is 250 mg BD or TDS. It is used with OCs to prevent pregnancy
treatment for endometriosis. Danazol is a very effective and avoid rise in gonadotropin levels. Liver function tests
medication; it improves the symptoms of endometriosis in should be periodically repeated.
more than 95% of the women who take it. It is usually taken
for six months. Uses
1. Hirsutism
Adverse Drug Reactions 2. Prostate cancer.
However, danazol can produce a number of side effects.
Common side effects are—Weight gain, headache, acne, Adverse Drug Reactions
hirsutism, muscle cramps, hoarseness of voice, amenorrhea, Hepatotoxicity, oligomenorrhea.
high cholesterol levels, hot flushes and sweats, reduced sex
drive, reduced breast size. (Danazol should not to be given Finasteride
for more than 6–9 months due to its antiestrogenic and It is a competitive inhibitor of the enzyme 5 α reductase,
virilizing effect). which converts testosterone into the more active
However, only a small percentage of women (5–10%) dihydrotesto-sterone responsible for androgenic action.
chose to discontinue danazol because of side effects. Most
Use
do not experience major problems and can complete the
course of treatment. Women who become pain-free while Hirsutism and benign prostate hypertrophy (BPH).
on danazol often feel well. Treatment with danazol usually Adverse Drug Reactions
lasts six to nine months. When the medication is stopped, a Decreased libido, skin rashes.
woman’s fertility returns in two to three months.
Uses Drospirenone
1. Endometriosis: 400–800 mg daily in divided doses It is a recent introduction. Being structurally similar to
estrogen it occupies estrogen’s nuclear receptors. Hence,
2. AUB 613
 concentration of estrogen receptors are reduced. There is OVULATION INDUCING AGENTS
no negative feedback to the hypothalamo pituitary axis. The Clomiphene citrate: It is the cheapest drug for induction of
neuroendocrine mechanism for GnRh secretion is activated ovulation. Clomiphene citrate is the most widely used
and the pulse frequency of FSH and LH is increased. For its ovulation inducing agent. It is a non- steroid tripheny-
antiandrogenic activity 3 mg with 30 mg ethinyl estradiol is lethylene and its 2 isomers, zuclomiphene (cis-clomiphene)
used in cases of PCOS. and enclomiphene (trans-clomiphene) are a weak estrogen
agonist and a potent antagonist respectively. It acts by
GnRH AGONISTS (ANALOGS) opposing the negative feedback effect of endogenous
They are synthetic analogs of naturally occuring estrogens. Thus stimulates ovulation indirectly by increase
gonadotropin releasing hormone (GnRH). They cause gonadotropin secretion and to stimulate ovulation (FHS and
persistent activation of GnRH receptors as in continuous LH) stimulate follicular maturation and Clomiphene occupies
GnRH exposure. There is an initial release of gonadotropin estrogen receptors.
Miscellaneous

(flare) followed by a profound suppression of secretion. They ↓

reduce estrogen concentration to within the postmenopausal Concentration of estrogen receptor
range. This effect is reversible. ↓
Under their effect, the ovaries stop ovulating and no No negative feedback to hypothalamo-pituitary axis
longer produce estrogen. The overall effect is termed ↓
“medical menopause.” They are inactivated when given by Activation of GnRH section
mouth, hence they are used parenterally only. ↓
This group of drugs has proven to be effective in treating Increased pulse frequency of FSH and LH
endometriosis, uterine leiomyoma, hirsutism, fibrocystic ↓
Section 18

disease of the breast, premenstrual syndrome, central Maturation of follicle(s) ⎯→ ovulation

precocious puberty, preoperatively, in ovarian, breast and It does not interfere swith adrenal and thyroid function.
endometrial cancer, and in fibroid uterus, in small doses for
Well-absorbed after oral administration. It has a long t1/2
induction of ovulation. However, they also tend to produce
of 5–7 days, which is due to plasma protein binding,
side effects that include:
enterohepatic circulation and accumulation in fatty tissues.
• Vaginal dryness
It is excreted in the feces and in the urine. It is usually
• Mood swings
administered in doses of 50 mg–100 mg daily for five days in a
• Hot flashes (a more common side-effect).
cycle (Day 2–6). Higher doses (150–200 mg) for 5 days or
Unlike danazol, they do not raise cholesterol levels. But
smaller doses (50–75 mg daily) for longer duration of 10 days
they do cause calcium loss from bone, which can result in
(Day 3–12) have also been tried.
osteoporosis. Hence, their use is limited to 6 months. This
Before starting clomiphene exclude any dysfunction of
side-effect is counteracted by add-back therapy. This varies
the pituitary, adrenal gland and thyroid gland. Exclude
with the indication of GnRH agonist, e.g. in fibroids a
galactorrhea. Look for adequate ovarian reserve.
combination of estrogen and progesterone is given, in
endometriosis it can be norethindrone and conjugated equine Indications
estrogen, in hirsutism it is an estrogen and progestin 1. No ovulation
combination, etc. Less common side effects include 2. Infrequent ovulation
decreased sex drive, reduced breast size, bloating, and 3. Inadequate FSH stimulation
excess hair growth. 4. In PCOS to improve timing and fequency of ovulation
The GnRH agonists (known also as GnRH analogs) are 5. Inadequate corpus luteum function
given as a monthly injection (3.5 mg depot) or daily nasal 6. In timing of ovulation, e.g. in same orthodox communities
spray and have become a popular (although more there is prohibition of sex in some ceremonies.
expensive) alternative to danazol. These drugs include
leuprolide acetate, and goserelin, buserelin, triptorelin, Special cases: In hirsutism add dexamethasone the night
nafarelin histrelin. before (0.5 mg) to reduce high-peak of ACTH and reduce the
As with danazol, GnRH agonists should not be taken during LH and androgen level. In PCOS oral contraceptives are
pregnancy, so effective contraception methods should be given for 2–3 months before the LH and androgen levels fall
used. A woman’s menstrual period will resume about two and then clomiphene can be started.
months after discontinuing the medication. Side-effects are relatively rare and may include abdominal
discomfort, ovarian enlargement, visual blurring, hot flashes
GnRH ANTAGONISTS and hair loss. Risk of ovarian cancer is seen if the therapy
They bind to GnRH receptors but do not induce release of exceeds 12 cycles.
gonadotropins. They neither deplete the stores of FSH and
Contradictions: Liver dysfunction, pregnancy, abnormal ovarian
LH nor inhibit gonadotropin synthesis.
enlargement. Any dysfunction of pituitary, adrenal and thyroid
Cetrorelix acetate and garirelix are the preparations
gland. The male partner should be normal.
available. They are used for induction of ovulation and
reducing flare and cost both. It can be used as a single dose Letrozole: Letrozole is third generation aromatase inhibitor.
of 3 mg on day 7th or daily 0.25 mg by flexible or fixed It inhibits the aromatase enzyme by binding to the heme of
regimens. It is given subcutaneously. cytochrome P450 subunit of the enzyme. Thus biosynthesis of
estrogen is reduced. It also selectively inhibits gonadal
GLUCOCORTICOIDS synthesis of steroids. The dose is 2.5 mg orally from day 3–7.
Used in treatment of hirsutism secondary to all forms of It increases intraovarian androgen concentration and in vitro
congenital and late onset adrenal hyperplasia. fertilization results in low responder women.
614
 It is used for ovulation induction in poor responders of GnRh Antagonists
clomiphene citrate. Gonadotropins: Gonadotropins (FSH, LH, and hCG) are glyco-
Gonadotropin Releasing Hormone (GnRH): GnRH controls proteins produced and secreted by the anterior pituitary,
the synthesis and secretion of FSH and LH by the anterior chorion and placenta.
pituitary (gonadotropes). GnRH is released in a pulsatile They are also present in the urine of pregnant and
fashion into the hypothalamic-pituitary-portal system. A postmenopausal women.
neural pulse generator, located in the mediobasal hypo- Commercial preparations
thalamus, regulates its release. The intermittent release of
GnRH is required for the proper synthesis and release of Chorionic gonadotropin (CG)—mimics the action of LH. It is
gonadotropins. obtained from the urine of pregnant women.
Synthetic GnRH: It has a short plasma half-life of 4–8 min. due Menotropins (HMG)—contains equal amounts of FSH and LH.

Chapter 79
to rapid enzymatic degradation. It is obtained from the urine of postmenopausal women. It is
of limited used as such, nowadays.
Diagnostic and therapeutic uses of GnRH
Urofollitropin (UFSH;): It is purified FSH obtained from the
Diagnostic: To differentiate between pituitary and hypo- urine of postmenopausal women.
thalamic defects in hypogonadotropic hypogonadism.
Metrodin HP: Highly purified FSH; can be administered
Dosage: 100 mg SC or IV Blood sample for LH is taken before subcutaneously.
and after 15, 30, 45, 60 and 120 min of injection.
Recombinant FSH (rFSH): For its production, the desired genes

Drugs Used in Gynecology

A normal LH response indicates normal pituitary function.
are inserted into a bacterial cell so that it produces a desired
Therapeutic: For induction of ovulation in patients with protein. Once identified, the gene that codes for the desired
hypogonadotropic hypogonadism. It is administered by an protein is isolated by enzymatically cleaving it from the DNA
IV pump in pulses to maintain a physiological cycle in the chain. Along with the vector sequence derived from two
dose of 2.5 g per pulse every 60–90 min. different sources is called recombinant DNA (g-DNA). This
GnRH analogues or agonist: GnRH analogs have better g-DNA is inserted into host cell. These g-FSH are more
receptor binding affinity. They exhibit enhanced potency and effective than urinary gonadotropins in follicular
a longer duration of action compared to GnRH. development. Available ones are:
GnRH analogues initially cause increased secretion (flare) a. Follitropin α
of FSH and LH. After 3–4 weeks there is downregulation of b. Follitropin β
GnRH receptors in the pituitary causing profound suppression
of gonadotropin secretion. As a result, the ovaries stop Therapeutic Applications
ovulating and no longer produce estrogen. The overall effect WHO Group 1—
is termed “medical menopause.” These analogs can be 1. Anovulatory infertility with hypogonadotropic hypo-
administered by intranasal and subcutaneous route. gonadism secondary to hypothalamic/pituitary dys-
Commonly used GnRH analogs are Buserelin, Nafarelin, function. FSH (75IU) is administered daily till cycle day 7.
Goserelin, Leuprolide acetate. This group of drugs is proven Number and size of developing follicles is assessed every
to be effective in treating endometriosis. A GnRH agonist 2–3 days by ultrasound. To complete follicular maturation
may be used prior to surgery to shrink ectopic implants, or and induce ovulation CG (5000-10,0001U) is given after
following surgery to eliminate any remaining implants. the last dose of FSH. Simultaneously, serum estradiol is
Recovery occurs within 2 months of stopping treatment. also measured.
Us es 2. In assisted reproduction technologies (ART)
• Precocious puberty 3. Male infertility due to hypogonadotropic hypogonadism
• Endometriosis—3.6 mg injection every month (maximum 4. Cryptorchidism
6 months) 5. Polycystic ovary syndrome in patients with failure of
• Premenopausal breast cancer clomiphene therapy.
• Uterine leiomyoma Adverse Drug Reactions: Ovarian hyperstimulation syndrome,
• Superovulation in in vitro fertilization multiple pregnancy.
• Prostatic carcinoma
• As contraceptive for both males and females Gonadotropin antagonists are also used.
They are under research for the following potential clinical
application ALTERNATIVE DRUGS FOR HRT IN MENOPAUSE
• Alzheimer’s disease Tibolone
• Functional bowel disease Tibolone is a synthetic steroid compound, which has
• PCOS estrogenic, progestogenic and androgenic properties. It is
• Premenstrual syndrome used in the dose of 2.5 mg orally daily. The active ingredient is
• Short stature tibolone. Most of its activity is derived from the three major
• Paraphilias and autism primary metabolites viz. the X 4-isomer, the 3d-hydroxy
• Chronic pelvic pain. metabolite and the 3b-hydroxy metabolite. It has centeral
Adverse Drug Reactions and peripheral effects.
• Hot flashes Central effects: It presses plasma FSH to a small extent.
• Loss of libido
Peripheral effects: a. Hormonal—It exerts estrogenic activity
• Vaginal dryness
at vaginal level thus relieving congenital atrophy. As it has
• Osteoporosis
affinity for progesterone receptors there is no endometrial 615
 proliferative effect. Its androgenic effects improve libido, Hormone Replacement Therapy (HRT)
cognitive function and mood. b. Bone: It prevents bone loss HRT may be used to prevent osteoporosis. HRT is often
by estrogen-like inhibitory effect on estroclasts. Tibolone effective against osteoporosis if taken during the first five
has been shown to increase bone mineral density, similar to years after menopause begins. HRT works against
that observed with conventional HRT. The improvement in osteoporosis as long as the woman is taking estrogen; women
mood and libido with tibolone is superior to that observed lose protection once they have stopped taking HRT. It is
with continuous combined HRT. Estrogen stimulates the estimated that HRT can lead to a 50–80% decrease in
endometrium, whereas tibolone does not resulting in vertebral fractures and a 25% decrease in non-vertebral
episodes of bleeding and spotting. However, the action of fractures with five years of use.
tibolone and estrogens on the vagina are similar. Tibolone
does not cause any stimulation of breast tissue and may in Bisphosphonates (Alendronate Sodium and
fact reduce the incidence of breast cancer. It provides bleed- Risedronate Sodium)
Miscellaneous

free HRT. They are commonly used to prevent and treat osteoporosis
in postmenopausal women. They are not estrogens and do
Selective Estrogen Receptor Modulators not carry the associated risks or benefits of estrogen. They
Raloxifene was specifically developed to maintain beneficial also reverse bone loss and help to reduce the risk of bone
estrogenic activity on bone and lipids. They exhibit anti- fractures by preventing further loss of bone and increase bone
estrogenic activity on endometrial and breast tissue Bone mass by direct action on osteoclasts (increasing apoptosis
mineral density, bone markers, and fracture prevention data by affecting metabolic activity) more so in the vertebral
have shown that SERMs are useful in preventing and treating bones. Alendronate is indicated for the prevention (5 mg a
osteoporosis. Their uterine effect (lack of endometrial day or 35 mg once a week) and treatment (10 mg a day or 70
Section 18

stimulation) is clearly beneficial. SERMs show significant mg once a week) of postmenopausal osteoporosis.
decrease in breast cancer as compared to placebo and Risedronate also reduces the risk of hip fracture in elderly
conventional HRT. Risk reduction with raloxifene is comparable with low bone mass density (BMD). Dose is 5 mg daily or
to tamoxifen. Raloxifene has shown no deleterious effects on 35–50 mg weekly. Ibandroic acid is also a nitrogen containing
the brain so far. Aggravation of vasomotor symptoms limits bisphosphonate. It is monosodium salt, monohydrate. It
the use of SERM in early postmenopausal women. comes in 150 mg film coated tablet containing 168.75 mg of
the drug which is equivalent to 150 mg of ibandronic acid. It
Phytoestrogens is given once a month.
Plants exhibit estrogenic activity in humans by acting as Bisphosphonates should be taken first thing in the morning
selective estrogen receptor modulators (Phytoestrogens), in an upright position (sitting or standing) with six to eight
e.g. Saponins and Tannins. Phytoestrogens are a group of ounces of plain water. The patients should not eat or drink
phytochemicals that exhibit estrogenic activity in the body anything besides plain water with the medicines, and they
by acting on estrogen receptors. 1, 2 Phytoestrogens are should not lie down within 30–60 minutes of taking the
weak estrogens having both estrogenic and anti estrogenic medicines. Calcium, vitamin D, or other supplements should
activity. This property may make them useful for various be taken at a separate time.
indications. Phytoestrogens are classified into three broad Side effects: Abdominal or musculoskeletal pain, nausea,
groups Isoflavones, Lignans or Coumestans. The most widely heartburn, irritation of the esophagus and dysphgia,
advertised and studied phytoestrogen is the soy. etc.
Although phytoestrogens are supposed to be protective, Zolendronic acid (fourth generation bisphosphonate) 5
it is also suggested that in order to have full benefits of soy, mg taken once a year by IV slowly injection is another, albeit
this supplementation should be started in the pubertal age expensive option.
where it may be acting by causing maturation of breast
terminal buds. Data on endometrial caners is not conclusive. Calcitonin
A meta-analysis of 38 studies done to see the effects of soy It is used to treat postmenopausal osteoporosis in women
isoflavones on the cardiovascular system showed that it who have low bone mass but cannot take estrogen (hormone
lowered total cholesterol, LDL cholesterol and triglycerides. replacement therapy). The drug is usually recommended to
HDL-cholesterol is unaffected. Blood pressure is unaffected. women who have been postmenopausal for at least five
It also increases the arterial compliance, which may be one of years. Calcitonin comes in the form of subcutaneous injection
the ways by which it affects cardiovascular health. They affect or nasal spray (not an inhaler) that enters the bloodstream
osteoclast activity and reduce bone loss to some extent. quickly to help strengthen bone and prevent bone loss by
inhibiting osteoclast activity.
MENOPAUSAL OSTEOPOROSIS
Side effects: Nasal symptoms (runny nose, crusting,
Preventing osteoporosis by maintaining a healthy diet rich nosebleed), back and/or joint pain, headache.
in calcium and vitamin D and exercising regularly can help
many women avoid the serious effects of osteoporosis. Contraindication: Allergy to synthetic calcitonin.
Women who have low bone mineral density or osteoporosis Raloxifene
may also benefit from taking hormone replacement therapy It is a SERM as discussed above. Raloxifene is indicated in
or other drug therapies including the bisphosphonates the prevention and treatment of postmenopausal osteo-
(alendronate and pamidronate), calcitonin, raloxifene and porosis. Raloxifene has agonistic effects on bone and
tibolone. These are antiresorptive drugs, i.e. they suppress lipoprotein production but has antagonistic effects on the
bone resorption, and improve bone mass and reduce fracture breast tissue and neutral effects on uterine mucosa. The
risk. Different treatments approaches are being used for dose is 60 mg/day.
treating osteoporosis.
616
Tibolone Side-effects: Abdominal pain, vertigo, changes in vision;
It is a synthetic tissue specific steroid related to postural hypotension and syncope, loss of appetite, swelling
norethynodrel. It has 1:50 potency of ethinyl estradiol and of hands, ankles, feet, or lower legs, weight gain or loss.
1:8 progestogen protency of norethisterone. As discussed They are less frequent and of shorter duration.
above. Tibolone decreases bone turnover and significantly
improves BMD, especially trabecular BMD, but data on Contraindications
fracture prevention are awaited. It has the added advantage Hypersensitivity to ergot alkaloids, diabetes, liver and renal
of relieving climacteric symptoms (hot fluses, etc.) and is dysfunction, cardiovascular disease.
used in doses of 2.5 mg daily. III Quinagolide and pergolide are also under trial for the
Teriparatide is a recombinant human parathyroid hormone. treatment of hyperprolactinemia. Quinagolide is a non-ergot
It increases bone mass and improve bone microstructure D2 receptor agonist. The dose is 75–150 mg daily.

Chapter 79
better than alendronate in some cases (iii).
HYPERINSULINEMIA IN PCOD
Strontium ranelate stimulate bone formation.
Drugs in use are:
Calcitriol is active metabolite of vitamin D and alfacalcidol.
Estrogen therapy is indicated when the patient cannot take Metformin
other drugs. It is a biguanide and has been extensively used in the
Phytoestrogens: Many formulation as food supplements are treatment of non-insulin dependent diabetes mellitus. It is
available with a combination of Licorice, oats, ginseng, an insulin sensitizer, and probably acts by promoting

Drugs Used in Gynecology

valerian, etc. There is currently sporadic evidence of their peripheral glucose utilization. Hyperinsulinemia and/or
usefulness. insulin resistance is noted in a good proportion of PCOS
subjects. Metformin improves insulin sensitivity and
HYPERPROLACTINEMIA decreases androgen levels and helps in restoring normal
When there is pathologically elevated levels of prolactin menstrual cycle. In the absence of spontaneous menses,
(Up to 20 ng/ml is normal). 20–40 mg/ml is mild hyper- ovulation induction may be achieved with relative ease
prolactinemia associated with AUB, 40–80 ng/ml moderate either with clomiphene citrate alone or with chlomiphene
hyperprotactinemia associated with amenorrhea, gala- citrate plus hCG or hMG plus hCG.
ctorrhea, anovulation and infertility and >80–100 ng may be When a PCOS patient on metformin therapy becomes
associated with microadenoma of pituitary. pregnant, this drug should be continued throughout pregnancy.
Drugs used in hyperprolactinemia are bromocryptine Properly conducted clinical studies have shown that
and cabergoline. metformin treatment prevents first trimester spontaneous
abortion and the chances of gestational diabetes. It does not
Bromocryptine have any teratogenic or other deleterious effects on the
It is a synthetic ergot derivative and a potent dopamine child followed upto 3–4 months after birth.
agonist. It decreases the prolactin (PRL) release from the
Dosage: 500 mg three times daily or 850 mg twice daily before
pituitary by acting on dopaminergic receptors on lactotroph
meals for 2–3 months or more. The new Metformin 500 mg
cells in the pituitary. Therefore, it is used in cases with
(SR) sustained release tablets are given once or twice daily,
hyperprolactinemia. This is to be administered in 2.5 mg
and shows better results.
doses given twice daily. Since PRL is a sleep-related hormone,
the main dose will be at bedtime and the other in the morning. Side effects: Gastrointestinal disturbances, and very
Initially we start by 2.5 mg daily at bed time for one week. rarely lactic acidosis. For prevention of lactic acidosis, it
After that the full dose is given. The effect is to be monitored should not be used in patients with serum creatinine higher
by blood PRL estimation, and the dosage adjusted than 1.5 mg/ml, and blood lactate level may also be
accordingly. During first week of therapy half the dose is monitored.
given daily at night. If the patient is able to tolerate this dose Contraindications
the full dose is started. If she becomes pregnant she can
Renal failure, hepatic insufficiency, high blood lactate
continue the drug throughout pregnancy because of its
concentration.
extensive safety profile.
Side-effects: Abdominal pain, vertigo, changes in vision; Pioglitazone
postural hypotension and syncope, loss of appetite, swelling It is a thiazolidenedione derivative. In cases with resistance
of hands, ankles, feet, or lower legs, weight gain or loss. to metformin, this may be administered in doses of 30–45
mg daily orally either alone or in combination with
Contraindications
metformin. This drug increases glucose insulin dependency
Hypersensitivity to ergot alkaloids, diabetes, liver and renal and peripheral glucose disposal, and decreases insulin
dysfunction, cardiovascular disease. resistance and hepatic glucose output. It should be
mentioned here that another similar effective drug,
Cabergoline
troglitazone, has been withdrawn from the market because
It is a new ergoline derivative with a long-acting dopamine of toxicity.
receptor agonist. It exerts direct inhibitory effect on pituitary
lactotrophs and is used in patients of hyperprolactinemia due Contraindications
to either idiopathic cause or pituitary adenomas (tumors). This This drug cannot be given to patients with impaired kidney
is to be administered in doses of 0.25 mg two times a week. Dose function. This drug should not be continued during pregnancy.
may be increased every four weeks as needed, according to Blood urea, creatinine and serum lactate levels should be
serum prolactin levels, up to 1 mg two times a week. monitored. 617
 N-Acetyl Cystine (NAC) analogues are PGF2α, PGE 2, mesoprostol (PGE 2) the last is
It improves levels of circulating insulin circulating levels taken orally. In gynecology it is used for (a) cervical ripening
and insulin sensitivity in PCOS cases. A dose of 1.8 gm 3 gm prior to dilatation and curettage and endometrial biopsy, (b)
per day is recommended depending on the patient’s weight. Medical management of missed and incomplete absortion,
(c) Cervical ripening prior to hysteroscopy, before and
DRUGS FOR ABNORMAL UTERINE BLEEDING (AUB) intrauterine insemination.
Besides hormones other drugs used for AUB are – The dose is 200 µg 4 hourly for (b) and a single dose of 600
a. Tranexamic acid: It is a synthetic lysin derivative that exerts µg for (d) and (c) (orally or vaginally).
its antifibrinolytic effect by reversibly blocking lysine
binding sites on plasminogen and thus prevent fibrin VAGINAL DRUGS FOR LOCAL INFECTIONS
degradation. Tranexamic acid also inhibits the proteolytic These are often used. In the form of pessaries or creams.
activity of plasmin is a blockage of the lysin binding sites They are clotrimazole tablet and cream, ciclopirox olamine
Miscellaneous

of plasmin, making inactivation by alpha-2-antiplasmin 1% cream, sertaconazole nitrate 500 mg vaginal tablet.
impossible. It can prevent the dissolution of hemostatic
fibrin by stabilizing fibrin structures. It also increases MICRONUTRIENTS AND ANTIOXIDANTS
collagen synthesis and as tensile strength with Micronutrients are substances that are vital to the body but
granulation tissue most likely by preserving in fibrin are needed in a very small amounts. They include vitamins,
matrix. Dose is 1–1.5 gm 3 times daily for first 5 days. It is minerals and trace elements. The majority of these are
effective and well-tolerated. It can be given parentally. antioxidants too. Antioxidants are substances that protect
b. Mefenamic acid is a nonsteroid antiprostaglandin and is against the deleterious effect of free radicals arising as a by-
used as 500 mg thrice a day for 5 days. product of normal metabolism or by chemical accidents.
Section 18

c. Ethamsylate acts on the capillary walls and improves Menopausal women are vulnerable to the action of free
platelet adhesiveness. It can be used orally and parenterally. radicals because of loss of the antioxidant effect of estrogen
d. Diclofenac sodium: It increases capillary resistance, as well as the decreased competence of antioxidants
suppresses PGE 2 secretion and improves lymphatic defences with aging. Under normal circumstances in healthy
drainage. The dose is 500 mg BD × 5 days before and individuals the effect of oxidants is counteracted by
during menses for 3 cycles. It is useful in adolescent antioxidant defences found in body’s cell compartments in
AUB, ovulatory menorrhagia, premenopausal DUB and the form of enzymatic and non-enzymatic antioxidants. The
primary hormonal failure. non-enzymatic ones are found naturally in diet and include
e . Intrauterine progestogens are progestasert, Mirena, vitamins A, C, E, carotenoids, taurine, cystine, linolenic acid
Mirena MLS and fibroplant (the last two are still under (pimrose oil) and glutathione. Minerals like selenium, zinc,
trial). There is significant reduction in menstrual loss (74– copper, iron, chromium, and manganese form a part of the
95%) in both nonsecretory endometrial hyperplasia and antioxidant system through enzymes.
endometriosis. Because of their cost their use is not
widespread. VACCINATION
Human Pipilloma Virus (HPV) Vaccine: As carcinoma of the cervix
DRUGS USED IN URINARY INCONTINENCE is mostly caused by human papilloma virus, vaccination
i. Estrogens are used in menopausal patients but a against this virus will help prevent this dreaded disease. At
substantial effect in the treatment of SUI has not been present two types of vaccines are available in India.
demonstrated. • Bivalent vaccine (Cervarix)
ii. Alpha adrenergics—Phenylpropanolamine and midodrine • Quadrivalent vaccine (Gardasil).
iii. Beta-adrenergic—Clenbuterol Dose-Bivalent 3 doses 0, 1 and 6 months intramuscular.
iv. Anticholinergic drug oxybutynin. It exerts a direct Quadrivalent 3 doses 0, 2 and 6 months intramuscular.
antispasmodic action on smooth muscles and inhibits It is at present, recommended for use in females. The
the muscarinic action of acetylcholine on smooth muscle. age at first dose varies from 9 years to 26 years. No testing
v. Tricyclic antidepressive—imipramine and doxepin. for HPV is recommended before starting.
vi. Serotonin—Norepinephrine reuptake inhibitor Dulox- • Screening for caneer cervix is to continue as in non-
entine inhibits the reuptake of serotonin and nore- immunized women
pinephrine. It shows a positive effect on bladder and • It is also found useful in the prevention of cancer of the
urethra. The dose is 40 mg twice a day for 12 weeks. vulva and the vagina and warts.
vii. Muscarinic receptor antagonist—tolterodine L-tartarate • It is not recommended during pregnancy.
2 mg twice a day or 4 mg once a day extended release
capsule in overactive bladder. BIBLIOGRAPHY
1 . American Diabetic Association (1998) Concensus development
SILDENAFIL conference on insulin resistance, November. Diabetic Care
It was initially used in pulmonary hypertension. It is a potent 1997;21:310-4.
2 . American Society for Reproductive Medicine Revised 2003
and selective inhibitor of CGMP. It is used in erectile
Consensus on diagnostic criteria and long-term health risks related
dysfunction in males. Dose 25–100 mg once a day. Other to polycystic ovary syndrome. Fertil Steril 2003;18:19-25.
drugs for similar effect are tadalafil and vardenafil. 3 . Aziz R, Ehrmann D, Legro RS, Witcomb R, et al. Troglitazone
improves ovulation and hirsutism in polycystic ovary syndrome:
PROSTAGLANDINS (PG) a multicenter, double blind, placebo-controlled trial. J Clin
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619
 80 Basis of Neo-Organo-Histogenesis in vivo:
Regeneration of Fallopian Tubes and Uterus

BG Matapurkar, H Koratkar

INTRODUCTION 7. Regeneration: The growth of destroyed or devitalized tissue

That plants and lower life forms in nature have the capacity or organ from the remnant tissue or organ. It is a
to regenerate lost parts is well-known. In higher animals reparative attempt of the body. This regeneration is
including mammals and man, this capacity is bare minimum different from neo-regeneration as it does not involve
or absent. The laws of nature have uniform applicability in formation of total tissue or organ and is not by
this universe. At the same time, one knows that the colonization or grafting tissue or cells which, in turn,
embryological organ and tissue formation in the womb is by undergo transformation and form new tissue.
cellular proliferation and differentiation of a single celled 8. Neo-organogenesis: Formation of organ from the
fertilized ovum. This single cell can form all the body tissues transformation of stem cells on colonization by
and organs having different structure and different function differentiation and proliferation.
(Fig. 80.1). Utilizing this nature’s marvel, an in vivo method of 9. Neo-histogenesis: Formation of tissues by differentiation and
neo-organo-histogenesis of different tissues and organs in proliferation of stem cells on colonization in the tissues.
the mammalian body is developed using adult tissue stem Neo-organogenesis and neo-histogenesis from adult
cells. Basically the adult stem cells are the specialized form stem cells can be better understood if the new phenomenon
of embryonic stem cells and in specialization have lost their of desired metaplasia is explained.
totipotent capacity to only pluripotent capacity, restricted by
germ layer to which these cells belong. The technique DESIRED METAPLASIA
comprises of surgically transferring appropriate, auto- (Adopted from original publications of the first author (BG
genous stem cells of adult tissue for colonization into the Matapurkar).
host tissue where organ regeneration /repair is required. Formation of human and mammalian body in mother’s
Selection of appropriate tissue is decided by the hypothesis womb, having different tissues and organs with different
of the first author (registered 1994)**, and published elsewhere. structure and functions is by single celled fertilized ovum.
Therefore, principles and laws of embryology can explain
GENERAL CONSIDERATIONS replacement and repair of tissues and organs in health,
The description of some of the words used in this article disease or abnormal transformation of tissues (metaplasia).
need special mention. Textbook concepts of metaplasia is the transformation of
1. Organogenesis: This term is generally used in embryology fully developed tissue into another fully developed tissue.
to signify the formation of organs from the fertilized ovum This transformed tissue is abnormal in the region of tissue
in developing embryo. system where this change has occurred and, therefore, it is
2. Histogenesis: Formation of tissues of the body. considered as abnormal and pathological viz. squamous
3. Plasia: Growth or a change (Latin – To mould). change in tracheal epithelium in chronic smokers or tissues
4. Metaplasia: Change of cells from a normal to an abnormal formed in the peritoneal cavity in patents with chronic
state (Latin – Meta + plasia) According to Steadman’s peritonitis. These tissue formations, are not normally seen
Medical Dictionary, transformation of a fully developed in health and normal conditions/environment. It is after
tissue into another fully developed tissue is known as abnormal exposure of cells to irritation, chemicals, infection,
metaplasia. etc. that such tissues are formed which are abnormal. Hence
5. Desired Metaplasia: Metaplasia that is useful needed, the metaplasia is often considered pathological.
desired and compatible anatomically, physiologically and In fact, such change is adaptive and protective in nature.
histologically, in the new region of exposure and is This is achieved by the stem cells of local tissues, having mono,
responsible for neo-regeneration of tissues and organs. bi, or pluripotent character. These cells have the capacity to
6. Stem cell: These cells can be defined in terms of their change their pathways and form different tissues under
functional capabilities. Stem cell is not a property but a abnormal conditions/exposure. Therefore, the concept is
spectrum of capability. clear that metaplasia is the result of transformation capacity

**
(narrated again for ease and understanding—it proposes that, “In postembryonic state if stem cells of autogenous tissues derived from a
germ layer of developing embryo are colonized with the tissues and tissue system which are derived from the same germ layer, neo-
regeneration of tissues and organs is a possibility provided that both host tissue and colonized cells have developed as neighbors in the
developing embryo”). The essential part being that the donor and host tissue must have developed in the neighborhood to each other in
developing embryo and belong to the same germ layer.
 Chapter 80
Basis of Neo-Organo-Histogenesis in vivo
Figs 80.1A to E: (A) Intra-embryonic mesoderm; (B) Structure of nephrogenic cord; (C) Formation of paramesonephric duct;
(D) and (E) Formation of uterovaginal canal

of the inherent stem cells present in the tissue. The In health there is constant wear and tear of epithelial
metaplastic tissue formation capacity depends upon the surfaces. A constant renovation and replacement of cells is
origin of these stem cells from the germ layer of the germ needed. This is achieved in nature by stem cells present in
disc of developing embryo. On review of literature in the the tissues, for example in the tracheobronchial muscosa the
section of epithelial metaplasia, in particular glandular stem cells divide and proliferate in a predicted manner and
metaplasia, (such as differentiation of hepatocytes in pattern, and differentiate to form ciliated columnar epithelium
pancreas) indicate that during embryonic development, essential in the region. This is committed differentiation and
gastric, intestinal hepatic and urothelial epithelia arise from after change in environment, as in chronic smokers, the
the cells of contiguous endoderm. There is a possibility that precursor cells adopt different pathways to meet the challenges
precursor cells capable of differentiating into any of these of a new environment. This produces more resistant epithelium
populations could persist into adult life. Such cells may commit in the region. This is a change in the commitment of precursor
themselves to differentiate towards a desired metaplastic cells. This change is reversible when irritation (smoking) is
version when there is chronic tissue damage. Therefore, it is removed and a normal environment is reestablished. The
clear that the exposure to a new environment has a great change is induced due to change in environment, which is not
effect on cells. In other words, even though, the precursor normal to that anatomical region. The changed environment in
cells are committed genetically, to form certain tissues, the the peritoneal cavity in patients with chronic peritonitis, resulting
change in environment and exposure to new functional need, in the formation of tissues (like: bone, cartilage, etc.) is an
can force these cells to different commitment, which is example.
inherent in them. Conceptually this capacity and behavioral The hematopoietic cells enjoy a special favor of
pattern inherent in the stem cells have been exploited and multiplasticity, as these cells have developed from the
utilized in organogenesis and histogenesis by desired wandering mesenchyme in developing embryo. These cells
metaplasia. The comparison and final outcome is given in have to travel through almost all the body tissues in the
(Table 80.1). blood stream and are conversant with the cytokines and 621
 Table 80.1: Comparison and final outcome of plasia, metaplasia and desired metaplasia

Plasia* Metaplasia Desired Metaplasia

Concerned cell Precursor cell normally Precursor cells in the Precursor cells from
Present in tissues tissue and organ. autogenous
Tissue from specific site.
Conditions Normal loss of cells due to Abnormal stimulus, e.g. Normal tissue conditions but
Wear and tear during health Irritation, Injurious agent. altered anatomical site
Cell commitment Normal commitment of cells Abnormal transformation Normal but altered in
Formation of different tissue. different tissue environment
and functional need.
Cause Cell damage due to normal Irritation, chronic cell Exposure to changed
Miscellaneous

wear and tear of body tissue Damage. Exposure to anatomy, physiology.

Abnormal conditions.
Functional need Normal Abnormal New functional need due to
Imposed functional need exposure to new tissue
environment.
Differentiation Committed differentiation Altered commitment and Desired commitment. Normal
Cell differentiation. embryological commitment.
Tissue produced Normal in the region Adoptive, protective tissue, Desired in the region
To restore damaged tissue To resist further damage Normal in new region
To restore anatomy and
Section 18

function in the new region.

Examples 1. Urinary system: Transi- 1. Urinary system: 1. Genitourinary system:
tion epithelium restored. Squamous epithelium in place ureter,fallopian tube, uterus,
2. Tracheobronchial of transitional epithelium urethra, are restored in new
tree ciliated epithelium 2. Tracheobronchial tree region.
restored Squamous epithelium in place 2. Aponeurosis from
of columnar epithelium. peritoneum inabdominal wall
Reversibility Nil. Reversible. If noxious, Nil. Normal conditions as in
Irritating agent removed. Plasia, So far no reversibilityor
If irritation persists, may any abnormality seen
show neoplasia and Long-term follow-up 15 years
malignant change in Incisional Hernia, 5 yrs. in
genito urinary rectal fistula.
Reversibility
Seen in Sweeny’s experiments.
* Plasia : Dictionary meaning = growth or change.
Sq. ep. = Squamous epithelium

integrins of different body tissues. Therefore, cell surface Embryological Facts about the Oral Mucosa
receptors can respond to the versed chemicals and Oral mucosa has developed from two sources (i) stomodeum
environments. Hence these cells possess the ability to hence ectodermal in origin. And (ii) from foregut hence
transdifferentiate into any of the tissues through which they endodermal in origin.
migrate. When oral mucosa is colonized with skin of the pinna, the
If the peritoneal stem cells are taken out from their stem cells of ectodermal part of the oral mucosa responded to
anatomical abode and subjected to the environment of the tissue cytokines of extracellular matrix (ECM) of the skin.
the urinary tract system, aponeurosis, etc. the change, This resulted in keratinization and metaplastic transformation
which takes place is normal and desired at the site of to skin element after two months. Later on after two months
exposure. The inherent property of the mesodermal stem the same graft along with ear cartilage was used to colonize
cells present in the peritoneal membrane of forming tissue tracheal tissue. The endodermal stem cells responded to the
derived from mesoderm germ layer (from which the ECM tissue cytokines of the endodermal trachea. This resulted
peritoneum is derived) is responsible for organogenesis in formation of ciliated columnar tissue exactly the same as
and histogenesis in the new region of exposure. In patients needed in the tracheal region. Interestingly, in the new region
with chronic peritonitis the tissues formed are abnormal of the trachea the keratinization slowly disappeared. This can
to the peritoneal cavity, hence this can be termed as be explained by the fact that the ECM tissue cytokines of the
metaplasia. But, on the contrary, the formation of smooth ectodermal skin were absent in the tracheal region. The
muscle and transitional epithelium, in the urinary tract ectoderm cells preferred apoptosis. The cell surface receptors
system, are desired and useful in the new situation. This (CSR) and ECM cytokine specificity of action is responsible for
change is physiological, anatomical and functionally desired this specific transformation. Another interesting fact noticed
in the new region of exposure and environment of the urinary by Sweeny et al, was that the histological changes observed
tract system. And hence this can be termed useful and/or were from the center of the graft and not from the periphery of
desired metaplasia. The formation of aponeurosis, the graft suggesting that the changes were in the graft and not
ureter, fallopian tube, uterus from peritoneal stem cells and from the remnant of the tissues where colonization was attempted.
urinary bladder, bile duct from stem cells of crypts in submucosa If the development of oral mucosa, pinna and trachea is
of the gut (US patent), are all in line with this concept and recapitulated, one finds that these tissues have developed
622 principle. in neighborhood to each other.
 On comparison of the plasia, metaplasia and desired
metaplasia at a glance, it is clear that the plasia is a growth or a
change while metaplasia is an abnormal transformation of one
tissue to another, both at their own anatomical abode. Plasia is
the result of normal wear and tear of tissue cells. It is basically
a replacement of lost cells. Desired metaplasia is formation of
tissue needed in the region which is achieved by transformation
of fully developed tissue stem cells to aponeurosis, ureter,
fallopian tube, etc. Like plasia it is irreversible as the
environment change is not removable. In metaplasia if the
noxious agent is removed the tissues return back to normal.

Chapter 80
What is the Outcome of Desired Metaplasia?
Once it is understood that the higher animals mammals and
man, like plants and lower animals, have the capacity to
grow their own tissues and organs by a physiological process
called desired metaplasia it is mandatory to know the
outcome and ultimate fate of this newly discovered
phenomena. It is known that the metaplasia is the result of Figs 80.2A and B: Technique of regeneration of the fallopian tube.

Basis of Neo-Organo-Histogenesis in vivo

chronic injurious agents and environment. Once the injurious (A) The fallopian tube is excised (dotted line). Replacement of excised
agent and environment is removed or disappears, the tube with peritoneal tube; (B) The placement of stent which was
brought down through uterus into vagina and secured with non-
metaplasia disappears and tissues revert to their normal
absorbable suture at the lower end of the vagina
structure. In desired metaplasia the change is the result of
local tissue environment, functional need and cytokines of
ECM of the tissue system. As long as the tissues thus formed (infant feeding tube). The stent bearing constructed tube is
are needed in the region the factors responsible for its transferred to the excised fallopian tube region. The stent
formation cannot be removed, hence the change stays over ends are introduced into the cut fimbrial and uterine ends of
indefinitely. the fallopian tube. The uterine end is brought down through
However, the possibility of neo-plastic change as in any the uterus into the vagina and secured at the lower end of the
other normal tissue cannot be ruled out. vagina to avoid accidental removal. The peritoneal tube is
anastomosed with spatulated ends of the fallopian tube. This
Mechanism of Desired Metaplasia is to avoid stricture formation at the anastomotic site. The
Extracellular Matrix (ECM) is a protein network in the cell stent is removed after three months of postoperative period.
habitat. This ECM exerts a great influence on the cells which it The gross and microscopic views of neogenerated fallopian
surrounds. This influence is exerted through the chemical tube is given in (Figs 80.3A to D).
substances called cytokines. The receptors on the cell surface The Paramesonephric Duct is formed from cells of the
directly communicate with ECM through direct mechanical or coelomic epithelium, invaginating the mesenchyme.
chemical signals. This is responsible for cell cycle regulation, Coelomic epithelium in the abdomen is known as peritoneum
i.e. whether the cells should live or undergo apoptosis, (3rd from top).
proliferate or differentiate and so on. These cytokines are
HUMAN UTILITY
cell-specific and cell cycle regulation depends upon this
specificity. This explains why endodermal stem cells do not Regenerative surgery is still in its infancy but greater
get regulatory signals to form mesodermal tissue, i.e. even if developments in this field are expected with time. The author
the intrinsic capacity of cells has the intelligence to form the has utilized this concept in the management of large
required tissues. Regeneration of tissues and organs in the incisional hernias and complex genitourinary rectal fistula.
body from autogenous tissue stem cells is probably the
Advantages of Biological Organs by Regenerative Surgery
outcome of these cytokine signaling ECM and cell receptors.
Such integrated actions are responsible for this metaplastic In vivo animal experiments of regenerating tissues and
transformation into tissues needed in the region. organs using autogenous tissue having stem cells by desired
Technique of neo-regeneration of fallopian tube: Once the metaplasia, reveal another fact that such venture will be
concept of desired metaplasia is understood, the free from problems and complications of transplant surgery.
regeneration of fallopian tube and uterus can be scientifically The obvious advantages of such management are:
explained. Embryological development of peritoneum is from • No donor needed
coelomic epithelium during intrauterine growth. Coelomic • No tissue matching
epithelium invaginates into surrounding mesenchyme to form • No rejection (body forms own organs)
paramesonephric duct. This duct forms fallopian tube and • No life-long immunosuppressant drug use post-
uterus. In other words the peritoneum forms the fallopian operatively
tube and uterus during embryonic development. Hence the • No disease transfer from donor
peritoneal cells from an appropriate site are used to neo- • No psychological/ethical/legal problems.
regenerate the fallopian tube and uterus. • Cost effective modality
The peritoneal tube is constructed from donor peritoneum • Host immunity remains undisturbed
obtained from retrovesicular and posterior abdominal wall • Only one surgical procedure needed
(Figs 80.2A and B). The edges of excised peritoneum are • Simple surgical techniques can regenerate tissues and
sutured with 5/0 vicryl eyeless suture on a suitable sized stent organs.
623
Miscellaneous
Section 18

Figs 80.3A to D: Neo-regeneration of fallopian tube. Gross view of mesodermal membrane (peritoneum) after colonization,
3 months postoperative period. Long slit to show inner lining of tube. (A) Transverse section of tube is compared with freshly prepared tube
from peritoneum membrane (in white) for comparison; (B) Low power (6.3 × 10 magnification) microscopic histology of the same H E stain;
(C) Histology—10 X 10 magnification—(Masson’s Tri Chrome stain) smooth muscles in eosin stain and fibrous tissue in green; (D) Histology to
show cilia in H E Stain in high power (10 X 40 magnification) microscope

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22 . Matapurkar BG, Rehan HMS, Agarwal A K, Kumar A. 357-60.
Organogenesis and tissue regeneration of ureter from autogenous 36 . Ryce P E Zimmer P I, de Kmion I B. Patch grafting of renal pelvis
primitive stem cells in adult Rhesus monkeys. Ind J of Urol and uretero pelvic junction. Urol Res 1998;16:37-9.
1996;13:1-4. 37 . Slack JMW, Holland PWH, Grahm CF. The zootype and the
23 . Matapurkar BG, Rehan HMS. Formation of neoureter in live phylotype stage. Nature 1993;361:490-2.

Basis of Neo-Organo-Histogenesis in vivo

animal model (dog). J of Expt Biol 1996;34:954-8. 38 . Sterioff S Jr, Smith J W. Autogenous peritoneum as an arterial
24 . Matapurkar BG, Hermeet Singh Rehan. New technique for repair patch graft. Am Surg 1972;38:53-5.
of complex genito-urinary rectal fistula using peritoneum for 39 . Singh IB, An introduction to embryology. 58th edn. P. 380, 1990
urethral 1997;13(1):36-44. Ltd. Madras, Jaipure, Patna, VAPI, Bangalore, Bhopal. Published
25 . Matapurkar B G, in textbook of R Maingot’s abdominal operations. by SG Wasani for Mac Millan India Press, Madras.
Edited by M J Zinner, S I Schwartz, H Ellis, 10th edn International 40 . Sweeny PR. Oral mucous membrane. J Surg Research 1975;
edition, Section III, Abdominal Wall. “Marlex peritoneal 19:303-8.
sandwich”; 1997.pp.568-80. 41 . Thuroff JW, Hutschenreiter G, Frohenberg D, Hohenfeller R,
26 . Matapurkar BG, Bhargave A, Dawson L, Sonal B. Organogenesis Transplantation of a free peritoneum patch in suygery of the
by desired metaplasia of autogenous stem cells. Ann of New renal pelvis and ureter. Eur Urol 191;7:304-8.
York Acad of Sc 1998;857:263-7. 42 . Till JE, McCulloch EA. A direct measurement of the radiation
27 . Matapurkar BG, Bhargave A, Dawson L, Sonal. B. Regeneration sensivity of normal mouse bone marrow cells. Radiat Res
of abdominal wall aponeurosis : New dimension in Marlex 1961;14:1419-30.
peritoneal sandwich repair of incisional hernia. World J Surg 43 . Tusji I, Kurada K, Fujieda J, Shirsishi Y, Kasai T, Ishida H A Clinicaln
1999;23:446-51. and experimental study on cystoplasty not using intestine. J of
28 . Matapurkar BG. Proceedings of the XVII National C M E Urol 1963;89:214-7.
Programme in Surgery, Department of Surgery, Maulana Azad 44 . Wombus AM, Bohler KR, Embryonic stem cell: Prospects for
Medical College, New Delhi, India. Compiled by Dr AK Sarda. developmental biology and Cell therapy. Physol Rev
Surgery Update 2000;7:248-57. 2005;85:635-78.
29 . Matapurkar BG. Bhargave A, Dawson L, Sonal B, Ramteke VK. 45 . Yoo JU, Barthel TS, Nishmura K, Solchaga L, Caplan AI, Goldberg
Organogenesis and tissue regeneration of fallopian tube: A desired VM, Johnstone B. The chondrogenic potential of human bone
metaplastic transformation of mesodermal stem cells in live animal marrow—derived mesenchymal progenitor cells. J Bone Joint
models (dogs). Ind J Exptl Biol. 2000;38:129-36. Surg Am 1998;80:1745-57.
30 . Matapurkar BG. A new physiological phenomenon of mammalian 46 . Yotsuyanagi T, Urushidate S, Watanabe M, Sawada Y,
body for organ and tissue neo-regeneration in vivo: Adult stem Reconstruction of three dimentional structure using cartilage
cell technology in the perspective of literature. Review regeneration from the perichondrium of rabbits. Plastic reconstr
article.Ind.J of Expt. Biol 2002;40:1331-43. Surg 1999;103:1120-3.

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 81 Stem Cells Research,
Cloning and Gene Therapy

Ankita Singal, Renuka Sinha, Sudha Salhan

STEM CELL RESEARCH

Stem cells are characterized by the ability to renew Properties of Stem Cells
themselves through mitotic cell division and differentiating The classical definition of a stem cell requires that it
into a diverse range of specialized cell types. Ernest A possesses two properties:
McCulloch and ames E Till in 1960 did pioneer research in 1. Self renewal It is the ability to go through numerous cycles of
stem cells. Stem cells may be used to replace or repair cell divisions while maintaining an undifferentiated state.
damaged cells, and have the potential to drastically change 2. Potency It is the capacity to differentiate into different
the treatment of conditions like cancer, Alzheimer ’s and specialized cell types. Stem cell research holds great
Parkinson’s disease and even paralysis. promise for improving human health by control of
Embryonic stem cells are found in blastocysts (human degenerative diseases and restoration of damaged
embryo). The human embryo is taken and grown in laboratory organs. Of utmost importance is assurance of safety,
(Fig. 81.1). This technique requires destruction of embryo and the rights of those donating.
making it morally incorrect. Adult stem cells they are obtained
from bone marrow, brain of cadavers of human and umbilical Types of Stem Cells
cord. Embryonic stem cells can differentiate (Fig. 81.2) into A unipotent stem cell is a cell that can differentiate along only
all of the specialized embryonic tissues but adult stem cells one lineage, but does have the important property of self-
lack potential to generate all the tissue types needed till renewal. Unipotent cells have vast therapeutic potential to
date. As stem cells can be grown and transformed into treat injuries and diseases, e.g. epithelial skin cells, but can
specialized cells like muscle, nerve, islets of Langerhans, take several weeks to grow a sufficiently sized piece of skin.
etc. Through tissue culture, a vast canvas of the therapeutic
Totipotent cells are cells which have the potential to
use of stem cells has been painted. It is called therapeutic
differentiate into any type of cell in the adult body. The only
cloning.

Fig. 81.1: Stem cell differentiation

 Chapter 81
Stem Cells Research, Cloning and Gene Therapy
Fig. 81.2: Differentiation of embryonal stem cells

source of totipotent cells is the fertilized ovum till the first 4 Pluripotent, embryonic stem cells originate as inner mass
or 8 cell stage after cleavage. Totipotent cells cannot make cells within a blastocyst. The stem cells can become any
more of themselves in mammals. tissue in the body, excluding a placenta. Only the Morula’s
Pluripotent stem cells are true stem cells, with the potential to cells are totipotent, able to become all tissues and a
differentiate into most cells in the body except those of the placenta.
placenta (which is derived from the trophoblast). There are Potency specifies the differentiation potential (the
three types of pluripotent stem cells. Embryonic Stem (ES) potential to differentiate into different cell types) of the
cells which can be isolated from the inner cell mass (ICM) of stem cell.
the blastocyst. Embryonic Germ (EG) Cells which can be • Totipotent stem cells are produced from the fusion of
isolated from the precursor to the gonads in aborted fetuses an egg and sperm cell. Cells produced by the first
and the Embryonic Carcinoma (EC) Cells which can be few divisions of the fertilized egg are also totipotent.
isolated from teratocarcinomas. All these types of pluripotent These cells can differentiate into embryonic and
stem cells can only be isolated from embryonic or fetal tissue extraembryonic cell types.
and can then be grown in culture with special methods to • Pluripotent stem cells are the descendants of
prevent them from differentiating. totipotent cells and can differentiate into cells derived
from any of the three germ layers. Multipotent stem
Multipotent stem cells can only differentiate into a limited cells can produce only cells of a closely related family
number of cell types, i.e. the bone marrow, heart, muscle, of cells.
nerves, etc. The sources are umbilical cord blood cells, Unipotent cells can produce only one cell type, but have
amniotic fluid and organs like brain and liver in the adult the property of self-renewal which distinguishes them from
body, where these cells can replace dead cells. These adult non-stem cells (e.g. muscle stem cells).
stem cells could possibly be the cells which produce cancer Embryonic stem cell lines (ES cell lines) are cultures of cells
cells after mutations. derived from the epiblast tissue of the inner cell mass
(ICM) of a blastocyst or earlier Morula stage embryos. A
Classification of Human Stem Cells blastocyst consists of 50–150 cells. ES cells are Pluripotent
On the basis of their origins three groups of stem cells are and give rise, during development, to all derivatives of
recognized: the three primary germ layers: ectoderm, endoderm and
1. uman embryonic stem (HES) cells, derived from blastocysts: mesoderm. In other words, they can develop into each of
i. Blastocysts derived from surplus embryos from IVF the more than 200 cell types of the adult body when given
clinics. sufficient and necessary stimulation for a specific cell type.
ii. Blastocysts derived specifically for research or They do not contribute to the extra-embryonic membranes
therapy using IVF. or the placenta. Nearly all research to date has taken
iii. Blastocysts derived by other techniques like SCNT, etc. place using mouse embryonic stem cells (mES) or human 627
 embryonic stem cells (hES). Both have the essential stem through public debate and future research, and further
cell characteristics, yet they require very different education of the public.
environments in order to maintain an undifferentiated state. Stem cells, however, are already used extensively in
Mouse ES cells are grown on a layer of gelatin and require research, and some scientists do not see cell therapy as the
the presence of Leukemia Inhibitory Factor (LIF) Human first goal of the research, but see the investigation of stem
ES cells are grown on a feeder layer of mouse embryonic cells as a goal worthy in itself.
fibroblast (MEFs) and require the presence of basic Fibroblast ord Blood Ban ing can be done to preserve stem cells for future
Growth Factor (bFGF or FGF-2). Without optimal culture use. Cord blood is stored at –70°C. It is available in India
conditions or genetic manipulation, embryonic stem cells but is expensive. The following points should be specifically
will rapidly differentiate. Pluripotent adult stem cells are considered while collecting umbilical cord blood for banking:
rare and generally small in number but can be found in a
number of tissues including umbilical cord blood and 1. No harm should occur to the fetus or the neonate.
Miscellaneous

menstrual blood.. A great deal of adult stem cell research 2. Exact timing of the clamping of umbilical cord should be
has focused on clarifying their capacity to divide or self- defined.
renew indefinitely and their differentiation potential. In mice, 3 Parents should be correctly informed regarding risks and
pluripotent stem cells are directly generated from adult benefits involved.
fibroblast cultures. 4. Free informed consent should be obtained from both
2. uman embryonic germ (hEG) cells, which are derived from parents. If there is disagreement between the parents,
primordial germ cells of the fetus. the mother’s wish shall prevail.
3. uman somatic stem (hSS) cells, which are derived from 5. ID card should be issued for voluntary donation to enable
fetal or adult tissues or organs, including umbilical cord access/benefit in future in case required for self/relatives.
Section 18

blood/placenta. Adult stem cell treatments have been 6. Standard Operative Procedures (SOPs) for collection,
successfully used for many years to treat leukemia and transportation, processing, storage (cryopreservation)
related bone/blood cancers through bone marrow and clinical use of umbilical cord blood/cells should be
transplants. laid down with approval of the appropriate authority.
7. If processed stem cells are proposed to be used, detailed
Amniotic placental stem cells In 2005, researchers at the protocol for isolation, expansion and characterization of
University of Pittsburgh discovered that embryo-like stem stem cells should be approved by appropriate authority.
cells could be obtained from the placenta. They are called Cord blood stem cell banking is permissible. However,
amniotic epithelial cells after the amnion—the outer all cord blood banks should be registered with the DCGI as
membrane of the placenta’s amniotic sac These cells combine per guidelines applicable to the blood banks. Commercial
the best features of both embryonic and adult stem cells: exploitation of stored blood should be regulated strictly. No
These stem cells can differentiate into several different tissue trading shall be permitted in this area as in organ donation.
types, including liver cells, neurons, heart cells, pancreatic Special care must be taken in collection, processing and
cells with the potential to produce insulin, uterus and fallopian storage of umbilical cord stem cells to avoid transmission of
and glial cells which form part of the nervous system. Each infections. Maternal screening should be carried out for
placenta contains about 300 million amniotic epithelial cells transmissible infections.
that could potentially be expanded to between 10 and 60
billion cells. Clinical Use of Umbilical Cord Blood Stem Cells
The ideal use of these cells at present is for allogenic
Advantages of Human Somatic Germ
hematopoietic stem cell transplantation. Expansion of
Cells over Embryonic Stem Cell
umbilical cord stem cells for transplantation in adult and use
1. They do not require the destruction of an embryo. Thus for non-hematopoietic indications is still in an experimental
there should be minimal protests from the prolife stage. Specific mention shall be made that at present the use
movement. of stored umbilical cord blood for self is practically nil. The
2. They can apparently be coaxed into developing into a ethical issues include concern about ownership, and risk of
wide range of cell types. transmission. Commercial aspects pose additional problems.
3. They are much easier to obtain than embryonic stem In India ICMR has issued guidelines on Stem Cell
cells. Research in 2007. Any project has to be first registered with
4. They can double in number every 36 hours. They can the council and prior permission is mandatory. According to
divide at least 250 times without mutating and without the source of stem cells and nature of experiments, the
forming tumors. They have been converted into bone, research on human stem cells is categorized into the
heart muscle, blood vessels, fat, nerve and liver tissues following three areas:
in lab mice. Unlike embryonic stem cells, they cannot • Permissible research areas
reproduce indefinitely. • Restricted research areas
• Prohibited research areas.
Therapeutic Use
Research involving introduction of hES/hEG/hSS cells/
In the future, medical researchers anticipate being able to cell lines into animals including primates, at the embryonic
use technologies derived from stem cell research to treat a or fetal stage of development for studies on pattern of
wider variety of diseases including cancer, Parkinson’s differentiation and integration of human cells into non-human
disease, spinal cord injuries, amyotrophic lateral sclerosis animal tissues. If there is a possibility that human cells could
and muscle damage, amongst a number of other contribute in a major way to the development of brain or
impairments and conditions. However, there still exists a gonads of the recipient animal, the scientific justification for
great deal of social and scientific uncertainty surrounding the experiments must be strong. The animals derived from
stem cell research, which could possibly be overcome
628 these experiments shall not be allowed to breed.
 Studies on chimeras where stem cells from two or more changeably. It may be described as creating multiple copies
species are mixed and introduced into animals including of a desired DNA sequence. Gene cloning means isolating
primates, at any stage of development viz., embryonic, fetal an exact copy of a single gene from the entire genome of an
or postnatal, for studies on pattern of development and organism and copying the DNA sequence of that gene into a
differentiation. Animals in which any of the human stem cells smaller and more accessible piece of DNA such as plasmid’.
have been introduced at any stage of development should Plasmids are self-replicating extra-chromosomal circular
not be allowed to breed. DNA molecules distinct from normal bacterial genome. In
Scientists are researching the transplantation of stem other words, the technology involves transfer of a DNA
cells into the ovaries to produce new eggs in infertile women segment of interest from one organism to a bacterium, and as
who have passed the usual age of conception. These eggs the bacterium reproduces, identical copies of DNA fragment
on fertilization may result in the birth of healthy infants. Stem inserted into it also replicate.
cells can be used to delay menopause. A small number of The process consists of a few essential steps. The DNA of

Chapter 81
female germline stem cells (FGSCS) from the ovaries of interest is extracted from the desired selected source using
adults rodents were transplanted into infertile mice. These specific restriction enzymes. The similar enzyme is used to
mice gave birth to offspring. This technique has great potential. cut plasmid from bacterium. In the next step the extracted
DNA from the source is inserted into a specific position on the
cut vector or plasmid and both the pieces of DNA are joined
GENE THERAPY AND CLONING together using DNA ligase enzyme. The new unit created is
called recombinant DNA molecule which carries the gene of
AN OVERVIEW

Stem Cells Research, Cloning and Gene Therapy

interest. It is then transferred into host cells which are cultured
Gene is a segment of DNA found on a chromosome that and the new DNA replicates along with host DNA.
codes for a particular protein. There are about 30,000 to 70,000 DNA cloning is an important research tool for gene
genes in humans coding for numerous proteins which are therapy, genetic engineering of organisms and sequencing
responsible for the proper functioning of the body. When a genomes. There are numerous applications of DNA technology
gene is defective, the blueprint of proteins it codes for is in medicine, e.g. production of insulin, human growth
imperfect resulting in abnormal protein formation. Gene hormone, clotting factors, erythropoietin, hepatitis B vaccine,
therapy is a treatment which consists of introducing a normal etc.
copy of one or more disease causing defective genes into
the affected cells of the patient. The goal of gene therapy is Reproductive Cloning
to cure a disease by repairing the damaged gene responsible Reproductive cloning is a type of asexual reproduction,
for the disease. involving taking up of genome from only one parent to form
Gene therapy is a novel promising approach aimed at an embryo. Using microsurgical techniques, the nucleus from
treating diseases which do not respond to conventional a donor somatic cell is removed and inserted into an egg
therapies. It has been a field of intense research for nearly from which the nucleus has already been removed. This
20 years. More than 1,000 genetherapy clinical trials have process is called somatic cell nuclear transfer (SCNT). Thus,
been conducted all over the world, but to date there are no an egg is created using genetic material from another source.
FDA approved gene therapies. Then, electrical or chemical stimuli are used to trigger cell
division and the egg starts developing into an embryo. When
BASICS OF GENE THERAPY this cloned embryo reaches an appropriate stage it is
To understand the basics of gene therapy, it is essential to implanted into the surrogate female host for further
have some knowledge about Stem cells and Cloning. Stem development.
Cells are increasingly being used to administer gene therapy Although the clone has nuclear DNA which is the same
while cloning is a technology used in gene therapy. as the donor, the cytoplasmic mitochondria of the egg are
not replaced by donor DNA. The mitochondria also contain
Cloning: ‘A Tool Widely Employed in Gene Therapy’ short segments of DNA and acquired mutations of
Although history of cloning dates back to 1952 when the first mitochondrial DNA could be responsible for playing a possible
animal tadpole was cloned, it received popularity only, when role in the disease process.
Dolly’ the sheep, was created by Scottish scientists at Roslin
Therapeutic Cloning
Institute in 1997. It generated a worldwide curiosity and
philosophical debates as well as concerns regarding its Therapeutic cloning or embryo cloning means production of
potential uses and misuses. Cloning and stem cell research human embryos for use in research. The objective of
are often confused as both involve usage of embryonic cells. therapeutic cloning is creation of embryos for the purpose
Cloning’ is a precise technique of creating genetically identical of harvesting stem cells. The embryonic cells from the inner
copies of an already existing molecule, i.e., DNA, fragment of cell mass of blastocysts are removed when it is five days
DNA, tissue or an entire organism. To most people, the word old. These are utilized to create any type of specialized cells
cloning’ generally means reproductive cloning whereas in the human body and hence can be used for patients to
there are three main types of cloning technologies: treat various diseases.
• DNA cloning The medical community is hopeful that these stem cells
• Reproductive cloning, and may serve as replacement cells for incurable diseases like
• Therapeutic cloning. degenerative disorders, Alzheimer ’s, cardiac disease,
cancers, spinal cord injuries and may be able to clone and
DNA Cloning generate tissues and organs for transplant. It is this type of
The DNA cloning or gene cloning is a simple and common cloning which although is useful in medicine but is criticized
form of cloning. It is a process of recombinant DNA and is highly controversial as it leads to destruction of the
technology and the terms are sometimes used inter- embryo following extraction of stem cells from them. 629
 Thus it is clear that cloning technology can be used as a DNA Cloning Recombinant DNA Technology
tool to make gene therapy work for the welfare of humans to
prevent many diseases not treated by conventional methods.

Possible Applications
Another apparently promising technology is human somatic
cell engineering. This technology involves creation of new
tissues with the patient’s own DNA by modifying one type of
cell into another type of cell, e.g. human skin cells into nerve
cells and immune system cells.
Replacing one’s own tissues and organs with the
younger ’ telomere-extended replacements is another
Miscellaneous

exciting new application of cloning technologies. By

repeatedly introducing cloned telomere-extended cells into
an organism over a period of time, the tissue or organ will be
dominated by the younger cells thereby the individual will
grow progressively younger without surgery. Breeding
animals with desirable traits and recreating endangered
species of animals is another important and exciting
application of cloning. One of the most promising new anti-
cancer treatments is an anti-angiogenesis drug which is
Section 18

produced in the milk of transgenic goats using the same

technology.

Risks
Reproductive cloning is highly expensive, inefficient and
has a low success rate. The cloned animal may be
immunocompromised and may have higher rates of infection,
tumor growth, birth defects, shorter lifespan as compared
with the natural variety, or suffer from other disorders. Dolly
the sheep had crippling arthritis and carcinoma of the lung
and died at the age of 6 years, i.e. half the average age of a
sheep.

GENE THERAPY: APPROACHES AND REQUIREMENTS

Fig. 81.3: Vector or carrier
Gene therapy is defined as any treatment that changes the
function of a gene. It involves replacing a patient’s
malfunctioning genes with a set of normal genes, thus curing
the disease. The normal DNA is inserted into a virus which DNA cargo into a sufficiently large population of cells to
then infects (transfects) the patient’s cells thereby transmitting produce a biological effect and mediate expression of the
its DNA into the nucleus of a patient’s cells. desired gene for a sustained period of time. Identifying a
gene transfer tool that meets all of these criteria has proven
Principles of Gene Therapy to be a difficult task. Effective transfer of genetic material into
Gene therapy that is used to treat patients with existing the DNA of human cells is executed by vectors. This
genetic disorders is termed somatic gene therapy, whereas technology is still in its infancy and several approaches are
germ line gene therapy is used to insert genes of interest being tested. On successful administration of the vector, the
(corrected) into the reproductive cells so that the future mutated gene may be replaced by a healthy copy of a gene,
offspring will not contain the malfunctioning genes from the may be inactivated or a new gene may be introduced.
parent. Genetic engineering technology is used for the
introduction or elimination of specific genes by providing a Reproductive Cloning (Fig. 81.4)
copy of a normal gene to directly repair the DNA, or by There are two major strategies used to administer gene
providing a gene that adds a new function or regulates the therapy. The first one is gene therapy, i.e. directly
activity of other genes. The instruction for this are contained infusing the genes of interest or the therapeutic genes into a
in the therapeutic transgenes (the new genetic material person. These include both genetically disabled viruses and
introduced into the patient) The success of gene therapy is a non-viral vectors .The second is an indirect transfer of
technical challenge and depends on the delivery of the therapeutic gene, i.e. ex vivo gene therapy In this method,
therapeutic transgene into the requisite human target cells the delivery cells, often a type of stem cell, a lymphocyte, or
as well as on the ability of the genes to function adequately a fibroblast are removed from the body, and the therapeutic
inside the cells. transgene is introduced into them using the same vehicles.
While still in the laboratory, the genetically modified cells
The Vectors: Viral and Non-viral (Fig. 81.3) are tested and then allowed to grow and multiply and, finally,
Vectors are delivery vehicles or carriers that encapsulate the are infused back into the patient. It must be inserted into the
therapeutic genes and transfer them to target cells. The gene DNA for adequate transcription and translation, so that
transfer vehicle has to be safe, should be able to introduce its desired enzymes are produced efficiently.
630
 gene therapy in animals for the improved performance/meat
production are also envisaged as a complex problem.
Legitimate concerns regarding the possible harms by the
therapy must be publicly debated. It is hoped that mankind
will have the wisdom to use this technology constructively.

Potential Problems/Challenges
The goal of effective gene therapies for human diseases is
not easy to achieve. The problem of immune response in the
patient, which can interfere with gene therapy by causing
vector provoked inflammation, is quite pronounced in most
cases. The vector may elicit antibodies which can destroy

Chapter 81
the vector when it is administered again.
Introduction of the gene into non-dividing cells like
hepatocytes, muscle, and neurons is another challenge. An
approach which still needs optimization is replication and
expression of genes indefinitely in dividing cells but
minimizing the risk of its insertion near a proto-oncogene
which could get activated producing a cancer.

Stem Cells Research, Cloning and Gene Therapy

To express the gene as required, bring it under the normal
physiological controls so that its product is produced where,
when, and in the amounts needed, is another outstanding
challenge before the researchers.
Safety concerns of human gene therapy are being actively
addressed by various researchers. Viral vectors may infect
more than one type of cells, thus, even healthy cells may get
infected. Another risk is of insertion into a wrong location
and causing mutations. In addition, viral vectors may
accidently be introduced into reproductive cells hence may
Fig. 81.4: Reproductive cloning even be inherited. Other concerns include overexpression
which can be harmful or lead to immunogenicity. Major
The viruses which are currently used are genetically challenges include more selective and effective delivery.
altered to act as vectors capable of carrying normal human
DNA. The viral genome is manipulated and therapeutic DISEASES TREATED WITH GENE THERAPY
genome is inserted into target cells where the vector unloads The first approved gene therapy procedure was performed
its genetic material. The host cells then carry out new on 14 Sept. 1990 on a 4-year-old patient suffering from SCID
instructions and produce more copies of the virus, hence (severe combined immune deficiency).
infecting more cells. The viruses used for this purpose are To date, more than 450 gene therapy clinical trials are
retroviruses, adenoviruses, adeno-associated viruses, being conducted in the United States have been conducted
lentiviruses, pox-viruses, alpha-viruses, and herpes viruses. or of these, approximately 30 percent have used human stem
There are alternatives to viral vectors, and offer the cells, specifically blood-forming, or hematopoietic, stem
advantage of avoiding immunogenicity which is inherent in cells—as the means for delivering transgenes into patients.
most viral systems. They also help deliver large amounts of The remarkable developmental potential of stem cells has
transgenic DNA. Amongst many non-viral vectors, some led the researchers into using them to replace the damaged
commonly employed ones are small amounts of naked T-cells of pancreas such as beta cells, myelin sheath around
plasmid DNA and synthetic oligonucleotides, which involve axons in multiple sclerosis, spinal cord injuries, etc. Some
the use of antisense codons specific to the target gene to success has been achieved in culturing human epithelial stem
disrupt the transcription of the defective gene. Other systems cells and using them to replace a damaged cornea, and the
used are cationic lipids, which can carry large quantity of successful repair of a damaged left bronchus using a section
DNA sequence, polyethylamines and biopolymers like gelatin of a donated trachea (Fig. 81.5).
and chitosan. Initially, gene therapy focused upon single gene defects
such as hemophilia, sickle cell anemia, or muscular dystrophy.
Ethical and Social Issues hree types of diseases can be distinguished for the purpose
Gene therapy technologies embody the paradigm of potential of gene therapy:
benefits and risks of modern science. As it involves changes 1. Monogenic disorders, such as severe combined
in the genetics of the human body, it raises unique ethical immunodeficiency, cystic fibrosis, hemophilia, sickle cell
issues. The debate surrounding this problem is complex and anemia, Duchene muscular dystrophy.
various religious leaders, human rights activists, lawyers, 2. Polygenic disorders, like diabetes, schizophrenia and
and even governments of various countries bring in different Alzheimer’s disease, heart disease and malignancies.
opinions on this issue. Gene doping by athletes have raised 3. Infectious diseases like HIV.
interest in the sports community. Gene therapy intended to Neurodegenerative diseases like Parkinsonism,
be used for treating muscle wasting disorders may be misused Huntington’s disease are also being targeted. Cancer multiple
for human enhancement (IGF1 and erythropoietin) or even gene therapy, oncolytic virotherapy, anti-angiogenesis and
for the sport of horse racing. Non-therapeutic applications of therapeutic gene vaccines are all under trial.
631
Miscellaneous
Section 18

Fig. 81.5: Delivery of therapeutic genes into patient

GENE THERAPY IN GYNECOLOGICAL CANCERS molecular chemotherapy is thymidine kinase gene from HSV
The growth and division of somatic cells is complexly which has been shown to cause apoptosis in ovarian cancer.
regulated and they have a defined life-span (apoptosis- Some researchers have used liposome mediated gene
programmed cell death). The cancer cells lose their usual transfer of gamma-interferon gene into a murine model. It
growth control, and many aberrant events and changes occur has been shown that transduction by adenoviruses enhances
in their cellular constitution which confer the ability to form a immunogenicity of ovarian cancer cells (implications).
tumor carcinogens may initiate or promote tumor formation
and may cause epigenetic changes to alter the genotype of Cervix
the cells. Oncogenes play a role in the growth of cells but The two HPV genes, E and E appear to play a role in cancer
when overexpressed or mutated can foster the growth of of the cervix. It has been shown that inactivation of p 3 by E
cancer. and E results in immortalization of cervical epithelial cells.
Others have shown introduction of an antisense RNA
Ovary transcript of E and E genes into cervical cancer cells and
In human cancers, two major types of genes are abnormal: the results were promising. In another recent study by Tsao,
oncogenes and tumor suppressor genes. Oncogenes multiple HPV positive and negative cell lines were infected
stimulate cell growth and tumor suppressor genes inhibit with a recombinant adenovirus containing p cDNA. Massive
cell growth and division. The most common gene that is apoptosis was observed in all cervical cell lines, infected with
mutated in ovarian cancers is a tumor suppressor gene called this factor.
p 3 which encodes a transcription factor which regulates the
cell cycle and functions as a tumor suppressor involved in Uterus
preventing cancer. Research has shown that if a copy of a There have been few in vitro studies on endometrial cancer
working p 3 gene replaces the malfunctioning p 3 gene in a using non-viral vectors. Transfection of S gene into an
cell, growth of a tumor can be slowed. endometrial adenocarcinoma cell line using non-viral vectors
Clinical trials are on wherein patients with advanced and significant growth inhibition was observed. Regarding
ovarian cancer with a minimal amount of cancer remaining the development of uterine fibroids, studies of the underlyin
in the abdomen following surgery will receive gene therapy g pathophysiology have shown that specific genes can ret
treatment in which a cold virus containing a normal copy of fetal gene therapy are particular reasons why fetal
the p 3 gene will be introduced into the abdominal cavity application might prove better than treatment in the adult
through a catheter. The gene therapy will be given about for prevention of early-onset genetic disorders like cystic
once a month for five consecutive days along with standard fibrosis and Duchene muscular dystrophy. Research shows
chemotherapy. that gene transfer to the developing fetus targets rapidly
Replacement of p 3 has been the focus of many growing populations of stem cells, which are difficult to access
researchers. It is showed that transfection with adenovirus after birth, and indicates that the use of integrating vector
mediated p 3 inhibited growth of ovarian cancer cells. It also systems results in permanent gene transfer. Recent
sensitizes ovarian cancer cells to paclitaxel and cisplatin. The developments in the understanding of genetic disease, vector
toxin used for ovarian carcinoma in order to accomplish design, and minimally invasive delivery techniques have
632
 7 . Human Pluripotent Stem Cell Research: Guidelines for CIHR-
Funded Research available on CIHR IRSC site created on 4/9/
2003.
8 . http://genomicscience.energy.gov/ Systems Biology for
Energy and Environment
9 . http://users.rcn.com/jkimball.ma.ultranet/Biology
10 . http://www.stemcellresearch.org/
11 . ICMR Ethical Guidelines for Biomedical Research in Human
Subjects 2000.
12 . ICMR Stem cell research guidelines 2007.
13 . INSERM UMR590, Unit d’Oncogen se et de Progression
Tumorale; Universit Lyon-1, Centre L on B rard, Lyon, France.
14 . Kimball’s biology pages, Kimball.,a.ultranet.

Chapter 81
15 . M Olivier, A Petitjean, V Marcel, A P tr , M Mounawar, A
Plymoth, C C de Fromentel and P Hainaut Group of Molecular
Carcinogenesis and Biomarkers, International Agency for
Research on Cancer (IARC), World Health Organization, Lyon,
France ancer Gene herapy (2009) 16, 1–12; doi:10.1038/
cgt.2008.69 Recent advances in p53 research: an interdisciplinary
perspective
Cloning and Stem Cell Research. David A Prentice, Ph D Family
Fig. 81.6: Stem cell colonies Research Council and Georgetown University Medical School

Stem Cells Research, Cloning and Gene Therapy

Washington, DC, USA
brought the distant dream of fetal gene therapy closer to 16 . National Academies Guidelines for Human Embryonic Stem
clinical practice. However, more research needs to be done Cell Research available on http://www.nap.edu/catalog/
before it can be introduced as a therapeutic option. 11278.html National Research Council, US.
17 . Olivier M, Petitjean A, Marcel V, et al. Cancer Gene Therapy
Now researchers have successfully used purified
(2009) 16, 1–12; doi:10.1038/cgt.2008.69; published online 19
proteins and DNA in non-viral methods to reprogram adult September 2008 Recent advances in p53 research: an interdis-
human cells into stem cells by prime gene reprogramming ciplinary perspective.
technology which is 3–4 times faster than previous viral 18 . Opinion on Ethical Aspects of Human Stem Cell Research and
methods which involve potential tumor causing viruses and Use. The European Group on Ethics. Paris: 2000.
genetic manipulation (Fig. 81.6). 19 . Sade RM, Khushf G. Gene therapy: ethical and social issues. So
The high efficiency particle delivery system transports Carolina Med Assoc 1998;94(9):406-410
proteins and DNA molecules directly into cells from the GENE THERAP : ETHICAL AND SOCIAL ISSUES
Robert M. Sade, MD and George Khushf, PhD
human skin, retina and kidney. Researchers found that after
From the Department of Surgery and Institute of Human Values
one week stem cells colonies arose that exhibited the in Health Care, Medical University of South Carolina (RMS),
markers of embryonic stem cells (ESC) and iPS cells. and the Department of Philosophy and Center for Bioethics,
University of South Carolina (GK).
BIBLIOGRAPHY 20 . Sade RM, Khushf G. Gene therapy: ethical and social issues. So
1 . Ayman Al-Hendy and Salama Salama, Gene therapy and uterine Carolina Med Assoc 1998;94(9):406-10.
leiomyoma: a review Human Reproduction Update Advance 21 . Warner K Huh, MD Fellow/Instructor, Division of Gynecologic
Access originally published online on April 7, 2006. Human Oncology, Department of Obstetrics and Gynecology,
Reproduction Update 2006 12(4):385-400; doi:10.1093/humupd/ University of Alabama: Gene Therapy for Gynecologic Cancer
dml015 Mack N. Barnes, MD, Assistant Professor of Obstetrics and
2 . Cloning resources: Researchers work towards safer gene therapy Gynecology; Associate Scientist, Division of Human Gene
9-9-07. Therapy, University of Alabam: Gene Therapy for Gynecologic
3 . Cloning resources:scientists seek test to detect gene doping in Cancer Lippencott Williams Wilkins, 2003.
athletes, 8-8-07. 22 . www.nap.edu National Academy Press In: Stem Cells and the
4 . Explore stem cells(UK).mht. Future of Regenerative Medicine 2002; Chapter 1: Project
5 . Gene therapy and uterine leiomyoma: a review Overview and Definitions 7-18.
Al-Hendy A and Salama S. Department of Obstetrics and 23 . www nature com stemcells
Gynecology, University of Texas Medical Branch, Galveston, 24 . World Health Organisation. Group of Molecular Carcinogenesis
T , USA. and Biomarkers, International Agency for Research on Cancer
6 . Human Genome project information: Genomics: GTL.DOE. (IARC), World Health Organization, Lyon, France.
Website 25 . www.International Society for Stem cell research.org.

633
 82 Care of a Terminally lIl Patient:
Palliative Care

Sudha Salhan

There are millions of patients with terminal illnesses. The They can play indoor games, are given occupational therapy
estimate deaths from terminal illness in the world is about 52 and make handicrafts. They also give psychologically
million each year. There is much suffering in the majority of support to the family. Some patients, if they are more ill,
them. Their spirit is burdened by unrelieved pain and other have their family member staying and help in caring. It is
physical symptoms besides depression, anxiety and other entirely run on donations.
psychological ailments. Family members are most affected In Kerala also the palliative care movement has started
by a constant difficult and stressful environment and by since late 1990. Volunteers are trained. They visit the patients
caring for them. at their homes, provide medical and psychological care. They
listen to the patients and their family members patiently.
DEFINITION They are in contact with well-wishing donors for purchase of
Palliative care—It comes from a Latin word “Palliare,” i.e. to drugs, wheelchairs, commodes, etc. They also provide
clock or to cover. It is the care of patients with active, support to the family in the form of provision for food (e.g.
progressive, advanced disease. Palliative care is care where rice) books, school fees for the children and clothes, etc. The
the goal of care is the relief and prevention of suffering and community contributes for all these in Malappuram model.
maintenance of quality of life instead of striving to stop, delay Hospices provide an excellent model for end-of-life care. In
or reverse progression of the disease itself or provide a cure. a study of patients with end stage cancer, perception of dignity
It includes care for terminally ill patients of malignancy, —a sense of being treated with respect is the biggest desire.
chronic progressive disease of lungs, kidneys, heart, If not provided they feel a burden on others. Attitude towards
neurological diseases and even infections like AIDS. WHO terminally ill must be sympathetic and one should try not to
included the improvement of the quality of life of these withhold life-sustaining choices. Give a positive image to the
patients and their families. A multi-disciplinary approach is patient and a continued sense of worth. There is an increased
needed involving doctors (both Ayurvedic and Allopathic), risk of suicide in them. Give your full and complete attention.
nurses, clinical social workers, psychologists, physio- Health care providers play a very important role by their
therapist, dietician, etc. Most people’s death could be far behavior towards terminally ill patients. Small acts of
better managed. Dame Cicely Saunders, Founder of the kindness with personalized care will give a sense of worth.
Modern Hospice Movement says ‘how people die remains Showing compassion is important. Talking about problems
in the memory of those who live on.’ Death is a certainty but will guide the health care provider to give the best care
we do not plan for it as we plan for new birth or other possible. Spiritual help may be provided in hospices.
occasions in life. Most people’s death could be far better WHO calls for inclusion of palliative care in the health
managed. Much more could be done. There is insufficient services of the country. The government of Kerala has come
training among health social care staff to delivery the best (the first of its kind in Asia) out with a palliative care policy.
care to terminally ill patients.
Pain is the most discomforting symptom of such patients. BIBLIOGRAPHY
One fourth of all cancer patients die of pain rather than the 1 . Chochinov HM, Hack T, Hassand J, et al. Dignity in the terminally
disease itself (WHO). ill: a cross-sectional Cohort Study. Lancet 2002;360:2026.
To relieve pain, drugs (oral and parenteral) are used. 2 . Chochinov HM. Dignity-conserving case—a new model for
palliative care, helping the patient feel evalued. JAMA
The physical rehabilitation departments help by providing
2002;287:2253.
physiotherapy, and teaching relaxing exercises and postures, 3 . Chochinov HM. Dignity and the essence of medicine: the A, B,
etc. Psychological help is required to relieve grief and give C and D of dignity conserving care BMJ 2007;335:184.
emotional support to the patient and the family members 4 . Chochinov HM, Cann BI. Interventions to enhance the spiritual
constantly caring for the patient. Giving all due dignity to the aspects of dying. J Palliat Med 2005; 8(1): S103-15.
suffering person is very important. The care is given as 5 . McPherson CJ, Wilsen KG, Murrey MA. Feeling like a burden,
outpatient in the hospitals and in various other institutions exploring the prespectives of patients at the end of life. Soc. Sci.
as in inhouse care. One of such institutions is ‘Shanti-Avedna Med 2007;64:417.
6 . Munillo M, Hotland IC. Clinical practice guidelines for the
Sadan’ (one is near our hospital) which is started by Dr
management of psychosocial distress at the end of life. E Alliat
D’Souza ( a cancer surgeon at Tata Memorial Hospital, Support Care 2004;2:65.
Mumbai) in India. These patients are given comfort and love.
 83 Biomedical Waste Management
and Handling Rules

Sudha Salhan

Waste is generated in our household, in the fields, industries, etc. used items (plastic bottles of intravenous fluid, plastic
in health centers and commercial establishments, etc. Waste syringes), cannulas, catheters, needles, blades, drugs,
is in the form of solid and liquid. Then there is radiation waste. chemicals and radioactive substances.
Hospitals, dental clinics, diagnostic laboratories, blood banks, There are six schedules in the rule:
etc. where patients with their attendants, generate different Schedule I of the biomedical waste (management and
types of wastes which need to be segregated and disposed handling, rule 1998 is categorizing of biomedical wastes.
off regularly to prevent their piling up and causing harm to Schedule II gives guidelines for color coding (type of
the patients, health workers (doctors, paramedicals and other container) for disposal of biomedical waste.
hospital staff) and the environment. Schedule III gives instructions for labels for biomedical
The main health hazards of biomedical waste in the waste containers (bags), etc. (Fig. 83.1).
hospital are mostly infections, viz. Hepatitis B and C, HIV, Schedule IV labels for the transport of biomedical waste
measles, mumps, pneumonia, tuberculosis (most of the time containers/bags.
multi-drug resistant type) dermatitis, etc. There can be The date, time, waste class, sender’s name and address,
accidental injuries from the sharps, from leakage of gases, receiver’s name and address with contact person is recorded.
formalin fumes, etc. Schedule V: Standards for treatment and disposal of
biomedical wastes.
Guidelines on Biomedical Waste Management Schedule VI: For time limit to installation of facilities like
for Hospital Staff incinerator, autoclave/microwave system.
Hospital waste management has emerged as an important The rules were amended and named. Biomedical Waste
area of concern in recent times due to its ramifications on Management and Handling (Amendment Rules 2003).
health facilities. Biomedical Waste Management in a new
Government Policy, is legally binding under the Biomedical Biomedical Waste Treatment Facility
Act (Handling and Management) Act, July 1998. It means any facility, wherein treatment, disposal of biomedical
All hospital staff must be aware of these guidelines. It waste or processes incidental to such treatment or disposal is
has a very important role in RCH II. carried out. The steps are waste generation, segregation,
package, transport, storage, treatment and final disposal.
Biomedical Waste Management and Handling Rule
This rule was published in the Gazette of India on July 27th, Segregation, Packing, Transport and Storage
1998 and came into force on the same date. This rule comes The waste generated in the hospital is enormous. It is
under the Environment Protection Act 1986 (29th of 1986). It approximately 0.43 kg/bed/day in a hospital and 0.50 kg/clinic/
applies to all persons who generate, collect, receive, store, day in clinics. Treating the whole amount specifically will
transport, treat, dispose or handle biomedical waste in any cost a lot. Hence, it is segregated into non-infected (requiring
form. Biomedical Waste means any waste generated during ordinary disposal) and infected (needs special treatment).
the diagnosis, treatment or immunization of human beings Non-infected waste forms 85% of the hospital waste.
or animals or in research activities pertaining thereto or in Therefore, infected waste is only 15% of the total and needs
the production or testing of biologicals and including other special treatment. Biomedical waste shall not be mixed with
waste like discarded medicines cytotoxic drugs, chemical
waste and incinerated ash, etc. Any hospital, nursing home,
clinic, dispensary, veterinary institution, dental clinic, animal
house, pathology laboratory, blood bank, etc. is called upon
to take steps to ensure that such waste is handled without
any adverse effect to human health and environment.
Handling, segregation, disinfection, storage, transport,
treatment and disposal of waste are the seven steps to reduce
the risk to health and environment. The waste generated in
the health center includes waste papers and packing material,
dirty clothes, dressing material, Plaster of Paris cast, soiled
swabs (after taking blood samples), body parts, placenta, Fig. 83.1: Biomedical waste container
 other wastes. It cannot be kept untreated for more than 48 3. If a container is transported from the premises where
hours. The container is labeled. It is transported only in biomedical waste is generated to any waste treatment
authorized vehicles. facility outside the premises, the container shall, apart
The prescribed authority for enforcement of the provision from the label prescribed in Schedule III, also carry
of these rules is the state pollution control board. In the Armed information prescribed in Schedule IV.
Forces under the Ministry of Defense the prescribed 4. Notwithstanding, anything contained in the Motor
authority in the Director General, Armed Forces Medical Vehicles Act, 1988, or rules thereunder, untreated
Sciences. Implementation of the rules is carried out by the biomedical waste shall be transported only in such
prescribed authority. vehicles as may be authorized for the purpose by the
An advisory committee is made and it advises the competent authority as specified by the government.
government regarding issues related to biomedical waste. 5. No untreated biomedical waste shall be kept stored
Annual reports are sent to the authority in a special form beyond a period of 48 hours.
Miscellaneous

(Form II) by the 31st of January every year. Provided that if for any reason, it becomes necessary to
Every authorized person in the facility (hospital) shall store the waste beyond such a period, the authorized person
maintain a record related to genesis, collection, reception, must take permission of the prescribed authority and take
storage, transport, treatment, disposal and/or any form of measures to ensure that the waste does not adversely affect
handling of biomedical waste. These records can be human health and the environment.
inspected and verified anytime. Categories are mentioned in Schedule I of the rules (Table
Segregation, packing, transport and storage of 83.1).
biomedical waste: 1. Color coding (Table 83.2) of waste categories with multiple
1. Biomedical waste shall not be mixed with other wastes. treatment options as defined in Schedule II shall be
Section 18

2. Biomedical waste shall be segregated into containers/ selected depending on treatment option chosen, which
bags at the point of generation in accordance with shall be as specified in Schedule I.
Schedule II prior to its storage, transportation, treatment 2. Waste collection bags for waste types needing
and disposal. The containers shall be labeled according incineration shall not be made of chlorinated plastics.
to Schedule III.

Table 83.1: Categories of biomedical waste

Option Waste Category Treatment and disposal

Category 1. Human anatomical waste (Human tissues, organs, Incineration/deep burial
body parts)
Category 2 Animal Waste (Animal tissues, organs, body parts, Incineration/deep burial
carcasses, bleeding parts, fluids, blood and experi-
mental animals used in research, waste generated
by veterinary hospitals, colleges, discharge from
hospital animal houses)
Category 3 Microbiology and biotechnology waste (wastes Local autoclaving/microwaving/
from laboratory cultures, stocks or specimen of incineration
microorganisms live or attenuated vaccines,
human and animal cell cultures used in
research and infectious agents from research and
industrial laboratories, waste from production of
biological, toxins, dishes and devices used for
transfer of cultures)
Category 4 Waste sharps (needles, syringes, scalpels, blades, Disinfection (chemical treatment/
glass, etc. that may cause puncture and cuts. This autoclaving/microwaving and
includes both used and unused sharps). mutilation/shredding)
Category 5 Discarded medicines and cytotoxic drugs (waste Incineration/destruction and drugs
comprising of outdated, contaminated and disposal in secured landfills.
discarded medicines)
Category 6 Soiled waste (Items contaminated with blood and Incineration/autoclaving/microwaving.
body fluids including cotton dressing, soiled
plaster casts, linen beddings, other material
contaminated with blood)
Category 7 Solid waste (waste generated from disposal items Disinfection by chemical treatment/
other than the waste shapers such as tubing, autoclaving microwaving and mutilation/
catheter, intravenous sets, etc.) shredding.
Category 8 Liquid waste(waste generated from laboratory Disinfection by chemical treatment and
and washing, cleaning, house-keeping and discharges into drains.
disinfection activities)
Category 9 Incineration ash(ash from incineration of any Disposal in municipal landfill
biomedical waste)
Category 10 Chemical waste(Chemical used in production of Chemical treatment and discharge into
biologicals, chemicals used in disinfection, as drains for liquids and secured landfill for
insecticides, etc.) solids.
636
 Table 83.2: Color coding and type of container for disposal of biomedical wastes

Color coding Type of container Waste category Treatment options as per schedule I
Yellow Plastic bag Cat.1, cat. 2 and Incineration/deep burial
cat. 3, cat.6
Red (not used now Disinfected container/ Cat.3, cat.6 and cat.7 Autoclaving/microwaving/chemical
because of environment plastic bag treatment and destruction/shredding
pollution by incineration)
Black Plastic bag Cat.5 and cat. 9 and Disposal in secured landfill
Cat 10 (solid)
ordinary waste
Blue Plastic bags Plastic and bottles Shredding and sold off
Puncture proof Cat. 4

Chapter 83
container

3. Categories 8 and 10 (liquid) do not require container/bags. temperature rises above 850°C by dry heat. Previously red
4. Category 3, if disinfected locally, need not be put in bags were sent for incineration. But they produced toxic
container/bags. fumes and polluted the atmosphere. They are no longer in
Fill bag only 4/5th and fasten it properly before transport use; only yellow bags are used.
to prevent spillage. Here the waste is destroyed by dry oxidation heat. The

Biomedical Waste Management and Handling Rules

organic biomedical waste (e.g. placenta, parts of the human
Pollution Collection—To be done taking care transport inside
body removed during operation, etc.) is converted to a small
the facility (Hospital) a fully covered labeled vehicle
volume of inorganic waste. The emission from these
(wheelbarrow). (Fig. 83.2)
incinerator is to be controlled according to emission standards
If there is spillage of mercury (broken thermometer or
to minimize pollution.
from blood pressure apparatus) use cardboard sheet and
collect all beeds of mercury together with gloved hands, Shredding (Fig. 83.6)
suck in a syringes and place in a container with some water. It is done to plastic IV bottles, plastic syringes, etc. (after
Put all (cardboard syringes, gloves) in a large plastic bag, disinfection). The waste is cut into smaller pieces to prevent
label it as mercury waste, transfer to a second bag and label unauthorized recycline of syringes, etc. (which is a very
it. It is disposed off in a hazardous waste facility or given to hazardous practice). The shredded plastic is sold off.
a mercury equipment manufacturer.
Radioactive waste is handled according to Bhabha Atomic
Research Centre, Mumbai Guidelines.
Some of the equipment used for biomedical waste
management and handling are as follows:
Needle destroyer: It is an electrically operated machine where
the needle is burnt after use. (Fig. 83.3).

Incinerator (Figs 83.4 and 83.5)

Objects intended for the incinerator are not disinfected
before hand. The yellow bags go for incineration. The

Fig. 83.3: Needle destroyer

Fig. 83.2: Transporting Fig. 83.4: Incinerator (outer view) 637

 Persons handling waste must wear gloves (Heavy duty
rubber gloves), aprons, mask, boots, etc. to protect
themselves. Mobile hospital waste management systems
for small health care units are on the anvil.

Some Common Procedures in the Hospital

I will be taking examples from some common procedures
done in our department to give an idea as to how waste
segregation is to be done.
I will start from the entry of the patient in the Gyne
Receiving Room (GRR) or OPD. To examine a fresh case,
one would use a pair of gloves, a savlon swab, and a
Miscellaneous

speculum. Please note that the color of the plastic bag at the
foot end of the examining table is red or yellow. Please don’t
use it as a waste paper basket. When gloves are worn, the
glove wrapping paper goes into the black bag. The savlon
swab used for examination and any biological tissue removed
Fig. 83.5: Incinerator (inner view) during examination (for example clots or products of
conception) are discarded into the red/yellow bag. After
examination the speculum and gloves are immersed in a
bucket containing 10 percent sodium hypochloride (bleach)
Section 18

solution. Immediately after removing the gloves, hands

should be washed again with soap and water. All metal
instruments (speculum in this case) should be removed from
bleach solution after 10 minutes, washed thoroughly with
lukewarm water and detergent and then sent for autoclaving.
Other items like gloves are soaked for at least half an hour,
after which they are also cleaned by water and sent for
autoclaving. This treatment of articles in 10 percent sodium
hypochlorite solution has been called decontamination or
pretreatment and whenever I refer to ‘decontamination’ it
means submersion of the object in a solution of 1% sodium
hypochloride.
In the ward during the conduct of preoperative
investigation, blood samples have to be drawn. No sampling
or insertion of intravenous catheter should ever be done
without wearing sterile gloves for the protection of the doctor.
Collecting blood samples: It is the most common procedure
in the wards. Always wear gloves. Ask all patients to press
Fig. 83.6: Shredder
the puncture site after collecting of the blood sample with a
swab. After drawing the last blood sample, with the same
Autoclave gloved hands gather the soiled swabs from all patients by
This uses disinfection by direct steam penetration with a doing a reverse round. Throw them in a yellow bag. The
temperature range of 121°C–135°C to kill micro-organisms used syringe and needle are dipped in hypochloride solution
and spores. Portable solar powered autoclaves are under (Fig. 83.7) after filling the syringe with the solution. After half
research in Sydney. an hour or more the needle tip is destroyed by the needle
Hydroclave destroyer and put in puncture proof container (Fig. 83.8). The
syringe is washed and sent for autoclaving (if a glass syringe)
It is a type of autoclave. Here the temperature reaches
or put in a blue bag for shredding (if of plastic). Discard gloves
between 350°C–750°C. The biomedical waste is put in a double
in bleach solution container and wash hands with soap and
sheeting layered cylinder where it is kept in movement during
water. Keep requisition forms away from samples. Do not
the process. It is heated by steam produced in a boiler. This
soil them with blood by keeping the vial on them.
steam passes between the two layers of the cylinder and
Another common waste in the ward is the returned blood
does not come in direct contact with the waste.
samples from the laboratory which are often thrown into the
Microwave nearest bag without thinking. The blood should first be
This Microwave is like a household microwave oven. The decontaminated by adding the sodium hypochloride solution
frequency of electromagnetic radiation is around 2400 to into the vial and leaving it for at least half an hour. After that
300,00 MHz and its wavelength is of 12.24 cm. The fluid content the blood can be poured down the drain and the vial cleaned
of the waste is quickly heated. autoclaved and recycled for more samples. At times, there
are outdated medicines to be discarded. The drugs including
Plasma Pyrolysis cytotoxic drugs are sent in the red or yellow bag for
By striking a discharge between two electrodes a plasma is incineration and the container vial can be washed and used
created at a very high temperature (more than 10,000°F). for blood samples.
The waste is exposed to this temperature, the gases Gloves are not required while giving intramuscular
638 produced as byproducts are burnt and quenched. injections, but they should always be worn while drawing blood
 Do not recap, bend or break needle before disposal. To
prevent unauthorized re-use of the needle it can be mutilated
with a needle destroyer (Fig. 83.3) (If available).
One more commonly performed procedure is wound
dressing in the ward. Gloves and masks are adequate
precautions for self-protection. The soiled gauze with the
sticking plaster, any removed stitches, savlon and spirit swabs
are all thrown in the yellow or red bag. If a rubber drain or
Foley catheter are removed, they are soaked in sodium
hypochloride solution for half an hour for decontamination
mutilated and discarded in the black bag. There are no clear-
cut guidelines regarding disposal of used blood bags and

Chapter 83
uro bags. We feel that if there is left over blood in the bag
(due to death of the patient or a reaction or for any other
reason) the contents can be emptied into the drain—the bag
Fig. 83.7: Hypochloride solution itself is to be cut from the center for mutilation, soaked into
the hypochlorite solution along with the syringes and placed
into the blue bag. Similarly the uro bag is emptied of its
contents, mutilated, decontaminated and sent in the blue

Biomedical Waste Management and Handling Rules

bags. If a stitch removal has been done, the surgical blade is
placed in the sharp decontamination unit, the same one as
for needles. Tooth forceps, scissors or any other instruments
used are decontaminated for 10 minutes, washed and sent
for autoclaving and the used gloves are decontaminated for
half an hour.
Ensure that the solution in the bowls is changed in every
shift of the nurse. The broken ampoule and the metal cap of
the vial are non-infectious and can be put directly into the
puncture proof box.

Operation Theater
Change clothes, wear cap, mask and goggles. Proper
handwashing should be done and should be followed by
Fig. 83.8: Sharp container
wearing gown and gloves by the proper method. (Chapter
60 Asepsis).
samples or starting intravenous IV lines. When an Cleaning of the part generates swabs with savlon and
intravenous catheter is inserted the paper from the wrapping other chemicals. During operation soiled swabs are
is thrown in the black bag, the plastic part of the wrapping in generated, IV drips are used and drugs are injected (syringes
the blue bag, the needle inside the catheter into the sharp and needles). Anesthetization by intubation generates a swab,
decontamination unit, the savlon swab into the red or yellow plastic disposables, mouth piece. Use a kidney tray to keep
bag. Please don’t leave it on the bed. Put the polythene cover sharps, e.g. scissor, needle. The surgeon will pick them up
of the drip set into the black bag, the cap of the IV bottle in herself/himself. Do not pass sharps by hand, to prevent injury.
the blue bag and the gloves are placed into the sodium The decontamination unit for the surgical instruments is
hypocloride solution. Hands are always washed with soap similar to the sharp decontamination unit but larger in size.
and water after removal of gloves. If a large sieve is not available, the bucket can be lined with
When an injection is given the sterile wrapping of both a large gauze. Immediately after use, all the instruments
syringe and needle are thrown into the black bag. The plastic are to be placed in this unit. They should be taken out in 10
cap of the needle is thrown into the blue bag. The needle is minutes by lifting the sieve or gauze and washed with
removed without touching the tip. After the injection, all used lukewarm water and detergent as chlorine corrodes metal.
syringes and needles are to be decontaminated in 1 percent Those instruments, which receive chemical disinfection, e.g.
sodium hypochloride solution before final disposal. Two bowls kochers and obstetric forceps, should be dried before insertion
filled with this solution are going to be provided at each into cidex to prevent dilution of cidex.
required site, one for syringes and other for sharp instrument. All plastic waste is placed in the blue bag. The non-
When putting the syringe for decontamination, draw infectious one like IV bottles and drip sets can be put directly
some of the fluid into the syringe for decontamintion and and the potentially infectious one like plastic syringes are
ensure that it is submerged completely. The glass syringes placed in the blue bag after decontamination. They are sent
are also placed in the bowl of sodium hypochloride. The sharp for shredding.
decontamination unit may contain a sieve inside a puncture The unsoiled linen (bed sheet, etc.) can be sent straight
proof bowl, and is meant for sharp wastes like injections to the laundry whereas the soiled linen should be soaked in
needle, suture needle and blades. After the instruments have a drum of sodium hypochloride for 10 minutes before being
been soaked for minimum of 30 minutes, the sieve is lifted to washed.
drain the fluid and the contents are emptied into a puncture If there is a spillage of blood or liquor on the mattress or
proof box without manual handling of the sharp objects. One floor please ensure that it is taken care of immediately. Sodium
can convert any discarded medicine box into a puncture hypochloride is poured over the area and left for 10 minutes
proof box. after which, it is mopped by a cloth/gauze. 639
 The types of waste generated in a major surgery are and will be sent in black bag to be carried away by MCD
more or less the same. When the bottle in the suction truck for land filling.
apparatus is nearly full, it is decontaminated by adding the 6. Used needles and syringes (both glass and plastic) should
sodium hypochloride solution. After half an hour, the suction be dipped in 10% sodium hypochloride solution. Leave
bottles are carefully emptied of their contents in the drain. the syringes and needles after drawing in the 10% sodium
Alternately, the sodium hypochloride solution can be placed hypochloride solution in the basin kept in the duty room
in the bottle at the very beginning, before starting any of the ward for at least 30 minutes. After that deconta-
procedure. If disposable gloves are used, they are deconta- mination glass syringes are sent for autoclaving and
minated for half an hour, mutilated by cutting with a pair of plastic syringes are sent for shredding.
scissors and placed in the black bag. Similarly, other 7. Dispose off human anatomical waste, blood and tissue
disposable rubber items like Foley’s catheter are to be fluid soaked cotton swabs, gauze and dressing in red or
decontaminated, mutilated, and placed in the black bag. yellow bags provided in the dressing trolley. These bags
Miscellaneous

Rubber cannot be recycled so it cannot be put in the blue will be sent for incineration as final disposal.
bag, and it cannot be incinerated, so it cannot be placed in 8. Blood or body fluid soaked lines must be kept separately
the red or yellow bag. Mutilation is safer to do with scissors from unspoiled linen. Soiled linen bed sheets, etc. should
rather than blade to prevent injury to the worker. Red rubber be put in 10% sodium hypochloride solution kept in a
catheter is decontaminated, cleaned and sent for autoclave. plastic bucket for 30 minutes before it is sent to the
In the minor OT, the Kelly’s pad should be cleaned with laundry.
hypochloride solution after every procedure. 9. Use color-coded bags for different types of wastes.
The plastic apron can be decontaminated with the linen, 10. Black polythene garbage bags will be used for non-
cleaned and reused or discarded after mutilation into the infectious waste like paper, left out food, peel of fruits
Section 18

black bag. The used cap and mask are discarded in the black and vegetables, unsoiled gauze, bandages, etc.
bag.
Don’ts
To summarize, the key points to highlight 1. Never throw used cotton swabs on the patient’s bed or
the facts we simply cannot afford to forget the floor.
1. Always take appropriate precautions for self-protection 2. Never pass sharps like needles or blades from one
2. Whenever discarding an object, pause, think and person to another person.
categorize the kind of waste and discard into appropriate 3. Never recap, bend or break disposable needles.
container. Needles can be destroyed by needle destroyer.
3. Segregation of waste is the responsibility of the person 4. For guiding sutures never use fingers. Always use
generating it (e.g. doctor who is taking blood sample is tissue forceps.
responsible for the waste generated viz. swabs, syringe, 5. Do not mix hazardous and non-hazardous waste.
needle, gloves). 6. Never mix soiled linen and unsoiled linen.
4. Yellow or red bags are for infectious biological non-sharp A zero waste idea is to be the final goal.
solid waste. Items placed in this bag should not be If the waste management is proper, there will be less
decontaminated (Rubber and PVC containing plastic hospital acquired infections to the patient, less exposure to
should not been thrown into the red and yellow bags). hazard for hospital employees and protection of community
Rubber, PVC and chlorine emit toxic fumes when and environment.
incinerated.
5. The blue bag is for plastic waste which goes for shredding. Universal (Work Place) Precautions
6. The black bag is for non-infections household wastes like These precautions are now called work place precautions.
paper, leftover food and discarded disposable rubber They are the precautions observed as a preventive measure
items after they have been rendered safe in the sodium against communicable diseases which have been standar-
hypochloride solution, unsoiled dressing (gauze, cotton), dized by the WHO. They are to be followed strictly in each
etc. health care setting irrespective of whether the patient is
HIV/HbsAg positive or not. This is in addition to the waste
Do’s management and protects from spread of infection.
1. Any person who is generating biomedical waste is These precautions are to be taken while examining the
responsible for safe disposal of that waste. patient, handling blood, body fluids (cerebrospinal fluid,
2. Segregation of different types of waste is to be done at pleural fluid, pericardial fluid) and all body tissues containing
the site of generation. If segregation is done by medical, visible blood.
paramedical and staff involved in patient health care These precautions include:
then 90% of the management problem is solved. Segre-
Handwashing with soap and water before and after examining
gation is a key factor in the management of biomedical
the patient, before putting on gloves, after removing gloves,
waste.
etc.
3. Use gloves during all invasive procedures, handling and
labeling of patient’s blood and other body fluids and Gloves: Are to be worn doing internal examination (per
tissues containing blood. vagingal, per rectal, etc.), drawing blood or body fluids. Wash
4. After removing of gloves (disposable and non-disposable) hand before wearing gloves and remove gloves after each
dip it in 1% sodium hypochloride solution or bleach examination. Wash hands after removing the gloves. Gloves
solution kept in a plastic container in the sister’s duty are also to be worn while starting an intravenous line and for
room for at least half an hour. washing used instruments after operation.
5. Recyclable gloves will be sent for autoclaving and Aprons and gowns are worn to protect the wearer from
640 disposable gloves will be mutilated by cutting with scissors infection.
Goggles are used to protect eyes from splashes of infected Punishment for not following the biomedical waste
fluids (liquor amni, blood, etc.). Masks are used to protect management and handling rule.
the patient from being infected. Cover the nasal opening The institutional head or the person who generates
and mouth properly. the waste (e.g. doctor collecting blood) and does not
Handling of sharps: Use a kidney tray to keep sharps (blade, properly dispose the cotton swab (in yellow bag) needle and
scissors, needle) and the surgeon will pick up these things syringe in 10 percent bleach sulution, etc. will be punished
from there. Do not pass sharps by hand. It can cause cuts. with an imprisonment of 5 years or a fine of one lac rupee or
both.
Needles are not to be recapped after taking blood or giving
injections. After passing through a needle destroyer put them BIBLIOGRAPHY
in puncture proof sharp container. 1 . Disposal of atomic waste www.barc.ernet .net/mercury waste,
Do not handle patients if you are having skin lesion on www.toxicslink.org. Govt.of India, Biomedical Waste

Chapter 83
your hands. (Management and Handling) rules, 1998. The Gazette of India,
All injuries from sharps (blade, needles) are to be reported Ministry of Environment and Forest 20th July 1998.
2 . Govt of India, Extraordinary Gazette of India, Ministry of
to the authorities in the hospital (e.g. causalty medical officer)
Environment and Forest Published on 2nd June 2000. (Amendment
for consideration of postexposure prophylaxis. to prio-medical waste management and Handling Rules 1998).
In case when accidental prick with a contaminated 3 . Manual for control of hospital infection standard operative
needle takes place, the following steps to be followed: procedures, NACO, Ministry of Health and Family Welfare, Govt
• Step I: The wound should be encouraged to bleed. of India, New Delhi 1999
4 . Press A, Townend WK. Teacher’s Guide: Safe management of

Biomedical Waste Management and Handling Rules

• Step II: Clean with soap and water thoroughly
• Step III: Cover the cut part with water proof dressing. waste from health care activities, WHO 1998.
In case of splashes to mouth or eyes with patients blood or 5 . WHO Health Care Waste Management WHO Fact sheet no. 201,
Oct 2004.
body fluid, e.g. rupture of membranes in normal delivery or
6 . WHO, WHO guidelines on Review of Health Impact from
laparotomy or during postmortem: Rinse and splash thoroughly microbiological hazards in health care wastes, Geneva 2004.
with plenty of running water. 7 . WHO management of solid health care waste at primary
All health care workers should be protected against health care centres. A decision making guide. WHO Geneva
Hepatitis B and Tetanus by active immunization. 2005.

641
 84 National Rural Health Mission (NRHM) and
Reproductive and Child Health II (RCH II)

Sudha Salhan

National Rural Health Mission (NRHM) (2005–2012)—The goal • NRHM for primary health center. Provision of 24 hrs services
of the mission is to improve the availability of and access to in 50% PHC (8756). Delivery and MTP services and basic
quality health care for people, especially for those residing emergency obstetric care (BEmOC) in all these. It provides
in the remotest rural areas, the poor, marginalized women drugs, united grants, maintenance grants, RKs grants. They
and children. have now 3 staff nurses. Pregnancy testing kits are made
It seeks to provide effective health care to the rural available at PHCs.
population throughout the country with special focus on 18 • NRHM for community health center (CHC) Operatio-
states which have weak public health indicators and/or weak nalizing—the First Referral Unit (FRU).
infrastructures viz. Arunachal Pradesh, Assam, Bihar, Comprehensive Emergency Obstetric Care (CEmOC)
Chattisgarh, Himachal Pradesh, Jharkhand, Jammu and unit, blood storage with a link with blood bank in district
Kashmir, Manipur, Mizoram, Meghalaya, Madhya Pradesh, hospital.
Nagaland, Orissa, Rajasthan, Sikkim, Tripura, Uttaranchal • NRHM for District hospital: All vertical health and family
and Uttar Pradesh. welfare programs at district and state level merge into
The government is committed to raise public spending one common District health mission at the district level
on Health from 0.9% of GDP to 2–3% of GDP (Gross Domestic and the state health mission at the state level. 318 districts
Product). have been given funds for mobile medical units.
The goals of NRHM are: • Training in anesthesia and cesarean section to the MBBS
1. Reduction in infant mortality rate (IMR)and maternal doctors.
mortality ratio (MMR)— MDG 4 and MDG 5. • Development of guidelines for public private partnership
2. Universal access to public health services such as (PPP) in health sector. In a hospital, if a gynecologist is not
women’s health, child health, water, sanitation and available for, say, cesarean section, the services of a private
hygiene, immunization and nutrition. gynecologist can be hired at the rate of ` 1500.00 per case
3. Prevention and control of communicable and non- (Public Private Partnership).
communicable diseases including locally endemic Outcomes envisaged by NRHM at the National level are:
diseases. 1. Decrease in MMR to 100/100,000 live birth Millennium
4. Access to integrated comprehensive primary health Developmental Goals (MDG 5).
care. 2. Decrease in IMR to 30/1000 live birth (MDG 4).
5. Population stabilization, gender and demographic 3. Decrease in total fertility to 2.1
balance. 4. Decrease in malaria, kala azar, dengue, Japanese
6. Revitalize local health traditions and mainstream AYUSH encephalitis mortality.
(Ayurveda, Yoga, Unani, Sidha, Homeopathy). 5. Improvement in other illness.
7. Promotion of healthy life-style. Monitoring forms an important component of NRHM.
RCH II is compressive sectorwide flagship program
In NRHM a female health activities ASHA (Accredited under the bigger umbrella of NRHM.
Social Health Activist) is introduced (about 5.5. lacs). She Reproductive and Child Health Program II (RCH-II) was
acts as the interface between the community and the public started in April 2005 in all states of the country. RCH II is an
health system. ASHA is also a bridge between the ANM and important and integral component of NRHM. Because ASHA
the village and shall be selected by and is accountable to the of NRHM does community mobilization of united funds to
panchayat. She is an honorary volunteer, receiving health facilities directly contributes to the outcomes expected
performance based compensation for promoting the following of the RCH II program. Three main areas in RCH II are the
activities: same as that of the NRHM, i.e. Reduction in MMR (less than
• Referral and escort services for Reproductive and Child 100) and IMR (less than 30) and total fertility rate less than
Health 2.1.
• Promoting universal immunization There is considerable variation across the states.
• Health care delivery programs It is in partnership with the State Government for these
• Construction of household toilets indices and consistent with RCH Government of India’s
ASHA are trained for 23 days and are given a drug kit National Population Policy 2000. National Health Policy 2001
containing generic AYUSH and allopathic formulations and the Millennium Development goals. It is more explicit
for common ailments which are replenished from time pro- poor with focus on results. There is emphasis on ‘bottom
to time.
up’ planning. RCH II is a centrally sponsored program. It is 3. Identify a functional Government health center or an
largely financed by the Government of India with support accredited private health institution for referral and
from Department of Intenational Development (DFID), Word delivery.(Public private partnership).
Bank, UNFPA, UNICEF, WHO, European Commission (EC), 4. Counsel for institutional delivery.
United States Agency for International Development 5. Escort the beneficiary woman to the predetermined
(USAID), GIZ and Japan International Cooperation Agency health center for delivery and stay with her till the woman
(JICA). RCH II flexible pool is created for dispersment of is discharged.
money in Janani Suraksha Yojna, etc. 6. Arrange to immunize the newborn till the age of 14 weeks.
RCH II Rank states into 4 categories, with category 1 being 7. Inform about the birth or death of the child or mother to
the best and category 4 being the worst in the above 3 the Auxiliary Nurse Midwife or Medical Officer (ANM/MO).
parameters. Ranking of performance on RCH II brings an 8. Postnatal visit: First visit is to be within 48 hours of delivery
element of competition amongst the states and hence and second within 7 days of delivery to track mother’s

Chapter 84
motivation to improve. health after delivery and facilitate in obtaining care,
Components of Reproductive and Child Health are: whenever necessary.
a. For mothers 9. Counsel for initiation of breastfeeding to the newborn
1. ANC checkup with 2 TT immunizations and iron folic within one hour of delivery and its continuation till 6 months.
acid tablets. Recognization of high risk pregnancy 10. Promote family planning. Knowing eligible couples of her
and its proper referral and management. areas and making them aware of the existing methods of
2. Promotion of institutional delivery or at least delivery family planning. The health worker has a store of condoms,

National Rural Health Mission (NRHM) and RCH II

by a trained birth attendant. oral contraceptives and emergency contraceptives and
3. Postnatal checkup and family welfare advise. pregnancy testing kits. She has to accompany the woman
b. For Children to the facility for Copper-T insertion and terminal methods
1. Essential newborn care of contraception.
2. Promoting breastfeeding The scheme focuses on the poor pregnant woman with
3. National immunization program special dispensation for the states having low institutional
4. Vitamin A prophylaxis delivery rates called low performing states (LPS).
5. ORS and diarrhea control 11. Holding adolescent meetings.
6. Acute respiratory infection control in children 12. Maintenance of record of drugs, vaccination, birth and
7. Nutrition supplementation. death.
c. For eligible couples JSY card with MCH card is issued by ASHA/ Angan Wadi
1. Promoting and providing contraceptive methods Worker (AWW)/ any other identified link worker. A micro-
2. Safe services for MTP birth plan is prepared for each pregnant woman. The plan
3. Effective nutrition service to vulnerable groups. includes identification of pregnant woman and her
d. For others registration, when and where to get ANC check up, TT
1. Prevention and treatment of RTI/STI Injections and IFA tablets. The mother should be informed
2. Reproductive health services for adolescents where to go when needed by identifying health center and
3. Screening and treatment of cancer. hospital beforehand. Also tell about expected date of delivery.
Recently partnership for maternal, newborn and child This can be summarized as 4 I’s namely –
health was launched in New York on Sept 12, 2008 making a 1. Inform the mother and the family of dates of 3 ANC +
bold new push for the reduction of maternal and child Tetanus toxoid injection
mortality around the world. 2. Identify the health center for referral
3. Identify place of delivery
Janani Suraksha Yojana (JSY) 4. Inform about the EDD.
It is a modified version of National Maternal benefit scheme. JSY has cash incentive as part of the scheme.
JSY is a safe motherhood intervention under NRHM being The Cash Assistance for home delivery is ` 500/-
implemented with the objective of reducing maternal and For institutional delivery the amount is different for Low
neonatal mortality by promising institutional delivery among Performing States (LPS) and High Performing States (HPS).
the poor pregnant women. This yojana was launched on 12th It is also different for rural and urbon areas as follows:
April 2005 by the Honorable Prime Minister and is being
implemented in all states and the union territories with Category Rural Urban
special focus on low performing states (LPS). JSY is a 100% Mother A SH A Mother A SH A
centrally sponsored scheme and it integrates cash assistance
with delivery and post- delivery care benefit of the National LP S 14 00 60 0 10 00 20 0
Maternity Benefit Scheme. The success of the scheme would HPS 70 0 – 60 0 –
be determined by the increase in institutional delivery among
the poor families, irrespective of the number of children. The Decentralization of the funds is done so that money is
Role of ASHA or other link health worker associated with JSY available for day to day gaps which is critical for preventing
is as follows: maternal mortality. Money is for the patient, motivator and
transport.
1. Identify pregnant women as a beneficiary of the scheme
Some states have come up with innovative ideas like
and report or facilitate registration for antenatal checkup
Chiranjeevi Yojana in Gujarat. Transport of Kharkar were made
(ANC).
available. Delhi Government is starting ‘LADLI’ scheme for girl
2. Assist the pregnant women in receiving at least 3 ANC
child. In addition, there are ambulances available, at a phone
checkups including 2 Tetanus Toxoid injection and Iron
call away, to transport pregnant women from home to facility
Folic Acid (IFA) tablets for at least 100 days.
for delivery. 643
 Ladli Scheme All these activities are under RCH II of the NRHM.
Govt. of NCT of Delhi has launched a new scheme for the In 2010, Indira Gandhi Matritva Sahyog Yojana (IGMSY)
protection of the girl child from January 2008. This is to enhance was approved for maternal and child health by the Cabinet
the social status of a girl child and to make her self-reliant by committee on economic affairs. It is a monetary scheme for
ensuring her economic security. There is periodic payment in pregnant lactating mother—on a piolet basis in 52 districts in
her name by the Government in the following manner as 11th Five-Year Plan. Each eligible woman will receive ` 4,000
fixed deposit: in 3 instalments between 2nd trimester of pregnancy until
the child is six months old. The woman will open an account
1. ` 11,000/- if the girl child is born in a hospital or nursing
in the bank or post office for cash transfer. It is implemented
home in the NCT of Delhi or Rs 10,000/- if born outside the
through integrated child development services (ICDS)
above mentioned sites.
scheme will be fully funded by the center. A special cell to
2. ` 5000/- on admission to class I
monitor the scheme will be set up within the Ministry of
Miscellaneous

3. ` 5000/- on admission to class VI

Women and Child Development. It will also encourage
4. ` 5000/- on admission to class IX
women to follow the practice of breastfeeding.
5. ` 5000/- on admission to class X
In November 2010, new scheme for the health and well-
6. ` 5000/- on admission to class XII
being of adolescent girls ‘SABLA’ or ‘Rajeev Gandhi Scheme
The fixed deposits in the name of the girl child will be for Adolescent Girls’ has been launched as a piolet project in
redeemed along with the interest when the child reaches 18 200 most backward districts of Uttar Pradesh, Madhya
years of age and has passed X examination and is a regular Pradesh, Bihar, Sikkim, Maharashtra, and Rajasthan. It is
student or gets admission in class XII. based on integrated child development services (ICDS)
In Assam a Boat club is made and arrangement of Palki platform addressing the nutritional and special training
Section 18

in Uttrakhand is ensured for transport of pregnant women to aspects of girls aged 11–18 years by Ministry of Women and
hospital. Child Development. It provides 600 calories and 18–20 gm of
In Andhra Pradesh in an example of public private protein and micronutrients at a rate of five rupees a
partnership number 108 can be dialed for an ambulance. beneficiary a day for 300 days a year. The success of this
They provide very fast service. scheme will make its universal launch in 12th Five-Year Plan.

644
 85 Specimen in Gynecology

Renuka Sinha, Sudha Salhan

GYNECOLOGY SPECIMENS Q. What is differential diagnosis?

General guidelines on how to describe the specimen: A. Ovarian cyst with hemorrhage or torsion or malignancy.
Q. How do you differentiate between benign and malignant
First inspect the specimen from all sides and then
ovarian tumor on gross examination?
• Identify the specimen
A. Simple, unilocular cyst with clear fluid is generally benign
• Identify different structures like uterus, tube, ovary,
whereas presence of solid area, thick septation, papillary
cervix, etc.
projections, areas of hemorrhage and necrosis suggest
• Comment about size, shape appearance if it is normal
malignancy. Final diagnosis is always by histopathology.
• Comment about any abnormality noted and describe it,
Q. What is management?
e.g. size and number of tumors, any typical appearance
A. The management is by surgical removal—either
like whorled appearance in case of fibroid
laparoscopic or open.
• Comment about the type of surgery performed on the patient.
The removal by laparotomy—either cystectomy,
OVARIAN TUMORS oophorectomy or TAH BSO can be done depending on
age of patient, need for future childbearing, gross
Dermoid (Fig. 85.1) findings on laparotomy.
Q. Describe the tumor. Laparoscopic removal is recommended only in clinically
A. Tumor of size about 5–6 cms, containing hair suggesting benign cysts with en-bloc removal to avoid spillage in
the diagnosis of dermoid. peritoneal cavity.
Q. What are characteristic features?
A. Dermoid is benign tumor arising from ovary, bilateral in Malignant Ovarian Tumor (Fig. 85.3)
10% of cases. Q. Describe the specimen.
Q. What is risk of malignancy? A. Bilateral solid ovarian tumor with areas of hemorrhage
A. Malignant transformation may occur in about 2% cases. and necrosis with normal sized uterus.
Q. How do you diagnose? Q. What are various types of malignant ovarian tumors?
A. The clinical presentation is either by incidental detection A. Various types of ovarian malignancies are epithelial
or mass in abdomen. ovarian cancers, germ cell tumors, malignant tumors
The diagnosis is confirmed by USG, sometimes X-ray. arising from ovarian stroma and connective tissue. Of
these, epithelial ovarian cancers are commonest.
Benign Ovarian Tumor (Fig. 85.2) Q. What is treatment of malignant ovarian tumor?
Q. Describe. A. Staging laparotomy followed by total abdominal
A. Solid ovararian tumor of ovary. hysterectomy with bilateral salpingo-oophorectomy

Fig. 85.1: Dermoid cyst ovary Fig. 85.2: Benign ovarian tumor
 Hydatidiform Mole (Fig. 85.5)
Q. Describe the specimen.
A. Bunch of grape-like structures suggestive of hydatidiform
mole.
Q. What are clinical features?
A. Woman usually present with amenorrhea and vaginal
bleeding. On clinical examination height uterus may be
bigger than period of gestation and fetal parts are not
felt. Sometimes exaggerated symptoms and signs of
pregnancy like hyperemesis gravidarum, early onset
pre-eclampsia may be present.
Miscellaneous

Q. How do you confirm the diagnosis?

A. The diagnosis is confirmed by ultrasonography which
Fig. 85.3: Malignant ovarian tumor shows typical snowstorm appearance.
Q. What is the treatment?
A. The treatment is suction evacuation of uterus.
partial omentectomy with lymph node sampling should Q. How do you follow-up the patient?
be done. Debulking surgery is performed in advanced A. Patient is followed-up by clinical evaluation and serial β-
ovarian cancer. Most of the cases will need chemo- hCG monitoring which is performed every week till
therapy after surgical treatment. negative, every fortnightly for 3 months and then monthly
for total of two years. Woman should use contraception
Section 18

Carcinoma Endometrium (Fig. 85.4)

during this period to avoid pregnancy.
Q. Describe the specimen.
A. Uterus bulky in size with both tubes and ovaries. Cut Fibroid Uterus (Fig. 85.6)
section shows friable growth arising from endometrium. Q. Describe the specimen.
Probable diagnosis is carcinoma endometrium. A. Specimen of uterus and cervix, enlarged irregularly to
Q. What is corpus cancer syndrome? about 12 weeks pregnant uterus size. Cut surface shows
A. Obese, diabetic and hypertensive women are at multiple small tumors with whorled uterus. Probable
increased risk of developing carcinoma endometrium. diagnosis is fibroid uterus.
Q. What is the commonest presenting symptom of carcinoma
endometrium? Fibroid Uterus (Fig. 85.7)
A. The commonest presenting symptom of ca endometrium Q. Describe the specimen.
is postmenopausal bleeding. A. Specimen of uterus showing a single large fundal fibroid.
Q. How do you confirm the diagnosis? Q. What are presenting symptoms of fibroid uterus?
A. The diagnosis is confirmed by histopathology of A. Symptoms of fibroid uterus will depend on size and location
endometrium obtained by D and C or hysteroscopically of fibroid. The commonest presenting symptom is
directed biopsy. menstrual disturbances in form of menorrhagia in
Q. How do you stage carcinoma endometrium? intramural fibroid. Submucous fibroid or polyp may present
A. Carcinoma endometrium is staged as per FIGO with intermenstrual bleeding. Cervical fibroid usually
classification after surgical staging (see chapter Carci- present with bladder or bowel symptoms in the form of
noma Endometrium). frequency initially and retention later. Subserous fibroid
Q. What is the treatment? may be asymptomatic or present as mass per abdomen.
A. The treatment is extrafascial hysterectomy and
radiotherapy either before or after surgery depending Fibroid Uterus (Fig. 85.8)
on stage of tumor. Chemotherapy and hormonal therapy Q. Describe the specimen.
has limited role in advanced or recurrent cancer. A. Big fibroid showing hyaline degeneration.

646 Fig. 85.4: Carcinoma endometrium Fig. 85.5: Hydatidiform mole

 Chapter 85
Fig. 85.6: Multiple fibroid uterus Fig. 85.7: Single fibroid in the uterus

Specimen in Gynecology
Fig. 85.8: Filtroid uterus with hyaline degeneration Fig. 85.9: Fibroid polyp

Fibroid Polyp (Figs 85.9 and 85.10)

Q. Describe the specimens.
A. Specimens showing fibroid polyp.
Q. How do you confirm the diagnosis?
A. The diagnosis can be made by per vaginal examination,
which may show irregularly enlarged uterus and
confirmed by ultrasonography.
Q. What are the treatment options for fibroid uterus?
A. The management options are observation, medical
treatment, uterine artery embolization, surgery—
myomectomy or hysterectomy.
Observation or conservative management can be done
in asymptomatic fibroid if they are less than 12 weeks
pregnant uterus size and woman is perimenopausal.
She should be counseled to follow-up regularly.
Fig. 85.10: Fibroid polyp with infection
Medical treatment in form of danazol or GnRH analogues
can cause temporary reduction in size of fibroid and is
generally used preoperatively when hysteroscopic or
laparoscopic surgery is planned. Myomectomy can be considered in young women who
Uterine artery embolization is found to be useful in want childbearing or conserve the uterus. It can be done
treatment of fibroids and can be considered where by open surgery, laparoscopically or hysteroscopically.
facilities are available. Hysterectomy is the definitive treatment for women who
Surgical treatment can be conservative if form of are not suitable for myomectomy. It can be done by
myomectomy or definitive in form of hysterectomy. vaginal or abdominal or laparoscopic route.

647
 86 Common Instruments in Gynecology

Asmita Muthal Rathore, Raksha Arora, Sudha Salhan

Specula and hence not useful for vaginal surgery. It may also
. hat is use of vaginal speculum cover lesions on vaginal wall which may be missed if
A. Vaginal speculum is the instrument inserted in vagina proper precautions are not taken.
to expose cervix and vaginal wall for examination or
minor and major surgeries. Two types of specula are Anterior Vaginal Wall Retractor (Fig. 86.3)
commonly used in gynecological practice. . Identify the instrument and what is its use
A. This is anterior vaginal wall retractor, used to retract
Sim’s Speculum (Fig. 86.1) anterior vaginal wall along with Sim’s speculum during
. Identify the instrument. vaginal examination or vaginal surgery.
A. This is Sim’s speculum used to retract posterior vaginal It may be confused with curette. Note large size and
wall. It is available in different sizes and appropriate fenestrations.
size blade can be used according to individual patient.
. hat are advantages Cervical Dilators (Fig. 86.4)
A. Its advantages are that it allows more exposure of . Identify and describe.
vaginal walls by sliding down or around and does not A. These dilators are serially numbered.
restrict the exposure and thus useful in vaginal surgery. . hat are uses of this instrument
The groove in the center also drains the secretion or A. It is used to dilate the cervix.
bleeding thus keeping the area dry. . How is it used
. hat are disadvantages A. Dilatation is started with smallest size dilator. It is
A. The disadvantage is that it usually needs an assistant inserted in cervical canal till it negotiates internal os and
for adequate exposure and also needs anterior wall then gradually increasing size dilator is used.
retractor to expose cervix.

Cusco’s Speculum (Fig. 86.2)

. Identify and describe.
A. This is bivalve self-retaining Cusco’s speculum.
. hat are its uses
A. It is mainly used in outpatient department for
examination of vagina and cervix. It can also be used
for minor procedures like IUCD insertion or
cauterization of cervical erosion, colposcopy, etc.
. hat are advantages and disadvantages
A. It is convenient to use in busy OPD as it does not need
assistant. No anterior wall retractor is needed. It has
advantage that it protects the vaginal walls while
performing procedures like cauterization. However, it
has limitation that it restricts the space in vaginal cavity Fig. 86.2: Cusco’s speculum

Fig. 86.1: Sim’s speculum Fig. 86.3: Anterior vaginal wall retractor
 . hat are advantages
A. This is done as outpatient procedure in premenstrual
phase of cycle and a strip of endometrium obtained is
sent for histopathology. It gives information about the
ovulation in that cycle and also rules out endometrial TB
which is quite common in India.
. hat are various tests used to detect ovulation
A. Other tests of ovulation are basal body temperature
recording, cervical mucus changes, serial ultrasono-
graphy, day 21 serum progesterone assay do it yourself
urine tests.

Chapter 86
Fig. 86.4: Cervical dilators Uterine Sound (Fig. 86.7)
. Identify and describe the instrument.
. hat are the indications A. Uterine sound is made of stainless steel. It is bent to an
A. Dilatation of cervix is performed prior to curettage in angle of 150° at a distance of 2 inches from its tip, i.e. at
patients with abnormal uterine bleeding. It is also done a distance of normal uterocervical length. The tip of the
in patients for first trimester MTP or evacuation of uterus instrument is blunt. It is graduated.
in patients with missed abortion, inevitable abortion or . hat are its uses

Common Instruments in Gynecology

vesicular mole. A. It is used in non-pregnant patients.
. hat is indication for only dilatation • To measure the uterocervical length
A. Only dilatation without curettage is done for drainage of • To confirm ante-or retroversion of uterus
pyometra or rarely in treatment of dysmenorrhea/ • To measure length of the cervical canal and to
cervical stenosis. diagnose supravaginal elongation of the cervix
• Prior to any procedure on uterine cavity, e.g.
Uterine Curettes Sharp and Blunt curette (Fig. 86.5) Dilatation and curettage, copper T insertion.
. hat are its uses • To differentiate between uterine polyp and chronic
A. This instrument is used in dilatation and curettage of inversion of the uterus, (care should be taken to use it
endometrial cavity by shape size dilatation and gently otherwise perforation may occur.)
evacuation of pregnant uterus in cases of incomplete or • Diagnosis of a missing IUCD
inevitable abortion, vesicular mole or retained products • Diagnosis of congenital malformation of uterus, e.g.
of conception by blunt size. Bicornuate uterus.
. hat are the indications for D and C
A. D and C is one of the methods to sample the endometrium Vulsellum (Fig. 86.8)
in cases of abnormal uterine bleeding due to fibroid, DUB, . Identify the instrument.
suspected endometrial cancer, postmenopausal A. It is vulsellum forceps.
bleeding. It is done in minor OT under anesthesia either . here is it used
local, regional or general. A. It is used to hold the anterior lip of non-pregnant uterus
. hat are other methods of endometrial sampling in various minor and major operations in uterus, e.g.
A. Other methods of endometrial sampling are endometrial insertion of IUCD, D and C and hysterectomis, etc.
aspiration using syringe and cannula or instruments like
vabra or pipette aspirator. Hysteroscopy with guided
biopsy is the gold standard.
. hat are the complications of D and C
A. The complications of D and C include bleeding, perforation
of the uterus, infection and trauma to the cervix.

Endometrial Biopsy (EB) Curette (Fig. 86.6)

. hat are its uses
A. This instrument is used for taking endometrial biopsy in
women with infertility (test for ovulation) or suspected
genital tuberculosis.
Fig. 86.7: Uterine sound

Fig. 86.5: Uterine curettes sharp and blunt curette

Fig. 86.6: Endometrial biopsy (EB) curette Fig. 86.8: Vulsellum 649
 . hen do you hold posterior lip of cervix
A. In culdocentesis, culdotemy and in vaginal hysterectomy
when operating posteriorly.

Sponge Holder (Fig. 86.9)

. here is it used
A. In on-table preparation of the part, for holding the lips of
pregnant uterus, to explore cervical injury, to hold the
margins of cut ends of uterus in cesarean section when
Green Armytage is not available. There is a lock.

Ovum Forceps (Fig. 86.10)

Miscellaneous

Fig. 86.11: Rubin/Leech Wilkinson cannula

. Identify and describe.
A. It has sp oon shaped, blunt and f enestr ated ends
. In which phase of menstrual cycle tubal patency tests are
which just come in contact with each other when the
done and why
forceps is closed. This achieves a good grip on the
A. Both these tubal patency tests are done in postmenstrual
structure held without nipping it at its base. There is
phase of cycle to ensure that patient is not pregnant at
no catch on the handles.
the time of test.
. hat are its uses
. hat are contraindications to tubal patency tests
A. It is used–
A. Active Genital tuberculosis or other pelvic infections.
• To remove products of conception in incomplete and
Section 18

inevitable abortion Karman Cannula (Fig. 86.12)

• Removal of bits of placenta and membranes.
. Identify and describe.
. How does it differ from sponge holder
A. This is plastic disposable cannula available in serial numbers
A. There is no lock.
corresponding to number of dilators.
Rubin/Leech Wilkinson Cannula (Fig. 86.11) . hat are its uses
A. They are used for suction evacuation either in MTP or in
. here it is used
cases of incomplete, inevitable abortion or vesicular mole.
A. This is used in tubal patency tests like hystero-
It can also be used for endometrial aspiration in patients
salpingography(HSG) or laparoscopic chromotubation
with abnormal uterine bleeding.
in patients with infertility.
. hat are complications of suction evacuation
. hat is principle of tubal patency tests
A. The complications of this procedure are hemorrhage,
A. With the help of these cannula the dye (water soluble
perforation and infection.
radio-opaque dye in HSG, methylene blue in laparo-
scopic chromotubation) is instilled in uterine cavity. The
Babcock’s Forceps (Fig. 86.13)
wider portion of tip of cannula obliterates the cervical
canal, thus preventing the regurgitation of dye from the . Identify and describe.
cervix. Spillage of the dye from fimbrial end indicates A. It is non-traumatizing type of tissue forceps. It has
tubal patency. fenestrated triangular blades and grooved jaws.
. hat are its uses
A. It is used to hold soft and delicate tissues like fallopian
tubes, ureter, appendix, etc. Due to its non-traumatizing
nature, it may be used to hold bowel and bladder.

Fig. 86.9: Sponge holder

Fig. 86.12: Karman cannula

650 Fig. 86.10: Ovum forceps Fig. 86.13: Babcock’s forceps

 • Removal of pedunculated cervical or uterine polyps.
• Removal of foreign bodies from the vagina.

Ayre Spatula (Fig. 86.14)

. Identify the instrument.
A. This is a disposable wooden spatula. It is about
15–17cm long. Its one end is 3 mm broad and 2 cm long.
The other end is broad and has two projections, one of
them projecting beyond the other.
. How is it sterilized
A. It is sterilized by dry heat in a hot air oven.

Chapter 86
. hat are its uses Fig. 86.16: Urethral catheters
A. It is used for collecting an exfoliative cytological smear
from the cervix (Pap smear), posterior vaginal fornix, . hat are complications of catheterization
upper one-third of the lateral vaginal wall or the buccal A. It increases the risk of urinary tract infections.
mucosa. . hat are different types of catheters and their uses
. hat are indications for Pap smear A. The catheters are available in different sizes and suitable
A. It is used as a screening method for carcinoma cervix. size should be used. The common catheters used in
gynecological practice include the following:

Common Instruments in Gynecology

Cervical Punch Biopsy Forceps (Fig. 86.15) Foley’s catheter: It is self-retaining disposable catheter
. How is it shaped available in presterilised pack. The balloon at tip is
A. This instrument is made of stainless steel. It has cup- inflated after putting the catheter in bladder, which keeps
shaped ends. The edges of the cups are cutting and it in place. The capacity of this balloon is written on the
inside of one cup has a tiny pin that fits into a tiny catheter by the manufacturer.
depression in a corresponding position in the other cup. Red rubber catheter: It is generally used for one time
This helps in holding the cervical biopsy specimen in catheterization of bladder. It is cheap, can be reused
place. There is no lock on the handles. after sterilization.
. here is it used After cleaning the urethral opening from above
A. This instrument is used to take cervical biopsy in the downwards the catheter is introduced into the urethra after
following situations: applying xylocaine jelly to its tip.
• Carcinoma cervix Metal catheter—This is used for emptying bladder
• Suspicion of cervical carcinoma before or during surgery. It has to be used when patient
• Abnormal colposcopic findings is under anesthesia as it is painful.
• Diagnosis of recurrence of cervical carcinoma.
Hysterectomy Clamp (Fig. 86.17)
Urethral Catheters (Fig. 86.16) . Identify instrument.
. here are they used A. They are hysterectomy clamps. It may be curved or
A. Urethral catheters are used for drainage of urine per straight.
urethra. . here is it used
. hat are indications for catheterization A. It is used in various procedures like hysterectomy,
A. Indications for catheterization include retention of urine, salpingectomy, etc. to hold pedicles.
prophylactically after pelvic surgery and after repair of . hat are various routes used to perform hysterectomy
VVF. A. Hysterectomy can be done by abdominal, vaginal or
laparoscopic route.
. hat are various types of abdominal hysterectomy
A. Various types are:
1. Subtotal hysterectomy—Only uterus is removed and
cervix and adnexa are left behind.

Fig. 86.14: Ayre spatula

Fig. 86.15: Cervical punch biopsy forceps Fig. 86.17: Hysterectomy clamp 651
 2. Total hysterectomy—Uterus and cervix are
removed. Ovaries are conserved in young patient to
prevent menopausal problems when hysterectomy
is done for benign conditions.
3. Total hysterectomy with bilateral salpingo-
oophorectomy—Uterus, cervix, both tubes and
ovaries are removed. Performed in peri or
postmenopausal patients for benign gynecological
diseases.
4. Extrafascial Hysterectomy—Uterus, cervix, along Fig. 86.20: Scissors
with its covering fascia and both tubes and ovaries
are removed. Done in cases of carcinoma
Miscellaneous

endometrium.
5. Radical Hysterectomy—Uterus, cervix, both tubes
and ovaries are removed along with parametrium
pelvic lymph nodes and upper vagina. Done in cases
of early carcinoma cervix.

Allis Forceps (Fig. 86.18)

. Identify instrument.
A. It is Allis forceps.
Section 18

. here is it used
A. It is used to catch hold of tough tissues.

Needle Holder (Fig. 86.19)

. Identify the instrument.
A. It is a needle holder.
. here is it used
A. It is used in holding needle in various stitching
procedures.

Scissors (Fig. 86.20)

. Identify the instrument.
A. It is a scissors.
. here is it used
A. It is used to cut suture material and tissue.
Figs 86.21A and B: Angled clamp
Angled Clamp (Figs 86.21 A and B)
. Identify the specimen. Tissue Holding Forceps (86.22)
A. It is angled clamp. . Identify the instrument.
. here is it used A. It is tissue holding forceps.
A. It is used to cut clamp fascia over blood vessels. . here is it used
A. It is used to catch thick tissues.

Bladder Sound (Fig. 86.23)

. Identify the instrument.
A. It is bladder sound.
. here is it used
A. It is used to find the limits of bladder especially in cystocele.

Blade Handle (Fig. 86.24)

. Identify the instrument.
A. It is a surgical blade handle.
Fig. 86.18: Allis forceps

652 Fig. 86.19: Needle holder Fig. 86.22: Tissue holding forceps
 Doyan’s Retractor (Fig. 86.28)
. Identify the instrument.
A. It is Doyan’s retractor.
. here is it used
A. It is used to retract the bladder and lower abdominal
Fig. 86.23: Bladder sound wall in pelvic surgery.

Self-retaining Abdominal Retraction (Fig. 86.29)

. Identify the instrument.
A. It is self-retaining abdominal retractor.
. hat is the advantage of using it
A. The abdomen is retracted without the help of an

Chapter 86
Fig. 86.24: Blade handle assistant.

Metal Retractor (Fig. 86.30)

. here is it used
. Identify the instrument.
A. It is used to hold surgical blade in operations.
A. It is metal retractor.
Tooth Forceps (Fig. 86.25) . here is it used
A. It is used in radical hysterectomy to pack off the intestines

Common Instruments in Gynecology

. Identify the instrument.
and omentum.
A. It is tooth forceps.
. here is it used
A. It is used to hold tissues while dissecting.

Myoma Screw (Fig. 86.26)

. Identify the instrument.
A. It is myoma screw.
. here is it used
A. It is used to help facilitate myomectomy.
. hat are the indications of myomectomy Fig. 86.28: Doyan’s retractor
A. Myomectomy is indicated in symptomatic young patients
who want to preserve fertility.

Small Retractor (Fig. 86.27)

. Identify the instrument.
A. It is a small retractor.
. here is it used
A. It is used to retract in minilaparotomy done for tubal
ligation of tubal recanalization.

Fig. 86.25: Tooth forceps

Fig. 86.29: Self-retaining abdominal retraction

Fig. 86.26: Myoma screw

Fig. 86.27: Small retractor Fig. 86.30: Metal retractor 653

 IUCD Hook and Removal (Fig. 86.31)
. Identify the instruments.
A. They are IUCD hook and IUCD removal.
. here are they used
A. They are used to locate and remove an IUCD from the
uterus in case of missing thread.

Intracervical Brush (Fig. 86.32) Fig. 86.34: Malecot’s catheter

. Identify the instrument.
A. It is disposable intracervical brush. Wertheim’s Clamps (Fig. 86.35)
. here is it used . Identify the instrument.
A. It is used in screening of cancer cervix. It obtains
Miscellaneous

A. It is Wertheim’s clamp.
exfoliative cells from cervical canal. . here is it used
A. It is used in Wertheim’s hysterectomy.
Endocervical Retractor (Fig. 86.33) . hat things are removed in ertheim’s hysterectomy
. Identify the instrument. A. Whole of uterus, both ovaries and tubes, parametrium,
A. It is endocervical retractor. upper third of vagina and pelvic lymph nodes.
. here is it used
A. It is used to visualize the T junction, if it is not visible. Microsurgical Instruments (Fig. 86.36)
. Identify the instrument tray.
Malecot’s Catheter (Fig. 86.34)
Section 18

A. It is microsurgery instrument tray.

. Identify the article. . here is it used
A. It is Malecot’s catheter. A. It is used in microsurgery on the fallopian tubes.
. here is it used
A. It is used as indwelling catheter and as a drain. It is used
with an insertion.

Fig. 86.35: Wertheim’s clamps

Fig. 86.31: IUCD hook and removal

Fig. 86.32: Endocervical brush

654 Fig. 86.33: Endocervical retractor Fig. 86.36: Microsurgical instruments

 Chapter 86
Fig. 86.40: Diagnostic hysteroscope

Fig. 86.37: Pneumoperitoneal needle and trochar and cannula

Common Instruments in Gynecology

Fig. 86.41: Operative hysteroscope

. here is it used
A. It is used to create pneumoperitoneum and then trochar
is introduced in laparoscopy.
Fig. 86.38: Instruments for operative laparoscopy
. How to be sure of
A. The Veress needle is introduced and then put normal
saline on it. If it goes in easily, it is in.

Instruments for Operative Laparoscopy (Figs 86.38 and 86.39)

. Identify the instruments.
A. They are instruments used for operative laparoscopy.
. How are they used
A. They are introduced through separate ports to hold, cut
and cauterize.

Diagnostic Hysteroscope (Fig. 86.40)

. Identify the instrument.
A. It is diagnostic hysteroscope and its sheath.
. hat is the media used
A. It is air.

Operative Hysteroscope (Fig. 86.41)

Fig. 86.39: Instruments for operative laparoscopy . Identify the instruments.
A. They are operative hysteroscope.
. hat is the media used
Pneumoperitoneal Needle and Trochar and Cannula A. It is normal saline or mannitol.
(Fig. 86.37) . How all above instruments are decontaminated
. hat are the instruments A. Immediately after use all instruments must be put in
A. They are pneumoperitoneal needles and trochar used 0.5–1 bleach solution for decontamination. Then they
in laparoscopy. are washed in water and sent for sterilization.

655
 87
Frequently Asked Questions
in Final MBBS

Meetu Salhan

1. Define primary and secondary amenorrhea. Enlist 22. Give differential diagnosis of postmenopausal bleeding.
important etiological factors of amenorrhea. How will you manage a case of carcinoma of the
2. Define primary amenorrhea. Describe clinical presentation endometrium?
and management of a case of imperforate hymen. 23. Give various cases of precocious puberty. How will you
3. Discuss abnormal uterine bleeding. How will you manage investigate and manage?
a case of AUB in an adolescent girl? 24. Give causes of puberty menorrhagia. How will you
4. Discuss anovulatory AUB. Give medical treatment. investigate and manage?
5. Define AUB. Give its causes and management. 25. Define menopause. Its manifestations. Give management.
6. Enumerate the causes of menorrhagia. How will you 26. Give manifestations of menopause.
manage a case of AUB in a 30-years-old woman? 27. Give advantage and disadvantage of hormonal replacement
7. Give causes of menorrhagia. How will you manage a case therapy.
of DUB in a 40-years-old multiparous woman? 28. Notes on
8. Describe the ovarian and endometrial changes in different – DEXA
phases of menstrual cycle. – HRT
9. What is menopause? Give the management of postcoital – SARMS.
bleeding. 29. Short notes on
10. Diagnose and manage a case of postmenopausal bleeding – Bicornuate uterus
in a woman of 60 years. – Turner syndrome
11. Investigate and manage a case of 55-years-old woman with – Paracervical block.
postmenopausal bleeding. 30. Short notes on
12. Give causes of postmenopausal bleeding. Give investigation – 3 swab test
and treatment. – Pap smear
13. Short notes on – Screening for cancer cervix.
– Puberty menorrhagia 31. Short notes on
– Preconcious puberty – Colposcopy
– Delayed menarche. – MTP law
14. Short notes on – Postcoital bleeding.
– Sexual maturity at puberty 32. Short notes on
– Postmenopausal bleeding – Pyometra
– Polycystic ovarian syndrome. – Hematocolpos
15. Give causes of postmenopausal bleeding. Give investigation – D & C.
and treatment of a small smooth polypoidal growth of 33. Give stages of cancer cervix (2009). How will you investigate
external os of the cervix. and manage?
16. Enumerate important causes of infertility. How will you 34. Give etiological factors for cancer cervix. How will you
investigate a woman who is married for 8 years and has investigate and manage?
never conceived? 35. Define fibroma. How will you manage a case of submucous
17. Describe investigations in a couple with primary infertility fibroma in a 45-years-old woman?
and their interpretation. 36. Short notes on
18. Investigate an infertile couple. Give management of – Tumor markers for ovarian malignancies
anovulation infertility. – Importance of hCG
19. Define infertility. Give causes. How will you investigate and – Causes of hemoperitoneum in gynecology give
manage tubal factors? management.
20. Notes on 37. Describe fibroid uterus and give its pathology. What are
– Semen analysis the changes it undergoes?
– Postcoital test 38. Give locations of fibroid uterus. How will you investigate
– Tests of tubal potency. and manage a case of 35-years-old woman?
21. Notes on 39. Notes on
– Intrauterine insemination – National Rural Health Mission
– Assisted reproductive technology – RCH II
– Hysterosalpingography. – PPNDT Act.
40. Define ectopic pregnancy. What are the sites of ectopic 56. Notes on
pregnancy? How will you manage one? – Intrauterine contraceptive devices
41. Classify ovarian tumors. How will you manage a case of – LNG IUCD
adenexal mass in a woman of 55 years of age? – Nonsteroidal contraceptives.
42. Short notes on 57. Notes on
– Preoperative preparation for hysterectomy – Male contraceptives
– Dysgerminoma – Immunological contraceptives
– Radiotherapy for cancer cervix. – Non-contraceptive benefits of oral contraceptives.
43. Classify uterovaginal prolapse. How will you manage a 50- 58. Describe causes of vesicovaginal fistula. Give preventive
years-old woman with 3rd degree uterovaginal descend? steps.
44. Enumerate supports of the uterus. How will manage a 60- 59. Short notes on
years-old woman with third degree uterovaginal descend? – VVF

Chapter 87
45. Notes on – Rectovaginal fistula
– Ring pessary – Hydrosalpinx.
– Stress urinary incontinence 60. Short notes on
– Chronic inversion of the uterus. – Hirsutism
46. Give differential diagnosis of a 16 weeks size swelling in – Ovulation induction
lower abdomen in a woman of 30 years of age. How will – Indication and complications of dilatation and curettage.
you investigate? 61. Short notes on

Frequently Asked Questions in Final MBBS

47. Short notes on – Osteoporosis
– Cervical erosion – Imperforate hymen
– Incompetent os. – Methods of 1st trimester MTP.
– Carcinoma situ of cervix 62. Short notes on
48. Short notes on – Fractional curettage
– Cervical dysplasia – Hydatidiform mole
– Transitional zone – Choriocarcinoma.
– Cone biopsy. 63. Short notes on
49. Describe clinical presentation of pelvic inflammatory – Dermoid cyst
disease. How will you manage a case of mild PID? – Principles of myomectomy
50. Define reproductive tract infection and sexually – Supports of the uterus.
transmitted infections. Enumerate them. What is 64. Short notes on
syndromic management? Give its advantages and – Fibroid polyp
disadvantages. – Empathy
51. What are the causes of abnormal vaginal discharge? – Non-verbal communication.
Describe the management of various common types of 65. What are the types of endometrial carcinoma? How will
infectious vaginitis. you investigate? Give 2009 staging.
52. Short notes on 66. Give physiology of lactation. Give its advantages.
– Trichomonal vaginitis 67. Name benign conditions of ovary. How will you investigate?
– Candidial vaginitis 68. Short notes on
– Universal precautions. – Semen examination
53. Short notes on – Role of ASHA
– Decontamination of instruments – Follow-up of a case of H Mole.
– Hospital waste management law 69. Short notes on
– Vaginal discharge. – Stem cells
54. Enumerate different forms of hormonal contraception. Give – Types of estrogen drugs
briefly the risks of hormonal contraception. – Hysteroscopy.
55. Notes on 70. Short notes on
– Emergency contraception – Steps of handwashing
– Natural contraceptive methods – Articles disposed off in black bag
– Barrier contraceptives. – WHO medical criteria for contraception.

657
 88 Often Asked Multiple Choice Questions in
MD/MS Entrance Examinations

Durgesh

Fibroids 8. Surgical treatment for asymptomatic uterine myoma is

indicated if
1. True about fibromyomas uterus is all except :
a. Myoma is pedunculated
a. It is well-circumscribed with a pseudocapsule
b. Tumor is larger than 12 wks
b. The central portion of the tumor receives maximum
c. Diagnosis is uncertain
blood supply
d. All of the above.
c. Most of them are malignant
d. Their growth depends upon estrogen. 9. Most common type of uterine fibroids are
2. True about red degeneration of fibroid is all except: a. Intramural
b. Submucous
a. Seen most commonly during 3rd Trimester of
c. Subserous
pregnancy
d. Cervical.
b. Caused by thrombosis of veins
c. Condition is aseptic with high fever, leucocytosis, 10. Sarcomatous change most commonly seen in
high ESR a. Intramural type of fibroid
d. Treated symptomatically. b. Cervical fibroid
3. Retention of urine is most likely to be caused by c. Pedunculated subserous fibroid
d. None.
a. Subserous fibromyoma
b. Interstitial fibromyoma
Carcinoma Endometrium
c. Submucous fibromyoma
d. Posterior cervical fibromyoma. 1. Risk factors for carcinoma endometrium includes all except:
4. Among the following, which one is the best contraceptive a. Multiparous female with late menopause
for a young female with a fibroid in uterine cavity ? b. Obesity, hypertension and diabetes
a. Hormonal contraceptive c. Tamoxifen therapy
b. IUCD d. Use of oral contraceptives.
c. Tubectomy 2. True about carcinoma endometrium is all except:
d. Barrier method. a. Associated with feminizing ovarian tumors.
5. True about sarcoma uterus is all except b. May be associated with PCOD
a. 0.5% of all myomas undergo sarcomatous change. c. Atypical hyperplasia of uterus progresses to
b. Commonly seen in postmenopausal women carcinoma endometrium in 70% cases
c. It is firm and encapsulated d. None of them.
d. Presents as rapid enlargement of myoma with pain 3. Superficial inguinal lymph nodes are involved in which
and fever. stage of carcinoma endometrium ?
6. The treatment of sarcoma of uterus is a. Stage IIIa
a. Total hysterectomy with B/L salpingo-oophorectomy b. Stage IIIb
b. TH with BSO followed by full course of radio- c. Stage IVa
therapy d. Stage IVb.
c. Chemotherapy and surgery 4. Mode of spread in endometrial cancer is correct in all except
d. Managed symptomatically. a. Fundal growth—paraovortic lymph nodes
7. A 38-year-old female on a routine USG is found to have a b. Cervical growth—pelvic glands
small fibroid in uterine cavity; she is asymptomatic c. Cervical growth—superficial inguinal lymph nodes
otherwise, so the plan of management includes d. Fundal growth—superficial inguinal lymph nodes.
a. Remove the uterine fibroid 5. Following hysterectomy, which is the most common site of
b. Hysterectomy recurrence in carcinoma endometrium?
c. Observe for few months a. Vaginal vault
d. Give GnRH analogues for 6 months. b. Myometrium
 c. Cervical ovaries c. Endometrioid carcinoma
d. Cervical stroma. d. Clear cell carcinoma.
6. The treatment of adenomatous hyperplasia of the uterus 9. True about germ cell tumors all except
in a perimenopausal female is a. Commonest tumor in girls under 10 years of age
a. Hysterectomy with or without B/L salpingo- b. Dermoid cysts are mostly bilateral
oophorectomy c. The risk of malignancy in dermoid cyst is around 2%
b. Observe for few months d. Commonest complication of teratoma is torsion.
c. Medical management 10. One of them is true about yolk sac tumors ?
d. Radiomimetic ablation.
a. Most screate germ cell tumors
7. Treatment of Stage II carcinoma endometrium is b. They create AFP and a-AT
a. Preoperative intracavitary radiotherapy followed by c. They are very slow growing tumors

Chapter 88
TAH + BSO d. They do not respond to chemotherapy.
b. Brachytherapy only 11. Most common pure malignant germ cell tumor is
c. TAH + BSO only
a. Embryonal cell carcinoma
d. TAH + BSO + post-operative radiotherapy to all patients.
b. Endodermal sinus tumor
Ovarian Cancers c. Dysgerminoma
d. Choriocarinoma.
1. Lynch – II Syndrome consists of

Often Asked Multiple Choice Questions in MD/MS Entrance Examinations

12. True about dysgerminoma is all except
a. Ovarian cancer, uterine cancer, nonpolyposis
a. It is highly radio sensitive
colorectal cancer
b. Corresponds to seminoma in males
b. Ovarian cancer, cervical cancer, fallopian tube
c. Characterized by lymphocystic infiltration with
cancer
fibrous septations
c. Cervical cancer, uterine cancer, ovarian cancer
d. It is rarely malignant when associated with genital
d. Cervical cancer, ovarian cancer, cancer of gall-
abnormality.
bladder.
13. Feminizing ovarian tumors included all except
2. True about chocolate cyst is all except
a. Granulose cell tumor
a. It arises as a result of endometriosis
b. Theca cell tumor
b. Bluish-brown in color
c. Arrhenoblastoma
c. Contains pseudoxanthoma cells
d. Theca cell tumor.
d. Small in size around 1 cm.
14. True about granulosa cell tumors is all except
3. True about functional cyst of ovaries is all except
a. Secrete estrogen and can cause postmenopausal
a. They never grow more than 7 cm in size.
bleeding
b. Unilocular, bluish in color
b. Consists of call exner bodies
c. Regress after sometime
c. Opposite ovary is last to get involved
d. Treated by USG guided puncture.
d. Carcinoma uterus may be associated with
4. The incidence of ovarian cancers in India is granulosa cell tumor.
a. 5% b. 8% 15. All are virilizing tumors of ovaries except
c. 3% d. 10%.
a. Arrhenoblastoma
5. The following factors somehow are linked to ovarian b. Hilus cell tumor
cancers, except: c. Gynandroblastoma
a. Oral contraceptives d. Endometrioid tumor.
b. Clomiphene therapy 16. All are true about Krukenberg tumor except
c. Chemical irritants like talc
a. Always unilateral involves ovaries
d. Early menarche.
b. B/L ovaries are always enlarged
6. Ovarian cancers are related to all except c. Characteristic feature is ‘signet ring-cell’
a. BRCA1, BRCA2 d. Most commonly arises from stomach cancer.
b. Her2/non ancogene 17. Marker of malignant epithetical tumors of ovaries is
c. Mutation in P53 gene
a. CA-125 b. β-hCG
d. a-AT Gene.
c. AFP d. ALP.
7. True about ovarian tumors are all except
18. Involvement of peritoneum is seen in which stage of
a. They are multiloculated cysts lined by epithelium carcinoma ovary ?
b. They are often large sized
a. Stage IC b. IIA
c. Most of them are malignant
c. IIB d. IIIA.
d. They may be combined with a dermoid cyst or a
Brenner tumor. 19. Debulking surgery is indicated in which stage of ovarian
cancer ?
8. Walthard cell rests are characteristically seen in
a. Stage Ia b. II b
a. Serious cyst adenoma
c. I II a d. IIc.
b. Brenner tumor
659
 Disorders of Menstruation Prolapse
1. All are causes of secondary amenorrhea except 1. Most common cause of UV prolapse is
a. Polycystic ovarian disease a. Atonicity and asthenia of muscle after menopause.
b. Masculanizing ovarian tumors b. Foreign body insertion
c. Asherman syndrome c. Iatrogenic trauma
d. Mayer-Rokitansky–Kuster Hauser syndrome. d. Childbirth.
2. All are causes of primary amenorrhea except 2. Most important structure preventing uterine prolapse
a. Testicular feminizing syndrome a. Round ligament
b. Hypopituitarism b. Broad ligament
c. Addison’s disease c. Cardinal ligament
d. Resistant ovarian syndrome. d. Uterosacral ligament.
Miscellaneous

3. All can cause cryptomenorrhea except 3. True about decubitus ulcers in uterovaginal prolapse is/
a. Cone biopsy of cervix are all except
b. Radium treatment of Ca cervix a. Seen on the dependent portion
c. Imperforate hymen b. Seen due to congestion and circulatory changes
d. Ca endometrium. c. Reduction of prolapse into vagina with daily packing
4. The best mode of treatment of uterine adhesions and heals them
synechiae is d. None of the above.
a. Breaking of synechiae by uterine sound under 4. Most common type of urinary complaint in prolapse is
Section 18

anesthesia a. Stress incontinence

b. Insertion of foreign body b. Retention of urine
c. Brachytherapy c. Frequency of micturition
d. All are equally correct. d. Urge incontinence.
5. All are correct about Steven Leventhal syndrome except 5. The treatment of prolapse in pregnant women in 2nd
a. Patient often complains of polymenorrhea trimester is
b. LH/FSH ratio is raised a. Pessary b. Leave it is as such
c. Endometruim is estrogenic c. Sling operation d. Any one of them.
d. Laparoscopic multiple punctures of ovary is one
6. The choice of operation in a female 40 years of age who
mode of treatment.
has completed her family but wants to retain her menstrual
6. In Mayer-Rokitansky-Kuster-Hauser Syndrome found function
a. Absence of vagina with uterus a. Sling operation b. Manchester operation
b. Absence of ovaries and fallopian tubes c. Hysterectomy d. Pessary.
c. Absence of uterus
7. Moscovitz repair is done for:
d. Absence of whole genital system.
a. Enterocoele repair b. Cystocoele repair
7. All are hypothalamic causes of amenorrhea except
c. Both of them d. Rectocoele.
a. Mayer-Rokitansky syndrome
b. Froelich syndrome Tuberculosis of the Genital Tract
c. Simmond disease
d. Cushing disease. 1. Most common part affected due to tuberculosis of genital
tract is
8. The karyotype of Kuster Hauser syndrome is
a. Fallopian tube b. Cervix
a. 46 XX b. 46 XY c. Vagina d. Uterus.
c. XO variant d. None.
2. All are wrong about tuberculosis of genital tract except
9. Spasmodic dysmenorrheal is seen in
a. It involves extremes of age
a. DUB b. Ovarian cyst b. In 40–60% cases the chief complaint is infertility
c. Submucous fibroid d. Endometriosis. c. Menorrhagia is the most common complaint
10. Mullerian dysgeneses include all except d. Thickening of broad ligament is present.
a. 46 XX karyotype b. Absent vagina 3. In tuberculosis salpingitis HSG picture shows?
c. Absent uterus d. Ovarian dysgenesis.
a. Lead pipe appearance
11. True about metropathia hemorrhagica are all except b. Cornual block
a. Short period of amenorrhea followed by vaginal c. Bending and variation in filling density
bleeding d. Calcification of tube
b. Bleeding is always painless with anovulation e. All of above.
c. Endometrium is thick without polypoidal growth
d. Ovarian function is intact. Diseases of Vagina
12. Metrorrhagia can be caused by the following except 1. The components of vaginal secretion are from all except
a. Cancer of the cervix and the uterus a. Acidic endocervical glands secretion
b. Submucous fibroids b. Endometrial glands secretion
c. Cystic glandular hyperplasia c. Vaginal epithelium transudate
660 d. Carcinoma of ovary. d. Secretion from racemose gland.
2. The normal vaginal pH during child bearing age 2. Kelly’s suture is applied on
a. pH 4.5 b. pH 6–8 a. Uterus b. Broad ligament
c. pH 5.7 d. pH 7. c. Cervix d. Vagina.
3. Cornification index is highest in vagina during which phase 3. Masshall–Marchetti- Krantz operation is done for
of menstrual cycle? a. Stress incontinence
a. Early proliferative phase b. Urinary fistulae
b. Late proliferative phase c. Cystitis
c. Early secretory phase d. Urethral stricture.
d. Late secretory phase. 4. Urethral caruncle is treated by
4. Doderlein bacillus is usally maximally found in which part a. Diathermy excision
of vagina?

Chapter 88
b. Estrogen
a. Upper two-third b. Middle third c. Progestogen
c. Lower third d. Same throughout. d. All of these.
5. A pregnant female comes to OPD complaining of profuse 5. Most common cause of vesicovaginal fistula
thin greenish frothy discharge, what is the most likely a. Prolonged and difficult labor
causative of this injection? b. Gynecological procedures
a. Trichomonas b. Candida c. Wertheim hysterectomy

Often Asked Multiple Choice Questions in MD/MS Entrance Examinations

c. Chlamydiasis d. Gonorrhea. d. None.
6. Clue cells are seen in which infection? 6. Most common types of fistula seen in cesarean section is
a. Gardnerella vaginalis a. Vesicouterine fistula
b. Trichomoniasis b. Vesicovaginal fistula
c. Candidiasis c. Uretrovaginal fistula
d. Chlamydiasis. d. All of above.
7. The timing of surgery for correction of obstetrical fistula is
Diseases of the Urinary System
a. Immediately b. At 3 m
1. Bonney’s test is done to assess:
c. At 6 m d. Left as such.
a. Stress incontinence
8. For how long, Foley’s catheter is left in situ after VVF repair?
b. Urinary fistulae
c. Urethritis a. 14 days b. 7 days
d. None of above. c. 2 days d. 5 days.

ANSWER
Fibroids
1. c 2. a 3. d 4. d 5. c 6. b 7. c 8. d
9. a 10. a
Caricinoma Endometrium
1. d 2. d 3. d 4. c and d 5. a 6. a 7. a
Ovarian Cancers
1. a 2. d 3. d 4. a 5. a 6. d 7. c 8. b
9. b 10. b 11. c 12. d 13. c and d 14. c 15. d 16. b
17. a 18. a 19. c
Disorders of Menstruation
1. d 2. c 3. d 4. a 5. a 6. a 7. a 8. a
9. c 10. d 11. d 12. d
Prolapse
1. a 2. c and d 3. d 4. a 5. b 6. b 7. a
Tuberculosis of the Genital Tract
1. a 2. b 3. e
Diseases of Vagina
1. a 2. a 3. b 4. a 5. a 6. a 7. a 8. d
Diseases of the urinary system
1. a 2. d 3. a 4. d 5. a 6. a 7. b 8. a

661
 Index

A Adhesions in uterine cavity on secreting adrenal tumor 97

hysteroscopy 546 Angle of vaginal canal 596
Abdominal
Adnexa 476 Angled clamp 582, 652
aorta 44
Adnexal mass 343 Anorexia nervosa 24, 92
ectopic pregnancy 172
Adolescent Anovulation in hyperandrogenemia 96
hysterectomy 561
friendly health services 82 Anovulatory
incision 556
gynecological issues 68 and ovulatory bleeding 105
myomectomy 325, 577
immunization 81 cycles 329
sling 591
Adopter of cannula of MVA 386 DUB 105
wound dehiscence 505
Adoption 137 Anterior
Abdomino cervicopexy 556
Adrenal abdominal wall 45
Abergolin 136
failure 384 colporrhaphy 549, 567, 568
Ablative therapy for CIN 307
hyperplasia 126 dissection 587
Abnormal
Adrenogenital syndrome 197 exenteration 588
bleeding 325
Advanced disease 358, 379 lip
Caliber vessels 441 Advantages of caught 564
conditions of breasts 604 colposcopy 530 of cervix 550
epithelium 265, 532 copper IUCD 398 pelvic exenteration 588
lactation 605 human somatic germ cells over vaginal
menstrual patterns 104 embryonic stem cell 628 incision 571
Pap test patients 264 laparoscopic wall 42, 203
placentation 187 surgery 600 Anti-anemic treatment 325
pregnancy 174 tubal anastomosis 574 Anti-fibrinolytic drugs 325
uterine bleeding 104, 332, 427 laser surgery 598 Anti-mullerian hormone 89
vaginal discharge 402 liquid-based cytology over conventional Antinuclear antibody 186
Abortion 381 cytology 263 Antiprogestins 612
Accidental hemorrhage 322 MRI 470 Antisperm antibodies in men 135
Accuracy of Pap screening 263 TVS 330 Antral follicle count 134
Acetowhite area 313 William’s operation 596 Apla heparin 129
Acetowhite Agenesis of uterus and vagina 189 Apogee system 591
epithelium 267, 531, 532 Air in peritoneum cavity 418 Aponeurosis of coccygeus muscles 43
squamous epithelium 265 Alendronate sodium 616 Appearance of abnormal bleeding 332
Acidemia 498 Alkalemia 498 Approach to newborn with ambiguous
Acidosis 498 Alkalosis 498 genitalia 197
Acne 80 Allis forceps 652 Arcuate uterus 193
Acquired genital tract disorders 125 Alloimmune treatment 129 on hysterosalpingograph 422
Active infection of cervix or vagina 132 Amastia 604 with heart shaped endometrial cavity 473
Actual bicarbonate 498 Ambiguous genitalia 196 withoblique septum in cervicovaginal
Acute Amenorrhea 70, 83, 84, 92, 177, 258 canal 473
abdomen 178 Amenorrheic women 125 Areawise distribution of cervical
lower abdomen pain 166 Amputation of cervix 554 carcinoma 310
maternal morbidity 217 Anaphylaxis 493 Areolar connective tissue 43
PID 253 Anastomizing cells 176 Aromatase inhibitors 120
renal failure 504 Anatomic abnormalities of uterus 159, 184 Arrhenoblastomas 96
salpingo-oophoritis 453 Anatomy of Arterial
Adenocarcinoma 96 breast 603 blood gas sampling 498
cervix 316 female genitourinary system 225 embolization 182
in hyperplasia endometrium 333 lactating breast 604 supply of pelvic organs 43
in situ 308 pelvic floor 202 Arteriovenous malformations 426, 427
uterus 330, 332 Ancillary Ascites 13
Adenomatous carcinoma extending to instrument of laparoscopy 538 Asherman’s syndrome 89, 127, 258
endocervix 336 procedures 569, 586 Aspiration of gastric contents 494
Adenomyosis 324, 328, 427, 433, 443, 450, Androblastomas 96 Assault victim 213
472 Androgen 147, 325 Assisted
high power 328 excess hatching 142
low power 328 in reproductive life 94 reproductive technology 121, 128, 139
Adenomyotic uterus 449 on ovary 95 Athelia 604
Adhesiolysis 541 insensitivity syndrome 89, 198 Atrophy 321
 Atypical Big uterus with multiple fibroids 570 Calcium 156
choriocarcinoma 176 Bilateral and osteoporosis 152
vessels 267 adnexal endometrioma 478 Calendar method 391
AUB complex adnexal masses 477 Cancer 26
in reproductive age 109 lymphadenectomy 378 cervix 18, 311
management 109 ovarian hydronephrotic changes 423
Auscultation 13 carcinoma 268 of uterine
Autoclave 638 dermoid 477 body 277
Autoimmune disorders 126 tubal block 420 cervix 273
Autonomic nerve supply 44 uterine artery embolization 326 of vulva 15
Aveling’s repositor 209 Billing’s method 391 rehabilitation 220
Ayre’s Biomedical waste Candida infection of cervix 302
Candidal
Textbook of Gynecology

spatula19, 514, 651 container 635

wooden spatula 263 management and handling rules 635 vaginitis 19
Azithromycin 289 treatment facility 635 vulvovaginitis 366
Azoospermia 130, 132, 135 Bipolar cautery method 410 Cannula 518
Bladder connected to suction 518
B and upper vagina 190 introduced 387
calculi 417 Capronor 404
Babcock’s forceps 650
catheterization 550 Capsular rupture 322
Backache 223
injury 492, 572, 590 Capsule of myoma and tumor 325
Bacterial
mobilization 564 Carboplatin 182, 358
infections 289
Blade handle 652, 653 Carcinoma
vaginosis 247, 290, 366
Blastomere biopsy 142 cervix 163
Bacteriology of PID 252
Bleeding endometrium 278, 646
Balloon system 528
from cervical erosion 163 in situ
Barium enema 423 cervix 307
Barrier methods 393 in early pregnancy 158
per vaginum 160 ecto-cervix 307
Bartholin of cervix 474
abscess 370, 520 Blighted ovum 163
Blood staging 476
cyst 15, 370, 371, 520 of fallopian tube 338
gland 34, 35 dyscrasias 104
gas sample 499 of vulva 478
adenocarcinoma 376, 380 ovary 278
Basal group 177
supply to female pelvic organs 43 vagina 280
body temperature vulva 280
methods 391 transfusion 501
Bone Cardinal ligaments are caught 553
monitoring 132 Carneous mole 162
cell carcinoma 376, 380 marrow and gastrointestinal
toxicity 182 Carpal tunnel syndrome 97
Base excess 498 Catching anterior lip of cervix 515
Basic anatomy of pelvic floor 200 mineral density 154
Borderline serous tumor of ovary 353 Cauliflower growth in invasive cancer 268
Basis of neo-organo-histogenesis Causes of
in vivo 620 Bowel injury 492, 572
Brachytherapy 274 anovulation 132
Behcet’s disease 368 hyperprolactinemia 126
Benefits of HRT 150 treatment units 273
infertility 123
Benign Breast 12
leukorrhea 285
conditions of cancer 183, 217, 269, 332
menorrhagia in adolescents 70
breast 607 diseases 603
ovarian failure 126
cervix 299 in pregnancy and lactation 605
unilateral dysmenorrhea 99
ovary 343 pain 607
Cefitraxone 289
uterus 320, 327 self-examination 269
Centchroman 403
vagina 283, 293 size 81
Central
vulva 369, 372 Bring rectal strip anterior 556
nervous system 111, 178
fibroma 465 Bromocryptine 617
venous pressure 496, 498
neoplasms 344 Bronchospasm 494
Cervical
ovarian Budding cells 288, 289
biopsy 521
conditions 476 and pseudohyphae of candida on gram
cancer 216, 313
tumor 345, 476, 645 staining 288
cap 395
tumors 293, 303, 365 Bulbourethral glands in males 35
cone biopsy 314
of breast 607 Bulging of breast tissue 269
dilators 648, 649
uterine conditions 472 Bulky uterus 474
ectopic pregnancy 170
Bicornis Burning micturition 224
erosion 18, 300
bicollis uteruson hysterosalpingograph Butterfly incision for radical vulvectomy 378
fibroid 303
422 incompetence 187, 472
unicollis uterus on hysterosalpingograph C intraepithelial neoplasm 304
422 Cabergoline 617 malignancy 313
Bicornuate uterus 185, 187, 192, 422, 425, Calcification ring 417 mucus 132, 391
437, 473 Calcified fibroid 417 polyps 18, 110, 163, 303
on hysterosalpingograph 422 Calcitonin 616 punch biopsy 531
with single vagina 193 Calcitriol 157 stenosisocervical brush 132
664
Cervicitis 300 Clomiphene citrate 136 anomalies of external genitalia 369
Cervicograms 265 challenge test 134 anorchia 198
Cervicography 265 Cloquet drain clitoris 45 cysts 292
Cervicovaginal canal 472 Closed suction drain 582 uterine
Cervicovaginitis emphysematous 300 Closure of groin dissection 584, 585 abnormalities 420, 421
Cervix 253, 299, 632 Cluster of abnormal vessels 464 malformations 432, 439
Chancroid 243, 370 Coccygeus muscle 43 Contact dermatitis 366
Changes in breasts 65 Coelomic metaplasia theory 113 Continuity of mullerian tube 89
Chemoradiation 379 Colon cancer 183 Contraception 390, 476
Chemotherapy 181, 278, 279, 335, 360 Colonic injury 572 in patients of GTD 183
and radiotherapy in gynecological Colpophotography 531 related amenorrhea 92
malignancies 272 Colposcopy 266, 530, 580 Contraceptive
method 397

Index
for early stage disease 357 of premalignant and malignant lesions of
for epithelial ovarian cancer 278, 357 cervix 531 prevalence rate 390
for germ cell tumors 362 Colpotomy 525 vaccine 406
of primary fallopian tube carcinoma 341 Combined vaginal rings 404, 405
Childhood puberty 64 contraceptives 402 Contraindications of HRT 150
Chlamydia 398 oral contraceptive 402 Controlled cord traction 209
trachomatis 61 Commercial ovulation detection kits 393 Cook ET catheter 143
Chlamydial Common Copper bearing IUCD’s 397
cervicitis 302 disorder of puberty 66 Cornual
discharge 289 iliac lymph nodes 45 angle 436
Chocolate cyst of ovary 324 instruments in gynecology 648 ectopic 541
Chorioadenoma destruens 175 menstrual disorders in adolescents 70 fibroid 570
Choriocarcinoma 176, 177, 280 urinary problems 504 opening 545
cells 176 Communication and counseling in Coronary heart disease 149
of ovary 362 gynecology 6 Corpora
Chorionic villi 176 Comparative parts of genital tracts 55 cavernosa 35
Chromotubation 540 Complete lutea 170
Chronic abortion 162, 384 spongiosa of males 36
benign cystic lesions 456, 457 agenesis of uterus and vagina 189 Corpus
endometritis 327 hydatidiform mole 174 albican 40
hypertension 217 molar pregnancy 177 luteal cyst 40
inflammation of endometrium 443 mole 177 luteum 40, 384
inversion 209 repair of perineal tear 535 in ovary 452
of uterus 208, 324 set up of robotic surgery 602 Corticosteroid therapy 128
maternal morbidity 217 vaginal vault eversion 205 Couple protection rate 390
pelvic pain 98, 100, 540 Completed three-incision vulvectomy 585 Cowper’s glands 35
PID 253, 254 Completing vaginal dissection 587 Craniotomy 182
respiratory tract disease 129 Completion of marsupialization 521 Creating vacuum in new MVA syringe 386
systemic corticosteroid administration Complications of Cryocautery 523, 524
384 abdominal hysterectomy 563 probe in position 524
Cryomyolysis 326
tubo-ovarian mass 324 anesthesia 493
Cryopreservation techniques 142
Cisplatin 182, 358 choriocarcinoma 176
Cryptomenorrhea 89
Clamping of female sterilization 410
CT machine 468
infundibulopelvic ligament 548 general anesthesia 493
Culdocentesis 165, 526
round ligament 580 H mole and invasive mole 176
Curdy white
uterosacral ligaments 566 HSG 419
discharge of candida 288
Classification of hysterectomy 478
vaginal discharge 366
antiosteoporotic drugs 156 IVF 144
Curette inserted in uterus 517
carcinoma of fallopian tube 339 laparoscopy 494
Cusco’s speculum 16, 648
epithelial ovarian tumors 352 leiomyoma 322
Cushing’s syndrome 96
FGM 215 local anesthesia 494
Cu-T removal hook 401
human stem cells 627 pregnancy and childbirth 217
Cutting of
prolapse 203 prolapse uterus 208
round ligament 580
severity of OHSS 144 regional anesthesia 494
vesicocervical ligament 551
sexual maturity rating in girls 64 surgery 570
Cyberknife 272
stress urinary incontinence 227 Components of laser machine 598
Cyclic
sutures 507 Concurrent chemoradiation 276
abdominal pain 89
syphilis 241 Condition of vulva in vVF 235 hematuria 190
Cleaning perineum 549 Condoms 393 lower abdomen pain 190
Clear cell Condyloma acuminata 366 Cyproterone acetate 613
carcinoma 336 Condylomata 14 Cystic corpora lutea 456
tumors 352 Cone biopsy 308, 522 Cystocele 202, 549
Climacteric 147 Congenital Cystoscopy 579
Clitoral growth 15 abnormalities of cervix 299 Cystourethrocele 227
Clitoris 34-36 adrenal hyperplasia 197 Cytobrush 263
665
 D sex development 194 Emergency contraception 406, 612
vertical fusion 190 Empty sella syndrome 92
Danazol 97, 120, 325, 613
Displaced Enclosing myoma 578
Day of
copper T 418 Endocervical
menstrual cycle 392
Lippes loop 418 brush 19, 654
ovum pick-up 445
Distended corpus 190 canal 132
Deep lymph nodes 45
DNA cloning 629 carcinoma 318
Defect in sperms and seminal fluid 124
Donovanosis 244 curettage 516
Dehydroepiandrostenedione 66
Donut Pessary in position 207 hyperplasia 302
Delayed puberty 66, 68
Double cervix 17, 191 polyps 303
Deoxyribonucleic acid synthesis 384
Doxycycline 289 retractor 530, 654
Depigmented skinwith scarring of vulva 367
Doyan’s retractor 653 Endocervix 38
Dermatitis 235
Textbook of Gynecology

Droplet infection 481 Endocrine disorders 126

Dermatoses of vulva 365
Drospirenone 613 Endocrine
Dermoid cyst 344, 345, 417, 429, 454, 645
Drugs abnormalities 116
ovary 645
for abnormal uterine bleeding 618 cycle 56
Descent of
interactions of oral contraceptives 612 tests 131
gonads 49
used in urinary incontinence 618 Endocrinology of spermatogenesis 123
ovary 49
Ducts of Endodermal
Destruction of myoma 326
Bartholin’s glands 35 cells 50
Detect
paraurethral glands 35 sinus tumor 361
adrenal tumor 66
Duplicate cervix 300 Endogenous
cervical precancer and cancer 266
Dye test 133 infections 75
Development of
Dysfunctional opiate peptides 111
external genitalia of female 51
cysts 455 Endometrial
fallopian tubes 50
uterine bleeding 105 ablation 108
female
Dysgenesis of mullerian ducts 189 aspiration 330
genital tract 46, 55
Dysgerminoma 361, 363 biopsy 132, 649
internal genital organ in relation to
with lymphoid stroma 361 cancer 269, 324, 333, 441
urinary system 50, 52
Dysmenorrhea 70, 98 carcinoma 110, 277, 336, 424, 427, 441,
urogenital system 52
Dyspareunia 116, 119, 402 472
kidney 53
Dysrhythmias 495 curette 514
male urogenital system 51
Dystrophies 369, 371 endometrioid carcinoma complex
ovary 47
paramesonephric duct 47 glandular structure 335
secondary sexual characteristics 65
E fluid collections 438, 442
testis and ovary 48 Early hyperplasia 110, 329
urethra 55 detection of breast cancer 269 polyps 110, 472
urinary bladder 53, 54 latent syphilis 242 sampling 330, 514
uterus and fallopian tubes 49, 50 menarche 332 thickness 424
Diabetes mellitus 126, 332 puberty 68 uterine polyp in fundus 545
Diagnostic hysteroscope 655 secretory endometrium 59 Endometrioid
Didelphic uterus 192 ECC brush 516 adenocarcinoma 335
Diet chart for girls 78 Echogenic dermoid in polycystic ovary 461 carcinoma
Dilatation of cervix 516, 517 Ectocervix 38 of ovary 355
Dilated tortuous vessel in pelvic Ectopic poorly differentiated 335
peritoneum 455 in rudimentary horn of uterus 191 well-differentiated 335
Direct obstetric morbidity 217 pregnancy 163, 164, 324, 346, 429, 452 tumors 352
Directly observed treatment short in fallopian tube 169 Endometriomas 428
course 260 Edema of vulva 372 Endometriosis 76, 113, 121, 126, 302, 343,
Disappearing testis syndrome 198 Effective method of contraception 397 451, 461, 478, 540
Discharge Ejaculatory Endometriotic
criteria systems 494 duct obstruction 135 adnexal lesions 461
of bacterial vaginosis 290 dysfunctions 134 ovaries 454, 461
of trichomonas vaginalis 286 Electrical vacuum aspiration 388 Endometritis 433
Diseases of Electrocautery 525 Endometrium 253, 426
cervix 299 Electrocoagulation 539 carcinoma 336
ovary 343 Electro-optical technique 268 Endopelvic fascia 465
urinary system 661 Elephantiasis 370 Endorphin 111
uterus and fallopian tubes 320 Eligibility of cervical screening 264 Enterobius vermicularis 61
vagina 283, 660 Eligible couple 390 Enterocele 203
vulva 365 Ellis tissue forceps 521 Eosinophilic cytotrophoblastic tumor
Disordered wound healing 504 Embryo cells 177
Disorders of selection 141 Epidemiology of
anterior pituitary 91 transfer technique 143 cancer cervix 310
lateral fusion 191 Embryonal stem cells 627 ovarian cancer 351
menstruation 660 Embryonic micromanipulation pelvic organ prolapse 201
pubertal growth and maturation 68 techniques 142 E-pill 407
666
Epithelial genital vagina 50
disorders 369 mutilation 214 Fossa navicularis 36
ovarian organs 214 Four Allis forceps applied 553
cancer 358 tract 240 Fox Fordyce disease367
tumors 352 infertility 128 Fractional curettage 517
tumors 278 internal genital organs 37 Frank’s
Erythema of vulva 366 sexual disfunction 148 dilation 593
Erythematous sterilization 407, 411 method 89
papillomatous growth of vulval warts 366 urethra 225 Free fluid in pelvis 452
papules 367 urogenital triangle 225 Functional
Erythromycin 289 Femidon 394 cortical tissue 90
Escherichia coli 61, 224 Feminine 90 cysts 428
Femoral

Index
Estrogen 147, 610 ovarian cysts 449
therapy 156 artery catheterization 326 Fundal fibroid polyp 322, 323
ET catheter loading 143 vein 45, 497 Fundus of uterus 322
Etoposide 182 puncture 497 Fungal disease 300
Evaluation of Fertilization 59, 140
amenorrhea 87 Fibroid 426, 440, 545, 658 G
ovarian function 132 polyp 326, 522, 647
Galactorrhea 12, 85, 607
Evidence based reproductive medicine 30 with infection 647
Gamete
Excess vaginal tissue and stitching 552 uterus 127, 324, 426, 542, 646
intrafallopian transfer 144
Excessive vaginal bleeding 384 Fibromyoma vulva 372
micromanipulation techniques 141
Excision FIGO
Gamma-amino butyric acid 111
biopsy 520 classification 2009 336
Gartner cyst 47
of fistula tract 237 risk factor scoring values H mole 180
Gas insufflators 538
Exposing introitus 594 staging
for ovarian carcinoma 356 Gellhorn Pessary in position 207
Exterior genital organs 34 Gene therapy in gynecological cancers 632
External gestational trophoblastic tumors 178
of primaryfallopian tube carcinoma Genetic counseling center 414
female genitalia 214 Genital
genitalia of newborn female child 61 340
Filtroid uterus with hyaline degeneration 647 fistula 233
iliac lymph nodes 45 hiatus 204
piles 206 Fimbriectomy 411
Finasteride 613 tuberculosis 257
urethral tumors in adolescents 76
meatus 36, 204, 224 First generation endometrial ablation
techniques 527 warts 248
opening 34, 35 Genitourinary
Extramammary Paget disease 376 Fistulae 216
Fixed air asepticizer 480 symptoms 148
Extra-ovarian anembryonic gestational system 37
sac 452 Flap splitting method 238
Flesh colored pearly papulesover vulva of Germ cell tumors 280
Eyed needle 510 Gestational trophoblastic
molluscum contagiosum 366
Fletcher-Suit applicator set for HDR disease 174, 181, 280, 281, 474
F neoplasm 427
brachytherapy 275
Facilitating normal ovulation and Flexural psoriasis 367, 368 Gestrinone 120, 325
conception 96 Fluid replacement 501 Glass in vagina 292
Failure to deposit sperms in vagina 124 Fluoroquinone 289 Glisson’s capsule 178
Falling hair 481 Flutamide 613 Globular ovary 452
Fallopian tube 39, 50, 132, 170, 253, 343, Focal Glucocorticoids 97, 614
443, 623 endometrial lesions 436 Glycine 544
carcinoma 338 subendometrial lesion 450 GnRH antagonist 614
prolapse 572 Foley’s Gonadal
Falope’s ring catheter 89 agenesis 90
applied on fallopian tube 411 indwelling catheter 490 dysgenesis 90
method 411 Follicular Gonadotropin-releasing hormone 136
Familial and hereditary ovarian cyst 344 Gonadotropins 147
cancers 351 maturation 444, 446 in PCOS 136
Fascia of denonvilliers 43 monitoring 140 Gonococcal
Fate of phase 57 cervicitis 302
ectopic pregnancy 167 place of ovulation 57 discharge 289
mesonephric duct in males 53 Folliculogenesis 57, 58 Gonorrhea 246, 398
paramesonephric duct in female and Foreign bodies in vagina 292 Grading of PID 255
male 54 Formation of Graafian follicle 40
Female female external genitalia 53 Graphic record of cervical lesion 531
and male external genitalia 54 paramesonephric duct 621 Greater vestibular glands 35
circumcision 214 Sturmdorf suture 554 Groin node dissection 584
condom 394 urogenital ridge 46 Gross choriocarcinoma 176
external urorectal septum 53 Gubernaculum of testis of male 43
genital organs 34 uterovaginal canal 621 Gynandroblastomas 96
genitalia 34 uterus and follopian tube 50 Gynecological concerns of adolescents 68
667
 H Hydrosalpinges 421 Infertility 23, 126, 127, 459, 539
Hydrosalpinx 429, 450 Inguinal
Hammond’s graph of cervix 531
Hymen 34, 36 ligament 45
Hand-knee rocking 219
Hyperandrogenism 72, 187 lymph nodes 45
Haultain technique 210
Hypercarbia 495 Inguinofemoral lymphadenectomy 378
Headache 325
Hyperemic arcuate arteries 454 Inhomogeneous endometrium 441
Heavy menstrual bleeding 398
Hyperinsulinemia in PCOD 617 Injectable contraceptives 403
Hematogenous and lymphatic spread
Hyperosmolar glucose 170 Inperforate hymen 16
theory 113
Hyperpigmentation and ulceration of Insemination 137
Hematometra 327
procidentia 206 Insomnia 325
Hemisection 569
Hyperplasia 302, 426 Instruments for
Hemorrhage 491, 503, 572
Hyperprolactinemia 97, 126, 135, 617 laparoscopic ligation 411
Hemorrhagic
Hyperprolactinemic infertile women 125
Textbook of Gynecology

cyst in ovary 478 operative laparoscopy 655

Hypertensive disorder of pregnancy 217 Insulin sensitizers 136
ovarian cyst 452
Hyperthyroidism 88, 177
Hemostatic instruments 539 Intercapillary distance 532
Hypertrophic cervix 300
Hepatic resection 183 Internal
Hypocalemia-hypoxia 495
Hepatitis 217 genitalia 65
Hypochloride solution 639
B 248 iliac
Hypogonadotropic hypogonadism 66, 135,
prevention 214 artery 44
137
virus 248 nodes 45
Hypoplastic uterus 472
Hereditary meatus of urinary bladder 42
Hypotension 494, 495
breast ovarian cancer syndrome 351 pelvic organs 37
Hypothalamic pituitary
nonpolyposis colorectal syndrome 351 Interpreting semen analysis 124
dysfunction 125
Herpes Interstitial
failure 125
genitalis 366 brachytherapy 275
ovarian axis 66
progenitalis 249 fibroid 447, 449
region 125
zoster 368 Interval debulking surgery 357
Hypothalamus 56
of vulva 367 Intracervical brush 654
Hypothyroidism 88
Herpetic cervicitis 301 Intracytoplasmic sperm injection 135, 141
Hysterectomy 25, 108, 182, 308, 326, 559
Heterogeneous echogenicity of Intra-embryonic mesoderm 621
clamp 651
endometrium 445 Intramural fibroid 320
Hysterocontrast sonography 429
Heterotopic pregnancies 144 Intraperitoneal hemorrhage 322, 411
Hysterosalpingogram 89, 420
High molecular weight media 544
Hysterosalpingography 133, 418 Intrauterine
Highlighting intracellular mucin 355
Hysteroscopic contraceptive devices 395, 407
Hip extension in
myoma resection 326 device in situ 384
prone position 219
myomectomy 578 gestational sac 452
standing position 219
Hysteroscopy 89, 543 insemination IUI 137
Histopathology leiomyoma 322
instruments 543 instillation of hypertonic solutions 389
HIV
counseling 214 pregnancy 170
infection 243
I Intravasal contraceptive device 405
Homogeneously echogenic Ifosfamide 182 Intravenous pyelogram 324
endometrium 445 Imperfect fusion of mullerian duct 191 Introducing cannula 387
Hormonal Imperforate Invasion in endometrioidadenocarcinoma
changes 64, 147 hymen 85, 89, 283, 521 337
regulation 56 vagina with Invasive neoplasms 279
replacement therapy 332 hematocolpos and hematometra 190 Inversion of uterus 208, 322
therapy 149, 278 hematometra 190 Inverted/retracted nipples 604
Hormone Implantation theory 113 Irregular
assay 130 Incision bleeding 402
estimation 66, 67 hernia 13 cycle 391
replacement therapy 90, 610, 616 of Perigee operation 555 heterogeneous soft tissue mass in
therapy 334 Incisional hernia 505 cervix 476
HPV Inclusion cyst 303 menstrual cycles in adolescents 70
infection 250, 300 Incomplete vaginal bleeding 322
screening 266 abortion 384 Irving method 409, 410
HSG bicornuate uterus 192 miscarriage 161 Ischial
Human Incubation period 243, 244, 246 spine 43
papilloma virus 311 Indirect obstetric morbidity 217 tuberosities 35
placental lactogen 176 Inevitable Ischiocavernosus muscles 35
Huntington procedure 210 abortion 162 Ischiopubic rami 35, 36
Hyaline miscarriage 160 Ischiorectal fossa 42
degeneration 321 Infections IUCD hook and removal 654
stroma 361 in adolescents 75
Hydatid of morgagni 344 of genital tract 240 J
Hydatidiform mole 163, 174, 177, 646 of vagina 285
Hydroclave 638 Inferior margin of pubic symphysis 227 Janani Suraksha Yojana 643
Hydropic swelling of chorionic villi 174 Joshi’s sling operation 557, 558
Infertile couple 129
668
K sclerosus 367 neoplasms 76
vulva 367 tumor 362, 645, 646
Kallmann syndrome 93
simplex chronicus 365 Malpas classification 203
Karman cannula 389, 516, 650
Lichenification of vulva 366, 367 Mammography 269
Kelly clamps 168
Ligation of infundibulopelvic ligament 581 Management chart for recurrent pregnancy
Khanna’s
Lipoma loss 187
posterior sling 557, 591
of abdominal wall 13 Management of
sling operation 556
vulva 372 abnormal cervical cytology during
Kissing sign 461
Lippes loop 396 pregnancy 308
Klebsiella pneumoniae 224
Live ectopic in adnexa 452 amenorrhea 88
Knee chest position 62
Location of fibroids 320 bubo 244
Low chronic inversion of uterus 209
L

Index
back stretching 219 drains 502
Labia minora 34, 35 grade disease 267 endometriosis 120
Labial molecular weight media: 544 herpes during delivery 250
agglutination 62 Lower lactation failure 606
stitches 564 isthmus 40 lymphedema 222
Lactating mother 392 urethra 42 ovarian cyst in postmenopausal
Lactational amenorrhea method 392 Lubricating syringe 386 women 349
Ladli scheme 644 Lugol’s iodine 265 pelvic organ prolapse 204
Laparoscopic Luteal cysts 456 postmenopausal women 149
assisted vaginal hysterectomy 541, 571 Lutein ovarian cysts 177 rape victim 213
myolysis 326 Luteinized unruptured follicle syndrome 126 sex partners of women with acute PID 256
myomectomy 325, 541, 578 threatened miscarriage 159
Lymph node dissection 581
ovarian urinary catheters 502
Lymphadenectomy 334
cystectomy 547 vault prolapse 590
Lymphatic
drilling 548 Manchester
drainage 44
salpingostomy for ectopic pregnancy 168 Fothergill operation 551
of cancer of cervix 315
sterilization 407, 541 system for brachytherapy in
of female pelvis 45
surgery 492, 600 gynecological malignancies 274
of uterine malignancy 337
tubal ligation 411 Manual vacuum aspiration 384, 388
of vulval carcinoma 377
Laparoscopy 101, 120, 348, 537, 600 Markers of poor ovarian reserve 139
trapezoid of Fletcher 276
Laparotomy 120, 183, 348 Marsupialization of Bartholin cyst 521
Lymphocyte immune therapy 129
Large Masson’s tri chrome stain 624
Lymphoedematous enlargement of labia
heterogeneous Mastalgia 607
majora 368
multiseptate mass 477 Mastodynia 607
Lymphogranuloma venereum 245, 370
soft tissue mass filling endometrial Maternal-paternal mixed lymphocytes
Lymphatic drainage of vagina 297
cavity 474 reactions 186
left ovarian dermoid 416 Maternofetal transmission 250
ovarian cysts 559
M
Mature cystic teratomas 344, 362
theca lutein cysts 177 Mackenrodt ligament 43 Maze of glands 355
uterus with heterogeneous mass 474 Making McCalls sutures 567
Laryngospasm 494 strip of rectus muscle 556 McIndoe operation 190, 593
Late vaginal mould 595 Medical
latent syphilis 242, 243 Malaria 217 abortion 381
menopause 332 Male methods for augmentation of
secretory endometrium 59 gonads 90 ovulation 136
sequelae 148 infertility 127 termination of pregnancy and safe
syphilis 242 injectable contraceptive 404 abortion 381
Lateral vaginal angle 563 intra-vas contraceptive devices 405 Medicinal intervention 112
LeFort pills 403 Medroxyprogesterone acetate 66
operation 554 pseudohermaphrodite 89 Melanoma 376
vaginal colpocleisis 590 sterilization 412 Menarche 66, 329
Left functional ovarian cyst 541 Malecot’s catheter 654 Menopausal osteoporosis 616
Leiomyoma 321, 322, 472 Malformations of female genital tract 189 Menopause 23, 147, 148, 322
polyp histopathology 326 Malignancies of Menorrhagia 70, 325
Letrozole 136 uterus 332 Menstrual
Leukoplakia 531 vagina 295 abnormality 324
of cervix 267, 301 Malignant changes 65, 398
vulva 368 adenocarcinoma 97 cycle 60, 66, 623
Leukorrhea 284 conditions of discharge 22, 190
Levator ani 37, 200 uterine cervix 310 disorders 70
muscles 43 uterus and fallopian tubes 332 flow 323
Levonorgestrel 119, 404 germ cell tumors of ovary 362 hygiene 68, 69
intrauterine devices 325 malenoma of vagina 296 Menstruation 56, 83
Lichen ovarian Mesodermal membrane 624
planus 366 conditions 477 Mesonephric
sclerosis 371 germ cell tumors 360 duct 47, 54
669
 hyperplasia 303 Multilayered columnar cells line duct 35 ovulation 461
remnants 303 Multiple rugae of vagina 36
Metal retractor 653 enlarged lymph nodes 462 saline 544
Metallic catheter 550 fibroid squamous epithelium 265
Metaplasia 302 in patient 321 uterus 424
Metastatic trophoblastic disease 178 uterus 647 vagina 36
Metformin 136, 617 nabothian follicles 262 Novasure endometrial ablation 529
Methods of pregnancy 144 Nulliparous women 36
contraception 78, 390 synechiae 89
endometrial ablation 527 Muscles of myometrium 38 O
inserting female condom 394 MVA syringe and cannulae 385
Obstetric
medical termination of pregnancy 384 Myalgia 325
fistulas 216
Textbook of Gynecology

recording of colposcopic findings 531 Myeloid leukemia 183

maternal morbidity 217
wearing gloves 485 Myocardial ischemia 495
Obstructive jaundice 504
Methods per abdomen 407 Myoma screw 325, 326, 653
Obtain cervical smear 262
Methotrexate 384 Myomectomy 321, 325, 577, 602
Obturator lymph node 45
Meyer-Rokitansky-Kuster-Hauser Myometrial
Odell’s diagram 531
syndrome 89 cyst 450
Oligomenorrhea 70
Microinvasive carcinoma 273 polyp 331
Omental thickening 471
Micropapillary serous carcinoma 354 Myometrium 450
Oocyte retrieval 140, 141
Microsurgery instruments 575 Myths in adolescent period 68
Oophorectomy 547, 548
Micturition 61
Opening of
Midampullary ectopic 168 N
broad ligament 581
Mifepristone 325, 381, 384, 389 Nabothian follicle 18, 302 pouch of Douglas 565
Migration of primordial germ cells 48 N-acetyl cystine 618 vagina 521
Minilaparotomy 408 Natural
Mirena 119, 396 Opening uterovesical pouch 565
barrier for PID 253 Operations of ovary 547
insertion 400 estrogens 610
Miscarriage 4, 25, 158, 217, 323 Operative hysteroscope 543, 655
methods of contraception 391 Optimization of embryo transfer
Misoprostol 381, 384 progestin 611
Misoprostone 389 technique 142
Needle Oral
Missed destroyer 637
menstrual period 402 contraceptive 119, 402, 611
holder 511, 652 emergency contraceptive 406
miscarriage 162 of Perigee method 555
pill 402 Ormeloxifene 325
Neoadjuvant chemotherapy 358 Osteoblasts 151
Missing with radiotherapy 277
IUD 541 Osteoporosis 149, 151, 325
Neonatal Ostrogen 150
strings 401 mastitis 605
Mitotic ovarian lesion 471 Oval well-defined mass in anterior pelvic
period 197 wall 476
Mixed Neoplasia in pregnancy 308
mullerian tumor 338 Ovarian
Neoplastic ovarian lesions 455 aging 133
tumors 354 Neo-regeneration of fallopian tube 624
Mobile air asepticizer 480 and round ligament clamped 567
Newborn with ambiguous genitalia 196
Mobious syndrome 384 biopsy 548
Nipple discharge 607, 608
Modified Pomeroy’s technique 408, 409 branch 44
Non-canalization of vagina 283
Molar pregnancy 174 cancers 659
Non-canalized vagina 86
Molluscum contagiosum 250, 366 carcinoma 423
Non-contraceptive
Mons cycle 13, 57
advantages of oral contraception 403
pubis 34, 35 cyst 13, 343, 428, 540, 541
benefits of progesterone infections 404
veneris 34 cystectomy 547
Non-estrogen combined pill 403
Morning afterpill 406 Non-gestational choriocarcinoma 183 disorders 90, 540
Most harmless method of contraception 394 Non-gonococcal urethritis 246 ectopic pregnancy 171
Motile sperms 132 Non-infectious cervicitis 302 endometrioma 117, 455, 461
MRI machine 469 Non-obstetric causes of bleeding first endometriosis 114, 428
MRKH syndrome 190 trimester 163 failure 125
Mucinous Non-scalpal vasectomy 412 function 323
carcinoma 335 Non-specific vaginitis 291 hilum 455
cystadenocarcinoma 354, 355, 464 Non-sterile insertion technique 398 hyperstimulation syndrome 144
cystadenoma 345, 355 Normal immature teratomas 363
tumors 352 bladder capacity 41 ligament fibromuscular cord 43
Mucopurulent cervix 17 malignancy 351, 429
cervicitis 302 continence of urine 225 masses 76
discharge 61 dexa of in adolescents 76
Mullerian femur 154 pains 100
abnormalities 89 left femur 155 stimulation 138
agenesis 89 female pelvis 416 torsion 322, 346
anomalies 435 hysterosalpingogram 420 tumor 63, 324, 429, 547, 645
development 89 menstruation 68 vein 44
670
 vessels 44 Perigee operation 555 Precocious puberty 66
volume 446 Perimenopausal depression 150 Pregnancy test 165
Ovaries 39, 425 Perineal tears 533 Premalignancies vulva 374
Overactive bladder 231 Period of amenorrhea 160 Premalignant conditions of
Ovulation 58, 540 Periosteum of fourth sacral verterba 43 uterus 329
Ovulatory DUB 105 Peritoneal telangiectasia 455 vagina 294
Ovum forceps 650 Permanent method of contraception 407 vulva 374
Oxytocin 389 Persistent Premature
reflex 605 gestational trophoblastic tumor 181 menarche 66
vaginal discharge 530 menopause 149
P PET machine 479 ovarian failure 90, 126
Paget’s disease 373 pH testing of vaginal discharge 288 pubarche 66

Index
of vulva 380 Phytoestrogens 151, 616 thelarche 66
Pain 115 Piercing of vulva 214 Premenopausal women 97, 348
Palliative chemotherapy 379 Pimples 80 Premenstrual syndrome 22, 72, 111
Pap smear 19, 312, 514, 531 Pioglitazone 617 Prevention of
Papillary serous Pipelle device 515 cervical carcinoma 317
carcinoma 335 Placental site trophoblastic tumor 176 endometriosis 119
cystadenocarcinoma 353 Plasma pyrolysis 638 OHSS 145
cystadenoma 354 Pneumoperitoneal needle and trocar 537 RTI/STI 251
Para-aortic nodes 472 and cannula 655 sexually transmitted diseases 214
Paracervical block 512 Pneumoperitoneum 493 vault prolapse 592
Paradoxical oophorectomy 548 Polycystic vVF 236
Parametrial cysts 428 ovarian Primary
Paraovarian cyst 344, 547 disease 126, 430 amenorrhea 89, 437
Paratubal cysts 345 syndrome 72, 90, 429 cause of cervical cancer 266
Parenchyma 603 ovaries 67, 343, 451, 458, 461 dysmenorrhea 98
Parkland method 409, 410 Polymenorrhagia 323 fallopian tube carcinoma 339, 341
Partial Polymenorrhea 70, 323 syphilis 242
colpocleisis 554 Polypectomy 523 venous congestion 454
hydatidiform mole 175 Polythelia 604 Progesterone
pressure 498 Polyurethane condom 394 antagonists 120
Parts of Pomeroy’s method 408 only pill 402
needle 509 Poor uterine descensus 569 Progestins 119, 611
telescope 543 Portio Prolactin reflex 605
Pearl index 390 supravaginalis 38 Prostaglandins 389, 618
Pediculosis pubis 248 vaginalis 38 Proteus mirabilis 224
Pedunculated Positive via test 265 Prune juice like appearance 177
myoma 326 Postcoital Pruritus vulvae 365
subserosal fibroid 322 bleeding 530 Pseudomonas aeruginosa 224
Pelvic contraceptive 406 Pubarche 65
atrophy 150 test 131 Puberty 64
colon 42 Postdural puncture headache 494 menorrhagia 106
diaphragm 43 Posterior Pubic
exenteration 588 colpoperineorrhaphy 550, 552, 567, 568 bone 35
floor colporrhaphy 568, 569 hair changes 65
exercise 220 Posterior symphysis 227
innervation 200 dissection 587 Pubocervical
muscle exercise instructions 221 exenteration 588 fascia 43
muscle exercise technique 221 pelvic exenteration 588 ligament 43
hematoma 503 vaginal wall 203 Pudendal
inflammatory disease 222, 252, 324, 476, wall vaginal cyst 292 block anesthesia 513
541 Postmenopausal nerve injury 590
malignancy 541 atrophy 465 Pulmonary
mass 190 bleeding 108 metastasis 178, 419
organ women 610 tuberculosis 419
displacements 200 Postoperative Punch biopsy forceps 520
prolapse quantification system 203 analgesia 501 Purandare’s sling operation 556
pain 119, 471 chemotherapy 334 Pure gonadal dysgenesis 90
in adolescents 75 complications 238, 502 Pyelonephritis 224
tilt exercise 218 feeding 501 Pyometra 327
tuberculosis 258 fever 503 Pyridoxine 111
varices 476 instructions 218
Penile urethra in males 35 management 239, 535 R
Percutaneous epididymal sperm aspiration Postpartum hemorrhage 216 Radical
135 Potassium chloride 170 hysterectomy 318, 560, 579
Performing evacuation 387 Pouch of Douglas 461, 472, 541 local excision 378
Perifollicular neovascularization 446 Preabortion counseling 382 radiotherapy 274
671
 vaginectomy 586, 587 Route of ureter 41 Sex
vulvectomy 582 Routine chromosomes 90
Raloxifene 150, 612, 616 blood investigations 131 cord-stromal tumors 280
Rapid test for trichomonas 287 preoperative anesthesia evaluation 489 Sexual
Rectal strips tied in front of cervix 557 tests 487 abuse 372
Rectovaginal Rubbing mother back to stimulate oxytocin coercion 212
endometriosis 117 reflex 606 excitation 35
endometriotic nodule volume 119 Rubin/Leech Wilkinson cannula 650 intercourse 212
fistula 239, 423 Rubin’s test 133 maturation 66
septum 43 Rule of threes 488 maturity rating stages 64
Rectus sheet brought anterior 557 Sexually
Recurrent S infantile 86
Textbook of Gynecology

carcinoma of cervix 277 Sacral colpopexy for prolapse 601 transmitted

disease 359, 380 Sacrospinous ligament 43 diseases 240
endometrial carcinoma 278 Safe abortion 78, 382 infections 75
pregnancy loss 184 Saline infusion sonohysterography 442 Sharp container 639
Red rubber catheter 490 Salpingectomy for tubal pregnancy 168 Sheehan’s syndrome 92, 126, 217
Reduce menstrual bleeding and Sarcoma 376 Shirodkar
cramping 397 modification 555
of vulva 380
Regular breast self-examination 269 of Manchester operation 553, 590
Sarcoptes scabiei 248
Regulation of menstrual cycle 83 posterior sling operation 555
Savage syndrome 126
Relation of urinary tract and genital tract 47 repair 555
Scabies 248
Releasing intrauterine system 119 Sickle cell anemia 217
Scar endometriosis 114
Remnant ovarian syndrome 350 Sigmoid colon 42
Schedule of vaccination 317
Removal of midampullary pregnancy 168 Signal breast cancer 269
Schiller’s iodine test 265
Renal calculi 417 Sildenafil 618
Scissors 538, 652
Repair of perineal tear 534 Silicon mould 596
Screening
Reproductive Sim’s
breast cancer 269, 608
cloning 629, 630 position 14
cervical cancer 262
diseases 216 speculum 16, 648
gynecological cancers 262
tract infections 240 Sim-Huhner test 131
mammograms 269
Residual Simple
methods of cancer cervix 266
ovarian syndrome 350 glandular hyperplasia without atypia 331
ovarian cancer 267
tumor burden 341 hysterectomy 317
Second
Resistant ovary syndrome 90, 126 ovary cyst 345
generation methods of endometrial
Rheumatic heart disease 217 fibroid in uterus 647
Rhythm method 391 ablation 528 mononuclear cells 176
Right line antituberculosis drugs 261 Sinus
cornual ectopic pregnancy 166 Secondary bradycardia 495
fallopian tube malignancy 338 changes in leiomyoma 321 tachycardia 495
iliac fossa 470 dysmenorrhea 99 Sites of
ovarian infertility 123 endometriosis 114
artery 44 syphilis 242 vesicovaginal fistula 235
dermoid 470 tumors 183 Skene’s
Ring pessary 207 Second-trimester abortion 398 ducts 36
insertion 207 Selective glands 35
Ringer lactate 544 estrogen receptor modulator 150, 612 tubules draining paraurethral glands 42
Risedronate sodium 616 serotonin reuptake inhibitors 111 Skin edema 269
Robotic Self-breast examination 269 Small
assisted minimally invasive surgery 600 Self-retaining abdominal retraction 653 corpus hemorrhagicum 461
hand compared with human hand 602 Semen analysis 130 retractor 653
myomectomy 578 Senile endometritis 327 Soft
surgery 558, 602 Sentinel node biopsy 378 chancre 243
in gynecology 600 Separation of fascia from vaginal fold 552 sore 243
Role of Septate Solid
chemotherapy 340 uterus 192 adnexal mass 465
counselors 66 vagina 192 caudal tip of mullerian duct 50
hormonal agents 340 Serological tests 243 ovarian tumors 429
hormones 603 Serous vaginal plate 50
radiotracers 423 carcinoma 354 Somatic nerves 45
rehabilitation medicine in gynecology cystadenoma ovary 353 Sonohysterography 324, 429
practice 218 Serum Soonawala’s unilateral posterior sling
second look laparotomy 341 markers 117 operation 557, 558
surgery in metastatic disease 182 testosterone 66 Sperm mucus interaction 131
tumor markers 340 Severe Spermatogenesis 123, 135
X-ray in gynecology 416 dysplasia 306 Spermicides 394
Rotational rubbing 482 pain abdomen 160 Spindle shaped cells 35
Roughosities of vagina 206 Severely hyperstimulated ovaries 144 Spironolactone 613
672
Sponge holder 650 excision of transverse vaginal septum 190 Transperitoneal sacropexy 592
Spontaneous miscarriage 116, 158, 159 method Transvaginal
Spread of for ovulation induction ovarian repair 590
cancer cervix 315 drilling 137 sacrospinous colpopexy 590
uterine cancer 337 of termination of pregnancy 384 sonography 268, 329
Spring clip method 411 scrub 481 Transverse
Squamocolumnar junction 39, 262 Suspect invasive cancer 531 septum of vagina 89
Squamous Suspected vaginal septum 89, 284
cell carcinoma 353, 375 adnexal masses 541 Trapped ovum 126
cervix 316 ectopic pregnancy 384 Treatment of
of vagina 296 Swaged needle 510 cervical carcinomas 317
cell hyperplasia 371 Swyer syndrome 198 discharge 285

Index
epithelial cells 265 Symphysis pubis 35, 408 dysmenorrhea 99
epithelium 35 Synechial bands in endometrium 443 endometriosis 119
Staging carcinoma of cervix 313 Syphilis 241, 370 female partner 135
Staging of and HIV 242 gestational trophoblastic disease 180
cancer cervix 314 Syringes and cannulae 386 infertile couple 134
gestational trophoblastic disease 179 Systemic diseases 369 inverted nipple 606
ovarian carcinoma 355 male partner 134
vaginal T OAB 231
carcinoma 297, 298 Tamoxifen 612 osteoporosis 154
malignancy 298 TB vulva 371 placental site trophoblastic tumor 183
vulvar carcinoma 376 Technique of cleaning and painting rape victim 214
Standard abdomen 491 specific causes erectile dysfunction 134
bicarbonate 498 Telangiectatic vessels 461 vulvar squamous cell cancer 378
day method 391, 392 Telescopes operative instruments 543 Treatment plan
treatment of contraceptive-related Tertiary syphilis 242 for carcinoma of cervix 318
amenorrhea 93 Testicular feminization syndrome 89 of endometrial hyperplasia 331
Staple removal 506 Testosterone 97 Trichomonas vaginalis 247, 287
Stem cell colonies 633 biosynthetic defects 198 Trichomoniasis 247, 286, 301
Steps of tubal recanalization 575 Tests for Triphasic pill 402
Sterile evaluation of ovarian reserve 134 Triple layered endometrium 445
covering of abdomen 491 ovulation 132 Triptorelin 139
glove 485 Thelarche 65 Trophoblastic
Sterilization 25 Thickened irregular endometrium 333 cells infiltrate myometrium 176
Steroids 129 Thin-walled unilocular cystic 455 disease 174
Stitching after excision biopsy 520 Thoracotomy 182 hyperplasia 174
Stitching of Threatened miscarriage 159 pseudotumor 176
prerectal fascia 552 Three incision T-shaped uterus 193
pubocervical fascia 551 for radical vulvectomy 378 Tubal
sphincter 535 technique 378 abortion 167
vaginal flap 553 Three-swab test 519 ectopic 541
Strawberry cervix 301 Thromboembolic disease 504 metaplasia 302
Streptococcus pneumonia 61 Thudichum speculum 62 ostia 258, 433
Stress Thumb impression 213 rupture 167
incontinence 478 Thyroid Tubercular
urinary incontinence 226 disorders 91 cervicitis 301
Stroma 603 dysfunction 126 endocervicitis 301
Structure of Tibolone 150, 615, 617 salpinx 451
breast 603 Tissue holding forceps 652 vaginitis 291
nephrogenic cord 621 Tooth forceps 653 Tuberculosis 217
Subfertility 115 Total of cervix 18
Submucous fibroids 321 abdominal hysterectomy 559 of genital tract 660
Subseptate uterus with submucous fibroids fertility rate 390 Tuberculous endometritis 258
and polyps 439 hysterectomy 563 Tuisted ovarian cyst 548
Subserous fibroids 321, 448 pelvic exenteration 588 Tumor atrophies 321
Suction spinal block 494 Tumors 369, 372
evacuation 388, 518 vaginal length 204 Turner mosaic 90
machine 389, 519 Toxins 124 Turner’s syndrome 85, 90, 199
Suicide 26 Traditional Twin pregnancy 144
Superficial femoral nodes 45 and laparoscopy surgery 600 Twisted ovarian cyst 346
Suppression of lactation 606 vasectomy 412 Twisting polyp 523
Supraventricular tachydysrhythmias 495 Transabdominal Types of
Surgery of asymptomatic menopausal scan 455 absorbable sutures 507
adnexal mass 348 ultrasonography 268 androgens present in females 94
Surgical Transdermal patches 405 anesthesia 493
alternatives to radical vulvectomy 377 Transformation zone 313 cervical biopsy 521
anatomy of female genital tract 34 Transitional cell tumors 352 dysmenorrhea 98
673
 hysterectomy 559 prolapse 216 prolapse 505, 589
infertility 123 sarcomas 278, 337, 474 Ventricular
leiomyomas 320 Uterosacral ligament 43 premature beats 495
myomectomy 577 Uterovaginal agenesis 89 tachycardia 495
nonabsorbable sutures 508 Uterus 37, 57, 424, 632 Verrucous carcinoma 376, 380
pains 98 after vaginal hysterectomy 567 Vesicovaginal
polyps 331 didelphys 436 fistulas 234
spontaneous miscarriage 159 with double vagina 193 space 564
stem cells 626 Vestibular bulb 34, 35
vaginal discharge 284 V Vinule cap 395
Vabra aspirator 516 Virilizing ovarian tumors 96
U Vaccination 618 Virkud’s sling operation 558
Textbook of Gynecology

Uchida method 409 for HPV 317 Virtual organ computer aided analysis 444
Ulcus molle 243 Vagina 36, 131, 253, 531 Visual inspection using Lugol’s iodine
Ultrasound Vaginal application 265
leiomyoma 324 agenesis 89 Visualization of cervix 263
machine 424 atresia 89 Visualizing cervix 515
Umbilical cord blood stem cells 628 bleeding 66, 177, 322 Vitamin D and osteoporosis 153
Unaided burns 291 Vitiligo 367
colposcopy 531 canal 402 depigmentation of vulvar skin 368
visual inspection 265 cancer 19, 270 Vulsellum 649
Unicornuate uterus 421, 436 candidiasis 289 Vulva 36, 46
Unilocular cystic lesions 465 carcinoma 16, 294, 586 Vulval
Uniqueness of vulvar dermatoses 365 changes in puberty 64 infections 369
Unsafe abortion 78 cyst 292 stitches 550
Upper isthmus 40 diaphragm 395 Vulvar
Ureter 40 discharge 61, 286, 332 biopsy 519
Ureteral injuries 491 douche 530 cancer 270
Ureteric dissection 581 entrance 34, 36 carcinoma 375
Urethra 35 epithelium 204 lymphedema 367
Urethral flap malignancy 374
caruncle 371 advancement 284 melanoma carcinoma 380
catheters 651 separated 551 vestibulitis 372
labia 36 fornices 43 Vulvodynia 372
meatus 371 growth 15 Vulvovaginitis 61
openings 36 hysterectomy 563, 570, 571 in childhood 286
orifice 41 infection 286, 392
surgery 586 length 204 W
swab 289 metastatic lesion 178
Wallace ET catheter 143
vaginal and cervical smears for gram method 210
myomectomy 326, 578 Wearing of surgical gloves 484
staining 289
orifice 36 Weight-related amenorrhea 92
Urinary
part 587 Wertheim’s clamps 582, 654
and feculent discharge 285
bladder 40, 41 pessary 530 Whiff test 290
incontinence 220, 225, 227, 571 pool sample 132 WHO
retention 572 procedures 549 classification for ovulatory disorder 125
tract infection 224 septum 17, 521 scoring system 181
Urogenital sidewall retractors 530 Wider margins 586
diaphragm 43 speculum 530 Wilfred Shaw’s classification 203
sinus 50 sterilization 407 William’s
Uterine swab 289 operation 596
abnormalities 541 temperature feedbacks 112 vaginoplasty 190
anomalies 187 tubal ligation 411 vulvovaginoplasty 595
artery vault prolapse 601 Womb stone 322
clamping 566 Vaginectomy 586 Women’s morbidity 216
embolism 526 Vaginitis 291, 531 Wooden Ayre’s type of spatula 262
embolization 326 Vaginoplasty 89, 593 Wound
balloon therapy 108 Vaginosis 290 dehiscence and incisional hernia 504
bleeding in perimenopausal woman 332 Validation 8 infection 411, 504
cancer 332, 334 Valva boils 370 Wristed instruments 601
cavities 437 Valval agglutination 371
clamps 567 Varicocele 135 X
curettage 108 Varicose vein 15 X-ray of sella turcica 130
curettes sharp and blunt curette 649 Vas aplasia 135 XY gonadal dysgenesis 198
cycle 58 Vasa deferentia 412 Xylocaine injection 412
descent 203 Vascular disease in pelvis 445
endometrial cycle 59 Vault
Z
morcellation 569 cap 395
perforation 389 of vagina 531 Zygote intrafallopian transfer 144
674