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E .a
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WhiteKnightLove
61 C0andooh

hy
DK- CDohffine,d A CDan doot,
of Obst&ics
Hssistant pxofessoK _Gy necology
Hin 6hams Univexsity

www. DR-MaNDooH. coM

WhiteKnightLove
@)2013 by Dar El Atebba publishing and distribution
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^publishing
easily and sirnply, sowetry to do our best to achreve rhat missiot We save
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ptesent to the scudent andrcader
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Changes in investigations and reacment aterequired.
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to be rcliable in their effor* to provide information that is complete and
generally in accord wich the standerd at che cime of publication.
We would like to thank Dr.E[-Mandooh for that new edition of the book
and for the effort done in preparing that edition.
Nonechele ss/ we chank him for choosing us as the publishing house for this
valuab[e work, and indeed.

W e ar e pr oud. of puhLshingthis boo h.

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at..l'/alt,,,':$l -;l.q ttlirl FiJ

2013 / 4069
!sBN 978-977-637246-l

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WhiteKnightLove
 Contents
Chapter 1: Basic Science
Anatomy 3
Embryology 27
Physiology 39

Chapter 2: Endocrinology
Puberty 28
Menopause 31
Amenorrhea 36
Anovulation-PCO 46
Abormal bleeding 56
Dysmenorrhea 64

Ghapter 3: lnfertility
Etiology 68
Assessment 71
Treatment 76
Assisted reporoduction 80

Chapter 4: Gontraception
Physiological 84
Mechanical 85
IUCD 86
Hormonal contraception 90
Surgical sterilization 97

Ghapter 5: lnfection
Vaginal discharge 100
Sexually transmitted disease 102
Vulvovaginitis 107
Cervicitis 110
Pelvic inflammatory disease 114
Chronic granulomatous disease 119
WhiteKnightLove
My 2 Aims in this book to be SIMPLE and COMPLETE, so I

save no effort for doing that.

It is hoped that the readers will find this book, presented in
4 volumes (GYNECOLOGY A means volume I ), a useful
source covering their necessary basic knowledge of
GYNECOLOGY AND OBSTETRJCS.
Your feedback and suggestions will be valuable to us, so we
hope to contact us on Email or website
MANDOOHM@HOTMAtL.COM
I^,MIWDR-MANDOOH.COM

Dr Mohamed Elmandooh

WhiteKnightLove
 A.^,..tovwV
€,trbryology
PLy=Lologv

WhiteKnightLove
 ?/rernln/? r4

Peritoneum (sercus layer)

Cornu

Anatomical internal os

----'----- Histological internal os

- Arbor viae ureri

lateml fornix
Excernal os

VaSina

Uterus
B lodder

..fornix
Anterior
Vogincfz fornix

Sogittol Section. Nor" onterior

t
ond posterior wolls normolly in
contoct, olso onterior ond posterior
forn i ces .

Nulliporous os Porolrs os

Supo-
voginol
rtion
The cervicol conol is
fusiform qnd morked by cu-
rious folds colled ihe iorbor
vitoet.
The cervix is divided
into supro- ond infrovoginol
porfions by the ottochmenfs
of ihe vogino. The infro-
voginol port is olso colled
the rportio voginolisr.
WhiteKnightLove
O^,o.tov*.yv A3lpllea3 s.Batr*v ffi

) Structure
- Hollow pear shaped muscular organ
- Dimensions :3x2x1' but (3Vz x2Vzx l7z in multi-gravida)
- Weight :50 gm but (70-80 gm in multi-gravida)

) Psrie

l. Bodv (corpus uteri)

o Upper Tb --r 2 inches
n Junction with tubes is cornu,part above insertion of tubes isfundus
* Peritoneum d adherent, covers it completely
$ antniort uterovesical pouch (between bladder & uterus)
z: Douglas pouch (behueen rectum & uterus)
*
, Outer longitudinal. ...modified as pace maker of the uterus
. Inner circular...... ...modified as sphincters in 3 sites
oblique /.. ..makes 8 shaped figures around vessels
*
. Columnar epithelium (partially ciliated)
. Glands (simple tubular), stroma & blood vessels
. Sensitive to E & P cyclic changes (endometrial cycle)

2- Cervix

o Lower 1A I inch
o Peritoneum -+ cover it only posteriorly
o Muscle layer - mainly formed of fibrous tissue (ms: 10% only)
o Cervical canal -+ fusiform with^
* internol :34 mm
o
2 os
externol : rounded, becomes slit shape in MP
o

* 2 Pafts
- Part projecting in vag. 4 portio vaginalis (lined by st.sq.epith.= ectocervix)
- Part above v4gina O suprovaginal part (lined by colum, epith =endoceruix):
lb mucosa is thrown into folds into rartrich racemose glands open
* 2 junctions
- Sqnamocolumnarjunction (TZ) between ectocertix & endocervix
- Histological internal os + between endoceruix & endometrium

WhiteKnightLove
 Physiologicol

Blodder

Cervix

Pc lv ic
' Brim

Blodder
--.Cewix beginning to oPen
. Ndool onus

SogiEo, sedron offie pdvb, wrdr dre womon h the ercct Position

WhiteKnightLove
 I
Basic Science

3. lsthmus

n 3-5 mm
n Between atomical internal os above and Histological internal os below
n Covered by loose peritoneum
o In pregnancy forms -+ the bwer uterine segrrent (10cm)
o It differs from the upper segment in o

Upper seqment Lower seomenf

Feritoneum Adherent Loose
Musde Thick gta Thin
Decidua Well develooed Less developed
Membmns Firmly adherent Loosely adherent
o
Action Active in labor Passive
(contracts & retracts) (dilates &

o Phvsioloeical retraction rins

It is a groove between the thick UUS & thin LUS below
the symphysis pubis. Normally it is not seen or palpable

Q Blood supply of uterus

(Outerine artery ,/ .......branch from internal iliac artery (ant division)
@ ovarian artery.. .. .. . ...branch from aorta (atL2)

Q Relation bel. body & cx W

Corpus Cervix
lnhoutorine llfo I 5
lnhntlle I 2
Prepubertol I I
+ AdulE / 2 I
IVlenooouse Comus shrinks > cervix

) Norrnql positlon of fhe genitql sgsteh

* FnteVersion ? whole uterus is inclined forward on vaginal axis by 90o
\due to tension between uterosacral & round ligament o
* llnteElex:igO # the body is bent forwards on the cervix by 160-170'
\due to the tone of the uterine muscles '
. In 20 % of females the uterus may be.rfl/ormallg retroverted -+ RVF
* €rternol os lies normally at I above the level of the ischial spines
* Vogino is directed upwards & backwards forming 45-60o with horizon

WhiteKnightLove
Rrboc€ryical llgament

gh',
pouch

Thefuomc,tB'of tE @tx

Round

Tronsverse i-Tronwerc
cervicql
ligoment

Pectum

WhiteKnightLove
) SuDDorts of ths uterus A
- AVF position
- Peritoneal attachment
- Position of the surrounding viscera
- {/ lJrm,ne UcA}tENTs (Tnus Orrrw) " rl. * I*gt,AToR ANt O

> Uterlne ligprrrents

AI
'r Fold of peritoneum between latsaluterine border & lateral pelvic wall
Contents (all are present in loose CT; the parametrium) @
- Upper border: (medially -+ F.tube, laterally + infi:ndibulopelvic lig.)
- Uterine & ovarian vessels
- Vestigial remnants (epoophron, paroophron, Garfirer duct)

BI
I From uterine cornu througfu inguinal canal to insert n labiq majora
. Raises a ridge on the anterior (inferior) layer of broad ligmrent o
r Important to maintain anteversio
I Supplied by Sampson a. (ftom ovarian a.) & br. from infedor epigastric a.

Cl (hnrian lioament + fromuterine comu to ovary

A] ,4 Pubo-erylcal lig. (pubo-cervico-vesical fascia)

B] + llad<enrcdt llg., cardinal llg., tansverce u llg.

. Strong, fan shaped ligament
r From lateral part of cx & upperpart of vag to lat. pelvic wall(white line)"
. The ureter passes through it (in the treteric canal) "
. It forms the base of the broad ligament

CI + uteromcral llg.
r From back of cervix to middle sacral piece
r Formed of 2 pairs (swrounds the rectum)
r THE oI{l-Y TRUE li&; "
(others are condensed CT, smooth ms, elastic fibers)

WhiteKnightLove
lnterstitiol port lsthmus Amsdjs nfundibulum 2cm
lcm long ond 2cm long, stroight 5cm long, thin long. The terminol
very nqrrow ond cord-like. wolled ord exponsion, with
(less thon lmm). lmm diqmeter. convoluted. briol process€s
\ I
\
which help
I to ottroct
the ovum

{1t
l,:t

*. ovorium
,",rr\ ll ,

WhiteKnightLove
 I
Basic Science

- Fallopian tub€s -
. Length -+10 cm ( inch)
. Extend from the cornu to open at the infundibulum
. Present in the free border of the broad ligament
) Perts lntsrdltlal

. Largest fimbria is called fimbria ovarica -+ important for ovum pick-up

. The utero-tubal sphincter is found at the tubal ostia to:
- Prevent retrograde menstruation into the pelvis
- Delay the fertilized ovum for 3 days (till maturation)
> Lsuels
o
' Peritoneal covering + complete except the interstitial part & a narrow
strip opposite the attachment to broad ligament
. llluscle -+ inner circular & outer longitudinal
. Endosalpirx -+ thrown into folds. Cells are columnar partially ciliated,
partially secretory !peg cells (immature orreserve cells)

> Blood suDDlg 4 uterine & ovarian vs (double supply .'. tubal gangrene is rare)

- Ovarg -
> Posft,oh
. Lies in the fossa ovarica (a depression in the lateral pelvic wall)
r The ureter & int. iliac artery are passing longitudinally behind it
a @onneded to back of broad ligament by mesovarium"
t @onneded to uterus by ovarian ligament
) Qonneded to pelvic side wall by infundibulopelvic lisament
> Size almond shaped + 3x 2x I cm (5 gm)
> Strucfure
. Hilum + vessels, lyr.phatics, nerves enter & leave through it
. Medulla -+ vascular CT stroma. ....small in size
. Cortex -+ follicles, colpus luteum & albicans. .. . . .main compartment

> r Tunica albuginea + coelomic cuboidal epithelium /

Covercd bu
\ Previously known as germinal epithelium,X
\ Ovary is Not covered by peritoneumo 'to allow ovulation'
> Blood supDtg ? ovarian artery
o
> LgmDh drqinsge # paraortic LN

WhiteKnightLove
 Urethri i* Rstrum

Lolerot View. Notc lhc clocc rc-

lotionship lo urcthro, blodder ond
recfum.

- Posferior fornix
nterior fornix
--Ureter

rigone
blodder

Loterol ,-(\
fornix
I /-- Vogino

WhiteKnightLove
> StructuDs
. Elastic fibromuscular canal extending from vulva to uterus
. The orifice is partially closed by hymen in virgins
. Cervix projects into the upper part of anterior wall -+ 4 fornices o
Anterior shallow..........Posterior deep.........2 lateral fornices
( .'. the anterior wall is 8 cm while posterior wall is lO cm o
> Relstlohg
o Ant. # lower 7a: (urethra).........upper45:. (bladder)
o Post.a (lower 7s: perineal body)...(mid 7s: rectum)...(upper 7s: D.pouch)
o lrat. 62 ureter.....levator ani & ischiorectal fossa....Bartholin gland

> Wsll
a turo umlls (anterior + posterior) opposed to each other (potential space)
- transverse section. .....O.....H-shaped
- longitudinal section....o.....Flask shaped
t l)'luxle --+ 2layers (outer longitudinal, inner circular)
. Epkhellum (mucosa, vag. skin)
lI Stratified squamous epithelium non-keratinized
2I Thrown into folds (rugae + allow distensibility)
3I No glands / o

t Secretions come from O cervix @ vag. transudation O Barttrolin

* Except after maternal exposure to DES a vaginal adenosis

4l Glycogen rich, E dependent -+ t thickness +t glycogen + tacidity

(through Doderlein bacilli : pH 3.5-4.5) -+ protective effect

.After puberty &, in nar,rborn (maternal E) -+ thick + tglycogen * acidic

.Prepubertal & postmenopausal + thin * no glycogen + alkaline
> rich...... r-
Btood eupDlg......relg
o Uterine -+. circular artery of cervix + ant. & post. arygous arteries

o rnternar *;:"":,T#T frilfi*:#il$:1?'1f,'.? 1,..,

o Internal pudendd -+ inferior rectal artery
> Nwe suDDIg a upper part (insensitive)............Iower 7+ -+ (pudendal n)

> LumDhsttsea upperpartwith cx......... ......lowerrh withvulva

> Vsglnqt suDDolt o attachment to cervix. .. ...cx ligaments ... ..levator ani

WhiteKnightLove
 Thewlvo of ov*gin

-,--* -- PrepG -l
-L----Glm fofCllrcrts
\- '' FrorIm I

+-- Vhrtlbulc

Hylm

Fordrue

ons pubis

j- -- Prepuce

-- C litoris

- Fourchefte

Bortholinrs glonds

WhiteKnightLove
1-Mons Publs (mons veneds)
o Pad of fat covering symphysis pubis -+ act as cushion during intercourse
o Covered by inverted V hair, while in male -+ apex may reach umbilicus

2-Lqblq mqloro (abium maius)

o Two longitudinal elliptical skin folds, extending:
-
Above -+ from the mons pubis
-
Down + join together posteriorly atrhe posterior commissure
o Formed of:
- Skin (keratin + hair follicles * subcutaneous fat) "
- Sweat (apocrine) glands -+ secretions with ccc odour
o Occasionally they contain can"af of xurL" (ufold of peritoneum)

3- (nymphae)
Lqblq mlnorq
o Two skin folds enclosed within the labia majora, each one will
-
sPlit.antedrorlvto enclosifff'Yiil
prepuceanteriorly
. The lower flap will form -+ the Frenulurn posteriorly
- Join together posteriorly to form -+ lhe@.
o
The depression between the fourchette & hymen is
present only in virgins & calledfu$s navicular!!
o Formed of
- Thin redundant skin (no-keratin + no hair follicles + no fat) o
- Pink colored -+ vascular connective tissue
4- Clttorls
o Length o21cm longo...... ...2-3 cm above urethra "
o Def . 4 v. sensith,e (t nerye supply) erectife (2 corpora cavemosa) tissue
o Parts 4 Etans (between prepuce & frenulum)......6odry.....2 crura

5- Vestlbule
o The area o within the two labia minora) It receives the openings
of:- - External urethral meatus
- Vaginal introitus (orifice)
- 2 Bartholin ducts

WhiteKnightLove
 Sup€.trdal dbre.don
Deep€r dbractton

lschlmlcmosus rude
Sphlncter ui€dtru
qtcf,tc

&rlbomnosumwle
t/e*ibullr bulb

Superf,ci.ltansffi Deep tmnwerse

pcrincal mslc
perlreal mscle

lshhl albcGlry
Bartholin's ghnd

Fat in lschiorurtal foE$

Lrtttor ill
Sacrooicous l[amett

Glccus ma{m SphhcGr ant oc.mus

Dbsecdon ofdre peaprm od',tttrcag,'fMrrusdcqfieposdon orgaidmh,sgrord

ondthe reffdor brrD.

Normol Hymen ofter

v irg in coitus (or ofter
hymen using tompons)
Corunculoe
myrtiformes
Bulbospongiosus
muscle (cut)
l

Bulb of
zvestibule

-- Bortholin ,s

g lond

WhiteKnightLove
6- Vestlbulsr bqlbs
o Two small collections of vascular sponry C.T.
o They lie on either sides of vaginal opening -+ act as a cushion
o They are continuous above with the clitoris
. They lie deep to balbo-sponsiosus muscle
7- Exlemcl urethrsl tnestus
o The female w€thra is 4 cm long o
o Urethra is lined by transitional epith.....the ext. meatus -+ st.sq.epith o

o Two paraurethral glands @ae_ry\@ open in its floor 1 cm

before the extemal urethral meatus

8- llsmen
. Thin membrane partially separating vasnal orffice from restbule
- FormedII of e CT lined on both sides by statified sq. epithelium
-
Types'o cresentic, septate, cribriform, annular /,lmperlorate X
o Afler deflorotion (lscoitus) + slight spotting (relatively vascular i)
o After lobor -+ remnants are called: caraunculae myrtiformis

9-
o ilo: . One on either side of the v4gina
o
. Embedded in the posterior 7s of the vestibular bulb

o *ry&nc
- Sizo of a pea (nonnally oan't be felt except if infected: abscess)
- Compound racemose glands, Its duct is 2-3 cm long + qpens
on either side ofthe vagrnal introitrs (5, 7 o'clock)
c Puncllon: alkaline vaginal secretion for lubrication during intercourse

stood'ouppt+" o
: I#:i,'": ,:.ilH#ffi'#'"?rnar pudendar)

,tv ewe ouoPw

o
4 __!:|;:f *
:ts.:Tff;ff"o,
1. Perineal br. of lat. & post. cutaneous n. ofthigh
2. Ilioinguinal, iliohypogastic
3. Genital branch of genitofemoral n.

2,Wpftalic6 + as in cmcer vulva: groln lll (inguinal & femoral)

+ each side drains to both corresponding & opposite LN, then
4 external iliac -+ common iliac + paraortic LN
WhiteKnightLove
 lnorsrithl pan of oDe

lnfundlbulo
pdrlclEilGtt

C.nl-d+rc
(dDot$s) t t rosacnl lE rolt

ThG lmoh p*vlc orgorF ir,,^dfio,n hd,t,'d, Onthebftthe od<hrEord tory orcbtthe pGitin ltundh dlo;oo dte 7,8rtr
dsedion hos becn mode'

?noslonoeis
urith I
ovoO'Alt

d.,p
doirl
.crd}6l
4liu;

- Pudendal
Risht
ovorlon
vein -----

Ovorion <(
orteries

lnlerior -'
mesenieric
orlery
in[. t.ta{1.
Labi.L porio..l

WhiteKnightLove
 Basic Science I
- Blood supplu of Pelvis -
> Internal iliac artery " OO
Antodbi dtoehn
l- Visceral
* Uterine l-Ilio-lumbar
* Superior vesical (obliterated umbilical)
* Inferior vesical (vaginal) 2-!atenlqacral
* Middle rectal (hemorroidal)
2- Muscular branch (obturator) 3 erior gluteal
3- Terminal branches (inf

NB - Superior rectal a. a continuation of inferior mesenteric artery

o

- Inferior rectal a. e a branch of internal pudendal artery

Uterine artery
o The main vessel, a branch from the anterior division of IIA
o They are tortuous (to allow uterine expansion during pregnancy)
o It runs mediallv to cross above o the lower end of the ureter
lateral to the supravaginal part of the cervix
o Then it tums upwards at the lateral border of the uterus
within the leaflet of the broad ligament.
o Branches:
. To the ureter
. Circular branch -+ to the cervix
. Descending branch --+ to the vagina (cervico-vaginal)
. fucending branch -+ gives arcuate (coronary) arteries
.'. the midline of the uterus is the least vascular
Radial arteries arise from the anterior & posterior
arcuate arteries to perforate the endometrium. They
will finally divide to
l- Basal artery....supplies basal parts only
ies the more
. Finally, it anastomoses with branches of ovarian a. at the cornuo
Ovarian artery
o Arises from aorta at L2 (iust below the renal artery) '
o At the pelvic brim, it crosses the external iliac vessels & enters
the pelvis in the iryfundibulo-pelvic ligament to reach the
mesovarium and enter the ovary through the hilum
o
o Left ovarian vein --+ drains into the left renal vein
o
o Right ovarian vein --+ drains into the inferior vena cava

WhiteKnightLove
 Foscio
wiih
nerves

Vossels

- Peritoneum

,'^.. 'Urogenitol
'.. trionclc'
lschiol
tuberrosjtt
f

Socro- \
Uterosocrql tvberans
ligoment ligoment -,1 .

Levotor oni

l/::: '
Oblurolor
internus

Ischiorecta I

fosso --
Urogenito I
of
The ischiorectol fof is diophrogm -
trqversed by the pudendol
vessels ond nerves ond some shows ihe relolion-
smoll perineol bronches of nd pelvic floor.
socrol nerves.
This pod of fot supports
fhe onol conol ond pelvic
diophrogm.
Perineol body lsch iocovernosus

Tronsversus
\ \r
- -Bu I bospong iosus
perinei
su perfic iqlis Urogen ito I

Y. diophrogm

Levotor oni

-- Coccygeus

WhiteKnightLove
[ll Pstu,c De]itoheurn
- It extends from over the bladder to the Uterovesical pouch then
over the ulerus then to the posterior surface o of cx &
o
vagina (Douelas pouch) then to the anterior surface of
the rectum (lower 7e of rectum not covered)o
- Lxerally + the two peritoneal folds form the broad ligament

[2] The peluic fqsclq

> It is divided into 2 parts
r Parietal fascia tr+ covers the muscles of pelvis
r Viscerd fascla,+ endopelvic fascia, pelvic cellular CT
> This fascia forms certain strong condensations
. Cervical ligaments (3)
r At the base of broad ligament,,+ parametrium
. Around thevagina,.r paracolpos
r Between the vagina & rectum,,+ rectovaginal fascia

[3] Pelvic dlephrqgm

> A fibromuscular sheet which supports pelvic contents
> It extends as a diamond shape from the lower border of SP to the
2 ischial tuberosities till the tip of coccyx
> It is composed of (2 levator ani &,2 coccygeal muscles) & their
supporting fascia (superior & inferior pelvic fascia)
> It is divided tnto 2 triangles
- The urogenital triangle (diaphragm).....anterior
- The anal triangle..... .. ...posterior

[4] Perineurn.., 2 .5 cm
> The area extending between skin (below) & the pelvic diaphragm (above)
> Divided into 2 pouches (superficial & deep) separated by a perineal memb
o Perineal body
- Fibromuscular pyramidal condensation
- Lies between vagina & anal canal
- Formed by decussation of 8 muscles
o Ischiorectal fossa
- Wedge shaped space on either side of anal canal filled by fat
- Boundaries
. Superior & medially -+ levator ani
. Lat.-+ obturator ms & fascia (splits to form pudendal: Alcock's canal)
. lnferiorly + skin

WhiteKnightLove
 Left uBrine
Cut ed$ o, artory
parltorcum

Venous plexus

ReGum

CuFde.ec

: --- Pubo-urclhro,lis

- -- Prbo-vqeinolls

+ P,.bo- reetalis

WhiteKnightLove
 . Origin: From back of S. pubis & anterior part of white line
(a thickening in the obturator fascia)
. Insertion:
- Side walls of urethra + Pubourethralis
- Side walls of vagina+ Pubovaginalis (fibers of Lushka)
- Side walls of rectum + Puborectalis
- Tip of cocclx & anococcygeal raphe -+ pubococcygeus proper
$ lfiococsvaeus
r From white line to perineal body, anococcygeal raphe & coccyx
> lscfiiococclrscus
4*
-l+t
From ischial spine to coccyx & sacrum

Nerve supply
* Pudendal n. Szsr -+ perineal surface (covered by inf. pelvic fascia)
* Branches of Ssl roots -+ pelvic surface (covered by sup. pelvic fascia)
Function
- Support ofviscera
- Maintain intrabdominal pressure
- Sphincter to urethra, vagina & rectum
- Important role in labor (rotation)

O The femorol tN (longlUdlnol)

- tuperfrcicl.....along the saphenous vein
- Dnup.....along the femoral vein (esp. LN of C/o4uet: in femoral canal)
9lhe lngulnol tN (tronwetso)
- EuyrftclqI.....below & parallel to the inguinal ligament
- Deep.....present in the inguinal canal
0The <ervlcol [N
- Paracartica[ + Darafietrlat + Vrelanc * Presacra[
OThe llloc [N
-lnternat itiac... ....along internal iliac vessels
-E;xlrrna[ illac.. 2-AvrnnroR, 3-MEDIAL, 1- LATERALgroups
- Obturator (interitlacl.. ....near the obtrnator foramen
- Conrmon i[iac.. ....along the common iliac vessels
6The porooltlc tN

WhiteKnightLove
 Pooton oilmry

AffidlubEfth

tbm]try
(twhudu.c)

Trigone of

-From renol ortery

------- From ovorion ortery

Ureter------
infernol ilioc ortery
,From
Commonilioc Frorn uterine ortory
Uterus --_ ry
// ,,
z/ voginol ortery
-..Frdn
"*-'- - -'From vesi col ortery

WhiteKnightLove
 Basic Science 11
r
- Pelvic Uneter -
Cource (10-lScm)
'k The ureter enters the pelvis by crossine the bifurcation of the
common iliac artery.
* It then passes downwards infront the internal iliac vessels to become
medial to them & behindthe infundibulopelvic ligament & ovary
* Just above the level of the ischial spine, it curves medially &
forwards to pass through the ureteric canal (in the Mackenrodt
ligament) till it reaches the bladder trigone
t It is crossed by the uterine arterJt o at the base of the broad
ligament. Here the ureter is 2 cm lateral lD et & 2 cm above
vaqinal vault

As it pesses sltnmt nelr to ell genttel structurer

Thic is due to close ernbrgologlcel origin e.g. during:- @
- Hysterectomy (abdominal or vaginal)
- Pelvic lymphadenectomy
- Bilateral intemal iliac artery ligation
- Adenexectomy (removal of ovarian swellings)
lnlury is incrcssed ln
- Distorted anatomy
( Congenital -+ malformations of the genital or urinary tract
6 Acquired -+ cervicalfibroid, broad lig. swelling, extensive adhesions /
- Rapid blind clamping / to stop massive bleeding

. Pre-oDerative ,+ IVP
. Intra-operative
- Proper identification of its anatomical course
- Clamping must onlybe done under vision
- Clamping must be near to the uterus
+
lnlury mov be
- Direct + cutting, crushing, suturing
- Indirect --+ devasculaiz.ation in radical hysterectomy / post-radiation
'Leods lo
- Hydroureter --+ hydronephrosis + renal atrophy
- Fistula formation

WhiteKnightLove
 Pudendol
'.-'--orlery

/
tiI lsch
t.
, sPrne

inside ischiol tuberosity

..'',u \
| 7n:

-."*t...
Piriformis 52 z ,/ 'l//h
^1
muscle

\i

WhiteKnightLove
lVlognlUde of the problem
o It means all procedures that involve partial I total removal of
external genitalia for cufturaf non-tfierapeutir reas ons
o It is still practiced in Egypt, Sudan (tradition? African? religious?)
o It is totally condemned by WHO; practiced only if
* Cosmetic (chafing: roughness)
* Simple hypertrophy of labia minora (dyspareunia)
* Nymphomania

IUHO closslflcotlon
.
TVPe I,+ excision of part (prepuce) or the whole clitoris
.
TVpe ll
".) as above + labia minora
.
TVPg lll "+ excision of all external genrtalia+ narrowing of introitus
(Sudanese circumcision, infibulation)
.
Typo lU ,,+ unclassified e.g. piercing, tattooing

Compllcotlons later on
oo . Severe pain . Psychological, sexual troubles
. Hemorrhage, infection . Recurrent UTI
. Injury to urethra . Retention dermoid cyst
. Obstructed labor d.t. fibrosis

* Uterus, cenix, upper vogino,.+ outonomic:

l -Svmoolhelic Tt -+ Lz
Postaganglionic fibers pass in the (superlor byoo€astclc
olexrs) over the promontory of sacrum & divides into O
right & left presacral nerves (on both sides of the rectum)

2- Porosvmoolhetic Sz,s. +
Preganglionic fibers (9 Pelvic / Splanchnic) pass along
with the pudendal nerves + relay at ganglia in or near
wall of viscera
*NB
. Thepelvic placus (loferlor hwo€astrtc plexus) : O + I
. The cervix is only sensitive to dilatation
. The body is only sensitive to distension
. Vulv4 perineum,lower 1/+ vagina'+ all somatic

WhiteKnightLove
 Spinol cord

of

WhiteKnightLove
€,-,bryology

* lntrc-uterlns
. The primitive gem cells appear in the wall of yolk sac (near the
hindgut) at the 3'd week. These cells migrate along dorsal
mesentery to reach the genital ridge (which is the medial thickened
part ofthe urogenital ridge)
. Germ cells t
will markedly in number by mitosis to reach a
ma)dmum of 6-7 million at the 20u week. Then mitosis stops
and the oogonia will start the 1$ reduction division (meiosis) in
which they will be arrested in prophase
r An out-growth from the surface epithelium into the substance of the
ovary will form the sex cords, while some cells from the
mesenchyme will form the sex stoma
- The setc cords erwelop the oocyte toform the sranulosa cells
- The sex stroma will form the theca cells (as an outer layer)
6 Rt blrth
A large number of lv follicles will be lost in intrauterine life by a
process of apoptosis (programmed cell death). Thus, follicles are

* iftor puberty
A certain number of primordial follicles (400-1000) in each cycle will
resume meiosis. Only 1 will become fully mature (the dominant
follicle) ,+ lry oocyte + l't polar body, while the remainder will
undergo atresia. izatlron, the 2"d meiotic division (mitotic
occtr
like) will e + a2n polar body
* Formotlon of llgoments
o

The lower part of the genital ridge becomes "gubernaculum",

which gains attachment to the cornu of the uterus:
-
The upperpart of the genital idge e lntundibulopelvic lig.
- Part between the ovary and the uterus ? Ovarian ligament
- Part between the uterus and labia majora d Round ligament
* fhlgrctlon (doscont 0 ) of ovorles "
Descent ofthe ovary into pelvis is d.t. unequal body growth (tnxtk
) rest of the body) &. not hormone dependent (unlike the testis)

WhiteKnightLove
 - -iesonephric
Poro-

groovc
I
I

I
bocomes

i
I

Porq-
mesonephric
' ducl
gonad

--
-Mesonephric
ducl

Mesonephros
tI ro,

Testis

bonod S$toli
6lls

ducl
---Mesonephric Molb.ian
-- -Ureter lnhibltor
8e
--cloo"o

M0floIiil
cgr$ion

i/tal€ dffdmlhuon.

Foll6pion or Developing
-- uterus
// Mu llerion
r.)

Dege .--
*i: -
oting
tubercle
mesonephric
duct (becomes '--.- \ rogenitol
Gortnerts duct) sinus

WhiteKnightLove
* In Males
. The WoWan duct (mesonephric) develops under effect of
SRY: Sex determining Region of Y chromosome)
( testosterone production from fudlg cells
. The Mullerian duct (para-mesonephric) regress under effect of
MIF o (Mull. inhibitory factor): AIVIH (anti-Mull. hormone)
( produced bySerof cells in testis
. o
Vestigial remnants rruy be found between the 2 layers of broad lig &
o
may leadto formation of large (paraovarian / br.ligamentary) cysts
l. KoBLET TUBULES '+ at outer part of broad ligament
2. Hvoern oF MoRGAGNI ,* rroar tubal fimbria
3. EpoopnnoN,+ between ovary & tube
4. PenooptnoN,'+ between ovary & uterus
5. Gennrcn DUCT "+ runs medially below the tube then -+ lateral to
uterus, cx, vagina -+ ends at the clitoris (forms Gartner cysts)

* ln Females
. lndifferent stage:
The Mullerian duct develops in the lateral part of the urogenital
ridge as a longitudinal invagination ofthe coelomic epithelium
. Control
- Absence of AMH + Mullerian ducts persists
- Absence oftestost. + Wolffian ducts ureteric bud)
This means........femininity rs the Nnumel state
& masculinity is the superimposed character "
Further developnrcnt
- Mullerian duct passes downwards & curves medially to fuse
with the opposite duct in the midline. Then, absorption of the
intervening septum will occw from below upwards
- The horizontal unfused parts form ,+ the fallopian tube
- The longitudinal fused parts form,+ the uterus, rrpp". * of the vagina
- "*,
The lower end of Mullerian duct will project as a tubercle into the
urogenital sinus to form a solid vaginal plate
- Canalizatron ofthis plate (20wks) will form,+ !W.)6. ofthe vagina
- Junction between the Mullerian duct & urogenital sinus,,+ the hymen

WhiteKnightLove
 - Ureter

itoris
C loocol-
- C I
membrqne septum
:.'!- Lobium
j-, --- moius

Ureter

Hind guf
Genitol
tubercle
Z Urogenitol
slnus

Urogeniiol
-, G lons penis Urogenitolz
sinus. Primitive membrqne
\\ --
urethrcl Anql membrcne'
groove
scrotot>a

WhiteKnightLove
 Basic Science 15

O lpevelopneot of tbe exteroal geoltalta

. At outer surface of urogenital sinus: 5 mesodermal swellings appear:
1. The genital tubercle (phallus) ,,+ clitoris
2.The Two urogenital folds ,+ labia minora
3. The rwo genital (labio-scrotal) swellings ,'+ labia majora
. Control
- IN MALES: Testosterone (by Leydig cells) -+ DHT (by 5o reductase
of prostate) -+ masculinization (enlargement &fusion)
- IN prulLBS: absence of testosterone -+ feminization

. Cloaca
- The urorectal septum divides the cloaca (5-6 weeks) into
.2 compartments: rectum & urogenital sinus
.2membrarres: anal & urogenital membranes
- The outmost part of the urogenital sinus forms -+ the vestibule

firwl wofiucts Female' Male "

Gonad Ovary Testis

Infundibulopelvic lig. Gubernaculum
Genital ridge
Ovarian lig., Round lig.
Mullerian duct Tubes, uterus, cx, Regress by MIF
(para-mesonephric) Upper f o{vggi5ra + remnants

Wolffian duct * All regresses except Ureteric bud

(mesonephric) * ure-teric buds &- trigone ." Fptdidxt:p, pj-ep, ng-t
Cloaca:
- UrogenitalEI
. Lower /s of the vagina . Prostatic utericle
>tnus . Seminal colliculus
. Cowper's glands
(bulbo-urethral)
. Urethra & prostate
. Bladder
- Analcanal + anus
o
Ext. genitalia
1l Genital tubercle - Penis
2l Genital fold - Penile urethra (ventral)
3l Gen. Swellins - Scrotum
kidney Pronephros -+ -& [esonephros -+
o
Metanenhros (the oe rmanent kidnev )

WhiteKnightLove
Ununited

of blodder
Floor of
urethro

The
vestibulor
onus

WhiteKnightLove
 Basic Science 16

,..... Co ng e nital t*alfo n t*atio |tc ......

(l External genitalia <DO
> Ambiguous genitalia (intersex)
>Clitoris .Elifid......ossociotad urith ectopio vesico
.Hypertrophv (clitromegaly)...isoloEed or port of genarolizad virilizotion

> Labial hypedrophy......dysparuenia or disfigurement -+ labial reduction

o......cong. or
>Labialadhesions acquired// (infactionorpost-menopousol)
TTT -+ simple surgical separation + local estrogen o
> Vestibular anus

@ Ouaries
> Aplasia & hypoplasia
- C/O -+ amenorrhea, infertility
- Diagnosis -+ see amenorrhea
- Treatment -+ HRT by cyclic E & P. pregnancy is impossible
> Dysgenetic ovaries e.g. Turner syndrome
- C/O -+ lry amenorrhea, no 2ry sexual characters
- Diagnosis:
't Phenotype -+ characteristic
* Karyotype -+ 45xo or mosaic: 45xol46xx OR 45xo/46xy
* Ovaries -+ streak (fibrous) gonads
- Treatment: HRT. Pregnancy is impossible
> Accessory (supemumerary) ovary + no complaint (found in br. lig.)
> Abnormal descent -+ very rare (the ovary found in high position)

O Fallopian tubes
> Aplasia -+ infertility (+ aplasia of uterus)
> Hypoplasia -+ short, tortuous, narrow -+ infertility, ectopic
> Accessory ostia / diverticulum -) infertility, ectopic

@ Cervix
> Cervical atresia
- CiO -+ cryptomenorrhea & cyclic lower abdominal pain
- Diagnosis -+ inability to introduce sound
- Treatment -+ dilatation, lf failed -+ hysterectomy !
> Patulous interna! os O habitual abortion
> Congenital elongation of portiovaginalis
- C/O -+ dyspareunia
- D.D. --> prolapse
- Treatment -+ amputation if symptomatic
WhiteKnightLove
cervices.

WhiteKnightLove
O Uterus h
) Aplasia: lv amenorrhea, infertility
> Hypoplasia
* Types: known by uterine index a Conponrru length / (Cenvrcnl length x 2)
'
Rudimentary (very small solid organ)
:
Infantile (body : cervix I :2)
'
* clo
'
Pubescenf (body : cervix = 1 : 1)

- Amenorthea or hypomenorrhea
- Infertility or habitual abortion (in ascending manner)
* Diagnosis of uterine diseases o

1. History 2. Uterine sound

3. Ultrasound (pregnant or non-pregnant)
4. HSG /
5. Hysteroscopy /
6. Laparoscopy
* Treatment
- Non-pregnant -+ cyclic E & P to t uterine size.....$
- Pregnant -+ cerclage
Fusion defects @

l- Ulerus dldelphyr e 2 bodies, 2 cervioes,2vagjna(vaginal sepfirm)

2- llleru blcomlr blcollls e 2 bodies, 2 cervices
3- Utedne blcornb unlcollls ra 2 bodies, I cenrix
4- Septote & rubaeptole
5- Arcuote (uterus cordiformis) a depression at the fimels
6- Unlcornuote (complete mest of devel,opmeut of one trdullerian duct)
7- Rudlmenlrory hom (rmderdevelopment of one Mullerian duct)
It mey be cwtmunicathg or nmt-connuuieatfug (blitrd hom)
* C/P - Usually asymptomatic /;
discovered accidentally or d.t. comp.
- Spasmodic dysmenorrhea may be more common
- Slightly t menstrual flow (menorrhagia) in double uterus
* Complications o

o Esilg plsghshcg
- Habitual abortion IPTL (abnormal shape & vascularity)
- Ectopic pregnancy (in rudimentary horn)
. Lgte pregnqhcg 6, malpresentations as transverse lie & breech
. Lqbor
- Obstructed labor (malpresentations)
o
- Morbid adherence of the placenta (P.accreta)
* Treatment + according to complaint and type of defect

WhiteKnightLove
 Complete obsence of vogino. There
is o slight depression over the hymen.
Normol coitus is not possible.

Septote (double) vogino showing olso

two cervices.
Normol pregnoncy ond delivery orc possible.

Hoemotocolpgg Only
the vogino is distended Hqemqtometro The Hoemotosolpinx ln
by oltered blood. uterus is qlso distended. longstonding coses the
tubes qre olso involved.

lmperforate hymen

WhiteKnightLove
 I
Basic Science 18

@ Ua9ina Ca

> Vaginal aplasia

. May be present alone OR
o
o More commonly with / absent uterus -+ Mullerion ogenesis )
Moyer- Rokilonsky- Kusler- Houser syndrome
o fie,.oC " 130Yo) 8.
gilttal" 1tSVo| anomalies UVP & X-ray is a mustl

Mullerion oqonesis Te*iculor feminlzotion $

Ettologg congenital anomaly insensitivity to androgens
KmgofuDs 46:or 46xy
Phenotgpe normal Q normal ? (tall + no hair))
Ooned ovary testis
[lomones estrogen d level androgen
lnt grrrlhllr
ExL rsnlhtlr vaginal pouch vaginal pouch

o Treatment
I. Frank method -+ use of progressive dilators
2' Vaginoplastyrrio"'.
operation: dissection bet. bladder & rectum
. William's operation: creation of a labial pouch
3. Abdominal -+ colon vaginoplasty + skin graft or amnion graft
4. Laparoscopic -+ Vachetti operation (gradual traction of a ball)

) Longitudinal vagina! septum (t duplication of uterus)

. C/O -+ asymptomatic or may lead to dyspareunia or obstructed
labor ifbreech overrides septum during breech delivery

) Transverse vagina! septum

. Upper -+ between the upper & middle Vs of the vagina
. Lower -+ site of fusion bet. Mull. ducts & urogenital sinus
- ,pp"r f & tower 7s -
) lmperforate Hymen //ee
. Dueto -+ failure of complete canalization of the vaginal plate
. Leading -+ to cryptomenorrhea: false amenorrhea
NA.....imperforate hymen is bluish & bulging than tr vag septum (thick)

WhiteKnightLove
 Pre-gronuloso Gronuloso
cblls -cel ls

Primory oocyte nucieus of ovum

Early
e
utrsl (0.F0.9 mm)

Larg.
o"'
anH (1-5 m)

I FSH

Pr€fllabry (1 8-20 mm)

lo0lclh0sEk. (FStl, l0Ildo6fl mllatlng
oEdan
lmmm; LH, ltrhhElno homorEJ

Theco interno
'. /
cel ls Y Thecq
-Gronuloso \ 7'
t,,
7/externo
folliculi I
in ontrum

- Coronq
rodioto

- Zono pellucido

WhiteKnightLove
 Basip $cience 19

PLy=Lologv UEenstau.al eVeUe ffi

C) Folliculor phose: 1-13 doy

> Pilmordlsl tolllcle (50p)

- Over 400-1000 primitive oocytes enter growth phase I cycle
- Each one is surrounded by single layer of granulosa cells
( arrested in prophase of l't meiotic division o

> Pregntlst fottlcle (200p)

- FSH stimulates follicular growth -> oocytes become
surrounded by several layers of granulosa cells -+ t
'E' production -+ t -or" FSH receptors -+ more
follicular growth (vicious cycle)
- Granulosa cells can't produce E alone

$be {wo cell tteory C:

* LH + stimulates 'androgen' rn theca cells
" FSH + stimulates 'estrogen' in granulosa
aromatization of An from theca cells

> Anfiqlfotllcle
- Multiple fluid spaces between granulosa cells join together
to form a large antrum full of "E'. This high 'E' (t
inhibin) J pSF{ -+ J uromatization + t local
-
androgen -+ atresia of most follicles
- The antral follicle (tbe aoobaot folllcle) is immune against
o
this atresia as it has large number of FSH receptors

Preovutetory fotliele (18-24mm ')

- Here, the oocyte resumes the prophase of meiosis !

( haploid (Vz) no of chromosomes *

l't polar body
- Meiosis l! (mitotic like) occurs upon fertilization
( 2v oocyte & 2nd polar body
- Layers of nature Graaflao follicle
.Ovum.. .......Perivitelline space..............Zona pellucida
. Cor ona r adiata... ..... C umulus Oophorus .,. ... .. Antrum folliculi
. Membrana granulos a.....Theca interna... ... .....Theca externa

WhiteKnightLove
 Ruptured
follicle -

Doy I 14 2-3
months
loier
-a--ls-- -\
l2
at '.a
-

WhiteKnightLove
(D Ovulotion: 13-15 "rhefertite phase"

o When E t > 200 pglml for > 50 hrs + +ve feedback on LH )

- Ll{ sutge + ovulation within 36 hours o

- There is also a smaller FSH surge @na surge) E

( to t LH receptors
o LH stimulates androgen production theca cells to:
- Ensure complete atresia of the non-dominant follicles
- lncrease libido at midcycle
o Extrusion ofthe ovumm.b.d.t.
- Proteolytic enzymes (collagenase, hyaluronidase)
- Contraction of ovarian smooth muscle (by PG)
- Pressure efftct of the antrum folliculi
o The midcyclic t in I-g is short-lived d.t.
- Exhaustion ofthe LH stomge in the pituitary
- Loss of the +ve feedback stimulus of E
O Luteo! phose: 14 doysG

o CcL fornatloo
1] Proliferative stage O 'G'& 'T' cells multiply rapidly
2] Luteinization stage ca deposition of cholestelol -+ yellow
vacuolated cells + steroidogenesis -+ E & P
(peakr within a wed< i.e" day 21)
- Granulosa cells + lutein cells
- Theca cells + paralutein cells
3] Vascularization (mature CL) + the . . . . . .. vascular organ in the body

o cfate of C%
4] lr ruo pnecultrlcv a Rotrogression:
( E & P from CL + -ve feedback on LH & FSH
+ CL starts degeneration atthe22n day
-+ Corpus albicans + corpus fibrosum
- JB&P + menses * release of-ve inhibition on LH & FSH
t
-r tU & FSH + start of anew cycle

5] lr pnecNeNcv occuns e CL of pregnancy:

( trophoblast -+ HCG + stimulates more growttr of
CL (hypertrophic, larger, cystic) + maintenance
of high E & P ttll 12 wks (ilt placenta forms)

WhiteKnightLove
 Eorly Lote
proliferotive proliferotive
phose phose

WhiteKnightLove
 * 4 9bases v

from basal elands from follicles

E effect P + E from Comus luteum
l-2 days 9-10 days 14 days - fixed period -
l-2 mm 3-4 mm 7-8 mm
High columnar * secretions
Cuboidal columnar appear in vesicles
E
ciliated (1.t fiey appear subnuclear
-r then become supra-nuclear)

Simple, T in number Tortuous (corksorew &

Tubular, Elongated Saw-tooth appearance)
Narrow Dilated * secretions distend lumen
a Few increased Tsize of cells,stromal edema
cellularity + leukocyte infiltration
Few l'ed ecrz" =PG&) Basal rspiral 0 pcrz")

* cFuclonal eodooetrluo
la5rers of
- Superficial (+b)......H. sensitive, contain spiral arteries -end arteries-
- Basal (1h)... .H. resistant, contain basal arteries -for regeneration-
* gryktologlcal layem of endooetrluo
- Stratum basalis... ..... ..(around gland bases). .....y4 thickness
- Stratum sponsiozum. . .(around gland bodies).. . .72 thickness
- Stratum compactum...(around gland necks)..... 7+ thickness
O Menstrua! phase (?

* Degeneration of CL ,.r withdrawal of progesterone:

- Shrinkage of endomet. & O edema -+ coiling of spiral arteries (up to 8 loops)
- Breakdown of lysosomes -+ PGFz" -+ VC & myometrial contraction
- This leads to severe ischemia of spiral vessels for 4-24 hrs
6 necrosis only of shata compacta & spongioza -+ shedding of
endometrium + opening of vessels follows -+ massive blood loss

* Menstrual blood,,+ stops due to:

- Vasoconstriction (mainly) & haemostatic plug formation
- Regeneration from zona basalis (protected from the monthly
shedding as it is supplied by the basal arterioles)

WhiteKnightLove
'Ferning' pottern in voginol smeor
due to oestrogen stimulotion.

WhiteKnightLove
 Basic Science 22
I
X Alomal,menttuatfun 9 9
> Rhyihm a.regular every 21_35 days
(<21 polymenorrhea, >35 --oligomenorrhea)
) Durotion O average 3-5 days
(<2 :hypomenomhea, >7
=nenorrhagia)
) Amount a 50-80 cc: average 3 napkins /day
(<3 0 :hypomenorrhea, >80 :menorrhagia)

) Composilion 4 blood, endometrial shreds, FDPs, leukocytes, cervical

mucous, desquamated vaginal epithelium, bacteria
4 Normally 75% arterial blood & 25% venous blood
- Normally menstrual shedding forms clots inside the uterine
cavity ,+ fibrinolysis .'. it pass outside as fluidy blood
- In cases of severe bleeding "+ blood clots / (bleeding
exceeds capacity of fibrinolytic system) * colichy pain

Follicular phase......... (EJ Luteal phase.......(P.)

o o
maximum at owlation Ume max 1 rak after owlaUon

Dlsohogr excessive watery (copious) scanty viscid (dry)

Eenr (if mucous

rve (t electrolytes: NaCl, KCI) -ve (no-arborization)
is left to drv)
Sptnrtrrkor
(stretchebility fve (stretchable up to 10 cm) -ve (non-sfetchable)
bet.2 slides) viscid, thick

Studied by vaginal smear (exfoliative cytology) from posterior fomix

6 maturation (comification) index -+ denotes the hormonal state

Follicular phase.........(E) Luteal phase.........(P.)

Superficial cells (polygonal) . Intennediate cells (navicular)
Acidophilic cytoplasm . Basophilic cvto
. Pyknotic nucleus (small, dark) . Clear (vesicular nuclei)
+ few leukocytes + manv leukocvtes

WhiteKnightLove
Hsrmonoa:

> Typos
- Estradiol (Ez) -+ most potent, most important o
- Estrone (Er) -+ less potent, estrogen of menopause
- Estriol (El) -+ least potent, very high levels in pregnancy
- Estetrol (Er) -+ very weak
> Sourco * Glands d ovory (GF,/./ + CL), ploconto, suprorenol cort@x
* rerlpheral conrrcrslon o of ondrogens (3O% of e)
> Itiotobollsn: 99Yo bound (SI{BG)... metabolized in liver

> flctlons O
-1- General - (anabolic & proliferation)
*
$tetabollc
- Protein -+ anabolic with nitrogen retention
- Lipid -+ protective effect against IHD (t HDL + J t-Ot-l
- CHO -+ some anti-insulin action
- Coagrrlation -+ t thrombosis (t clotting factors + J fibrinolysis)
iBom e) stimulates osteoblastic activity + growth spurt then closure
n
of the epiphysis. But it still protects against osteoporosis.
* t[odocrtoal sJ/steo
- Pituitarygfland: -ve feedback on FSH, +ve on LH -+ ovulation
- Breasts: Stimulates duct r system mainly + f vascularity + t fat
ln pregnancy -+ 1 prolactin release but blocks its action
- lmreasec all binding globulins (SHBG, TBG, cBG)

-2- Loca!- (esp at puberty & pregnancy)

* tulva
Q vaftoa #
- lncrease vascularity, size + deposition of fat
- More deposition of glycogen -+ lactobacillus Doderlines
* €ervlx d secretion becomes fluidy, alkaline -) +ve Spinb. & Fern
*cUterus d proliferation & hyperplasia + 1 vascularity
o
n
Tube d t vascularity, hypertrophy of muscles + t peristalsis
> Usos O
1l Contraception ,+ e.g. in contraceptive pills
2l lnfertility E) to improve pattern of cervical mucous
3l lnfections tr+ to improve healing (postmenop., trophic ulcer, vulval dystrophy)
4l Menstrual disturbances u+ DUB, dysmenorrhea
5l Menopause,+ ERT (Estrogen Replacement Therapy)

WhiteKnightLove
 Basic Science 24
I

r Tvpes
l) il atual pugutewnn . ..utrogestan, duphoston
2) SyntfrPlic
o
I gonero
' "l2 ru o r r-+ Norethindrone, Noresthisterone, Norgestrel
o PREGNA&6-+ Medroxy progesterone acetate
| 2d ganarotion: Levonorgestrel
) 3'd ganerotion: (new progestins) : t pot"rr"y + .1, androgenic effects
Desogestrel (Marvelon) - Gestodene (Gynera) - Norgestimate (Cilest)

> Source O Ovary (CLr/r/), placenta, suprarenal glands

o
> Metobollsm a bound to SHBG. .. metabolized in liver (pregnandiol )

> Bctlons <D

-1- General -- anti-estrogen
. Thermogenic (increased BBT)
. Stimulates respiration (esp in pregnancy)..depth & not rate
. Relaxes smooth muscles (e.g. GIT & ureter)
. Salt & water loss "
. Breast -+ stimulates alveolar o system development in breast
(but blocks the action of prolactin during pregnancy)
r pituitary -+ -ve feedback on FSH &LH + inhibition of ovulation
-2- !-ocal -- prepare for pregnancy
* tagtoa J thickness & J acidity of epithelium
J maturation (increased intermediate folded basophilic cells)
" 6ienrh J secretions -+ viscid & cellular with -ve Spinb. & Fern test
"'tfterus
- Bndometrium -+.changes from proliferative -+ secretory
.In pregnancy-+ decidua. . .Prolonged use-+ atrophy
- Myometrium -+ hypertrophy & decreased tone & motility
(J sensitivity of pregnant uterus to oxytocin)
'k
cfubes -+ decreased motility

> Uses @

- ThreoEenod obortion - €ndometriosls - HRT, some omenorheo cosos

- C. luteum lnzufflclencg - €ndornet. hgperploslo - DUB (dystuncEionolut. Bleeding)
- Hobituolobortion - €ndomotriol corcinomo - Pf\tlT (PremensWol tension)
- COC

WhiteKnightLove
I
2s Qsw@4

> Tgpos & sources OVARY ADR,ENAL

25% Testosterone 2s%
50% tv Androstenedione r-r 50%
t0% DT{EA 90%
0% DI{EA-S t00 %
> Metobolism
- Bound (99%) to SHBG & albumin. .....1o/ofree
- 'T' (in hair follicle) -+ 5cr-reductase + DHT (dihydro-testosterone)
> Action
. Normally the level is too low to cause any effect
(axillary & pubic hair, normal female libido)
r But it may increase (e.g. PCO & androgen producing tumors) )
- Anovulation & infertility
- Hirsutism
- Defeminization followed by -+ virilization

> Uses X X (notpreferred at all).......but may be used in

. Vulval dystrophies (atrophic types)
. Some sexual disorders (Jed hbido //)
$natonry of tbe pituitary glaod M
o Lies in the sella turcica
r Covered by diaphragma sellae + pierced by the pituitary stalk
(carries vessels & nerves from hypothalamus to pituitary)
o
o Lies behind the optic chiasma
I On each side -+ the cavernous sinus
r Below it -+ the sphenoid bone

9arts of the pituitary gland M

Post. lobo
Rathke's pouch (upper part of pharynx) Down from dienceph,
Nerve fibres
- Oxytocin & ADH
- Formed in hypothalamus
- Pass along axons in stalk
- Stored & released ftom pit.

WhiteKnightLove
> Source
- FSH, LH are secreted by the anterior pituitary (basophils)
o

- HCG is secreted by trophoblast (also produces some FSH & LH')

- They pass to blood free (unbound) as they are released in little amounts
o

> Chemlstry
o
They are all glycopeptides having similar u-chains, different B-chains
So in cases of assay ofHCG we do B-subunit assay

- Similar to LH o

- Maintains CL in preg. till placental steroidogenesis is sufficient (>12 wk)

- Important for proper sperrnatogenesis in male fetus o

> Uses @
o FSH & LH,+ induction of ovulation in:
. Hypothalami c failare, pit.uitary failure, clomiphene inducttonfailure
. Unexplained infertility
. Assisted reproductive techniques (ART)
. Male infertility

o HCG ,+
. Ovulation (tH like activity) given as 5.000 - 10.000 IU / IM
. Corpus luteum insufficiency
. Some cases of threatened abortion (instead of progesterone)

WhiteKnightLove
 Jp-hydroxystetoid

I 7-Hydroxypregnenolone
progesterone

DEhydroepian<lrosterone
I 7-FJydroxyprogesterone

<__*

Testosteron€

I
I
I P4soa

I
V

Estradiol

WhiteKnightLove
 > Functlon
o GnRH (previously LHRII) is a decapeptide wlttch stimulates
- Synthesis & storage of Gn (re*wa pool)
- Induce immediate release of gonadotropins (roleosoble pool)
o GnRH is released in pulsatile fashion (every horn)
> Conuol
o
O Negafnc feedbackloops
r Long feedback loop by ovarian steroids
. Short feedback loop by Gn
! Ulmshort feedback loop: GnRH inhibit its own release
O Neurofansmitter contol on the Hypothalamus
r Noradrenaline+tCnruf
. Dopamine, serotonin, p-endorphins - J GnRH
> [Jsas of GnRH onologues @
o Nasal Wray aNafarelin (synarel).... Buserelin (superfact)
o SC injectionO Goserelin (zoladex)
o IM injecti on o Triptorelin (decapeptyl). . . ..Leuprolide (lupron)
o
I lf used ln pulsatile mannor
( induction of ovulation (with no risk of OHSS )
2) fiused in continuous manner
* Down regulation of pituitary receptors -+ inhibition
of FSH & LH - J B (medical castration) .'. used for
- Superovulation+ART
- Contraception
- Some 'E' dependant tumors: fibroids, end.lryperplasia, EA
- Dysfunctional uterine bleeding
- Idiopathic precoc ious puberty ..... Idiopathic hirsutism
* So main side effect is + pseudo-menopausal state esp
Osteoporosrs .'.ADDBacrTrmne.pv of "E * P" may be given
o

Norraal
l{rcllnornal
lc.e7r. cK

WhiteKnightLove
 F..b"rty
.Irvler^.ope\rse

q,^o.vrori3;:B
Qlo.rrrn ol bl""Jing
Dy=,,Ner^.o
,rlr.o
WhiteKnightLove
I ,(
E4dzrnlar?

IANNER STAOING

(t/ (// (\t (r/

5ta6e2 5ta6e.$ 1taqe4 5taqe5

5reaetbud graast,elwailon Areolarmound Adultcontour

\l
/)
7re?ubertal
Y
Sexual hair
Ir l
Mid-esculcheon
Y
Femaleescuq,heon
FfiCWiat@nerr,]

us TAllllER qAsslFKATl0l{ s
Breast Publc hair
1 Pre-pub elevated breast oapillae Not oreseflt
2 1O yrs Breast bud -+ smal! mound Sparse on labia majora
3 11 yrs Furherenlaroement (round & small) Darker, coarser, curled
4 12 vrs 2'v mound (areola proiect out) Also on mons oubis
5 14 yrs Adultcontour (2ry mound disappear) Also on medialthioh

WhiteKnightLove
 of tansition from chitdhood to odulthood physically ending
in full sexugl& reoroduclive development
. Puberty is aperiod oftime (8-13 yr), menarche is an event (l2yr)

There is no / very little 'E' secreted due to:

- GnRH suppression (unknovm, mosUy controlled by a gene in GnRH nucleus)
- Very sensitive HPO axis to -ve feedback of steroids

Variation of age of start of puberty is due to several factorse: e.g.

- Constitutional, genetic predisposition
- Psychological faetors
- Nutrition, activity (athletes have later puberty)
- Melatonin release o from pineal glands

. It takes a period of time +2-5 yr

. Girls reach puberf + t 2years < boys

> Somaflc chames

- Growth spwt // [peaks at 11 yr]...followed by + closure of epiphysis
- Deposition of fat + feminine round contour
- Persistence of high pitched voice

> Secondarvsexual characters

- Gonadarche r the initial release of LH & FSH
- Thelarcbe r first appeafiurce of breast buds...........fhe l* euenf
o

- Adrenarcbe t actlation of adrenal androgens

gPubarcbe (fullappearance of axillary & pubic hair)
- Menarche D occurs 2yt aftrr onset of breast.........fhe test event "
( initial oycles are usually anovulatory

> Genital chanqes (d.t. t E) .... ..development of the reproductive organs

WhiteKnightLove
 Precodous puberty Delayed puberty

CNS lnfestlon CNS lnlscdon

o Meninsitis o Meningitis
o Enceoh-alitis o Encephalltis
o Absc'ess o Abscess
CNS tumoE
o Gllomas Cl{S tumon
o Neurofibromas o Destructlve
o Ependymoma o Pitultary
o Hamartoma
Head tauma Head trauma

Thyrcld
o Hypothyroidism oHypothyroidism
Adnnd Adrcnel
oCongenital adrenal
hyperplasia

Ovay
oPCOS
oResirtant ovarv
syndrome
G.n dc
oTumer's svndrome
-McCune-Albright oPrader-Willl syndrome
syndlome o Laurenc+Moon-8ledl
svndrome
o /esticular femlnization
(X linked)
oGonadal dysgenesis (45XY)
oKallmann syndlome

WhiteKnightLove
 Endocrinology 29
I
lodolasr;anca I h
lo Congenital a ambiguous genitalia (intersex)
o Traumatic ? circumcision. sexual abuse. accidental trauma (FB)
.. . .

o I rufla nt m ato ry o prepubetal vulvovagini tis / {

o Neoplastic O ovary (genn cell tumor), vagina (sarcoma botryoids)
o Mitcellaneous o
- Early (precocious) / Delayed Puberty
- Menorrhagia (l$ exclude coagulopathy)
t - Dysmenorrhea

Q. The commonost pro-pvbartol 9yn. comploinl? discharge (V.Vaginitis)

Q. Tho commonest prepubertol gyn. bleeding? F, body i severe V.Vaginitis
Q. tUhot oro dro lndlcotlons of P/R ln gynecology?
)Vfigfrrn, //
I Congrralhl -+ imperforate hymen
)Ttaunallc --> . completeperineal tears &fistula
. differentiates rectocele from enterocele
) Neoplaetlc -+ -routine in all tumors e.g. cancer cervix
-masses in D. pouch e.g. endometrioma
) I'lfir,etbtrreow -+ Bleeding / rectum

o Delayed pueefly
Definition
) No menarche by 16
) No secondary sexual characters by 14
) No menarche for 5 years after completed thelarche
Etiology
- Constitutional /, malnutrition, chronic illness
- tgpergonadotrophic -+ ovarian failure
- lgpogonadotrophlc + hypothalamic - pituitary failure
- Normogonadotlophic -+ end-organ-insensitivity
(Mullerian agenesis, TFS, imperforate hymen)
lnvestigations
(
LH, FSH to differentiate the 3 types
- Hyper-gonadotrophic (FSH > 30 mru/ rnl-) - karyotyping
- Hypo-gonadotrophic (FSH < 10 mIU/ rnl,) -+ CT skull
- Normo-gonadotrophic -+ ultrasound pelvis
Treatment --> acc to cause

WhiteKnightLove
r
DIA6NO9TIC WORK-UP OF ?RECrcIOIJS ?UO:ERIY

t, on

Laborahry or alualton ail lma1tnq studlae

. TOH, LH, F5H c,onaentratlona
. oex iteroii aoncanttatton,
. ab domin al1 dvl c
ultra a ound
1 lalroqenic (conotitutlonal)
?ubarty
. radiologic bone aqe
2 Gntrral neNouo oyokm leeione (b\A%) ' head CI scan or head MRt
. amic h am artafi a6
hy p oth al
. craniopharynqiomae
, aglrocytomaq )
. granulooa cell tunoora(lO%)
'enceVhalitio
. crahiallrradlation , warlantollioular oyaw (1O.e
. hydrocephalua . M aCune- Alb rtqht sy ndr ome (b%)
. ekull injury

'tuberculoais
. naurotibromatosis - hyVothyroidiom
'epilepay - aonqenital aAranal hyperplaaia

Pruodour and dehyed prbcty

History of trauma./ Excfude Exclude CAH Exdudc PCOS

hvpothyroidism
Iffi,r.oo E2 secre0ng

ilotsclhronklllrrssand sorne gcnctk syndrcmc alto cause dcraycd p,brrty

WhiteKnightLove
 I
Endocrinology 30

@ ?rucocious pueeilg h
Appearance of any pubertal changes earlier than its mean by 2 SD
o
Approximately:- < 8 years for breast & < 10 years for menarche

) lsolated (incomplete) = premature:

l-Thelarche (1 or 2) ) notinE.'.nottt
2-Adrenarche ) just local tissue sensitivity
3-Pubarche ) other pubertal changes occur normally
> Complete )
...Hstsrossxusl...
0 en)rs,"
l-tdiopathic/ consdtudonal
o
/ I
1- Est. secreting ovarian tumors 1- And sec. tumors:

in 9070 of cases early i

2- latrogenic - Ovarian

\ maturation of HPO axis 3- Hypothyroidism - Adrenal

2- latrogenic
i
4- McCune Albright $......Triad:'
2lgenic bpinlggion - Precocious Puberty 3- Cushing
trauma / tumors / meningitis i
- Polyostotic fibrous dysplasia 4- Adrenogenital $
: stimulation of HPO axis - Caf6-au lait (congenital adrenal
. Normal ovulation . No T in Gn + no ovulation hyperplasia /)
. Pregnancy can occur &qlqzpligl-
'onlv,

1) Bone aqe 2) Hormonal assay 3) FSH & tH

. Retarded -+ hypothyroidism r Androgens +heterosexual: . High + True -+ CT brain
. Normal + isolated PP - CT abdomen: adrenal tumor . Low +
False:
. Advanced -+ (tall child but...) - Pelvic U/S: ovarian tumor . Pelvic U/S
- lsosexual or - 17OH progesterone: CAH . Te,Tl
- Heterosexual PP . Estrooens -+ isosexual +7 . Bone scan (McC. Alb)

Freotmend
o Of the CaUSe e.g. -+ surgery for ovarian tumor, thyroxin for Juv. hypothyroid.
o ISOSexUal,,+anti-estrogensttttillageof 12yr. ........4s inendometriosis
o Heterosexual,+ anti-androgen. .....as in hirsutism

WhiteKnightLove
Ilrc rcdualon h drestse ofdre derus rn oU qe

25 yax mlllpara 75 )urs

o cgrDnary heart
otSease
o myocadlal
inhrtlon
o stroke

The cllnlcal feafures of menopause.

WhiteKnightLove
_O,l_to ly otu4l_ cha ng
9_g
) J Ez ond inhibin -+ d.t. exhausted ovarian follicles
) t FSH / ond [H -+ d.t. loss of-ve feedback of EsP
) J P -+ but small amounts are secreted from the adrenal gland "
) T -+ continues to be secreted (adrenal -75%- & ovary -25%) by the
same levels as before menopause .'. there is a relative t in T "
Er + . produced by peripheral conversion from andr. (fat, liver, ms)
o
. the main posfinenopausal E -+ weaker than Ez

O Local Ghanges
) Ovqries + fibrotic, small, no follicles
) Ulerus -+ atrophy of all layers (atrophic endomet. is the /
cause of PMB)
) Cx, vulvo, vog + smooth, atrophic, J glycogen -+ alkaline -+ infection
) Supports of genilol lrocl -+ weakening -+ Prolapse or SUI
) Breosl-+ atrophy of glandular tissue * more fat deposition -+ small & flabby

@ Geruenel
) Hot flush (flosh)
- Sudden sense of heat & flushing in face, neck, chest d.t.
( attacks of VD + palpitation & sweating then VC + cold shiver
- Each attack last for few seconds + few minutes
( It may be repeated from twice lday -+ one /15 min
- Mostly due to hypothalamic instability associated with t FSH
) Cordiovosculor
- t I-OI- (dangerous) t J fpl-
Qrotective) -+ CHD
- Atherosclerosis (deposition of cholesterol) -+ hypertension
- Pdf Q *ve FH, diabetes, obesity

) Osleoporosis
- Progressive systemic bone resorption -+ O glrm -+ O fractures esp:-
( Cancellous bone: L.vertebra,femur neck, distal radius
- Peak bone mass is acquired at25 yrs -+ then rate of bone loss O
( From 0.5% lyr up to 2-3 o/o inpost-menop. life
- Pdf 4 *veFH, cigarette, alcohol, sedentary life, slimo ,white'
d chronic liver /renal, drugs (steroids, heparin, thyroxin)

WhiteKnightLove
I
qrlucrnh% r(

Bone mineral density trends wlth age in women

Bone density

(+20%) +2SD

Mean

(-20%) -2SD

Fncure zom

50
Age (yeB)
WHO dlagnostlc c.t gorlcs for osteoporosis
Norm:l: Bone mineml density not more rhan ISD below
the man vialue for peak bone mass in young adults

l-ow bone dendty, or osteopenl* Values between ISD

and 2.5SD below dre mean value for peak bone mass in
young adults

O*eoporceb: Valus morc dun 2.5SD below the mean

nlue fo peak bone mass ln loung adults

Osteoporosis bone fro m the fioc oest of o 20-yeorold

8,,ne minerol de,lisity ond osteoporosb. womon (o) comporcd with thot of o 60-yeor-old womon (b).

What isthe difrercnce between

) Osteomolocio r softening of bones due to defective mineralization (Ca* & P*)

Osteoponosis D J BMD (matrix & minerals < -2.5) --> micro-architectural deterioration
Osteopenio D J BMD with T-score between -1 and -2.5

) T-scot'e D comparing BMD with SDof adulTs

Z-score D comparing BMD with SD of matching gender / age

WhiteKnightLove
 Endocrinology 32

Tl'te eueqtof physiological permanent cessation of menstruation

\ due to exhaustion of ovarian follicles (51.a yr)

It usually occurs gradually. Rarely it stops suddenly (<10%A

I with J length of cycles & irregular menstruation
Menopause is diagnosed retrograde "
\when menskuation has ceasedfor 6-12 months in woman > 45 yr

* AmlcERK a the peild during which the female passes from the
reproductive to post-menopausal stage (45-52 yrs)
* PtPttlsDPA0sE a period of life around menopause (before & 1 yr after)
* posrUnomosE a period of life after 1 yr from menopause
* pnrmlrunt Mo{oElosEo ovarian failure < 40 yrs
* tUotXO MhloPAUst a surgical / medical / irradiation

( the annoying symptoms of g inl0%)

E (severe
ll Vosomotor inslobililV ahot flushes 50-85%,/
2l Cordiovosculor d coronary heart disease, hypertension
3l Osteoporosis 7 rheumatic joint pains, backache, dowager hump
4l Genitourinory a .Discharge (senile endometritis & vaginitis), pruritis
.Dyspareunia (dryness of vagina)
.Frequency, urgency, SUI, recurrent cystitis
5] GIT symploms r7 dyspepsia, flatulence, change in appetite
6l Skin + mild hirsutism (upper lip & chin)
7l Psychologicol o depression, irritability, anxiety, insomnia, J tiUiAo

WhiteKnightLove
 ?lrrcrnlnT? ,1

Recrnr vrEw rN Benefils / Risks of HRT o e

(Wou,e,wEea)frfu1nifi,a.twa -wHt tfunf )
IorEel Effect
Vasomotor
Deflnite Genitourinary ISN in symptoms. However, tr5r to use
J,
benefll (urethral syndrome) HRT for flushes for min. time as possible
f sy, inbone density, J,30% in fractures.
Osteoporosis However, try to use other altemative non-
hormonal drugs for osteoporosis

Dellnlle Endometrial cancer " Significantt Q-ag. Jed by adding 'p'

rlsk o
Venous thromboembolism Significantt Q-ag. Jed by screening for
hereditary deficiency of clotting factors
- Cardiovascular disease " Significantt. Therefore no HRT should be
usedfor lry prevention of CHD

** Breast cancer 3 Some t related to length of use (esp>5 yr)

Proboble
t ln rlsk
Estrogen protects the normal breast cells from malignant change but it
may enhance the growth of some types of alrea4v existent malignant
cells. The other problem is that the highest incidence of breast cancer
occurs in old ages (i.e. in the age group who will receive HRT: Bias)

No
proven Quality of life, dementia, cognitive function, sleep, depression, sexuality
efiect

WhiteKnightLove
 I
Endocrinology 33

ldorrronc Rcplaoatcnt Thenapy ax

# clndications
l. S)tmptoms of estrogen deficiency (menopausal syndrome)
2. Asvmptomatic women with high risk for osteoporosis ot CHD
3. Routine for all postmenopausal women
4. Premature ovarian failure

# Conttaindications

Abcolute Relative
Unexplained vag.bleeding: cr ?? Endometriosis
Active liver disease - Chronic impaired liver function
- Gall bladder disease
- Recent myocardial infarction -Contolled hlpertension " & DM
o

- Recent I active vascular disease af,en't contraindication

Historv of estrosen related DVT Thrombophlebitis

# lMechaoism of acion
> Pmtsstion fiorn osteopomsls bg
- O action of osteoclasts (through inhibiting effect of parathormone)
- O Ca* (t Cff absorption, J renal loss, stimulation of calcitonin)
> Protec+lon from CVD bg
- O fDL, O I-OI- & cholesterol ) recently masked by
- O cholesterol deposition in vessels + VD ) the t in CV accidents

# {ilork up needed before HRT

History taking
Physical uamination (Blood Pr., weight, breast, PV)
Investigations:
> General + FBS, lipid profrle (+ liver function tests)
> Local + mammogram/, Pipelle & Pap smear (if bleeding)

# lDuratloo of therapv
- Start at any age after menopause (never too late)
- Some say 10 years are the minimal
- Others -+ HRT must be given for life
- The most recent (& correct) + not recommended for > 2yrs ,/,/r/
WhiteKnightLove
 34 q%enhrq r,
O EsrnoGENs Orulv (ERT)

> Onql, THERAPY

- Indicated onfi -+ if the uterus is removed (.'. no need for 'P')
- Drugs. CEE (Premarin): 0.625-1.25 mg /d
. Estriol (Ovestin) 1 mg /day

> NoN-onar,
Drugs
ll Skin poich (estraderm)
2l Skin gel(estragel)
3l Voginol Creom (premarin)
4l Subcutoneous lmplont 1mg
-+ applied twice weekly (0.05 mg)
-+ applied twice daily to arms or legs
-+ for atrophic vaginitis & dyspareunia
-+ inserted in abdominalwall/ 6 m

lndications.............they by-poss GIT & liver

l. Malabsorption syndrome
2. T\ey give a higher E2 concentration, .'. given in:
. Failure of oral therapy to control symptoms
. Severe cases e,g.: osteoporosis
3. Metabolic disorders e.g. DM, HTN
4. History of DVT: oral estrogen stimulates the liver to
t clouing factors & J anti-thrombin III

€) CorvrBrNED E & P THERAPY (HRT)

> A progestogen must be added if the uterus is present to prevent. .. .. ..

> It may be given aloneto relieve hot flushes
> Regiment
l. Cyclic (sequentiol)
-
CEE 0.625 mlday + MPA 10 mg /d for 10-14 days
-
But leads to cyclic withdrawal bleeding
2. Continuovs //
- CEE 0.625 mg+ MPA 2.5 mg daily
- It avoids withdrawal bleeding
(FQS leads to
lgcelttv. tbe iil.rl{ studv orceed ttat
Deflntts O tn rlsk of endometrial cr o, venous thromboembolism o, CVD o
Probcble O tn rtck of breast cancer (related to length of use)
No proverr ftot on quality of life, dementia" depression, sleep, libido
Non-horrnonst drqgs are better used for menopausal symptoms

WhiteKnightLove
 O ruox-HoRMoNAL Dnucs
> SER^ /
- Selective Estogen Receptor Modulators (agonist antagonist) are
drugs which stimulate different estrogen receptors (a,P)..'.
. Exert estrogenic effects on desired tissues (CVS & bones)
. Avoids estrogen stimulation on others (uterus, breast)
- Commonest drugs are Tamortfen (1$ generation).... Raloxifen

> Tibolone Q-ivial) /

- Synthetic steroid with weak est, progest, androg effect
- Good relieve of menopausal symptoms, also:
. Estrogen doesn't stimulate uterus or breasts
. Progesleronehas no need to be added
.Androgen improves osteoporosis & uano
- Dose + 2.5 mgtfulet lrJo.y

> For hot flushes

- Agno[ brvno niptine (dopamine agonists)

- Cbnidine patclt (twice weekly), cr methyl-dopa

- Plryn-utrrgens / (natural'E'found in soya beans)

> For osteoporosis

g Prupfukxis //,/
. Cessation of smoking & alcohol
. Regular weight bearing exercises
. Adequate intake of Ca & vit D form adulthood
Calclum -+ 1000 mg daily ) slows bone loss but don't
vitamln D -+ 800 IU daily ) t tne bone mass
( Estmgen 1<
. CEE 0.625 mg daily (or SC E2 implants lmg)
. Given mainly for the l$ 10 yrs (ma:r rate of bone loss)
. If HRT is stopped -+ rebound bone loss .'.better to give t
*
( Non-homonal theraplt t
- Bisphosphonates / inhibit Osreo-Cmsrs a J bone resorption
o
. They are the most potent --r t BMD by l0% after I year
. Alendronate (Fosamax) + l0 mg/day or 70 mg once wkly
- Clacitonin (sahnon) c? intranasal spray 200 ru (miacalcic)
- Fluoride + theonly known Osrpo-Braslc drug "
- Teriparatide I.M. for Zyrs e anabolic bone eflect - recent -
WhiteKnightLove
 B0pr0ductiv6 onltlow lract dlsotdors
o Asherman's syndrome
. M0llerlan aoenesis
r Transverse uginal septum
o lmpertorate hymen
. Testicular feminization syndrome

0varian dlsordo13
. Anovulation, e.g. polycystic ovarian syndrom€ (pCoS)
. Gonadal dysgenBsls, e.g. Tumer's syndrome
. Promature ovarian failure
. Resistant ovary syndrome

Piluilary disordors
. Adonomas such as prolactinoma
. Pituitary necrosis, e.g. Sheehan's syndrom€

Hypolhalamlc mallunctlons
. Resulting from Bxcesslve exercise
. Resulting from woi0ht losyanorexia nervoM
. Resulting lrom stress
. Craoiopharyngioma
. Kallman's syndrome

HoemqtocolDos Onlv
the vogino is disfended Hqflnot"ometrq The
by oltered blood. uterus is olso distended.
imperforate hymen
Hoemotosolpinx ln
longsfonding coses the
tubes crre olso involved.

WhiteKnightLove
 Endocrinology 36

* Amenorr$ea *
Types
S lrv omenorrheo
Absence of menstruation in a patient who has never menstruated
before, either at: 14 years -+ without 2ry sexual characters,
16 years -+ with 2v sexual characters
S 2'v omenorrheo
Cessation of menstruation for a period equal to
3 cycles -+ if previous menses were regular, or
6 months -+ if they were irregular or infrequent
Etiology
* +9fra,siotnoicol
- Before puberty,,+ Gonadotrophin secretion not yet established
- After menopouse "+ despite tt CrrnH (d.t. exhaustion of follicles)
- During pregnqncy/ / ,,+ continuous placental steroid production (E+P)
- During loclotion ,+ Prolactin Q- I GnRH, Z- J Gn action on ovary,
3- Jovarian steroidogenesis, 4- J action of E)
* 9affinlnaical.
(l Folse omenonhoo (Cryptomenorrhea)
> €tiologv (outfloru troct obstruction)
- Imperforate hymen / (the commonest cause )
o

-l - Transverse vaginal septum / vaginal aplasia

- Congenital cervical atresia
> Sgmptoms " lstorting ot pubertg)
- 1ry amenorrhea -+ cryptomenorrhea (false amenorrhea)
- Cyclic lower abdominal pain
o
- Abdominal swelling (mainly hematocolpos )
- Pressure manifestations: as dysuria & retention of urine /
> Signs
- Abd. 4 tense cystic pelviabdominal swelling
- Vag. a bluish bulging hymen
-PlR/+ distended vagina (continuous with the abd. swelling)
> Complicotlons
Haematocolpos, haematometra, haematosalpinx -+ spillage of blood
into peritoneal cavity -+ adhesions -+ infertility (.'. don't postpone!)
> Treotment
- General anesthesia * catheterization
- Cruciate incision I r excision of edges OR
.Opening a hole in the hymen after traction from its center
- Leave blood to drain slowly + antibiotics coverage

WhiteKnightLove
 37 qq.Krih?" r(
@ lrua amenorrhea OOO

o Sypotbalamus -rV- o
l - coneeoital syndromes
> Frohtich -+ n J GH RH -., J height, central obesity
* No GnRH -+ affionoffhea, genital hypoplasia, no 2'v sexualccc

) Laurence Moon liedl -+ - Limb deformity. . .. .. Polydactly / Syndactly

As Frohlich + - Mental... ,.........Retardation
- giindn.sr.. ... ... Retinitis pigmentosa '
> Kallmann syndrome + * Amenorrhea (isolated GnRH deficiency)
" Anosmia (d.t. common embryologicalpathway")
2- Traomatic ,+ fracture base of the skull
3- InflammatOfy ,+ after meningitis or encephalitis
4- TumofS ,+ destroying the hypothalamus

s- Miscellaneous
> Hyporproloctlnomio of hgpotholomlc origln
( due to loss of -ve feedback of PIF (dopamine) by drugs / lesions
> Postplll omenorrheo (Sheormon syndrome)
( persistence of hypothalamic suppression after stopping COC
( If am. lasts > 6 months -+ search for causes other than pills
> Psychologlcol <onditions
i- Sovere stross (extreme grief - war), severe exercise or rapid weight
loss (Ballet dancers - Joggers) -+ t prolactin & B-endorphins
-+ J pulsatile GnRH secretion

b- Flnororio norvoso-+ severe psychological disturbance affecting

both: hypothalamus & appetite -+ marked anorexia,
emaciation, hypoglycemia, low BMR

c- Bulimio -+ characterized by binge purge eating (episodes of

overeating) followed by - self induced vomiting,
fasting, use of laxatives & diuretics

d- Psoudocuesis -+ extreme desire to get pregnant (infertile patients)

or marked fear from it (near menopause) )
- amenorrhea (d.t. J Coruf secretion)
- abdominal distension (fat, gas, increased lordosis)
- fetal kicks (intestinal movement)

WhiteKnightLove
 I
EndocrinoJogrly 38
e 9ttuttary -III- a
r - coogenital
* LevFloraln syndrome:
= I
GH + J gonadotrophins -+ dwarfism * amenorrhea
2- Post-traumatic
3- Postinflammatorv ostriae'
-+ acne, hirsutism
4- pifuitary tumors | .,,","li"orosen
| - Pituitary (C.disease) -r basophil adenoma
- Adrenal (C.syndrome) -+ adenoma / adenocarcinoma

carcinoma of lung

* Destructive -+ e.g. craniopharyngioma

* Secretory:
- PRor,ecrntoue (usually chromophobe adenoma),+ prolactin
- Acidophil adenoma,+ GH -+ acromegaly or gigantism
- Basophil adenoma,,+ t ACTH -+ bilat. ad. Hyperplasia
s- Miscellaneous
* €*?trSelbogndrume
Itv -+ congenital herniation of subarachnoid space into the sella turcica
2ry -+ exposure of pituitary to surgery, infarction, tumors, irradiation
. Effect 1t CSfl -+ Gradual enlargement of the sella turcica
L Compression ofpit. gland -+ amenorrhea
b Compression of pit. stalk + hyperprolactinemia
. Diagnosis + CT, MRI

* Simmond.'o di,seante Pan-hypopituitarism (pit. cachexia) d.t. any cause

* Sft2tfran'o diaeaae
> Etioloey
Panhypopituitarism due to necrosis of anterior pit after

"':T**f;r:ii#5H,'-ges in preg. > its vascurar suppry

- Shift of blood to post. lobe in labor to secrete oxytocin
> C/P
J rsn & LH -+ amenorrhea + infertility + genital ahophy
J rsn -+ 2v hypothyroid. -+ weakness, cold intolerance, constipation
J lcrn + adrenal insufficiency
Jcn
J prolactin -+ failure of lactation (1't manifestation in Sheehan)
J usn + decreased pigmentation
) Treatment: replacement therapy of the deficient hormones

WhiteKnightLove
 NoY cfiromoeorne
NoTDF
No testost€rone

i No M0llerian
jlnhlbltor

Miilleilan
d€volopment
Failure of Uterus
development Ealloplan tubes
o, oocytes Cervlx
Vaglna
il Turnafs sydrom.

streaYovary
Turnerb syndrome. ODF, tostcuhr determinlng fac{or.)

WhiteKnightLove
 I
Endocrinology 39

o 0vary -II- o
t - Coneenital
- Agenesis / Dysgenesis (pure, mixed, Tmer//, others)
- Testicular feminization syndrome
- Superfemale (47xxx)
2- Traumatic -+ oophrectomy (surgical, medical, irradiation)
3- lnflilnmatorv -+ mumps, T.B.
4- iileoplastic
- Destructive tumors -+ bilateral
- Secretory . O g ,+ estrogen producing tumors
. O ao,+ androgen secreting tumor
' Both "+ Polycystic ovarian disease /
s- Misce*aneous
- Premature ovarian failure - Hyperprolactinemia
- Resistant ovary syndrome - Hyperandrogenism

* irrnnersvnfiomd
o Clinical picture
- Genotype -+ 45 chromosomes (45xo) i.e. no Barr body'
OR \ Mosaic (45xo - 46xx) or Chimerism (45xo - 46xy)
\ may be tall / get menses -pregnant / but finally....POF
- Phenotype
. Short < 150 cm, webbed neck
. Shield chest (widely spaced nipples + underdeveloped breasts)
o
. Coarctation of aorta , cardiac & renal abnormalities
. Cubitus vulgus (wide carrying angle)
- Exlernol genitolio -+ infantile
- lnternol genitolio -+ streak ovaries (fibrous 6411ds * no follicles)
o Suspected in neonate by o -+ lymphedema of dorsum of hands & feet
+ Short 4n metacarpal
o Investigations: J B + t fSF{ (hypergonadotrophic hypogonadism)
o Treatment
l- Cyclic EsP
- To stimulate breasts, menstruation, prevents osteoporosis & CVD
- Not given < 13 yrs (bone age) to avoid premature closure of epiphysis
- Growth hormone can be added to increase height (+ 8cm)
2- Oophrectomy is done only in mosaic types with Y-chromosome
( risk of malignancy is -+ 25Yo: dysgerminoma
3- The only hope in pregnancy -+ oocyte donation r(

WhiteKnightLove
of

loaca

WhiteKnightLove
 (Androgen Insensitivity Syndrome)
Pathogenesis
X-linked recessive diseases + absent or insensitive recqrtors in breasts,
hair follicle, vulva -+ no response to AltDRocENs secreted from testis
(i.e. end organ insensitivity) + .'. they develop in a feminine direction

Clinical picture
- Koryotype 4 46 XY (male)'
- Phenotype
* Complete form ,.+ attactive female with well developed breasts
(fat only - no glands) with small nipples,
pale areola" pubic & axillary hair are absent
* lncomplete form ,,+ variable degree of masculinized female
- lntemol genilolio d testis (found intra-abdominally, in a hemial sac,
in groin, in labia). They secrete a hormone from sertoli
cells (anti-Mullerian horurone) + no uterus, tubes
- Externol genitolio Q avaginalpouch o

Investigations
- Normal d level testosterone (> 300 ngldl)
- Normal d level estradiol (30 pg/mt) produced from
. Adrenals, testis, peripheral conversion (androstenedione to estrone)
. This small E amount is unopposed by T -+ breast development
- Nonnal FSH, LH levels
Treatment
1- Leave the patient till 16-18 years: to allow breast development
( followed by gonadectomy (a must as + malignancy is 25%o)
( followed by ERT (no need for progesterone):
To maintain the ferninine character, avoid osteoporosis, C\lD
2- For vaginal pouch -+ gradual dilatation orplastic surgery

* (Iriple X syndrome) M
- Genotype + 47xpr.OR48xxxx
- Phenotype + majority are normal (may have lowered IQ)
- External genitalia -+ infantile, amenorrhea, infertility
' Treatrnent + induction of ovulation
*au
- Partial deletion of short arm (46xx p-)
- Deletion of long arm (46m q-)
- Isochromosome of x chromosome

WhiteKnightLove
I
?/nzriln r/ /4

Ashermann svndrome
seen by hvsteroscope

WhiteKnightLove
 Endocrinology 41
I
o cUterus -f- o
l - Conoenilql + aplasia, hypoplasia
2- lnflommolorv
3- Iroumolic -+ Hysterectomy or !
Asherman syndrome Ea
(amenorrhea traumatica, intrauterine synechiae)
o &iolngy:Q
- Ut. operations "+ excess DsC-basal layer-, myomectomy, metroplasty
manual removal of placenta, intra-cavitary radiation
- Ut. infections,+ septic abortion, puerperal sepsis, T.B. endometritis
o SWeo
t t€rirE adhesbns Tuba! octia
Evaluated by
lllnhal < /+ involved both are seen
Hysteroscopy
llodente Vt -3/+ involved one ls seen
Sanerc > 3/e involved none rs seen

o e19,,+ l. Amenorrhea, hypomenorrhea

2.Infertility
3. If got pregnant -+ . Habitual abortion / Preterm labor
. Placenta previa / Placenta accreta
o Diagwaa
- History: of any of the etiologic factors
- Examination: lirnted mobility of the uterine sound
- Iwestiqation:.-ve E*P challenge tests with normal FSH & LH levels
. adhesions are seen by HSG, hysteroscope (best)

o Srcalnwt
- Adhesiolyis,+ DaC (or better hysteroscopic) + 3n1i6io,i"t
- Avoid new adhesions by,+ Foley's catheter for 10 days
- Induce new endometrium,'+ cyclic E+P in high doses (CEE 2.5mgdaily)

o $eoeral o
Endocrine - Thyroid (hypo or hyper)
- Adrenal (hypo or hyper)
- Acromegaly
Generol debilitoting diseose - Severe anemia & malnutrition
- Chronic diseases as T.B. / D.M. / R.F.
Drugs - Drugs causing hyperprolactinemia fi
- Drugs containing hormones: . anabolic steroids, androgens I danazol
. continuous COC / progestins / CnRH

WhiteKnightLove
 qrlrornlaq? r4

Summary of clinical management

lnitial management:

I Exclude pregnancy.
E Ask about perimenopausal symptoms (e.g ftushings,
vaginal dryness).
I Take a history including weight changes, drugs, medical
dlsdders and thyrcid symptoms.
I Cary out an exmination, looking particularly at height,
weight, visual fields and the presence o, hirsutism or
virilization Als cilry out a polvic examination, unless
thls is contraindicated
I Check smm lor LH, FSH, prolactin, testosterone,
thyrcxine and thyroid-stimulating hormone [tSH).
I Arange a transvaginal ultrasound scan, looking fd poly-
cystic ovaries
r Beview wlth the rsults .

c l" ameftorrhea ,-+ Fa.lsE (cryptomenonhea) + cyclio pain

TRUa -+ most cornmon causes are (coNs't-trurtoNnl./):
l,
Ovarian dysgenesis (307o)
2.
Mullerian agcnesis
.1. Testicular Feminization Syndrome
o 2" arnenorrhea ,.+ I " thing exclude pregnancy (the commoncst)
I. PCO
2. Hyperprolactinernia
3. hyperandrogeuism
a Hvpomenorrhen e { amount/ duration of menstruation
O Oligomenorchea + infrggq_gnt merrstruqlion (>3ldays)
Both hypo/oligo may be constitutional or endocrine
, in origin. Should be invesligated & treated same as
in amenorrhea; but prognosis rs better

Causes of pr imary amenorrhoea Causes of secondary amenorrhoea

kllrM Xo-Ttffisyndrcm Ftrysidogicd PrDg,Ercl Cmm

6,XY DSD Ld8tbo Como
OvohMltr DSO M6nof@ Cm
HyplhJd ftygdogblddoy Hypohalffi $bhht loGs/addia Cqm6
Woielil lc/s,widtEryffitu fulM Hsvy exeis CdnM
lelald G.!RH ddldffiy Sh6 CmIM
Cqsibl CNS d€l* k
ffinldtulIffi h PitJitry Hypdrd&tinamie l.bt ffim
Pilbutolal hFopituitadsm Fm
Piluilry tudianod trymiutonm k€ TGumd6u.gsy
Hymldl@nh Fa@
Be@
HMwy adgEm kh PoVqElb mry syrfrm CornM
Etrpty s€{a rydr@ Barc Plmfure owisn lalrre lJffimn
Trudrcry Sugery/radiotuary/cfmolhsapy Ulffimn
Ovehn Tm egs* k$tant@ydlrre M
M@wdmffi€ MdlLino@dil tulltqE FEB
MlldchmMdepr/dffi Olh.r qdocdm Primary hyFliryddlsn Ree
Pot/ct6iic dd6 AdGml tt)Fdab fuE
YdlHryffitullM h Adrendlffi k
ktudm FYnEylrypthyddsn M Uladne&agi@l SurEdy - hlFlddi, Coltmn
AdqEl iDsphttkr Rm EndMdatih
tqEltu h Cffi
PrDo@logo lddrldim ddi@ Cmn
ulsingrlaghd Inp€iftGb hymn ilot ulMmm Ashmb Byndme RaE
tXryiEl{sEls Re

WhiteKnightLove
 s Assessmerfi s
O Historv r
Personal
- Age-*------to differentiate lry or 2v or physiological (<9 or >40)
- Maxital status-----to exclude pregnancy
- Parity-------------previous pregnancy
- Occupation-------stress / ballet dancers
Complainh -amenorrhea

History of present illness: Amenorrhea *

) Other Gynecologlca! problems:
- Esnogn (anoruktion) . Short arnenorrhea followed by PPI bleeding
.Infetility
. Seeondary sexual ccc (breast / hair)
- Virilirytioa + hirsutism, acRe (e.g. PCO)
- Galactarrhea
) Other Endocrinologlcal problerns;
! HyporHyRoDIsM e cold intolerance, easy fatigability, constipation
r CusIfr.IG a obesity, stiae, fatigue, hirsutisrn, muscle weakness
. Acnowcel,y a enlargement ofhmds, feet & facial structure
r DIABETES a polyuria, polydlpsia, polyphagia, pnritis
) Odrer system problems:
- Severe anemia + pallor, palpitation, easy fatigability
- T.B. -+ chest troubles
Menstruol history
- Menarche ---
- Cycles------- were regular or not
- Cyclic symptoms------suggestive of cryptomenorrhea
Obstetric history 3 PoSTIARTUM Ar\rEhroRRrDA )
- Lactational
- Anotherpegnancy
- Uterus -+ Ashennann or hysterectomy was done
- Pituitary + Sheehan syndrome
Past history
- Medical ---- TB., DM, endocrine
- Surgery ---- hysterectomy, DsC, ovarian surgery
- Drugs --- drugs causing hyperprolactinemia
Contraceptive history
- Postpill ammorrhea
- Amenorrhea following injectable contraceptives
WhiteKnightLove
I q4aanla% r4

ldiopathic premature ovarian failure

Steroidogenic enzyme defects (primary amenorrhea)
Cholesterol side-chain cleavage
3p-ol-dehydrogenase
1 7-hydroxylase

l7-desmolase
1 7-ketoreductase

Testicular regression syndrome

True hermaphroditism
Gonadal dysgenesis
Pure gonadal dysgenesis (Swyer's syndrome)
(46,XX and 46,XY)
Turner! syndrome (45,XO)
Turner variants
Ovarian resistance syndrome (Savage's syndrome)
Autoimmune oophoritis
Postinfection (e.9., mu mps)
Postoophorectomy (also wedge resections)
Post irradiation
Post chemotherapy

Hy p ot h a Ia m ic dy sfu nct i o n
Kallmannt syndrome
Tumors of hypothalamus (craniopharyngioma)
Constitutional delay of puberty
Severe hypothalamic dysfunction
Anorexia nervosa
Severe weight loss
Severe stress
Exercise
Pituitary disorder
Sheehan's syndrome
Panhypopituitarism
lsolated gonadotropin deficiency
Hemosiderosis (primarily from thalassemia major)

WhiteKnightLove
 I
Endocrinology 43

@ Examination \
* Primary amenorrhea
r Geherql'+
.Phenotypic character. . ..Turner stigmata
.Pubertal development ....Tanner staging
t [acql ,+
.Hymen inspection. . ...cryptomenorrhea
.Clitromegaly. . . . . . . . . . . . ambiguous genitalia
.PR (in virgins)..........absent uterus

* Secondary amenorrhea

First of all...exclude pregnancy

- SnoRr -+ Frohlich / LMB / Levi-Lorain / Turner
^ Hslght
- Tar,l + gigantism / acromegaly / TFS

DM
^ Wslght . T}rtI.I -+ anorexia nervosa / hyperthyroid /
. OsssB -+ PCO / hypothyroid / Cushing i Frohlich / LMB

v Arnsnonho{ * gqlqcto}rhal -+ causes of hyperprolactinemia

v Arnsnorhea * vlrltlzgtlon + PCO, CAH, androgen sec. tumor

) 2's soxugl chslecter

o
Uterus prceent (absent brcast) Boft present

. Acquired causes
( hypergonadotrophic hypogonadism (9ry omenorrheo)
.Pituitary & hypothalamic -9NDBoi,l6. - HPO- axis
( hypogonadotropic hypogonadism - Uterus
.General constifutional cause .Cryptomenorrhea

Breast prcsent (abent utarus)o Both ahent(l%o)

. TesHcular feminization e5mdrome Enrymatic pathway defects in

. Mullerian agenesis testosterone synthesis in xy
- differentiated by .Testosterone level
Cong. lipoid adrenal hyperplasia
-Absence of hair
l7o-hydrorylase ddiciency
. Congenital I Asherman s5mdrome 17-20 desmolase deficiency

WhiteKnightLove
 Karyotype:
Testicular feminization,
M0llerian agenesis,
46,XY steroid enzyme
pure gonadal dysgenesis, or
anorchia

lmperforate hyrnen,
transverse vaginal
or vaginal agenesis

Consider as if progesterone
challenge negative
(see figure 19-3)

. Diagnostic flowchart for patients with primary amenorrhea.

Rule out Asherman's

syndrome and cervical
stenosis

Polycystic ovary
syndrome
Rule out ovarian tumor
Rule out adrenal tumor

Swere hypothalamic
dysfunction

. Diagnostic flowchart for patients with secondary amenonhea,

WhiteKnightLove
 Endocrinology u
€) lnvesfigafions \
O First of all -+ exclude presnancy -+ B-HCG "o
OThen determine level . Prolactin level.........
. TSH t T3, Ta.

r Progesterone challenge test: 5mg 1x2x10 oTDMPA (150 mg IM)

*ve bleedin,q -+ means that the ovary is producing estrogen but
there is no progesterone i.e. no CL i.e. anovulation
-ve bleedins -+ either:
- Ovary doesn't produce estrogen e.g. Turner
- Uterus is not responding e.g. synechiae, hypoplasia
D E + P withdrawal test: COC for 3 weeks
-ve bleedine + i.e. problem in uterus i.e. refractory endometrium
( uterine investigations -+ sound
+ve bleeding -+ i.e. No estrogen i.e. problem is in the HPO axis
r Serum FSH, LH
High FSH (> 40 mIU/mL) -+ ovarian failure
Low FSH (< 5 mIU/mL) -+ either: Hypothalamus / Pituitary
r GnRH test + CT / MRI
FSH increased -+ hypothalamic problem
FSH not increased -+ pituitary problem

OOthers:
> Huperandrogenism
- Adrenal gland investigations:
. DHEA-S -+ diagnose adrenal origin
. Cortisol & ACTH level -+ in Cushing
. l7-OH progesterone -+ in CAII
.CT/MRI -+ to exclude tumors
- Testosterone level (diagnose ovarian origin)
> Hyperprol actinemia. .. ..Prolactin level +CT brain
> lry amenorrhea
- Turner syndrome + karyotyping + laparoscopic ov. biopsy
- Mullerian agenesis -+ U/S (absent uterus)
- Test. Feminization -+ testosterone level
fgle of ctl$ lo aoeurbea
* Uterus...absent (Mullerian agenesis|IFS)...infantile (uterine index <1)
...absent normal trilaminar endomet is suggestive of Ascherman
t Clvarles........absent (Tumer).....swelling (PCO /functional cyst /neoplasm)
r Vagina & hematometra

WhiteKnightLove
 q4r.anb% rl
Exclude physiological
causes:
o pregnancy
o lactation
o menopause
Asherman's syndrome
Sheehan's syndrome
Cervical stenosis
Algorithm for secondary amenorrhea
1 . Primary amenorrhea is the absence of menarche
by age '15 or 4 years after the larche,
2, Primary amenorhea can be caused by congenital
abnormallties of the genital tract, chromosomal
abnormalitles,enzyme or hormonal de6clencies,
gonadal agenesis, ovarian failure. or disruption of
the hypothalamic-pituitary axis.
3. The work-up of primary amenorrhea is usually
organized into four categories based on the pres-
ence or absence of a uterus and the presence or
absence of breast development.
4, ln the absence of both uterus and breasts, karyo-
type usually reveals 46,XY.
5. ln the absence of a uterus and presence of
breasts, karyotype will dlfferentiate between miil-
lerian agenesis and testicular feminization.
6. ln the absence of breasts and presence of a
uterut FSH will differentiate between hyper-
gonadotropic and hypogonadotropic hypogo-
nadism. Karyotype may be n<essary to rule out
gonadal agenesis in a 46,XY.
7. Patients wlth both a uterus and breasts should
be evaluated as if presenting with secondary
amenorrhea.
l. Anatomic abnormalities including Asherman's
syndrome and cervical stenosis may lead to sec-
ondary amenorrhea.These patients fall to
respond to estrogen and progesterone
withdrawal.
2. Hyperprolactinemia is a common cause of sec-
ondary amenorrhea.
3. Patients with normal prolactin levels may be
given a progesterone challenge to investigate
whether or not the endometrium is estrogenized.
4, With progesterone challenge failure, the differen-
tial diagnosis becomes hypergonadotropic or
hypogonadotropic hypogonadism that can be dif-
ferentiated by an FSH mcasurcmcnt.
5. For patients not seeklng current fertility, it is
important to treat the specific cause of amenor-
rhea and to ensure that the hypoestrogenic
patient receives hormone replacement therapy
(HRT).
6. For patients who desire fertllity,ovulation induc-
tion can usually be achieved. Patients with hyper-
prolactinemia require bromocriptine, whereas
patients with other forms of hypogonadism may
respond to clomiphene and gonadotropins.
WhiteKnightLove
 slftanogement s
OGeneral
r Correct anemia & malnutrition
r Reduction ofweight if obese
r Alleviate stress
o ltimaq amenonhea
r Norrno-gonq&tmDffc
\. Imperforatehymen ...cruciateincision
\.Mullerianagenesis,.. .neo-vagina(vaginoplasty)
\. Testicular feminization. . . ....gonadectomy at 18 yrs
r llgDo-ronq&tmDhlc
\. Hypoth-pituitary causes......cyclic HRT or HMG/HCG
r llgDoFgonqdot]oDhla
\. Ovarian (Turner)... ...cyclic HRT at 13 yrs

osecondary amenorhea
r Hormonsl
\. Cyclic HRT e POF
Cycloprogynova (estradiol valerate + norgestrel)
Yasmin /Gynera
Cyclic progestogen for 7-10 days /month
\. Induction of ovulation 4 PCO
Clomiphene citate (clomid)
HMG /HCG
\. HYPerProlactinemia
Dopamine agonists (parlodel - dopergine - dostinex)
\. HYPerandrogenism
Androcur (cyproterone acetate) / Spironolactone / Diane
\.Thyroid dysfunction
Eltroxin in hypothyroidism
Thiouracil in thyrotoxicosis

r Surdcql
\. PCO.. .........laparoscopic ovarian drilling
\. Asherman syndrome.. .......hysteroscopic resection
\. Pituitary adenoma only if....refractory to medical ttt
\. Resection of.... ........adrenal tumor

WhiteKnightLove
WhiteKnightLove
 Endocrinology 46
I
* Xnovvfg,trofi *
E"H.d
Failure of ovulation, which may be classified into )
Group I Hypothalamic pituitary failure Low.. ....LH & FSH
Group ll Hvpothalamic pituitary dysfunction Normal...LH & FSH
Group lll Ovarian failure Hish......LH & FSH

. Phgsiologcel ,+ prepubertal, postmenopausal, pregnancy & lactation

. PatholoElcat *+ Hypothalamus.../pituitary.../thyroid. ..ladrenal...lovary...
. GEnprgl tr+ severe malnutrition, anemia, DM, TB, exercise, stress
. ldiopathic nr) rrost frequent (functional error in the HPO al<is?) //
. lahogenic ,"+ COC, androgens, drugs inducing hyperprolactinemia

@EelPlsqd
D C/P of anovulation
1. Menstrual inegularity -+ amenorrhea, oligo-hypomenorrhea, DUB
2.Infertility
) CIP of etiology (as in amenorrhea) *.....,.e.g:
1. PCO + SOFIA
2. Hyperprolactinemia -+ galactorrhea
3. Hyperandrogenism -+ hirsutism
4. Other endocrine disease -+ thyroid (goiter, tremors)

r Tests for anovulation * *....... very important

r Tests for etiology *.......e.g.
1. Thyroid function tests & prolactin level
2. PCO-+LHlFSHratio
3. Testosterone level -+ virilizing ovarian tumors
4. DHEA'S level -+ adrenal origin

o Generol -+ correction of malnutrition, anemia, DM

o Medicol -+ induction of ovulation, bromocriptine if hyperprolactinemia
o Surgicol -+ ovarian drilling for PCO, surgery for virilizing ovarian tumor

WhiteKnightLove
 OF ?OLYCYSTI,
Diotubad ncwoendoarlna
.- Hypoilvlamua-Vttuitary
funotion ol aentr*l neruous t GnRH
oyatem )

l Estroqeno
(eef,rone and
eqtradiollTp)

I Tenpharal (extra-
,landular) ammarizailon
of androqana - eatroleno
AdipoecAede

t Estrudiol-1zg
I Andr n^dion

I Ovarlan androqa

Obeoity lwv*^@1 aearefion

1
I
V daNdroo?androate.one
J
Adranalgland A

I SHBG
I frcm llver

Polyclretic owrlcr

WhiteKnightLove
 Endocrinology 4l
I
I. PolvcYsrrc OvnnnN SyNoRoME $
(Stein Leventhal Syndrome -1935)

[oanffi
. A syndrome ccc by d ov. dysfunction & loss ofnormal hormonal cyclicity
. Presented by o lnferlilily, ODeslty, Hlrsullsm,Onouulatlon

h'-qp!q!Ed
. Affects 5-10 oA of females in the reproductive age
. It is the commonest / ovaimcause of 2,v amenorrhea, chronic anov & infertility
. Etiology is unclear * p41ytL1qt. & csNe TENDENCv

> B vlclous cgclo, rnog stot onguhcrc:

- Primary CNS error a
hypothalamus, pituitary
- Primary endocrinological(enzymatic) error O ovary, adrenal, liver
> IhGr. ls hlgtt tll pulsc / iuquency
\ stimulates androgen formation by theca cells & ovarian stroma
I Inhibits aromatase enzyme (responsible for conversion of androgen into Ez)
> Thls urlll rusult ln hypercndrcgonlsm, Iooding to
\ arrest of follicular development at various stages + thick capsule
\ multiple subcapsular cysts but with no CL -+ anovulation & infertility
\ peripheral conversion of the high androgen to Er (in fat)
> Thls ocycllc lncrcec ln €r lcods bo
\
*ve feedback on LH &-ve feedback on FSH+ O vicious cycle o
\
stimulation of endom-+ prolif+ amen & bleeding-+ hlperplasia+ cr
o

VScsocfadog tosuflD reshtaoce iu fould rlr.qO% of 969 ;

( t local ovarian ILGF stimulation of androgen synthesis
( t
Androgens 1......-+ insulin resistance furthermore
2......-+ J SHAG -+ t free E & An tufthermore
3 -+ central -+ J sttgc furthermore

* Uterus.... ........unopposed E -+ symmetrically enlarged

-+ adenomyosis * end. hyperplasia
* Ovaries.. .........fu0[ycystic,sc[erccysticl
- Size a
enlarged 2-4 times
- Tunico olbugineo #
thick, ivory white, smooth (no stigma of ovulation)
- Cysts a
multiple, small, subcapsular filled with clear fluid (rich in E+[)
- Stromo #
hyperplasia of theca & stroma cells (stromal hyperthecosis)

WhiteKnightLove
 48 fuernh% r,
DleeleEedE

O Suggestive clinical picture

> tywptoms ... ... avariable scope of C/P (SOHA)........
- Anovulation (periods of amen /oligohypom + PPI bleeding)
- lnfertility + habitual abortion (probably d.t. the high LH)
- Hirsutism & acne (hyperandrogenism) -7lyo, acanthosis nigricans
- Obesity - 50Yo: (obesity : BMI > 27 k{m2)
> Signs
- Symmetrically enlarged uterus
- Bilateral enlarged ovaries

€) Ultrasonic criteria suggestive of PCO

. Necklace appearance (> 10 subcapsular cystic follicles) ) Aaams
. Each cyst is 2-10 mm in diameter -+ microcysts \ slterla
. The whole ovarian volume is increased > 10 cm3 )
> By lapanoscoqY "'r large ovary withsmooth white capsule

These findings are Normal in 25% (pl,lcystic like ovories)

As it occur in any case of anovulation* hyDer'E'

O Specific hormonal changes

o O LH, I Fsu. ...LtvFSH ratio > 2.5 .//
o O Androgens (testosterone, drostenedione, DIIEAS) //
u O Estrogens (El mainly)
o O Prolactin (<30 ng/ml)
o O Insulin -+ hyperinsulinemia (fasting glucose / insulin ratio < 4.5)

O ..longtermrisks
o DaC -+ enffinefrfal hrrperplasia + circinofiut
o GTT -+ [M
o HDL, LDL, cholesterol -+ CUD

... ... .....2 or more of........ .....

o ClP .. ...Chronic anovulation o

2'v amenorrhea / oligomenorrhea \ llotter6.an
o U/S......Ultrasonic criteria z7 suggestive of PCO ) crfterfA
o Horm...Hyperandrogenism e hirsutism, O LH, O free testost. ) -recent-

WhiteKnightLove
 Endocrinology
I
49

According to C/O
ll Weight reduction ///,'+ O hyperinsulinemia & hyperandrogenism
2] If the main complaint is hirsutism
> COC.. ....containing 3ra generation 'P' e.g. Yasmin/ Gynera/ Marvelon/ Cylest
> Diane.....35pg EE + 2mg cyproterone acetate
6l lf the main complaint is irregular uterine bleeding
> Medical
- COC: 21 days -+ stop 7 days -+ repeat
- Progesterone
( Provera (medroxy progesterone acetate) 10 mg
( Prevents also end. hyperplasia d.t. unopposed 'E'
>D&C
- Therapeutic -+ if medical therapy failed
- Diagnostic -+ to exclude endometrial hyperplasia & malignancy
> Hysterectomy
- Atypical hyperplasia OR Endometrial carcinoma
- ln old patient -+ with failed medical therapy and DsC
4l If pregnancy is desired
> Medical
- Induction of ovulationf.*'
-Oral hypoglycemics ///
metformin (glucophage) 500 mg 1x3
( J insulin resistance -+ J androgens -+ spontaneous preg.
> Surgical ,"+ if failed induction
* Laparoscopic ovarian drilling
. 4-8 punctures in each ovary for 24 seconds each
. Advantages -+ less adhesions:- pregnancy rale70 %

I Michanism if ictnn of surgical dritling(unknown, m.b.d.t. )

; - Removal of the thick tunica -+ allows the follicles to rupture
- Removal of part of theca cells -+ reduction of androgens
- Removal of the ted ovarian tension + conection of local factors
- Removal of a large pg( of the ovary -+ allows better GnRH control

* Bilateral wedge resection XXXX

. Removal o'f %or%of theovary
. Disadvantage -+ more adhesions:- pregnancy rate 50 %

> ART *r if failed all other measures

WhiteKnightLove
I
50 ?frzrilrr" /,

* Chemistry -+ alcohol soluble polypeptide hormone o

* Source + anterior pituitary lactotropes (acidophils) -+ lactotrophic hormone

* Function -+ prepares the breast for milk secretion, inhibits ovulation (how?)
* Norma! Level
.2-25 nglml
. Presentin 3 forms (small/ / .. . . . ....big.. . . . . ..big big)
. Secretion is variable .'. measured 3 times at least
* Control + prolactin inhibiting factor (dopamine) from hypothalamus
* Galactorrhea
. Any persistent discharge from the breast except blood or pus
in absence of lactation. It is more commonly bilateral"
. Diagnosed by mic. / exanination (fatty) + Sudan III stain
. Hyperprolactinaemia in males + galactorrhea & impotence

Fu"i"eil ooo
H),pothalamic "+ tumors destroying the inhibitory pathway

Pituitary,,+ prolactinoma (pit. adenoma) -+ THE coMMoNEsr (50o/o) //

Omrian,+ PCO (prolactin t to:O nglmldue to t E)

v ldiopathic (phpiolo$cal) ?MLd tnlrlM Gtn c.It. tnrp.oLEtoGtr

'lYF o, dnrt Dnl! chrr
. Pregnancy -+ up to 400 nglml (due to estrogen)
Anupsyrffic drugs Ph6otl.r82ln€s
. Suckling (lactation) -+ up to 200 nglml Haloperuol
. Stress / Sleep / Sexual intercourse Antldepresank Irlcydk antdep.essank
/ Some emotional disturbances AntitryFtensls I mefYaopa

Iatrogenic (anddopaminergic drugs) Rc*rdne

. Estrogen & COC Eslrotffi | Comuned OCP

Hrreepior ilta8nlstu | Clmtldlm

. Antidepressants & tranquilizers -+ diazepam
Reltldlft
. Antiemetics + metoclopramide (eruurEneN) Mctodoprmld€ and
domperklone
. Antihypertensives -+ reserpine, o-methyl dopa
Dmt forget chefircth€npy lor mallgnarry ot

Chnonic diseases lmmunolo8k dlsorders.

Hypothyroidism -, t tRH -+ stimulates lactotropes

o
.
. Chronic renal or hepatic failure (J prolactin metabolism)o
. Chronic irritation of nipple + burn, scar, herpes zoster
o
. Ectopic secretion + oat ceIl carcinoma of lung

WhiteKnightLove
 ........ .(eruexonRHEl -cAlllcrolRt{EA srruonorue).

1. Anovulation -+ amenorhea, oligomenorrhea, DUB

) teads to
t
2. Luteal phase defect: as prolactin -+ luteorysis
) lnrertility
3. Galactorrhea -+ only in 30- 60 % of hypelprolactinaemia
Premenstrual syndrome
4. f
Hirsutism (prolactin + adrenal androgens)

t Manifestations of pituitary tumors (".g. t ICT, visual field defects)

) Exclude t+ pr€grutnclt lactation........drugs........tlryroidfunctiontests

) Prolactin level,+
r 30 nglml..............PCO (U/S + LH / FSH ratio)
. < 100 n91m1......... mostprobablynotatumor
I 100-200 nglm1........may be a tumor or not
r 200 llr91m,1...............almost diagnostic oftumor
)
) For etiology "+ cr scan (MR! better): maoro (>1) or micro (<1) - adenoma
* Visual field examination

{Mmrp
1. Treatnent ofthe cau8e
+ hypothyroidism or renal failure
2. Stop anycausafive drq
3. Brcrnoffipline (Padodel)
{{ + dopa:nine agonist o
* It is an ergot alkaloid
* Dose: 2.5 mgtablet twice daily
* Side effects:
. NaV + avoided by giving it
with meals or vaginally"
. Postural hypotension + avoid
by sradual f ofdose
4.fr
ver + satisfactory results (7s disappear spont. " )
* IndicaUons ofsurgery
. Tumor doesn't J in size with drugs
. Vision is affected (compression of optic chiasma)
.Intolerable side effects ofthe drugs
5. ffgot pregnant
* Continue dopamine agonists o (not teratogenic)
x Follow up the visual field / trimester
WhiteKnightLove
 52 qqrzrnhrrl r4
& Lurenl PHAsE Derecr (LPD) h
Definltion
Inadequate progesterone in the luteal phase leading to
C 4% of infertility cases
C 35% of repeated abortions
€tlologV @@
1. Defect in CL function
- Normally in -+ post-menarcheal, post-delivery, pre-menopausal
- Reduced follicular maturation (I nSU & LH.....pit or hypothalamic)
2. Early degeneration (luteolysis) of CL
- Endometriosis (t PG-F2,)
- Hyperprolactinemia, Hyperandrogenism, Hypothyroidism
3. Endometrial insensitivity to progesterone

Dlssoosis + tests for owlotlon #

. Sremenstruaf spotting,,+ irregular ripening of endometrium
. Eipfrasic 6ot1tenp,+ short < 10 days
. fuliltuteaf serum prog esterone,+ 3 - 12 ngl ml
. (Premms tru.of m[ometri^a f fuiops1,+
- lag ) 2 days in endometrial development ) poor secretory
- "Out of phase when compared to normal" ) changes

Traotment
o Prog. in the 2"d
'A of the cycle ocontinue by DMPA lM/wk for 10 wks if preg.
o HCG in the 2"d Y, of the cycle
o Induction of ovulation....*
- Clomid t HCG
- Clomid + parlodel or thyroxine or steroids
- Gonadotrophins + HCG

4 LUTEINIz;ED UNnUpTURED FOU-ICI-E (LUFS)

Pothogenesis
. Failure of rupture of the mature GF (probably due to PG imbalance)
. This is followed by luteinization of cells -+ progesterone secretion
. The resultant is -+ NO ovulation in the presence of ROEOURTE luteal phase
Dlognosis
- Tests for LPD -ve
- Follow up of GF by U/S -+ no collapse of follicle
Ilestment
Proper induction of ovulation * give high dose HCG at ovulation time

WhiteKnightLove
 Endocrinology 53

F Pnenr^aruRE OvARnN FaITURE (POF)

Definitlon,.+ cessation of menses < 40 yrs due to depletion of follicles (1%)

€tlologv........did by Cl8 {D@

1. skuclion by . Chemotherapy
. Radiotherapy
. Hysterectomy
2. ldiopothlc "+ commonest / (+ve family history)
- helped by smoking, alcohol, undernourishment-
3. bililoting diseose ,.+ pemicious anemia
o

4. Chromosomolu+Turner, trisomy 18 or 13
5. lnfections tr+ mumps?, TB
6. Autoimmune ,'+ anti-ovarian antibodies -+ lymphocytes & plasma
cells surrounds the follicles e.g. Hashimoto thyroiditis

DJognosJs
o Hislory -+ amenorrhoea < 40 yrs (take care ..... .pregnant? ...... !!) O
. C/? -+ of estrogen deficiency (as hot flushes)
.lnvestigotions
- FSH > 2540 mIU /mL (hgpeqonadotrophic-hgpogonadisrn)
- Chromosomal -+ Tumer syndrome
- Ovarian biopsy:
. POF -+ no follicles
. Autoimmune -+ lymphocytes & plasma cells
. Resistant ovary syndrome -+ normal number of follicles

IfT ,+ HRT: J risk of CHD & osteoporosis

o)
6 ResrsrraNT ovARy syNDRoME (Savage syndrome

LoEhogelasls
- Failure of the ovary to respond to pituitary Gn
- d.t. absence of Gn receptors in ovary or presence of antibodies
lnvestlootions
- JB + trsrr (hgper-gonadotrophic hgpo-gonadism)
- Ovarian biopsy -> normal follicles (to differentiate it from POF)
Treotment
- Spontaneous recovery may occur
- Induction of ovulation is vERY difficult (needs large doses of Gn)
- Oocyte donation (condemned?)

WhiteKnightLove
 54 q4rcerohg r{
7 HYprnANonocENrsM

oo
O O androgen productioo ffij
qH
Erdude:
P@i
CrcFnos
dtut Md6
) Endogenous
C#drrydm
lfufu
Afusln.ffis

- Ouory.. common) or virilizing tumor

.. . ..PCO (2nd
- Adrenal. ..CAH, Cushing synd. q virilizingtumor
> Exogenous -+ anabolic steroids, some progestogens, danazol

O + aodrogeo bindiog,+ due to O SHBG

> Liver diseases (SI{BG is synthesized in liver)
> Hypothyroidism, acromegaly, obesity, insulin resistance
> Hyperprolactinemia, hyperandrogenism

€) O seosittvity of halr folllcles to normal T levels I idiopathic,

or O scr-reductase activit5r (converts T to DHT) \ constitutional
) Commonest cause /
) Menstruation is regular & androgens level is normal

t. H,rcutisrn fferriman Gallurey scorlng systeml

- Growth of terminal (sexual) thick pigmented hair mainly in central areas
(
early age of onset suggests -+ familial tendency
( rapid rate of progression suggests -+ tumors
- Hypertrichosis is growth of villus (non-sexual) thin & unpigmented hair
2. Vlriliation signs
- Acne, seborrhea, temporal baldness l. Hirsutism is excess hair growth with a male
- Skeletal muscle hypertrophy, pattern on the face, back, chest, abdomen, and
inner thighs, usually in response to excess
deepening ofvoice
- Clitromegaly, increased libido,
androgenr
2. Virilism is a constellation of symptoms including
menstrual irregularities hirsutism, deepening of the voice, frontal balding,
clitoromegaly, and increased musculature.
3. Primary causes of hirsutism and virilization
include PCOS, ovarian tumors, adrenal tumorS

3. en sqqqes'Five of etiologg
CAH, and Cushingt syndrome.

- Family history of hirsutism 4. Diagnosis is made by history and physical, serum

- History of drug intake assays for testosterone, DHEAS, and

imaging studies.
17{HB and

- Galactorrhea, hypothyroidism s. Managementinvolvesprimarytreatmentforthe

,nderlying cause; hormonal therapy with OCPI
- SWelling:
*Abdominal-+adrenaltumor ffll1ifl:'**ons;andcosmetictreatmentor
" Pelvic -+ PCO, ovarian tumor
WhiteKnightLove
 Endocrinology 55

) Excf ude,+ family his tory.... ....drugs ... .....thyroid function tests
) Testosterone level ,+
r If normal.... 0.2-{.8 nglml ......no further investigation (idiopathic)
r If testosterone > 150-200 ngldl (N: 20-80)...ovarian tumor. . . . . ..U/S
I If DHEA-S > 700 pgldl (N: 150-300)............adrenaltumor.......CT
) For etiology
r U/S + LI{/FSH ratio } 3 -+ PCO
r Serum prolactin -+ hyperprolactinemia
r Serum cortisol & serum DHEAS + Cushing synd.
r Serum 17cr- OH progest. -+ CAH

liroornend
t. Treatm€nt of th€ care e.g. Iaparoscope for PCO

2. Co$netic treatfiplil e.g. shaving, depilation, waxing, laser

3. DrugS ,,+ the response to treatment is slow (after 6-9 months)

as hair life cycle is slow. .'. drugs given for l-2 yrs

OvARY
O Estrogen O Progest. (D Dexam- O Flutamide @ cnnn
ethasone analogues
receptor
t synthesis J LH secretion 0.2F0.5m9 /
(eulexin JovarianE&A
of SHGB + day
250 mg/day) amenonhoea
-+ J ovarian + OFlnasteride
(but leads to
J tree Androgen osteoporosis
suppress the (proscar) within 6 m)
androgen e.g.
adrenal gland
. Ptovera 5cr-reductase
ts, (10m9/d) , enz. (Smg/d)
- lasmlne . DrfipA sN
afoneru (150 mg /3m)

Olhers (importont)
o Androcur (cyproterone acetate) -+ progestogenic & antiandrogenic
o Spironolactone { { (aldactone) 25 mg /d -+ acts as androcur
o Diane + 35pg EE+ 2 mg cyproterone acetate

WhiteKnightLove
 Endometriosis
Fibroid

Pelvic inflommotion

Endometriol polyp cervicol polyp

Uetrin polyps

WhiteKnightLove
 .".FMOoDmrfEfaoCI[t A
Defloltloas
l) Cgcllc bleedtng
-
Menorrhogio (excessive amount I duration attime of menses)
-
Polymenorrheo (too frequent menstruation d.t. too short cycles)
-
Polymenonhogio (combination of the above)
9) Hcgcllc bleedlng
- Metronhogio (irregular bleeding unrelated to menstrual cycles)
- Menometrorrhogio
- lntermensiruol bleeding

) lncreased bleedinE tendencv

- Blood diseases affecting coagulation e.g. VWD, ITP
- Hypertension, Congestive heart failure
> 9r ..18!!rc 4 renal/ liver (J E metabolism, J SrmG, J clotting factors)
) Endocrin e 4 adrenal / thyroid disorders (J or t;...DM (vasculopathy)
> 9lggg o antiplatelet, anticoagulants, contraceptive drugs

Et rocatl oo
> eomplicatiaru ol puanancq.
o Earlg abortion, ectopic, V.M.
o APhgre - placental, extraplacental
c pphgre - atonic, traumatic, retained placenta, DIC
> ?ehie pqtfuW
1l@onqenltal d uterus didelphys / bicornis -+ menorrhagia
2ltrautmtlc d obstetric, surgical, direct. ......IUCD
3lgntlammatora O acute / chronic infection -+ ulcers & pelvic congestion
4l.Eumors O
- Cervix (benign + polyp 7& - malignant + carcinoma or sarcoma)
- Uterus (benign + fibroid 3096 - malignant + carcinoma or sarcoma)
- Endomehiosis & adenomyosis
- Ovary (neoplastic or non-neoplastic)

46enltal dlsplacements d prolapse, RVF, chronic inversion of uterus

WhiteKnightLove
 57 qrl.,crnlar" r,

* Dgsfunctional (functionol)
DrrrNrrroN
o Abnormal uterine bleeding in absence of obvious ORGANIC cause

o Common near . Puberty (immature FIPO axis). .....20%

. Menopause (reduced no of follicles)... ...40%

o Due to
. Hormonal dysfunction (I{PO axis)......Metrorrhagia(80o/o of DUB)
.Local."jfi?"j[i1##ffi").......Menorrhagia(20%of D|IB)

[l Ovutar fcvclicJ r+ m€norhaeial

c+ Functionol Polumonorrhoo & Polumenorrhogio
o The cycles are very short (d.t. short follicular phase)

cr lrrequlor rioening of endomotrium (CL!. LPD)

o Poor formation of CL -+ premature shedding of endometrium
-) premenstrual spotting
9 lrregulor strodding oF endometrium
o Incomplete & slow degeneration of endometrium
-> postmenstrual spotting

cr Holbon's diseoso (Persistent CL)

o Unknown etiology but there may be -+ PG imbalance in ovaries
(PG is important for luteolysis) -+ abnormal uterine bleeding
o DD is ectopic pregnancy - differentiated by B-HCG

t;rsmtrwrfi for sf............

* Ip gteEDING
- Progesterone (e.g. provera or primolut l0 mgld)
- COC +inhibits pituitary & start artificial cycles

* lr rxreRTrLITY
- HCG or clomid + HCG
- ART + if failed induction

WhiteKnightLove
 frpvular facyc{icJ rrr+

1l Mrrnoparu^1, H^muonnulcrca (Scm.ornun's Drsrlsr)

> Definition
Acyclic bleeding resultinsfroa + periods of drovulation,
fron + proliferative endometrium,
occurrins
It may be ues&d.by + periods of amenorhea
> Pathophysiology
o Anovulation -+ persistence of follicles + E but no P (no CL)
\
slnrt periods of amenorrhea
o Unopposed hyperestrogenemia + proliferation of endometrium
tr Temporary J B level r necrosis & sloughing of endometrium
\
breqhhrough bleeding
> Pathology
. Uterus
l)Macrucopic
- Symmetricallyenlarged uterus due to :
- Endometial hyperplasi4 pollps, myohyperplasia

2) Mictoscopic
- Endometrium + proliferative endometrium but no secretionso
- Epithelium -+ t treigtrt (cuboidal - tall columnar - crowded)
- Glands t No, sizn, dilatation (cystic glandular hyperplasia)
-
- Stroma -+ hyperplasia
. Ovaries
. Enlarged with + unilateral follicular functional oyst (<6 cm)
. No corpus luteum

> Clinical picture

- Short period of amenorrhea followed by PPI bleeding
- PN + symmetrically enlarged uterus + enlarged adenexae

> lnvestigation
- TVIIS + .... ..asrnMacpatholng
- DaC -+ ... ...as nMic pathahg
> Differential diagnosis
- Amenorrhea followed by bleeding (e.g. abortion, ectopic, V.M.)
- Irregular utedne bleeding (e.g. tumors, fibroid)

WhiteKnightLove
Menorhagia
Algorithm for
menorrhagla.

Hyn ro3coplc yLw of lntnutrlno polyp. An ffi.lt!.dm progaatog.o-rd.rthg r,5hm ln {r. ut rua

H@ter
Eise lluld
temptrature

--End(retrium

UEang syrlnge, fluH le tnlrl€d

tlurgh cdtFtd, hnalirg b6lloon
Con.d.thn.urgLrl truhot'lor mnorrhlgar (A) A the,mal balloon; (B) impedaftHontrolled auaii@;
(C) mk@ave sdmeuial at{atim.

WhiteKnightLove
 Endocrinology Sg

Treatment
L- eme,ul
o Corect anemia (even blood transfusion may be required)
o Anti-PG {/ e.g. Mefenamic acid, Ponstan, ibuprofen
o Anti-fibrinolytics e.g. tranexamic acid (cyklolapron)
o Haemostatics e.g. diosmin (daflon), ethamsylate (dicynone)
2- Shtmnnal
o lf Bleeding
,+ Progestins
- Provera l0 mgld for 2l
- LNG-IUS @!g) // -+ | bleeding 9\Yoin 1 yr o
,+ COC
- Once daily: 21 days -+ stop 1 wk + repeat
o lf failed
,,+ Danazol or Dimetriose (gestrinone)
',+ GnRH analogues
o lf infertility........induction of ovulation

3- Swaical
. DaC -+ diagnostic (ovular or not - tumor or not) & therapeutic,.,50%
o Hysteroscopic endometrial ablation 3
- ,+ .t generation.
1 .. .endometrial loop resection / diathenny / laser
,q fnd generation. .. microwave / radiofrequency ablation (ngyasud / / e
o Hysterectomy -vaginal, abdominal, laparoscopic-
"+ Failed all above measures to stop bleeding
,+ Associating pathology is found
*+ Old age

* Hospitalization& resuscitation (2 wide bore cannula)

* High doses ofa Estrogen [CEE 25 mglV I 4 hrs] or COC U x4x5l
DaC

2lTnnrsnolo BmrorNc
> Etiology
Occurs at extremes of reproductive life due to waxing &
waning of estrogen levels which are high enough to stimulate
proliferation but not to maintain it
) Treatment
- Estrogen for 10 d. then -+ E+ P for 10 d. -+ repeat for 3 cycles
- lnduction of ovulotion if infertility
WhiteKnightLove
 60 qqrealn q ri
g to Aowloea0 actioa--
o'V/itbdraual p+v)
- Normal menstruation
- After COC
o Breakthrougb
- E + metropathiahaemorhrg1ca
- P -+ injectable conftaception or Norplant
Nile: -.......---.
Day start:

xrlwy 2 3 4 5
mDltr 1 6 7 8 ,|
2 3 4 I
r:\ 5 6 7

!J I il
o
a I il ll NI il
I

t
ilt lil
-
:lob./ lp loP f,ot/
F

Plctorial blood-loss assessment chart.

+ %monfiogia(noo rnoun as HMB = heaW menstruatbteedtng)

D Local .....,..,.....flbr0id, endometriosis, plD
o Systemic........,...blood disorders
a DUB.., ..,......... irregular ripening or shedding
9 rPotywort{un
o Local ...,..........ovarian congestion (endometriosis, plD)
o Systemic
o DUB.......,......functional polymenorrhea

9 *laton{ugb
o Local ..............benign/marignant neoprasms, cervicar urcers
o Systemic........,.,irregular use of contraceptives, IUCD
o DUB........,...,.metropathia haemorrhagica
9 Contrct fite?f,tng
o cervicitis.........cervical ulcers (erosion)......cervical ectopy
o C1N...............cancer cervix
o Vaginal or uterine tumors bulging into vagina
o Severe vaginitis esp senile type
Contact bleeding is considered CIN
until proved othersdse
WhiteKnightLove
 --- Ahnonta0 goalla0 &eeodlng aaaotdlng to ago --

Neonoutpeid
Slight bleeding may occur in the 1$ week + birth crisis d.t.
withdrawal of 'E' obtained from maternal circulation

Cffifiod......h
o Traumatic + foreign body /, sexual abuse
s Inflamm atory + Pre-pubertal vulvovaginitis,/,/
u Neoplastic + . Sarcoma bo@oids (cervix or vagina)
. Germ or Granulosa cell tumor (ovary)
o Miscellaneous -+ Precocious puhrty

L> eufiertt
o Dysfunctional utedne bleeding
o Coagulopathies $rWD)
Cfrihtie4rh,gpetut
o Complications of ptegnancy
o Complications of conttaceptio
futhtonoptltdt fititsrq....., h OO
o Dysfi:nctional utetine bleeding
o Otganic + incidence of tumots is increased (e.g. fibtoid, CIN)
futt 5bt&rg....... h @O
ttotopotlrot
o Malignant ttrmors of genital ftLcty
- The most setious but not the most cotnmofl (tisk is 10-20 oA
-Endometdal catcinoma. . ..cervical cancer.. ...others
o Benign conditions of genital tract
- Tumors -+ endometdal hyperplasia, fibtoids, polyps /
- Atophic Qeruile) endometrium ..../(ttt by HRT)
- Postmenopausal aftophic vulvo-vaginitis
o Complications of HRT or Ptolapse:-
- Ttophic ulcers
- Neglected retained pessalT
o Non-gynecological conditions
- Genetal. ..........hemato1ogic diseases, severe hypertension
- Bleeding / wethra......urethtal caruncle
- glsgding / tectum.. ....piles or malignancy

WhiteKnightLove
 Thyroid function tests
Ckitting studies where
clinicalI indlcated

lnvestigating menorrhagia.

Hysteroscopic surgery Mirena IUD Endometrial Hvstercctomv

OCPs ablation/resectlon
Algorithm for abnormal
uterine bleeding.

WhiteKnightLove
 u ruse of ubnormul oenilul
bleetino h
> I{isto}g
o Age.
-
a Maital status........complications of pregnancy
a Present bist0ry........
,"+ Analysis of bleeding e onset, duration, amount, coc, ttt received
-
"':'T:i:ffif,?#y
;irl:r*""'
- Fever, pain , offensive discharge + PID
a Menslrual bbtor1.....to see if cyclic or acyolic
a Obstetric hitory......recent abortion (2o hge), recent VM (choriocarcinoma)
o Contractptiae ...,.....inegular COC intake, long acting injectabtes
o Pa$ history... ........ .hypertension, endocrine disease, easy bruises

> Exsmihetion
o Genral
- Anemia & its degree
- General disease e.g. hypertension" endocrinologicat diseiue
- Metastasis & jaundice
o Abdoninal
- PelviaMominal swelling (frbroid, ovarian tumor)
- Pregnancy
a Vagi*al + detect a local cause + P/R

> lnuestigqtion
a Bbod tests
- CBC, coagulation profiLe /{
- Organ function test (etiology or preoperative preparation)
- Hormonal assay (for DIJB)
- Tumormarkers
o Scanning
- X-ray (ches! HSG)
- U/S (abdominal, vaginal),
CT, MRI
o EndoscoBt + Laparoscopy, hysteroscopy, colposcopy
BroPg - Endometrial sarnpling
" -
Cervical biopsy
-
Vaginal cYtologY

WhiteKnightLove
 qqernli4? r(

1 . DUB is a diagnosis of exclusion when no other

source for abnormal bleeding can be identified.
2. DUB is thought to be secondary to anovulation,
and is therefore more prevalent near menarche
and menopause.
3. Treatment includes initial medical therapy but
may require surgical modalities for those patients
whose symptoms are not controlled with medical
management.

1. The most common cause of oligomenorrhea and

secondary amenorrhea is pregnancy.
2. Structural abnormalities-polyps, fibroids, adeno-
myosis, and cancer-cause most of the menorrha-
gia, metronhagia, and menometrorrhagia except
that which is related to pregnancy.

1. Postmenopausal bleeding should always be inves-

tigated to rule out cancer.
2. Causes ofpostmenopausal bleeding include
cancer of the upper and lower genital tract,
endometrial polyps, exogenous hormonal stimu-
lation, vaginal atrophy, and nongynecologic
sources.

Ceryical smear and/or

colposcopy if indicated

Cystoscopy if
hematuria suspected

Algorithm for PMB.

WhiteKnightLove
 h Disruss posl-menopou5ol bleebing h
> Ddnlton,.r bleeding from genital tract 1 year after menopause

> Eflolog #.Riskofmalignancyis l0 -20%

. PMB is considered malignant until proved otherwise
> l{Uoru
o Age. . post-menopausal
a Race. .endometrial cancer more coilrmon in white race
a Present ltittor1........
'+ Analysis of bleeding a onset, duration, amoun! ccc, ttt received
*
"":'olfr:ff}lf,.1;H-'-
- pro,ap s e
- Pain, dysparueniq discharge -+ atrophic changes
a Ob$etric bist0ry........
& ovary
r ffi,1113, I :H:;".:f,Tetrium
a Pa$ birto':
*;^;togic diseases, hypertension
- Horrrone intake
> Enmlneflon
o General
-General disease e.g. hlpertension, hematological disease
-Metastasis & jaundice
a Abdominal
- Pelvi-abdominal swelling (ovarian tumor, pyometra in cr. end. / cx)
- Hepato-splenomegaly (metastasis)
o Vaginal + detect a local cause (in details)
- Inspection & palpation vulva
- PV&cusco
- Bimanual examination
- PR is very important in tumors
> lnuegtlgstlon *,
o Diagnosit '+ U/S, hysteroscope, DjgI$J @sC or pap), tumor markers
a Preoperatiue '+ CBC, coagulation profile, blood glucose, ECG
o Metasta$s,+ chestx-ftry, CT abdomen
o Other taufis,-
> Trestmeil ...of the cause * in short (end.cr., cx.cr)

WhiteKnightLove
 64 qrlerrahq? ,4
(Poin roloted to menstruotion)

l. Spasuoors (1"') DvsMENoRRHEA

&turtrg!l Colicky pain of uterine origin occurring on 1" day menses

In absence of any oRGANIC pelvic pathology (idiopathic dysm.) e.g.
- Pelvic patholog.......examination, U/S
- Ectopic . . . .... . ..no cervical motion tenderness

- Salpingitis. . ... ... . . ....cx smear: no chlamydia or gonorrhea

- Appendicitis............no rebound tenderness, normal TLC, ESR

> TuPe of pstieht

. Occurs only in ovulatory cycles
r Starts 2-3 years after menarche & improves after age of 25
. More in virgins & nulliparus (esp if sedentary life)
. Improved after childbirth (cervical dilatation)
> Tgpe of pein
r sit@ ,+ . Lower abdominal colicky intermittent pain

r T me,* IY.3l#:?HJ;"Hff:l'*li!1jlit:?::'""il" now, then

- Rapidly J in intensityafter 24!:trs (with establishment of flow)
. MoV bo ossocioEed u-rith ".r NsV, diarrhea, urinary disturbances
Sweating & facialpallor (t PCZ)

Etiotogvl unknown (theories)

) Exce$ Dmsteglqndins (esp PGF2g) as
- PGFzo causes painful cont. & explains some associating sympt. [NaV)
- Progesterone tes PG production (.'.anovulatory cycles are painless)
> Retentlon of melrstrusl flow as in
- Obstructive theory (acute AVF uterus or cervical stenosis)
- Hypoplastic theory (underdeveloped uterus can't expel blood)
- Disturbed polarity (contraction of cervix & isthmus)

[reot'ne;i
lllledtcst //
> Anti-PG e.g. Mefenamic acid, naproxen, ibuprofen, aspirin
> Honnonal suppression of ovulation: COC
> Recently... glyceryl trinitrite. . ..vasopressin antagonist. . ..sildenafil
2lSurg,csl ,(/Y
> D&C -+ dilate the pathway & lacerates paracervical sympathetic nerves
> Presacral neurectomy (LIINA) -+ intemrpts motor nerves

WhiteKnightLove
 Endocrinology 65
I
2. GoxcesrtvE DvsuexoRRHEA

Continuous dull aching pain in lower abdomen & back SrcoruoRny to

presence of PEtvtc ParHolocy. Pain is relieved by menstrual flow.

o Age -+ usually occurs later inlife (> in MP)

a Pain-+ - Starts few days (3-5) before menses
- Gradually J with the flow & on lying down
Associated symptoms -+ of pelvic congestion:
Menorrhaeia .polvmenorrhea .vaginal discharee

tr9f9gy] (of pelvic congestion)

- Congenital -+ uterine anomalies
- Inflammatory -+ cellulitis, peritonitis, cervicitis, PID
- Neoplastic + fibroids, ovarian tumors
- Displacement (RVF & prolapse)
- Functional or simple (anxiety, emotional disturbance, sedentary
life, constipation, coitus intemrptus)
NB: Endometriosis has special ccc of pain -+ 2ry spasmodic (crescendo)

[@g!Egqd
- Treatment of the cause
- Avoid constipation
- Glycerine icthyol suppositories * I pelvic congestion & pain

3. OTHERS
> Membranous dysmenorrhea
r Painful passage of large endometrial casts during menses of unknown etiology
r character -'.t",",:;:1?##:"1"
finffi#H:l"3 [l[ *ur-..,,,
. Followed byrelief of pain & increased flow
r TTT-+ suppress ovulation (COC pills for few cycles)

> Ovarian dvsmenorrhea (Dlittleschmertz)

r Midcycle dull aching pain felt at ovulation in one or both iliac fossa
o Character -+ . It lasts only for few hours (sometimes 24 hours)

:llilHi::::::i:l:i#Hilfty,:?""j.,11":lg:"",%'"-
o TTT-+ reassurance t analgesics (inhibition of ovulation if severe)

WhiteKnightLove
 ProaoarCrud rracrroao (PMS, PMT)

Definition 4 cyclic recurrence of physical lpsychological sympt occurring in

luteal phase (few days < menses) & relieved completely after menses

fncidence
o 50 - 80 % of females will report uncomfortable / distressing symptoms
o Severe symptoms occurs in 5 %o only + intemrption of social life style,
drug dependence (PMDD: PreMenstrual horic Disorder)
o Up to 60% wrth severe PMS have an underlying psychiatric disorder

Etiology unlmown: theories

> Endocrlne
- tBlJPratio
- t epg & aldosterone + salt &ItzO retention
- t prolactin -+ mastalgia
> &rrtrqt
- Serotonin & p-endorphins imbalance /-)
- Psychological & mood disturbance (anxiety or depression)
> Prostqgfqhdlns
- May explain symptoms in some organs (GIIT, GIT, URT)
> Drc
- High salt r low sugar intake
- Vitamin deficiency (Bo, Br) + cofactors for newopeptides

Clinicol picfiire: diagnosedfor at least 3 cycles.....

o Presence of cycltc
sympt at luteal phase (.'. cycles must be ovulatory)
. ABSENT symptoms at follicular phase (i.e. relieved by menses)
o Physical & laboratory examination EXCLUDES organic pathology
. SyMproMS: (ny 150)
> flftUAi.al
- Mastalgia (pain & congestion of breast)
- Jointpain, muscle cramps, backache
- Abdominal distension, NsV, diarrhea or constipation
-
Waterretention -+ edema of face, LL, t body weight
> floyilalngical
- Depression, fatigue, headache, irritability, change in libido

WhiteKnightLove
 Endocrinology 6T
I
Treotment
l. Generql
- Reassurance
- Depression + . Tranquilizers & antidepressants
. Psychotherapy for resistant cases
Antiprostaglandins -+ J pain
2.Diet
Increase sugar intake & decrease salt
Linolenic acid derivatives (primarose)
Encowage exercise
Diuretics: spironolactone (J aldosterone)
25mg1x3+JNaAnO
3. Mesfql[is
- Vitamin 86 @yridoxine) 100 mg + tserotonin & dopamine
- Dopamine agonists + parlodel or dopergine
& Hormones

> SeruInnin'u.uptabo infrihibn {{{

\ Fluoxetine is considered now the l't line ttt for severe PMS
> Jnftifrilian al ouulatian
- COC (the best ttt)
- Depo-provera (MPA) 150mg IM / 3 m
- GnRH analogues.........osteoporosis on long term
- Danazol ) androgenic
- Gestrinone (dimetriose) ) side effects
- Mifepristone @U-486)
Mo.th ...-..- Nimc

;",';;;l
Jt":* ll [1"*n::,
llil*.,",
llll*"'r-,.r
rl
" , li;'l*l
l__lt_
lBtruction5 for complcdnE

I Fil h drc nii'IclciIh8hr 6e6.c

b.d I aavc blink i, /on
'!orir8.o
lorF. to n[ tr in h&c rctriry
2 rrr cr(h rFpbrn pla(c r mnd
drc.il.k whi.l' bcn.or'.lpoods
'n
to d'c dct,ce or sevc'tryol (rt
rnprotrr cxpqiahc.d drtr dV
] men thc diiry nnr b.dr
for the month,Nrn dE piSe on ts
lidc and loin up thc nirkr @ dbin
aAnpl' Ior ach ![pron'
a The d'nry !6uld & kA( ror tM or
rhree mcn$uilqclc.

r'ieMd hinory dlory.

WhiteKnightLove
 etiobsy
Cs3es^vw",nU
1r"ot.nn
"rn
t
A = =L=L"
I re po rod.,."tlo rn

WhiteKnightLove
I
Et/rrecrh% r1

30% Male factor only 30% Female factor only

20% Combination male

and female factors
'15% Unexplained
infertility

. Causes of infertility.

100

BO

_q
o
l
o
o 60
o
s
40

20
o 6 12 18

<umuhtlv. pregnancy rater ln tho nomalfertilc

popuratlon.

WhiteKnightLove
 !nfertility 68
I
Inlottlltty
Definition
lrs idrrtilifu is INasrt,lry To CoNcErvE qfter 1 year of continuous
marital lifewithout use of any contraceptive method

Ery irtrrrtililg.... Pngvtous pregnancy occured (regardless outcome)

without using contraception (including lactation)
* Yecundibilily o the monthly probability of pregnancy among fertile
couples QFZ1Yo / cycle inunprotected intercourse)
* Eterility e
irreversible infertility ?
* Start essessttent early <a if O previous known disease or O > 35 yrs

> Incidence
\ lO - l5 % (incidence rise with t of aXe)"
\ N. conception rate: 20% Qm),60Yo @m),80% Qm), 90% @m)

> €Eiologv ,+ (may be > one cause ")

O Imperfect spermotogenesis
. lv testicular failure... .........high FSHO
- Congenitol -+ sertoli cell only $, undescended testis, Klinefelter $
- Troumotic -+ direct (immunol.), thermal (varicocele + J motility)
- Inflommotory -+ mumps orchitis, syphilis
- Neoplostic -+ tumors destroying the testis
. 2v testicular failure (pituitary)... ...........row FSH O

@ Obstruction to tronsport
. Congenitol+ congenital absence of vas, cystic fibrosis, Kanagener$
. Troumotic -+ surgery (for hernia or prostate)
. /{ fnflommatory -+ epididymitis, funiculitis, prostatitis (chlamydia)
. Neoplostic -+ tumors of epididymis or prostate
O Foilure of deposition of sperms
. Anotomicol + h;rpospadius & epispadius
. Neurogenic + retrograde ejaculation (diabetic neuropathy & spinal injuries)
-+ interference with innervation (known by urinanalysis)
. Psychologicol -+ impotence & premature ejaculation

WhiteKnightLove
 @ ?'v.12

- Regressing
corpur luteum
Doy 22
Doyl / '( Dav.28
Primordiol follicle -Eorly corpus olbicois

Causes of femalc lnfertlllty

Iypc ol prcDhm Curo ol lnlciultty

Ovulatory problcm Chronlc systemlc lllness
Eatlng dlsorderc

Abnormal pltultary/
hypothalamlc/endocrlne proff le
. PCOS
. Hyperprolactlnemla
. Hypo- or hyperthytoldism
Cannabis use
NSAIDs

Tubal problem Prevlous tubal surgery

Previous ectopic pregnancy

Endometrlosis
Uterlne problem Submucosal flbrold

Uterlne septum
Asherman syndrome
Uterlne anomalles

Coltal problah lntercourse not occurring often

enough
lmpotence
Vaginlsmus

Causes of female lnfertlllty.

WhiteKnightLove
 lnfertility
I
69

O Ovory (3}oh),+ the commonest cause of 1ryl Infertility

o Group I...... H-p failure .... ..as in amenorrhea
.
tr Group rr..... H-P dysfunction........pco, idiopathic anowlation
o Group Ill....Ovarian failure. .Turner $, ROS, pOF
o others
...(zo%of ovulatory dysfunction)

- LPD........Luteal phase defect (4yo of infertile patients)

- LUFS ... ... .... Luteinized Unruptured Follicle Syndrome

@ Pelvic (peritoneol)
o Tn[ometri.osk(IE21%ofinfertility) ] DDof
o j frozen
"ID@rD
s Extensiye surgery ) pelvis
o Tube (20Vo),+ the commonest cause of 2ry / infertility
o Congenitaf. hlpoplasia, diverticula, accessory ostia
o lraurnatk ......surgeryonorneartothefube
o tnftarnmatory .....salpingitis/l
o Steoyfaxn .......broad lig. fibroid or ovarian cysts

€) Uterus (5%)
a Corgenitaf ................. ....aplasia, hypoplasia
o y'rantmatfu......................surgery ) Aschermon
o Inftammatory.. ....endometritis ) syndrome
o Steoyfasm... .. .... ...polyp or fibroid
o lvlisce[fane.ous.................prolapse & RVF + v. rare
0 Cervix (5%)
tr Congenitaf ......atresia (pin-hole os)
o lrattmatic ... ....cautery, cone biopsy ) poor hostile
a Inffamm^atory.... ...chronic cervicitis ] cx mucous
o Steoy[asm........ .....polyp ortumor
@ Vogino
o Cangenitaf.... .......atresia, septum
tr Trautnatic ...........previous surgery, stenosis
a Inftarnmatory . .vulvo-vaginitis -+ hostile to sperms
tr Steoy[asm. ...cysts interfering with intercourse
.

WhiteKnightLove
Toil tip-to-roil tip

WhiteKnightLove
 I
lnfertility 70

> Antibodies against sperms may be performed in:

o tvlafe -+ autoantibodies (after surgery on male genital tract)
a femnfe
- Antibodies against blastocyst (IgM) large -+ serum only
- Antibodies against speflns (IgG) -+ formed in cx mucous
> Antibodies arc either:
o Aggtutinating -+ head to head, head to tail, tail to tail
s Immabifbing -+ head shakers, rotatory, lost forward motility

) Interference of coitus -+ impotence, dyspareunia, vaginismus, anorgasmia

) Frcquency &timing
J frequency -+ decrease chance ofconception ) best is every
t frequ.r.y -+ produce immature sperms ) other day
Use of lubricants & postcoital douching -+ kill sperns
Effluvium seminis (escape of semen from vagina after coitus is normal ?!)

) Definition -+ Infeftility in spite of:

. Normal owlst on (proved by tests for ovulation)
. Normal petanttuDes (proved by HSG + laparoscopy)
. Normal qtsilns coyltg (proved by PEB + hysteroscopy)
. Normal semerr rnelgsis (at least done twice)
. Normal pmtcoltsl test (good cx mucus & sperm motility)
> Unexplained infertility in increasing nowadays (up to 15-30
o/o). lt denotes the inability to identifu
a cause rather than
absence of a cause... Possible causes:-
. Ovatrl ) EA O5%) -+ at early stages .'. laparoscopy /
. Tube ) Sperm dysfunction (inability to attach or penetrate ZP)
. W t Immunologtcaldisorders
. Vagfrnat Subclinical infection (chlamydia, mycoplasma)
) Treatment
. Induction of ovulation (t bromocriptine + antibiotics)
. If failed -+ AIH
. If failed -+ ART
WhiteKnightLove
I
?/n&nk% r4

Drugs that Decrease Semen Quality and Quantity

Cimetidine Nitrofurans Anabolic steroids
Sulfasalazine Erythromycin Chemotherapeutic
agents
Spironolactone Tetracyclines Heavy marijuana/
alcohol use

Examinatlon of a man

Scrotum Varicocele

Size (volume) of the testes Small testes associated with

oligospermia

Position of the testes Undescended lestes

Prostate Chronic infection

Abnormalities...OTA...Rqrcat after 2-3 m

3 lbnormataurnDer
- No sernen + aspermia
- Azoospermia -+ semen but with no sperms
- Oligospermia + low count < 20 million / ml (may cause infertility)
- Polyspermia -+ high count > 250 million / ml

3 Neeospennia + oll sporrs dood ) usually d.t. infections or

3 Isthenospernria + urodr spenm ) immunological causes
3 Teratospermla + dces; obnormol frilns > 85% (e.9. vorlcocelo)
3 goapermta+ prrs ln semen (> 3-5 / HPF)

CASA (computer assisted semen analysls)

A....progressive fonvard motility... ......25y"
B....sluggishmotility. .........oRA+B: 50%
C....abnormal motility
D....immotile

WhiteKnightLove
 lnfertility 71
n $ssessmeot of infertility
...... Mole 0 is ossessed first ......

O Hsronv
, pororrl
o Age---------------testicular function declines gradually with age
o Marital status---If has children or not fit fromprevious marriage
o Address-----------rural areas (Bilhariziasis)
o Occupation------. Exposure to heat (bakeries, ovens) -+ thermalinjury
. Exposure to irradiation or lead -+ testicular damage
o Special habits----Marijtana, smoking -+ impotence
t C/O ,4, orry senital or uroloqical problems e.g. varicocele, urethral discharge

> Past history

o Surgical + hernia.......urinary I genital.......spine / CNS
o Medical -+ DM I TB lMumps
o Drugs -+ . anti-hypertensive, antidepressant -+ impotence
. cytotoxic, irradiation -+ germinal cell aplasia
. anti-fungal, anti-malarial -+ J spermatogenesis

O lmuesrceroNs C'
> Semen analysis
Collected in a sterile container (& not condom)...after 3 days of abstinence
Normal semenog:am
. Macroscopic
- Character-:-----viscid, whitish, liquefles within % hour
- Volume------------2 to 4 ml
- Odor----------characteristic
- pH----------alkaline (7.? - 7.8) "
o
. Microscopic
- Count---- > 20 ,/ million /ml (60-120 @ )
- Morphology----- > 30% have normal shape
- Motility--- > 50% show fonruard motility after 60 min
- Pus cells------------less < 1- 2IHPF
- Antisperm Abs ----- -ve (MAR) mixed agglut. reaction
> If azospermia ,+ testicular biopsy
o If *ve -+ obstructive -+ vasography to know the site
o If -ve -+ testicular -+ l. chromosome analysis
2. FSH & LH (differentiates lry / 2ry test. failure)

> If OTA,,+ immunological studies or CnS

WhiteKnightLove
 f\ist"ry
B netls..'-YrqS -S: Bqr:,tt
.

t History suSgesrive of ovarlan factor

- Estrogen . frregulor menses
. Lock of 2ry sexuol ccc

-'orqcrorrh.'..iffi:ffff;Ii:]']fi lflg:1'o*,*o.rodenomo)
- Hirsutism
- Chorges in hoir texture,weight, hot/cold intoleronce (thyroid)
0 History suggestive o6tubal factor
- Previous PfD (fever, obdqninol poin, dischorge)
- Previous surgery
- Endometriosis (severe poin, bleeding)
f Hlstory suggestive of uterlne factor
- Hypomenorrheo (septic obortion, Aschermon)
- illenorrhogio (endometriol polypi)
0 History suggestive of cervlcal factor
- Previous surgery to cervix
- Excessive leucorrheo
- Chronic bocloche

WhiteKnightLove
> Personal
.Age------ very young + ovulation not yet established
. older -+ have less chance, so proceed rapidly for ttt
.llsrthl strtus--------less chance on longer periods of infertility
.Pslttg------------to determine if lv or 2ry infertility
.Address-----------------Bilhariziasis : tubal block
.0ccuprflon-------irradiation or heavy metals -+ ovarian damage
Spectrt hsblh......... ...............Personqt Historg of the Husbsnd

> Couplaint zp faiture to conceive 2v)

(1ry or
* amenorrhea * galactorrhea t hirsutism

> Menstrual history

Msngche--If delayed menarche or lv amenorrhea -+ anovulatory disorders
Ue-----------. Inegularity -+ anovulation
. Dysmmenorrhea + - Spasmodic----usually ovulatory
Congestive-----pelvic pathology
2ry spasmodic--endometriosis
. Premenstrual tension -+ usually ovulatory
. Premenstrual spotting -+ corpus luteum insufficiency
LMP-----important to plan treafnent

> Obstetric (only in 2v infertility)

tPuerperal sepsis -+ Ascherman syndrome
rSevere hemorrhage -+ Sheehan syndrome
> Past history
.Medical -+ TB, DM, HTN, fever, endocrine disorders
'Surgical -+ CS, DsC, ovarian cystectomy, laparoscopy

> Pnesent history

Arnenonhee----Galactorrhea--Hirsutism
Bleedtng-----'-organic or functional (ovul ar or anovul ar)
Dtscherge----cervical or vaginal infection
Enlggernelt --abdominal swelling: fibroid or ovarian or pregnant
!rin------------dYsPareunia
.If superficial -+ vulvitis, vaginitis
.If deep -+ endometriosis, PID, tumors, displacement
Prwlous lnru*nftg tnuestlgrtlons or Therapg Tilqls----**
> Eexual histony o AS lN 0OIAL EA0T0RS
WhiteKnightLove
 Post-ovulotory
squomes.hi €'@
Prercvulotorv
squomes Progesterone motures
the sguomes
A lorge cell with'
which develop
o smoll nucleus
rolled edges.-*
shows oestrogen'
stimulotion

3. Endometriol Biop_gy
Premenstruo I endometrium is cleor evidence of on ovulotory cycle, but curettoge
or ospirotion is uncomfortoble lcor the potient, ond not olwoys feosible through o
nulliporous cervix.

lrtq:C]glo_ry endo- Post-ovu lotorv

metrium showing endometrium
oestrogen siimulqtion. showing the
Note the norrow effect of
non-secreting glonds, progesterone.
The epitheliol ond Note the
stromol cells show diloted
prol iferotive octivity, secretory glonds.

There ls no evidence that the

use of temperature charts or
LH "ovulation predictorl' klts
to time lntercourse around
oruhtion mpro\res the chance
of conceptlon; body temperature is a
poor predictor of ovulation, and LH
kits, although better, are expensive,
Also. timing intercourse is
psychologlcally stressful and can be
countelproduetive.

WhiteKnightLove
OSymptoms suggesting ovulation
> Regu laritv / / of cycles. . ...spasmodic dysmenorrhea. . . .PMS

> Midcvclic (ovulatory) symptoms:-

- Discharge -+ due to t cervical secretion (E effect)
- Pain (Mittleschmertz) -+ due to ovulation
- Spotting -+ due to relative drop of estrogen level
OTests for ovulation (DtD
o
> MattrVg7f (0.2-0.3'c rise in 2nd half of cycle) d.t. 'P'
- Biphasic -+ ovulatory
- Monophasic -+ anovular
- Shom (10d) + CL insufficiency
Disadvantage: not so accurate, affected by infeaions & fevers

> Vutrvl gmear 4 progesterone effect (intermediate cells)

> Cervlczl wcus e) profuse, +ve Spinnbarkeit, rve fern. ...E effect
turns -ve on day l7-2L ..P effect

> ?remen*rual endandrlal blo?eu o [& di"tr.b o possible pnegnoncg ??J

- If ovulation -+ secretory endometrium
- If CL insufficiency -+ lag behind menstrual dates by ) 2-3 days
- Diagnosis of diseases of endometrium + TB endometritis
> lhrmme mgaq
- Mid-luteal / progesterone (21")
- >10 ng/ml + ovulation * good CL funetion
- 5-10 nglml -+ ovulation + CL insufficiency
- < 5 nglml -+ anovulation
- Urinary LH kits 7 ovulation within 36 hrs [for eonlg detection]
> Tdltaiandru (serial U/S) a gradual t in follicle size to 20-22 mm
followed by sudden collapse
a tri-laminar endometrial lini
Ovarian n*erwe is known by day 3 FSH, antral follicle count CIV-US).
clomi chal test, inhibin B and AMH (anti-Mullerian hormone

OTests for other ovulatory dysfunction

> lf anenonhea---------Prolactin ,Tt a +, progesterone challenge test,
o
Gn. assay...dav 3
> lf h4?erprdactsnenta---Prolactin, CT brain
> lf hu?eratdrwntm------Dl{EA-S, testosterone

WhiteKnightLove
 qrt.rrlogq r,

Ul6ru6 tull of
cfilEst agenl

Righl Fallopian
tube

(a) Hyslermalpinoo0ram conllmlng lubal patency; lhore is bilat€ral psritoml splll (b) Schematic represenlalion

(a) Hyste.monlrasl syf,ogEplry showino a Fallopian tubc (b) Schomatic rep.esentation

WhiteKnightLove
 I

lndlcotlors "r infertility, after tubal surgery or myomectomy

ConEolndlcotlons'+ pregnancy, bleeding, infections
Tlmlng + best is 2 - 3 days postsnensEual o
- To avoid disturbing a possible pregnancy
- Thin endomefrium. J rist of embolism or infravasation
. J rist< of endometiosis
. Avoid false negative results

(D Hvsterosalpinsographv
MeUrod + radio-opaque material is injected through cx & x-ray is taken
Advantages
- Oiagnostic......localizes exact site of pathology (uterus, tubes, peritoneum)
- llfurapeutic..,....Pressure during injection can break some thin adhesions
.I2 has antibacterial effect

@ Laparoscopv

relPru$!ry__
PCO & other ovadan for PCO, ovarian
cauterization of
Ovum pick up in IVF

@ @ycosy)
> llsthod - Injection of Echovist (a galactose suspension) via the cx
- The flow of solution is seen by transvaginal U/S
> Aduentage 4 no radiation, no anesthesia, offrce procedure

@ Tuboscopv
> Mathod - Falloposcory-+ trans-cx endoscopy oftube (via hysteroscope)
- Salpingoscopy-> trans-abd. endoscopy oftube (via laparoscope)
> Advonhge + both tubal anatomy..&..phytiology [mucosal cilia] are studied

@ Tubat cannulation
> Method - Transcervically, try to pass a catheter through the tubal ostium
- This is done guided by hysteroscope
> Advqhtsge <) bypasses cornual block

@ Older methods ,(
> Tubsl lnsrrffistlon (Rubln's tsstl - inject air through cx canal then do x-ray
> Kgmogsphg - pressure changes are recorded on a revolving drum

WhiteKnightLove
I

Role of Hysteroscopy in infertillty

Dtqgmstrc Theroperrttc
Tubes r-glel hl_qq.k (qg99_9s
the -c-o_1pu
Any major pathology
Uterus

Role of Ultrasonography in infertillty

Tubes
Ovary
Uterus

fhe Postcoitol Test (PCT) fhe Sperm lnwsion Test (SlT)

This test demonstrotes the obiliiy of
sperm to remoin motile in ovulotbry cervi-
cql mucus. A somple of cervicol mucus is
obtoined obout 4 hours ofter coitus ond
exomined microscopicolly. At leost ten
octive sperms should be present in o high
power field. Defects of motiiity ore qn
indicotion for ontibody testing.
Thistest is corried outwhen the
PCT is persistently negotive, ond
requires o specimen of eioculote,
o drop of which is ploced with o
drop of cervicol mucus on qwormed
slide. The sperms should be ob-
servedqctivel y invoding the mucus.

WhiteKnightLove
> Ultrosonogrophg (Q..tlrttot ts Ere rrclue of U/S in tnferilliry?) (2
> Hystaroscopy (Q..tUhot ls the rroluo of hgsteroscopy tn tnferrille?) e
) PramonsBuol endomeHol biopsy
) Hvsterosolpingogrophy

> Sims-(Huhner postcoitq[ tsst

- Semen analysis must be normal
o
- lntercourse is done at midcycle (favorable cx mucus) after abstinence 3 days
- 6 hrs later, a drop of cx mucous is collected
- Normally -+ sperms are found to have forward motility in the cx mucous
- The following is assessed (Mognissiscorel

U Cervlcol mucus scoro (0,1,2,3) for

. Amount. .... .viscosity. . ... Spinnbarkeit. . ..Ferning. . ..cellularity
. Total score <5 -+ Hosrtm cx mucus
5-10 -+ Urvrevonenln cx mucus
10-15 -+ Fevon-e-nr,E cx mucus
2l Sprm <ount & motllltv ossossment
. More than5-20 / IIPF spe(ms with forward motility / IIPF
. Immotile, shaking, rotatory movement denotes infection I antibodies

oo
Ettotog of cr hogfiffig or -ue PCT *o
o Wrong time of cycle -+ Pr. effect or lack of adequate estrogen effect
o Poor glandular secretion d.t.
- congenital, poor estrogen response, cr.ouilo therapy
- Destruction of glands by cautery or amputation
A Infection + CgS from vaginal& cervical mucus
,\ Immunological factorc -+ cervical mucus (lgG) or in serum (lgM)

> Eperm wnetration tast (Done tf pcl ls -vef = 0x rnucous 0ontsct test
U Sllde test
. Cx mucus * donor healthy semen -+ detect abnormality in mucus
. Donor healthy cx mucus * semen + detect abnormality in sperms
2l Coplllory ube test
. Semen is put in a reservoir & cx mucus is sucked in a cap. tube
. The tube is examined for sperm migration after 30, 60, 180 min
WhiteKnightLove
 Factom advesely affe(ting conception mts Preonception advice

Lifestyle
Female factors Male factors Combined factols
Stop smoking Optimire mnaBement of
Age (>37years) Low numbers Duration of mediel prcblem
of motilc, infertility Stop recrational Eliminate drugs not rfe for
healthy sperm (>2 years) drugs Pregnancy
Optinrire body weight to a
MenstLual FSH Dlug intake No previous body mas index of20-30
level (> l0 u/L) conception in Eliminate drugs not safe for
curtent Pregnsncy
relationship Regular uual Preprcgnancyffient
inlcr@uree, 2-3 tim6 by an obstaric physician
a week Commence folic acid
FSH, follicle-stimulating honnone.
supplements
Ensure immunity to rubella

Splint

r.;+I'
\I'i\
, Ulerus

Thq tube is guidod into thc

utrrus qnd 3ulurcd in ploce .

Splint

, Ulorus
I T 't
rolrnosis
w6ll

WhiteKnightLove
> deneral .............,pcR- qq..............
- Correct Psycgoroctclt factors
- Correct Coner errors.. ..good timing
- RressuneNcp if the patient seeks rapid outcome
- Improve GBNsner health
- Treatment of any Gnoss pathology (fibroid) or local infections
> if ovarian cause
- Anovulation e.g. PCO -+ induction of ovulation....lap. ov drilling
- Hyperprolactinemia -+ dopaminergic drugs
. LUFS -+ induction of ovulation
. LPD + prog. in the 2"d 7/z of the cycle
- Resistant ovary syndrome -+ induction by high doses Gn.

if oeritoneal cause (endometriosis)

- Induction of ovulation -+ if no masses or adhesions found
- Surgery if there are -+ masses or tuboplasty if -+ tubal adhesions
> if tuhal cause .. tuboplasty (microsurgery)....

Perih.bol odheslol gsis (lysis of adhesions) -+ best prognosis /

Neoslpingostomg + new opening (as in hydrosalpinx)
€nd to end ono*omosis + to bypass occluded segment
Tubo! relmplonhtlon -+ in isthmic block rr

- Laparoscopy is better than laparotomy

- Previously repeated tubal insffiation or hydrotubation were tried
- Prognosis is poor (conception rate 1040%o, ectopic may occur)

> if uterine cause O surgery e.g. polypectomy, myomectomy, hysteroscopic

lysis of adhesions in Ascherman syndrome, metroplasty
......What is surrogate mother?
if cervical causes
- Cervical infection -+ antibiotic according to CsS or cauterization
- Poor quality of cx mucus -+ CEE (Premarin) 0.625 mg at days l0,tl,lz
- Immune causes -+ steroids + condom for 6 months -+ to J antibody level
- Failure / resistant cases ,,.t A!ts
in all cases.......if failed......,'+ ART
WhiteKnightLove
O errcsfoear
o Clomiphcne citrote (Clomid) + 50 m9
r Tomoxifen (Nolvodex) + 10 mg lt?hrs
o Aronatose inhibitors (Letrozole)

Chrntd
Action
, Synthetic non-steroidal antiestrogen E
. competes with E for its receptors on pit. & hypoth. (hypo-estrogenemia)
-+ Decreased -ve feedback on FSH & GnRH
-tGnnu *t
rSH & LH -+ follicular development
o
Dose (Tab = 50 mg )
.7 x2 x 5 starting from the 2* (5*) day of the cycle for 6 cycles
. lf there is amenorrhea + give progesterone...withdrawal bteeding...then start
. If no ovulation -+ increase the dose up to S tab /day (250 mg)
o
Side effects
. Hot flushes, dqr vagina, breast tenderness, headache, visual disturbance
. Multiple pregnancy (5-10%)
. OHSS (Ovarian Hyper Stimulation Syndrome) -+ rare
' Relation to tumors ' ' '
i I'11 'i"H#.t f :fl,.?il & ,o anraeonistic acrion)
Results
s GmdresPonso (75%) known by
- Biphasic Body Temperature
- Mid-luteal progesterone
- U/S + folliculome@ (mature Graafian follicle : lB-22mm)
\ llo resDonee (CC failure or resistance) m.b.d.t.
- Another cause of infertility
'
- Poor cx mucous (anti-E etrecg + add small dose of b atovulation
- LPD + glve HCG orprogesterone
- LLJF + give HCG
\ ff fs,ld, nrrg rdd tho ftltortng
- Merprr,n -+ Or.u,y in cases with PnovsN insulin resistance in pCO
- Bromocrlpdne + even if the prolactin level is normal
- Tttyro)dn -+ in cases ofhypothyroidism
- Daemethasone + suppress adrenal androgen
- Natotrerorp (opioid receptor blocker) -+ opiods J Cnruf release

WhiteKnightLove
 lnfertility 78
@ Antiestrosen + HCG
> Preparation
c Pregnant urine -+ Pregnyl, Profosi (IM)
o Recombinant DNA -+ Ovidrel(SC)

> Action. ... acts like LH

> Dose'*'
lofnl tHfi:'3.qJH,ff.tilio,-r
- E2 is 1000-1500 pilml (not given if > 2000 to avoid OHSS)
,,+ advice intercourse on same & next day of injection

@ Human Menopausal Gn fHMGJ

> Preparation
c Postmenopausal urine (IM)
- Both FSH (150 ru) & LH(75 ru) -+ Pergonol, Humegon
- Mainly FSH (150 ru) & LH (< 1 ru) -+ Metrodin (esp for PCO)
;DNA (SC) : FSH& LH (no)
-+ Puregon, Gonol F
) Dose,+ Ilampoules on 3'd day of cycle -+ repeated on days 5, 7, 9
- HCG is given according to folliculometry & serum E2
- Combination with AIH may improve outcome
> Response
- Ovulation occurs in more than > 90Yoper treatment cycle
-
Treatment is continued for 3-4 successive cycles
> Side effects
1. Multiple pregnancy ..2OYo "
2. Abortion & PTL.
....15%
3. Ectopic pregnancy ...5%
4. OHSS. ....2%

Other indications of HMG

o
- Hypothalamic-pituitary failure (group I & ID
Unexplained infertility
- To induce forART

@ CnRA rLHTHJ
) Dose ,'l
ev€ry 60 - 90 min for 2-4 wks by:
\
a special pump (IV or SC). . ..OR.. ...nasal spray y'
> Adu ,,* uS€d if ovary is resistant to induction
> Disadv,* expensive & difficult
WhiteKnightLove
 Eqderaln% r,

Blood supply Slimulated bllides

(b)

(a) Ultrasound showino stlmulated ovary with multiple follicl0s and associated blood supply. (b) Sdromatic r€presentation.

Ratc
wenLc, includa
'warianrupWrcwil,}],
lwmorrhaqe and adull,
raaplraroty Aibt cbg
oyttdrome., ?leutal
(ARDe) \:-._ cl'l\tEions

:\a aite6

Ovarian
Oli6rria, cnlarqefianl
cledttolyla >12 cm
imbalanoc
'llromDo.
anbolism

WhiteKnightLove
tDathoEeoesls

o HCG injection + 1pc... ..Ez......histamine -r t capiilarypermeability

+ shift of fluid from intravascular to etctravascular space
o It occurs olt v after injection of HCG (3-6 days after injection)
\ nenE with clomid alone
\ with GnRH o
r.lsvER
o Prognosis will be worsened if . test is +ve (why ?)

Cllnlcal plcture
1. Mild form + ovarian enlargement without cyst fonnation
+ abdominal discomfort
2. Moderate form + ovarian enlargement with cysts < l0 cm
+ abdominal pain, NaV, diarrhea and weight gain
3. Severe form o + as above but cysts are large
+ . hypovolaemiq hlpotension, oligr.uia
. haemoconcentration + DVT & embolism
. J renal perfusion -+ Na & ffrO retention -> edenra,
ascites, pleural effirsion, hyperkalemia & acidosis
(reatment
> Pmphglodc ,'t avoid HCG injection if - serum E2 is > 2OOO pghnl
- 2 3 follicles each Z 16 mm
> tlfid foitn '.+ no treatnent (rest at home * frequent follow-up)
> llodents & ssvsla ".r HospITarZATroN (even in ICt) +
l. Complete bed rest + no P/V (to avoid ovarian nrpture)
2. Analgesics for pain, anti-histaminics, anti-prostaglandins
A Hukl & sats rcotrlcfion to rcdue ascltes, hydrodrorax
t
- No diuretics (f hypovolaemia -+ haemoconcentration)
- Fluid chart to monitor intake & output
- Paracentesis or pleurocentesis (in resistant cases)"
? Follow up of
- Vitaldata (P, T, BPr)
- Hct, BUN, creatinine, coagulation profile, ECG (t K)
- U/S to follow the decrease in size of ovaries

5. No laparotomy Excppr IF o + complicated cysts (rupture, torsion)

6. New lines of therapy: Heparin / Albumin

WhiteKnightLove
Egg collection

WhiteKnightLove
O Glo {Iltro cFecillzadoo e, tsobwo cfransfer -lVF& ET-
> lndhstlons
o Tubes -r damaged or absent
o Peritoneum + dense adhesions e.g. endometriosis
o Hostile cr (e.g. antibodies or infections) -+ after failed IUI
.Unexploined infertilitg "
- Mole infatllity + d.t. severe OTA (only fewthousands are needed)
> Te$nlque
l. Superovulation,+ multiple ova
- Down-regulation by GnRH o (inhibits ovarian fimction < induction)
* Lonq protocol.,....starts day 21of the previous cycle
*Short orotocol (flare up)..,.starts with the
same cycle
- Then give: different protocols of HMG -+ folliculomety follow up
- Then give: HCG IM + complete ovum maturation within 34-36h:l" "
2. Oocyte (pic k-up) retrieval,+ transvag inal U I S /
.,,:.::i: g.Fertilization invitro
- Ova are incubated in a culture medium at37oc for 4-6 hours
- Then prepared sperms are added for fertilization.
- Wait till the fertilizndegg reaches 4-8 cell stage (takes 48 hrs)
4Embryo transfer
- The fertilized eggs are injected into the uterine cavrty near firndus
- Transfer (acc. to age)2-3 embryos b l, %of multiple pregnancy
- The remaining embryos are frozen (cryo-preservation) for later use
g.Luteal phase support "+ progesterone or HCG

> Resulh
. The procedure is repeated for 3 or 4 successive cycles
. -
The pregnancy rate is 20-30 % Q5 yrs) l0% (40yrs) per ttt cycle
. Multiple pregmncy occurs in about 35%
. Ectopic pregnancy occurs inabolt3 %o

O -etFT-
> Omgte & cperrns are placed into the fallopian tubes either through:
(
Ampulla (via laparoscope) or Isthmus (via hysteroscope)
> Ruulh ,+ 3}Yopreg. rate (better than IVF but with > ectopic)

O -ilrr-
> The fertilized oocytes are placed into the tubes as zuEdes

WhiteKnightLove
 hlrq[oplasmlc spom lnlstion.

Uterur \,.

WhiteKnightLove
 I
lnfertility 81
U@-@sg=ila-seuoits-at8@rn-

> $ntraqrtoplasmic sperm lnjection -ICSI- r/

* Technique

'A single sperm is injected into the cytoplasm under microscope

I In case of obstructive azoospermia, sperms are aspirated by:
M ESA (4qicroinsemination aft er gpididymal gperm 4spiration)

TESA @sticular gperm 4spiration)

* lndicotions
. Failure of IVF trials (better results)
. Refractory unexplained infertility
. Marked oligospermia
' Marked asthenospermia
$ubzonal insemination -SUZI- X
* Technique
. A hole is made in the zona pellucida (enzlrmatic, laser, zona drill)
. 3-6 spermalozoa are introduced into the subzonal space
* Resulls -+ fertilization rate is 15-30% (.'. replaced by ICSI :30-60Yo)

A"rtitr0eiiarl Lssem,Ln a,tii@n.

$nclications
* Arliflciol inseminotion husbond (AIH)
! Coital factor (failure of deposition of semen in the vagina)
' Male infertility (OTA)
. Cervical hostility
' Unexplained infertility
* Artificiol inseminotion donor -+ in sterile husband (unreligious, unethical)

Technigue
l. Induction of ovulation
( Better results when AIH is done with induction of ovulation
( Better results with gonadotrophins than clomid
2. Processing (preparation) of semen
- Anti-PG. ..........as it -+ uterine cramps (expulsion of sperms)
- Anti-biotic..... .. ifpyospermia
- Proteolytic.... .. ..........J viscosity
- Caffeine, Kallikerine... . . asthenospermia
3.Injection of 0.3 - 0.8 ml intrauterine (IUI) bV special catheter

WhiteKnightLove
 *.,
Ji,

Tgstoslerore
LH+

a;\
( @tt
)
Fl0w diagram illustrating the relationships oflhe
hyp0lhahmo-pituitary-.te61irular uis. (LH, tuteinizln0
hormonei FSH, iofid}stimulating hormone; LHfiH, luteinizing
hormonB-releasing hormone.l

WhiteKnightLove
 I
lnfertility 82
-- 1[xtras --
Historv
o lpulseBrcxrtn 11't IVF bom child) 1978 has gone her own baby naturally
. Edurards + Stemoe (British) won Noble prize (2010) for developing IVF

Advanced tacts in ART

. Ovarian reserve (to assess how much ova are present to predict IVF success)
is known by O ovarian volume, antral follicle count, (DFSH, LH,
E2level, inhibin B, AMH (anti-Mullerian hormone) O Doppler
. Superovulation doesn't lead to early menopause
I llumber oFfollicEs doesn't guarantee number of eggs to be collected
. Embryo grading (l/-2-3-4x) depends on ORapid division, Oequality of
cells, Ofragmentation
. Number oF embrro transfer depends mainly on age (max 3). Recently there
is a strong drive for SET (single embryo transfer)
. SeEctive embryo reduction is better to be performed If triplets results
o QryopresewatioD: Sperm freezing is best - Embryo freezing is more
successful > egg fieezing - Ov. tissue freezingis still experimental
. So( determlnation is possible by PGD
(pre-implantation genetic diagnosis)
. Assisted laser ha,tchfng (to zona pellucida) may improve embryo uptake. Still
the most difficult step to be controlled is embryo uptake by endomet.
. CFMF < I yo (e.g. hypospadius) is not more than in natural cycles
. Bta$ocystoaDsfer (day9) is recently popular than ET (dayO). The embryo that
divides till blastocyst stage is probably healthier with better success

Management of male infertilitv

Chronic prostatitis -+ antibiotics (according to CsS) for long time
"o Persistent low sperm count
- Clomiphene25 mgld for 25 days * mucolytic
- Gonadotrophins (if FSH is low)
o Hyperprolactinemia -+ bromocryptine
o Varicocele -+ surgery (improves qualrty if it is significant - grade III)
o Impotence, premature ejaculation -+ IUI (AID)
o Oligospermia -+ ICSI
o Obstruction -+ TESA, MESA

Causes of sterilitv
o Female -+ POF.....absent ovaries (Turner).......uterus (M. agenesis)
o Male + Klinefelter syndrome.. . . . . .. . ...absent testis (Mumps)

WhiteKnightLove
WhiteKnightLove
 Ror*ingof corfiwefltirc meduds by
rote ofeftrtir,eness

Fallurc ratea
per l00HrrVY
GroupA l,lortefiectire
Tubal ligation/vasectomy 0.005-o.04
Comtined oral 0.00H.30
Sequential oral 0.20-o.s6
Group B Hlghlysfrcdte
IUD 0.5-3.5
Continuous progestogen t.5-2.3
Dephram orcondom anC cream
All users 4.O-7.0
Highly motivated t.5-3.0
Fariodk abstinence
All users t0.0-30.0
Highly rnotlwted 2.5-5.0
GrcupG ls.€ftc(lv€
Coitus interruptus 30.0-40.0
Vaginal foam or cre:rm 30.0-40.0
Grorp D l,eesGeilhcthrc
Postccial dotrche 45.0
Prolonged breastfeeding 45.0

WhiteKnightLove
 I
Gontraception 83

{rtt ScuatlV plrnnlngl Zrtir

9obs of familv plannio€

- SregnanE qpdctw (whether reversible or permanent)
- Management of ufertititl
- Management of recurrentfetaf foss & gmetic counseting
l}Iethods usecl

llAe coilon SpenntctdA hs+ lende

?ende condan Foom -loporoscopg
€ffiaruescant liledtabed -Loporotomy
VE, dtEWun -Cocfpzr -Hgsteroscopy
TobleEs
Cervtcd cq Geom - Progost.
Ya, s?ow Supposltorle (mlreno) lMe
s Jellg Vosectomy
C-film

"No ide,o! controception is present; ue use onlg he most sr.lltoble"

Q. urhot ore the controindicotions for pregnoncy ?? sae lost pogo

cfherr could be dlvided lnto

> Hormonal
Combined (E + P) ,+ OCP,....monthly injectable.....,..vaginal ring....,...skin patch
Progesterone only,+ POP..... injectable (DMPA)....implants....Pr. releasing IUCD
> Non-hormonal "+ l.physiological,Z.barlier, 3.chemical, 4.IUCD, S.surgical

> Short acting...........physiologica1, barrier, chemical, OCPs

> Long acting. . .. . . . . ....i-plants, injectables, IUCD, surgical

> Irreversible,+ surgical

> Reversible "+ all others

Qearl tndex (Pl)

It is method used to determine the pregnancy (Fntr.unE) rate
- among 100 women (HWY)
- using a contraceptive method for 12 months
x Perfect use rate -) represents the theoretical efficiency
* Typical use rate -+ represents the actual users' experience
.Higlrly effective method has a failure rate < I/HWY

WhiteKnightLove
I
q,cltarnln% rl

l. Natural family planning methods are the least

effective methods of contraception and should
not be used if pregnancy prevention is a high
priority.
2. These methods rely on physiology to prevent
pregnancy and require highly motivated users.
3. Periodic abstinence relies on accurate prediction
of ovulation and abstinence from intercourse
during periods of maximal fertility.
4. Coitus interruptus has a high failure rate attrib-
uted to the neid for sufficient self-control to with
draw the penis before ejaculatlon and the high
likelihood of deposition of pre-ejaculate into the
vagrna.
5, The length oflactational amenorrhea varies
htw. d,&aw the nnr (ettuM) m&od widely during breast-feeding; therefore, breast-
feeding should be used for contraception for a
maximum of 6 months after delivery.
U,ht*ilt. I iM:llNotilfuil

5
NO
doys
No n.htltloilal cofrlfceptlot nec-
er&ry

988

986
o
c
c
984 o
c
6
I
982

980

WhiteKnightLove
 I
Contraception 84

O Safe period: -fertility olvoreness-

" Calendar method d ovulation occurs 14 d < the l't day of the next cycle
. I.C. is avoided 2 days < & 2 days > the calculated day
. Ovum lives -+ 24hrs / sperms live 48 hours

" Besal bodg tempereture O l.C. is only allowed after owlation has
occurred by 3 d, i.e. after 3 d of rise of BBT
n Ceruieal rnueus method a l.C. is allowed only after 3 days from
'Billing's method' disappearance of wetness
- €sLrogon +
profuse c( mucous +
ru@t sensoEion
- efter ovuloEion, CL -+ progesEorono -+ dryness of secretion
o
- The aest is combinotion (sgmpto-thermol)

" Urinarg LH fits (Persona) d detects ovulation by LH surge in urine

I irqrtrc,*; ; i"grt*.i"t"r, ;du;-t.aE*"tirrt"a.""ples - I

I oisadrrantage> rate (15-30 / HWY) |

O Lactational amenorrhea method

Idea: prolactin -+ inhibition of ovulation
rncreasins

iffiffi*";iilftJ..i{; day&2 by night)

. No supplementary food is given
Advantage + available from l't day, not costy, healthy to infant
D i sadva nta': .
l;lf br eeding o ccur)
m;: ,f il,fJi?t'Hffit
O Coitus interruptus &, interfemoris
Idea -+ withdrawal of penis and ejaculation outside the vagina
or intercourse between both thighs
Disadvantages
' Pregnancy may occur in spite of ejaculation outside the
vagina as the pre-ejaculatory fluid may contain speflns
. Less sexual satisfaction -+ pelvic congestion
q menorrhagia, leucorrhea & backache

WhiteKnightLove
I
qr/rurnlnf/ /4

. Banis methods and rpemicids

. Placement of the vaginal diaphragm.

Spermicide
creom ln-
iected into
the uppcr
vogino.

i
))
Z,

rdom,

1. Condoms. dlaphragms, and cervical caps act as

mechanical barriers between sperm and egg.
Their efficacy is rate is 80% to 90% with practical
u5e.
2. Condoms and spermicides containing nonoxynol-
9 provide prophylaxis against STDs.
3. Diaphragms and cervical caps must be prescribed
and fitted by a physician.
4. Spermlcides come ln a variety of over-the-countel
forms at minimal cost. Spelmicides have both a
barrier and spermicldal effect.
5. Efficacy of spermicides is 75% to 80%, but
varlability in user technique can significantly
lower efficacy.
6, Etficacy rates are greatly lmproved when using
. Placement ofthe cervical cap, both barrier and spermicidal methods together.

WhiteKnightLove
 Contraception 85
I

ll Condom (French letter)

SF
15 x 3.5 x 0.02-0.07
r No side efiflects or contraindications
. Non contraceptive benefits -+
- Protect against STD ", PlD, CIN
- Treatment of immunological infertility
- Collection of semen for semen analysis (spermicide free)
2l Female condom (vaginal pouch)
. A polyethylene rubber sheath which lines the vagina (17 x 8 cm)
. Has 2 ends # a closed end and an open end

3l Vasina! diaphraem (Dutch cap) 5G95 mm

. Inserted in vagina < IC & removed after 8 hrs (till all sperms die)
. Disadvantages
- Difficult to apply -+ needs well training in the clinic "
- May lead to cystitis if large size, not suitable in prolapse

4l Ceruical cap
. Applied directly to cervix (22-25-28-31 mm)
. Used if there is prolapse (diaphragm can't be applied)

5l Vasinal sponse (Today)

. Synthetic polyurethane sponge containing Nonoxynol-9
. Very easy to insert & remove (up to 24 hows)
. o
Disadv. -+ Toxic shock syndrome if left long (staph aureus )

No effect on Failure rate -+ I14 / HWY

No svstemic side effects lead to ic reaction
Easy to initiate & continue I lntenupt natural act (J sensation + t erectile difficulties
Condom protect against ST

" Method
- Spermicidals -+ Nonoxynol-9 & Octoxynol-9
- Action -+ destroy sperm memb + J Oz uptake

'? Supplied as foam / jell / cream / effervescent tablets / suppositories

't Use P - Inserted 15 min before intercourse ) high failure rate
- Intercourse must occur within 2 hours ) :
- Delay postcoital douching for 6 hours ) 30 / HWY
WhiteKnightLove
 Plasllc lntrautsdne devices: Lippes Loop, Sat-T
coll, Dalkofl shield.

CoppoFbearim lntaub.ine dwlces: Multllmd,

Copp€r T 380.

Hormono-releaslng lntrauterln€ devlces:

progesterono-reloasing lUD, levonotgestrel-rolsasing lUD.

kvonorgestrel- releasing intrauterine

system

Disadvantages

Highly effective Persistent spotting and

Dramatic reduction irr
rnenstrual blood loss
Protection against pelvic
inflammatory disease
irregular bleeding in
first few months of use
Progestogenic side
effects, e,g. acne,
breast tendelness

WhiteKnightLove
 I
Gontraception 86

a Made of .Polyethylene (non-irritant plastic), with 2 nylon threads

\ marker for its presence & facilitates removal
. Barium -+ make them radio-opaque to confirm their site
e Tvpes
nDec Duraton
1l Ineft
Replaced now by t&pes loop Double S shaped Indefinite I

medicated devices 4 sizes:- ABCD I

2l Medicated Wlth copper

Most commonly
-Cu7 CuT200, CuT220 CuT3806{{ !10 yr
- Cu T 3806, (+ silver)
used now are-+
iess pain & bleeding
- Nova T
Multiload Cu250, Multiload Cu 375
l{tfi progesdru (levonorgesterel "; LNG-IUS
-better pregn. protecti
* Progestasert ) most recent
lyr
5yr
n Mirena" Icvonova
) but expensive "

o Mode of action
o
1- Aseptic endometritis -+ histological changes in endomet. -+ hostile for fertiliz.
2- Uterine & tubal initability (t pC) -+ interfere with sperm & ovum transport
3- lf + Copper
. Inhibit sperm o -+ affects motility & capacitation
. Inhibit implantatioz + affects endometrial metabolism
. Inhibit zygote + affects carbonic anhydrase (necessary to remove of COz)
Adv of adding Copper + it allows use of smaller IUDs (without loss of their efficiency)
Adv of addino Silver -+ it orolonos lifie soan of IUDs (bv orevenUno Cu

4- lf + Progesterone
- Atrophic endometrium
- Thick, scanty, viscid cervical mucous (prevents spenn ascent)
- Prevents spenn capacitatio
a Advantages @
r One decision method & cheap
'. Left for long periods & reversible on removal
No systemic effects & no interference with intercourse or lactation
'r Reliable (failure 1-2 /HWY " ). .....(0.2 in Levonova)
Non-contraceptive benefits of utG releasing intrauterine s,6tem (lUS) e:
- Treatment of dysfunctional uterine bleeding
o

- Prevention & ffeatment of endometrial hyperplasia

- Protection from PID'

WhiteKnightLove
I 87 q.laerrln q r4
e Contraindications (mainly local)

IUgD o Distorted anatomy -+ fibroids, CMF of uterus

oB + severe anemia, bleedi

llfrreots
.
Pelvic infection (PID) or previous ectopic
r
Immunosupression, steroids, DM, RHD (fear of IEC)
Cu** o Wilson disease
! Amenorrhea + suspect pre gnancy
'Unf,wgrusa I
Bleedine -+ suspect malimancy

Complications 7P @a hh
7l E0oadleO
> ?eb'lnser|lon e?ohq-+ reassure
> lhenmiqta or ne*on*taqla (25-50 % I )
o lEtiofog1-+ mechanical irritation of endom.
(Treatment
- t pC & fibrinolytics
o
- Exclude pathology l't /
- Anti-PG & anti-fibrinolytics (tranexamic acid)
- If persistent -+ use a smaller or medicated loop
- If still persistent -) use another method
2) Pain
>?otb'tneerblon (* v66ragal attack) -+ exclude perf. then reassure
>?q;menartea
o Spasmo[ic f,1smenorrfi.ea is only accepted
o Otfrerwise e4c[u[e -+
Lar ge device, expuls ion, perforation,
infection, abortion, ectopic pregnancy
3\ PTp
o lEtiofog1+ septic technique during insertion (throods octs os o lodder)
\ risk is slight o: esp in the l't month (octinomycosis isrooli E )
o ?ropfr,-+ aseptic conditions, cut threads short (difflculty in removol)
o I(TT-+remove IUCD (1" step) + strong antibiotics (oc<. to C"S)
>Vaginal disch / backache are common (pelvic congestion / <hr cervicitis)

4l oxPa0sloa
o 50Yo occur in l't 3 months; esp during menses
o 8[f I If insertea fo.pu.t* / fregnancy occurs
* Too large ltoo small / bad technique on insertion
* Local abnormality of uterus / cervix
o Y__gytg
"_g9
1 ryllfparity
WhiteKnightLove
 o
5l Patotdtott (rare )
o cP[f -+ satne as above y'
(mostimpisthereluctance/overconfidenceofthedoctor)
o Sus7tecte[ f,uring
- Insertion -+ severe persistent pain & vaginal bleeding
- Gradual perforation later on leads to:-
. PID (2'r')
. Mssedthreads
o *tarugamm, + as in missed loop

6l Ptoerurcv
> lnbrahqtrv,+ i.e. failure (1-2 /HWD
o Due to..... ......misplacement, perforation, expulsion
o Presents as.. . . . ....... .omenorrheo + B-HCG + U/S
o There is risk of........septic abortion, PROM, PTL
o Management:-
- If tfrrei& accesi6b-+ remove " ...........25 %iskof abortion
- If not accessifib + continue .......50 Yonsk of abortion
(with t o/o of sepsis but no f inW of CFMF)
> Ex*ah*ttc'* i.e. ectopic (l-2 /10.000)
o lEtbhgy
- Associated tubal infection
- Decreased tubal motility (as in mirena)
- Good protection of intrauterine but not extrauterine preg.
** Some say -+ ILID I ectopic i esp Cu T 380 A/
\ as it I the overall rate of pregrancy
o futatugunmt-+ as in ectopic pregnancy * remove IUD

7l nile*d tAteds(Missed IUD)

> VWdqa - Adherence to vag wall, threads cut too short
- Expuls ion, P erforation, Pregnancy
> llV locahzal,ton
. ltt step'+ um
. 2od step,+ test)
. 3rd step,+
- Abdomen + plain X-ray (AP t lat with uterine sound)
- Uterus + hysteroscopy
> l,llatryn*b
. If intra-uterine -+ hysteroscopic removal or DsC
. If extra-uterine -+ remove by Lfi,qRoscorv /, minilaparotomy

WhiteKnightLove
 E7rrailn rl
"
PRINCIPLE OF INSERIION OF lUDs

JT

)'iq

l. The IUD is first of oll folded ond 2. The introducer is then

pulled into o ploslic tube colled irserted inlo lhe uterus.
the introducer.

ii\
.'i'

3. The IUD is forced out of the 4. ., ,..ond tokes up its postition

introducer by o rod..... .. in the uterus.

l. lUDs are less well tolerated by nulliparous women

but are ideal for the monogamous multiparous
women for whom the pill is contraindicated.
2. The primary mechanism of action is a sterlle
spermicidal infl ammatory response. Other
mechanisrns include inhibition of implantation
and alteration in tubal motility.
3. The failure rates for IUD use are very low (<2%)
with prolonged use but higher in the first year of
use.
4. Potentially serious side effects include insertion-
related salpingitit spontaneous abortion, and
uterine perforation.
5, The IUD provides protection against ectopic preg-
nancy while in situ.
6. The progesterone-containing IUD has the
added benefit of decreasing bleeding and
dysmennorhea.

WhiteKnightLove
a Technique of insertion c
8 Cowscttfie ptintfu
o Tlpe / duration of IUCD
o Failure rate
o Warning signs 11
.....Missing threads / period
.....severe pain / discharge / bleeding
,ffig
o Post-menstrual (cx is somewhat patulous, sure notpreg.)
o Post-abortion (by one week)
o Post-partum (1't 48 hours or after puerperium)
o Post-coital (emergency)contracepion
tl gteefiotism
o Anesthesia .....no need (ust 2 supp. anti-PG)
o Position. .........lithotomy
o limanual examinauon........size, position, any contraindication
o Cusco speculmr. ......sterilize cervix by antiseptic solution
o Grasp arrterior ox lip.......vo1sellum
o Uter{ne souDd.. ......length & direction of uterus
o firyo different techniques for insertion of [UCD:-
Ilv p*'af,Lednt4n
- Used for inert devices as Lippes loop
- The inserter tip just passes the internal cervical os and the
piston then pushes the device inside the uterus
- The nylon threads are then... cut 2-3 cm...fromthe cervix
Ilv wtlMrau d +edmt4.le,t,t
- Used for copper devices
- The inserter is intoduced to reach near uterine fundus,
then the outer sheath is withdravrn externally.
- This technique. ..reduces...rncidence of uterine perforation
3l ,fotow ttp .The patient is examined after the nqt menses & then every year
.Self exarrination after each menstuation to feel threads

tl tntru*rc ofmovat
o Whenpregnancy is desired
o Ifpregnancyocour
o If complicatiorxi occur
o Each device has a certain Vzlife
o After menopause (usually by one year)
WhiteKnightLove
 Co m bi ned oral contraceptive pill preparations.

A
t75
150
Norrnalcycle
125

100

75

50

2.5

0
/,,L
2 4 6 I rO1214161820222426
Days

B
150

125

r00
75

50

25

WhiteKnightLove
 .t, l. COC pitls .!}'

> Composltloo
E. used +. Ethinyl estradiol or
. Mestranol (Methyl EE). It has Vz potency of EE & requires
removal of the methyl group in liver
P. (gestagen) used a similar to testosterone
o

) l* genorotlon
o ESTRAN€ ....Nolesthisterone,Norethindrone,Norgestrel
o PR E GNA NE ...... ..Medroxy progesterone aEBtatE
) 9d genorotlon: Levonorgestrel
) 3'd genorotion: (new progestins) : t potency + J androgenic side effectso
o Desogeshel... ....,1Tlattelone
. Eestodene...... ....danera
. Norgestimate.... ..eibs!
) 4s generotlon: drospirenone.... ....Uasnat
> {-lmes
O monophasic,,+ all pills contain same concentration of E+P
according to E content -+ may be:
- High dose: 50 pg EE e.g. ovral
- Low dose: 35/30120 ytgEE e.g. microvlar, norminest

O Biphasic "+ all pills contain E + P but pills taken last 1l days in the
cycle have double P concentration e.g. binoyum

O Triphasic ,4 3 types of pills but all contain E + P in different concentration

(6+5+10) trying to mimic nature to J side effects e.g. trinovum

> !l'[ode of actlon

1) lnhibition of ovulation //
On hypothalamuszE + suppress FSH I P + suppress LH
On ovaryz J response to trophic hormones & J steroidogenesis
2) Unfavorable endometrium
J size, vascularity, stroma -+ pseudo-atrophic state [P effect]
3) Thick scanty cervical mucous (interfere with sperm ascent) [P effect]
4) Decrease tubal motility [P effect]
5) lnhibition of sperm capacitation [P effect]

WhiteKnightLove
 ' Mon

@
PREGA

- Sun < Sat < Frl < Thurs

tlfrlal€ . --|> L.sstpn El:i> Dont lrory. Just blG

at€ you? r' 12 houE lde v' tha&t#plld
once, and fu][rr
pfib 8r u$al,
THea[.

J-
v tloE than r F>.
12 hours lele v
. DEcard arry oarll€r
dseod plb
. Ulo o(ia P|uutbn3
(oorxbm, hrhsbte)
tor hs nd 7 (hy8
fl
tl
il
V
How many dL aI€ lelt
lr' - :r ln emost
,, ,'''
il
J.
7 or morg
plls

flv
Wh{youha\rllhbhod Whenyouluro
he paclq leeyg tio ueral [nEFd the padq Srt
rurybmal b€6lr otarhg 0le rFxf pd( ne((hy,
heDodpack ntfioutaboaft

WhiteKnightLove
> -Sdvanta€es (DO
* Controceptlon
- Failure rate :0.1 / HWY (most effective method)o
- Cheap, easy to use, not related to intercourse, rapidly reversible o

* Non controceptlve benoflts o

- Confiol of dysfiurctional uterine bleeding
- Decreased menorrhagia + decreased anemia o

I Dysmenorrhea & Premenstrual tension decreased

o
+ Endomeffiosis, fibroids, endomehial carcinoma (NB -+ cr cx liulet )
+ Functional ovarian cyst, ovarian carcinoma
- Deoreased PID (thick cx mucus) but doesn't protect against STD
o

- Suppression of lactation & { benigR breast lesions

>@-
Choloe of pills -+ better to use
- Low dose E pills (less E side effects with same potency)
- Triphasic pills (more similar to natural cyclic changes) i
- New (3d generation) containinl pills (less A side effects)
Stailing pills
- From day 2-5 of cycle one tablet is taken daily for 21 days then
stop 7 days + menstruation (after 2-3 days). Then repeat
- May start fromthe ls day of cycle + better protection
- The 2Spackcontains 7 days ofiron(norminestFe)
- May start 4 week after labor (non-lactating)
\ or I week after abortion
Missing pills
- If 1 pill is forgotten + take one as soon as possible then the
next pill is taken at usual time
- If 2 pills are missed + as above but
\ exta-precaution backup for the rest of cycle (e.9. condom)
\ if < 7 pills are remaining in the pack + start another pack
next day...(thus omiuing the usual 7 day free interval)

Drug interactions
* Drugs + J pills " (sedatives, anti-epileptics, anti-histaminic, antibiotics /)
* Pills -+ I drugs (anticoagulants, antidiabetics, antihypertensives)

WhiteKnightLove
$tde effects g Conplicatlons h
> CNS [P effect]
- Headache & nigraine
- Mood cbanges -+ depression & irritability
> gg!
- ,E, ffirt -+ liability to thrombosis / (effect on clotting factors)
- P effect . Astherosclerosis (effect on lipid profile)
. Hypertension (salt &grOretention & t renin-angiotensin)

> Breast ['E' effect]

- Breast engorgement dz ma$algia
- Demased nilk pmduction
- Cancer breart . Premenopausal + very liule risk (esp if use > 10 yrs)
. Postmenopausal + risk is less & even may drop
> glf ['E'efflect1
- Nauea & Voniting+ esp on 1$ fewweeks
- Uwr -+ . Tendenry to chole$aris, gall rtones, rilqy afect liaer enrytmet
, VrrJ rarefi -+ bepatocellular adenona"
> Metabolism
- CHO metabolism + insulin antagonism ['E'+ P effect]
- lVeigbtgain [salt & water retention or anabolic effect of P]
> Menstrual
- Hlpomenorrhea -+ usually improves menstrual control
o

- Amenonbea
- Exclude pregnancy (P-HCG + U/S) then + start pills after 7 d
- If persistent for 2-3 months -+ pos@ill amenorrhea
- Spotting
- If occasional + reassure (inappropriate hormone content of the pill)
- If early + use pill with more estrogen
- If late -) use pill with more progesterone
- Also may take 2 pills forrest of the cycle
- Breakthmryb bkeding
- Stop pills 5 days then restart (+ backup contraception for 2 wks)
- Or use pills with more estrogen
- Change in libido /I*uchorrhea(pelvic congestion)
> Skin
- f n;gmentation -+ chloasma [e' +P1
- Acne, birsutfun -+ recentll inprowd " (with 3d generation e.g. Diane)

WhiteKnightLove
Cor*ralodlcatloos (qfiu ohtz. . ..ar,. . ..,rclnrrul

> cNs
. Migraine
' Epilepsy (COC + decrease anti-epileptic drug efficacy)
o Otosclerosis
o Optic neuritis & glaucoma
. Porphyria
o

r Persistent visual symptoms esp if suggestive of TIA

history of thrombosis, pulmonary embolism,

coronary hgart disgaso............................8bg01utg #
r Patients with risk of thrombosis as
- Prolonged immobili zatron
- Before and after surgery ('t-6 wks)
- Sickle cell disease or sickle 'C' disease o
- Varicose veins
- History of myocardial infarction in a parent
'. Hypertensivepatients
All patients > 45 years
Patients > 35 years ifthey ate smokers ot obese

t+
> !4g]g!lon @...............4bs01ute#
> Egr
. Mmkedly impaired liver function, history of cholestasis during
prggnancyr adgnoma ............ o............. o...Abgolufg #
' Hyperlipedemia @ + increases triglycerides)

> Diabetes mellitus + thvrotoxicosis

> Local conditions

. Pregnancy:
- No evidence of teratogenic effect
- Very rarely + VACTREL sYndrome @)
'. Undiagtrrosed amenorrhea
Undiagnosed bleeding

WhiteKnightLove
 + 2. POP (Minipitls) 'f"
Preporoiion
Pills containing very small amount ofProgesterone
+
o Levonorgestel Microlut (30 pg)
o Noresthisterone;p Mcronor (350 pg)
o Lynestrenol Exlutona
Mode of oclion
, On oervical mucous -+ thick //
I On endometrium -+ atrophy
. CIr speflns + inhibits capacitation
. To less extent -+ alter tubal motility & suppression of ovulation (50%)

Use 1ss toblel /pock)

I tablet is taken DeirY from the 1o duy of the cycle COxTh,EJSLY at
the same timeo. If forgotten or DuAvrD > 3hr+ continue backup 14 ds
E
.1V'7. .. . ..Ceraqette is a N(tU G€N€BRTIoN "desogestrel"
\ could be delayed up to 12 hor.rs safely

Indlcollons
1. I-actating
2. ,4: thm ir no atmgen side fficts:
- [VS.........Liver
- 0ld'......smoker o
3. Ar thm * nin. Prog. ,fttt (rg.CHO, lipid netabolisn, weightgain)
- Diabetics E hypertensive
- 0hese

Dlsodvonloges & slde effecls

. Higher failure rate than combined pills: 1-2 /I{WY o
. Liability to ectopic pregnancy (due to effect on tubes)
. Mensfual side effects e.g. Spotting or Irregular cycles
6 use another tSpe with more progestin
G but don't use esh,ogeh as it interferes with
progesterone action on mucous & endometrium

Conlrolndlcollons
- Undiagnosedamensrrhea
o
- Undiagnosed genital bleeding
- Previous ectopicpregnancy

WhiteKnightLove
 "$ 3. Injectables "f"

Preoorollon,+ Depot Me{ rory-progesteroDe acetate

: Depo-Provera 150 mg IM / 3 months o
'rr Combined (E&P)... See below
Mode of ocllon
o o
Ttrc same as COC (--,--,--,--,-)......mainly by thick cx mucous
:. Rdiabh as COC (>99%)
:. Non+ontraceptiae beneftt
-Endometriosis, endomet. hyperplasia or carcinoma
-Improves PMT & dysmenorrhea
-Precocious puberty, hirsutism
o)
-Protects against PID (but not STD

lndicollons
l. Lactating(with no in caneer breast) t
2, At then b no eshogen sifu fficts:
- [VS.........Liver
- 0ld "......smoker "
Dlsodvonlooe & slde efrecls (D(D
t Can't reverce contraception once injection started (may take up to 9 m)
. 1 Risk of o$eopowtis f used in.ltoungerage o (reversible)
. As tbere is Prug. efet
- Weight gain in some patiEnts E
- Few metabolic effects -+ mild anti-insulin action. Decreased HDL-[

. Meru$raal imgularitiw (most common 1y'

o

-
Amenorrhea + TAYoby the end of l$ year
-
Olieomenorrhea / h).pomenorrhea -+ reassure
-
lreeular bleedine + exclude pathology then give:-

l. Tqlcg hord DUPA lnletton b&m drtq or....

2. Noresthlstelohe osrrsrrthste ([ff-ENl
6 Norshat or Norigest 200 mglM I 2 months
3. Recerrflg: monthtg comblned lnlectrble Gonhscsptton
6 [yclofum (DIIPA 25 mg+ estradiol fypionate 5 mg)
G llesygyna (DMPA 50 mg + estradiol valerate 5 mg)

::::: : : :1"Ift'.f,l:i*:*#:T#il'J#::Tfffi ;: :-

WhiteKnightLove
WhiteKnightLove
 & 4. Subdermal fmplants +,

ilethod (Norplant)
- slx cylinders containing Levonorgestrel o (36 mg / cylinder)
- Inserted SC on inner aspect of medial side of arm in a fan shaped manner
- Slow release of progestin + lasts for fiwe years

Agtion -+ as POP "

Adv -+ . Long acting (99Yo protection ")
. Action is rapidly reversible
o after removal
. No side effects of estrogen
Dlsadv -+ . Headache / breast tenderness / weight gain
. Menstrual inegularities / amenorrhea (the cause of removal)
. Difficult insertion & removal (needs provider's help)

.1W+ Inplaton is a Stpg.€ cylinder left for 3 years // o

"etanogestrel"
:, it recently replaced Norplant (FDA approved 2006)

.&. 5. Vaginal contraceptive ring (VCR) &

Combined voolnol rlno (FE + Levonorgestrel)

As COC (inserted for 3 weeks & removed for 1 week)
(Failure ra;tn:0.5 / Hlfll)
Proqeslerone-onlv voqlnol rino (Levonorgestrel)
. Used monthly or every 3 month
. Less effective

# Advantage of vaginal rings

- Immediatelyreversible
- Simple introduction & removal
- Fewer side effects (bypass l't effect of hepatic metabolism)

.&, 6. Gombined hormone patches .&

? Evra patch for 3 wks and then removed I wk
a Failure rute 1.2 /HWY

't' 7. P.releasing IUCD .!,

WhiteKnightLove
 q/rczriln% rl

The clip hos two iows '.

of inert plostic rcteriol, \,
locked together by o r 7
gold-plotod stoinles steel qrrrng.

The forceps grip the tube ond

drow it through o silicone

Method of Success Rates

Tubal Sterilizatlon for Reversal (in %l
Clips 84
Bands 72
Pomeroy 50
Electrocauterization 41

cD
. A-D:The Pomeroy method of tubal neriliation.This technique is typically perfomed durlng the lmmedlate post-
partum perlod through a small subumblllcal lncislon.

WhiteKnightLove
33 Tvpes
1) Male,'+ Bllateral Vasectomy
.
Done under local anesthesia ) v. easybut
r
Use another method for 70 days ) not
.
Efficiency confirmed by 2 -ve semen analysis ) inEgypt
2) Female,"r Tubal tJgadon
t La?awscW / electrocoagulation of tubeorapplication of a Falope ringor clip
. Minila?aytonJ resection ligation of a part of the tube (Porwnov method)
t Poslbartum
- At C.section (common)
- After VD (2-3 days later via a small sub-umbilical ineision)
3t lndlcotlons
-
( permanent contraception:
o Completed family, old couple (> 35) -+ with failed all other methods
o Contraindication for pregnancy -+ v. weak scar, v. serious illness
8t Conlroindlcqllons
( as reversibility is difficult:
o Young uncertain couple with marital or mental problems
33 Compllcotlons
o Co@lications of anesthe$a or rffiXery (infection, bleeding bowel injury)
oPresnanE-K:::A;:r#;Jr.ffi
ffi:rargevasculartube)
- Faulty technique
o Post-ligation yndrone e
Menorrhagia & congestive dysmenorrhea months or
years after the procedure. Mostly due to interference
with ovannx venous refurn + congestion

$lale cootracefiloo.@ *
fuimonent r+ vasectomy
Tompolwy,+
> Physiological.......... coitus intemrptus & interfemoris
> Mechanical............male condom
> Chemical. ..............Gos sypol (inhibits mitochondria & motility)
> Hormonal..............progesterone I danaznl / LHRH analogues
> Imm u nological....... contraceptive vaccines against spenns
clmmuoolo$lcal cootraceptloo #
> Antibodies (passive) or antigen (active) for
) Sperns I zonapellucida IHCG
WhiteKnightLove
 98 E f.zrilng? /4
9ostpartum contraceptlon @ -:N,

> Immedlate[
\
Breast-feeding, Barriers, sterilization
> lnctoting u,omen irt 6 tr,Ks
\
Progestagen only methods (POP, DMPA, implants)
\
IUCD
> lnc-rating u,omen at 6 momhs
\
Methods containing E (COC, combined monthly injectable, VCR)

tpostcoital (emer$ency) contraceptlon x,

> Hormones
o o
( Given immediately or within 72 hours (the rnorning affer-pill)
o
{Large doses -+ N6V -+ antiemetic must be added
( They inhibit ovulation + early luteolysis (intereeption)
o POP e.g. Postinor (7501tg levonorgestrel): I tab.......repeat after 12 hrs
o tablets.
Htgh dose COC e.g. Ovral: 2 ....repeat after 12 hrs
o Anti-Sonadotrophin e.g.Danazol 600 mg. ......repeat after 12 hrs
o Anti-progestetone e.g. ellaOne 30 mg tab..... .,once

> Mochonlcol
o IUCD is inserted immediately even up to one week o. FR: 1 %
o ltlensfual aspiration -+ suction of the uterine contents by Karman cannula

$peclal groups -:irs

POP
Baniers & sterilizaUon are avaihbb offier for all

DM risk of PID
Cardiac X risk of IEC
maIIled

FJdeily (>40)

€ontralndications for preglnaocy 4:*

> fllloErer + High risk preg (DM, heart)
+ Infection (Rubella).....Vaccination (MMR)
+ Drugs (e.g. acne therapy with retinoic acid - 6m at least)
> Uterus...scarred with liability to rupture

WhiteKnightLove
 Gontraception 99

€ounseling before starting contraception *Y.

> Method. .......cost, duration, failure rate, reversibility
> Techniqua...... .way of usage / missing-discontinuation / removal
> Potient. ...advarttage ldisadvarrtage/ contraindication /side effects

WSO 9ledical Efgibilitv $riterla (WHo.MEc) <2 <, +*

I .r[/o restriction Use the method

2 Advantage of usage ovotweighe theoretical /proven risk
{/
I Theoretical /proven risk overweighe using contraception Do not use the
I Oot agcommcnded methodX

WHO-MEC has replaced the old classi.fication into

indic ations / rel ativ e c ontr aindic ations / ab s olute contraindi c ation

jlot use lfay use

- Heavy smoker >35 yrc, mild smoker
- Severe HTN, complicated DM Mild / mod HTN, controlled DM

coc - Active liver disease / cinhosis/ liver tumors

- Pregnancy
Lactating during first 6 wks
- Unexplained vaginal bleeding, Breast cancer
- Migraine, epilepsy
- Thrombo-embolid lschemic/ Valvular lesions
Gall bladder disease
Lactating from 6 wks till 6 ms
NonJactating during first 3 wks
Cunent ttt with antibiotics:-
Rifampicin / Griseofulvin
Antiepileptics

Pregnancy / Lactating during first 6 wks

Active liver disease / cinhosis/ liver tumors
+ Gall bladder disease
POP
Unexplained vaginal bleeding / Breast cancer
Cunent ttt with antibiotics:-
+ Rifampicin / Griseofulvin
+ Antieuileotics
!nject. - Pregnancy Lactating during first 6 wks
(prog. - Unexplained vaginal bleeding Severe HTN, complicated DM
- Breast cancer Thrombo-embolic/ lschemic /stroke history
only)
Active liver disease / cirrhosis/ liver tumors

- Cunent / recent:- - Risk of developing STls

IUCD PlD, STls, septic abortion, pelvic TB - HIV / AIDS infection
- Pregnancy / Distorted uterine cavity
- Unexplained vag bleeding / genital tumons

WhiteKnightLove
 ogtrn ol ll."L'.r?!e
S"rrrlly tto^*n.,. LLL"I lirr"or"
\JdrovagtrrLtL=
C"ruLcltls
FdrL" Lrn flavwvwrtory llr"or"
CLron Lc gro.n n [or.^.oto w. ll=ea*e
WhiteKnightLove
I
Elrcaik% r4

Q +Ve G -ve
Aerobes Lactobacillus E-coli
Staph aureus, strept Klebsiella, proteus
Enterococcus faecalis Enterobacter
Diphteroids Pseudomonas
Anaerobes Peptostreptococcus Bacteroids
Clostridium Bacteroids fragilis
Lactobacillus Fusobacterium
Gardnerella vaginalis
Yeast (candida)

Nrfldvogir'r/ frou
OrSllLm Fcrc.nt gr
lactobacilli 8G-90
Staphy'ococcl,micrococcl 50-70
Urerrp/rr;mo ,rc-50
Anaerobes 20-50
Streptococci 20-30
@dnerClo lG30
Edi 5-15
Conddo spp. 5-15
Soctemltes LlO
Irkhononos 3-7

WhiteKnightLove
 I
lnfection 100

Yrrrnrr aurcDrlt
o
trUclffhtd is clearmucoid (non-infected) vaginal discharge d.t. excess
of normal secretions. @g.leucorrhea means ony
abnormal discharge from vagina except blood)
Normal vaginal discharge 1
SflJKI
vtlvA Bartholin eland * Skene's
glands
vActltA Serous transudate + Barttrolin + cx mucus
(Rvtx (T*byE'-@)_.
UIROS _sp
j99l9l9lJ_pbgs_e)_
lrrEs Goblet

bacteria .abalance of
- Lacto-acilopfi.ifus fiacitfi// (Doderlein bacilli, gtve rods)
- $trept,, stapfr., lE-cofi
- Can[i[a, tricfromonas, mlcoptasmn, g-ge on4ero6es, {ipfrteroils

al defensive mechan
yagjna ffily by the 2 labia(opposedo )
-
o
. Lined by thick stratified squamous epithelium
o
. Acidic media -+ hostile for organisms (lost by O+O+9+intercourse)
Cervix + closed mechanically by a mucous plug
Uterus -+ monthly shedding of superficial layer of endometrium
Tubes -+ movement of cilia towards uterine cavity

s mechanism is interfered with

Prepubertal & postmenoPausal
- Less acidic pH O
- Thin vaginal lining
- No endometrial shedding
Menstruation
- Less acidic pH (neutralizedby alkaline menses) @
- Loss of cervical plug
After labot & abortion
- Less acidic pH (neutralizedby alkaline lochia) I
- Loss of cervical plug (& cervix is opened)
- Presence ofrawplacental bed (t lacerations)
- Lowered maternal resistance (d.t. exhaustion)
- No endometrial shedding

WhiteKnightLove
I q.fianln rl
"
Algorithm for vaginal discharge.

Age
Sexual history
Odor/irritation
Urinary symptoms

Tachycardia
Fever
Abdominal tenderness
Cervhal motion
Pelvic tendemess

Microbiology swabs
Clean catch urine specimen
Laparoscopy

Worl.up ol veglnal dlrchargc

Ceur of dlrdn6c
Mlcroblologlc swabs Wet mount
Candlda alblcans
Trldtomonas vaglnalls

Bacterlal vaglnosls

Endocervlcal/urethral swab
Chlamydla t*homatls
Nelserla gononhoeae
Clean cakh urlne
speclmen

Cervlcal cytology Cervical dlsease

Endomehlal sampllng/
lrysteroscopy
Pelvk ultrasound
PID

Pelvlc mallgnanry

WhiteKnightLove
 I
lnfection 101

.9 AccoRDING To souRcE M
t. True leucorrhea (t"d normal secretions or transudation)
(esp estrogen)
. Puberty
. Premenstrual & midcyclic
. Pregnancy
. Puerperium (lochia alba)
- Pelvic coNGEsrIoN (constipation, coitus intemrptus,
sexual dissatisfactisn + pelvic pathology)

z. Patholoqic causes

-Bact. vaginosis -PID

-TV & monilia -Pelvic abscess
vaginal adenosisl infected tumors e.g. cr endomet., fibroid, polyps

Ll^ AscoRorNG To cHARAcTER e

- True leucorrhea
- Monilia - Bacterial vaginosis

. Vaginal adenosis . ROM . Urinary fistula

. Cervicitis . Intermittent hydrosalpinx

- Endometritis, pyometra
- PID, P. abscess if opens into vag

. Foreign body
. Vag., cx, uterine -+ .Infection -+ p. sepsis, p.abscess
ulcers, erosion . Neoplasms -+ infected tumors
polyps, cancer . Fistula -+ fistula

WhiteKnightLove
 q/r&i(nf? /4

fuu|c of s!reod of nG
Secondery lnfection
gnxred ord gonorocal n@im.
Adts elplngids
Pyosrlpinx

Pclvlc peribnitis

Prlmay infectlon

Crypc of odeewix
Pelvic abGcess

Sk re's obuls

EXAMINATION
The lobio crre held oport, ond the ureihro,
Skene's ducts ond Bortholin's ducts exomined for
signs of infect
for specimens
fronr th: cerv
infection "

1 . N. gonorrhoede causes a reported 2 miilion infec-

tions Per Year.
2, Common conditions caused include cervicitis, PlD,

TOA, and Bartholin abscess.

3. Diagnosis can be made with culture, Gram's stain,
or DNA probe.
4. Treatment for uncomplicated infections is ceftriax-
one 250mg intramuscularlY once.
5. Treatment for N.gonorrhoeae should always
include doxycycline 1 00 mg orally BID for 1 week
to treat likely concomitant chlamydial infections'

WhiteKnightLove
 I
lnfection 1O2

8o=urllf Errnouf$od Dfrolror

> Etroloov
Cause -+ gonococcus (gram -ve intracellular diplococcus)
Transmission + sexual intercourse......incubation period: 3-7 d
> Cttucal PtcruRE
Primary sites (V) a O Skene's glands & urethra
O Bartholin gland
O Endocx (angry red cervix * mucopurulent discharge)
\ the main reservoir of organism
other sites d
3 i}:qo.;|#i,fTj:xH,l,ffi onj unctivitis in adurts
Spread
o Local -+ .Vulvovaginitis (only prepubertal or postmenopausal)
pelvic or generalized peritonitis
. PID,
. Perihepatitis -+ Fitz-Hugh-Curtis (FHC $)
o General -+ septic arthritis, meningitis, endocarditis

> lNvesttcarotts (C&S)

- Smear -+ endocervix, rectum, pharynx
o
- Culture -+ on Thayer-Martin orNew York City medium
- Antigen detection from lv sites -+ ELISA / NAAT (nucleic acid amplification test)
- Serologg -+ CFT / I{AI
> TReatueNr

ll Uncomplicated a acute gonorrhea . . .. . ..CDC recommendation...

CephdosporhE ceftriaxone 250m lM or cefixime 400 mg orally (single dose)..or

Quinoboes: ciprofloxacin 500 mg or ofloxacin 400 mg orally (single dose)..0r
Azifimmxin: 2 g orally (single dose). ....P[E
Donvordtre: 100 mg I 12hrs orally for 7 days if coinfection with Cru,auvon'

ftevlously oProcaine penicillin 4.8 million units IM once * Probenicid

oSPectinom)tcin 2gIM"
tTetrac.vcline or ervthromycin if resistant/ allergy to penicillin

2l Complicated a chronic gonorrhea e.g.

. Chronic cervicitis -+ cauterization
. Bartholin abscess -+ drainage
. Chronic PID -+ adenexectomy

WhiteKnightLove
r E4/4aco,/n q /4

The picture shows on

odvonced cose of LGV.

3. Treatment is with doxycycline l0O

mg BID; alterna-
uvety, a one_time I g dose of azithromycin
can be
used.
4. LGV is caused by the L_serotypes of Chlamydia.

WhiteKnightLove
 lnfection 103
I

) Bacteriolonr (incubation period + 1-2 weeks)

- StNtuR To vtRUS tN -+ obligatory intracellularo * inclusion bodies
- Stmtun ro BAcTERIA tN + . two types of nucleic acid
. divides by binary fission
. sensitive to some antibiotics
* It affects 5% of females
'k However, it is asymptomatic in 50olo'

) Serotvpes (15 ?D
9 A B, C.........Trarl1t,prb
$ D-K..... .......9(y'/6lib€16 the corr/rmonest " flJD r/
u On 9 ,+ cervicitis, Bartholinitis, PID (more insidious / worse course than G)
o On pnncNeNCy'-r abortion, PROM, PTL, intrauterine infection
s On newborn tr+ ophthalmia neonatorum, pneumonia
u On d ,+ urethritis (sterile pyuriao), epididymitis, conjunctivitis
9 L l, L2, Lr..........@figtr anfirlot+1s aerugr clim
o Vulva, vAGINA, CERVIx ,.+ single or multiple papules, vesicles or
pustules + ulcers -+ fibrosis, stricture & fistula
o LvtvlpgapENoPATlry (bubo) ,.) suppuration, matting together, sinuses
o Crnouc LYMPHANGITIS ,4 obstruction, edema, fibrosis, elephantiasis
o Pnoctocolmls ,+ diarrhea, fibrosis, strictures & fistula

) Investigations
- Sm.ear -+ intracellular inclusion bodies + >10 pus cells / oil immersion field
- Culfiire + on tissue culture @ggq$.. the most reliable (but takes 0 )
- Antigen detedion -+ . ELISA ... .....the most rapd
. PCR -using NAAT technique-. . ... . ..the most expensire
- Serologg -+ micro-IFT", CFT
-
> Treatment CDC recommendation

Azithorucin:"'1 g orally once (suitable during pregnancy).. .........0r

Ibroto'dre fvDranxinl: 100 mg/12 hrs orally for 7 days (not in pregnancy)....0r
Oritrolone$ as ofloxacin: 300 mg/12 hns orally for 7 days (not in pregnancy)

t Screeningfor high risk asymptomatic cases Q sexually active <25 yrs,

multiple partners, history of previous / other STD
o Abstinencefrom sexual intercourse a till complete therapy
t Clindamycin/ Erythromycin/ Tetracycline were used for both a chlamydia & 6

WhiteKnightLove
 'Clue celb',seen in Bocrerio, vdgi4iris.

Asmeqr infected with G.wginqlis.

Note the 'clue cells', voginol
epitheliol cells stippled with smoll
coccobocilli.

1. Bacterial vaginosis is polymicrobial but usually

attributed to Gardnerello.
2. The discharge is usually thin, yellow, and has a
characteristic "fishy" amine odor; the whiff test
exaggerates this odor with KOH.
3. Formal diagnosis is made by visualizing clue cells
on wet prep.
4. First-line treatment is metronidazole (Flagyl) for a
7-day course.

WhiteKnightLove
 I
lnfection 104

Gardnerella vaginalis
(Haemophilus vaginalis)
> DertrurtroN
Bacterial vaginosis means replacement of normal vaginal flora
(Doderlein bacilli) by other bacterial colonies (mainly
G.vaginalis, mycoplasma" hominis, ureaplasma urealyticum)
o
lncidence -+ l0-25%oof population(//60% of vulvo-vaginitis )
Predisposing factors (alkaline medium)
- Frequent sexual intercourse o
- Frequent use of alkaline vaginal douches
> Clrrutcal PrcruRE
- flrymptonntic(50%,")
- folitdvufito<taginitis -+ no PPdd (. . .osis & not.. .itis) -+ no p-us-eells "
- '/aginnt discfiarge (profuse, thin, greyish, malodorous)
(Fishy odoro is due to formation of amines from a.a. by anaerobic
bacteria especially apparent after intercourse or menstruation)

> luvrsttcATroN E
(O of the O AMSEL criteria are enough)
7l Characteristic vaginal discharge
2l Vaginal pH > 4.5
3l Clue cell (grmular appearance of vaginal epithelial cells due to
adherence of bacteria to their surface). Demonstrated by:
- Gram stain -+ gram -ve cocobacilli (H. vaginalis)
- Wet smear -+ drop of saline + drop of vag. discharge
4l tthiff test (add 10% KOH -+ fishy odor)
> CoNpLtcaloNS:
*
Pdf tor infection in :-
- Non-pregnant -+ chronic PID, UTI
- Pregnant + chorioamnionitis, PROM, PTL
- Wound infection after surgery e.g. vag. cuff after hysterectomy
*
However, there is no generalaercement on prophvlaxis

> Tnratueut CDC recommendation

mg lx2x7). . . . . .... . . or. . . . . ....local gel

Flagr{ = !4etronirhzole " (500
G&rdanvch {alacin C- (300 mg Ix2x7)..........or........local cream
Broadspectrumasel@_ogygl2_tgtralyghgl j j:.S_00_*g_t_1!{,..[

WhiteKnightLove
I
ql/n€rnhq? ,4

Mycelio ond spores of TRICHOMONAS VAGINALIS

C.olbicons. Note the
presence of leucocytes.

l. As with vulvitis, the number one cause of vaginitis

is Candido.
2. Diagnosis is often made with a wet prep (trich
yrEs
and BV) or KOH prep (yeast).
3. ln the absence of microscopic evidencq symp-
toms and type of discharge should dictate the
treatment.

I . Seventy-five percent of sexual partners of those

withTrichomonos will also be colonized and
Irkhomonm voginolh.
presumptively treated,
should be,
2. Diagnosis ls made via wet prep, but is usually pre-
surned with a prbfuse, malodoious, gray-green,
frothy discharge.
3. Treatment is metronldazole 2 g orally one time.

WhiteKnightLove
*-rH/n''1 '
lnfection 105

.& @ cordldo (monitia, thrush) 6 uaornoffE voglnolls

2,'d cause of V.vaginitis (3096) 3d cause of V.vaginitis (25%)

Predisposing -t vaginal acidity & moisture - Alkaline medium

-t vaginal epithelial glycogen
foctors
(prygnancv' tSrt;illillnce
(DM, steroids)
- PJolonged use of antibiotics (altered flora balance)

lrtode of . NonvRlt v present in vagina (20-40% candida). '.(50% TV)

. Contamination from -> STD/ /, hands, towels, instruments
infection
Premenstrual Postmenstrual
- Severe vulvovaginitis (PPdd) -Severe vulvovaginitis (PPdd)
Clinico! -Discharge is ooonLsss, whitish, - Discharge + MALoDoRous,
Picture thick, curdy-cheese like, scantyi greenish, tiothy, profuse
O/E -+ O/E -+
adherent white patches --+
red edematous *punctate
removal leaves slight bleeding hge (srRawsennv vagina " )

o PH -+ acidic a alkaline
Investigotion o Smear -+ Gram *ve o G -ve
o Fresh drop of disclnrge -> o motile flagellated organism
mycelia
hyphae or (slightly larger than leucocyte)

o Culture medium a Diamond, Feinberg,

Sabouraud's "/Nickerson Trichocele
r Antigen detection + microstix rn Colposcopy: T-shaped vessel

- Prophyloxis Eliminate pdf + use alkaline / acidic vagina[ douches

t" Local " Local
-
Mycostatin(Nystatin) - Metronidazole vag tab.
-
Clotrimazole(Canestan) (500 mg' I lxlxl0
- Treotment * -
Miconazole(Daktarin)
Ora[ (in virgins, resistance) 't Oral
- Ketoconazoie(Nizoral) - Metronidazole
200 mg lx2x5 (500 mg) lx2x7
- Fluconazol (Diflucan) - Tinidazole (better compliance)
150 mg once (2 gm once) 4 tablets
- Itraconazole (Sporanox) - Ornidazole
lgm once (1.5 gm once) 3 tablets

- Recurrence . Treat pdf (e.g. DM) I TReRt HusseNo (in atl inf) //
. Extend ttt for 3-6 weeks I Avoid vaginal douches

WhiteKnightLove
I
q//..rrnlng? rl

o Mo$ 0enilal walts are caused by se)(ually transmitted

strains ol HPV.
o Long-lasting resolutlon ol visibh warts roquires a 0o0d

cell-medlated immune response.

o lnle,ctions persist for many years, and lelapse can occur

at any time,
o Sewnltypes of HPV particularly 16 and 18, are

associatod with corvical cancer.

o Attention should be paid lo reversible rlsl lactors such
as smoking.

WhiteKnightLove
 lnfection 106
I
I
* usually type II
| "Papova virus family (genital warts)
' \sometimes 20Yotypel" \ the commonest /viral STD o
- DNA virus o - DNA virus "
- Incubation period -+ 5-7 days - 70 sero-types
-May affect -+ vulva, perineum, (6.11...:.16,18.....g1,gg,gs,89 I

vagina, cx, urethra, oral cavity ......41,43,44....51,52,56)

I

* Primary (1$ infection) * Tvoes

.Ganarcl a FAHM (fluJike) . Condylomo occuminotum
. Locolly e painful vesicles -+ \
on vulva, anus, perineum
shallow grey ulcers + LN \
multiple cauliflower masses
Fota ra heals rapidly spont.
o
. . Flot condylomo
but remains dormant in \ especially on cervix
sacral ganglia .lnvarted condylomo
* Secondary (reactivation) * Recurrence (600/o) esp in d
. General syrr.ptoms +
none . hegnancy, COC
o+
. Local -+ mild sympt no LN . DM, immunosuppression

- Secondary infection - Related to malignant & premalignant

- Urinary retention ' lesions of LGT (IO.tg)'
- On pregnancy + abortion, PTL e.g. CIN, VIN, VAIN
- on nervDom-+ encephalomYelitis - on nervtom -+ laryngeal PaPilloma
(.'. CS if having active HSV)

a Sm.ear + eosinoPhilic intra- o Smear -+ KoilocYtes

"
nuclear inclusion bodies in (vacuolated multinucleated cells)
multinucleated giant cells a Biopsy -+ mimics malig.
o Atlfitre+ chorioallantoic memb :. Colposapg + PaP + exclude malig
a krologp + CFT,IFT :. rcR Southem blot" +specific type

- Symptomatlc * antib. for 2ry inf. - Local destructlon

- Antlviral drugs * Crrpulcer, cAUTERY
\ doesn't eradicate it but J o
.Trichloroocetic ocid " 75o/o

convalescence & recurrence .Podophgllin rosin 0.5olo -+ toxic

.lmiquimod 5oh -+ self aPPlied
. Acyclovir, idoxuridine o CO, Lesen, cRYocauTERY
(1x5x5) -+ most used
- Surgical excision
- Antlvlral agent as 5%o 5-fluorouracil
-Vacclnatlon (2006 in USA)'/'/'/'/

WhiteKnightLove
 Erfr€rih?q /4

Sterile

l
Doderlein's bacilli

Secretion abundant

Doderlein's bacilli

Secretion abundant

Cyclic cltonges in the wdho rdolEd to o*e.

(a)
(b)

(a) ilormat: hctobacilli

(b) Candidimis:
(c) Eacterial rrdoinosisj
(d) Trichomoniasis:

WhiteKnightLove
 ,o PrlmqrJ (l ry)

fiqdsda+ 6, Bacterial vaginosis O,..... .........S, tS

limoal -+ Candidiasis g
!?aflaaitea + Trichomonas vaglnalis @,.. . .. -... .. ..'. ....... ..8
eilanunia-+ lynphogranuloma venereum (LGV)
Abuteo + HSV, CMV, HPV (cond. accuminatum)

',,+ Secordorv (To)

- disdurge
Cervica! & Yagina!
Urinary oondiUons + incontinence, fisfula, glucosuria, pyuria
Recral onditions + R-V fistula, complete perineal tear
Chemtcal + douches, sprays, Perfumes
+ scratching, irradiation
Ph yslca t
Tlaumattc + foreign body, prolapse, neglected pessary

nical
.Symptoms -+ - Pain (soreness) & Pruritis vulvae
- Dysuria & Dyspareunia
- Discharge .....mention the discharge of O I O
.^Sigzs + red hot, swollerl edematous, tender
+ inguinal lyrnphadenitis * scratch ulcer

. Any disCharge bacteriological examination.....mention the inv. of O

+ O I
. Any SUSpiCiOUS area + skin biopsy e.g. from leucoplakia........esp. in old age
. Any suspicion of DM (severe irching + moniliasis) " " " " " " " "esp if recurrent

Ireatmen(
1l Of cause .... mention the ttt of O O I
2l- local
Good local hygiene d
. keep vulva dry & clean (best is neutral douche)
-- . Underwears should be cotton,loose, dry
- Antipruritic 4
antihistaminic t
anesthetic * cortisone
3l Geaeral measures to irrltatlon l
- Sedatives + Phenobarbitone
- Antihistaminics

WhiteKnightLove
 lg ffirollnltls
Pqthologg: aeute inflammation of Barttrolin gland @.coli " )
W Synptoms -+ pain: 1$ aching then throbbing (if pus forms)
^Sigzs
+.
Red edematous skin + indr.ration
. Pus may be discharged from the duct
. Gland is palpable & tender
Fqts + complete resolution.....abscess formation .',

. ....chronic bartholinitis /
TTT - Bartholinitis + antibiotics + hot fomentation
- Bartholin abscess + incise & drainage
Cyst
of
e ffirolln a,st Bortholin's
glond
Pqthololq
- It is the commonest VULVAL " cyst /
- Due to obstruction of the gland duct by + infection, mucous, trdumd
TgDes
- Cysl of the ductis much more common / (lined by transitional epithelium)
- Cyst of the gland is rare (lined by columnar epithelium)
CIP o painless cystic swelling in the lower 7s ofthe labia majora

TTT
f. Marsuplallzation / "
- Elliptical incision of the cyst & suturing the edges to the surrormding
-
Advantages -+ preseryation of the lubricant function, less bleeding
2. Drcisloa (esp. posmenopausal d.r risk of hidden................)

us Torlc shodr syn&omo

o
Pqth. + Tampon use -) introduction of Staph. Aueus -+ multiplication in
retained menstrual blood in tampon -+ exotoxin -+ systemic effects

W laftet2d day of menses)

- FAHMR.
- Septicemia -+ hypotension, diarrhea, skin edema
- Organ affection -+ liver, kidney, heart DIC
TTT . Resuscitation in ICU
. Remove tampon
. Antibiotics according to CsS from vagina & tampon

WhiteKnightLove
 os Prepubortol (dlldhood) Vuhovoglnltls h
PDF a thin vaginal mucosa (a.t. .l estrogen + J vaginal acidity)

Mode of infection
O erintrl
* concntra + cong. fistula, ectopic anus......parasites (oxyuris, amoebiasis)
* t,,f"r,*rry-+ transmission from adult ...srD (G, TV, monilia)
* tnaunroc + accidental FB in vagina { ......non-specific (staph, str,, E.coli)
* tteoptartc -+ sarcoma botryoids

0 Secontaty
* ct rta [rtb0on + diaper rash, soaps
* poo, hlgfl€ne + wiping perineum from anus to vagina

CIP 4. as vulvitis & vaginitis *' X

. Note presence of lacerations (trauma),peri-anal erythema (parasites)

TTT
.GARAI il$P(lCll0iE +
antihistaminics, antipruritics, local hygiene
.nfAlltWf 0F I[
+ any discharge -+ smear, gram stain
(fllSE
antibiotic is given according to CaS
.ltl PEFfAl{f OSE + may give'E'?? locally to inorease resistance I
.lF PIPSISIWI/S$SAIIGIIOUS 9lS(l[APG[ + inspect for F.B. / tumors:
1P/R" X-oy, U/S, vaginoscope (or cystoscope)

rs Sonllo (oUophlc) Vulvovoglnltls

PDF + thin vaginal mucosa (d.t. .t 'E' -) I vaginal acidity) -+ mixed inf.

CIP Oposfinenopausal scanty yellowish / serosanginous discharge + PPdd

TTT
lllslPoKloiF + antihistaminics, antipruritics, local hygiene
.mffl]rBlf $ If, (fllSE -+ any discharge -+ smear, gram stain
rding to CgS
(0'625mg) for few wks
. [l REFrA]{r
' lt ffilsloff senile endometritis

WhiteKnightLove
I 110 qlrea@h? r,

I ) flcute caN,
erutatiae uu.aniamls
. Non-specific -+ strept., staph., E.coli
. STD's -+ monilia-Tv,.........viruses. G-chlamydia

friute -+ Obst (abortion, labor). .........Gyn (D&C /IUCD, intercourse)

+Ainical oidua
Symptoms - General -+ FAHM-R
- Local -+ discharge, dyspareunia, SACK pAnl
Signs
. Red, swollen, tender on mobility,
. exuding mucopurulent orpurulent discharge

9,eatment a antibiotics systemically + antiseptic pessaries

9) Chronlc cerulcltl
ku,satiae uuraniama
. Non-specihc. . . . . . STD' s. . ..chronic granulomatous (TB, B, actinomycosis)
. Either a
* Persistence of acute cervicitis + chronic (due to:)
- Glands are racemose -+ difficult drainage
- No monthly shedding of epithelium
- The glands are in the depth so if surrounded by fibrosis -+
difficult penetration of antibiotics
* Chronic from the start as -+ postoperative, postabortive,
postpartum infected lacerations

?affrotssical lstna
t. Chronic endocervicitis # normal cx exuding mucopurulent discharge
2. Mucous polvp ohyperplasia of endocx epith.-+ multiple small reddish polyps
g. Nabothian follicles //+ obstruction of gland ducts -+ multiple small retention
cysts either: bluish (full of mucus) or yellowish
$ns)
a. chronic hvpertrophic cervicitis # swelling & hyperemia of cx
s. Chronic atrophic cervicitis + cervical stenosis
6. Cervical ulcers Obrightred erosions (true ulcers)
z. Ectropion er eversion of the endocervical mucosa (d.t. bilateral
cx tears)

WhiteKnightLove
Qlinical pidua fit affecb many women.....mostly is asymptomatic)

* Symptoms.....congestive rymptoms
a Discharge -+ mucopurulent or purulent
d Pain +- Dysmenorrhea (congestive)
- Dyspareunia
- Deep lower abdominal pain (affection ofparametrium)
- Dorsal pain (affection of uterosacral ligaments)
? Bleeding +
eontact bleeding

* 5igns............tenderneJs on movement * any pathological form

eatmlicaliotu
- Pregnancy -+ abortion, PROM, infection
- Gynecolory
\ Spread + . local: to vulva (PPdd), UTI (frequency, dysuria)
. Cieneral: acts as aseptic focus + rheumatic pains
\ Infertility + hostile cervical mucusr
- \ Malignancy (afterlPv)

lrueotiaaliaru
C.ulture +
swab from endocervix for gonorrhea or chlamydia
ps& TLC, CRP
B.rood - f
C.omplications
-Cofposcryy -+ to exclude malignant conditions

- -Infefiifrry+ post coital test

l. Prophylaxis
- Avoid sexualpromiscuity
- Aseptic techniques (delivery, DsC,IUCD)
- Prompt diagnosis & early ttt......otherwise....chronic cervicitis
2.l,ledical
- Warm vaginal douches
- Antiseptic pessaries e.g. albothyl /
- Antibiotics + not effective (deep seated infection)

3. C-auterization d elecfrocautery, cryocautery, chemical, Laser

4. Surgery
- Conization
- Amputation
- Rarely hysterectomy (extensive infection or if coexisting disease)

WhiteKnightLove
CERVICITIS
An infection of the cervicqt ECTROPION
ep.ithelium ond stromo, usuoily An erosion or infection in o
following erosion. goping or locerofed cervix.

Exposed
endocervix
Old heoled
teor t-

Cervicol polyp
with cervicllis

Cervix
\.

Diothermy under geneml

onoesthesio will destroy
tissue to o depth of 7-8mm.

WhiteKnightLove
Dillumtial diaaruoio
l,@antsa of cenilcitis
?,Gausa of leucorrhea &, vaginal dixharge
),Qauses of contact bleeding
Definition+ bleeding after intercourse, vaginal examination, douching
Etioloov e . Cewicitis / cervical erosions I cewical ulcers

- .$ilffiTffffi#'il*, burging into vagina

. Severe vaginitis esp senile type
TfT O smear & colposcopy + specific management

\@ausa of ceruical Ectopu (Erostofl h

DefiniUon: . Replacement of columnar epith. to the normal squamous
lining of part of ectocervix+ shows underlying vessels
. Erosion is not an accurate name (as it usually said instead
o
of ulcers - denuded epithelium)
Etiology
- Chronic cervicitis
- Congenital + persistence of columnar lining of ectocervix
(normally present intrauterine only)
- Hornonal - t 'E' as in -+ pregnancy,lactation, COC
Symptoms (asynptomatic)
- Mucoid vag discharge (purulent if infected)
- Contact bleeding (rare)
Signs
a) Simple (flat) + bright red area at ectocervix
b) Papillary -+velvety appearmce
c) Follicular -+ blue or yellow Simple erosion

Investigation O smear, colposcopy, biopsy to exclude CIN #*

TTT
a According to cause: hormonal (follow up)....cervicias (antibiotics)
a if failed: CautpruzLttox ) but avoid 3, 9 o'clock
* lEtectrocautery 4 co4ulates unhealthy tissue + drrainage of deep glands

* cryocautery ra using coz or Nz at -60"c for 24 minutes

. Disadv -+ profuse watery discharge (very common)
* Cfremicaf cauter)o AgNoa orconc.ZnClzusing Feryusson speculum

* f,aser tfrcrary e rapid healing with minimal fibrosis, less side effects

WhiteKnightLove
 113 Qflzrnln rl
"
.f" Aadonotiltls M 4'
Tvrrs
ifrc o rare due to cyclic
frc o bilharziasis, T

Ct-ttttclt- P|CTURE -+ irregular cycles, amen., infertility, dysmen., discharge

F
Definition -+ pus in the uterus l. Endomyometritis occurs most commonly after a

delivery or instrumentation of the endometrial

Etiology -+ infections * obstruction by cavity.
- Cancer (cervix, endometrium) 2. Diagnosis is made with uterine tenderness, fever,
- Stenosis (post rr* menopausal, and elernted WBC count.
caUterization, irradiation)
'
3. lnanonpuerperalpatienqthediagnosiscanbe
made with endometrial biopsy.

4. Treatment is broad spectrum with intravenous

Clinical picture clindamycin and gentamicin; less severe infections

are treated with intravenous cephalosporins
Symptoms: . General +FAHM-R
. Abdominal -+ lower abdominal pain
. Vaginal -+ intermittent purulent discharge
Signs:. Enlarged tender uterus
. SouttotNc -+ pus from cervix
Treatment
- Drainage by ou.ereuoN then antibiotics
- Curettage after 2 weeks for diagnosis of possible tumors

Definition -+ inflammation of the CT within the leaflets of broad ligament

Etiology -+ direct or lymphatic spread from
- Cervicitis / endometritis after abortion or labor / salpingoophritis
- Genital tract malignancy (d.t. infection or radiotherapy)
Pathology
.Inflammatory collection in the broad ligament
. Fate -+ resolution / chronicity / abscess formation

Clinical picture
- Sympt. -+ FAIIMR * lower abdominal pain + sympt of p.congestion
- Signs -+ tender swelling pushing the uterus to the opposite side
Treatment -+ as pelvic abscess

WhiteKnightLove
 lnfection 114
I
*' }" Po0vla lel0aneatoty dlsaasa 't'
DerrHrrrou
Infection & inflammation of upper genital tract i.e.
Tubes, ovaries, pelvic peritoneum (|uterus) O2-3Yo of population

ErrolocY

PDF
-Sexually active females with multiple sexual partners....usually after
menses (loss of cx plug, degenerated endomet, retrograde menstruation)
- IUCD users (Barriers * COC -+ * PIO;
- Recent instrumentation of uterus (e.g.D&C IHSG)

Routes of infection
I Ascending through
. LuurN (as chlamydial & gonococcal) e en[osatpingitis
. Lvllprnrtcs (esp puerperal & postabortive) o interstiti"afsatpingitis
) Direct from neighboring organs as appendicitis a perisafpingitis
> Blood spread as T.B.

f,cute PID

€fioW
- STD's esp coNococcus (40%), cHLAMypIA (60%
- Puerperal or postabortive
- Non-specific organisms (aerobic or anaerobic) :usually mixed
0atfrnhart
+

a) Acute catarrhal salpineitis

- Resistance of the patient is high
- Infection only of m.m. + serous exudate in lumen
- Fate -+ complete resolution

b) Acute suppurative salpingitis

- Virulence ofthe organism is high
- Infection extends to all layers -+ purulent exudate in lumen
- Fate + chronicity, spread (pelvic peritonitis)
c) Acute perisalpineitis a fimbrial adhesions + closure of fimbrial end

WhiteKnightLove
 q4/r*rrla% r1

PID rlsk factors

Rlsk factor De3cilpuon

Age 75% of patients are below 25 years Damage to endocervix and tubal mucosa
of age
Marltal status Single

Sexual history Young at first intercourse

High frequency of sexual lntercourse

Multlple sexual partners
Medical hlstory Past history of sexually transmitted
disease in patlent or partner

Past hlstory of PID in patient

Recenf instrumentation of uterlrs, e g

termination of pregnancy
Contraceptlon Use of IUD especlally insertion wlthin
3 weeks Development of PlD.

Cornplicatlons of acutc PID

1. There may be as many as 1 million cases of PID
reported annually.
Type of compllcatlon Descrlptlon
2. Twenty percent of patlents with PID will become
Short term Pelvic abscess formation infertile.
3. PID can be diagnosed with uterlne and adnexal
Septicemia tendernes5fever, elevated WBC count, and cul-
tures or tests for gonorhea and Chlomydio.
Septic shock 4. Eecause ofthe seriousness ofthis disease and lts
Long term lnfertllity sequelae, patients ate often hospitalized and
treated with lV antlbiotlcs.
Ectoplc pregnancy
Chronic pelvic pain
Dyspareunia
I . Chronic or acute PID can lead to TOAS or TOCS.
Menstrual disturbances 2. Diagnosis of TOA orTOC is most likely when there
is an adnexal mass in the setting of PID symp
Psychological effects
toms. Confirmation is usually achieved wlth an
imaging study such as pelvic ultrasound or CT.
3. Treatment includes hospitaliztion and lV antibi-
otics. ForTOAS not responsive to antibiotlcs,
adnexal surgery is the definltive cure.

WhiteKnightLove
 lnfection 115

Ainical oicttu.e
t. Symptoms (history of pdf +)
- General-+ FAHM-R
- Abdominal + acute lower abdominal pain
- Pelvic -+ congestive symptoms (pain, bleeding, discharge) o-
z. Signs
- - General -+ signs of infection
- Abdominal -+ . tendemess & rigidity in lower abdomen (peritonitis)
. maximum 3 cm above mid-inguinal point (tubal point)
- P/Y -+ tender movement of cx, tender adenexae * tender mass

If. goaorrhea lworserf C. trachonatis

More acute May remain for months
after menses in tube
Milder (silent PID
More but later on
Srueiliaatiottt
+
C.ullure + swab from endocervix, rectum, pharyrx
B.tood - t ps& TLC, CRP
C.omplicotions
- Ultrasound -+ adnexal swelling
- *' [r"p"atoscopli + . red, swollen, edematous tube * mass
G (gold standardo; . Pus may exude from fimbrial end -+ cytology

Criteriq fot die{nosis

$ftotmro cdterla + Ooe eddltloml

- Lower abd. pain tT t RT - Temp 38oc, T ES& TLC > 10.500
>
- Adenexal tendemess - Inflammatory mass (by P/V or U/S)
- Cx motion tenderness culdocentesis, endocx swab

D illsutial dioana,s ia o ... .. . .causes of acute a bdomen........

- Disturbed ectopic, acute appendicitis
- Ruptured ovarian cyst, complicated fibroid
- Inflammatory bowel disease e.g. appendicitis, diverticulitis

eamnlicalfuna
+
o Recurrence.........Chronicity -esp chlamydir (chronic pelvic pain)
o Infeftility.............Ectopic pregnancy
tr Spread +........- Pelvic abscess formation
- - Thrombophlebitis
- Peritonitis, Septicemia

WhiteKnightLove
 ?rt errh?q r4

GDC RECoMMENDATIoN FoR PID

Cefoxitin I I Cefotetan
2gtYt6hr lo"lzetY/t2h Levofloxacin 500 mg
+ doxycycline 100 mg IV I l2hrs 1xlxl4

Ampicillin/sulbactam 39 IV/6 hr Ofloxacin 400 mg

\f
t doxycycline 100 mg IV ll2hrs r' Plus \ X
N
x
Metronidazole 5OO

Clindamycin | | Gentamycin
900mg lol Loading Ceftriaxone I I Cefoxitin
IV/8hr lll 2mstr<g 250 mg I ORI 2 sm
0. | | _+r.s mg/ once I I once

NB.....antibiotics in pregnancy
- The most safe ate penicillins / cephalosporiru
- Anti-tubercnlorzs drugs could be given
- Quinolones are absolutely contraindicated
- Intravaginal antifungals (candida) are safe from first trimester
- Metronidazole (Trichomonas) can be used in 2"d &,3d timester

WhiteKnightLove
 lnfection 1rG
I
9uufmenf
F( Prophylaxis
- Avoid sexual promiscuity
- Aseptic techniques (delivery, D&C,IUCD)
- Prompt diagnosis &early ttt......otherwise....chronic pID within ......

}( S,ctive
G General lines
- Antipyretics
- Analgesics & hot fomentation
- Antibiotics in cornbination in high doses
- Complete bed rest in Fowler position
- Treatment of partners
G lndications for hospitalization
- Nulliparity or low pariry -+ to avoid infertility
- Bad
T.:ffi ,ffi i*'":rm,:rfffltT:f"i# lTlr
G Antibiotic therapy rcontinued 48 hrs after resolution of feven
o Regimen L.......cefoxitin (2od) or cefotaxime (3'u) + Doxycycline
o Regimen II... .. .clindamycin * gentamycin
o Regimen III.....ampicillin * gentamycin * metronidazole

N8.... CDC recommendation for HD 0

... TTT of specific organisms (uncomplicated)

G Surgical intervention
- If Orcuere dhease refractorjt to medical ttt or
@ruptured /bwge tubooaarian abscess or
@ ge nera liqe d p eritonitis
\ I-a.?arotom:t // + drainage *
peritoneal toilet
+ ....... unilateral adenexectomy (to preserve fertility)
:
OR ..... .pelvic clearance TAH +BSO (for older age)
- If wall tuboouarian abscess -+ aspiration I (U/S guided or Laparoscopy)
- Pebic -+ drain by posterior colpotomy
abscess
- Thmrubopbkbitis -+ heparin

WhiteKnightLove
 Blocked qnd distended
tubes in PID

lrdtucoDhx l,rc ttr rctondropcd d$udoa of Ole.r,f6rd,

iBfloterd druilc safifuftb,

WhiteKnightLove
&ialoart
. STD's. .... .non-specific. . ..chronic granulomatous (fB, B)
. Either a
- * Pemistence of acute PID (due to:)

: frr$'#: ?:"fr";: ;ffi:",1 ffilffi, by nbrosis

+ difiEcult penetration of antibiotics
*chronic from the start
0arftnlnau
1) Hydrosalpinx
- Catarrhal alpingitis olosure ofthe fimbrial end distension
+
with serous fluid + pelvic pressure t pain
- - HSG + retort shaped swelling
- It is liable to -+ torsion, infection, rupture
*Tuboousdrn oust a hydrosalpinx communicating with ovarian cyst

2) hrosalpinx
- Suppurative salpingitis -+ thickened tube full of pus
- HSG + smaller in size than hydrosalpinx
- Less liable fortorsion than hydrosalpiro (infection -+ adhesions)
*Tuboousrlqn qbscesc 4 pyosalpinx communicating with ovarian abscess

3) Perisalpinsitis
- Thi kinked tube sr.urounded by adhesions + infertility, ectopic

4) Salpingitis isthmica nodosa (chronic interstitial salpingitis)

- Multiple bilateral nodules & diverticula (esp in isthmus)
- DD -+ TB, B, gonococcal, endometriosis (t m.b. in healthy tubes?)

5) Fitz-Hugt-Curtis wndrome
- Perihepatitis associated with chronic PID (esp chlarnydia, gonorrhea)
- CIP -+ recurrent upper right abdominal pain @D: cholecystitis)
- Inv. -+ laparoscopy + violin string-like bands of adhesions

efinical oidurc.
> Historv + previous attacks of acute PID or ectopic
) Svmntoms
o Infertility
---o Congestive symptoms +-
o Recurrent acute exacerbations
-
WhiteKnightLove
m@,d D,64hSili - ile opDc@re ot +.ro&n

Obstructed
fallopian tube

N^
\\
Tubo-ovarian
abscess

. Findings associated with chronic pelvic inflam-

matory disease, including tubo-ovarian abscess, adhesions,
pyosalpinx, and an abscess located in the posterior cuFde-sac.

WhiteKnightLove
 > S€..
o General -+ ill health....TB toxemia
a AMominal -+ signs of TB peritonitis or bilharziasis HSM
o Pelvic + . Tendenness (lower abdominal, cervical motion) r/
. Tubo-ovarian (adenexal) mass y'y'
. Fixed RVF
Oi,llswtial clAagnoai,o ..EruoouerRtosts, Ceucen OvRny, TB
lruaotioatioaa
- Diagnosis o
c.ullure -+ swab from endocx, rectum, pharynx (chlamydia, gonorrhea)
B.tood + t gSR, TLC, CRp
C.omplicotions
.ultrasound.......ifpain prevents PV & to follow up To abscess size
-
.Laparoscopy....if diagnosis is uncertain or no improvement within 4$-72hr
- Etiobg + TB (tuberculin, chest X-ray)
- Comp. O e.g. infertility + HSG, laparoscopy (+tuUa biopsy)
9wafment
Prophylactic -+ prevent puerperal, postabortive & surgical infection
Active
a Acute *K#:l:{i;fr1"#:1t3; 48 hours initia'v
. Antibiotics, hot fomentation
o If good re,sponse (improvement of general health) -+ continue
o If no response or there is a mass (abscess) from the start ) surgery
. Unilateral adnexectomy (if young + conservative)
. TAH + BSO (esp if bilateral & > 40 years)
.If infertility -+ tuboplasty fails .'. remove + IVF/ICSI (better)
a In chronic specffic -+ treat cause as B or TB

lry -+ not preceded by pregnancy I trauma / surgery -+ better prognosis

2ry -+ postabortive, postarptum, post-ectopic (infected haematocoele)
post-traumatic, extension from near by focus (appendicitis)
grganioma -+ usually mixed (ls aerobes then anaerobes)
Anicaloidurc
Symptoms +*
(pain more severe) urinary t & rectal pressure symptoms
-
Signs Tender cervl& tender adenexae
- Tender soft swelling in Douglas pouch (also felt by PR)
1tcafunsrl+ as in chronic PID

- WhiteKnightLove
 Elrizrnln% rl

lncubationperiod 7-14days 2-1 0 days 4-7 days 3-12 days

Primarylesion Papule Vesicle Papule/pustule Papule/veslcle
Number of lesions Single Multiple 1-3, occasionally more Single
Size 5-l 5 rnm l-3mm 2-20mm 2-l0mm
Painful No Yes Yes No
Diagnostic test Dark-field microscopy Viral culture Gram! stain with "school Complement
RPR/MHA.TPIFTA.ABS of fish" appearance fixation
Treatment Penicillin Acyclovir Ceft riaxone oa azithromycin Doxycycline

WhiteKnightLove
 lnfection
I
119

Chr.ontc trqrnulonrtous Clrorcor

> Couse a Treponema pallidum (a spirochete)

> Tvpes
Al Congenital + abortion,IUFD, malformations (early or late)
Bl Acquired
$ t'r + hard chancre (after 9 - 90 days)
- Appears in LGT, anorectal region, rarely in lips
- Painless, single (/) or multiple firm papules + punched out ulcer
- Painless hard non-suppurated LN
- Infectious -+ spontaneously healing occurs within 6 wk

I zo + muco+utaneous stage (6 wk - 6 m)
- General symptoms (blood spread), generalized LN
- Rash, mucous patches esp on palms & soles
- Condyloma latum (warly growth on vulva & perineum)
- Infectious

$ Sr a Gumma formation
- Early latent (within 4years of 2ry)
- Late latent (> 4 yrs): Neurosyphilis or cardiovascular syphilis

> lnvestiootlons
* Dark ground iltumination in l,v and 2,r + spirochetes "
* Non specific tests -+ Wassermann, Khan, RPR, VDRL
. Positive after 2 weeks from chancre
. May be false *ve in some immune diseases such as SLE
. Confirm by:
* Specific tests + TPl, FTA
> Treotmont
Early (lv, 2o,3o < lyear)
Benzathine penicillin 2.4 million units IM once
Or Procaine penicillin I million units / day for 10 days
Or Tetracycline / Erythromycin / Doxycycline (100 mg lx2xl4)
late syphilis
Benzathine penicillin 2.4 million units IM lweek for 3 wks
Neurosyphilis
Aqueous Penicillin G 12-24 million Ulday IV for 10 days
Then Benzathine penicillin 2.4 million units IM /week for 3 wks

WhiteKnightLove
> €tlologv
. Mycobacterium tuberculosis (human bacillus) > Mycobacterium boviso
. Becoming more cofllmon nowadays + 5% infErtility cases o S
> Boute of lnfactlon
- Blood borne /
(from lvpulmonary TB) -+ most common o
- Peritoneal spread (TB peritonitis)
- Lymphatic spread (TB of mesenteric LNs)
- Ascending with infected semen (TB epididymitis)
> Fohologv
S tubes " 1LOO9%,4 d adhesive or exudative
r PERISALeINGmS + miliary tubercles * adhesions
. Irutensrmlt SALPINGmS + thiclq nodules, caseation
. EttoosltpINGITIS + pyosalpinx full of caseous material
. SALPINGITIS ISTHMIcA NoDoSA

S Uterus (50%) + .Tubercles surrounded by granulomatous tissue

o
. Caseation, atrophn Asherman's syndrome
$ ovarie s Q5%) omay appear normal or granulomas, caseation, fibrosis
9 Cx, vd9, vulva (5%) -+ Hypertrophic + polypi
+ Ulcers: setpiginous outline, turdermined
plchro
> Cllntcol edges, yellow floor, not indurated

I ristory (family or exposure or endemic area)

I srqrtome
* General -+ tTB toxemia (NNLL)......chest symptoms of TB
*Abdomen -+ * peritoneal TB.........ascites, sinuses
* Pelvic
- Infertitiry(due to J GC, tubalblock, anovulation, endometrial TB)
- Setrtic cotgestimt e-
. Pain @'s)
. Bleeding
. Discharge
- Annwrrfua(J, GC, anovulation, endometrial TB, .f E by TB toxins)

WhiteKnightLove
 I sigras General / chest
Abdominal
Local +. Tubercles (nodules) in vulva, vagina, cervix
. Uterus + t fixed R\lF
. Adenexae + * adnexal swelling
. Douglas pouch + * nodules

) lnvostlootlons
General Blood (lLC, ESR), chest X-ray
+
O Endometrium @6C biopsy or menstrual shedding by cx cap) for
- ZeilNeilson stain -+ bacilli * excess lymphocytes
- Culfure on Dorset egg or Lowenstein Jensen medium
- Animal inoculation + guineapig (liver & spleen examined after 40 days)
O Vulva. vaeina. cervix + biopsy from lesions

O Tubes
* llSG + . Sausage shaped, lead pipe, hydrosalpinx, calcificatisn * patent
. Peritubal adhesions (localized collections of dye)
. Intrauterine adhesions, micropouche intravasations

* €tdoscopy + laparoscopy + biopsy

tube is sausage shaped pde with tubercles,
calcification, caseation, dense adhesions
> Treotrnent

Medlcal //o antituberculous drugs "

2 montlts -+ Isoniazid (5 mg /rg/day)+
Rifampicin (10 mg/kg/daD +
Ethambutol (15 mg/kg/day) or Streptomycin (lgm IM /day)
7 months + Rifanpicin + Isoniazid

Surglcd e
o No tubal microsurgery (v. imp)
o TAH & BSO are only done if large masses are present + fistula

WhiteKnightLove
> €tlologv + Schistosoma haematobium > Sch. Mansoni

> Routos of lnfoctlon

Communication between vesical,rectal &vaginal plexus +
o Polyps I small, sessile, firm, single ormultiple
Er Ul-cers O superficial, multiple, dirty
tr Sandy patches a calcified ova beneath the surface
tr Calcif ication a fibrosis, sfictures, fistula
> Pothologv
- {.//.....Vulva + pseudo-elephantiasis + thickening ofhymen
- ,// .......Yagina -+ granular vaginitis + vaginal stenosis + polypoidal mass
- {.........Cervix + infertility
.......Uterus -+ very rare (monthly shedding)
... ....Tubes + salpingitis isthmica nodosa (mucosa free i.e. tube patent)
.......bary -> large, ttrickened, nodular
> CllnlcolplcUro
xistory + endemic areas esp farners
symptoms
- Of urinary or rectal bilharuiasis
- Pelvic congestion h + pain / bleeding / discharge
- Infertili(y (due to PID)
signs
. Polyps / ulcers / sandy patehes
. PID

> lnvestlootlons
- Urine & stool analysis + for ova
- Cystoscopy, sigmoidoscopy, laparosoopio biopsy
- Vulval &vagjrulbiopsy
- CFT
> TreoUnent
- Prophylactic
- Antibilharzial +. Biltricide @raziquantel) single dose (20-60 mglkg)
. Ambilhar (niridazol) 500mg 1x3x7
- Surgical excision ofresidual lesions

WhiteKnightLove
Other organisms

Cause + Haemophilus ducreyi (gram -ve bacillus)

Ct-rNrcat PrcruRE
o Papules -+ pustules -+ rupture
( soft ulcer (multiple, shallow, painful)
o Suppurative lymphadenopathy with sinus formation
luvesttcattotts
-Smear +
gram stain
-Culture on enriched medium
- Serologt + CFT, Fluorescent antibody
iopsy
TnearN T ... ... .....Tetracyclines ... ..... Sulfonamides

Cnuse + Calymmato-bacterium (gram -ve bacillus)

Cttxtcau ptcruRe + affects vulva mainly
o Papules + rupture
( ulcers * fibrosis * stricture
o Lymphadenopathy (pseudobubo formation)
lHvesrroarron
- Giemsa stain + Donovan bodies (mononuclear cells containing
large number of bacilli)
- Biopsy
Tneatuerur ... ... .....Tetracyclines ... ... ... Erythromycin

OncaNtsy -+ Actinomyces Israeli (fungus)

Roure oF tNFEcnoN
-
Direct spread from ruptured appendix or perforated colon + tubes
-
Direct spread from rectum + vagina
-
May produce PID in association with IUD
Patnoloev + masses, sinuses discharging pus & sulfur granules
Dtacruosts + Gram stain /
Biopsy Pap.Smear I
TRrarNerur
- Remove IUCD
- Antibiotics for long time (penicillin, erythromycin, tetrarycline)

Vtnoloe y + RNA virus (reverse transcriptase -a retovirus-)

Destruction of T-lymphocytes + immune suppression
WhiteKnightLove
 urse (semen & saliva)
D Blood or blood products / Infected .yring",
E vertical transmission Qo % ofpregnancies) oAntepartum + placenta
O Intraparhrm + birth canal O Postpartum -+ lactation
Clrrurcal flcruRE
l- Asymptomatic...S0%. ..............up to l0 years
2- rnilial Hrv exp o s ure .. . ... fever, my algia, generaliznd. lymphadenopathy
3' Months$rs latet.......weight loss, infections (h.zoster, oral candidiasis)
4- AIDS. ........Opportunistio infection + pneumonia cystitis carnii
Malignancy + Kaposi sarcoma
Draeuosrs
> Screening for at risk population @LrsA)
. Male homosexuals / Intravenous drug users
. Infection with other STD's / Neonates born to infected woillen
> Confirmation
. Westem blot test
. PCR for HIV RNA (viral load)
Tnearmeut
> Prophylaxis
- Avoid sexual contact with infectedpersons
- Proper screening for blood or its products
- Vaccination against opportunistic infections
> Active
- There is no ttt that cures HIV
- Only drugs available are to suppress viral replication
. Retroviral inhibitors. . .nucleoside analogues (Zidovudine)
. Protease inhibitor. . ...Indinavir
. Fusion inhibitor.......Fuzeon
- HAART (gighly Active AntiRetroviral Therapy is the
combination of 2 nucleoside analogues + a protease inhibitor)
- Vaccine developm
- ent is undertrial (very difficult)
9!.dp.!cu rad trr.9
HfV screening should be offered for all at risk czues. Risk of fetal
transfer is l5:2.5o/o (without ttt). Lactation adds another 1G-15% risk
while maternal ttt, CS, avoidance of breast reduces that risk.

WhiteKnightLove
 lnfection 125
I
CDC REC FOR PID
Parerrteral
Cefoxitin I I Cefotetan
2 glY I 6hr l"' l2 gIY I l2h Levofloxacin Sffi mg
+ doxycycline 100 mg IV ll2hrs 1xkl4

Ampicillin/sulbactam 39 IV/6 hr Ofloxacin 4ffi mg

\t
F
* doxycycline 100 mg IV / l2hrs r'flus\ x
N
X
F
Metronidazole 5OO

Clindamycin Gentamycin
900 mg Loading Ceftriaxone Cefoxitin
IV/E hr 2 mgfi<g 250 mg 2gm
+ 1.5 mg/ once once

- The most safe are penicillins / cephalosporins

- Anti-tuberculous drugs could be given
- Quinolones are absolutely contraindicated
- Intravaginal antifungals (candida) are safe from first
trimester
- Metronidazole (Trichomonas) can be used in 2"d &, 3'd
I trimester
@ +Ve G -\,e
Aerobes Lactobacillus E-coli
Staph aureus, strept Klebsiella, proteus
Enterococcus faecalis Enterobacter
Diphteroids Pseudomonas
Anaerobes Peptostreptococcus Bacteroids
Clostridium Bacteroids fragilis
Lactobacillus Fusobacterium
Gardnerella vaginalis
Yeast (candida)
WhiteKnightLove