Firstranker's choice

GYNAECOLOGY

Disorders of sexual development

Embryology of female genito urinary system

Cloaca ? rectum, vesicourethral canal (bladder & urethra)

? upper portion of cloaca

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lower portion (urogenital sinus)

pelvic part

tower urethra

Phallic part

?

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tata / vagina

Homologous structures

Embryonal structure

primordial germ cell

genital ridge

sex cords

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Gubernaculum

Mesonephric tubule

Mesonephric duct

Paramesonephric duct

?

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ova

ovary

granulosa cells

round ligament

epoopheron, paroophoron

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gartners duct

uterus, fallopian

tube, upper vagina

?

spermatozoa

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tests

seminiferous tubule,

sertoli cells

gubernaculum testis

efferent ductules,

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paradidymis

epididymis, vas

deferens, ejaculatory

duct

prostatic utricle,

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appendix of testis,

hydatid of Morgagni

target gene for SRY s favour testis differentiation is 80% 9

?genes & favour ovary differentiation are Writ4, Repo & DAX1

Gartner's cyst:

• It is a DD for UV prolapse

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• vaginal epithelium over gartner's cyst is stretched & shiny,
• rugosities are lost
• no cough impulse
• well defined
• fo - cacation

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Mullerian fusion defects:

Uterus didelphys

• paramesonephric duct fails to unite completely
• two horns of uterus & 2 cervix
• septum in vagina may be seen

Bicornuate uterus

• incomplete fusion of paramesonephric ducts

  complete

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  partial

Septate uterus

• similar to bicornuate uterus, but no endometrial tissue
• in b/w, only septum present

  complete

  partial

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Arcuate uterus:

• mild indentation in fundus of uterus

Unicornuate uterus:

• One paramesonephric duct fails to develop
• only one horn present, other rudimentary horn
• may be communicating or non communicating

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• ectopic pregnancy may occur in rudimentary horn

* Modality of choice for investigation ? 3D USG

* surgery for bicornuate uterus ? Strassman operation ? Ix recurrent abortion

* Rx for septate uterus? hysteroscopic septal resection

Mullerian agenesis / MRKH syndrome:

• 1° amenorrhoea

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• 2° sexual characters well developed
• uterus no /cervix /vagina
• ovaries are developed
• repair for vaginal agenesis can be done at time of marriage ? for coital purpose

STD's :

Bacterial vaginosis:

• A flora ? anaerobic >>> aerobic

  ?

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  eg: Lactobacillus ? maintains the acidic pH

• pH > 4 to 4.5
• vaginal cells produce glycogen under the influence of estrogen
• Lactobacillus acts on glycogen & produce lactic acid responsible for acidic pH

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• when lactobacilli are outnumbered by gardnerella vaginalis, M. hominis, ureaplasma urealyticum, mobiluncus to cause bacterial vaginosis
• presents & foul smelling, greyish white vaginal discharge
• profuse discharge
• no itching (no inflammation)
• Clue cells are seen in microscopy

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• amine test ? whiff test ? fishy odour
• AMSEL criteria is used to diagnose vaginosis
• Not transmitted sexually
• RFs ? new sexual partner, many partners, douching, smoking, IUCDs.
• Rx ? no need to Rx the partner

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• * metronidazole 400 mg daily BD x 7 days
• whiff test is aka amine test
• abundance of gram variable coccobacilli may be seen
• discharge doesn't contain any cells, WBCs
• On ex ? Cx is ? = no discharge

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Candidiasis

• caused by C. albicans > C. glabrata > c. tropicalis
• occurs at pH <4.5
• RF: immunocompromised states
• Sx? curdy white discharge
  • vulva is inflamed & red
  • severe itching

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• ? 10% KOH ? dimorphic nature of candida seen
• Types complicated & uncomplicated
  • longer Rx ? >4 episodes/yr
  • duration : =1 RF
  • non candida albicans inf

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  • single episode, no RF
  • easy to Rx
  • candida albicans

• Rx: azole group of antifungals (clotrimazole, butoconazole, fluconazole etc)

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• for complicated? boric acid capsules

Trichomonas vaginitis

• caused by T. vaginalis
• sexually transmitted
• affects female >> male
• cause vaginal discharge, cervicitis

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• Sx ? dyspareunia, spotting, discharge, urethritis, proctitis
• males are asymptomatic
• discharge is frothy green & itching present
• ?: swab + 10% KOH ? motile organisms seen
• Speculum examination ? strawberry cervix

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• Rx metronidazole
• Rx the partner too

Sequelae

• Bacterial vaginosis ? pregnancy : PTL, PROM
• pelvic surgery: infection of cuff
• marker of other STDs

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TB of genital tracts

• caused by M. tuberculosis (95%) & M. bovis (5%)
• m/c in childhood TB
• becomes-symptomatic by puberty

• Involves fallopian tube & vulva
• Causes infertility, ectopic pregnancy (fallopian tube rv)

  ? menorrhagia foll by amenorrhoea (endometrium)

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  ? ulcers (cx, ovary, vagina)

• ?D? moth eaten appearance of tube on HSG

  aka beaded appearance / leopard spot appearance

  ? clubbed ends of fimbriae

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• Rx? ATT (doesn't cure infertility)

  golf club appearance

  ?tobacco pouch appearance

PID:

• infection of upper genital tract
• causative ? N. gonorrhoeae, Chlamydia trachomatis (m/c)

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• vaginal flora too

• Minimum criteria? uterine tenderness
• cervical motion tenderness
• adnexal tenderness

• Additional criteria? white discharge PV

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• Fever >101°F
• ?CRP, ? ESR
• NAAT (s gonorrhoea & chlamydia)

• Gonorrhoea ? Sx develop in 3-7 days

  ? cervicitis, urethritis, PID

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• Chlamydia ? no direct pathogenic effect on genital organs

? presents = sequale of PID

?delayed hypersensitivity damage of? PLD tubes

• syndromic m/m ? KIT 1
• NACO ? lower abd pain ? KIT 6 ? cefixime, metro & doxy

  gonorrhoea

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  chlamydia

• pt may prevent & tubo-ovarian abcess ? do laparoscopy, obtain cultures from fallopian tube
• most sensitive test for chlamydia ? NAAT (PCR)
• Doc for chlamydia in pregnancy is erythromycin

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Genital ulcers

• Syphilis ? 1° chancre

  ? 14-21 days after sexual contact

  ? a single ulcer on vulva / vagina / cx

  ? painless ulcer & reared indurated border

  ? base of ulcer is clean & non infected; deep

  ? disappears after some time

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• H. ducreyi ? cause chancreed.

  ? red beefy, extremely painful ulcer

  ? occurs on vulva /vagina / cx

  ? single lesion

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• Herpes, HSV 2 ? extremely painful, numerous ulcers

  ? the previous episodes

  ? occurs on vulva /vagina

  ? occur in crops

  ? Rx acyclovir / ganaclovir ? ? no of ulcers / recurrence

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• LGV ? buboes are present

Sex & intersexuality

Puberty:

• 1st sign ? thelarche (breast budding)
• 2nd ? pubic/axillary hair ? pubarche / adrenarche
• 3rd ? menarche is just preceeded by a growth spurt

* GnRH ? pulsatile secretion ( night > day) ? responsible for pubertal growth ing

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?

LH >> FSH

?

GnRH pulse throughout day

?

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FSH & LH ? ovary ? follicle development ? estrogen

?

priming of endometrium

• estrogen for 1 yr? 1° ovulation ? progesterone ? menarche
• precocious puberty> rabo 2° sexual characters before 8 yrs of age

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• absence of 2° sexual characters & menstruation at 14 yore
• 2° sexual characters absence of menstruation even en presence of menstruation at 16 yore

  ? both needs evaluation re delayed puberty

• Ab pubertal development
• @ precocious puberty (PP) central ?aka gonadotrophin dependant precocious

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• peripheral ? m/cc is Idiopathic puberty
• central PP causes ? hypothalamic hamartoma, optic glioma (in NF) radiation, head trauma, cns anomalies, infection

• Toupin Albers syndrome ? ovarian cyst adrenal estrogen
• producing tumours, exogenous estrogen
• Hypothalamic hamartomas present & gelastic seizures / laughing fits

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• precocious puberty ? f>M
• delayed puberty ? M>F
• m/cc is constitutional ? hypogonadotropic hypogonadism
• ?1°gonadal failure : hypergonadotrophic hypogonadism

Me Cure Albright syndrome:

• Precocious puberty

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• Cafe au lait pigmentation
• Polyostotic fibrous dysplasia of bone
• somatic mutation in GNAS1 gene
• girls > boys

Basics of menstruation :

• @ hypothalamus, pituitary, ovary / gonads, endometrium

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Basics of gonadal sex:

• AMH ? mullerian hormone
• Testis Sertoli cells ? Testosterone Binding Factor (TBF)
• Leydig cells ? Testosterone, DHT ? male ext. genitalia
• De novo sex ? ?

• Sex chromosome disorder:

  - 45 XO Turner

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  - 47 XXY Klinefelter

• 46 XY disorder

  - pure gonadal dysgenesis (swyer syndrome)

  - partial gonadal dysgenesis

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• 46 XX disorders

*m/cc of 1° amenorrhoea ? Turner > mullerian agenesis > testicular feminising syndrome

Cryptomenorrhea:

• D/T imperforate hymen / transverse vaginal septum / cervical atresia
• pt presents = 1° amenorrhoea

Imperforate hymen

• 1°amenorrhoea, monthly abd. pain

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• O/E bulging bluish membrane
• USG ? hematocolpos (blood in vagina), hematometra (blood in uterus)

  ? blood may sometimes spill into abdominal cavity

• Rx cruciate incision in hymen

Amenorrhoea

• 1°

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• 2° +ve progesterone challenge test

• Kallman syndrome ? delayed menstruation / puberty + anemia
  • defect in anosmin gene
  • defective hypothalamus
  • hypogonadotrophic hypogonadism

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• Withdrawal bleeding following administration of progesterone indicates progesterone deficiency & estrogen secretion
• Androgen insensitivity / testicular feminisation syndrome = (AIS / TFS)
  • 46 XY chromosome
  • though per testosterone is produced, testosterone receptor is absent
  • failure of testicular deacent ? inguinal swelling ±
  • external female genitalia

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  • breast development
  • absent pubic /axillary hair, 1°amenorrhoea
• Refenstein syndrome:
  • almost like a lever degree of AIS
  • male & some degree of feminization

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  • bifid scrotum, hypospadias
  • partial androgen insensitivity syndrome
• Other syndrome & delayed puberty ? Prader Willi syndrome, Laurence Moon Biedl syndrome,

• Sheehan's syndrome

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• Pituitary necrosis /apoplexy d/t severe long PPH
• 2° amenorrhoea
• & amenorrhoea is seen in persone = systemic discares leaders debility, anorexia nervosa ehe. ? It is hypogonadotrophic
• m/cc of congenital adrenal hypoplasia ? 21 OH deficiency
• Fitz Hugh Curtis syndrome ? violin string adhesions between R fallopian tube & undersurface of liver

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Menopause & HRT

• d/t loss of ovarian follicular activity
• cessation of menopause to menstruation for 12 months
• avg age ? 45 to 55 yrs (50 you)
• before 40? premature ovarian failure
• Menopausal transition ? begins menstrual irregularity & extends to 1yr after permanent cessation of menses

  ? average of 47 years & lasts 4-7 years

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• classification of female reproductive aging is called STRAN

Prediction of approaching menopause:

• Fall in the level of inhibin B ?FSH
• fall in antimullerian hormone (AMH) suggest low ovarian reserve & low antral follicular count
• ? LH (but
• Study of FSH level on 2nd day 2-5 after last menstrual period detects premenopausal stage

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Marker of ovarian reserve:

• Day 3 serum FSH > 10-15 IU/L
• day 3 serum estradiol > 60-80pg/ml
• Low AMH (0.2-0.7 ng/ml) ? ovarian volume
• loro serum inhibin B

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• antral follicular count (N-20 to 150)

• AMH
• AMH is secreted by sertoli cells (in ?) & granulosa cells (in ?)
• peptide hormone
• in ?, AMH secreted by 7th week of IUL till puberty

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• in ?, AMH secreted after puberty
• lerd & 2-6.8ng/ml
• Helps in follicular development & oocyte maturation
• Level reflects no of growing follicles

In postmenopausal period:

• ?FSH, ? LH, ? estrone

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• ? AMH, ? androstenedione

* No. of oocytes at menopause ? 1000

Sx of menopause:

• menstrual Sx
• hot flushes
• dyspareunia

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• Jed libido
• urinary stress incontinence
• osteoporosis
• neurological
• psychological

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* Hot Flushes are d/t ved estrogen & Ted noradrenaline

? peripheral vasodilatation ? skin temp ?, expin fingerne toes

?

sweating, ? BP

?d/t rapid fluctuation in estrogen levels

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? altered serotonin levels

• Rate of bone loss after menopause ?2-5°/%

Perimenopausal osteoporosis:

• Bone max measured by DEXA (dual energy xray absorbimetry)
• gives 5) Tscore (compares your results to a healthy young adult 20-35)
  • expressed as std deviations from mean
  • o score ?

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  • -1.5 to -2.4 indicate osteopenia
• ii) z core ? compares your results to a person of the same gender & age as yourely
  • score -2.5 indicate osteoporosis
• all menopausal women should be given 1g Calcium (if not on HRT)

  - if on HRT ? 500mg Calcium is given

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• pH of vagina is maximum during menopause (pH 6-7.5)
• androstenedione is converted to estrone
• mest potent estrogen is estradiol (E2) ? reproductive age
• estrone (E1) ? menopause

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• estriol (E3)? pregnancy [potency E2>E1>E3] (least potent)
• There is 50% reduction in androgen production & 60% reduction in estrogen at menopause

• oestrogen level 10 to 80 pg/ml
• estrogen level >40 pg/mL exerts bone & cardiotrophic effect & <20pg/mL predispose to osteoporosis & IHD
• 500 FSH >40 is diagnostic of menopause

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HRT

• Ix? vasomotor SX, vaginal atrophy, osteoporosis preventation or Rx
• re-evaluation of need for HRT at 6-12 month intervals
• prescribed in lowest posible dose for shortat period
• HRT is not useful in CAD
• Estrogen causes ? ? LDL, & cholesterol, ? HDL, ?TGA, ? coagulation factors, ? lethogenicity of bile (stone forming capacity)

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• progesterone causes ? LDL, ? HDL

Drugs for postmenopausal osteoporosis:

• Antiresorptive agents:
  • estrogen
  • SERM- raloxifene
  • Bisphosphanates
  • Denosumab mab against RANK-L

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  • Cal citonia
  • vitD
• Anabolic agents ( stimulate bone formation)
  • Teriparatide (recombinant human parathormone)

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• [Raloxifene for bone, tamoxifen for breast]

• Raloxifene ? incidenal endometrial ca
• * # rate,
• * dosent cave endometrial hyperplasia / breast carcinoma
• *STE ? hot flushes

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• * 1/2 in renal disease
• * progesterone is added to estrogen in HRT only if deres to prevent endometrial cancer; not go in pts who have undergone hysterectomy

* Hot Flushes a

• hormonal agents
  • estrogen - CEE, 17 BE2
  • progestine - MPA
  • combined E & P

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  • TSEC: CEE + BZA
• [ conjugated equine estrogen-CEE Tissue selective estrogen complex Baredorfene - BZA] -TSEC
• C/I for HRT
  • Thrombess
  • undiagnosed ab genital bleeding

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  • Know / eus perted / tho Ca breast
  • Any estrogen dependant neoplasia
  • TE
  • stroke IMI
  • liver dis

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• Non hormonal
  • SSRI's
  • SNRIs
  • clonidine
  • gabapentine

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• DOC for ? libido- androgens
• HRT ve alzheimers, colorectal ca

Abnormal uterine bleeding

Characteristics of menstrual cycle

• ? length of cycle: 24 to 35 days
• avg " - 28 days (Reen only in 15%)

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• No. of days of bleeding : 2-7d
• Avg no. of days of " - 4 to 5d
• ? blood loss : 5-80 ml
• Avg " " : 30 ml

Definitions in ab uterine bleeding:

• Menorrhagia ? cyclic bleeding at ? intervals; the bleeding is either excessive in amount (>80ml) or duration (>7 days) or both

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• Metrorrhagia ? irregular, acyclic bleeding
• Oligomenorrhoea? occur less frequently is more than 35 days apart
• Hypomenorrhea ? scanty bleeding, Jest <2 days

Causes of metrorrhagia

• Fibroid polyp
• Ca Cx & Ca endometrium

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• Wethral de caruncle
• IUCD
• decubitus ulcers
• withdrawal bleeding in pill users

superficial functional layer

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Endometrium

deep basal layer

Stratum compactum (superficial)

Stratum spongiosum (deep)

• The superficial functional layer is hormone sensitive

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• deep basal layer is hormone insensitive & contain stem cells.
• After every menstruation, regeneration occurs from deep basal layer

AUB

Anatomical causes (PALM)

• Polyp
• Adenomas
• Leiomyoma

  aubmucosal

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  others

• Malignancy & hyperplasia

Causes of AUB:

General causes

• Blood dyscrasia
• coagulopathy

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• Thyroid dysfn
• genital TB

Pelvic causa

• PID, pelvic adhesions
• outerine fibroids
• endometrial hyperplasia

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• adenomyosis
• feminizing tumor of ovary
• endometriosis
• pelvic congestion
• varicose veine în pelvis

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Contraceptive use

• INED
• pest tubal sterilization
• POPe

Hormonal DUB

• ovulatory -Irregular ripening/ shedding
• Anovulatory- reeting endometrium 8%

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• metropathia Demonhargica

* Halban disease ? irregular shedding of corpus luteum

• Rule out coagulopathy, pelvic lesions, hypothyroidism
• m/cc is anovulation > blood dyscrasias
• off of PCOS ? cyproterone acetate

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• of puberty menorrhagia ? progaterone, Ocps, GnRH analogue
• m/c endometrial pattern in DUB is ?

M/m of AUB

• Young women
  • progestogens
  • Combined ocps
  • NSAID

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  • Tranexamic acid
  • GnRH aralogue
• In older women who have completed family
  • hysterectomy
  • endometrial ablation

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• In AUB ? 1st investigation is TVS
• IOC is endometrial bx
• m/cc of postmenopausal bleeding

  globally? la endometri LUD

  India? Ca cx

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• Dysmenorrhea - cramping pain during menstruation
  • 1°? no pelvic pathology
  • 2°? pelvic pathology + ? eg. fibroids, adenomyosis, PID, endometriosis
  • Spasmodic dysmenorrhea? cramping pain on 1st & 2nd day, most prevalent
  • Congestive " "? manifest as Ting pelvic pain

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  • Anovulatory bleeding is painless

ENDOMETRIOSIS

• Theories of endometriosis :
  • Sampson's retrograde menstruation theory - meat crccepted & oldest
  • Meyer & Ivanoffk coelomic metaplasia theory
  • Stem cell theory

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  • Lymphatic or vascular spread
• Common sites of endometriosis in decreasing Frequency.
  • Ovary
  • cul de sac (pouch of Douglas).
  • uterosacral ligament

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  • vermiform appendix
  • rectosigmoid colon
  • ate ureters
  • urinary bladder

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• Endometriosis doesnot occur in spleen
• Endometriosis is hormone dependant
• 1° method of le laparoscopy, I or without Bx or histologic (gold std)
• RFs:
  • Infertility
  • low BMI

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  • nulli parity
  • white women > other races
  • pelvic pain
  • red hair
  • high socioeconomic status, late child birth

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• O/E: retroverted & fixed uterus may be seen
• cobblestone feel of uterosacral ligament is sean

Scar endometriosis:

• Painful & tender swelling over the scar
• usually not a/w pelvic endometriosis

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• can occur at episiotomy sites, hysterectomy /cesarean seas,
• cannot be treated - hormones myomectomy Hubectomy
• scar should be excused
• implantation theory explain its entity

classification:

• American society for reproductive medicine classification: (ASRM 4)
  • stage I- minimal

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  • II- mild
  • III- moderate
  • IV - severe
• menorrhagia may be seen

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• Pain in endometriosis is d/t PG in peritoneal fluid
• Depth of penetration is more related to sx than spread
• Javóns penetration > 5mm are responsible for pain, dysmenorrhea & dyspareunia

Examination findings

• pelvic tenderness
• bluish or blackab spots in posterior fornix & are tender

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• V/L or B/L chocolate cysts (adnexal mass) of varying sizes

• Early lestone: papulas & red veside filled w hemorragic fluid I surrounding flame like lerone
• with age ? dark cred, bluish or black cystic areas
• poroder burnt areas are wiactive old lesions scattered over pelvic peritoneum
• Healed areas are seen as emall peritoneal defects (windows) or white por patches

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chocolate cyst

• mostly B/L
• lined by columnar epithelium.
• pseudoxanthoma cells are po large macrophages of ecavenge celle & brown colour is alt hemosiderin in them

Rx:

M/m of pain

Drug Rx:

• OC
• mirera LUCD

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• porogestogen
• androgens
• GnRH
• Letrozole
• RU-486

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Laparoscopy

• destruction by cautery, laver vapourization
• excision of cyst
• adhesiolysis
• presacral neurectomy
• LUNA (laparoscopic uterosacral ablation)

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Laparotomy

• incision of chocolate cyst & removal of linong
• oralpingo-oophorectomy
• hysterectomy & ulk or B/L salpingo-oophorectomy
• excision of scar endometriosis

In Infertility:

clomiphene, Letrozole (high doses)

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• Danazol causa ab diver enzymes

LNG IUCD - non contraceptive wes (M.frena)

• Menorrhagia | DUB
• dysmenorrhoea
• premenstrual syndrome
• endometriosi

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• * lifespan of mirena 5 yous
• adeno myosis
• leiomyoma
• endometrial hyperplasia
• endometrial ca

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• HRT

Adenomyosis:

• It is ingerowth of endometrium both stromal & glandular components derictly into myometrium
• Etiology : vigorous curettage, crepeated childbirth (excess estrogen
• CF:
  • women above age 40, parous women
  • menorrhagia (70%), dysmenorrhoea (30%), urinary frequency, dyspareunia, unfertility

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• M/m: surgery ? TOC
• hormonal therapy is not much effective

• Commonest benign tumor of uterus & commonest benign solid tumor in female
• Histologically, compered of smooth muscle & fituroco connective tissue

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• each myoma is derived from smooth muscle cell rests, either from vessel wall or wtowne musculative
• derived from wingle progenitor myocyte

Classification:

• Subser
  

  This download link is referred from the post: MBBS Lecture Notes for all subjects (updated for 2021 syllabus) - All universities

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