Unit Vii Gynae MSC II Year

1 UNIT: VII Gynaecological problems and nursing management -----------------------------------------------------------------------------------------------------------Dysmenorrhea Definition: Dysmenorrhoea is a gynecological medical condition of pain during
menstruation that interferes with daily activities. Dysmenorrhea can feature different kinds of pain, including sharp, throbbing, dull, nauseating, burning, or shooting pain. Dysmenorrhea may precede menstruation by several days or may accompany it, and it usually subsides as menstruation tapers off. Dysmenorrhea may coexist with excessively heavy blood loss, known as menorrhagia. Classification: Primary or secondary based on the absence or presence of an underlying cause. Secondary dysmenorrhea is dysmenorrhea which is associated with an existing condition. he most common cause of secondary dysmenorrhea is endometriosis. !ther causes include leiomyoma, adenomyosis, ovarian cysts, and pelvic congestions. he presence of a copper "#D can also cause dysmenorrhea. "n patients with adenomyosis, the levonorgestrel intrauterine system $%irena& was observed to provide relief. Symptoms: Pain concentrated in the lower abdomen, in the umbilical region or the suprapubic region of the abdomen. "t is also commonly felt in the right or left abdomen. "t may radiate to the thighs and lower back. Symptoms often co-occurring with menstrual pain include nausea and vomiting, diarrhea or constipation, headache, di''iness, disorientation, hypersensitivity to sound, light, smell and touch, fainting, and fatigue. Symptoms of dysmenorrhea often begin immediately following ovulation and can last until the end of menstruation. his is because dysmenorrhea is often associated with changes in hormonal levels in the body that occur with ovulation. he use of certain types of birth control pills can prevent the symptoms of dysmenorrhea, because the birth control pills stop ovulation from occurring. athophysiology: Prostaglandins are released during menstruation, due to the destruction of the endometrial cells, and the resultant release of their contents. (elease of prostaglandins and other inflammatory mediators in the uterus cause the uterus to contract. hese substances are thought to be a ma)or factor in primary dysmenorrhea. *hen the uterine muscles contract, they constrict the blood supply to the tissue of the endometrium, which, in turn, breaks down and dies. hese
PREPARED BY KAWALJIT KANG, MSC. MAI BHAGO COLLEGE OF NURSING, TARN TARAN
+ uterine contractions continue as they s,uee'e the old, dead endometrial tissue through the cervix and out of the body through the vagina. hese contractions, and the resulting temporary oxygen deprivation to nearby tissues, are responsible for the pain or -cramps- experienced during menstruation. Diagnosis: %edical history of menstrual pain $categories& that interferes with daily activities. %enstrual bleeding and degree of interference with daily activities. Pelvic examination. . pap test. /ertain lab tests. 0ynecologic ultrasonography. 1aparoscopy may be re,uired.
!anagement: 2S."Ds 2on-steroidal anti-inflammatory drugs "NS#IDs$ are effective in relieving the pain of primary dysmenorrhea. hey can have side effects of nausea, dyspepsia, peptic ulcer, and diarrhea. Patient who are unable to take the more common 2S."Ds, may be prescribed C%&'( inhibitor. - he effect of three cyclo-oxygenase inhibitors is on intensity of primary dysmenorrheic pain-. 3esides these drugs anti-spasmodic4s like drotra)ine is used that relax the muscles and helps to reduce the pain. 5ormonal contraceptives .lthough use of hormonal contraception can improve or relieve symptoms of primary dysmenorrhea, Norplant and Depo'pro)era are also effective, since these methods often induce amenorrhea. he "ntra#terine System $%irena "#D& has been cited as useful in reducing symptoms of dysmenorrhea. "n case of severe blood loss, iron supplements like folic acid and iron polymaltose are used. .lternative medicine . number of alternative therapies have been studied in the treatment of dysmenorrhea. he effectiveness of acupressure, behavioral interventions, thiamine, vitamin 6, topical heat, and
7 transcutaneous electrical nerve stimulation is likely while the effect of acupuncture, fish oil, magnets and vitamin 31+ is unknown. Spinal manipulation is unlikely to be helpful. 3ehavioral therapies assume that the physiological process underlying dysmenorrhea is influenced by environmental and psychological factors, and that dysmenorrhea can be effectively treated by physical and cognitive procedures that focus on coping strategies for the symptoms rather than on changes to the underlying processes. .cupuncture and acupressure are used to treat dysmenorrhea.
#menrrohea Definition: .menrrohea is the medical term for the absence of menstrual periods, either on a permanent or temporary basis. .menorrhea can be classified as primary or secondary. "n primary amenorrhea, menstrual periods have never begun $by age 18&, whereas secondary amenorrhea is defined as the absence of menstrual periods for three consecutive cycles or a time period of more than six months in a woman who was previously menstruating. *is+ factors: ransient changes in hormonal levels, stress, and illness, environmental factors. #nderlying medical condition in uterus. Presence of a disease or chronic condition.
Causes: 1evels of hormones and secreted by the ovaries. 5ormonal signals from the pituitary gland 5ormones produced in the hypothalamus of the brain. Disorders that affect any component of this regulatory cycle can lead to amenorrhea. #ndiagnosed pregnancy. hypothalamic problems, .norexia or extreme exercise.
rimary amenorrhea:
9 Primary amenorrhea is typically the result of a genetic or anatomic condition in young females that never develop menstrual periods $by age 18& and is not pregnant. Diseases of the pituitary gland and hypothalamus $a region of the brain important for the control of hormone production& can also cause primary amenorrhea since these areas play a critical role in the regulation of ovarian hormones. 0onadal dysgenesis is the name of a condition in which the ovaries are prematurely depleted of follicles and oocytes $egg cells& leading to premature failure of the ovaries. "t is one of the most common cases of primary amenorrhea in young women. .nother genetic cause is urner syndrome, in which women are lacking all or part of one of the two : chromosomes normally present in the female. "n this ovaries are replaced by scar tissue and estrogen production is minimal, resulting in amenorrhea. 6strogen-induced maturation of the external female genitalia and sex characteristics also fails to occur in urner syndrome. !ther conditions that may be causes of primary amenorrhea include androgen insensitivity $in which individuals have :; $male& chromosomes but do not develop the external characteristics of males due to a lack of response to testosterone and its effects&, congenital adrenal hyperplasia, and polycystic ovary syndrome $P/!S&. Secondary amenorrhea: Pregnancy is an obvious cause of amenorrhea and is the most common reason for secondary amenorrhea. <urther causes are varied and may include conditions that affect the ovaries, uterus, hypothalamus, or pituitary gland. 5ypothalamic amenorrhea is defined as amenorrhea that is due to a disruption in the regulator hormones produced by the hypothalamus in the brain. hese hormones influence the pituitary gland, which in turn sends signals to the ovaries to produce the characteristic cyclic hormones. . number of conditions can affect the hypothalamus and lead to hypothalamic amenorrhea, such as= 6xtreme weight loss, emotional or physical stress, rigorous exercise, and severe illness. !ther types of medical conditions can cause secondary amenorrhea= tumors or other diseases of the pituitary gland that lead to elevated levels of the hormone prolactin $which is involved in milk production& also cause amenorrhea due to the elevated prolactin levels,hypothyroidism,elevated levels of androgens $male hormones&, either from outside sources or from disorders that cause the body to produce too high levels of male hormones,ovarian failure $premature ovarian failure or early menopause&>polycystic ovary syndrome,.sherman4s syndrome is an example of uterine disease that causes amenorrhea. "t
? results from scarring of the uterine lining following instrumentation $such as dilation and curettage& of the uterine cavity to manage postpartum bleeding or infection. Post-pill amenorrhea that have stopped taking oral contraceptive pills should experience the return of menstruation within three months after discontinuing pill use, suppose menses stopped means it should be evaluated for causes of secondary amenorrhea.
Symptoms: 5istory of absence of menstruation, "rregular menstrual periods, #nwanted hair growth, Deepening of the voice, and acne. 6levated prolactin levels as a cause of amenorrhea can result in galactorrhea $a milky discharge from the nipples that is not related to normal breastfeeding&.
Diagnosis: %edical history, %edical conditions, Physical examination, Pelvic examination, 3lood tests may be ordered to examine the levels of ovarian, pituitary, and thyroid hormones. hese tests may include measurements of prolactin, follicle-stimulating hormone $<S.&, estrogen, thyrotropin, dehydroepiandrosterone sulfate $D56.-S&, and testosterone. <or some individuals, a pregnancy test is the first test performed.
"maging studies, such as ultrasound, :-ray, and / or %(" scanning may also be recommended in certain individuals to help establish the cause of amenorrhea Treatment for amenorrhea: reatment goals can be to relieve symptoms of hormonal imbalance, to establish menstruation, prevent complications associated with amenorrhea, and@or to achieve fertility, although not all of these goals can be achieved in every case.
8 "n cases in which genetic or anatomical abnormalities are the cause of amenorrhea $typically primary amenorrhea&, surgery may be recommended to correct anatomical abnormalities. 5ypothalamic amenorrhea that is related to weight loss, excessive exercise, physical illness, or emotional stress can typically be corrected by addressing the underlying cause. <or example, weight gain and reduction in intensity of exercise can usually restore menstrual periods in women who have developed amenorrhea due to weight loss or overly intensive exercise, respectively, who do not have additional causes of amenorrhea. "n some cases, nutritional counseling may be of benefit. "n premature ovarian failure, hormone therapy may be recommended both to avoid the unpleasant symptoms of estrogen depletion as well as prevent complications $see below& of low estrogen level such as osteoporosis. his may consist of oral contraceptive pills for those women who do not desire pregnancy or alternative estrogen and progesterone medications. *hile postmenopausal hormone therapy has been associated with certain health risks in older women, younger women with premature ovarian failure can benefit from this therapy to prevent bone loss. *omen with P/!S $polycystic ovary syndrome& may benefit from treatments that reduce the level or activity of male hormones, or androgens. Dopamine agonist medications such as bromocriptine $Parlodel& can reduce elevated prolactin levels, which may be responsible for amenorrhea. /onse,uently, medication levels may be ad)usted by the person4s physician if appropriate. .ssisted reproductive technologies and the administration of gonadotropin medications $drugs that stimulate follicle maturation in the ovaries& can be appropriate for women with some types of amenorrhea who wish to attempt to become pregnant. Complications of amenorrhea: "nfertility, !steopenia $a reduction in bone density& or osteoporosis is a complication of low estrogen levels. re)ention, .menorrhea is a symptom and not a disease in itself. herefore, amenorrhea can be prevented only to the extent that the underlying cause can be prevented. <or example, amenorrhea that results from genetic or inborn conditions cannot be prevented. !n the other
A hand, amenorrhea that results from self-imposed stringent dieting or intensive exercise is typically preventable.
!enorrohagia Introduction: %enorrohagia is an abnormally heavy and prolonged menstrual period at regular intervals. %enorrhagia can be caused by abnormal blood clotting, disruption of normal hormonal regulation of periods, or disorders of the endometrial lining of the uterus. Depending upon the cause, it may be associated with abnormally painful periods $dysmenorrhea&. Definition: . normal menstrual cycle is +?B7? days in duration, with bleeding lasting an average of ? days and total blood flow between +? and CD m1. . blood loss of greater than CD ml or lasting longer than A days constitutes menorrhagia $also called hypermenorrhea&. Cause: Disorders of coagulation 3lood disorders of platelets $such as " P& or coagulation $such as von *illebrand disease& or use of anticoagulant medication $such as warfarin& are therefore possible causes, although a rare minority of cases. 6xcessive build up in endometrial lining Periods soon after the onset of menstruation in girls $the menarche& and )ust before menopause may in some women be particularly heavy. 5ormonal disorders involving the ovaries-pituitary-hypothalamus $the 4ovarian endocrine axis4& account for many cases, and hormonal-based treatments may regulate effectively. .s women age and move towards menopause, ovulation is delayed and the remaining follicles in the ovaries become resistant to 0n(5 $0onadotropin releasing hormone& secreted by the hypothalamus gland in the brain. 6ither that or they don4t develop an egg, and thus no progesterone is produced. *ithout progesterone, the estrogen is -unopposed- and keeps building up the lining of the uterus. During a woman4s period, the endometrial lining which is normally shed never gets the signal to stop thickening. "t keeps growing and sheds irregularly. Due to the extra thickness, the bleeding is unusually heavy. 1ess fre,uently in this age group, too little estrogen causes the
C irregular bleeding. %ost cases of hemorrhagic are due to normal hormonal changes preceding menopause. "rritation of the endometrium may result in increased blood flow, e.g. from infection $acute or chronic pelvic inflammatory disease& or the contraceptive intrauterine device $note the distinction from the "ntra#terine System which is used to treat this condition&. <ibroids in the wall of the uterus sometimes can cause increased menstrual loss if they protrude into the central cavity and thereby increase endometrium4s surface area. .n abnormality of the endometrium such as adenomyosis $so called -internal endometriosis-& where there is extension into the wall of the uterus gives rise to an enlarged tender uterus. 2ote true endometriosis is a cause of pain $dysmenorrhoea& but usually not alteration in menstrual blood loss. 6ndometrial carcinoma $cancer of the uterine lining& usually causes irregular bleeding, rather than the cyclical pattern of menorrhagia. 3leeding in between periods $intermenstrual bleeding or "%3& or after the menopause $post-menopausal bleeding or P%3& should always be considered suspicious. Diagnosis: Pelvic and rectal examination Pap smear Pelvic ultrasound scan is the first line diagnostic tool for identifying structural abnormalities. 6ndometrial biopsy to exclude endometrial cancer or atypical hyperplasia 5ysteroscopy
Treatment: <irst line "ntra#terine System insertion Second 1ine ranexamic acid an antifibrinolytic agent 2on-steroidal anti-inflammatory drugs $2S."Ds& /ombined oral contraceptive pills to prevent proliferation of the endometrium hird line !ral progestogen $e.g. norethisterone&, to prevent proliferation of the endometrium "n)ected progestogen $e.g. Depo provera&
E !ther options 0onadotrophin-releasing hormone $0n(5& agonists $e.g. 0oserelin& Surgery Dilation and curettage $DF/& is no longer performed for cases of simple menorrhagia, having a reserved role if a spontaneous abortion is incomplete. 6ndometrial ablation. #terine artery embolisation $#.6&. 5ysteroscopic myomectomy to remove fibroids over 7 cm in diameter. .nemia must keep in mind to treat with iron supplementation. Complications: !ver time the blood loss may prove to be greater than the body iron reserves or the rate of blood replenishment, leading to anemia. Symptoms attributable to the anemia may include shortness of breath, tiredness, weakness, tingling and numbness in fingers and toes, headaches, depression, becoming cold more easily, and poor concentration. !etrorrhagia Definition: %etrorrhagia, also known as breakthrough bleeding or spotting, is uterine bleeding at irregular intervals, particularly between the expected menstrual periods.Some women experience acute mid-cycle abdominal pain around the time of ovulation $sometimes referred to by the 0erman term for this phenomenon, mittelschmer'&. his may also occur at the same time as menstrual spotting. %etrorrhagia may also be a sign of an underlying disorder, such as hormone imbalance, endometriosis, uterine fibroids, or cancer of the reproductive organs.Due to repeated bleeding, it may cause significant anemia. Cause: "ntermittent spotting between periods can result from any of numerous reproductive system disorders. Dysfunctional uterine bleeding 6ndometriosis .denomyosis 6ctopic pregnancy 5ormone imbalance
1D 6ndometrial hyperplasia Polyps 6ndometritis /ervicitis Gaginitis Diets which induce ketosis, such as the .tkins diet #se of progestin-only contraceptives, such as Depo Provera /ervical cancer #terine cancer Gaginal cancer 6ndometrial cancer Primary fallopian tube cancer !varian cancer #terine leiomyomas 6nlarged uterus with menorrhea "rregular ovulation, commonly caused by polycystic ovarian syndrome Pregnancy $implantation bleeding, ectopic pregnancy, or incomplete miscarriage& Sexually ransmitted "nfections Gon *illebrand Disease Pelvic inflammatory disease P/!S /hange in oral contraception rauma Sexual abuse or rape
el)ic inflammatory disease "or disorder$ " ID$ Definition: Pelvic inflammatory disease $or disorder& $P"D& is a term for inflammation of the uterus, fallopian tubes, and@or ovaries as it progresses to scar formation with adhesions to nearby tissues and organs. his can lead to infertility. Classification - route of transmission: P"D is a vague term and can refer to viral, fungal, parasitic, though most often bacterial infections. P"D should be classified by affected organs, the stage of the infection, and the organism$s& causing it. .lthough an S " is often the cause, many other routes are possible, including lymphatic, postpartum, postabortal $either miscarriage or abortion& or intrauterine
11 device $"#D& related, and hematogenous spread. wo thirds of patients with laparoscopic evidence of previous P"D were not aware they had P"D. Incidence: P"D causes over 1DD,DDD women to become infertile in the #S each year. 2. gonorrhoea is isolated in 9DB8DH of women with acute salpingitis. /. trachomatis is estimated to be the cause in about 8DH of cases of salpingitis, which may lead to P"D. Symptoms: Symptoms in P"D range from subclinical $asymptomatic& to severe. "f there are symptoms, then fever, cervical motion tenderness, lower abdominal pain, new or different discharge, painful intercourse, or irregular menstrual bleeding may be noted. Diagnosis: 5istory collection Physical examination 1aparoscopic identification is helpful in diagnosing tubal disease, (egular Sexually ransmitted "nfection $S "& testing is important for prevention. 0ynecologic ultrasound, a potential finding is tubo-ovarian complex, which is edematous and dilated pelvic structures as evidenced by vague margins, but without abscess formation.
Differential diagnosis .ppendicitis, ectopic pregnancy, septic abortion, hemorrhagic or ruptured ovarian cysts or tumors, twisted ovarian cyst, degeneration of a myoma, and acute enteritis must be considered. rognosis: .lthough the P"D infection itself may be cured, effects of the infection may be permanent. his makes early identification by someone who can prescribe appropriate curative treatment very important in the prevention of damage to the reproductive system. Since early gonococcal infection may be asymptomatic, regular screening of individuals at risk for common agents $history of multiple partners, history of any unprotected sex, or people with symptoms& or because of certain procedures $post pelvic operation, postpartum, miscarriage or abortion&. Prevention is also very important in maintaining viable reproduction capabilities.
1+ Complications: P"D can cause scarring inside the reproductive organs, which can later cause serious complications, including chronic pelvic pain, infertility, ectopic pregnancy $the leading cause of pregnancy-related deaths in adult females&, and other dangerous complications of pregnancy. !ccasionally, the infection can spread to in the peritoneum causing inflammation and the formation of scar tissue on the external surface of the liver $<it'-5ugh-/urtis syndrome&. %ultiple infections and infections that are treated later are more likely to result in complications. <ertility may be restored in women affected by P"D. raditionally tuboplastic surgery was the main approach to correct tubal obstruction or adhesion formation, however success rates tended to be very limited. "n vitro fertili'ation $"G<& has been used to bypass tubal problems and has become the main treatment for patients who want to become pregnant. Treatment: .ntibiotic therapy= "f the patient has not improved within two to three days after beginning treatment with the antibiotics, they should return to the hospital for further treatment. 5ospitali'ation may be necessary if the patient has ubo-ovarian abscesses> is very ill, immunodeficient, pregnant, or incompetent> or because a life-threatening condition cannot be ruled out. reating partners for S "s is a very important part of treatment and prevention. .nyone with P"D and partners of patients with P"D since six months prior to diagnosis should be treated to prevent reinfection. Psychotherapy is highly recommended to women diagnosed with P"D as the fear of redeveloping the disease after being cured may exist. (egimens include cefoxitin or cefotetan plus doxycycline, clindamycin plus gentamicin, ampicillin and sulbactam plus doxycycline, and ceftriaxone or cefoxitin plus doxycycline.
re)ention: (isk reduction against sexually transmitted infections through barrier methods such as condoms> see human sexual behavior for other listings. 0oing to the doctor immediately if symptoms of P"D. 0etting regular gynecological $pelvic& exams with S " testing to screen for symptomless P"D. Discussing sexual history with a trusted physician in order to get properly screened for sexually transmitted diseases.
17 (egularly scheduling S " testing with a physician and discussing which tests will be performed that session. 0etting a S " history from your current partner and insisting they be tested and treated before intercourse. reating partners to prevent reinfection or spreading the infection to other people. Diligence in avoiding vaginal activity, particularly intercourse, after the end of a pregnancy $delivery, miscarriage, or abortion& or certain gynecological procedures, to ensure that the cervix closes.
UT.*IN. #/N%*!#0IT1 Introduction: - #terine abnormalities are congenital F also ac,uired congenital anomalies may be due to defect in mullerian duct fusion or reabsorbtion here are unicornuate, bicornuate septate or double uterus. hese are the structural abnormalities of the uterus. <ailure of development of one or both mullerian ducts= - he absence of both ducts leads to absence of uterus including oviducts. here is also absence of the vagina. Primary amenorrhoea is the chief complaint. .bsence of one duct leads to a unicarnuated uterus with a single oviduct. <ailure of recanalisation of the mullerian ducts= - .genesis of the upper vagina or of the cervix. <ailure of fusion of mullerian ducts= - "n this the failure of the fusion of the mullerian duct. he detection is made accident during the investigation or infertility or repeated pregnancy instate. "t also diagnosis is made during DI6 operation manual removal of placenta of during caesarean section. T1 . %2 2USI%N #N%!#0I.S= .rcuate= - he cornual part of the uterus remains separated. he uterine fundus looks concave with heart shaped cavity outline. #terus didolphys= - here is complete lack of fusion of the mullerian ducts with a double uterus double cervix F a double vagina. #terus bicornis= - here is varying degree of fusion of the muscle walls of the two ducts. #terus bicornis bicollis= - here are two uterine cavities with double cervix with or without vaginal septum. #terus bicormis unicollis= - here are two uterine cavities with one cervix. he horns may be e,ual or one horn may be rudimentary F have no communication with the development horn. Septate uterus= - he two mullerian ducts fused together but there is persistence of septum in between the two either partially $subseptate& or completely. #terus unicarnis= - <ailure of development of one mullerian ducts. D6S related abnormality= - is due to D6S exposure during intrauterine life varieties of malformed action are included e.g. hypo plastic uterus J Jshaped uterus F cervical hyperplasia. Clinical feature= - here are two type of the clinical feature=
19 0ynaecological= - "nfertility F dysparanoia are after related in association with vaginal septum. - Dysmenarrhaea in bicornuate uterus or due to cryptomenarrhaea $pent up menstrual blood in rudimentary&. - %enarrhagia= - due to increased surface area in bicarnuate uterus. - !bstetrical= - %idtrimester abortion which may be recurrent. - /orneal pregnancy with inevitable rupture the rudimentary harm. - "ncreased incidence of malpresentation transverse lies in arcuate or subseplate breech in bicornuate, unicernuate or complete septate uterus. - Preterm labour "#0(, "#D. - Prolonged labour due to incardinate uterus action. - !bstructed labour B obstruction by non-gravid horn of the bicarnuate uterus or rudimentary horn. - (etained placenta F postpartum haemorrhage where the placenta is implanted over uterine septum. Diagnosis: ' - 5ysterography= radiographic study of the interior uterotubal anatomy with contrast media. - 5ysteroscopy. - 1aparoscopy. - %(". Treatment: - Surgical treatment. .bdominal metroplasty= - .bdominal metroplasty is the surgical procedure. "t could be done either by the excising the septum or by incision the septum success of this procedure in them of live birth is high $?-A?H&. 5ysteroscopic %etroplasty= - his is becoming popular these days. (esection of the septum can be done either by a laparoscopy or by laser. .dvantages= - 5igh success rate CDH-CEH. - Short hospital stay. - (educed post operative morbidity. - Subse,uent chance of vaginal delivery is high as compared to abdominal metroplasty. -
2allobian tube disorder: 2allopian tube cancer: Definition:
1? Primary fallopian tube cancer $P< /&, often )ust tubal cancer, is a malignant neoplasm that originates from the fallopian tube.primary cancer among women accounting for 1 to + percent of all gynecologic cancers.6vidence is accumulating that individuals with mutations of 3(/.1 and 3(/.+ are at higher risks for the development of P< /. athology: he most common cancer type is the adenocarcinoma> poorly differentiated, unilateral, and the distribution showed a third each with local, regional, and distant extensions. (arer forms of tubal neoplasm include the leiomyosarcoma, and the transitional cell carcinoma.Secondary tubal cancer usually originates from cancer of the ovaries, the endometrium, the 0" tract, the peritoneum, and the breast. Symptoms: Symptoms are nonspecific and may consist of pain and vaginal discharge or bleeding. . pelvic mass may be detected on a routine gynecologic examination.Gaginal discharge in fallopion tube carcinoma result from intermittent hydrosalphinx that is called as hydrops tubae profluens. Diagnosis: . pelvic examination may detect an adnexal mass. . /.-1+? blood test is a nonspecific test that tends to be elevated in patients with tubal cancer. gynecologic ultrasound examination, . / scan or an %(" of the pelvis.
Treatment: he initial approach to tubal cancer is generally surgical and similar to that of ovarian cancer. .s the lesion will spread first to the ad)acent uterus and ovary, . total abdominal hysterectomy is an essential part of this approach and removes the ovaries, the tubes, and the uterus with the cervix. .lso, peritoneal washings are taken, the omentum is removed and pelvic and paraaortic lymph nodes are sampled. Staging at the time of surgery and pathological findings will determine further steps. "n advanced cases when the cancer has spread to other organs and cannot be completely removed cytoreductive surgery is used to lessen the tumor burden for subse,uent treatments.
18 Surgical treatments are typically followed by ad)uvant usually platinum-based chemotherapy. .lso radiation therapy has been applied with some success to patients with tubal cancer for palliative or curative indications. Staging: <"0! staging is done at the time of surgery= Stage D =/arcinoma in situ Stage " =0rowth limited to fallopian tubes Stage "" =0rowth involving one or both fallopian tubes with extension to pelvis Stage """= umor involving one or both fallopian tubes with spread outside pelvis Stage "G =0rowth involving one or more fallopian tubes with distant metastases rognosis: Prognosis depends to a large degree on the stage of the condition. "n 1EE1 it was reported that about half of the patients with advanced stage disease survived ? years with a surgical approach followed by cisplatinum-based chemotherapy.
%)arian disorder %)arian cancer: Introduction: !varian cancer is a cancerous growth arising from the ovary. %ost $more than EDH& ovarian cancers are classified as -epithelial- and are believed to arise from the surface $epithelium& of the ovary. 5owever, some evidence suggests that the fallopian tube could also be the source of some ovarian cancers. !ther types may arise from the egg cells $germ cell tumor& or supporting cells. hese cancers are grouped into the category of gynecologic cancer. Signs and symptoms: Signs and symptoms of ovarian cancer are fre,uently absent early on and when they exist they may be subtle. he symptoms persist for several months before being recogni'ed and diagnosed. %ost typical symptoms include= bloating, abdominal or pelvic pain, difficulty eating, and possibly urinary symptoms.
1A !ther findings include an abdominal mass, back pain, constipation, tiredness and a range of other non-specific symptoms, as well as more specific symptoms such as abnormal vaginal bleeding or involuntary weight loss. here can be a build-up of fluid $ascites& in the abdominal cavity.
Causes: #nknown. !lder women, and in those who have a first or second degree relative with the disease, have an increased risk. 5ereditary forms of ovarian cancer can be caused by mutations in specific genes $most notably 3(/.1 and 3(/.+, but also in genes for hereditary nonpolyposis colorectal cancer&. high-grade serous ovarian adenocarcinomas found that the P?7 gene was mutated in E8H of cases.!ther genes commonly mutated were 2<1, (31 and cyclindependent kinase 1+ $/DK1+&. "nfertile women and those with a condition called endometriosis, and those who use postmenopausal estrogen replacement therapy are at increased risk. he more children a woman has, the lower her risk of ovarian cancer. 6arly age at first pregnancy, older age of final pregnancy and the use of low dose hormonal contraception have also been shown to have a protective effect. he risk is also lower in women who have had their fallopian tubes blocked surgically $tubal ligation&. . strong family history of uterine cancer, colon cancer, or other gastrointestinal cancers may indicate the presence of a syndrome known as hereditary nonpolyposis colorectal cancer $52P//, also known as 1ynch syndrome&.
*is+ factors: *omen who have not children are more likely to develop ovarian cancer. Diagnosis: . very large ovarian cancer as seen on / %icrograph of serous carcinoma, a type of ovarian cancer, diagnosed in peritoneal fluid. Diagnosis of ovarian cancer starts with a physical examination $including a pelvic examination&, ransvaginal ultrasound.
1C he diagnosis must be confirmed with surgery to inspect the abdominal cavity, take biopsies $tissue samples for microscopic analysis& and look for cancer cells in the abdominal fluid. he serum 35/0 level should be measured in any female in whom pregnancy is a possibility. "n addition, serum alpha-fetoprotein $.<P& and lactate dehydrogenase $1D5& should be measured in young girls and adolescents with suspected ovarian tumors because the younger the patient, the greater the likelihood of a malignant germ cell tumor. . complete blood count $/3/& and serum electrolyte test should be obtained in all patients. . blood test called /.-1+? is useful in differential diagnosis and in follow up of the disease. Pelvic examination may reveal an ovarian or abdominal mass. he pelvic examination can include a (ectovaginal component for better palpation of the ovaries. <or very young patients, magnetic resonance imaging may be preferred to rectal and vaginal examination.
Classification= Surface epithelial-stromal tumour, also known as ovarian epithelial carcinoma, is the most common type of ovarian cancer. "t includes serous tumour, endometrioid tumor, and mucinous cystadenocarcinoma. Sex cord-stromal tumor, including estrogen-producing granulosa cell tumor and virili'ing Sertoli-1eydig cell tumor or arrhenoblastoma, accounts for CH of ovarian cancers. 0erm cell tumor accounts for approximately 7DH of ovarian tumors but only ?H of ovarian cancers, because most germ cell tumors are teratomas and most teratomas are benign. 0erm cell tumors tend to occur in young women and girls. he prognosis depends on the specific histology of germ cell tumor, but overall is favorable. %ixed tumors, containing elements of more than one of the above classes of tumor histology. AH of ovarian cancers are due to metastases while the rest are primary cancers. /ommon primary cancers are breast cancer and gastrointestinal cancer. Staging: Stage " L limited to one or both ovaries ". L involves one ovary> capsule intact> no tumor on ovarian surface> no malignant cells in ascites or peritoneal washings "3 L involves both ovaries> capsule intact> no tumor on ovarian surface> negative washings "/ L tumor limited to ovaries with any of the following= capsule ruptured, tumor on ovarian surface, positive washings Stage "" L pelvic extension or implants "". L extension or implants onto uterus or fallopian tube> negative washings
1E ""3 L extension or implants onto other pelvic structures> negative washings ""/ L pelvic extension or implants with positive peritoneal washings !varian adenocarcinoma deposit in the mesentry of the small bowel Stage """ L peritoneal implants outside of the pelvis> or limited to the pelvis with extension to the small bowel or omentum """. L microscopic peritoneal metastases beyond pelvis """3 L macroscopic peritoneal metastases beyond pelvis less than + cm in si'e """/ L peritoneal metastases beyond pelvis M + cm or lymph node metastases Stage "G L distant metastases to the liver or outside the peritoneal cavity Para-aortic lymph node metastases are considered regional lymph nodes $Stage """/&. .s there is only one para-aortic lymph node intervening before the thoracic duct on the right side of the body, the ovarian cancer can rapidly spread to distant sites such as the lung. re)ention: ubal ligation appears to reduce the risk of ovarian cancer in women who carry the 3(/.1 $but not 3(/.+& gene. he use of oral contraceptives $birth control pills& for five years decreases the risk of ovarian cancer in later life by half. !anagement: reatment usually involves chemotherapy and surgery, and sometimes radiotherapy. he type of surgery depends upon how widespread the cancer is when diagnosed $the cancer stage&, as well as the presumed type and grade of cancer. he surgeon may remove one $unilateral oophorectomy& or both ovaries $bilateral oophorectomy&, the fallopian tubes $salpingectomy&, and the uterus $hysterectomy&. <or some very early tumors $stage 1, low grade or low-risk disease&, only the involved ovary and fallopian tube will be removed $called a -unilateral salpingo-oophorectomy,- #S!&, especially in young females who wish to preserve their fertility. "n advanced malignancy, where complete resection is not feasible, as much tumor as possible is removed $debulking surgery&. "n cases where this type of surgery is successful $i.e. N 1 cm in diameter of tumor is left behind O-optimal debulking-P&, the prognosis is improved compared to patients where large tumor masses $M 1 cm in diameter& are left behind. %inimally invasive surgical techni,ues may facilitate the safe removal of very large $greater than 1D cm& tumors with fewer complications of surgery.
+D /hemotherapy is used after surgery to treat any residual disease, if appropriate. his depends on the histology of the tumor> some kinds of tumor $particularly teratoma& are not sensitive to chemotherapy. (adiation therapy is not effective for advanced stages because when vital organs are in the radiation field, a high dose cannot be safely delivered. (adiation therapy is then commonly avoided in such stages as the vital organs may not be able to withstand the problems associated with these ovarian cancer treatments. rognosis: (elative ?-year survival of invasive epithelial ovarian cancer by stage.!varian cancer usually has a poor prognosis. !varian cancer is the second most common gynecologic cancer and the deadliest in terms of absolute figure. Complications: Spread of the cancer to other organs Progressive function loss of various organs .scites $fluid in the abdomen& "ntestinal obstructions hese cells can implant on other abdominal $peritoneal& structures, including the uterus, urinary bladder, bowel, lining of the bowel wall $omentum& and, less fre,uently, to the lungs.
%)arian cyst .n ovarian cyst is any collection of fluid, surrounded by a very thin wall, within an ovary. .ny ovarian follicle that is larger than about two centimeters is termed an ovarian cyst. .n ovarian cyst can be as small as a pea, or larger than an orange. %ost ovarian cysts are functional in nature and harmless $benign&. "n the #S, ovarian cysts are found in nearly all premenopausal women, and in up to 19.CH of postmenopausal women. !varian cysts affect women of all ages. hey occur most often, however, during a woman4s childbearing years.Some ovarian cysts cause problems, such as bleeding and pain. Surgery may be re,uired to remove cysts larger than ? centimeters in diameter. Classification: <unctional cysts are mainly.
+1 <ollicular cyst, the most common type of ovarian cyst. /orpus luteum cyst. 2on-functional cysts !ther types as follows=
. polycystic-appearing ovary is diagnosed based on its enlarged si'e L usually twice normal Lwith small cysts present around the outside of the ovary. "t can be found in -normal- women, and in women with endocrine disorders. .n ultrasound is used to view the ovary in diagnosing the condition. Polycystic-appearing ovary is different from the polycystic ovarian syndrome, which includes other symptoms in addition to the presence of ovarian cysts. /hocolate cyst of ovary= .n endometrioma, endometrioid cyst, endometrial cyst, or chocolate cyst is caused by endometriosis, and formed when a tiny patch of endometrial tissue $the mucous membrane that makes up the inner layer of the uterine wall& bleeds, sloughs off, becomes transplanted, and grows and enlarges inside the ovaries. 5aemorrhagic ovarian cyst Dermoid cyst !varian serous cystadenoma !varian mucinous cystadenoma Paraovarian cyst /ystic adenofibroma 3orderline tumoral cysts Signs and symptoms Dull aching, or severe, sudden, and sharp pain or discomfort in the lower abdomen $one or both sides&, pelvis, vagina, lower back, or thighs> pain may be constant or intermittent Lthis is the most common symptom <ullness, heaviness, pressure, swelling, or bloating in the abdomen 3reast tenderness Pain during or shortly after beginning or end of menstrual period. "rregular periods, or abnormal uterine bleeding or spotting /hange in fre,uency or ease of urination $such as inability to fully empty the bladder&, or difficulty with bowel movements due to pressure on ad)acent pelvic anatomy *eight gain 2ausea or vomiting <atigue
++ "nfertility "ncreased level of hair growth "ncreased facial hair or body hair 5eadaches Strange pains in ribs, which feel muscular 3loating Strange nodules that feel like bruises under the layer of skin
Diagnosis: !varian cysts are usually diagnosed by either ultrasound or / scan. Treatment .bout E?H of ovarian cysts are benign, meaning they are not cancerous. reatment for cysts depends on the si'e of the cyst and symptoms. Pain relievers, including acetaminophen@paracetamol $ ylenol or Panado&, nonsteroidal anti-inflammatory drugs such as ibuprofen $%otrin, .dvil&, or narcotic pain medicine $by prescription& may help reduce pelvic pain.2S."Ds usually work best when taken at the first signs of the pain. . warm bath, or heating pad, or hot water bottle applied to the lower abdomen near the ovaries can relax tense muscles and relieve cramping, lessen discomfort, and stimulate circulation and healing in the ovaries.3ags of ice covered with towels can be used alternately as cold treatments to increase local circulation. /ombined methods of hormonal contraception such as the combined oral contraceptive pill B the hormones in the pills may regulate the menstrual cycle, prevent the formation of follicles that can turn into cysts, and possibly shrink an existing cyst. .lso, limiting strenuous activity may reduce the risk of cyst rupture or torsion. /ysts that persist beyond two or three menstrual cycles, or occur in post-menopausal women, may indicate more serious disease and should be investigated through ultrasonography and laparoscopy, especially in cases where family members have had ovarian cancer. Such cysts may re,uire surgical biopsy. .dditionally, a blood test may be taken before surgery to check for elevated /.-1+?, a tumor marker, which is often found in increased levels in ovarian cancer, although it can also be elevated by other conditions resulting in a large number of false positives. <or more serious cases where cysts are large and persisting, doctors may suggest surgery. Some surgeries can be performed to successfully remove the cyst$s& without hurting the ovaries, while others may re,uire removal of one or both ovaries.
+7
Salpingitis Definition: Salpingitis is an infection and inflammation in the fallopian tubes. "t is often used synonymously with Pelvic inflammatory disease $P"D&. Types of salpingitis= .cute salpingitis and chronic salpingitis. Symptoms: he symptoms usually appear after a menstrual period. he most common are= .bnormal smell and colour of vaginal discharge. Pain during ovulation Pain during sexual intercourse Pain coming and going in periods .bdominal pain 1ower back pain <ever 2ausea Gomiting 3loating Causes and pathophysiology: he infection usually has its origin in the vagina, and ascends to the fallopian tube from there. 3ecause the infection can spread via the lymph vessels, infection in one fallopian tube usually leads to infection of the other. *is+ factors: %enstrual flow and the cervix opening during menstruation allow the infection to reach the fallopian tubes. !ther risk factors include= Surgical procedures, breaking the cervical barrier via endometrial biopsy,curettage,hysteroscopy. .nother risk is factors that alter the microenvironment in the vagina and cervix, allowing infecting organisms to proliferate and eventually ascend to the fallopian tube= antibiotic treatment,ovulation,menstruation,sexually transmitted disease $S D&
+9 <inally, sexual intercourse may facilitate the spread of disease from vagina to fallopian tube. /oital risk factors are=, #terine contractions,Sperm, carrying organisms upwards. 3acterial species are =2. gonorrhoeae, /hlamydia trachomatis,%ycoplasma Staphylococcus, Streptococcus., #reaplasma urealyticum,anaerobic and aerobic bacteria.
.ndometrial polyps Definition: .n endometrial polyp or uterine polyp is a mass in the inner lining of the uterus. hey may have a large flat base $sessile& or be attached to the uterus by an elongated pedicle $pedunculated&.Pedunculated polyps are more common than sessile ones. hey range in si'e from a few millimeters to several centimeters."f pedunculated, they can protrude through the cervix into the vagina.Small blood vessels may be present, particularly in large polyps. Cause and symptoms: 2o definitive cause of endometrial polyps is known, but they appear to be affected by hormone levels and grow in response to circulating estrogen. hey often cause no symptoms.symptoms include irregular menstrual bleeding, bleeding between menstrual periods, excessively heavy menstrual bleeding $menorrhagia&, and vaginal bleeding after menopause.3leeding from the blood vessels of the polyp contributes to an increase of blood loss during menstruation and blood -spotting- between menstrual periods, or after menopause."f the polyp protrudes through the cervix into the vagina, pain $dysmenorrhea& may result. Diagnosis: %icrograph of an endometrial polyp. 5F6 stain. 6ndometrial polyps can be detected by vaginal ultrasound $sonohysterography&, hysteroscopy and dilation and curettage. Detection by ultrasonography can be difficult, particularly when there is endometrial hyperplasia $excessive thickening of the endometrium&. 1arger polyps may be missed by curettage. Treatment: Polyps can be surgically removed using curettage with or without hysteroscopy. *hen curettage is performed without hysteroscopy, polyps may be missed. o reduce this risk, the uterus can be first explored using grasping forceps at the beginning of the curettage procedure.
+? 5ysteroscopy involves visualising the endometrium $inner lining of the uterus& and polyp with a camera inserted through the cervix. "f it is a large polyp, it can be cut into sections before each section is removed. "f cancerous cells are discovered, a hysterectomy $surgical removal of the uterus& may be performed.. hysterectomy would usually not be considered if cancer has been ruled out. *hichever method is used, polyps are usually treated under general anesthetic. rognosis and complications: 6ndometrial polyps are usually benign although some may be precancerous or cancerous. .bout D.?H of endometrial polyps contain adenocarcinoma cells.Polyps can increase the risk of miscarriage in women undergoing "G< treatment."f they develop near the fallopian tubes, they may lead to difficulty in becoming pregnant..lthough treatments such as hysteroscopy usually cure the polyp concerned, recurrence of endometrial polyps. .ndometriosis Definition: 6ndometriosis is a gynecological medical condition in which cells from the lining of the uterus $endometrium& appear and flourish outside the uterine cavity, most commonly on the peritoneum which lines the uterine cavity. he uterine cavity is lined by endometrial cells, which are under the influence of female hormones. hese endometrial-like cells in areas outside the uterus $endometriosis& are influenced by hormonal changes and respond in a way that is similar to the cells found inside the uterus. Symptoms often worsen with the menstrual cycle. Signs and symptoms: . ma)or symptom of endometriosis is recurring pelvic pain. he pain can be mild to severe cramping that occurs on both sides of the pelvis, in the lower back and rectal area, and even down the legs. he amount of pain a woman feels correlates poorly with the extent or stage $1 through 9& of endometriosis. hrobbing, gnawing, and dragging pain to the legs are reported more commonly by women with endometriosis./ompared with women with superficial endometriosis, those with deep disease appear to be more likely to report shooting rectal pain and a sense of their insides being pulled down. Dysmenorrhea B painful, sometimes disabling cramps during menses> pain may get worse over time $progressive pain&, also lower back pains linked to the pelvis. Dyspareunia B painful sex. Dysuria B urinary urgency, fre,uency, and sometimes painful voiding. 6ndometriosis lesions react to hormonal stimulation and may -bleed- at the time of menstruation. he blood accumulates locally, causes swelling, and triggers inflammatory responses with the activation of cytokines.
+8 <allopian tubes, ovaries, the uterus, the bowels, and the bladder can be bound together in ways that are painful on a daily basis, not )ust during menstrual periods. .lso, endometriotic lesions can develop their own nerve supply, thereby creating a direct and two-way interaction between lesions and the central nervous system, potentially producing a variety of individual differences in pain that can, in some women, become independent of the disease itself. 6ndometriosis can lead to anatomical distortions and adhesions $the fibrous bands that form between tissues and organs following recovery from an in)ury&.it will give the result of infertility. !ther symptoms include constipation and chronic fatigue. /urrent research has demonstrated an association between endometriosis and certain types of cancers, notably ovarian cancer, non-5odgkin4s lymphoma and brain cancer. 6ndometriosis often also coexists with leiomyoma or adenomyosis, as well as autoimmune disorders.
*is+ factors: 0enetic predisposition plays a role in endometriosis.6xamples of altered gene expression include that of mi(2.s. .ging brings with it many effects that may reduce fertility. Depletion over time of ovarian follicles affects menstrual regularity. 6ndometriosis has more time to produce scarring of the ovary and tubes so they cannot move freely or it can even replace ovarian follicular tissue if ovarian endometriosis persists and grows. 1eiomyomata $fibroids& can slowly grow and start causing endometrial bleeding that disrupts implantation sites or distorts the endometrial cavity which affects carrying a pregnancy in the very early stages. .bdominal adhesions from other intraabdominal surgery, or ruptured ovarian cysts can also affect tubal motility needed to sweep the ovary and gather an ovulated follicle $egg&. 6ndometriosis in postmenopausal women does occur and has been described as an aggressive form of this disease characteri'ed by complete progesterone resistance and extraordinarily high levels of aromatase expression."n less common cases, girls may have endometriosis symptoms before they even reach menarche. athophysiology: he main theories for the formation of ectopic endometrium are retrograde menstruation, mQllerianosis, coelomic metaplasia and transplantation, each further described below. he theory of retrograde menstruation $also called the implantation theory or transplantation theory& is the most widely accepted theory for the formation of ectopic endometrium in endometriosis."t suggests that during a woman4s menstrual flow, some of the
+A endometrial debris exits the uterus through the fallopian tubes and attaches itself to the peritoneal surface $the lining of the abdominal cavity& where it can proceed to invade the tissue as endometriosis. *hile most women may have some retrograde menstrual flow, typically their immune system is able to clear the debris and prevent implantation and growth of cells from this occurrence. 5owever, in some patients, endometrial tissue transplanted by retrograde menstruation may be able to implant and establish itself as endometriosis. e.g., hereditary factors, toxins, or a compromised immune system. "n rare cases where imperforate hymen does not resolve itself prior to the first menstrual cycle and goes undetected, blood and endometrium are trapped within the uterus of the patient until such time as the problem is resolved by surgical incision. !3llerianosis: . competing theory states that cells with the potential to become endometrial are laid down in tracts during embryonic development and organogenesis. hese tracts follow the female reproductive $%ullerian& tract as it migrates caudally $downward& at CB 1D weeks of embryonic life. Primitive endometrial cells become dislocated from the migrating uterus and act like seeds or stem cells. his theory is supported by foetal autopsy. Coelomic metaplasia= his theory is based on the fact that coelomic epithelium is the common ancestor of endometrial and peritoneal cells and hypothesi'es that later metaplasia $transformation& from one type of cell to the other is possible, perhaps triggered by inflammation. Vasculogenesis= #p to 7AH of the microvascular endothelium of ectopic endometrial tissue originates from endothelial progenitor cells, which result in de novo formation of microvessels by the process vasculogenesis rather than the conventional process of angiogenesis. 0ocali4ation: !varies $the most common site& <allopian tubes he back of the uterus and the posterior cul-de-sac he front of the uterus and the anterior cul-de-sac #terine ligaments such as the broad or round ligament of the uterus Pelvic and back wall "ntestines, most commonly the rectosigmoid #rinary bladder and ureters 3owel endometriosis affects approximately 1DH of women with endometriosis, and can cause severe pain with bowel movements. 6ndometriosis may spread to the cervix and vagina or to sites of a surgical abdominal incision.
+C 6ndometriosis may also present with skin lesions in cutaneous endometriosis. 1ess commonly lesions can be found on the diaphragm. Diaphragmatic endometriosis is rare, almost always on the right hemidiaphragm, and may inflict cyclic pain of the right shoulder )ust before and during menses. (arely, endometriosis can be extraperitoneal and is found in the lungs and /2S.
Diagnosis: . health history and a physical examination can in many patients lead the physician to suspect endometriosis. 1aparoscopy, a surgical procedure where a camera is used to look inside the abdominal cavity, is the gold standard in diagnosis. #se of imaging tests may identify endometriotic cysts or larger endometriotic areas. "t also may identify free fluid often within the (ecto-uterine pouch. he two most common imaging tests are ultrasound and magnetic resonance imaging $%("&. o the eye, lesions can appear dark blue, powder-burn black, red, white, yellow, brown or non-pigmented. 1esions vary in si'e. Some within the pelvis walls may not be visible, as normalappearing peritoneum of infertile women reveals endometriosis on biopsy in 8B17H of cases. Surgically, endometriosis can be staged "B"G $(evised /lassification of the .merican Society of (eproductive %edicine&. Stage " $%inimal& <indings restricted to only superficial lesions and possibly a few filmy adhesions Stage "" $%ild& "n addition, some deep lesions are present in the cul-de-sac Stage """ $%oderate& .s above, plus presence of endometriomas on the ovary and more adhesions. Stage "G $Severe& .s above, plus large endometriomas, extensive adhesions. ypical endometriotic lesions show histopathologic features similar to endometrium, namely endometrial stroma, endometrial epithelium, and glands that respond to hormonal stimuli. !lder lesions may display no glands but hemosiderindeposits as residual. !anagement: *hile there is no cure for endometriosis, in many people menopause $natural or surgical& will abate the process. "n patients in the reproductive years, endometriosis is merely managed= the goal is to provide pain relief, to restrict progression of the process, and to restore or preserve fertility where needed. "n younger women with unfulfilled reproductive potential, surgical
+E treatment attempts to remove endometrial tissue and preserving the ovaries without damaging normal tissue. "n general, the diagnosis of endometriosis is confirmed during surgery, at which time ablative steps can be taken. <urther steps depend on circumstances= patients without infertility can be managed with hormonal medication that suppress the natural cycle and pain medication, while infertile patients may be treated expectantly after surgery, with fertility medication, or with "G<. Sonography is a method to monitor recurrence of endometriomas during treatments. reatments for endometriosis in women who do not wish to become pregnant include= rogesterone or rogestins: Progesterone counteracts estrogen and inhibits the growth of the endometrium. Such therapy can reduce or eliminate menstruation in a controlled and reversible fashion. 5ormone contraception therapy: !ral contraceptives reduce the menstrual pain associated with endometriosis. hey may function by reducing or eliminating menstrual flow and providing estrogen support. ypically, it is a long-term approach. (ecently Seasonale was <D. approved to reduce periods to 9 per year./ontinuous hormonal contraception consists of the use of combined oral contraceptive pills without the use of placebo pills, or the use of 2uva(ing or the contraceptive patch without the break week. his eliminates monthly bleeding episodes. Dana'ol $Danocrine& and gestrinone are suppressive steroids with some androgenic activity. 3oth agents inhibit the growth of endometriosis but their use remains limited as they may cause hirsutism and voice changes. Gonadotropin *eleasing 5ormone "Gn*5$ agonist= hese agents work by increasing the levels of 0n(5. /onsistent stimulation of the 0n(5 receptors results in downregulation, inducing a profound hypoestrogenism by decreasing <S5 and 15 levels. *hile effective in some patients, they induce unpleasant menopausal symptoms, and over time may lead to osteoporosis. o counteract such side effects some estrogen may have to be given back $add-back therapy&. hese drugs can only be used for six months at a time. 1upron depo shot is a 0n(5 agonist and is used to lower the hormone levels in the woman4s body to prevent or reduce growth of endometriosis. he in)ection is given in + different doses= a 7 month course of monthly in)ections, each with the dosage of $11.+? mg&> or a 8 month course of monthly in)ections, each with the dosage of $7.A? mg&. .romatase inhibitors are medications that block the formation of estrogen and have become of interest for researchers who are treating endometriosis. NS#IDs:%S = %orphine sulphate tablets and other opioid painkillers work by mimicking the action of naturally occurring pain-reducing chemicals called -endorphins-. here
7D are different long acting and short acting medications that can be used alone or in combination to provide appropriate pain control. Pentoxifylline, a phosphodiesterase inhibitor, has a proposed action of inhibiting the production of inflammatory cytokines as well as inhibiting the activation of immune cells in peritoneal fluid, thereby decreasing pain from endometriosis and improving fertility. Surgery Procedures are classified as conservative when reproductive organs are retained, semi-conservative when ovarian function is allowed to continue, /onservative therapy consists of the excision $called cystectomy& of the endometrium, adhesions, resection of endometriomas, and restoration of normal pelvic anatomy as much as is possible.1aparoscopy, besides being used for diagnosis, can also be an option for surgery. "t4s considered a -minimally invasive- surgery because the surgeon makes very small openings $incisions& at $or around& the belly button and lower portion of the belly. . thin telescope-like instrument $the laparoscope& is placed into one incision, which allows the doctor to look for endometriosis using a small camera attached to the laparoscope. Small instruments are inserted through the incisions to remove the tissue and adhesions. 3ecause the incisions are very small, there will only be small scars on the skin after the procedure. Semi-conservative therapy preserves a healthy appearing ovary, but also increases the risk of recurrence. <or patients with extreme pain, a presacral neurectomy may be indicated where the nerves to the uterus are cut. his is because the nerves to be transected in the procedure are innervating the central or the midline region in the female pelvis.women who had presacral neurectomy have higher prevalence of chronic constipation not responding well to medication treatment because of the potential in)ury to the parasympathetic nerve in the vicinity during the procedure. #se of fertility medication that stimulates ovulation $clomiphene citrate, gonadotropins& combined with intrauterine insemination $"#"& enhances fertility in these patients."n-vitro fertili'ation $"G<& procedures are effective in improving fertility in many women with endometriosis. Prognosis Proper counseling of patients with endometriosis re,uires attention to several aspects of the disorder. !f primary importance is the initial operative staging of the disease to obtain ade,uate information on which to base future decisions about therapy. he patient4s symptoms and desire for childbearing dictate appropriate therapy.
71 Complications: /omplications of endometriosis include internal scarring, adhesions, pelvic cysts, chocolate cyst of ovaries, ruptured cysts, and bowel and ureteral obstruction resulting from pelvic adhesions."nfertility can be related to scar formation and anatomical distortions due to the endometriosis> however, endometriosis may also interfere in more subtle ways= cytokines and other chemical agents may be released that interfere with reproduction.Peritonitis from bowel perforation can occur.
*etro)erted uterus Definition: . retroverted uterus $tilted uterus, tipped uterus& is a uterus that is tilted backwards instead of forwards. his is in contrast to the slightly -anteverted- uterus that most women have, which is tipped forward toward the bladder, with the anterior end slightly concave. Causes: Pelvic surgery, Pelvic adhesions, 6ndometriosis, <ibroids,
7+ Pelvic inflammatory disease, he labor of childbirth.
Symptoms: Pain in the lower back. Dyspareunia $pain during sexual intercourse& Dysmenorrhea $pain during menstruation&. (arely $1 in 7DDD to CDDD pregnancies& a tipped uterus will cause painful and difficult urination, and can cause severe urinary retention. Diagnosis: 5istory collection #ltrasonography %("
Treatment: %anual anteversion of the uterus, and usually re,uires intermittent or continuous catheter drainage of the uterus until the problem is rectified or spontaneously resolves by the natural enlargement of the uterus, which brings it out of the tipped position. "n addition to manual anteversion and bladder drainage, treatment of urinary retention due to retroverted uterus can re,uire the use of a pessary, or even surgery, but often is as simple as having the pregnant mother sleep on her stomach for a day or two, to allow the retroverted uterus to move forward. "f a uterus does not right itself, it may be labeled persistent. Kegals exercises.
.ndometrial cancer Definition: 6ndometrial cancer refers to several types of malignancies that arise from the endometrium, or lining, of the uterus. he most common subtype, endometrioid adenocarcinoma, typically occurs within a few decades of menopause, is associated with obesity, excessive estrogen exposure, often develops in the setting of endometrial hyperplasia, and presents most often with vaginal bleeding. 6ndometrial carcinoma is the third most common cause of gynecologic cancer death $behind ovarian and cervical cancer&. . total abdominal hysterectomy
77 $surgical removal of the uterus& with bilateral salpingo-oophorectomy is the most common therapeutic approach. 6ndometrial cancer may sometimes be referred to as uterine cancer. 5owever, different cancers may develop not only from the endometrium itself but also from other tissues of the uterus, including cervical cancer, sarcoma of the myometrium, and trophoblastic disease. %ost endometrial cancers are carcinomas $usually adenocarcinomas&, meaning that they originate from the single layer of epithelial cells that line the endometrium and form the endometrial glands. here are many microscopic subtypes of endometrial carcinoma, including the common endometrioid type, in which the cancer cells grow in patterns reminiscent of normal endometrium, and the far more aggressive papillary serous carcinoma and clear cell endometrial carcinomas. Type I: hese cancers occur most commonly in pre- and peri-menopausal women, often with a history of unopposed estrogen exposure and@or endometrial hyperplasia. hey are often minimally invasive into the underlying uterine wall, are of the low-grade endometrioid type, and carry a good prognosis. Type II= hese cancers occur in older, post-menopausal women, are more common in .frican.mericans, are not associated with increased exposure to estrogen, and carry a poorer prognosis. hey include= the high-grade endometrioid cancer, the uterine papillary serous carcinoma, the uterine clear cell carcinoma. 2IG% grading of .ndometrial Carcinoma 01= 5ighly differentiated $composed of glands and ?H of lesion is of solid growth pattern&. 0+= %oderately differentiated $ 8H-?DH of lesion composed of solid sheets of cells&. 07= #ndifferentiated $ M ?DH of lesion composed of solid sheets of cells&. Uterine sarcoma: "n contrast to endometrial carcinomas, the uncommon endometrial stromal sarcomas are cancers that originate in the non-glandular connective tissue of the endometrium. #terine carcinosarcoma, formerly called %alignant mixed mQllerian tumor, is a rare uterine cancer that contains cancerous cells of both glandular and sarcomatous appearance - in this case, the cell of origin is unknown.O+P 6ndometrial stromal sarcoma.
79 #terine carcinosarcoma. .n endometrial adenocarcinoma invading the uterine muscle. Signs and symptoms Gaginal bleeding and@or spotting in postmenopausal women. .bnormal uterine bleeding, abnormal menstrual periods. 3leeding between normal periods in premenopausal women in women older than 9D= extremely long, heavy, or fre,uent episodes of bleeding $may indicate premalignant changes&. .nemia, caused by chronic loss of blood. $ his may occur if the woman has ignored symptoms of prolonged or fre,uent abnormal menstrual bleeding.& 1ower abdominal pain or pelvic cramping. hin white or clear vaginal discharge in postmenopausal women. *is+ factors obesity - the larger the woman, the larger the risk high levels of estrogen endometrial hyperplasia hypertension polycystic ovary syndrome nulliparity $never having carried a pregnancy& infertility $inability to become pregnant& early menarche $onset of menstruation& late menopause $cessation of menstruation& endometrial polyps or other benign growths of the uterine lining diabetes amoxifen high intake of animal fat pelvic radiation therapy breast cancer ovarian cancer anovulatory cycles age over 7? lack of exercise heavy daily alcohol consumption $possibly a risk factor&
Diagnosis
7?
/linical evaluation (outine screening of asymptomatic women is not indicated, since the disease is highly curable in its early stages. (esults from a pelvic examination are fre,uently normal, especially in the early stages of disease. /hanges in the si'e, shape or consistency of the uterus and@or its surrounding, supporting structures may exist when the disease is more advanced. . Pap smear may be either normal or show abnormal cellular changes. . Pap smear is used to screen for cervical cancer not endometrial cancer. !ffice endometrial biopsy is the traditional diagnostic method. 3oth endometrial and endocervical material should be sampled. "f endometrial biopsy does not yield sufficient diagnostic material, a dilation and curettage $DF/& is necessary for diagnosing the cancer. 5ysteroscopy allows the direct visuali'ation of the uterine cavity and can be used to detect the presence of lesions or tumours. "t also permits the doctor to obtain cell samples with minimal damage to the endometrial lining $unlike blind DF/&. 6ndometrial biopsy or aspiration may assist the diagnosis. ransvaginal ultrasound to evaluate the endometrial thickness in women with postmenopausal bleeding is increasingly being used to evaluate for endometrial cancer. !ngoing research suggests that serum p?7 antibody may hold value in identifying highrisk endometrial cancer.
Diagnostic test study of S-p?7 .b and agreement study for high-risk endometrial cancer Kappa= D.AD Sensitivity $H&= 89 Specificity$H&= E8 PPG= AC 2PG= E+ athology: 6ndometrial adenocarcinoma he histopathology of endometrial cancers is highly diverse. he most common finding is a well-differentiated endometrioid adenocarcinoma, which is composed of numerous, small, crowded glands with varying degrees of nuclear atypia, mitotic activity, and stratification. his often appears on a background of endometrial hyperplasia. <rank adenocarcinoma may be distinguished from atypical hyperplasia by the finding of clear stromal invasion, or -back-toback- glands which represent nondestructive replacement of the endometrial stroma by the cancer. *ith progression of the disease, the myometrium is infiltrated.5owever, other subtypes of endometrial cancer exist and carry a less favorable diagnosis such as the uterine papillary serous carcinoma and the clear cell carcinoma.
78 <urther evaluation Patients with newly-diagnosed endometrial cancer do not routinely undergo imaging studies, such as / scans, to evaluate for extent of disease, since this is of low yield. Preoperative evaluation should include a complete medical history and physical examination, pelvic examination and rectal examination with stool guaiac test, chest :-ray, complete blood count, and blood chemistry tests, including liver function tests. /olonoscopy is recommended if the stool is guaiac positive or the woman has symptoms, due to the etiologic factors common to both endometrial cancer and colon cancer. he tumor marker /.-1+? is sometimes checked, since this can predict advanced stage disease. "n addition to this, both DF/ and Pipelle biopsy curettage give 8?-ADH positive predictive value. 3ut most important of these is hysteroscopy which gives ED-E?H positive predictive value. Staging: 6ndometrial carcinoma is surgically staged using the <"0! cancer staging system. he +D1D <"0! staging system is as follows= /arcinoma of the 6ndometrium ". umor confined to the uterus, no or N R myometrial invasion "3 umor confined to the uterus, M R myometrial invasion "" /ervical stromal invasion, but not beyond uterus """. umor invades serosa or adnexa """3 Gaginal and@or parametrial involvement """/1 Pelvic lymph node involvement """/+ Para-aortic lymph node involvement, with or without pelvic node involvement "G. umor invasion bladder mucosa and@or bowel mucosa "G3 Distant metastases including abdominal metastases and@or inguinal lymph nodes Treatment: he primary treatment is surgical. Surgical treatment should consist of, at least, cytologic sampling of the peritoneal fluid, abdominal exploration, palpation and biopsy of suspicious lymph nodes, abdominal hysterectomy, and removal of both ovaries $bilateral salpingooophorectomy&. 1ymphadenectomy, or removal of pelvic and para-aortic lymph nodes, is sometimes performed for tumors that have high risk features, such as pathologic grade 7 serous or clear-cell tumors, invasion of more than 1@+ the myometrium, or extension to the cervix or adnexa. Sometimes, removal of the omentum is also performed.
7A .bdominal hysterectomy is recommended over vaginal hysterectomy because it affords the opportunity to examine and obtain washings of the abdominal cavity to detect any further evidence of cancer. *omen with stage 1 disease who are at increased risk for recurrence and those with stage + disease are often offered surgery in combination with radiation therapy.OEP /hemotherapy may be considered in some cases, especially for those with stage 7 and 9 disease. 5ormonal therapy with progestins and antiestrogens has been used for the treatment of endometrial stromal sarcomas. he antibody 5erceptin, which is used to treat breast cancers that overexpress the 56(+@neu protein, has been tried with some success in a phase "" trial in women with uterine papillary serous carcinomas that overexpress 56(+@neu. /omplications of treatment #terine perforation may occur during a DF/ or an endometrial biopsy.
Uterine prolapse Definition: #terine prolapse is a form of female genital prolapse. "t is also called pelvic organ prolapse or prolapse of the uterus $womb&. Causes: he most common cause of uterine prolapse is trauma during childbirth, in particular multiple or difficult births."t is more common as women get older, particularly in those who have gone through the menopause. athophysiology: he uterus $womb& is normally held in place by a hammock of muscles and ligaments. Prolapse happens when the ligaments supporting the uterus become so weak that the uterus cannot stay in place and slips down from its normal position. hese ligaments are the round ligament, uterosacral ligaments, broad ligament and the ovarian ligament. he utereosacral ligaments are by far the most important ligaments in preventing uterine prolapse. Treatment:
7C reatment is surgical, and the options include hysterectomy or uterus-sparing techni,ues such as sacrohysteropexy or the %anchester operation.
Cystocele Definition: . cystocele is a medical condition that occurs when the tough fibrous wall between a woman4s bladder and her vagina $the pubocervical fascia& is torn by childbirth, allowing the bladder to herniate into the vagina. #rethroceles often occur with cystoceles. Causes: he elastic tissues of the vagina may compensate for this tear for some time after the in)ury occurs. 3ecause the hormone estrogen helps keep the elastic tissues around the vagina strong, a cystocele may not occur until menopause, when levels of estrogen decrease. Symptoms: Discomfort and problems with emptying the bladder. #nwanted urine leakage and incomplete emptying of the bladder. he pubocervical fascia provides back support to the mid urethra, allowing compression when abdominal pressure is increased. his prevents urine loss with sudden increases in pressure, as with coughs, snee'es, laughs, or moves in any way that puts pressure on the bladder. "f this compression is lost by tissue tears, then stress incontinence results. "f the base of the bladder herniates, then urine will sump down into the inside of the hernia, and bladder emptying will be impaired. Classification: . cystocele is mild $grade 1& when the bladder droops only a short way into the vagina. *ith more severe $grade +& cystocele, the bladder sinks far enough to reach the opening of the vagina. he most advanced $grade 7& cystocele occurs when the bladder bulges out through the opening of the vagina. Diagnosis: "n more complex instances, additional testing will be re,uested. . -voiding cystourethrogram- a test that involves taking x-rays of the bladder during urination. his x-ray shows the shape of the bladder and lets the doctor see any problems that might block the normal
7E flow of urine. !ther tests may be needed to find or rule out problems in other parts of the urinary system. Treatment: reatment options range from no treatment for a mild cystocele to surgery for a serious cystocele. "f a cystocele is not bothersome, may only recommend avoiding heavy lifting or straining that could cause the cystocele to worsen. "f symptoms are moderately bothersome, may recommend a pessary.a device placed in the vagina to hold the bladder in place. Pessaries come in a variety of shapes and si'es to allow the doctor to find the most comfortable fit for the patient. Pessaries must be removed regularly to avoid infection or ulcers. 1arge cystoceles may re,uire surgery to move the bladder back into a more normal position and keep it there. Urethrocele Definition: . urethrocele is the prolapse of the female urethra into the vagina. *eakening of the tissues that hold the urethra in place cause it to move and to put pressure on the vagina, leading to the descent of the anterior distal wall of the vagina.#rethroceles often occur with cystoceles, $involving the urinary bladder as well as the urethra&."n this case, the term used is a cystourethrocele. Causes: #rethroceles are often caused by childbirth, the movement of the baby through the vagina causing damage to the surrounding tissues. *hen they occur in women who have never had children, they may be the result of a congenital weakness in the tissues of the pelvic floor. Symptoms: Stress incontinence, "ncreased urinary fre,uency and difficulty in emptying the bladder. Pain during sexual intercourse may also occur.
Treatment: Surgical
9D Complications: *here a urethrocele causes difficulty in urinating, this can lead to cystitis.
*ectocele Definition: . rectocele results from a tear in the rectovaginal septum $which is normally a tough, fibrous, sheet-like divider between the rectum and vagina&. (ectal tissue bulges through this tear and into the vagina as a hernia. Causes: /hildbirth, especially with babies over nine pounds in weight, or rapid births. he use of forceps is more likely a marker for the vaginal in)ury, than a direct cause of the tear. 6pisiotomy or lower vaginal tears play little role in the formation of a cystocele, but may in rectoceles. he risk increases with the number of vaginal births, although it can also happen in women who have never borne a child. . hysterectomy or other pelvic surgery can be a cause, as can chronic constipation and straining to pass bowel movements. "t is more common in older women than in younger ones> estrogen which helps to keep the pelvic tissues elastic decreases after menopause. .nother cause which is sometimes overlooked in younger women is sexual abuse during childhood
Symptoms of rectocele: %ild cases may simply produce a sense of pressure or protrusion within the vagina, and the occasional feeling that the rectum has not been completely emptied after a bowel movement. %oderate cases may involve difficulty passing stool $because the attempt to evacuate pushes the stool into the rectocele instead of out through the anus&, discomfort or pain during evacuation or intercourse, constipation, and a general sensation that something is -falling downor -falling out- within the pelvis. Severe cases may cause vaginal bleeding, intermittent fecal incontinence, or even the prolapse of the bulge through the mouth of the vagina, or rectal prolapse through the anus. Digital evacuation, or, manual pushing, on the posterior wall of the vagina helps to aid in bowel movement in a ma)ority of cases of rectocele.
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Treatment: reatment depends on the severity of the problem, and may include changes in diet $increase in fiber and water intake&, pelvic floor exercises such as Kegel exercises, use of stool softeners, hormone replacement therapy for post-menopausal women, "nsertion of a pessary into the vagina, and various forms of surgery $usually posterior colporrhaphy - the suturing of vaginal tissue&. %ore recent developments in surgery are directed at repairs to the rectovaginal septum, than simple excision or plication of vaginal skin, which provides no support.
Cer)ical disorders Cer)icitis Definition: /ervicitis is inflammation of the uterine cervix.
Types: .cute cervicitis and chronic cervicitis and mucopurulent cervicitis Causes:
9+ 2on-infectious causes of cervicitis can include intrauterine devices, contraceptive diaphragms, and allergic reactions to spermicides or latex condoms, trauma, radiation therapy, or cancer, sexually transmitted disease are the most common cause for cervicitis. "nfectious causes are %ycoplasma genitalium and bacterial vaginosis, /hlamydia trachomatis, 2eisseria gonorrhoeae, herpes simplex virus $5SG&, and human papillomavirus $5PG&. #ntreated bacterial cervicitis can spread to involve other organs in the pelvis leading to pelvic inflammatory disease or P"D.
!ucopurulent cer)icitis: %ucopurulent cervicitis $%P/& is characteri'ed by a purulent or mucopurulent endocervical exudate visible in the endocervical canal or in an endocervical swab specimen. %P/ often is without symptoms, but some women have an abnormal vaginal discharge and vaginal bleeding $e.g., after sexual intercourse&. %P/ can be caused by /hlamydia trachomatis or 2eisseria gonorrhoeae> however, in most cases neither organism can be isolated.%P/ can persist despite repeated courses of antimicrobial therapy. 3ecause relapse or reinfection with /. trachomatis or 2. gonorrhoeae usually does not occur in persons with persistent cases of %P/, other non-microbiologic determinants $e.g., inflammation in the 'one of ectopy& might be involved.
#cute Cer)icitis Symptoms Gaginal discharge %ay be white, gray, or yellow in color, %ay have foul odor Gaginal pain, Pelvic pain, Pain during intercourse 1ower abdominal pain, Pain during urination #rinary fre,uency, Gaginal bleeding after intercourse "rregular menstrual bleeding, 1ow back pain Chronic cer)icitis causes includes fre,uent bacterial infections leading to acute cervicitis. *hen an episode of acute cervicitis is not treated, it develops into chronic cervicitis. he risk of cervicitis increases when a woman is suffering from diabetes, acute and recurrent vaginitis or has multiple sexual partners. Surgical intervention like curettage, labor, etc, also leads to cervicitis. Symptoms: 2on-existent and unnoticeable. #nnoticeable vaginal discharge. Discomfort and pain during urination as well as intercourse.
97 *hen left untreated, it leads to profuse vaginal discharge, bleeding between periods and bleeding or spotting after sex.
/hronic /ervicitis with S,uamous %etaplasia /hronic cervicitis with s,uamous metaplasia is a benign condition. "t causes inflammation of the cervix that is not normal. "t occurs on the s,uamous cells on the surface if the cervix. his inflammation occurs when the cells undergo the process of maturation, that is, metaplasia. his condition can be detected with the help of a Pap smear. Diagnosis: Pap smears and gives the vaginal discharge for culture. 3iopsy of the cervix may be carried out. Treatment: %ild cervicitis may be treated with help of antibiotics and other medications. his treatment includes cauteri'ation, where a heated probe is used to burn the chronically inflamed and infected cells. his method helps get rid of the cells that cause inflammation of the cervix. Second method is cryosurgery, where extremely cold nitrous oxide or carbon dioxide gas it used. his gas helps free'e and kill the abnormal cells. his method is easier and less painful than cauteri'ation. 1astly, one of the most widely used treatments is laser surgery. his method helps treat large areas of chronically inflamed cervix. his method however may take about + months for complete treatment. herefore, it is more expensive than the other two methods for treating inflamed cervix. "f left untreated it may lead to many serious medical complications like miscarriage and infertility. herefore, anyone who has suffered from a bacterial or sexually transmitted disease, should undergo medical checkups at least every six months. his is the only way to detect chronic cervicitis and get early treatment
Cer)ical cancer Definition: /ervical cancer is the term for a malignant neoplasm arising from cells originating in the cervix uterus. Causes:
99
"nfection with some types of human papilloma virus $5PG& is the greatest risk factor for cervical cancer. ypes 18 and 1C are generally acknowledged to cause about ADH of cervical cancer cases. ogether with type 71, they are the prime risk factors for cervical cancer. 5uman immunodeficiency virus. *omen who have many sexual partners $or who have sex with men who have had many other partners& have a greater risk. 0enital warts, which are a form of benign tumor of epithelial cells, are also caused by various strains of 5PG.
Symptoms: he early stages of cervical cancer may be completely asymptomatic. Gaginal bleeding, contact bleeding, or $rarely& a vaginal mass may indicate the presence of malignancy. %oderate pain during sexual intercourse and vaginal discharge are symptoms of cervical cancer. "n advanced disease, metastases may be present in the abdomen, lungs or elsewhere. Symptoms of advanced cervical cancer may include= loss of appetite, weight loss, fatigue, pelvic pain, back pain, leg pain, swollen legs, heavy bleeding from the vagina, bone fractures, and@or $rarely& leakage of urine or faeces from the vagina $rarely&.
Diagnosis:
*hile the Pap smear is an effective screening test, confirmation of the diagnosis of cervical cancer or pre-cancer re,uires a biopsy of the cervix. his is often done through colposcopy, a magnified visual inspection of the cervix aided by using a dilute acetic acid $e.g. vinegar& solution to highlight abnormal cells on the surface of the cervix.%edical devices used for biopsy of the cervix include punch forceps or Spira3rush /:. /olposcopic impression, the estimate of disease severity based on the visual inspection, forms part of the diagnosis. <urther diagnostic and treatment procedures are loop electrical excision procedure $166P& and coni'ation, in which the inner lining of the cervix is removed to be examined pathologically. hese are carried out if the biopsy confirms severe cervical intraepithelial neoplasia.
9?
/ervical intraepithelial neoplasia, the potential precursor to cervical cancer, is often diagnosed on examination of cervical biopsies by a pathologist.<or premalignant dysplastic changes, the /"2 $cervical intraepithelial neoplasia& grading is used. /ancer subtypes= S,uamous cell carcinoma $about CD-C?HOcitation neededP& .denocarcinoma $about 1?H of cervical cancers in the #KO1CP& .denos,uamous carcinoma Small cell carcinoma 2euroendocrine tumour 0lassy cell carcinoma Gilloglandular adenocarcinoma 2on-carcinoma malignancies which can rarely occur in the cervix include %elanoma 1ymphoma
re)ention: here are two 5PG vaccines $0ardasil and /ervarix& which reduce the risk of cancerous or precancerous changes of the cervix and perineum by about E7H. /ondoms are thought to offer some protection against cervical cancer. 2utrition Gitamin . is associated with a lower risk,
Treatment: 3ecause cervical cancers are radiosensitive, radiation may be used in all stages where surgical options do not exist. %icroinvasive cancer $stage ".& may be treated by hysterectomy $removal of the whole uterus including part of the vagina&. <or stage ".+, the lymph nodes are removed as well. .lternatives include local surgical procedures such as a loop electrical excision procedure $166P& or cone biopsy. <or 1.1 disease, a cone biopsy $aka cervical coni'ation& is considered curative. . radical abdominal trachelectomy with lymphadenectomy usually only re,uires a two to three day hospital stay, and most women recover very ,uickly $approximately six weeks&.
98 /omplications are uncommon, although women who are able to conceive after surgery are susceptible to preterm labor and possible late miscarriage. Cer)ical polyp Definition: . cervical polyp is a common benign polyp or tumour on the surface of the cervical canal. Cause: he cause of cervical polyps is uncertain, but they are often associated with inflammation of the cervix. hey may also occur as a result of raised levels of estrogen or clogged cervical blood vessels. *is+ factors: /ervical polyps are most common in women who have had children and perimenopausal women. hey are rare in pre-menstrual women and uncommon in post-menopausal women. Structure: /ervical polyps are finger-like growths, generally less than 1 cm in diameter. hey are generally bright red in colour, with a spongy texture. hey may be attached to the cervix by a stalk $pedunculated& and occasionally prolapse into the vagina where they can be mistaken for endometrial polyps or submucosal fibroids. Symptoms: /ervical polyps often show no symptoms.*here there are symptoms, they include intermenstrual bleeding, abnormally heavy menstrual bleeding $menorrhagia&, vaginal bleeding in post-menopausal women, bleeding after sex and thick white vaginal or yellowish discharge $leukorrhoea&. Diagnosis: #ltrasound /ervical polyps can be seen during a pelvic examination as red or purple pro)ections from the cervical canal. Diagnosis can be confirmed by a cervical biopsy which will reveal the nature of the cells present.
9A Treatment: /ervical polyps can be removed using ring forceps. hey can also be removed by tying surgical string around the polyp and cutting it off. he remaining base of the polyp can then be removed using a laser or by cauterisation. "f the polyp is infected, an antibiotic may be prescribed. rognosis: EEH of cervical polyps will remain benign and 1H will at some point show neoplastic change. /ervical polyps are unlikely to regrow.
9C
Vaginal disorder Vaginitis Definition: Gaginitis is an inflammation of the vagina. he three main kinds of vaginitis are bacterial vaginosis $3G&, vaginal candidiasis, and trichomoniasis. Causes: /andidiasis= vaginitis caused by /andida albicans yeast&. 3acterial vaginosis= vaginitis caused by 0ardnerella $a bacterium&. !ther less common infections are caused by gonorrhea, chlamydia, %ycoplasma, herpes, /ampylobacter, improper hygiene, and some parasites, notably richomonas vaginalis. 6ither a change in p5 balance or introduction of foreign bacteria in the vagina can lead to infection known as vaginitis. here are physical factors that can contribute to development of infection, such as constantly wet vulva due to tight clothing, chemicals coming in contact with the vagina via scented tampons, antibiotics, birth control pills, or a diet favoring refined sugar and yeast. here is also psychological and emotional dimension to vaginitis. 5ormonal vaginitis includes atrophic vaginitis usually found in postmenopausal or postpartum women. Sometimes it can occur in young girls before puberty. "n these situations the estrogen support of the vagina is poor. "rritant vaginitis can be caused by allergies to condoms, spermicides, soaps, perfumes, douches, lubricants and semen. "t can also be caused by hot tubs, abrasion, tissue, tampons or topical medications. <oreign body vaginitis= foreign bodies $most commonly retained tampons or condoms& cause extremely malodorous vaginal discharges. reatment consists of removal, for which ring forceps may be useful. <urther treatment is generally not necessary. *omen who have diabetes develop infectious vaginitis more often than women who do not.
Diagnosis:
9E
Diagnosis is made with microscopy $mostly by vaginal wet mount& and culture of the discharge after a careful history and physical examination have been completed. he color, consistency, acidity, and other characteristics of the discharge may be predictive of the causative agent. Determining the agent is especially important because women may have more than one infection, or have symptoms that overlap those of another infection, which dictates different treatment processes to cure the infection. /andidiasis is a fungal infection that usually causes a watery, white, cottage cheese-like vaginal discharges. he discharge is irritating to the vagina and the surrounding skin.low $9.DB9.?& .trophic vaginitis $or Senile vaginitis& usually causes scant vaginal discharge with no odor, dry vagina and painful intercourse. hese symptoms are usually due to decreased hormones usually occurring during and after menopause. 3acterial vaginitis 0ardnerella usually causes a discharge with a fish-like odor. "t is associated with itching and irritation, but not pain during intercourse. richomonas vaginalis can cause a profuse discharge with a fish-like odor, pain upon urination, painful intercourse, and inflammation of the external genitals.
Symptoms: "rritation and@or itching of the genital area "nflammation $irritation, redness, and swelling caused by the presence of extra immune cells& of the labia ma)ora, labia minora, or perineal area Gaginal discharge <oul vaginal odor Pain@irritation with sexual intercourse Complications: <or bacterial vaginosis, these include -premature delivery, postpartum infections, clinically apparent and subclinical pelvic inflammatory disease, postsurgical complications $after abortion, hysterectomy, and caesarian section&, increased vulnerability to 5"G infection and, possibly, infertility-. <urther, persistent discomfort, superficial skin infection $from scratching& Treatment: he cause of the infection determines the appropriate treatment. "t may include oral or topical antibiotics and@or antifungal creams, antibacterial creams, or similar medications.
?D . cream containing cortisone may also be used to relieve some of the irritation. "f an allergic reaction is involved, an antihistamine may also be prescribed. <or women who have irritation and inflammation caused by low levels of estrogen $postmenopausal&, a topical estrogen cream might be prescribed. he following are typical treatments for trichomoniasis, bacterial vaginosis, and yeast infections= richomoniasis= Single oral doses of + grams of either metronida'ole, or tinida'ole. 3acterial vaginosis= he most commonly used antibiotics are metroni'adole, available in both pill and gel form, and clindamycin available in both pill and cream form. ;east infections= 1ocal .'ole, in the form of ovula and cream, associated with alcaline genital soap. hese anti-fungal medications, which are available in over the counter form, are generally used to treat yeast infections. reatment may last anywhere between one, three, or seven days. re)ention: "n case of candidiasis starts with good hygiene= drying completely after bathing, wearing fresh undergarments, and wiping from front to rear after defecation all help to prevent contamination of the vagina with harmful bacteria. Douching is never recommended, as it often does more harm than good, by upsetting the normal balance of yeast in the vagina. Prevention of bacterial vaginosis includes healthy diets and behaviors as well as minimi'ing stress as all these factors can affect the p5 balance of the vagina./onsuming good bacteria in products with live-culture, such as yogurt, sauerkraut and kimchi, or simply through probiotic supplements, one can reduce the likelihood of developing vaginitis due to antibiotics. Prevention of trichomoniasis revolves around avoiding other people4s wet towels and hot tubs, and safe-sex procedures, such as condom use.
Vaginal cancer Definition: Gaginal cancer is any type of cancer that forms in the tissues of the vagina. Primary vaginal cancer is rare in the general population of women and is usually a s,uamous carcinoma. %etastases are more common. Gaginal cancer occurs more often in women over age ?D, but can occur at any age, even in infancy. "t often can be cured if found and treated in early stages. Types of )aginal cancer: here are two primary types of vaginal cancer= s,uamous cell carcinoma and adenocarcinoma. Gaginal s,uamous cell carcinoma arises from the thin, flat s,uamous cells that line the vagina. his is the most common type of vaginal cancer. "t is found most often in women aged 8D or older.
?1 Gaginal adenocarcinoma arises from the glandular $secretory& cells in the lining of the vagina that produce some vaginal fluids. .denocarcinoma is more likely than s,uamous cell cancer to spread to the lungs and lymph nodes. "t is found most often in women aged 7D or younger. . specific subtype of adenocarcinoma $-/lear /ell-& occurs in a small percent of women $termed -D6S-Daughters-& born between 1E7C and 1EA7 $later outside the #nited States& that were exposed to the drug diethylstilbestrol $D6S& in utero. D6S was prescribed to ? to 1D million mothers in that timespan to prevent possible miscarriages and premature birth. ypically, patients present with D6S-related adenocarcinoma before age 7D, but increasing evidence suggests possible effects or cancers $including other forms of vaginal glandular tumors& at a later age for D6S-exposed women. D6S-exposure in women is also linked to various infertility and pregnancy complications. Daughters exposed to D6S in utero may also have an increased risk of moderate@severe cervical s,uamous cell dysplasia and an increased risk of breast cancer. .pproximately one in 1,DDD $D.1 H& D6S Daughters will be diagnosed with //.. he risk is virtually non-existent among premenopausal women not exposed to D6S. Gaginal germ cell tumors $primarily teratoma and endodermal sinus tumor& are rare. hey are found most often in infants and children. Sarcoma botryoides, a rhabdomyosarcoma also is found most often in infants and children. *is+ factors for )aginal cancer: 3eing aged 8D or older. 3eing exposed to D6S while in the mother4s womb. "n the 1E?Ds, 5aving human papilloma virus $5PG& infection. 5aving a history of abnormal cells in the cervix.
Signs and Symptoms: !ften there are no symptoms, and cancer is found through a routine gynecologic exam. "f there are symptoms, they are commonly abnormal vaginal bleeding, which may be postcoital, intermenstrual, prepubertal, or postmenopausal. !ther, less specific signs include difficult or painful urination, pain during intercourse, and pain in the pelvic area. *omen who suspect exposure to D6S should undergo a more extensive gynecological exam on a regular basis because the normal exam procedure does not closely examine the areas of the vagina usually obscured by the speculum in standard gynecological exams.
Diagnosis: Several tests are used to diagnose vaginal cancer, including=

?+ Physical exam and history Pelvic exam Pap smear 3iopsy /olposcopy hysical e6am and history= .n exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. . history of the patient4s health habits and past illnesses and treatments will also be taken. el)ic e6am= .n exam of the vagina, cervix, uterus, fallopian tubes, ovaries, and rectum. he doctor or nurse inserts one or two lubricated, gloved fingers of one hand into the vagina and places the other hand over the lower abdomen to feel the si'e, shape, and position of the uterus and ovaries. . speculum is also inserted into the vagina and the doctor or nurse looks at the vagina and cervix for signs of disease. . Pap test or Pap smear of the cervix is usually done. he doctor or nurse also inserts a lubricated, gloved finger into the rectum to feel for lumps or abnormal areas. ap smear= . procedure to collect cells from the surface of the cervix and vagina. . piece of cotton, a brush, or a small wooden stick is used to gently scrape cells from the cervix and vagina. he cells are viewed under a microscope to find out if they are abnormal. his procedure is also called a Pap test. /iopsy= he removal of cells or tissues from the vagina and cervix so they can be viewed under a microscope by a pathologist to check for signs of cancer. "f a Pap smear shows abnormal cells in the vagina, a biopsy may be done during a colposcopy. Colposcopy= . procedure in which a colposcope $a lighted, magnifying instrument& is used to check the vagina and cervix for abnormal areas. issue samples may be taken using a curette $spoon-shaped instrument& and checked under a microscope for signs of diseas rognosis: he stage of the cancer $whether it is in the vagina only or has spread to other areas&. he si'e of the tumor. he grade of tumor cells $how different they are from normal cells&. *here the cancer is within the vagina. *hether there are symptoms. he patient4s age and general health. *hether the cancer has )ust been diagnosed or has recurred $come back&. Treatment options depend on the follo7ing= he stage, si'e, and location of the cancer. *hether the tumor cells are s,uamous cell or adenocarcinoma. *hether the patient has a uterus or has had a hysterectomy. *hether the patient has had past radiation treatment to the pelvis.
?7 he following procedures may be used in the staging process= /iopsy= . biopsy may be done to find out if cancer has spread to the cervix. . sample of tissue is cut from the cervix and viewed under a microscope. . biopsy that removes only a small amount of tissue is usually done in the doctor4s office. . woman may need to go to a hospital for a cone biopsy $removal of a larger, cone-shaped piece of tissue from the cervix and cervical canal&. . biopsy of the vulva may also be done to see if cancer has spread there. Chest 6'ray= .n x-ray of the organs and bones inside the chest. .n x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body. Cystoscopy= . procedure to look inside the bladder and urethra to check for abnormal areas. . cystoscope is inserted through the urethra into the bladder. . cystoscope is a thin, tube-like instrument with a light and a lens for viewing. "t may also have a tool to remove tissue samples, which are checked under a microscope for signs of cancer. Ureteroscopy= . procedure to look inside the ureters to check for abnormal areas. . ureteroscope is inserted through the bladder and into the ureters. . ureteroscope is a thin, tubelike instrument with a light and a lens for viewing. "t may also have a tool to remove tissue to be checked under a microscope for signs of disease. . ureteroscopy and cystoscopy may be done during the same procedure. roctoscopy= . procedure to look inside the rectum to check for abnormal areas. . proctoscope is inserted through the rectum. . proctoscope is a thin, tube-like instrument with a light and a lens for viewing. "t may also have a tool to remove tissue to be checked under a microscope for signs of disease. CT scan "C#T scan$: . procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. he pictures are made by a computer linked to an x-ray machine. . dye may be in)ected into a vein or swallowed to help the organs or tissues show up more clearly. his procedure is also called computed tomography, computeri'ed tomography, or computeri'ed axial tomography. !*I "magnetic resonance imaging$= . procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. his procedure is also called nuclear magnetic resonance imaging $2%("&. 0ymphangiogram= . procedure used to x-ray the lymph system. . dye is in)ected into the lymph vessels in the feet. he dye travels upward through the lymph nodes and lymph vessels and x-rays are taken to see if there are any blockages. his test helps find out whether cancer has spread to the lymph nodes. Stage D $carcinoma in situ& "n stage D, s,uamous cell cancer is found in tissue lining the inside of the vagina. Stage D cancer is also called carcinoma in situ. Stage "
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"n stage ", cancer is found only in the vagina. Stage "" "n stage "", cancer has spread from the vagina to the tissue around the vagina. Stage """ "n stage """, cancer has spread from the vagina to the lymph nodes in the pelvis or groin, or to the pelvis, or both. Stage "G Stage "G is divided into stage "G. and stage "G3= Stage "G.= /ancer may have spread to lymph nodes in the pelvis or groin and has spread to one or both of the following areas= he lining of the bladder or rectum. 3eyond the pelvis. Stage "G3= /ancer has spread to parts of the body that are not near the vagina, such as the lungs. /ancer may also have spread to the lymph nodes. /hoosing the most appropriate cancer treatment is a decision that ideally involves the patient, family, and health care team. hree types of standard treatment are used= Surgery: Surgery is the most common treatment of vaginal cancer. he following surgical procedures may be used= 0aser surgery: . surgical procedure that uses a laser beam $a narrow beam of intense light& as a knife to make bloodless cuts in tissue or to remove a surface lesion such as a tumor. 8ide local e6cision= . surgical procedure that takes out the cancer and some of the healthy tissue around it. Vaginectomy= Surgery to remove all or part of the vagina. Total hysterectomy= Surgery to remove the uterus, including the cervix. "f the uterus and cervix are taken out through the vagina, the operation is called a vaginal hysterectomy. "f the uterus and cervix are taken out through a large incision $cut& in the abdomen, the operation is called a total abdominal hysterectomy. "f the uterus and cervix are taken out through a small incision in the abdomen using a laparoscope, the operation is called a total laparoscopic hysterectomy.
?? 0ymphadenectomy= . surgical procedure in which lymph nodes are removed and checked under a microscope for signs of cancer. his procedure is also called lymph node dissection. "f the cancer is in the upper vagina, the pelvic lymph nodes may be removed. "f the cancer is in the lower vagina, lymph nodes in the groin may be removed. Pelvic exenteration= Surgery to remove the lower colon, rectum, and bladder. "n women, the cervix, vagina, ovaries, and nearby lymph nodes are also removed. .rtificial openings $stoma& are made for urine and stool to flow from the body into a collection bag. S+in grafting may follow surgery, to repair or reconstruct the vagina. Skin grafting is a surgical procedure in which skin is moved from one part of the body to another. . piece of healthy skin is taken from a part of the body that is usually hidden, such as the buttock or thigh, and used to repair or rebuild the area treated with surgery. 6ven if the doctor removes all the cancer that can be seen at the time of the surgery, some patients may be given radiation therapy after surgery to kill any cancer cells that are left. reatment given after the surgery, to increase the chances of a cure, is called ad)uvant therapy. *adiation therapy: (adiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. here are two types of radiation therapy. 6xternal radiation therapy uses a machine outside the body to send radiation toward the cancer. "nternal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. he way the radiation therapy is given depends on the type and stage of the cancer being treated. Chemotherapy: /hemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. *hen chemotherapy is taken by mouth or in)ected into a vein or muscle, the drugs enter the bloodstream and can affect cancer cells throughout the body $systemic chemotherapy&. *hen chemotherapy is placed directly into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas $regional chemotherapy&. he way the chemotherapy is given depends on the type and stage of the cancer being treated. opical chemotherapy for s,uamous cell vaginal cancer may be applied to the vagina in a cream or lotion. *adiosensiti4ers:
?8 (adiosensiti'ers are drugs that make tumor cells more sensitive to radiation therapy. /ombining radiation therapy with radiosensiti'ers may kill more tumor cells. Stage 9 Vaginal Cancer "carcinoma in situ$ reatment of vaginal s,uamous cell carcinoma in situ may include the following= *ide local excision, with or without a skin graft. Partial or total vaginectomy, with or without a skin graft. opical chemotherapy. 1aser surgery. "nternal radiation therapy. Stage I Vaginal Cancer reatment of stage " s,uamous cell vaginal cancer may include the following= "nternal radiation therapy, with or without external radiation therapy to lymph nodes or large tumors. *ide local excision or vaginectomy with vaginal reconstruction. (adiation therapy may be given after the surgery. Gaginectomy and lymphadenectomy, with or without vaginal reconstruction. (adiation therapy may be given after the surgery. Treatment of stage I )aginal adenocarcinoma may include the follo7ing: Gaginectomy, hysterectomy, and lymphadenectomy. his may be followed by vaginal reconstruction and@or radiation therapy. "nternal radiation therapy, with or without external radiation therapy to lymph nodes. . combination of therapies that may include wide local excision with or without lymphadenectomy and internal radiation therapy. Stage II Vaginal Cancer reatment of stage "" vaginal cancer is the same for s,uamous cell cancer and adenocarcinoma. reatment may include the following= 3oth internal and external radiation therapy to the vagina, with or without external radiation therapy to lymph nodes. Gaginectomy or pelvic exenteration, with or without radiation therapy. Stage III Vaginal Cancer reatment of stage """ vaginal cancer is the same for s,uamous cell cancer and adenocarcinoma. reatment may include both internal and external radiation therapy, with or without surgery.
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Stage IV# Vaginal Cancer reatment of stage "G. vaginal cancer is the same for s,uamous cell cancer and adenocarcinoma. reatment may include both internal and external radiation therapy, with or without surgery. Stage IV/ Vaginal Cancer reatment of stage "G3 vaginal cancer is the same for s,uamous cell cancer and adenocarcinoma. reatment may include the following= (adiation therapy as palliative therapy, to relieve symptoms and improve the ,uality of life. /hemotherapy may also be given. . clinical trial of chemotherapy and@or radiosensiti'ers.
Treatment options for recurrent )aginal cancer reatment of recurrent vaginal cancer may include the following= Pelvic exenteration. (adiation therapy. . clinical trial of a new treatment.
Vaginal Discharge Definition: %ost of the time vaginal discharge is perfectly normal. he amount can vary from woman to woman, and the normal color can range from clear to a milky whitish, depending on the time in your menstrual cycle.
?C Causes: .ntibiotic or steroid use 3acterial vaginosis, which is a bacterial infection more common in pregnant women or women who have multiple sexual partners 3irth control pills /ervical cancer /hlamydia or gonorrhea, which are sexually transmitted infections Diabetes Douches, scented soaps or lotions, bubble bath Pelvic infection after surgery Pelvic inflammatory disease $P"D& richomoniasis, which is a parasitic infection typically caused by having unprotected sex Gaginal atrophy, which is thinning and drying out of the vaginal walls during menopause Gaginitis, which is irritation in or around the vagina ;east infections
Type of Discharge: 3loody or brown "rregular menstrual cycles, or less often, cervical or endometrial cancer .bnormal vaginal bleeding, pelvic pain /loudy or yellow 0onorrhea 3leeding between periods, urinary incontinence <rothy, yellow or greenish with a bad smell richomoniasis Pain and itching while urinating Pink Shedding of the uterine lining after childbirth $lochia&
hick, white, cheesy ;east infection Swelling and pain around the vulva, itching, painful sexual intercourse
?E *hite, gray, or yellow with fishy odor 3acterial vaginosis "tching or burning, redness and swelling of the vagina or vulva Diagnosis: 5ealth history *hen did the abnormal discharge begin *hat color is the discharge "s there any smell .ny itching, pain, or burning in or around the vagina %ore than one sexual partner Douche Pap test to collect cells from your cervix for further examination. Treatment: reatement will depend on the condition thatSs causing the problem. <or example, yeast infections are usually treated with antifungal medications inserted into the vagina in cream or gel form. 3acterial vaginosis is treated with antibiotic pills or creams. richomoniasis is usually treated with the drug metronida'ole $<lagyl& or tinida'ole $ indamax&. Tips for pre)enting )aginal infections: Keep the vagina clean by washing regularly with a gentle soap and warm water. 2ever use scented soaps or douche. .lso avoid feminine sprays and bubble baths. .fter going to the bathroom, always wipe from front to back to prevent bacteria from getting into the vagina and causing an infection. *ear 1DDH cotton underpants, and avoid overly tight clothing.
0eu+orrhea Definition: 1eukorrhea $#S& or leucorrhoea $/ommonwealth& is a medical term that denotes a thick, whitish or yellowish vaginal discharge.
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Classification: hysiologic leu+orrhea "t is not a ma)or issue but is to be resolved as soon as possible. "t can be a natural defense mechanism that the vagina uses to maintain its chemical balance, as well as to preserve the flexibility of the vaginal tissue. he term -physiologic leukorrhea- is used to refer to leukorrhea due to estrogen stimulation. 1eukorrhea may occur normally during pregnancy. his is caused by increased bloodflow to the vagina due to increased estrogen. <emale infants may have leukorrhea for a short time after birth due to their in-uterine exposure to estrogen. Inflammatory leu+orrhea "t may also result from inflammation or congestion of the vaginal mucosa. "n cases where it is yellowish or gives off an odor, a doctor should be consulted since it could be a sign of several disease processes, including an organic bacterial infection or S D. .fter delivery, leukorrhea accompanied by backache and foul-smelling lochia $post-partum vaginal discharge, containing blood, mucus, and placental tissue& may suggest the failure of involution $the uterus returning to pre-pregnancy si'e& due to infection. "nvestigations= wet smear, 0ram stain, culture, pap smear and biopsy.
"t is important to understand that the underlying factor in most of these conditions is congestion of the pelvic organs which inevitably results in an increased activity of the cervical, endometrial and vaginal epithelium to produce an excessive secretion. .tiology of leucorrhea: he most common conditions, in which excess of this discharge is likely to be present, are pregnancy, premenstrual or menstrual periods, and congestion of the uterus. Pathological conditions of the female genital, organs, e.g., infection, growths and displacements, eg =0onorrhea,/ervical erosion,Displacements of uterus retroversion.,Prolapsed of uterus.,/ancer of all types.,1eukoplakic vulvitis.,/hronic salpingitis,cancer of reproductive system. "rritation due to mechanical factors, e.g., use of chemical contraceptives, pessaries, intrauterine devices, etc, may also establish chronic inflammatory process causing congestion and hence leucorrhea.
81 Psychogenic causes, e.g., worries, anxiety, overwork, and sexual excitement without fulfillment may also cause chronic leucorrhoea. "t may seem strange, though it is now certain that emotional upsets affect hypothalamus, which in turn upsets the gonadotrophic functions of the pituitary gland, so much so that even an ovulation has been caused by mental stress and emotional situations. /onsidering the close relationship between pituitary, ovarian functions, glycogen deposition and P5 value of vaginal flora, the hormonal theory also seems to be a possible cause. (ecently, endocrinal factors have been given a great deal of prominence as a possible cause of leucorrhoea as is clear by the fact that the non-infective erosion is due to excess of oestrin in the system. Pregnancy and menstrual periods are also examples of hypersecretion due to large amounts of oestrin in the blood at those periods. 6rrors in diet, excessive use of stimulants, e.g., tea, coffee, alcohol, smoking, all these things have been suggested to cause leucorrhoea it seems to be possible because of the absorption of toxic substances or by stimulation the nervous mechanism of gland causing hormonal imbalance. "t is also suggested that faulty and deficient diet or severe %alabsorption apart from causing undernourishment and debility depresses the activity of pituitary gland producing hormonal disturbance, or a deficient diet may deprive the glands of raw material from which hormones are manufactured.
In)estigations: 1. 5istory Duration of the complaint. <ungus infection richomonas. 0onorrhea. 6xcessive intercourse .bout the discharge> character, modality etc. +. 6xternal examination L 6xamination of vulva= bartholinSs glands, urethra, etc. 7. Special e6aminations:' $i& $ii& $iii& $iv& $v& $vi& Smears from urethra, vagina and cervix. 3lood examination. #rine examination. 3lood pressure examination. 3iopsy= for evidence of malignancy. <or richomonas, hanging drop method is done.
General Treatment: $i& (est and exercise.

8+ $ii& Diet= none stimulating, but nourishing. $iii& Personal hygiene is important. $iv& (egularity of bowel movements and habits. 0ocal Treatment : "f the discharge is acrid and too, copious douche of normal saline water is beneficial, otherwise, nothing is advised to apply. "n some cases, 5ydrastis lotion is recommended.
2istulas Definition: . fistula is an abnormal connection or passageway between two parts of the body. Types of fistulas: Gesicovaginal fistula $bladder@vagina& B .lso known as a bladder fistula, this type of fistula occurs between the vagina and urinary bladder, allowing urine to flow into the vagina. Gesicouterine fistula $bladder@uterus& B his rare type of fistula occurs between the bladder and uterus and is typically caused by trauma to the bladder. Gesicocutaneous fistula $bladder@skin& B .n opening between the skin and the bladder that typically closes spontaneously. (ectovaginal $rectum@vagina& B .lso called rectal fistulas, these occur between the vagina and the rectum, enabling feces to pass into the vagina. #rethrovaginal fistula $fistula@diverticulum& B his unnatural passageway occurs between the vagina and urethra, the tube that carries urine out of the body. Causes: "nfection "nflammation 2eoplasm $abnormal growth of tissue& /ongenital conditions rauma "n)ury to the reproductive organs or urinary system (adiation therapy /omplications of gynecologic and obstetric procedures and surgeries /omplications of interventional radiologic procedures <ulguration $destruction of tissue by electric current&
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Symptoms of fistulas: "ncontinence .bdominal distention <ever Stool, air or fluid in the vagina %enouria $menstruation occurring through the bladder& .menorrhea $absence of menstruation& Diagnosis: 5istory collection Physical examination reatment= Depend on the type and cause of the fistula.
Vesico)aginal fistula Definition: GG< is an abnormal fistulous tract extending between the bladder and the vagina that allows the continuous involuntary discharge of urine into the vaginal vault. Causes: "t is often caused by childbirth $in which case it is known as an obstetric fistula&, when a prolonged labor presses the unborn child tightly against the pelvis, cutting off blood flow to the vesicovaginal wall. he affected tissue may necroti'e $die&, leaving a hole. Gaginal fistulas can also result from violent rape. his in)ury has become common in some war 'ones, where rape is used as a weapon against female civilians. "t can also be associated with hysterectomy, and cone biopsy. his is an in)ury, often secondary to an obstetric manipulation, gynecologic surgery, radiation or invasive cancer of the cervix. Patients will present with constant leakage of urine.
Diagnosis:
89 /ystoscopy usually reveals the fistulous opening between the bladder and vagina. Gaginography, which is performed by inserting a catheter into the vagina, instilling a radioopa,ue solution and taking the appropriate x-rays, will usually show the vesicovaginal, ureterovaginal and@or rectovaginal fistula. "f the fistula is very small and not readily apparent, it may be necessary to instill methylene blue via a catheter and detect any staining on a vaginallyplaced tampon. "f no methylene blue dye is found staining a vaginal pledget, then intravenous indigo carmine should be administered> and if staining is detected, a ureterovaginal fistula may be responsible. "f the staining is found only at the string end of the tampon, then the leakage probably represents urethral incontinence and not leakage from a vesicovaginal fistula. Treatment: (epair is usually undertaken some C-1+ weeks after the in)ury. his time delay allows resolution of wound inflammation prior to attempting corrective surgery. "n postmenopausal patients, estrogen replacement prior to surgery may improve the chances of successful closure. reatment options include the following= .. /onservative <or very small fistulae, an indwelling <oley catheter to remain in place for about 9 weeks may result in closure. 3. 6ndoscopic /auteri'ing a very small fistulous tract in the bladder and@or the vagina may allow healing of the fistulous tract. /uretting with a fine probe may possibly seal a fine fistulous tract by allowing fresh margins to heal. /. Surgery 1. ransvesical approach. his approach is usually done when the fistula is located at the level of the ureteral orifices or higher or if the vagina is stenotic. .fter opening the bladder, ureteral stents are placed to identify the ureters. he fistula is exposed, circumscribed and excised, thus allowing closure of the individual vaginal and bladder layers. !mentum can be useful to interpose between suture lines to improve healing rates. +. Gaginal approach.
8? his approach is ideal for low-lying fistulae with an ade,uate vagina. he fistula is excised and surrounding tissues gently mobili'ed to allow layered closure. "mmediately prior to the repair, cystoscopy and ureteral catheteri'ation may be reasonable to allow identification of the ureteral orifices. Postoperative care. . light vaginal pack is used for +9 hours. . <oley catheter is left for about 19 days. he appropriate anti-spasmodics are used to prevent bladder spasms and damage to the repair site. .ntibiotics are also administered. Patients are also instructed to avoid intercourse for at least 8 weeks after surgery to allow complete healing of the repair site.
*ecto)aginal fistula Definition: . rectovaginal fistula is a medical condition where there is a fistula or abnormal connection between the rectum and the vagina. Causes: (ectovaginal fistulae are often the result of trauma during childbirth $in which case it is known as obstetric fistula&. <istulas can also develop in women and children who are raped> "t is also associated with female genital mutilation. 1ymphogranuloma venereum. #nintended result of surgery, such as episiotomy. hey may present as a complication of vaginal surgery, including vaginal hysterectomy. hey are a recogni'ed presentation of rectal carcinoma or rarely diverticular disease of the bowel or /rohn4s disease. (arely after radiotherapy treatment for cervical cancer.
Symptoms: "t will allow both flatulence and feces to escape through the vagina, leading to fecal incontinence. here is an association with recurrent urinary and vaginal infections.
Urethro)aginal 2istula
88 Definition: his is an opening between the urethra and vagina and is usually due to obstetric in)ury. Symptoms: Depends upon location. <istulae in the urethra close to the bladder neck are often associated with incontinence. Diagnosis: "nspection will usually identify a large fistula, whereas urethroscopy, cystoscopy and vaginoscopy may be needed to detect a smaller one. "t is important to rule out an associated vesicovaginal fistula. Treatment: %ost are repaired after some 1+ weeks to allow the original inflammation of the in)ury to settle. Symptomatic fistulae are best repaired by careful excision and layered closure. he use of a labial fat pad $%artius flap& or gracilis muscle flap may be useful. . <oley catheter is left for about 19 days. /omplications include incontinence, recurrent fistula formation and urethral stricture.
Vul)itis Definition: Gulvitis is a condition of inflammation of the vulva of a female. he vulva includes the labia, clitoris, and entrance to the vagina $the vestibule of the vagina&. Gulvitis is not a condition or disease> it is a symptom that results from a number of different causes including allergies, infections, in)uries, and other external irritants. Causes: !ral sex. Scented or colored toilet tissue. 3acterial or fungal infection. 5ot tubs and swimming pools. 5orseback riding. 1eaving a wet swimming suit on for a long period. 3icycle riding. .llergic reactions to products such as= soaps,shampoos,bubble baths,
8A powders, deodorants, sanitary napkins, non-cotton underwear, pantyhose, vaginal douches, topical medications.
*is+ factors: Diabetic women face increased risk of developing vulvitis because the high sugar content of their cells increases susceptibility to infections. .s estrogen levels drop during perimenopause, vulvar tissues become thinner, drier, and less elastic increasing a woman4s chance of developing vulvitis, or other infections such as vaginitis. ;oung girls who have not yet reached puberty are also at possible risk due to the fact that ade,uate hormone levels have not yet been reached. .ny woman, who is allergy-prone, has sensitive skin, or who has other infections or diseases can develop vulvitis. Symptoms of vulvitis= "tching. (edness. Swelling. <luid-filled, clear blisters that break open, and form a crust $sometimes mistaken for herpes&. Soreness. Scaly appearance. hickened or whitish patches. Diagnosis: Several diagnostic tools such as blood tests, urinalysis, testing for sexually transmitted diseases $S Ds&, and Pap smears help your doctor diagnose vulvitis. Treatment for )ul)itis: he treatment for vulvitis varies according to cause. !nce these factors are considered, several methods of treatment are available including both self-help measures, and prescribed medications.
8C 1ow-dose hydrocortisone creams may be prescribed for short periods. .nti-fungal creams are sometimes helpful for treatment of vulvitis. Post menopausal women may find topical estrogen relieves their symptoms. Self-help treatments include= 3aths containing soothing compounds such as .veeno baths or comfrey tea baths. Stopping the use of any products that may be a contributing factor. he vulva should be kept clean, dry, and cool. .lways remember to wipe from front to back. 5ot boric acid compresses. /old compresses filled with plain yogurt or cottage cheese help ease itching and irritation. /alamine lotion. #sing sterile, non-irritating personal lubricants such as K-; Telly, or .stroglide during sexual activity. 1earning to reduce stress. 6ating an ade,uate and nutritious diet. %aking sure you get enough sleep at night.
5o7 to pre)ent )ul)itis: hings you can do to help prevent vulvitis include wearing white cotton panties, practicing good hygiene, and avoiding vaginal douches. Gaginal sprays and powders should also be avoided, as should tight pants. #nless you4re in a long-term monogamous relationship, always use condoms during sexual activities to reduce your risk of vulvitis, S Ds, and other vaginal infections.
Vul)ar cyst . cyst is a closed sac that forms at any place in or on the body. Depending on its location, a cyst may contain fluid or semi solid masses within it. Some cysts even contain gas within them. "n most cases, the term cyst refers to a swelling or a boil that appears on the surface of the skin. %ost skin cysts are a result of impacted hair follicles. 5air grows on the skin of the body in many different places. 5air on the arms and legs, for example, is designed for thermoregulation. *hen hair is growing through a follicle that is blocked or damaged, it may grow inwards. his allows opportunistic infections to develop on the site of the hair follicle because of the exposed inner skin. his may result in the release of a fluid by the body to combat the infectious material. /ysts are sometimes self resolving when they burst and release their fluid. !ther cysts need to be removed surgically. Definition:
8E . cyst is nothing but a pus filled inflamed lesion. "t goes into the skin and can cause a lot of pain. 3artholins glands are very small, round, nonpalable and located in posterolateral vaginal orifice. !bstruction of 3artholin duct causes these glands to enlarge due to mucus resulting in vulvar cysts. /auses of obstruction are still unknown. Causes: <irstly an obstruction to the normal flow of fluid may lead to vulvar cysts. Secondly, chronic inflammatory conditions and vaginal infections are also responsible for causing this disorder. "mperfections in developing organs and genetically inherited conditions may also be the factors that cause vulvar cysts. 3artholinSs gland or gland on the outer surface gets blocked. 1ack of normal levels of hydration is to be blamed. *omen who are not sexually active will suffer from such conditions as there is no regular flow of blood as a result of stimulation to the area. Symptoms: Pain while walking, Gulvar irritation, dyspareunia and vulvar asymmetry. .bscesses. hese cysts are unilateral, palpable and nontender near vaginal orifice. /ysts distend the distressed labia ma)ora which causes vulvar asymmetry. .bscesses tend to give severe vulvar pain and at times high fever. .bscesses are typically erthematous. Treatment: . Surgery produces permanent opening from duct part to the exterior. Surgery is regarded as a permanent solution to the problem of vulvar cysts. <or external cysts, this treatment is often used. During this time, the woman needs to wash the area regularly and thoroughly, without applying too much pressure on the cyst. he use of antibiotics for a vulvar abscess may be re,uired as this will ensure that there is no development of an infection from the site. *hile treating a vulvar cyst, women should avoid all forms of sexual activity. his holds true even for vulvar abscess treatment. he development of infections is far more likely in period. <urthermore, a removed or burst cyst may be sore during the recovery period which may cause considerable pain to the woman. he area must be cleaned regularly after treatment and must be kept dry as well. hese small steps are essential for the health of the vulva and to ensure that there is no repeat development of a cyst. /ysts contain infected material and this must not be allowed to
AD spread either to the vagina or to the urinary system. it is therefore necessary to prevent altogether the condition from occurring. .n everyday self check for the vulva cysts symptoms would help in keeping the condition at bay.
Vul)ar cancer Definition: Gulvar cancer, a malignant invasive growth in the vulva, accounts for about 9 H of all gynecological cancers and typically affects women in later life.Gulvar carcinoma is separated from vulvar intraepithelial neoplasia $G"2&, a non-invasive lesion of the epithelium that can progress via carcinoma-in-situ to s,uamous cell cancer, and from Paget disease of the vulva. .tiology /ondyloma or s,uamous dysplasias. 5uman papillomavirus $5PG& is suspected to be a possible risk factor in the etiology of vulvar cancer. Patients infected with 5"G tend to be more susceptible to vulvar malignancy. .lso, smokers tend to be at higher risk.
Types: S:uamous cell carcinoma he vast ma)ority of vulvar cancer $approximately EDH& is s,uamous cell carcinoma, which originates from the epidermis of the vulvar tissue. /arcinoma-in-situ is a precursor stage of s,uamous cell cancer prior to invading through the basement membrane. %ost lesions originate in the labia, primarily the labia ma)ora. !ther areas affected are the clitoris, and fourchette, and the local glands. *hile the lesion is more common with advancing age, younger women who have risk factors $v.i.& may also be affected. "n the elderly treatment may be complicated by the interference of other medical conditions. S,uamous lesions tend to be unifocal, growing with local extension, and spreading via the local lymph system. he lymphatic drainage of the labia proceeds to the upper vulva and mons, then to the inguinal and femoral nodes with both superficial and deep lymph nodes. he last deep femoral node is called the /lo,uetSs node> spread beyond this node affects the lymph nodes of the pelvis. he tumor may also invade ad)acent organs such as the vagina, urethra, and rectum and spread via their lymphatics. %elanoma
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.bout ?H of vulvar malignancy is caused by melanoma of the vulva. Such melanoma behaves like melanoma in other locations and may affect a much younger population. /ontrary to s,uamous carcinoma, melanoma has a high risk of metastasis. 3asal cell carcinoma 3asal cell carcinoma affects about 1-+H of vulvar cancer is a slowly growing lesion and affects the elderly. "ts behavior is similar to basal cell carcinoma in other locations that is it tends to grow locally with a low potential of deep invasion or metastasis Signs and Symptoms: ypically a lesion is present in form of a lump or ulceration, often associated with itching, irritation, sometimes local bleeding and discharge. .lso dysuria, dyspareunia and pain may be noted. Diagnosis: 6xamination of the vulva is part of the gynecologic evaluation and may reveal ulceration, a lump, or a mass. . suspicious lesion needs to undergo a biopsy that generally can be performed in an office setting under local anesthesia. 6xamination of the vulva should include a thorough inspection of the perineal area, including areas around the clitoris and urethra. Palpation of the 3artholin4s glands should be performed as well. Supplemental evaluation may include a chest :-ray, an "GP, cystoscopy and proctoscopy, as well as blood counts and metabolic assessment. .tiology /ondyloma or s,uamous dysplasias. 5uman papillomavirus $5PG& is suspected to be a possible risk factor in the etiology of vulvar cancer. Patients infected with 5"G tend to be more susceptible to vulvar malignancy. .lso, smokers tend to be at higher risk. Staging: Preclinical staging has been supplemented by anatomical staging since 1ECC. <"0!Ss revised staging 2% classification system uses criteria of tumor si'e $ &, involvement of lymph
A+ nodes $2&, and metastasis $%&. Stage " and stage "" describe the early stage of the cancer that still appears to be confined to the site of origin, stage """ defines less or more extensive extensions to neighboring tissue and unilateral inguinal lymph nodes, while stage "G indicates metastatic disease to inguinal nodes bilaterally or distant metastases.O7P Treatment: (adical vulvectomy, removal of vulvar tissue as well as the removal of lymph nodes from the inguinal and femoral areas. /omplications of such surgery include wound infection, sexual dysfunction, edema and thrombosis. Sentinel lymph node $S12& dissection may eventually replace routine groin node dissection. Surgery is significantly more extensive when vulvar cancer has spread to ad)acent organs such as urethra, vagina, and rectum. "n cases of early vulvar carcinoma the surgery may be less radical and disfiguring and consist of wide excision or a simple vulvectomy. (adiation therapy and chemotherapy are usually not a primary choice of therapy but may be used in selected case
Vul)ar intraepithelial neoplasia "VIN$
he term Gulvar intraepithelial neoplasia $G"2& refers to particular changes that can occur in the skin that covers the vulva. G"2 is not cancer, and in some women it disappears without treatment. Types: 1ichen sclerosus S,uamous hyperplasia !ther dermatoses %ixed neoplastic and nonneoplastic disorders "ntraepithelial neoplasia S,uamous vulvar intraepithelial neoplasia $G"2& G"2 ", mildest form G"2 "", intermediate G"2 """, most severe form including carcinoma in situ of the vulva 2on-s,uamous intraepithelial neoplasia
A7 6xtramammary Paget4s disease umors of melanocytes, non invasive "nvasive disease $vulvar carcinoma& Causes: U 5PG 5uman Papilloma Girus& U 5SG-+ $5erpes simplex Girus - ype +& U Smoking U "mmunosuppression U /hronic vulvar irritation U /onditions such as 1ichen Sclerosus Diagnosis: Symptoms= he patient may have no symptoms, or local symptomatology including itching, burning, and pain. he diagnosis is always based on a careful inspection and a targeted biopsy. re)ention: Gaccinating girls with 5PG vaccine before their initial sexual contact has been shown to reduce incidence of G"2. Treatment: he treatment of G"2 is local to wide excision> in case of very extensive involvement or recurrency even a simple vulvectomy. 1aser therapy has also been useful for G"2.
!astitis Definition: %astitis is the inflammation of breast tissue.S. aureus is the most common etiological organism responsible, but S. epidermidis and streptococci are occasionally isolated as well. Types, "t is called puerperal mastitis when it occurs in lactating mothers and non-puerperal otherwise. .nd as per clinical staging types are acute and chronic mastitis
A9 uerperal mastitis: Puerperal mastitis is the inflammation of breast in connection with pregnancy, breastfeeding or weaning. Since one of the most prominent symptoms is tension and engorgement of the breast, it is thought to be caused by blocked milk ducts or milk excess. Nonpuerperal mastitis: he term nonpuerperal mastitis describes inflammatory lesions of the breast occurring unrelated to pregnancy and breastfeeding.
Causes: %astitis typically develops when the milk is not properly removed from the breast. %ilk stasis can lead to the milk ducts in the breasts becoming blocked, as the breast milk not being properly and regularly expressed. "t has also been suggested that blocked milk ducts can occur as a result of pressure on the breast, such as tight-fitting clothing or an over-restrictive bra, although there is sparse evidence for this supposition . %astitis may occur when the baby is not appropriately attached to the breast while feeding, when the baby has infre,uent feeds or has problems suckling the milk out of the breast. !ne theory is that it may be due to the presence of cytokines in breast milk. /ytokines are special proteins that are used by the immune system and are passed on to the baby in order to help them resist infection. "t may be the case that the woman4s immune system mistakes these cytokines for a bacterial or viral infection and responds by inflaming the breast tissue in an attempt to stop the spread of what the body perceives as an infection. 3acteria from the skin or the baby4s mouth that entering the milk ducts through skin lesions of the nipple or through the opening of the nipple."nfection is usually caused by staphylococcus aureus. *is+ factors: *omen who are breastfeeding are at risk for developing mastitis especially if they have sore or cracked nipples or have had mastitis before while breastfeeding another baby. .lso, the chances of getting mastitis increases if women use only one position to breastfeed or wear a tight-fitting bra, which may restrict milk flow .
A? *omen with diabetes, chronic illness, ."DS, or an impaired immune system may be more susceptible to the development of mastitis. Symptoms: 3reast tenderness or warmth to the touch 0eneral malaise or feeling ill Swelling of the breast Pain or a burning sensation continuously or while breast-feeding Skin redness, often in a wedge-shaped pattern <ever of 1D1 < $7C.7 /& or greater he affected breast can then start to appear lumpy and red. .ches Shivering and chills <eeling anxious or stressed <atigue Tests and diagnosis: he diagnosis of mastitis and breast abscess can usually be made based on a physical examination. he ultrasound provides a clear image of the breast tissue and may be helpful in distinguishing between simple mastitis and abscess or in diagnosing an abscess deep in the breast. "n cases of infectious mastitis, cultures may be needed in order to determine what type of organism is causing the infection. /ultures are helpful in deciding the specific type of antibiotics that will be used in curing the disease. hese cultures may be taken either from the breast milk or of the material aspirated from an abscess. %ammograms or breast biopsies are normally performed on women who do not respond to treatment or on non-breastfeeding women.
Complications: /omplications that may arise from mastitis include recurrence, milk stasis and abscess. he abscess is the most severe complication that women can get from this condition. .lso, women who have had mastitis once are likely to develop it again with a future child or with the same infant. (ecurrence appears especially in cases of delayed or inade,uate treatment. %ilk stasis is another complication that may arise from mastitis and it occurs when the milk is not completely drained from the breast. his causes increased pressure on the ducts and leakage of milk into surrounding breast tissue, which can lead to pain and inflammation.
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Delayed treatment or inade,uate treatment, especially in mastitis related to milk stasis, may lead to the formation of an abscess within the breast tissue. .n abscess is a collection of pus that develops into the breast which ultimately re,uires surgical drainage.
#cute mastitis= 0enerally characteri'ed by redness, heat, pain, hardness or swelling> there can be fever, loss of appetite, lower milk production. here are four types of acute mastitis "nflammatory= following a change in habits, transportation, parasitic electricity, a fall, blow or nervous shock. - at calving - after a difficult calving, or if shes is a big producer. "nfectious= Pus begins to be generated, there are lumps and the animal is depressed. 6-coli= %ilk becomes yellow, then watery, it can even contain blood. $ .ct fast & Summer mastitis= /arried by flies, it is caught near the forests, during a wet season. he discharge from abcesses is infected, thick as cheese and smells very bad. Scarring is very slow. Sub-acute mastitis. Sub-acute mastitis1ittle or no acute stage = persistence of lumps and sometimes swelling, lower production, few symptoms. "nfectious = "t is the continuation and the convalescence of an acute mastitis. /linical= there are only lumps without swelling> this type of mastitis is ,uite fre,uent among cows that have already been treated with antibiotics, which suppress the acute phase. Sub-clinical mastitis 1ittle or no general or local symptoms, but a high leucocyte count due to staphylococci. /hronic mastitis .fter effects of repeated bouts of mastitis at the level of the teat= humps, lesions, hardenings, damaged teats, lost ,uarter, nodulary thelitis, drop in milk production. reatment of acute mastitis. "t is very important the prophylactic treatment which is based on rigorous rules of hygiene, both before and after breast-feeding $nipple should be washed with soap and water before and after child feeding&.
AA "f there are any cracks in the nipple they should be followed carefully and treated with topical antiseptic solutions. 3reast pump will be used to avoid stasis. "f the infection has started it is necessary to stop breastfeeding and apply compresses with antiseptic solution and take antibiotics. *hen the collection is formed it must be evacuated by incision followed by drainage of abscess cavity. Chronic mastitis occurs in women who are not breastfeeding. "n postmenopausal women, breast infections may be associated with chronic inflammation of the ducts below the nipple. 5ormonal changes in the body can cause the milk ducts to become clogged with dead skin cells and debris. hese clogged ducts make the breast more open to bacterial infection. "nfection tends to come back after treatment with antibiotics. enderness and swelling 3ody aches <atigue 3reast engorgement <ever and chills .bscess= Sometimes a breast abscess can complicate mastitis. 2oncancerous masses such as abscesses are more often tender and fre,uently feel mobile beneath the skin. he edge of the mass is usually regular and well defined. "ndications that this more serious infection has occurred include the following= ender lump in the breast that does not get smaller after breastfeeding a newborn $"f the abscess is deep in the breast, you may not be able to feel it.& Pus draining from the nipple Persistent fever and no improvement of symptoms within 9C-A+ hours of treatment he diagnosis of mastitis and a breast abscess can usually be made based on a physical exam. "f it is unclear whether a mass is due to a fluid-filled abscess or to a solid mass such as a tumor, a test such as an ultrasound may be done. .n ultrasound may also be helpful in distinguishing between simple mastitis and abscess or in diagnosing an abscess deep in the breast. "f an abscess is confirmed, aspiration or surgical drainage, and "G antibiotics, are often re,uired. /ultures may be taken, either of breast milk or of material taken out of an abscess through a syringe, to determine the type of organism causing the infection. 2onbreastfeeding women with mastitis, or those who do not respond to treatment, may have a mammogram or breast biopsy. his is a precautionary measure because a rare type of breast cancer can produce symptoms of mastitis.
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Pain medication= ake acetaminophen $ ylenol& or ibuprofen $such as .dvil& for pain. hese drugs are safe while breastfeeding and will not harm your breastfeeding baby. "n mild cases of mastitis, antibiotics may not be prescribed at all. "f you are prescribed antibiotics, finishing the prescription even if you feel better in a few days is very important. <re,uent feedings= Do not stop breastfeeding from the affected breast, even though it will be painful. <re,uent emptying of the breast prevents engorgement and clogged ducts that can only make mastitis worse. he infection will not harm the baby because the germs that caused the infection probably came from the babySs mouth in the first place. .n alternative to this is to pump the affected breast to relieve the milk and discard the milk. 3reastfeed from the unaffected side and supplement with infant formula as needed. Pain relief= . warm compress applied before and after feedings can often provide some relief. . warm bath may work as well. "f heat is ineffective, ice packs applied after feedings may provide some comfort and relief. .void using ice packs )ust before breastfeeding because it can slow down milk flow. Drink plenty of water -- at least 1D glasses a day. 6at well-balanced meals and add ?DD extra calories a day while breastfeeding. Dehydration and poor nutrition can decrease milk supply and make you feel worse.
!edications for !astitis /ephalexin $Keflex& and dicloxacillin $Dycill& are two of the most common antibiotics chosen, but a number of others are available. /hronic mastitis in nonbreastfeeding women can be complicated. (ecurrent episodes of mastitis are common. Surgery for !astitis "f an abscess is present, it must be drained. .fter in)ection of a local anesthetic, the doctor may drain an abscess near the surface of the skin either by aspiration with a needle and syringe or by using a small incision. "f the abscess is deep in the breast, however, it may re,uire surgical drainage in the operating room. his procedure is usually done under general anesthesia to minimi'e pain and completely drain the abscess. .ntibiotics and heat on the area are also used to treat abscesses.
AE re)ention: 3reastfeed e,ually from both breasts. 6mpty breasts completely to prevent engorgement and blocked ducts. #se good breastfeeding techni,ues to prevent sore, cracked nipples. .void dehydration by drinking plenty of fluids. Practice careful hygiene= 5andwashing, cleaning the nipples, keeping baby clean. !utlook for 3reast "nfections
/reast cyst Definition: . breast cyst is a fluid-filled sac within the breast. !ne breast can have one or more breast cysts. hey4re often described as round or oval lumps with distinct edges. "n texture, a breast cyst usually feels like a soft grape or a water-filled balloon, but sometimes a breast cyst feels firm. Symptoms: . smooth, easily movable round or oval breast lump with distinct edges. 3reast pain or tenderness in the area of the lump. "ncreased lump si'e and tenderness )ust before period. Decreased lump si'e and resolution of other signs and symptoms after period. 5aving one or many simple breast cysts doesn4t increase risk of breast cancer. Diagnosis he cystic nature of a breast lump can be confirmed by ultrasound examination, aspiration $removal of contents with needle&, or mammogram. #ltrasound can also show if the cyst contains solid nodules, a sign that the lesion may be precancerous or cancerous. 6xamination by a cytopathologist of the fluid aspirated from the cyst may also help with this diagnosis. %edical history and physical examination also play an important role in establishing an accurate diagnosis. Treatment= ypical treatment involves a 2eedle aspiration biopsy. .spirated cysts often recur $come back&> definitive treatment may re,uire surgery.
CD Draining the fluid and then waiting for the cyst to resolve it is the main treatment applied in these cases. %oreover, cysts that are aspirated and the fluid looks normal do not re,uire any other medical attention apart from following-up to make sure it completely disappeared. 5ormone therapy by the means of oral contraceptives is sometimes prescribed to reduce their recurrence and to regulate the menstrual cycle of the patient $which is likely to cause them in the first place&. Dana'ol may also be prescribed to treat this condition and it is usually considered in patients on whom the non-medical treatment fails and the symptoms are intense. Surgical removal of a breast cyst is necessary only in a few unusual circumstances. "f an uncomfortable breast cyst recurs month after month, or if a breast cyst contains bloodtinged fluid and displays other worrisome signs, surgery may be considered. he recommended measures one is able to take in order to avoid the formation of the cysts include practicing good health and avoiding certain medications, eating a balanced diet, taking necessary vitamins and supplements, getting exercise, and avoiding stress.
/reast cancer
Definition= 3reast cancer is a type of cancer originating from breast tissue, most commonly from the inner lining of milk ducts or the lobules that supply the ducts with milk./ancers originating from ducts are known as ductal carcinomas, while those originating from lobules are known as lobular carcinomas. he si'e, stage, rate of growth, and other characteristics of a breast cancer determine the kinds of treatment. reatment may include surgery, drugs $hormonal therapy and chemotherapy&, radiation and@or immunotherapy.O7P Surgical removal of the tumor provides the single largest benefit, with surgery alone curing many cases. o increase the likelihood of cure, several chemotherapy regimens are commonly given in addition to surgery. (adiation is used after breast-conserving surgery and substantially improves local relapse rates and in many circumstances also overall survival.O9P Some breast cancers are sensitive to hormones such as estrogen and@or progesterone, which makes it possible to treat them by blocking the effects of these hormones. Prognosis and survival rates for breast cancer vary greatly depending on the cancer type, stage, treatment, and geographical location of the patient. Signs and symptoms:
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6arly signs of breast cancer 3reast cancer showing an inverted nipple, lump and skin dimpling. one breast becoming larger or lower, a nipple changing position or shape or becoming inverted, skin puckering or dimpling, a rash on or around a nipple, discharge from nipple@s, constant pain in part of the breast or armpit, and swelling beneath the armpit or around the collarbone. Pain $-mastodynia-& is an unreliable tool in determining the presence or absence of breast cancer, but may be indicative of other breast health issues. /ommon sites of metastasis include bone, liver, lung and brain.#nexplained weight loss can occasionally herald an occult breast cancer, as can symptoms of fevers or chills. 3one or )oint pains can sometimes be manifestations of metastatic breast cancer, as can )aundice or neurological symptoms. hese symptoms are called non-specific, meaning they could be manifestations of many other illnesses. *is+ factors: he primary risk factors for breast cancer are female sex and older age. !ther potential risk factors include= lack of childbearing or breastfeeding. 5igher hormone levels, Diet and obesity. 1ifestyle Smoking tobacco. . lack of physical activity. high fat diet,alcohol intake, Dietary iodine deficiency may also play a role. !ther risk factors include radiation,and shift-work.. number of chemicals have also been linked including= polychlorinated biphenyls, polycyclic aromatic hydrocarbons, and organic solvents. 0enetics his include those who carry the 3(/.1 and 3(/.+ gene mutation.!ther significant mutations include= p?7 $1i-<raumeni syndrome&, P 62 $/owden syndrome&, and S K11 $Peut'BTeghers syndrome&, /56K+, . %, 3("P1, and P.13+.O9+P athophysiology: !verview of signal transduction pathways involved in apoptosis. %utations leading to loss of apoptosis can lead to tumorigenesis. 3reast cancer, like other cancers, occurs because of an interaction between the environment and a defective gene. 2ormal cells divide as many times as needed and stop. hey attach to other cells and stay in place in tissues. /ells become cancerous when mutations destroy their ability to stop dividing, to attach to other cells and to stay where they belong.
C+ 2ormal cells will commit cell suicide $apoptosis& when they are no longer needed. #ntil then, they are protected from cell suicide by several protein clusters and pathways. !ne of the protective pathways is the P"7K@.K pathway> another is the (.S@%6K@6(K pathway. Sometimes the genes along these protective pathways are mutated in a way that turns them permanently -on-, rendering the cell incapable of committing suicide when it is no longer needed. his is one of the steps that causes cancer in combination with other mutations. 2ormally, the P 62 protein turns off the P"7K@.K pathway when the cell is ready for cell suicide. "n some breast cancers, the gene for the P 62 protein is mutated, so the P"7K@.K pathway is stuck in the -on- position, and the cancer cell does not commit suicide. <ailure of immune surveillance, the removal of malignant cells throughout one4s life by the immune system. .bnormal growth factor signaling in the interaction between stromal cells and epithelial cells can facilitate malignant cell growth."n breast adipose tissue, overexpression of leptin leads to increased cell proliferation and cancer. Diagnosis: %ost types of breast cancer are easy to diagnose by microscopic analysis of the biopsy. here are however, rarer types of breast cancer that re,uire speciali'ed lab exams. *hile screening techni,ues are useful in determining the possibility of cancer, a further testing is necessary to confirm whether a lump detected on screening is cancer, as opposed to a benign alternative such as a simple cyst. Gery often the results of noninvasive examination, mammography and additional tests that are performed in special circumstances such as ultrasound or %( imaging are sufficient to warrant excisional biopsy as the definitive diagnostic and curative method. *hen the tests are inconclusive <ine 2eedle .spiration and /ytology $<2./& may be used to involve attempting to extract a small portion of fluid from the lump. /lear fluid makes the lump highly unlikely to be cancerous, but bloody fluid may be sent off for inspection under a microscope for cancerous cells. ogether, these three tools can be used to diagnose breast cancer with a good degree of accuracy. !ther options for biopsy include core biopsy, where a section of the breast lump is removed, and an excisional biopsy, where the entire lump is removed. "n addition vacuum-assisted breast biopsy $G.3& may help diagnose breast cancer among patients with a mammographically detected breast in women.
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5istopathology. 3reast cancer is usually classified primarily by its histological appearance. %ost breast cancers are derived from the epithelium lining the ducts or lobules, and these cancers are classified as ductal or lobular carcinoma. Pathologists describe cells as well differentiated $low grade&, moderately differentiated $intermediate grade&, and poorly differentiated $high grade& as the cells progressively lose the features seen in normal breast cells. Poorly differentiated cancers have a worse prognosis. Stage. 3reast cancer staging using the 2% system is based on the si'e of thetumor $ &, whether or not the tumor has spread to the lymph nodes $2& in the armpits, and whether the tumor has metastasi'ed $%& $i.e. spread to a more distant part of the body&. 1arger si'e, nodal spread, and metastasis have a larger stage number and a worse prognosis. Stage D is a pre-cancerous or marker condition, either ductal carcinoma in situ $D/"S& or lobular carcinoma in situ $1/"S&. Stages 1B7 are within the breast or regional lymph nodes. Stage 9 is 4metastatic4 cancer that has a less favorable prognosis. (eceptor status. 3reast cancer cells have receptors on their surface and in their cytoplasm and nucleus. /hemical messengers such as hormones bind to receptors, and this causes changes in the cell. 3reast cancer cells may or may not have three important receptors= estrogen receptor $6(&, progesterone receptor $P(&, and 56(+. 6(I cancer cells depend on estrogen for their growth, so they can be treated with drugs to block estrogen effects $e.g. tamoxifen&, and generally have a better prognosis. 56(+I breast cancer had a worse prognosis, but 56(+I cancer cells respond to drugs such as the monoclonal antibody trastu'umab $in combination with conventional chemotherapy&, and this has improved the prognosis significantly./ells with none of these receptors are called triple negative although they fre,uently express receptors for other hormones such as androgen receptor and prolactin receptor. D2. assays. D2. testing of various types including D2. microarrays have compared normal cells to breast cancer cells. he specific changes in a particular breast cancer can be used to classify the cancer in several ways, and may assist in choosing the most effective treatment for that D2. type. re)ention: he benefits with moderate exercise such as brisk walking are seen at all age groups including postmenopausal women. Prophylactic bilateral mastectomy may be considered in people with 3(/.1 and 3(/.+ mutations.
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!anagement: 3reast cancer is usually treated with surgery and then possibly with chemotherapy or radiation, or both. . multidisciplinary approach is preferable.5ormone positive cancers are treated with long term hormone blocking therapy. reatments are given with increasing aggressiveness according to the prognosis and risk of recurrence. Stage 1 cancers have an excellent prognosis and are generally treated with lumpectomy and sometimes radiation.56(+I cancers should be treated with the trastu'umab $5erceptin& regime./hemotherapy is uncommon for other types of stage 1 cancers. Stage + and 7 cancers with a progressively poorer prognosis and greater risk of recurrence are generally treated with surgery $lumpectomy or mastectomy with or without lymph node removal&, chemotherapy $plus trastu'umab for 56(+I cancers& and sometimes radiation $particularly following large cancers, multiple positive nodes or lumpectomy&. Stage 9, metastatic cancer, $i.e. spread to distant sites& has poor prognosis and is managed by various combination of all treatments from surgery, radiation, chemotherapy and targeted therapies. Surgery: Surgery involves the physical removal of the tumor, typically along with some of the surrounding tissue and fre,uently sentinel node biopsy. Standard surgeries include= %astectomy= (emoval of the whole breast. Vuadrantectomy= (emoval of one ,uarter of the breast. 1umpectomy= (emoval of a small part of the breast. "f the patient desires, then breast reconstruction surgery, a type of cosmetic surgery, may be performed to create an aesthetic appearance. "n other cases, women use breast prostheses to simulate a breast under clothing, or choose a flat chest. !edication: Drugs used after and in addition to surgery are called ad)uvant therapy. /hemotherapy or other types of therapy prior to surgery are called neoad)uvant therapy. here are currently three main groups of medications used for ad)uvant breast cancer treatment= hormone blocking therapy, chemotherapy, and monoclonal antibodies. 5ormone bloc+ing therapy
C? Some breast cancers re,uire estrogen to continue growing. hey can be identified by the presence of estrogen receptors $6(I& and progesterone receptors $P(I& on their surface $sometimes referred to together as hormone receptors&. hese 6(I cancers can be treated with drugs that either block the receptors, e.g. tamoxifen $2olvadex&, or alternatively block the production of estrogen with an aromatase inhibitor, e.g. anastro'ole $.rimidex&OC1P or letro'ole $<emara&. .romatase inhibitors, however, are only suitable for post-menopausal patients. his is because the active aromatase in postmenopausal women is different from the prevalent form in premenopausal women, and therefore these agents are ineffective in inhibiting the predominant aromatase of premenopausal women. Chemotherapy: Predominately used for stage +B9 disease, being particularly beneficial in estrogen receptor-negative $6(-& disease. hey are given in combinations, usually for 7B8 months. !ne of the most common treatments is cyclophosphamide plus doxorubicin $.driamycin&, known as ./. %ost chemotherapy medications work by destroying fast-growing and@or fast-replicating cancer cells either by causing D2. damage upon replication or other mechanisms> these drugs also damage fast-growing normal cells where they cause serious side effects. Damage to the heart muscle is the most dangerous complication of doxorubicin. Sometimes a taxane drug, such as docetaxel, is added, and the regime is then known as /. > taxane attacks the microtubules in cancer cells. .nother common treatment, which produces e,uivalent results, is cyclophosphamide, methotrexate, and fluorouracil $/%<&. $/hemotherapy can literally refer to any drug, but it is usually used to refer to traditional non-hormone treatments for cancer.& !onoclonal antibodies: rastu'umab $5erceptin&, a monoclonal antibody to 56(+, has improved the ? year disease free survival of stage 1B7 56(+I breast cancers to about CAH $overall survival E?H&. *adiation: (adiotherapy is given after surgery to the region of the tumor bed and regional lymph nodes, to destroy microscopic tumor cells that may have escaped surgery. "t may also have a beneficial effect on tumor microenvironment. (adiation therapy can be delivered as external beam radiotherapy or as brachytherapy $internal radiotherapy&. /onventionally radiotherapy is given after the operation for breast cancer. (adiation can also be given at the time of operation on the breast cancer- intraoperatively. rognosis . prognosis is an estimate, as patients with the same classification will survive a different amount of time, and classifications are not always precise. Survival is usually calculated as an
C8 average number of months $or years& that ?DH of patients survive, or the percentage of patients that are alive after 1, ?, 1?, and +D years.
/reast Deformity /reast #symmetry Subcategories of breast asymmetry can include= /ongenital Developmental. raumatic. Status post mastectomy or lumpectomy after breast cancer exenteration and reconstruction. Poland4s deformity. 3reast asymmetry for cancer reconstruction can include the use of flaps, including a (.% $ ransverse (ectus .bdominus %uscle& flap, pedicle or free flap, latissimus dorsi flap from the back with or without a silicone or saline implant as necessary.
CA 3reast asymmetry surgery is an operation similar to breast reduction surgery and leads to thankful with patients improved self-esteem for the rest of their lives. oland;s deformity. here are three classes of Poland4s deformity. /lass " is considered the mild form. "t is where there is hypoplasia of the breast as well as the pectoralis muscle and possibly the nipple areolar complex. here is usually a small nipple areolar complex which is elevated. here is also absence of a sternal head of the pectoralis ma)or muscle, which can be reduced in si'e. /lass "" Poland4s deformity is a classic form in which there is a complete absence of the sternal head of the pectoralis ma)or muscle as well as an aplastic or hypoplastic breast as well as a small nipple areolar complex. "n the most severe form or /lass """ deformity, there is rib and sternal abnormality, absence of the sternocostal and sternoclavicular portions of the pec ma)or can also be associated with hypoplastic or absence of fingers or digits. Tubular /reast Deformity ubular breast deformities are seen in a significant percentage of our patients. .pproximately +H of our patients will show signs of tubular breast deformity, which will include= . poorly defined inframammary fold or no fold. Pseudo-herniation of breast tissue into the nipple areolar complex. . flattening along the lower pole of the breast with minimal rounding appearance. his is a deformity that can be corrected, depending upon the amount of breast tissue available, is to perform the dual plane techni,ue if there is si'e -3- or smaller breast, if there is a significant amount of breast tissue and the patient has a thicker or endomorphic build with thick chest wall and thick chest muscle and hardened glandular tissue or endomorphic build, then these patients may do better with a subglandular or retromammary approach in order to round out some of the upper pole of the breast which may be flattened or refaced if the implant is placed under the muscle on these thicker chested women. ectus Carinatum Pectus carinatum is associated with a pigeon bowing chest deformity of the sternum in which the sternum bows outward as in a pigeon4s chest deformity. he ribcage will often slope from medial to lateral. herefore, dissection needs to be precise and careful in order to prevent intrapleural pneumothorax.Preoperative chest x-rays and / scans are useful to identify other abnormalities of the costochondral )unction sternum as well as the ribcage and chest wall itself.
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ectus .6ca)atum= Pectus excavatum patients can be very complicated. he deformity specifically is associated with a sternal deformity in which the sternum and sometimes the ribs and costochondral )unctions and sometimes even laterally the ribs themselves, are depressed, showing a concave appearance to the sternum, which can lead to severe chest wall deformity, as well as pulmonary problems. Patients with severe pectus excavatum should seek consultation of a pulmonologist, a lung specialist, in order to determine their <6G1, total lung capacity, etc. "mplants on mild pectus excavatum can certainly be placed in the dual plane techni,ue in order to allow for muscle coverage along the middle or medial aspect of the breast pocket. Patients with pectus excavatum that is severe, which may extend to the lateral chest wall, may do better with a subglandular or retromammary approach in order to fill in the upper pole depression, as well as to prevent pneumothorax or intrapleural spaced dissection, which can be ,uite dangerous. Nipple 5ypertrophy: Patients do arrive with nipple hypertrophy. hey have desires to have the nipples made smaller. hey can show signs of emaciation, excoriation and rashes from the nipple hypertrophy. <unctionally, this can be great to reduce the si'e of the nipples in order to allow for a cessation of the patient4s symptoms. "n any case, nipples can be reduced by doing multiple different operations. Procedure to perform the superior pedicle flap with resection of the inferior portion of the nipple from the 7 o4clock to the E o4clock position in a wedge resection and then a superior flap is brought down inferiorly and sutured into place with simple ?-D Prolene sutures which are maintained for at least +D days.
Infertility< Introduction:' he term infertility is in most cases inappropriate as it is only in extreme cases such as premature menopause or complete lack of sperm where there is no chance of conceiving at all most infertility F therapies needs specialist help to conceive, including some who have conceived before. Definition=-
CE he *5! defines the infertility inability of a couple to achieve conception or to bring or pregnancy to term after a year or more of regular unprotected intercourse. Incidence=he factors responsible for infertility are many F varied with an incidence in men up to 7DF in women up to 9DH. he most common causes are ovulation failure F semen disorders. Causes of male infertility Defective spermatogenesis 6ndocrine disorder= Dysfunction of hypothalamus, pituitary, adrenals, thyroid. Systematic disease=D%, celiac disease, renal failure. esticular disorders= rauma 6nvironmental $5igh temperature& /ongenital $5ydrocele, undecended testis& !ccupational $furnace man, long distance lorry drives& .c,uired $varicose, lightening& Physical disorders=!besity, anorexia, strict dieting, excessive exercise. !varian disordersW5ormonal, ovarian cysts or tumours Polycystic ovary disease, ovarian endometriosis. Defective transports !vum, uball obstruction "nfection gonorrhoea, peritonitis, pelvic inflammatory disease. Previous tubal surgery <ibrials adhesions,Previous surgery, endometriosis. Sperm Gagina,Psychosexual problems,"nfection,/ongenital anomaly Defect transport=!bstruction or absence of seminal duct.,"nfection.,/ongenital anomalies rauma "mpaired secretion from prostate or seminal fluid, infection, metabolic disorders. "neffective deliveries Psychosexual problems Drug induced, physical anomalies, hypospadiasis, epipadiasis, retrograde e)aculation. Causes of female infertility Defect in ovulation 6ndocrine disorders Dysfunction of pituitary, adrenal, thyroid. /ervix /ervical trauma or surgery, infection
ED
Defect in implantation 5ormonal imbalance, congenital anomalies, fibroids, infection. Pathophsiology Due to any etiological factor such as impotant male or female reproduction function "nability of sperm to fertili'e with over /hange of conception get reduced "nfertility #ssessment - diagnostic findings Physical examination 6ndocrinology investigation /onsideration of psychosocial factors. here complete histories one of each partner one of the couple 1aboratory studies= (ule out such as causative factors as previous S D F anomalies,in)uries, tuberculosis, mumps, adenitis, impairs sperm production, endometriosis, D6S exposure, antis perm antibodies. %)arian factors Studies performed ovulation F if present endometrial is ade,uate for implantation may include a basal body temperature chart include a basal body temperature chart for at least four cycles, an endometrial biopsy, serum progesterone level F ovulation cycle the ovulation index , urine stick test is determines if the surge in 15 that beeches a follicular has occurred. Tubal factors:' 5ysterosalpinography is used rule out uterine or tubal abnormalitiesS through laparoscopy visuali'ation of the tubes that may interfere with fertility endometriosis. Cer)ical factors:' he cervical mucus can be examined at ovulation F after interview occur that promotes sperm penetration F surgical. . post coital cervical mucus test $Sims nunnery test & is performed + to Chours after intercourse. /ervical mucus is aspirated with a medicine dropper like instrument. .spirated material is placed on a slide F examined under the microscope for the presence F viability of sperm cells. Semen factors:' .fter + to 7 days of sexual abstinence, a specimen of e)eculation is called in a clean container, kept warm, F examined within @hour for the no of sperm percentage of moving forms ,uality of forward movement $forward progression& F morphology $shape Aform& from + to 8 ml of watery alkali semen is normal count is 8D million to 1DD million be men is normal count .
E1 Spean although the incidence of impregnation is used only when the count drops bellow +D million sperm& me ..bnormal semen analysis should show the following. Golume more than 1 ml /oncentration more than +D million 1 ml %otility more than ?DH of the farms should be moving. %orphology more than 8DH of sperm should more normal farmer 2o sperm clumping significant red or white blood cells or thickening of seminal fluid chyperviscasity. !edical management:' Clumiphene "clamed$ /lumiphene is used when the hypothalamus is not stimulating the pituitary gland to release <?9dl9, the medicatiDon stimulate follicles in the ovary ."t is usually taken for ? days beginning on the fifth day of the menstrual cycle ovulation should occur 9 to C days. .fter the lost dose patient receive instruction about timing intercourse to facilitate fertili'ation. !onotonic "pentagonal$ %entoring a combination of <S5 d 15 is used for women with deficiencies in this hormone. Urofallitropin:' #rofallitropin containing <S5 with a small amount of 15 is used in some disorders to stimulate follicle growth clamed is then used to stimulation ovulation. Croo+nec+ gonadotrophin:' /hronics gonadotrophin is used to stimulate release of the egg from the ovary F may be used in combination with the above medication. #ssisted reproduction techni:ues:' . range of assisted reproduction techni,ues is available to treat the infertile coupled it is important i.e. the appropriate tempt option is offered. he general fractional, the local hospital are licensed clinic may offer some tempt but may centre i.e. provided techni,ue that in value fertilising. !utside the body has to regulate by the human fertilisation F embryology. #uthority= "n vitro fertilisation $" G <& Donor insemination $D "& 0amete in lea fallopian transfer where donated sperm are eggs are used in that "ntra cytoplasm sperm in)ection.
Storage of gamete or embryo:'

E+ "ntrauterine insemination=- "# insemination is indicated where there are problems such as hostile cervical mucus, angiosperm antibodies or male fertility problems such as low sperm count premature e)aculation retrograde e)aculation anatomical problems or impotence. "t is also useful far cases of unexplained infertility sperm used far the procedure is fleshing produced from the male partner then a licence is not re,uired. "f the sperm from the male paten has previously fro'en then the clinic earring out the procedure must be licensed by the <"<6. for the storage of sperm. Donor insemination:' Donor insemination is a procedure in which sperm from an anonymous diaries used may be indicated where the following are present in the more partner. !'oospermmia $absence of spermato'oa& !ligospermia $reduce no of spermato'oid& Gasectomy or failed reveres. 6)aculatory failure chemotherapy or radiotherapy ransmissible genetic disorder. In)iter fertilisation:' "n vitro fertilising describes the techni,ue were fertilising occur outside the body. I#P is involves ovarian stimulation egg retrieval fertili'ationF embryo transfer. his produce is accomplished by first stimulating the ovary to produce multiple eggs or over usually with medications because success rates are greater with more than one early embryo. Patients are carefully selected F evaluated F cycles are carefully monitored using ultrasound F steroidal levels. .t the appropriate time, the ova are recovered by translational ultrasound retrieval sperms F eggs are co incubated for up to 78 hours F the embryo are transferred about 9C hour often retrieval ."mplantation should occur in 7 to ? day. =ygote intra fallopian transfer:' /onsists of coyote retrieval F fertili'ation inviters the 'ygotes are placed into the fallopian tubes via laparoscopy. Gamete intra fallopian transfer:' 0amete intra fallopian transfer a variation of "GP is the tempt of choice far pt with ovarian failure buses rates very from 1D to 7DH he ovaries are stimulate with gonadotrophin derivatives F follicles are observed with vaginal ultrasound once the coyote is mature it is retired by fluoroscopy or trans vaginally with ultrasound guidance.
E7 Intra cytoplasmic sperm in>ection:' !ne single spermato'oa a directly inserted to cytoplasm of oo'yte by micro punctured of the 'one pellucid. Nursing management:' .ssessment=In)estment for male:' 5istory regarding marriage %edical history any type of drug used F any type of disease. Se6ual history:' "nspection F palpation of genitalia "n speed the genital part like testiest scrotum area #rine test 9D level Seminal fluid test he normal p9 of the seminal fluid is A.+toA.C $normal& <ructose level 17 Serum hormone <S5 F 1S5 level esticular biopsy rans rectal ultrasonography "mmunological test $sperm antibodies&
2or female 5istory age %edical history F sexual history %enstrual history !bstetrical history previous pregnancy abortion /ontraceptive method 0ynaecological examination
Vaginal infection:' Spectular examination $vaginal discharge has to be identified& 3asal body temperature
E9 /ervical mucus study 6nd metros biopsy Sonography of the uterus .ssist in reducing stress in the relationship 6ncourage cooperation Protect privacy foster understanding refer to the couple to appropriate are resource when necessary. 3ecause infertility work up are expensive time consuming invasive successful not always successful couple need support in working together do deal with this endeavour.
Contraception method Introduction:' !ne of the most important problems for "ndia is the increasing F rapid rate of population growth. hese are many methods used for the control of fertility .%otivation of people towards the acceptance of various method of family planning are prime important. Contraception=- he prevention of conception
a$Contracepti)e:'.ny process, device or method that prevents conception. Types=Temporary contracepti)e method:' a. 2atural methods b. 3arrier methods c. "ntrauterine contraceptive device d. !ral contraceptives e. "gnitable contraceptives f. Dermatologic methods ermanent contracepti)e methods:' . <emale sterilisation 3 %ale sterilisation
Temporary C!:' 2atural method=(hythm method=PREPARED BY KAWALJIT KANG, MSC. MAI BHAGO COLLEGE OF NURSING, TARN TARAN
E?
he method is based identification of the fertile period of a cycle F to abstain from sexual intercourse during that period. he method to determine the approximate time of ovulation F he fertile period include= (ecording of previous menstrual cycle %onitoring the basal body temperature chart %onitoring of excessive mucoid vaginal discharge Coitus interrupts:' "t is used by man. "t necessitates withdrawal of penis shortly before e)aculation. /reastfeeding:'Prolonged F sustained breastfeeding offers a natural protection of pregnancy. /arrier method:' hese methods prevent sperm deposition in the vagina and sperm penetration to cervical canal. These follo7ing are including:' !echanical method:' %ale-condom <emale-condom, diaphragm, cervical cap. Chemical ")aginal contraception$:' /reams-deafen Telly-precept in, velars, paste <oam tablets-.erosol foams, confab Sponge-today Combination=-/ombined use of mechanical F chemical methods. !ale condom:' /ondoms are made of polyurethane or later. he condom is unrolled over the erect penis before any genital contract after use> it should be checked for tears before throwing it away ."t is found torn> a spermicidal )elly should be put into vagina immediately. "t should throw away after single use. "t also protects against S Ds. 2emale condom:'
E8 "t is a pouch made of polyurethane> c lines the vagima and external genitalia. he condom is inserted into the vagina in such a mummer that the closed inner end is anchored in place by the polyurethane ring, whilst the open edge protection against S Ds. Diaphragm="t is an intravaginal device made of rubber with flexible metal or spring at the margins. "t is inserted dome down c some spermicidal )elly c in the cap F along the rime. he device should be introduced up to 7 hours before intercourse F kept for attest 8 hours after the last coital act. 3y holding it up to a bright light, she can ensure that there are no pinpoint holes, cracks or tears in the diaphragm. Cer)ical cap:' he cervical cap is much smaller than the diaphragm and covers only the /x, it is used within a spermicidal. if a women can feel her /x, she can usually learn to use a cervical cap. he cap may be left in place for + days. Vaginal contracepti)e:' /hemicals= - several spermicidal agents are available in the market in the form of cream, )elly or foam tablet. hese agents mostly cause sperm immobili'ation when they come in contact. he cream or )elly is introduced high in the vagina c plastic applicators attest 1? min before sexual intercourse. <oam tablets are to introduced high in the vagina attests ? min priors to intercourse he sponge is made of polyurethane c lines the vagina F external generation. "t gives protection against S D F P"D. Intrauterine contracepti)e de)ice:' hese are small plastic or metal forms to which a tail of nylon threads is usually attached. hese are worn by woman in their uterine charity. Types=2on medical %edicated 2irst generation IUDS:'
"t include lippies loop safe
coil and Dana super.
Second generation IUDS:' "t was found that metallic copper had a strong ant fertility effect. Third generation IUDS:' . hese are based on still another principle i.e., release of a hormone
EA Description of de)ice:' -/oper-+DD-in this threads are used for detection and removed. "t contains 1+Dmg of copper. he device is to be removed after 7 years. -/opper-7CD-.- hese device is to be removed after 1D years. -!ther-%ultiload cu+?D %ultiload 7A? %ral contracepti)es:' 5ormonal contraceptives when properly used are the most effective spacing method of contraception. hese are 1DDH effective in preventing the pregnancy !ral contraceptives are given below=%ral pills:' /ombined pill Progestogen- only pill$mini pill& Post B curtail pill !nce a month pill $ long acting& Types of pills:'
%ale 2- 6thanol, 6straderm D.D7 mg %ale-D- 6thanol 6straderm D.D7 mg 2orSeaster D.7 mg %ale-D is available in a package of +C pills $+& of oral contraceptive pills V A brown, ferrous fume rate coated tablets at a price of rupees + per pocket %ale-2 is supplied free of cost through all P5/ and urban family welfare centres. In>ect able contracepti)es:' here are of two types=-D%P. $ Depot- medroxy progesterone acetate& -26 -62 $ 2orethysterone enantate& 3oth are administered "%. D%P. is given in a dose of 1?D mg every three months or 7DD mg every six months. 26 -62 is given in dose of +DDmg at a monthly interval. -Sub dermal implantsS=-2orplant is the long term contraception. 2orplant is easier to insert F remove. 2orplant provide effective contraception for five years.
EC ermanent method "sterilisation$:'
!ale sterilisation:' "t is permanent sterilisation operation done in the made where a segment of vas deferens of both sides are re)ected $1cm& and the cut ends are legated. he legated end are then folded back on then F sutured into position so that the cut ends face away from each others. <ollowing vasectomy, sperm production F hormone output 2emale sterilisation:' "n this smaller abdomen incision is given about +.?-7 cm under local anaesthesia. . small segment $1.? cm& of both fallopian tubes is legated F re)ected to achieve pregnant sterilisation. !edical termination of pregnancy Introduction:' "n "ndia, he medical termination of pregnancy is previously a health care measure to reduce maternal death resulting from illegal abortion from Xthe abortion war legalised by medical termination of pregnancy act 1EA1 F has been enforced in the year .pril 1EA+. he provision of act has been retrieved in 1EA?. Definition=.bortion F deliberate termination of pregnancy before the liability of the fetes is called induction of abortion. he medical termination of pregnancy act 1EAC.the medical termination of pregnancy act, 1EA1 lays down=he condition under which a pregnancy can be terminated. he person or persons who can perform such termination. he place where such termination can be performed. he condition under which pregnancy can be terminated under the % P act 1EA1. here are five conditions. a. %edical F where continuation of the pregnancy might endanger the mothers life or causes grave in)ury to her physical or mental health. b. 6ugenic F where there is substantial risk of child being born with serious handicaps due to physical or mental abnormities. c. 5umanitarian F where pregnancy is the result of rape. d. Socio- economic F where pregnancy actual or reasonable foreseeable envy could lead to risk of in)ury to health of mother. e. <ailure of contraceptive devices the assignsS caused lay are minted pregnancy resulting from a failure of any contraceptive device or method.
EE
+. he person or person who can perfDormed abortion . he act provided safeguards to mother by authorising only a registered medical practitioner having exertive in gynaecology F obstetricsS to perform abortion where the length of pregnancy does not exceeds 1+weeks. 7. where abortion care be done F the act stipulates that no termination of pregnancy shall be made at any place other than a hospital established or maintained by government or a place approved for the purpose of this act by government. %ethod of termination of pregnancy="n first trimester $up to 1+ week& Surgical method F manual vacuum aspiration= he cervix is dilated manually by instrumentation or by luminaries. . uterine aspirator is introduced. Suction is applied F tissue is removed from the uterus. he section most of this procedure is used. Suction evacuation or curettage F cervical dilation with lain aria followed by vacuum aspiration Dilation F evacuation F 1. (apid method. +. Slow method.
%edical mifepristone F it is progesterone antagonist that prevents purplenatation of ovum. .dministration orally within 1D days an expected menstrual period. /ombined with a presto 1ondon suppository, mifepristone causes abortion E?H of pt. Prolonged balding may occur. Side effects may include abdominal pain, F vomiting F diarrhoea. %ethotrexate F methotrexate has also used to terminate pregnancy because it is a treatise that is /atha to the fetes it has been formed to have minimal risk of few side effect in women. %isoprostol F it is a synthetic prostaglandin among that produce cervical effacement F uterine contract it is effective in terminating a pregnancy in about A?H of cases. *hen combined with o methotraxate or mifepristone, misoprostols effectiveness rate is high is high. Tamo6ifen - misoprostol:' Dilation trimester $17-+D weeks&
1DD "ntra-uterine instillation of hyper somatic solution a. "ntra-aromatic hypertonic urea $9DH& salve $+DHD b. 6xtra-aromatic ethacrydine lactate postal ladings $P06+ ,P0<+& Prostaglandins P06,$misofrostol& 1? wealthy P06+ $carburets&, P06+ $ dinprostone& 9 their analogues used intra vaginally, intramuscularly or intra- anatomically !xytocin infusion light does used along with either of above two methods. 5ysterectomy $abdominal& less continually done nursing management. Pt. teaching is an important aspect of care for women who elect to terminate a pregnancy. 6xplain the all aspect to the women F to the family about side effect of % P. Psychological support is another important aspect of nursing care. *ritten consent should be taken from guardian F husband. .vailable contraceptive method is reviewed with the pt. at this time. 2urse should be aware side effect of contraceptive drugs which is used to terminate the pregnancy. /omplete testing F evolution should be done before abortion. 1aboratory study before an abortion must include a pregnancy test to confirm the pregnancy. . pt. with anaemia may need an iron supplement. . pelvic exam is performed to determine uterine si'e. . nurse or counsellor trained in pregnancy counselling explores with the pt. her fear feeling F option 2urse should be known all legislation F % P rules that is beneficial both nurse F pt. .dvice the pt. to take nutrition healthy diet. .ll services that is imp- for pt. should be explain to pt. F her @his relative. 2ibroids Definition: . uterine fibroid is a leiomyoma $benign $non-cancerous& tumor from smooth muscle tissue& that originates from the smooth muscle layer $myometrium& of the uterus. <ibroids are often multiple and if the uterus contains too many leiomyomata to count, it is referred to as diffuse uterine leiomyomatosis. he malignant version of a fibroid is extremely uncommon and termed a leiomyosarcoma. !ther common names are uterine leiomyoma, myoma, fibromyoma, fibroleiomyoma.
1D1 *is+ factors: "ncreased oestrogen,nulliparity,obesity,epidermal growth factor Types: 7 types, interstitial or intramural, sub peritoneal, sub mucosal. Clinical manifestation= asymptomatic and symptomatic "n symptomatic= abnormal gynecologic hemorrhage, heavy or painful periods, abdominal discomfort or bloating, painful defecation, back ache, urinary fre,uency or retention, and in some cases, infertility. here may also be pain during intercourse, depending on the location of the fibroid. During pregnancy they may be the cause of miscarriage, bleeding, premature labor, or interference with the position of the fetus,torsion of uterus ,intra uterine growth retardation,post partum haemarrhage,pelvic inflammatory disease,,pressure symptoms= constipation,dysuria,hydroureter, Sign= nodulous mobility, mass collection found, athophysiology: 1eiomyomata grossly appear as round, well circumscribed $but not encapsulated&, solid nodules that are white or tan, and show whorled appearance on histological section. %icroscopically, tumor cells resemble normal cells $elongated, spindle-shaped, with a cigarshaped nucleus& and form bundles with different directions $whorled&. hese cells are uniform in si'e and shape, with scarce mitoses. here are three benign variants= bi'arre $atypical&> cellular> and mitotically active. 0ocation Intramural fibroids are located within the wall of the uterus and are the most common type> unless large, they may be asymptomatic. "ntramural fibroids begin as small nodules in the muscular wall of the uterus. *ith time, intramural fibroids may expand inwards, causing distortion and elongation of the uterine cavity. Subserosal fibroids are located underneath the mucosal $peritoneal& surface of the uterus and can become very large. hey can also grow out in a papillary manner to become pedunculated fibroids. hese pedunculated growths can actually detach from the uterus to become a parasitic leiomyoma. Submucosal fibroids are located in the muscle beneath the endometrium of the uterus and distort the uterine cavity> even small lesion in this location may lead to bleeding and infertility. .
1D+ pedunculated lesion within the cavity is termed an intracavitary fibroid and can be passed through the cervix. Cer)ical fibroids are located in the wall of the cervix $neck of the uterus&. (arely fibroids are found in the supporting structures $round ligament, broad ligament, or uterosacral ligament& of the uterus that also contain smooth muscle tissue. athogenesis: <ibroid growth is strongly dependent on estrogen and progesterone. .lthough both estrogen and progesterone are usually regarded as growth-promoting they will also cause growth restriction in some circumstances. Paradoxically, fibroids rarely grow during pregnancy despite very high steroid hormone levels and pregnancy appears to exert a certain protective effect. his protective effect might be partially mediated by an interaction between estrogen and the oxytocin receptor. "t is believed that estrogen and progesterone have a mitogenic effect on leiomyoma cells and also act by influencing $directly and indirectly& a large number of growth factors, cytokines and apoptotic factors as well as other hormones. D?.: #ltrasound, %(", hysteroscopy /olour Doppler study. *hile a bimanual examination typically can identify the presence of larger fibroids, gynecologic ultrasonography $ultrasound& has evolved as the standard tool to evaluate the uterus for fibroids. Sonography will depict the fibroids as focal masses with a heterogeneous texture, which usually cause shadowing of the ultrasound beam. he location can be determined and dimensions of the lesion measured. .lso magnetic resonance imaging $%("& can be used to define the depiction of the si'e and location of the fibroids within the uterus. "maging modalities cannot clearly distinguish between the benign uterine leiomyoma and the malignant uterine leiomyosarcoma> however, the latter is ,uite rare. <ast growth or unexpected growth, such as enlargement of a lesion after menopause, raise the level of suspicion that the lesion might be a sarcoma. .lso, with advanced malignant lesions there may be evidence of local invasion. 3iopsy is rarely performed and if performed, is rarely diagnostic. Should there be an uncertain diagnosis after ultrasounds and %(" imaging, surgery is generally indicated.
1D7
Schematic drawing of various types of uterine fibroids= aYsubserosal fibroids, bYintramural fibroids, cYsubmucosal fibroid, dYpedunculated submucosal fibroid, eYfibroid in statu nascendi, fYfibroid of the broad ligament Treatment %ost fibroids do not re,uire treatment unless they are causing symptoms. .fter menopause fibroids shrink and it is unusual for fibroids to cause problems. Symptomatic uterine fibroids can be treated by= %edication to control symptoms %edication aimed at shrinking tumours #ltrasound fibroid destruction Garious surgically aided methods to reduce blood supply of fibroids %yomectomy or radio fre,uency ablation 5ysterectomy reatment for infection and anemia 6mboli'ation !edication: 2S."Ds can be used to reduce painful menses. !ral contraceptive pills are prescribed to reduce uterine bleeding and cramps. .nemia may have to be treated with iron supplementation. 1evonorgestrel intrauterine devices are highly effective in limiting menstrual blood flow and improving other symptoms. Side effects are typically very moderate because the levonorgestrel $a progestin& is released in low concentration locally. Dana'ol is an effective treatment to shrink fibroids and control symptoms. "ts use is limited by unpleasant side effects. %echanism of action is thought to be antiestrogenic effects. (ecent experience indicates that safety and side effect profile can be improved by more cautious dosing.
1D9
Dostinex in a moderate and well tolerated doses has been shown in + studies to shrink fibroids effectively. 0onadotropin-releasing hormone analogs cause temporary regression of fibroids by decreasing estrogen levels. "ts is typically used for a maximum of 8 months or shorter because after longer use they could cause osteoporosis and other typically postmenopausal complications. he main side effects are transient postmenopausal symptoms. "n many cases the fibroids will regrow after cessation of treatment, however significant benefits may persists for much longer time in some cases. Several variations are possible, such as 0n(5 agonists with add-back regimens intended to decrease the adverse effects of estrogen deficiency. Several add-back regimes are possible, tibolone, raloxifene, progestogens alone, estrogen alone, and combined estrogens and progestogens. #lipristal acetate is a synthetic selective progesterone receptor modulator for the treatment of fibroids. .romatase inhibitors have been used experimentally to reduce fibroids. he effect is believed to be due partially by lowering systemic estrogen levels and partially by inhibiting locally overexpressed aromatase in fibroids. Progesterone antagonists have been shown to decrease the si'e of uterine fibroids. %ifepristone was effective. Uterine artery emboli4ation #terine artery emboli'ation $#.6&= #sing interventional radiology techni,ues, the interventional radiologist occludes both uterine arteries, thus reducing blood supply to the fibroid. his intervention is not usually recommended when fertility should be preserved although subse,uent pregnancies are usually possible. . small catheter $1 mm in diameter& is inserted into the femoral artery at the level of the groin under local anesthesia. #nder imaging guidance, the interventional radiologist will enter selectively into both uterine arteries and in)ect small $?DD Zm& particles that will block the blood supply to the fibroids. . patient will usually recover from the procedure within a few days. he #.6 procedure should result in limited blood supply to the fibroids which should prevent them from further growth, heavy bleeding and possibly shrink them. Uterine artery ligation
1D? #terine artery ligation, sometimes also laparoscopic occlusion of uterine arteries are minimally invasive methods to limit blood supply of the uterus by a small surgery that can be performed transvaginally or laparoscopically. *adio fre:uency ablation (adiofre,uency ablation is one of the newest minimally invasive treatments for fibroids. "n this techni,ue the fibroid is shrunk by inserting a needle-like device into the fibroid through the abdomen and heating it with radio-fre,uency $(<& electrical energy to cause necrosis of cells. he treatment is a potential option for women who have fibroids, have completed child-bearing and want to avoid a hysterectomy. !yomectomy %yomectomy is a surgery to remove one or more fibroids. "t is usually recommended when more conservative treatment options fail for women who want fertility preserving surgery or who express desire to retain the uterus. his surgery is fertility preserving although in some circumstances subse,uent pregnancies can be difficult or impossible. here are three techni,ues types of myomectomy= "n a hysteroscopic myomectomy, the fibroid is removed by the use of a resectoscope, an endoscopic instrument inserted through the vagina and cervix that can use high-fre,uency electrical energy to cut tissue. 5ysteroscopic myomectomies can be done as an outpatient procedure, with either local or general anesthesia used. 5ysteroscopic myomectomy is most often recommended for submucosal fibroids. . laparoscopic myomectomy re,uires a small incision near the navel. he physician then inserts a laparoscope into the uterus and uses surgical instruments to remove the fibroids. . laparotomic myomectomy $also known as an open or abdominal myomectomy& is the most invasive surgical procedure to remove fibroids. he physician makes an incision in the abdominal wall and removes the fibroid from the uterus. 5ysterectomy: 5ysterectomy is the classical method of treating fibroids. .ndometrial ablation:
1D8 6ndometrial ablation can be used if the fibroids are only within the uterus and not intramural and relatively small. 5igh failure and recurrence rates are expected in the presence of larger or intramural fibroids.
!enopause Definition: %enopause is a term used to describe the permanent cessation of the primary functions of the human ovaries the ripening and release of ova and the release of hormones that cause both the creation of the uterine lining and the subse,uent shedding of the uterine lining $ the menses or the period&. %enopause typically $but not always& occurs in women in midlife, during their late 9Ds or early ?Ds, and signals the end of the fertile phase of a woman4s life. he word -menopause- literally means the -end of monthly cycles- from the 0reek word pausis $cessation& and the root men- $month&,. Symptoms: hese include= irregular menses, vasomotor instability $hot flashes and night sweats&, atrophy of genitourinary tissue, increased stress, breast tenderness, vaginal dryness, forgetfulness, mood changes, and in certain cases osteoporosis and@or heart disease. Causes: .n early menopause can be related to cigarette smoking, higher body mass index, racial and ethnic factors, illnesses, chemotherapy, radiation and the surgical removal of the ovaries, with or without the removal of the uterus. .ge he most typical age range for menopause $last period from natural causes& is between the ages of 9D and 81, and the average age for last period is ?1 years. *omen who smoke cigarettes experience menopause significantly earlier than non-smokers. *omen who have undergone hysterectomy with ovary conservation go through menopause on average 7.A years earlier than the expected age. Premature ovarian failure is not considered to be due to the normal effects of aging. Known causes of premature ovarian failure include autoimmune disorders, thyroid disease, diabetes mellitus, chemotherapy, being a carrier of the fragile : syndrome gene, and radiotherapy. *here a woman4s ovaries are removed $oophorectomy&, even if the uterus were to be left intact, the woman will immediately be in -surgical menopause-. Surgical menopause is a menopause
1DA which is induced both suddenly and totally, by removal of both ovaries prior to the age of natural menopause. he term -perimenopause-, which literally means -around the menopause-, refers to the menopause transition years, a span of time both before and after the date of the final episode of flow.
%enopause is based on the natural or surgical cessation of estradiol and progesterone production by the ovaries, which are a part of the body4s endocrine system of hormone production, in this case the hormones which make reproduction possible and influence sexual behavior. .fter menopause, estrogen continues to be produced in other tissues, notably the ovaries, but also in bone, blood vessels and even in the brain. 5owever the dramatic fall in circulating estradiol levels at menopause impacts many tissues, from brain to skin. Premenopause Premenopause is a word used to describe the years leading up to the last period, when the levels of reproductive hormones are already becoming lower and more erratic, and the effects of hormone withdrawal may be present. Postmenopause he term postmenopause is applied to women who have not experienced a menstrual bleed for a minimum of 1+ months, assuming that they do still have a uterus, and are not pregnant or lactating. "n women without a uterus, menopause or postmenopause is identified by a very high <S5 level. hus postmenopause is all of the time in a woman4s life that take place after her last period, or more accurately, all of the time that follows the point when her ovaries become inactive.
%anagement= Perimenopause is a natural stage of life. "t is not a disease or a disorder, and therefore it does not automatically re,uire any kind of medical treatment at all. 5owever, in those cases where the physical, mental, and emotional effects of perimenopause are strong enough that they significantly disrupt the everyday life of the woman experiencing them, palliative medical therapy may sometimes be appropriate.
1DC 5ormone replacement therapy= refers to the use of estrogen plus progestin for a woman who has an intact uterus, or estrogen alone for a woman who has had a hysterectomy. raditionally such therapy was provided as tablets but now is available in a range of formulations including skin patches, gels, skin sprays, subcutaneous implants and so forth. . popular alternative to conventional 5( is a synthetic hormone $derived from the %exican yam& called tibolone. !f the non hormonal therapies for hot flushes, some of the SS("s appear to provide some pharmaceutical relief. .dverse effects of 5( appear to vary according to formulation and dose. See the section below on -.dverse effects of con)ugated e,uine estrogens-. "n addition to relief from hot flashes, hormone therapy can alleviate vaginal dryness, improve sleep ,uality and )oint pain. "t is also extremely effective for preventing bone loss and osteoporotic fracture. !ral administration of progesterone is convenient, however the oral micronised form is rapidly metaboli'ed and inactivated in the liver, and therefore high doses must be administered to achieve ade,uate circulating blood levels. Synthetic progestins have been developed and are prescribed to overcome this problem. Synthetic progestins are more resistant to liver metabolism> therefore lower doses can be used to achieve the desired endometrial effect. "t is not uncommon for women to experience side effects with progesterone or progestin therapy. Progesterone may cause sedation so is best taken at bedtime.Synthetic progestins may cause irritability and mood changes in some women. ypes of 5ormone (eplacement herapy /on)ugated e,uine estrogens contain estrogen molecules con)ugated to hydrophilic side groups $e.g. sulfate& and are produced from the urine of pregnant 6,uidae $horses& mares. Premarin is the prime example of this, either alone or in Prempro, where it is combined with a synthetic progestin, medroxyprogesterone acetate.
0abapentin
1DE 0abapentin $sometimes called by its brand name, 2eurontin& and other 0.3. analogs are antisei'ure medications. Several 0.3. analogs are prescribed off-label for a variety of other conditions $such as pregabalin being used to treat the symptoms of fibromyalgia under the brand name 1yrica&> gabapentin itself has been shown to be as effective as estrogen at reducing hot flashes. 3lood pressure medicines 3lood pressure medicines including clonidine $/atapres& are about as effective as antidepressants for hot flashes, but do not have the other mind and mood benefits of antidepressants. 5owever they may merit special consideration by women suffering both from high blood pressure and hot flashes. .lternative medicine "t is important to examine the claim that herbal remedies help relieve menopausal symptoms.Some botanical sources, referred to as phytoestrogens, do not simply mimic the effects of human steroidal estrogen but exhibit both similar and divergent actions. he ultimate actions of these compounds in specific cells is determined by many factors including the relative levels of the estrogen receptors 6( alpha and beta and the diverse mix of coactivators and corepressors present in any given cell type. hus they have been described to act somewhat like selective estrogen receptor modulators $S6(%s&. 6ffects vary according to the phytoestrogen studied, cell line, tissue, species and response being evaluated. .ndrogen replacement therapy $andropausal and ergogenic use& is a hormone treatment often prescribed to counter the effects of male hypogonadism. "t is also prescribed to lessen the effects or delay the onset of normal male aging. .dditionally, androgen replacement therapy is used for men who have lost their testicular function to disease, cancer, or other causes.
11D (ape trauma syndrome (ape trauma syndrome $( S& is a form of psychological trauma experienced by a rape victim that consist of disruptions to normal physical, emotional, cognitive, behavioral, and interpersonal characteristics. he theory was first described by psychiatrist .nn *olbert 3urgess and sociologist 1ynda 1ytle 5olmstrom in 1EA9.O1P ( S describes a cluster of psychological and physical signs, symptoms and reactions common to most rape victims, during, immediately following, and for months or years after a rape.O+P *hile most research into ( S has focused on female victims, males who are sexually abused $whether by male or female perpetrators& have also exhibited ( S symptoms.O7PO9P ( S also paved the way for consideration of /omplex Post raumatic Stress Disorder, which can more accurately describe the conse,uences of serious, protracted trauma than Post raumatic Stress Disorder alone.O?P he symptoms of ( S and Post- raumatic Stress Syndrome overlap> however, individually each syndrome can have long devastating effects on rape victims./ontents OhideP /ommon stages of ( S ( S identifies three stages of psychological trauma a rape survivor goes through= the acute stage, the outer ad)ustment stage, and the renormali'ation stage. OeditP .cute stage he acute stage occurs in the days or weeks after a rape. Durations vary as to the amount of time a survivor may remain in the acute stage. he immediate symptoms may last a few days to a few weeks and may overlap with the outward ad)ustment stage. .ccording to ScarseO8P there is no -typical- response amongst rape victims. 5owever, the #.S. (ape .buse and "ncest 2ational 2etworkOAP $(."22& asserts that, in most cases, a rape survivor4s acute stage can be classified as one of three responses= expressed $-5e or she may appear agitated or hysterical, OandP may suffer from crying spells or anxiety attacks-&> controlled $-the survivor appears to be without emotion and acts as if 4nothing happened4 and 4everything is fine4-&> or shock@disbelief $-the survivor reacts with a strong sense of disorientation. hey may have difficulty concentrating, making decisions, or doing everyday tasks. hey may also have poor recall of the assault-&. 2ot all rape survivors show their emotions outwardly. Some may appear calm and unaffected by the assault.O+P 3ehaviors present in the acute stage can include= Diminished alertness. 2umbness. Dulled sensory, affective and memory functions.
111 Disorgani'ed thought content. Gomiting.OCP 2ausea. Paraly'ing anxiety. Pronounced internal tremor. !bsession to wash or clean themselves. 5ysteria, confusion and crying. 3ewilderment. .cute sensitivity to the reaction of other people. OeditP he outward ad)ustment stage Survivors in this stage seem to have resumed their normal lifestyle. 5owever, they simultaneously suffer profound internal turmoil, which may manifest in a variety of ways as the survivor copes with the long-term trauma of a rape. "n a 1EA8 paper, 3urgess and 5olmstromOEP note that all but 1 of their E+ sub)ects exhibited maladaptive coping mechanisms after a rape. he outward ad)ustment stage may last from several months to many years after a rape. (."22OAP identifies five main coping strategies during the outward ad)ustment phase= minimi'ation $pretending 4everything is fine4& dramati'ation $cannot stop talking about the assault& suppression $refuses to discuss the rape& explanation $analy'es what happened& flight $moves to a new home or city, alters appearance& !ther coping mechanisms that may appear during the outward ad)ustment phase include= poor health in general.O9P continuing anxiety sense of helplessness hypervigilance inability to maintain previously close relationships experiencing a general response of nervousness known as the -startle responsepersistent fear and or depression at much higher rates than the general populationO1DP mood swings from relatively happy to depression or anger extreme anger and hostility $more typical of male or masculine victims than female or feminine victimsO11P& sleep disturbances such as vivid dreams and recurring nightmares insomnia, wakefulness, night terrorsO1+P flashbacks dissociation $feeling like one is not attached to one4s body& panic attacks
11+ reliance on coping mechanisms, some of which may be beneficial $e.g., philosophy and family support&, and others that may ultimately be counterproductive $e.g., self harm, drug, or alcohol abuseO17PO19P& OeditP 1ifestyle Survivors in this stage can have their lifestyle affected in some of the following ways= heir sense of personal security or safety is damaged. hey feel hesitant to enter new relationships. Vuestioning their sexual identity or sexual orientation $more typical of men raped by other menO1?PO18P&. Sexual relationships become disturbed.O1AP %any survivors have reported that they were unable to re-establish normal sexual relations and often shied away from sexual contact for some time after the rape. Some report inhibited sexual response and flashbacks to the rape during intercourse. /onversely, some rape survivors become hyper-sexual or promiscuous following sexual attacks, sometimes as a way to reassert a measure of control over their sexual relations. Some rape survivors now see the world as a more threatening place to live after the rape so they will place restrictions on their lives so that normal activities will be interrupted. <or example, they may discontinue previously active involvements in societies, groups or clubs, or a mother who was a survivor of rape may place restrictions on the freedom of her children. OeditP Physiological responses *hether or not they were in)ured during a sexual assault, rape survivors exhibit higher rates of poor health in the months and years after an assault,O9P including acute somatoform disorders $physical symptoms with no identifiable cause&.O1P Physiological reactions such as tension headaches, fatigue, general feelings of soreness or locali'ed pain in the chest, throat, arms or legs. Specific symptoms may occur that relate to the area of the body assaulted. Survivors of oral rape may have a variety of mouth and throat complaints, while survivors of vaginal or anal rape have physical reactions related to these areas. OeditP 2ature of the assault he nature of the act, the relationship with the offender, the type and amount of force used, and the circumstances of the assault all influence the impact of an assault on the victim. *hen the assault is committed by a stranger, fear seems to be the most difficult emotion to manage for many people.$<eelings of vulnerability arise&. %ore commonly, assaults are committed by someone the victim knows and trusts. %ay be heightened feelings of self-blame and guilt. OeditP #nderground stage
117 Gictims attempt to return to their lives as if nothing happened. %ay block thoughts of the assault from their minds and may not want to talk about the incident or any of the related issues. $ hey don4t want to think about it&. Gictims may have difficulty in concentrating and some depression. Dissociation and trying to get back to their lives before the assault. he underground stage may last for years and the victim seems as though that they are -over it-, despite the fact the emotional issues are not resolved. OeditP (eorgani'ation stage %ay return to emotional turmoil "t can be extremely frightening to people in this stage to once again find themselves in the same emotional pain. <ears and phobias may develop. hey may be related specificity to the assailant or the circumstances or the attack or they may be much more generali'ed. .ppetite disturbances such as nausea and vomiting. (ape survivors are also prone to developing anorexia nervosa and@or bulimia. 2ightmares, night terrors feel like they plague the victim. Giolent fantasies of revenge may also arise. OeditP Phobias . common psychological defense that is seen in rape survivors is the development of fears and phobias specific to the circumstances of the rape, for example= . fear of being in crowds. . fear of being left alone anywhere. . fear of men. . fear of going out at all, agoraphobia. . fear of being touched, hapnophobia. Specific fears related to certain characteristics of the assailant, e.g. mustache, curly hair, the smell of alcohol or cigarettes, type of clothing or car. Some survivors develop very suspicious, paranoid feelings about strangers. Some feel a pervasive fear of most or all other people. OeditP he renormali'ation stage "n this stage, the survivor begins to recogni'e their ad)ustment phase. Particularly important is recogni'ing the impact of the rape for survivors who were in denial, and recogni'ing the secondary damage of any counterproductive coping tactics $e.g., recogni'ing that one4s drug abuse began to help cope with the aftermath of a rape&. ypical of male victims is a long interval between the sexual assault and the victim4s seeking psychotherapyLaccording to 1acey and (oberts,O1CP less than half of male victims sought therapy within six months and the average
119 interval between assault and therapy was +.? years> King and *oollett4sO1EP study of over 1DD male rape victims found that the mean interval between assault and therapy was 18.9 years. During renormali'ation, the survivor integrates the sexual assault into their life so that the rape is no longer the central focus of their life. During this stage negative feelings such as guilt and shame become resolved and the survivor no longer blames themselves for the attack.
Sexual violence Sexual violence occurs throughout the world, although in most countries there has been little research conducted on the problem.O1P Due to the private nature of sexual violence, estimating the extent of the problem is difficult.O+P (esearch in South .frica and an'ania suggests that nearly one in four women may experience sexual violence by an intimate partner, and up to onethird of adolescent girls report their first sexual experience as being forced.O7PO9PO?P Sexual violence has a profound impact on physical and mental health. .s well as causing physical in)ury, it is associated with an increased risk of a range of sexual and reproductive health problems, with both immediate and long-term conse,uences.O8P "ts impact on mental health can be as serious as its physical impact, and may be e,ually long lasting.OAP Deaths following sexual violence may be as a result of suicide, 5"G infection or murder B the latter occurring either during a sexual assault or subse,uently, as a murder of [[honourSS. Sexual violence can also profoundly affect the social wellbeing of victims> individuals may be stigmati'ed and ostraci'ed by their families and others as a conse,uence.OCP /oerced sex may result in sexual gratification on the part of the perpetrator, though its underlying purpose is fre,uently the expression of power and dominance over the person assaulted. !ften, people who coerce their spouses into sexual acts believe their actions are legitimate because they are married. (ape of women and of men is often used as a weapon of war, as a form of attack on the enemy, typifying the con,uest and degradation of its women or men or captured male or female fighters.OEP "t may also be used to punish people for transgressing social or moral codes, for instance, those prohibiting adultery or drunkenness in public. *omen and men may also be raped when in police custody or in prison./ontents OhideP Definition of sexual violence Sexual violence is defined as= any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, or otherwise directed, against a personSs sexuality using coercion, by any person regardless of their relationship to the victim, in any setting, including but not limited to home and work.O1DP
11?
/oercion can cover a whole spectrum of degrees of force. .part from physical force, it may involve psychological intimidation, blackmail or other threats B for instance, the threat of physical harm, of being dismissed from a )ob or of not obtaining a )ob that is sought. "t may also occur when the person aggressed is unable to give consent B for instance, while drunk, drugged, asleep or mentally incapable of understanding the situation. Sexual violence includes rape, defined by some as physically forced or otherwise coerced penetration of the vulva or anus, using a penis, other body parts or an ob)ect. he attempt to do so is known as attempted rape. (ape of a person by two or more perpetrators is known as gang rape. Sexual violence can include other forms of assault involving a sexual organ, including coerced contact between the mouth and penis, vulva or anus. OeditP <orms and contexts of sexual violence . wide range of sexually violent acts can take place in different circumstances and settings. hese include, for example= (ape by strangers> rape within marriage or dating relationships> systematic -war rape- during armed conflict> unwanted sexual advances or sexual harassment, including demanding sex in return for favors> sexual abuse of mentally or physically disabled people> sexual abuse of children> forced marriage or cohabitation, including the marriage of children> denial of the right to use contraception or to adopt other measures to protect against sexually transmitted diseases> forced abortion> violent acts against sexual integrity, including genital mutilation and obligatory inspections for virginity> forced prostitution and trafficking of people for the purpose of sexual exploitation. OeditP he extent of the problem %ain article= 6stimates of sexual violence
Data on sexual violence typically come from police, clinical settings, nongovernmental organi'ations and survey research. he relationship between these sources and the global magnitude of the problem of sexual violence maybe viewed as corresponding to an iceberg floating in water $see diagram&.O+P he small visible tip represents cases reported to police. . larger section may be elucidated through survey research and the work of nongovernmental
118 organi'ations. 3ut beneath the surface remains a substantial although un,uantified component of the problem. "n general, sexual violence has been a neglected area of research. he available data are scanty and fragmented. Police data, for instance, are often incomplete and limited. %any people do not report sexual violence to police because they are ashamed, or fear being blamed, not believed or otherwise mistreated. Data from medico-legal clinics, on the other hand, may be biased towards the more violent incidents of sexual abuse. he proportion of people who seek medical services for immediate problems related to sexual violence is also relatively small. .lthough there have been considerable advances over the past decade in measuring the phenomenon through survey research, the definitions used have varied considerably across studies. here are also significant differences across cultures in the willingness to disclose sexual violence to researchers. /aution is therefore needed when making global comparisons of the prevalence of sexual violence. he *5! has conducted a survey of available data and studies globally to assess the extent of this issue and issued a chapter-length report, called JSexual Giolence,- as part of the *5!Ss larger +DD+ J*orld (eport on Giolence and 5ealth.W he report states that, globally, one in four women will likely experience sexual violence by an intimate partner and one in three girls report their first sexual experience being forced. Survey data taken during single calendar years in the 1EEDs showed that women reported being sexually assaulted at high levels in certain cities globally. During a 1+-month period, CH of women in (io de Taniero, 3ra'il reported assaults> 9.?H in Kampala, #ganda> ?.CH in 3uenos .ires, .rgentina. he rates over time show an even more drastic problem. 3etween 1ECE and +DDD, A.AH of women in the #nited States reported sexual crimes against them> +7H in north 1ondon, #.K.> +E.EH in 3angkok> 1?.7H in oronto, /anada. %ore than 9DH of women in parts of %exico and Peru reported sexual violence during that period. .mong the countries studied, <inland stood out for having the lowest rate L ?.EH. O11P OeditP <actors associated with being a victim of sexual violence %ain article= <actors associated with being a victim of sexual violence 6xplaining sexual violence is complicated by the multiple forms it takes and contexts in which it occurs. here is considerable overlap between forms of sexual violence and intimate partner violence. here are factors increasing the risk of someone being coerced into sex, factors increasing the risk of an individual person forcing sex on another person, and factors within the social environment including peers and family influencing the likelihood of rape and the reaction to it.
11A (esearch suggests that the various factors have an additive effect, so that the more factors present, the greater the likelihood of sexual violence. "n addition, a particular factor may vary in importance according to the life stage. OeditP <actors increasing men4s risk of committing rape %ain article= <actors increasing men4s risk of committing rape Data on sexually violent men are somewhat limited and heavily biased towards apprehended rapists, except in the #nited States, where research has also been conducted on male college students. Despite the limited amount of information on sexually violent men, it appears that sexual violence is found in almost all countries $though with differences in prevalence&, in all socioeconomic classes and in all age groups from childhood onwards. Data on sexually violent men also show that most direct their acts at women whom they already know.O1+PO17P .mong the factors increasing the risk of a man committing rape are those related to attitudes and beliefs, as well as behaviour arising from situations and social conditions that provide opportunities and support for abuse OeditP he conse,uences of sexual violence %ain article= 6ffects and aftermath of rape Physical force is not necessarily used in rape, and physical in)uries are not always a conse,uence. Deaths associated with rape are known to occur, though the prevalence of fatalities varies considerably across the world. .mong the more common conse,uences of sexual violence are those related to reproductive, mental health and social wellbeing. OeditP *hat is being done to prevent sexual violence %ain article= "nitiatives to prevent sexual violence he number of initiatives addressing sexual violence is limited and few have been evaluated. %ost interventions have been developed and implemented in industriali'ed countries. 5ow relevant they may be in other settings is not well known. he interventions that have been developed can be categori'ed as follows."nitiatives to prevent sexual violence "ndividual approaches 5ealth care responses /ommunity based efforts 1egal and policy responses Psychological care and support %edico-legal services Prevention campaigns 1egal reform Programmes for perpetrators raining for health care professionals/ommunity activism by men "nternational treaties Developmental approaches Prophylaxis for 5"G infection School-based programmes /entres providing comprehensive care *eproducti)e tract infection "se6ually transmitted diseases$
11C Introduction:' S D include those diseases are predominantly transmitted though sexual contact from a infected partner. 0ynaecological diseases associated with S D , high chronic pelvic infection, cervical neoplastic are the long term condition. Definition:' S D are of reproductive tract infections which occurred due to infective intersexual relationship with morbid partner and result in considerable abnormal changes. Classification of se6ually transmitted disease
Disease 0onorrhoea 2on gonococcus arthritis Syphilis 1ymphogranuloma venerlum /ancroidsS 0laucoma inguinal Girginities ."DS 0enital herpes richomonas virginities %onilial virginities
.gent 3acterial
Giral Proto'oal <ungal
Cancroids@ "S%2T S%*.$ he coactive organism is a gram vie streptobaceller haemophilia dupery. he incubation period is very short 7-? days or less. Clinical manifestation:' 1esions starts as multiple vesicopustules over the vulva vagina or cervix it may results in haemorrhagic discharge in later stage - #nilateral inguinal lymphadenitis. Treatment=/eftriaxone +?D mg "% single dose is effective sexual> partner should also be treatment /o-trimaxo'ole + tab $E8D mg& tee rice daily orally for two weeks is effective. 6rythromycin c?DD mg lay month every 8 hour for A days can also be needed for patient who are positive withy 5"G. -
11E 0ymphogranuloma )enerium' 1ymphogranuloma venerium is caused by chlamydia trachoma is usually intercellular organism . he incubation period is +-+1 days. Clinical manifestation:' 1esion on Golvo 1ymphangites 1ymphadenitis 1ymphatic obstruction leads to vulvas swelling <ibrosis
Diagnostic e)olution:' - /ulture and isolation of 10G $/hlamydia serotypes 9,+,7& is confirmatory. - Deletion of 10G antigen is performed by using immunoflurence method. - Deletion of 10G antigen by 61"S. method. - 10G complement fixation test when positive with rising tetra Complication:' - Perineal scarring - Dyspareunia - (ectal stricture - Sinus and fistula formation Treatment:' etracycline ?DD mg is given orally 8 5arley for +-9 weeks - 6rythromycin ?DD mg orally 8 hours for +-9 weeks - Sexual partner should also treated Surgical .bscessesS should be aspirated but not be excused %anual dilatation of stricture weekly re)ention - #se of condom or avoid intercourse with infected partner - #se of sulphonamide in define explosive. Glaucoma inguinal ")enerlum& his is a /herie progressive glaucomatous disease of the vulva ,vagina or cervix. the causative organismSs gram negative bacillus calymatobouterium granulomatics $donor .na&. Clinical manifestation: 1esion starts as pustule and erode ad)acent tissue. "ndurate granulation tissue
1+D 2eoplasia Diagnostic e)olution:' Diagnostic is confirmed by demonstrating the donors is with in the mononuclear cell in material $scrapings& from the ulcer. *hen stained by green method. Treatment= etracycline or imperilling +gm orally in divided doses for +-7 weeks. Surgical= he residual destruction lesion in plastic surgical or vulvotomy. 5.* .S G.NIT#0IS he causative organism is herpes simplex virus type 1 and type +. "t is usually transmitted sexually8 by a infected partner but may transmitted by or genital tract. he incubation period is +-19 days. Clinical manifestation:' (ed painful inflammatory area appear on clitoris, labia, perineum F cervix %ultiply vesicles can result in ulcers. "nguinal lymphaneopathy. <ever, malaria, headache. (etention of urine. Diagnostic e)aluation:' .& Girus tissue and isolation confirmatory. 3& Deletion of virus antigen by 61"S. or immunoflurence method. Caution= 3oth the partner are warned that they are inflation whenever any lesion are evident women should have annual cervical smear. he women should in farm the physician about the history of 5erpes when becoming pregnant. Treatment= .cyclovir clear inhibits the intracellular synthesis of D2. by urine has been found to be effective in acute attacks. "t is better to be given orally in doses of +DDmg F times a day for A days. he cream is also available as topical ? percent acyclovir Saline bath may relieve the pain. to victims of sexual assault

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1 UNIT: VII Gynaecological problems and nursing management -----------------------------------------------------------------------------------------------------------Dysmenorrhea Definition: Dysmenorrhoea is a gynecological medical condition of pain during

2allobian tube disorder: 2allopian tube cancer: Definition:

7+ Pelvic inflammatory disease, he labor of childbirth.

Cer)ical disorders Cer)icitis Definition: /ervicitis is inflammation of the uterine cervix.

Diagnosis: Several tests are used to diagnose vaginal cancer, including=

General Treatment: $i& (est and exercise.

Vul)ar intraepithelial neoplasia "VIN$

Storage of gamete or embryo:'

"t include lippies loop safe

coil and Dana super.

EC ermanent method "sterilisation$:'

Giral Proto'oal <ungal

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