81

Front Cover
82
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Front Cover Inside
INDEX
EDITORIAL 3
PRESIDENTS MESSAGE 5
HON STATE SECRETARYS MESSAGE 7
GUEST EDITORIAL 8
DYSMENORRHOEA 9
ABNORMAL UTERINE BLEEDING 14
OVARIAN CYSTS 20
ENDOMETRIOSIS 24
POLYCYSTIC OVARIAN SYNDROME 29
UTERINE FIBROIDS 35
HYSTERECTOMY 43
UTI 49
CHRONIC PELVIC PAIN 53
CERVICAL CANCER 57
ASSISTED REPRODUCTIVE TECHNIQUES 63
ULTRASOUND IN GYNECOLOGY 68
CT & MRI IN GYNECOLOGY 71
BREAST SCREENING 75
REPORTS 80
CHAIRMAN DR. DEEPAK J UMANI
MEMBERS :
DR. P. N. RAO
DR. RAJ ESH SUBHEDAR
DR. Y. S. DESHPANDE
DR. NIRANJ AN VAIDYA
DR. RAJ ENDRA GANDHI
DR. KRISHNESHKAR
DR. GURUDATTA BHAT
DR. GOVIND DHAVALE
DR. ANIL SUCHAK
DR. AJ OY K. SAHA
DR. HOZIE D. KAPADIA
DR. GOPINATH INDUMATI
DR. VYANKATESH METAN
DR. SANJ AY DESHPANDE
DR. RAVI PATEL
DR. AJ AY TILWE
Published by : IMA MAHARASHTRA STATE
Contact for write-ups, articles, interviews and
advertisements : Editor : Dr. Deepak Jumani
Cell : 98210 44556 E-mail : deepak.jumani@gmail.com
IMA Bldg, 2nd Floor, J .R.Mhatre Marg, J .V.P.D. Scheme,
J uhu, Mumbai-400 049. Ofce : 2623 2965/6521 5756
E-mail : imamsmumbai@yahooo.co.in
Website : www.imamaharashtrastate.org
Advertisement Cheques must be drawn
in favour of IMA MAHARASHTRA STATE
DISCLAIMER : Opinions experssed in the various articles are those of the authors and do not reect the views of Indian Medical
Association Maharashtra State Branch. The appearance of advertisement in MAHIMA is not a guarantee or endoresement of the
product or the claims made for the product by the manufacturer
2
President,
Dr. JAYAGHOSH A. KADDU
GEETANJALI HOSPITAL, NEAR S.T. STAND
WAI, DISTRICT :- SATARA - 412 803
Ph. No. (02167) 220233, Mobile :-09822409291
Email : geetanjalihospital@gmail.com
Imm. Past President,
DR . BAKULESH S. MEHTA
RUBY TERRACE, M. V. ROAD,
ANDHERI (E), MUMBAI- 400069
Tel. No. (022) 26832359/9820131926
Email : dr.bsmehta@yahoo.in
Hon. State Secretary,
DR. JAYESH M. LELE
201-A, GIRDHAR PARK, MITH CHOWK,
MARVE ROAD, MALAD (W),
MUMBAI - 400064
Tel. (022) 28823408 / 9819812996
Email : drjayeshlele@gmail.com
Hon. Treasurer,
DR. SHIVKUMAR S. UTTURE
162, PRASAD, VEER SAVARKAR MARG -2,
SHIVAJI PARK, MUMBAI - 400 028
Tel. (022) 24305373 / 9820089321
Email : utture@yahoo.com
Sr. Vice President,
DR. SANJEEV SHARANGPANI
EYE HOSPITAL, PARKER COMPLEX
CHIPLUN - 415605, DIST. RATNAGIRI
Tel. (02355) 256565 / 260665/9422429224
Email : drsharangpani@gmail.com
Vice President,
Dr. SUNITA KSHIRSAGAR
C- 57, 7TH FLOOR, HYDERABAD ESTATE,
NEPEANSEA ROAD, MUMBAI - 400 036
Tel: 24932909/ 9820118181
Vice President,
DR. ANIL LADDHAD
SHWETA EYE CLINIC,292/01, CENTRAL
AVENUE, NAGPUR - 440002
Tel. (0712) 2765287 / 9822565225
Vice President
Dr. RAJENDRA V. KULKARNI
SHREE CLINIC, KALE APARTMENT
BEHD. NEHRU GARDEN, SHALIMAR,
NASHIK - 422 001
Ph : (0253) 2506994/ 2595982/83/
Mob : 9823067946
Email : rajakulkarni@hotmail.com
Hon. Jt. Secretary
DR. MANGESH GULWADE
GULWADE HOSPITAL,
MAIN RAOD, CHANDRAPUR-442 402
Mob : 9822565130 / TEL NO. (07172) - 274547.
Email:mangeshgulwade@redifmail.com
Hon. Jt. Secretary
DR. PARTHIV SANGHVI
601, MATOSHREE KUNJ, NEAR AMBE MATA
CHOWK, IRLA LANE, VILE PARLE (W),
MUMBAI - 400 056
Tel: (022) 26714722, MOB. 9820304284
Email : dr_parthiv@redifmail.com
Hon. Jt. Secretary
DR. DILIP SARDA
GAURI APTS. 275, SHANIWAR PETH, NEAR
OMKARESHWAR TEMPLE, PUNE - 411 030
PH. NO. (020) 24452512 27010726 /
09823041533 Email: dilip2in@yahoo.com
Chairman, IMA MS SSS
DR. ANIL J. TALATHI
APROOP, CHINCHPADA ROAD,
PEN - 402107, DIST. RAIGAD
Tel. (02143) 252261 / 9422594236
Email : anita_talathi@yahoo.co.in
Hon. Secretary, IMA MS SSS
DR. SHRIKANT H. KOTHARI
5, JAI NEMINATH, SANGHANI ESTATE L.B.S.
ROAD, GHATKOPAR (W), MUMBAI - 400 086
Tel.(022) 25171198 /25001269/ 9821012970
Email : drshkothari@yahoo.co.in
Hon. Treasurer, IMA MS SSS
DR. SHAILENDRA C. MEHTALIA
A/15, ANUPAM, 2ND FLOOR, L.B.S. MARG,
GHATKOPAR (W), MUMBAI - 400 086
Tel.(022) 25132114 / 9820377174
Email : drskcmehtalia@hotmail.com
Director of Studies of IMA MS CGP
Faculty
DR. ANIL PACHNEKAR
AROKUL, 49/B, KAMGAR NAGAR, KURLA,
MUMBAI - 400 024
TEL. (022) 25221390 / M. 9869001873
dranilpachnekar@redifmail.com/
indiatimes.com
Hon. Secretary, IMA MS CGP
Faculty
DR. VIVEK BILLAMPELLY
1666, LANE 20 , OFF R S KEDARI ROAD,
CAMP, PUNE - 411001
Tel. (020) 26832658 / 9822894963
Email : drbillampellyvivek@gmail.com
Hon. Jt. Secretary, IMA MS CGP
Faculty
DR. JAYANT MAKARANDE
AMEYA PATH. LAB. 1ST FLOOR , AMRUT
MARKET, SOCIALIST CHOWK, WARDHA
- 442001
MOB. 09422140238 / (07152) 250238
Email : drjayant_mak@redifmail.com
Chairman, IMA AMS Chapter
DR. RAVI S. WANKHEDKAR
62, VIKAS COLONY, SAKRI ROAD,
DHULE - 424 001
Tel. (02562) 246695 /94222 96495
Email : raviwankhedkar@gmail.com
Hon. Secretary, IMA AMS Chapter
DR. MAYA TULPULE
26, SAHAWAS SOCIETY, KARVE NAGAR,
PUNE - 411 052
Tel. (020) 25440530 / 9923709210
Chairman IMA MS PPS
DR. KRISHNA M. PARATE
Parate Nursing Home, Akshay Apt., Hindustan
Colony, Nagpur - 440 015
Tel:- (0712) 2250101 / Mob:- 9823050575
Co- Chairman IMA MS PPS
DR. ANAND N. KATE
Ameya Hospital, Khare Town, Dharampeth
Nagpur - 440 010
Tel:- (0712) 2536634 / Mob:- 9822278590
Love rules without rules
3
Pranaam to all my Respected teachers and all the members of medical
fraternity.
Imagine looking through a keyhole at a room lled with incredible
treasures.
You cant see much through the little hole. But what you can see
amazes you. Things that would make you wealthy, healthy, and happy are there, right in front of
your eyes. Whats separating you from them seems so imsy. But though you try and try, you just
cant get through.
Then, all of a sudden, the door opens.
Now you can see everything. Its even more amazing than youd thought.Its lled with
gifts and opportunities you couldnt see before, possibilities youd never dreamed of! A whole
world of riches and theres nothing separating you from it any more. Youre in the middle of
it, surrounded by it everywhere you look. Thats exactly what happens when you switch from
a scarcity to the Abundance . Just like that, your view of whats possible goes from narrow to
innite. Your access to whats available goes from restricted to unlimited
This is what happens when one meets Dr Rakesh Sinha a Champion in Laparoscopic
Surgery and I always feel profusely blessed whenever I met this angelic soul who has been
the only Indian Laparoscopic Surgeon on the soil of Maharashtra, India to be honored in the
Guinness Book of World records for his spectacular skills. Dr Rakesh Sinha is also a member of
our IMA MW branch and now rightly and we are proud of him as our beloved Guest Editor for
this issue of Mahima.
When we meet him he opens a portal that enables ideas to ow into your mind freely and
efortlessly. He elevates your positive energy instantaneously to transform any moment. He
dissolves all of the limitations that are currently compromising your growth and happiness.
Through his walks of talks, We always received guiding messages from our subconscious
alerting us to the below-the-radar issues that need our attention most. We thus experienced
paradise right here, right now. He helps erase all toxicity from your interpersonal
relationships. He eliminates destructive hidden beliefs automatically, without having to
examine or revisit them.
The only secret to Dr Sinhas success has been the fact, that He ACTS from pure, positive
inspiration instead of old, faulty programming.
Time waits for none, Life and death are not in anyones hands and one thing which is as
true as truth and it prevails is the fact that successful people generally have a history of hard
work and a certain USP (Unique Selling Proposition), which we should learn and see if it can
be adapted so that it works for us too. Dr Rakesh Sinha is a live model of such a unique splendid
paradigm which I feel one should emulate.
The Good and the Bad always co exist, and as one sows so shall he reap. We must also be
actively aware that doing a good deed does not permit us to do bad and get away with it, thinking
Editorial
Hope is patience with the lamp lit
4
that we have already done our share of good and I am a very very happy man seeing all the
good work and prosperity of IMA MS and I welcome every venture and every idea from
any member, for giving our members all the wisdom and growth expressed our joyous and
dearest President Dr Jayghosh Kaddu.
Always follow the practice of action that is aimed towards achieving results with
objectivity. One such Individual at our Indian Medical Association, who has been able to
inuence us in choosing the right path and right decisions in several matters related to IMA
MS and infact he has truly been a leader among leaders is our dynamic Secretary General Dr
Jayesh Lele who has undying zeal and passion to glorify and dignify IMA MS beyond words.
The project of IMAMS Resource Directory which he has masterminded shall be the greatest
boon to IMA MS.
For me, hard work represents the supreme luxury of life, I had to put in many, many,
many tiny eforts that nobody sees or appreciates before one achieve anything worthwhile. We
are not creatures of circumstance; we are creators of circumstance and I have no Napoleonic
dream. Im just hard-working and pragmatic said Shri T P Pandey the Chief of Taco Visions
a giant publishing house owner who with his team of devoted soldiers are on war foot to
complete the IMA MS Resource Directory.
There is nothing to be proud of. We should have objective discussions and solve issues. We
may share our feedback and agree to disagree. But once a decision has been taken we should
work hard towards it as team players and leaders. Leadership is all about trusting people and
owning failures said Dr Kishore Taori the President Elect of Maharashtra Medical Council.
Virtual CME is the buzz word and soon it shall be a reality. The Executive committee shall
meet and stream line the whole process added Dr Taori. Our Best teacher and a Senior
Physician of Mumbai has already taken a lead to live relay his popular marathon lecture series
for the benet of all from Bombay Hospital to various places in Maharashtra ..indeed a great
service to our medical fraternity.
We Congratulate our dearest members Dr Avinash Yelikar as Vice President and Dr
Bipin Pandit, Dr Shivkumar Utture, Dr Santosh Kadam, Dr Ravi Wankhedkar, Dr Manoj
Deshmulkh and Dr Sudhir Nanadkar as Executive Members of MMC who have now
stationed nally at the MMC of ce and shall be our guiding lights for every needs and wants
of all our members.
Working at IMA MS with all the enterprising and zesty members which include Dr Anil
Suchak, , Dr Bakulesh Mehta, Dr Niranjan Vaidya, Dr Hozie Kapadia, Dr Jayesh Lele, Dr
Shivkumar Utture, Dr Anil Pachnekar Dr S Mehtalia, Dr S Kothari its been like a unending
joy and a happy family environment and its truly said that one of lifes greatest blessings is a
loving family With loads of love and light,.
Dr Deepak K Jumani
Editor
Fear is the lengthened shadow of ignorance
5
It is a proud and a happy moment for me to communicate with all of
you through this issue of MHAIMA-JULY. It is because of your support,
co-operation and afection which has given us the momentum to tackle
many issues favourably and successfully to progress prospectively in
IMA.
No Institution can be progressed prospectively and dynamically (for
that matter IMA) without the positive contribution from the visionary
collective leadership, coordinate thinking at all levels and implementing vision into action
with hard work, humbleness, sincerity, and a single focused mind to contribute for the
progress of IMA.
So friends, I am happy as a state a president to note that IMA MS progressing with
collective leadership and keeping in mind the above philosophy. We have already completed
six months of this year and IMA MS is progressing with leaps and bounds, with ying
colours in many spheres of activities.
I am happy to note that there is inux of new members all over the state in every branch
almost already crossing more than double of our target within six months (almost 4000-5000
members are added) thanks to the credit hours of MMC. Many new branches are coming up.
IMA MS coming with innovative ideas of printing and publishing IMA Resource
Directory which is in very much progress. It is unique and rst of its kind endeavour to bring
medical practitioners, medical service providers, and medical equipment manufacturers at
one stop .The resource directory is a ready reference and a easy connectivity for all concerned
with medical fraternity. So I kindly request all of you to send the database of each member
to the state of ce as early as possible. In this endeavour I appreciate the work of our state
secretary Dr. Jayesh Lele , Mr. Purandare and all the state of ce team who are putting
enormous eforts to complete this project by November 2011.
I am happy to note that the young generation of our state along with young doctors of
the other states have come forward under a banner Young Doctors Association of India
(YDAI)under the aegis of IMA and they have done an exemplary work on getting the Exit
Test postponed. I strongly believe that the young generation is the strength and the future of
our organisation.
During the annual budget session, honourable nance minister proposed 5% service tax
on medical services, but due to the joint efort of medicos and IMA this had to be rolled back.
Friends, today our profession has again showed that with unity and proper vision you can
achieve great heights. IMA has always stood for corruption free society and transparency
in high of ce and fully supported the crusade against corruption and request for the early
Lokpal Bill.
Our priority will be to bridge the gap between IMA of ce and the members by
percolating the information to grass root levels and involving each and every member in the
policy making. So I would like you all to have valuable inputs from all the IMA members and
further I assure you with collective vision we shall strive to make a strong and prosperous
dynamic organisation.
Friends, we all are doing community and welfare activities individually as well as
organised by local branches. I appeal of all the leaders of the local branches to send the reports
Presidential Message
Wisdom is nothing more than healed pain
6
to the state and national headquarters regularly. The theme for this years WHO Day is anti-
microbial resistance, No action today is No cure tomorrow drug resistance costs vast amount
of money and afects vast number of lives. So I request you all to advocate and contribute for
rational use of antibiotics.
Health of all of us as well as of our family members is important. Our national president
Dr. Vinay Agarwal rightly has given a call that a quarter from 7th April to 1st July be observed
as our healthcare and efort should be made to arrange executive healthy check up camps for
doctors and their families. So I kindly request all of you to take care of your health.
Friends, we shall be celebrating Doctors Day on 1st July on the occasion of birth and death
anniversary of most reverent personality, Bharat Ratna Dr. B.C.Roy as Blood Donation Day all
over Maharashtra in all branches so I request you to donate blood and celebrate Doctors Day
and motivate all others to do the same.
One more feather on the crown of IMA-MS is the formation of MMC. It is at the instance
and persuasion of IMA-MS , the MMC has been nally reformed after a gap of 12 years and
has started functioning. Dr.Kishore Taori, IMA Stalwart from Nagpur branch has been
elected as a president of the same. We congratulate him and all the elected and nominated
members for the successful tenure.
IMA wins the battle on many fronts The GOI withdraws service tax on healthcare, Exit
Test is postponed, Govt. is reconsidering BHRC as a second look. So kudos and congratulations
to our national leaders i.e. Dr. Vinay Agarwal and Dr. D.R.RAI and their team.
Further I feel that on so many occasions because of apathy, unawareness, self-centeredness
and because of all our busyness in daily practice we do not oppose any oppressive measures
and verdicts that are brought against us. So we must learn to ght by tooth and nail to oppose
anything that might be brought against our profession however trivial it maybe. While being
busy with our medical practice one must not lose great opportunity to serve our organisation
IMA, which is a source of golden mine to all of us. By serving we not only shine ourselves but
IMA too. So let us serve and shine.
Friends, The days are long, the years are short. I may have heard it or read it somewhere
but I love what it stands for. Every day in our life is so important and yet before we know it, we
wake up to another day, one week, one month and one year older. The days, months, quarters,
years just vanish. So we have complete two quarters and are entering in the 3rd quarter. The
woods are dark and nights are long and the journey is long before we sleep. So friends, let us
make our journey in IMA an enjoyable and a fruitful one.
So let us all awake and arise to the occasion and full the aspiration with inspiration for
the cause, prosperity and progress of IMA.
JAI IMA!
Dr. Jayaghosh A Kaddu
President IMA-MS
The bad news is time flies. The good news is youre the pilot
7
Dear Friends
It is a great pleasure to present to you this MAHIMA special issue on the occasion of
DOCTORS DAY.
We are proud that Dr Rakesh Sinha, who is Guest editor for this issue, has won many
International awards to his Credit. We salute him for his excellent work; dedication
towards the medical profession. His detailed Bio data shows his pioneering work in this
eld.
This year our Blood Donation drive on the occasion of DOCTORS DAY celebrations has shown tremendous
response and so far 84 IMA branches have conrmed participation. Dr Rajendra Chauhan is a dedicated worker
himself and has inspired more doctors to take up this work.
Dr Vijaya Mali from IMA Dhule branch, our Chairperson Womens Wing has done great work in the project
of MISSION PINK in villages and areas around Dhule. She has prepared cassettes for the same and is being sent
free to all our branches, various associations, schools.
We congratulate Dr Kishore Taori being elected as President, Dr Avinash Yelikar Vice President, and Dr
Bipin Pandit, Dr Shivkumar Utture, Dr Manoj Deshmukh, Dr Ravi Wankhedkar, Dr Dr Sudhir Nanadkar and
Dr Santosh Kadam as executive members at Maharashtra Medical Council.
This year we are in the process of publishing IMA Maharashtra State Resource Directory 2011 one of its kinds
and work on data collections from various branches is being done. We request all to send updated list of members
details so as to print correct data. Many members have sent their details by email; this is going to be very much
helpful for future communication. We shall be following the list as per the approved members from IMA HQ.
This year 4 new IMA Branches, Shirpur, Sakri, Nalasopar a and Jamner have been formed; also we revived
Jintur Branch which was derecognized last year due to IMA HQ rule. We are in the process of touching magic no
of 25,000 members and still many members are joining us. We have listed all the members on our website. Also
IMA TELE Data update web page is available, so as all can visit the web site, download the form and send updated
form to us.
IMA Maharashtra State CGP chapter is organizing Western Regional conference on 18Sep 2011 at J W
Marriott Hotel, Juhu. Dr Anil Pachnekar and his team are working hard. The detailed program shall be available
in next issue.
IMA Pune branch shall be hoisting Womens conference on 9th OCT 2011, at Pune. Dr Bharti Dhorepati and
her team are looking after the minute details to present memorable conference.
Dr Deepak Jumani Our Editor MAHIMA has worked hard to present this issue. He has 3 more issues lined
up for the members. We are also working on arrangement to make more copies of the MAHIMA, so that we can
reach many more members.
Dr Mangesh Gulwade busy with the preparations of MASTACON 2011, being held at Chandrapur on 25th,
26th and 27th November 2011.
New challenges for our members shall be Clinical Establishment bill being table in Maharashtra. We are also
working out for easier arrangement for our members for this accreditation process.
Many of our IMA branches are conducting MMC approved Accreditation for CME hours and in near future
if MMC approves online CME accreditation, we shall also make arrangements for distant members in this
regards.
Please do communicate to us your views
HAPPY DOCTORS DAY
DR JAYESH LELE
HON STATE SECRETARY
IMA MAHARASHTRA STATE
CELL + 91 981 981 2996 E mail: drjayeshlele@gmail.com
SECRETARY MESSAGE
Each man the architect of his own fate
8
HeyFriends!!!
It is such an honour and privilege to be invited as the guest editor of
this issue of Mahima of Indian Medical Association Maharashtra State
Branch.
Medical care is becoming more and more complex. Over two million
articles are published annually in the bio medical literature in over 20,000 journals, so
where can physicians and surgeons turn to, to update their knowledge. This special issue in
gynecology is an attempt to highlight the important subjects in gynecology as a ready reference
for all of us.
The last two decades have been a glorious era for endoscopic surgery. Laparoscopy is now an
essential part of gynecological surgery and is dominated by a single imperative The quest for
machine like perfection in the delivery of care.
I have personally selected essential topics in gynecology and have some brilliant authors to
write these chapters. From dysmenorrhoea and abnormal uterine bleeding to Urinary Tract
Infection and chronic pelvic pain for the general practitioner. The more complex subjects like
endometriosis, ovarian cysts, poly cystic ovarian disease and assisted reproductive techniques
have been simplied for non gynecologists to understand.
I would like to thank my co-editors Dr. Shweta Raje & Dr. Gayatri Rao for having worked
very hard on this issue.
My heartiest congratulations to the dynamic editor of Mahima Dr. Deepak Jumani who has
pain stakingly worked for this issue. I would also like to congratulate the President Dr. Jayghosh
Kaddu and the secretary Dr. Jayesh Lele and the other managing committee members for
consistently bringing out speciality issues.
Id like to thank Dr. Manju Sinha, who has been the lynch pin for this issue.
This issue has been conceived and designed to understand the necessary everyday maladies
of a women and the newer techniques available to manage them.
Decisions are made in the head, Commitments are made in the heart;
Let us commit to make safe endoscopy our goal!
Heres wishing you All the very Best!
Dr. Rakesh Sinha
Guest Editor
GUEST EDITORIAL
Compassion is the basis of all morality
01
99999999
9
0000000000000000000000000000000000000000001111111
Dr Shweta Raje
M.D., D.N.B.
Consultant Gynaecological Endo-
scopic Surgeon
Beams Hospital, Khar, Mumbai
DYSMENORRHOEA
D
ysmenorrhoea (painful menstrual
cramps of uterine origin) seems to
be the most common gynaecological
condition in women regardless of age
& parity. Prevalence estimates vary
from 45% to 95%. Cultural inuences, such as a womans
status within society, her life stage, religion, education
and employment and the personal signicance of
dysmenorrhoea determine whether a woman seeks
medical help for menstrual problems.
ETIOLOGY
What types of dysmenorrhoea are there?
Primary dysmenorrhoea is menstrual pain without organic disease, and secondary
dysmenorrhoea is menstrual pain associated with an identiable disease.
Common causes of secondary dysmenorrhoea:
Uterine Extrauterine Non-gynaecological
Fibroids Endometriosis Psychosomatic disorder
Adenomyosis Pelvic inammatory disease Irritable bowel syndrome
Polyp Adhesions Chronic constipation
Menorrhagia Retained tampon Inammatory bowel disease
IUCD Musculoskeletal referred pain
Cervical stenosis Renal calculi/urinary tract infection
Pelvic adhesions Uterine broids Endometriosis
Leadership is an action, not a position. - Donald H. McGannon
10
CLINICAL PRESENTATION
Primary dysmenorrhoea Secondary dysmenorrhoea
Onset soon after menarche Onset at any age, sometimes after years of pain
free menses Increasing pain with increasing age
Pain - Before/during menstruation Not necessarily limited to menstruation Usu-
ally worse day 1and persists for 4872 hours
Pain - Similar with each period Worsens with time
May be worse with defecation, urination
May radiate to lower back and rectum
Symptoms - PMS , physical and emotional
symptoms
Menorrhagia, irregular cycles, infertility,
urinary retention, nausea, vomiting, migraine,
bloating cyclic haematuria, dysuria, diarrhoea,
dyspareunia, vaginal discharge
Pelvic Examination - Normal Tenderness
Adnexal mass
Fixed retroverted uterus
Cervical tenderness
History -Nil relevant Exposure to STIs
Intrauterine device (IUD)
Tampon use
Previous surgery
Sexual dysfunction
COCP, NSAIDs Usually alleviates the pain Minimal improvement, if any
What are the risk factors for dysmenorrhoea?
The severity of dysmenorrhoea is signicantly associated with duration of menstrual ow,
age of menarche, smoking, obesity, and alcohol consumption.High levels of stress can also
greatly increase the incidence of dysmenorrhoea, as can depression,anxiety, and disruption
of social networks. Primary dysmenorrhoea often improves in the third decade of a womans
reproductive life and after childbirth. The relation between the prognosis of secondary
dysmenorrhoea and the severity of underlying disease is unclear.
How should dysmenorrhoea be investigated?
PATIENT ASSESSMENT
Pain assessment
severity
cyclic versus noncyclic
chronic versus acute
relationship to menstruation
Leaders think and talk about the solutions. Followers think and talk about the problems. - Brian Tracy
11
Associated symptoms
premenstrual syndrome
menorrhagia
dyspareunia
nongynaecological symptoms urinary, bowel, musculoskeletal
Medication: medications tried and with what success
Sexual history current/past relationships, sexual abuse, sexual partners,exposure to STIs
Gynaecological history menarche, parity, contraception, IUD use, surgery
Psychological assessment depression/anxiety symptoms, psychosomatic disorders
Social assessment efect of symptoms on daily activities/work/sport/social activities/
relationships
INVESTIGATIONS
Pelvic ultrasound : To detect any pelvic pathology
Full blood examination : To assess anaemia related to chronic menorrhagia, infection (PID)
Cervical/vaginal swabs : Pelvic inammatory disease, choice of antibiotic
Mid stream urine : To exclude urinary tract pathology
B-HCG :To exclude pregnancy with miscarriage/ectopic pregnancy
Plain abdominal X-ray, To exclude bowel obstruction, renal calculi,
Laparoscopy : Both diagnostic and therapeutic
Hysteroscopy : Denes intrauterine pathology and provides an endometrial tissue sample
for histology
TREATMENT OPTIONS
Simple analgesics
Simple analgesics, such as paracetamol, may be useful as a starting point.
Non-steroidal anti-inammatory drugs
The diferent formulations of NSAIDs have similar ef cacy for dysmenorrhoea, and pain
relief is achieved in most women. Between 17% and 95% (mean 67%) of women achieve pain
relief with an NSAID. Non-steroidal anti-inammatory drugs (NSAIDs) such as mefenamic
acid can be very efective alone in relieving dysmenorrhoea. However, for maximal benet it
is necessary to commence them at least 48 hours before the period commences. They are safe,
efective, inexpensive, and only require intermittent use.
Oral contraceptives
As dysmenorrhoea is mainly seen in ovulating women, by rendering a woman anovulatory
with the Combined oral contraceptive pills, dysmenorrhoea may be resolved. The COCP may
have other benets for women also managing issues such as PMS, contraception, cycle control
and menorrhagia. Low dose (or combined) oral contraceptives signicantly reduce pain.
Leadership is the challenge to be something more than average. - Jim Rohn
12
Progestogens and antiprogestogens
Progestogens such as medroxyprogesterone acetate and gestrinone induce anovulation with
resulting ameno rhoea and therefore can successfully treat the symptoms of dysmenorrhoea
in women with endometriosis.
Gonadotrophin releasing hormones ( Injectable) and danazol
Gonadotrophin releasing hormones and danazol confer the same degree of pain relief. The
side efect proles of these treatments are diferent, however, with danazol having more
androgenic side efects, while gonadotrophin releasing hormones tend to produce more hypo-
oestrogenic symptoms
Levonorgestrel releasing intrauterine system
The levonorgestrel releasing intrauterine system releases levonorgestrel (20 /day) into the
uterine cavity for at least ve years, thus preventing the thickening of the lining of the uterus
with reduction in dysmenorrhoea.
Mirena IUD has the following benets:
Provides efective and reversible contraception if needed
Minimizes, and in most cases eliminates, menstrual bleeding (there may be unpredictable
bleeding in the rst few months)
Side efects are rare as the progesterone is acting locally with minimal systemic absorption
Natural ovarian function is maintained (attractive to many older women who do not want
to disrupt their hormones unnaturally with the OCP or resort to surgery)
Combined drug treatments
A combination of analgesics and the oral contraceptive or the Mirena intrauterine device is
also an option in cases that do not respond to a single treatment.
Surgery
Surgery would be an extreme management option for primary dysmenorrhoea alone, but
is a valid option in many women for the management of secondary dysmenorrhoea due
to underlying pelvic pathology or in those with associated debilitating symptoms such as
menorrhagia.
The aim of surgery is to either remove a potential cause of pain or ablate or remove
the endometrium itself. Minimally invasive techniques have obvious advantages over
conventional surgery in reducing the length of hospital stay and postoperative recovery period
and avoid the trauma and risks of conventional surgery and reducing health care costs.
Division of the uterosacral ligament has limited or no benet. Laparoscopic presacral
neurectomy may be efective in treatment of severe cases.
Exercise
Physical exercise may reduce dysmenorrhoea. It is hypothesized that exercise works by
improving blood ow at the pelvic level as well as stimulating the release of endorphins,
which act as non-specic analgesics.
The book you dont read wont help.
13
KEY POINTS
It is important to obtain a detailed history that covers the onset, location, duration, and
characteristics of pain, plus any aggravating or relieving factors.
Adolescents are unlikely to have underlying disease and so do not usually require a pelvic
examination
Pelvic ultrasonography is a helpful investigation to detect / rule out underlying pathology.
First line treatment for dysmenorrhoea should be paracetamol or non-steroidal anti-in
ammatory drugs
If contraception is desired then the combined oral contraceptive may be considered.
It may be helpful to give the patient additional information on alternative treatments (e.g.
heat, thiamine, magnesium, and vitamin E)
Specialist referral is indicated if oral contraceptives and non- steroidal anti-inammatory
drugs fail.
Some people read so little they have rickets of the mind.
1 411111 4444444
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Dr. Gayatri Rao
D.G.O., D.N.B.
Consultant Gynaecological Endo-
scopic Surgeon
Beams Hospital, Khar, Mumbai
ABNORMAL
UTERINE BLEEDING
A
bnormal uterine bleeding (AUB),
also known as dysfunctional uterine
bleeding is the occurrence of uterine
bleeding unrelated to structural
abnormalities of the uterus or the
endometrial lining. It is a diagnosis of exclusion
made after structural causes of bleeding and chronic
medical diseases have been ruled out.It is a common
problem for menstruating women, particularly
those at the beginning (adolescence) and end
(perimenopause) of their reproductive years.
physiology
Normal volume of menstrual blood loss is less than 80ml, with 30ml being an average ow.
Normal interval between menstrual cycles is considered to be 28 days(+/- 7 days)
Duration of ow ranges between 2 and 7 days for normal menses.
Abnormal uterine bleeding patterns- various patterns have been described
Figure 1:
The Menstrual cycle- showing the changes in the pituitary and ovarian hormones
and the histological changes in the endometrium
Miss a meal if you to, but dont miss a book.
15
Pathophysiology
Anovulatory dysfunctional uterine bleeding results from a disturbance of the normal
hypothalamic-pituitary-ovarian axis and is particularly common at the extremes of the
reproductive years. When ovulation does not occur, no progesterone is produced to stabilize the
endometrium; thus, proliferative endometrium persists. Bleeding episodes become irregular,
and amenorrhea, metrorrhagia, and menometrorrhagia are common.
Ovulatory dysfunctional uterine bleeding: bleeding occurs cyclically, and menorrhagia is
thought to originate from defects in the control mechanisms of menstruation.
TERMS USED TO DESCRIBE ABNORMAL UTERINE BLEEDING
TERM ABNORMAL UTERINE BLEEDING PATTERN
Oligomenorrhea Bleeding occurs at intervals of > 35 days and usually is caused by a
prolonged follicular phase.
Polymenorrhea Bleeding occurs at intervals of < 21 days and may be caused by a
luteal-phase defect.
Menorrhagia Bleeding occurs at normal intervals (21 to 35 days) but with heavy
ow ( > 80 mL) or duration ( > 7 days).
Menometrorrhagia Bleeding occurs at irregular, noncyclic intervals and with heavy
ow ( > 80 mL) or duration ( > 7 days).
Metrorrhagia Irregular bleeding occurs between ovulatory cycles; causes to
consider include intermenstrual cervical disease, intrauterine
device, endometritis, polyps, submucousmyomas, endometrial
hyperplasia, and cancer.
Amenorrhea Bleeding is absent for 6 months or more in a nonmenopausal woman.
Midcycle spotting Spotting occurs just before ovulation, usually because of a decline
in the estrogen level.
Postmenopausal bleeding Bleeding recurs in a menopausal woman at least 1 year after ces-
sation of cycles.
Causes of abnormal uterine bleeding.
Endocrine
Cushings disease
immature hypothalamic-pituitary axis
hyperprolactinemia
hypothyroidism
menopause
obesity
polycystic ovary disease
premature ovarian failure
Stuctural lesions
adenomyosis
coagulopathies
Success is not to be pursued; it is to be attracted by the person we become.
16
condylomaacuminata
dysplastic or malignant lesion of the
cervix or vagina
endometriosis
endometrial cancer
uterine or cervical polyps
uterine leiomyomata
trauma
Infections
chlamydia
gonorrhea
Pelvic Inammatory Disease
Medications
hormonal agents
low-dose oral contraceptive pills (OCPs)
nonprogestin-containing IUDs
nonsteroidal anti-inammatory drugs (NSAIDS)
Norplant System
progestin-only contraceptive (the mini pill)
tamoxifen
warfarin
Pregnancy
ectopic pregnancy
incomplete abortion
pregnancy complications
History
Menstrual history : cycle length, number of bleeding days, intermenstrual or postcoital
bleeding, degree of blood loss passage of clots; pain associated with bleeding (dysmenorrhoea).
Contraception : current method; need; family complete?
Symptoms suggesting underlying pathology:
Metabolic disorders: symptoms suggesting PCOS and hypothyroidism.
Haematological disorders: excessive bleeding after childbirth or tooth extraction, easy bruising.
PID/infection: pelvic pain, pain on intercourse (dyspareunia), vaginal discharge.
Endometriosis: pelvic pain, dysmenorrhoea.
Postcoital and intermenstrual bleeding also suggests pelvic pathology.
Examination
Abdominal examination: tenderness, palpable masses (uterine, ovarian).
Pelvic examination:
Uterine or ovarian structural abnormalities, including leiomyoma or broid uterus, may
be noted on bimanual examination.
If you care at all, youll get some results. If you care enough, youll get incredible results.
17
Cervical smear: as appropriate.
Infection screening: high vaginal and endocervical swabs as appropriate.
LABORATORY ASSESSMENT OF SEVERE BLEEDING
Initial evaluation
Complete blood count and diferential
Blood clotting prole
Hormone tests
FSH
LH
Male hormone (androgen) levels
Prolactin
Progesterone
Serum or urine HCG (to rule out pregnancy)
Thyroid function tests
If bleeding is severe or prolonged or associated with menarche or ifthe initial screen in
abnormal
Von Willebrands factor antigen
Factor VIII activity
Factor XI antigen
Ristocetin C co-factor
Platelet aggregation studies
Further investigations that usually take place in secondary care:
Imaging Studies
Pelvic ultrasonographyrst-line diagnostic tool for identifying structural abnormalities.
Endometrial thickness may also be assessed. It may determine the etiology of the bleeding
such as a broid uterus, endometrial thickening, or a focal mass.
Computed tomography is used primarily for evaluation of other causes of acute abdominal
or pelvic pain.
Magnetic resonance imaging is used primarily for cancer staging.
The following procedures may be done:
Hysteroscopy and Endometrial biopsy.
An endometrial biopsy is often performed in women over age 35 to rule out endometrial cancer
or abnormal endometrial growths. A biopsy may also be performed in women younger than
35 if they have risk factors for endometrial cancer. Risks include obesity, chronic anovulation,
history of breast cancer, tamoxifen use or a family history of breast cancer or colon cancer.
During hysteroscopy, a small scope is insertedvia the birth passage through the cervix into
the uterus.Fluid is injected to expand the uterus ,allowing the gynaecologist to see the inside
of the uterus. Tissue samples are now taken under vision . Anesthesia is used to minimize
discomfort during the procedure.
Success is not so much what we have as it is what we are.
18
Agent Dosage Purpose of treatment
Combination OCP 20 to 35 mcg of ethinyl estradiol plus a
Cycle regulation progestin; monophasic
or triphasic pill taken
35-mcg pill from twice daily to every six
hours for ve to seven days until menses
is stopped, followed by taper to one pill
daily for bleeding completion of 28-day
pack; then one OCP packet per month for
three to six months
Contraception
Prevention of endometrial
hyperplasia
Management of nonemer-
gency heavy bleeding
Conjugated estrogens,
IV (Premarin)
25 mg IV every 4 to 6 hours until bleeding
ceases, or for 24 hours; then OCP as above
Management of acute emer-
gency bleeding
Progestins
Medroxyprogesterone
acetate (Deviry)
Norethindrone acetate
(Regesterone)
Micronized progesterone
(susten)
5 or 10 mg per day from3rd day of cyclefor
a period of 21 days per month
5 to 10 mg per day for from3rd day of
cyclefor a period of 21 days per month
200 mg per day for 12 days per month
Cycle regulation
Prevention of endometrial
hyperplasia
NSAIDS Mefenamic acid -500 mg TiD, Efective for long-term use.
Watch for GI and renal side-
efects.
Danazol 200 to 800 mg/day
for 3 to 6 months
Androgenic side-efects limit
use. Acts as anti-estrogen and
prevents ovulation.
GnRH agonists Goserelin acetate (Zoladex), 3.6 mg SC
every 28 days (3 doses); Leuprolide acetate
(Lupron) or nafarelin acetate (Syneral)
Primarily used to thin the
endometrium prior to surgery.
Used when hormonal methods
have failed or are containdi-
cated. May cause osteoporosis
on chronic use.
Management of dysfunctional uterine bleeding
First-line:Tranexamic acid or non-steroidal anti-inammatory drugs (NSAIDs) or com
bined oral contraceptive pills (COCPs).
Second-line:Norethisterone (15 mg) daily from days 5 to 26 of the menstrual cycle, or inject
able long-acting progestogens.
Third-line:Levonorgestrel-releasing intrauterine system, (Mirena ) provided long-term use
(at least 12 months) is anticipated.
Medical Management of Anovulatory Dysfunctional Uterine Bleeding
Surgical management of DUB
This should only be considered if:
Pharmacological management has failed.
There is severe impact on quality of life.
When the promise is clear, the price gets easy.
19
There is no desire to conceive.
Endometrial Ablation
Balloon thermal ablation (balloon inserted through cervix to endometrial cavity,
inated with a pressurised solution then heated to destroy the endometrium).
Hysteroscopic Endometrial Ablation :
Disadvantage is that denite amenorrhoea cannot be guaranteed
General anaesthesia usually used.
Rollerball ablation (a current is passed through a rollerball electrode that is moved around
the endometrium).
Transcervical resection of the endometrium (the endometrial lining is removed using a
cutting loop).
Hysterectomy
To be considered as last option whenother non surgical management has failed
Other treatments are contra-indicated or declined.
There is desire for amenorrhoea.
The woman is fully informed and requests it.
There is no desire to retain the uterus and fertility.
Laparoscopic hysterectomy is the best option .
We all have two choices: We can make a living or we can design a life.
2 02222222 0000000
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Dr. Meenakshi Sundaram
Consultant Endoscopic
Gynecological Surgeon
Beams hospital, Mumbai
Ovarian Cysts
O
varian cysts are small uid-lled
sacs that develop in a womans
ovaries. Most cysts are harmless,
but some may cause problems such
as rupturing, bleeding, or pain; and
surgery may be required to remove the cyst(s). Ovarian
cysts afect women of all ages. The vast majority of
ovarian cysts are considered functional (or physiologic).
The cyst contains only uid and is surrounded by
a very thin wall. This kind of cyst is also called a
functional cyst, or simple cyst. Small cysts (smaller
than one-half inch) may be present in a normal ovary
while follicles are being formed.
The most common types of ovarian cysts are the following:
Follicular cyst: This type of simple cyst can form when ovulation does not occur or when a
mature follicle involutes (collapses on itself). The rupture of this type of cyst can create sharp
severe pain on the side of the ovary on which the cyst appears. Usually, these cysts produce no
symptoms and disappear by themselves within a few months.
Corpus luteum cyst: This type of functional ovarian cyst occurs after an egg has been released
from a follicle. After this happens, the follicle becomes what is known as a corpus luteum
which may ll with uid or blood and persist on the ovary. Usually, this cyst is found on only
one side and produces no symptoms.
Hemorrhagic cyst: This type of functional cyst occurs when bleeding occurs within a cyst.
Symptoms such as abdominal pain on one side of the body may be present with this type of
cyst.
Dermoid cyst: This is a type of benign tumor sometimes referred to as mature cystic teratoma.
A dermoid cyst can contain other types of growths of body tissues such as fat and occasionally
bone, hair, and cartilage.
The ultrasound image of this cyst type can vary because of the spectrum of contents,
but a CT scan and magnetic resonance imaging (MRI) can show the presence of fat and
dense calcications.
These cysts can become inamed. They can also twist around (a condition known as
ovarian torsion), compromising their blood supply and causing severe abdominal pain.
The greatest definition for concentration I ever heard is, Wherever you are, be there!
21
Polycystic ovaries Chocolate coloured uid draining
Endometriomas or endometrioid cysts: Part of the condition known as endometriosis, this
type of cyst is formed when endometrial tissue (the lining tissue of the uterus) is present on
the ovaries. It afects women during the reproductive years and may cause chronic pelvic
pain associated with menstruation.
Endometriosis is the presence of endometrial glands and tissue outside the uterus.
Women with endometriosis may have problems with fertility.
Endometrioid cysts, often lled with dark, reddish-brown blood, may range in size
from 0.75-8 inches.
Dermoid cyst Dermoid cyst in endobag Morcellation of dermoid cyst inside endobag
Right ovarian endometriotic cyst Chocolate coloured uid draining Excision of cyst wall
Polycystic-appearing ovary: Polycystic-appearing ovary is diagnosed based on its enlarged
size - with small cysts present around the outside of the ovary. This condition can be found
in healthy women and in women with hormonal (endocrine) disorders. An ultrasound is
used to view the ovary in diagnosing this condition.
Polycystic ovarian syndrome involves metabolic and cardiovascular risks linked to
insulin resistance. These risks include increased glucose tolerance, type 2 diabetes,
and high blood pressure.
Polycystic ovarian syndrome is associated with infertility, abnormal bleeding,
increased incidences of miscarriage, and pregnancy-related complications.
Polycystic ovarian syndrome is extremely common and is thought to occur in 4%-7%
of women of reproductive age
21
You dont get paid for the hour. You get paid for the value you bring to an hour.
22
Excision of cyst wall
Opening the cyst wall Excision of cyst wall Final reconstructed ovary
Cystadenoma: A cystadenoma is a type of benign tumor
that develops from ovarian tissue. They may be lled
with a mucous-type uid material. Cystadenomas can
become very large and require surgical removal.
Ovarian Cysts Diagnosis
A health care practitioner may perform the following tests to determine if a woman has an
ovarian cyst or to help characterize the type of cyst that is present:
Clinical assesment by pervaginal examination and perabdominal examination are mandatory
for any pelvic pathology.
Transvaginal ultrasound: This type of imaging test is a special form of ultrasound
developed to examine the pelvic organs and is the best test for diagnosing an ovarian cyst.
A cyst can be diagnosed based on its appearance on the ultrasound.
Other imaging: CT scanning aids in assessing the extent of the condition. MRI scanning
may also be used to clarify results of an ultrasound.
Serum CA-125 assay: This blood test checks for a substance called CA-125, which is associ-
ated with ovarian cancer This test is used in the assessment of epithelial ovarian cancer
and may help determine if an ovarian mass is harmless or cancerous. However, sometimes
Ovarian Cysts Symptoms
Usually ovarian cysts do not produce symptoms and are found during a routine physical exam
or are seen by chance on an ultrasound performed for other reasons. However, the following
symptoms may be present:
Lower abdominal or pelvic pain,
Irregular menstrual periods
Feeling of lower abdominal or pelvic pressure or fullness
Long-term pelvic pain during menstrual period that may also be felt in the lower back
Pelvic pain after strenuous exercise or sexual intercourse
Nausea and vomiting
Vaginal pain or spotty bleeding from the vagina
Infertility
Learn to hide your need and show your skill.
23
benign conditions such as endometriosis or uterine broids may result in the elevated lev-
els of CA-125 in the blood, so the test does not positively establish the diagnosis of ovarian
cancer.
Hormone levels: A blood test to check LH, FSH, estradiol, and testosterone levels may
indicate potential problems concerning these hormone levels.
Ovarian Cysts Treatment
Functional ovarian cysts are the most common type of ovarian cyst. They usually disap-
pear by themselves and seldom require treatment. Growths that become abnormally large
or last longer than a few months should be removed or examined to determine if they are a
sign of a more serious condition.
Ovarian Cyst Medical management
Oral contraceptives: Birth control pills may be helpful to regulate the menstrual cycle, pre-
vent the formation of follicles that can turn into cysts, and possibly reduce the size of an
existing cyst.
Pain relievers: Anti-inammatory medication may help reduce pelvic pain.
Surgical management of ovarian cysts:
Laparoscopic surgery:
Polycystic ovaries not responding to medical management can be drilled
laparoscopically.
Endometriotic cysts require laparoscopic cyst excision or cyst wall ablation and
fulguration of endometriotic implants.
Cystadenomas require cyst excision or in suspicious cases of malignancy may require
removal of the ovary
Dermoid cyst require excision irrespective of the size. The dermoid cyst can be excised
and removed in an endobag to prevent spillage of the contents into the abdomen.
Laparotomy: This is a more invasive surgery in which an incision is made through the
abdominal wall in order to remove a cyst.
Surgery for ovarian torsion: An ovarian cyst may twist and cause severe abdominal pain as
well as nausea and vomiting. This is an emergency, surgery is necessary to correct it.
If you dont like where you are, change it! Youre not a tree.
2 42222222 4444444
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Dr. Meenakshi Sundaram
Consultant Endoscopic
Gynecological Surgeon
Beams hospital, Mumbai
Endometriosis
E
ndometriosis (from endo, inside, and
metra, womb) The uterine cavity
is lined by endometrial cells, which
are under the inuence of female
hormones. These endometrial-like cells
in areas outside the uterus are inuenced by hormonal
changes and respond in a way that is similar to the cells
found inside the uterus leading to a condition called
Endometriosis. Endometriosis is a common nding
in women with infertility. endometriosis occurs in
roughly 5-10% of women, more common in women with
infertility (2050%) and women with chronic pelvic pain
(about 80%).
Signs and symptoms
Pelvic pain
A major symptom of endometriosis is recurring pelvic pain. The 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. The amount of pain a woman feels correlates poorly with the extent or stage (1 through
4) of endometriosis.
dysmenorrhoea painful, sometimes disabling cramps during menses; pain may get worse
over time (progressive pain).
chronic pelvic pain typically accompanied by lower back pain or abdominal pain.
dyspareunia painful sex.
dysuria urinary urgency, frequency, and sometimes painful voiding.
Infertility
Endometriosis can lead to anatomical distortions and adhesions leading to infertility. It has been
suggested that endometriotic lesions release factors which are detrimental to gametes or embryos,
or, alternatively, endometriosis may more likely develop in women who fail to conceive for other
reasons and thus be a secondary phenomenon.
Other
Other symptoms may be present, including:
Constipation
Change takes a moment, it is thinking about changing that takes a long time!
25
chronic fatigue
heavy or long uncontrollable menstrual periods with small or large blood clots
gastrointestinal problems including diarrhoea, bloating and painful defaecation
premenstrual spotting
mild to severe fever
headaches
depression
hypoglycemia (low blood sugar)
anxiety
Patients who rupture an endometriotic cyst may present with an acute abdomen as a medical
emergency.
Figure 1: Two large chocolate cysts are seen
Occasionally pain may also occur in other regions. Cysts
can occur in the bladder (although rare) and cause pain
and even bleeding during urination. Endometriosis
can invade the intestine and cause painful bowel move-
ments or diarrhoea.
Cause
While the exact cause of endometriosis remains unknown, many theories have been presented
to better understand and explain its development.
Estrogens
Retrograde menstruation
Mllerianosis
Coelomic Metaplasia
Genetics
Transplantation
Immune system
Environment
Birth Defect
Pathophysiology
Early endometriosis typically occurs on the surfaces of organs in the pelvic and intra-abdomi-
nal areas. Larger lesions may be seen within the ovaries as endometriomas or chocolate cysts,
chocolate because they contain a thick brownish uid, mostly old blood.
Figure 2: Left chocolate cyst showing chocolate uid
being drained.
22222555555
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The root of all relationship issues is a part of us that we are yet to love and accept! pttttttttttttttttttttttt!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
26
Organs involved :
Ovaries (the most common site)
Fallopian tubes
The back of the uterus and the posterior cul-de-sac
The front of the uterus and the anterior cul-de-sac
Uterine ligaments such as the broad or round ligament of the uterus
Pelvic and back wall
Intestines, most commonly the rectosigmoid
Urinary bladder and ureters
Complications
Complications of endometriosis include:
Internal scarring
Adhesions
Pelvic cysts
Chocolate cyst of ovaries
Ruptured cyst
Blocked bowel/bowel obstruction
Figure 3 : Bowel adhesions to uterus as a result of
Endometriosis
Other complications of endometriosis include bow-
el and ureteral obstruction resulting from pelvic
adhesions. Also, peritonitis from bowel perforation
can occur.
Diagnosis
Surgery is the gold standard in diagnosis. Use of imaging tests may identify endometriotic
cysts or larger endometriotic areas. The two most common imaging tests are ultrasound
and magnetic resonance imaging (MRI). Normal results on these tests do not eliminate
the possibility of endometriosis. Areas of endometriosis are often too small to be seen by
these tests.
The only way to diagnose endometriosis is by laparoscopy or laparotomy with lesion
biopsy. The diagnosis is based on the characteristic appearance of the disease, and should
be corroborated by a biopsy. Surgery for diagnoses also allows for surgical treatment of
endometriosis at the same time.
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Those who are yet to love and accept themselves, can never truly give love to others!
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Staging
Stage I (Minimal)
Findings restricted to only supercial lesions and possibly
a few lmy adhesions
Stage II (Mild)
In addition, some deep lesions are present in the cul-de-sac
Stage III (Moderate)
As above, plus presence of endometriomas on the ovary
and more adhesions
Stage IV (Severe)
As above, plus large endometriomas, extensive adhesions.
Treatments
The goal is to provide pain relief, to restrict progression of the process, and to restore or preserve
fertility where needed.
Treatments for endometriosis in women who do not wish to become pregnant include:
Hormonal medication
Progesterone or Progestins
Hormone contraception therapy: Continuous hormonal contraception consists of the
use of combined oral contraceptive pills without the use of placebo pills. This eliminates
monthly bleeding episodes.
Danazol and gestrinone are suppressive steroids with some androgenic activity. Both agents
inhibit the growth of endometriosis but their use remains limited as they may cause hir-
sutism and voice changes.
Gonadotropin Releasing Hormone (GnRH) agonist: These agents work by increasing the
levels of GnRH. While efective in some patients, they induce unpleasant menopausal
symptoms, and over time may lead to osteoporosis. To counteract such side efects some
estrogen may have to be given (add-back therapy).
Aromatase inhibitors are medications that block the formation of estrogen and have be-
come of interest for researchers who are treating endometriosis.
Other medication
NSAIDs: Anti-inammatory.
Diclofenac in suppository or pill form.
Surgery
Conservative therapy consists of the excision of
endometrial implants, adhesions, resection of
endometriomas, and restoration of normal pelvic
anatomy as much as is possible. Laparoscopy, besides being
used for diagnosis, can also be an option for surgery
Figure 4: Two large chocolate cysts of both the ovaries
I can chose to be happy when I want to !
28
For patients with extreme pain, a presacral neurectomy may be indicated where the nerves to
the uterus are cut. After surgical treatment of deeply inltrating endometriosis with color-
ectal involvement, a review study estimated the overall endometriosis recurrence rate to be
approximately 10% (ranging between 525%).
Treatment of infertility
While roughly similar to medicinal interventions in treating pain, the ef cacy of surgery is
especially signicant in treating infertility. One study has shown that surgical treatment of
endometriosis approximately doubles the pregnancy rate. The use of medical suppression after
surgery for minimal/mild endometriosis has not shown benets for patients with infertility.
Use of fertility medication that stimulates ovulation (Clomiphene citrate, Gonadotropins)
combined with Intrauterine Insemination (IUI) enhances fertility in these patients.
The decision when to apply IVF in endometriosis-associated infertility takes into account the
age of the patient, the severity of the endometriosis, the presence of other infertility factors,
and the results and duration of past treatments.
Recurrence
The underlying process that causes endometriosis may not cease after surgical or medical
intervention. The most recent studies have shown that endometriosis recurs at a rate of 20 to
40 percent within ve years following conservative surgery, unless hysterectomy is performed
or menopause is reached. Monitoring of patients consists of periodic clinical examinations
and sonography.
Figure 5: Chocolate cyst
drained and cyst wall excised
for complete treatment of the
Endometriosis
Figure 6: Adhesiolysis of
Rectum and Ovaries done to
restore normal anatomy.
Figure 7: Adhesion barrier
placed to prevent reformation
of adhesions.
People dont care how much you know... until they knw how much you care!
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Dr. Mandakini Parihar, MD,
DGO, FICOG
Director , Mandakini IVF
Centre
1st Vice-President Elect,
FOGSI 2012
Past President , Navi Mumbai
Obs & Gyn Society
Consultant, BEAMS Hospital
and Fortis Hospital
Polycystic Ovarian Syndrome
Polycystic Ovarian Syndrome (PCOS) is a common and
heterogeneous disorder of women of reproductive age,
characterized by chronic anovulation and hyperandrogenism.
Features of PCOS may manifest at any age, ranging from
childhood (premature puberty), teenage years (hirsuitism,
menstrual abnormalities), early adulthood and middle life
(infertility, glucose intolerance) to later life (diabetes mellitus and
cardiovascular disease). Hyperinsulinaemia has proved to be a
key link in the enigmatic generation of the symptoms of PCOS.
Regression of these symptoms may be achieved by reducing the
hyperinsulinaemia. As obesity exaggerates the expression of the
symptoms, a low calorie diet and lifestyle change resulting in
loss of weight for obese women with PCOS is capable of reversing
these symptoms. PCOS is a multiorgan disorder and can give rise
to long-term potential health risks. Endometrial cancer remains
one of the more serious potential complications for women with
polycystic ovarian syndrome.
Lets Meet Ms. Polly Systic
An enigma wrapped in riddle
and surrounded by mystery
- Sir Winston Churchill
Incidence:
Polycystic ovary syndrome (PCOS) is the commonest cause of irregular menstrual cycles. It
is postulated to be about 20-30% in the general population. But, 40% of women with irregular
menses, 84% of women with hirsuitism(excessive hair growth) and 100% of women presenting
with severe acne, have PCOS as their etiology.
Rotterdam Consensus Meeting on PCOS now denes the syndrome of PCOS as presence of any
two of the following three criteria
Ultrasound appearance of Polycystic ovaries
Menstrual disturbances
Evidence of hyperandrogenism, acne, hirsuitism, etc, after other causes of hyperandrogenism
have been ruled out, especially congenital adrenal hyperplasia.
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Progress and Imporvements are made day to day, not year to year!
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Table 1: Pathophysiology
Genetic
Hyperinsulinaemia and insulin resistance
Abnormalities of both insulin secretion and intracellular insulin signaling have both
been proposed in women with PCOS
Hypersecretion of LH
Environmental and Life style problems
Table 2: Clinical Symptoms
anovulation
irregular menstrual cycles
amenorrhoea & oligomenorrhoea
infertility
hyperandrogenism
hirsuitism & acne
insulin resistance
obesity
Table 3: Clinical Case Presentations
First Stage of Presentation Adolescence or Teenage years
A young 16 year old girl presents with Irregular cycles, Obesity, Mild to Moderate Acne,
and Hirsuitism. She is a shy girl, with poor body image and Poor social skills or some-
times can be extremely Aggressive and Defensive.
Second stage of Presentation - After Marriage with infertility
A young married girl will present with history of dif culy in getting pregnant. She may
have put on weight after marriage resulting in obesity with irregular cycles, may also
have hirsuitism. She is married for the last 2-4 years and is wanting pregnancy and is
very worried as she has uncontrolled anovulation and now bleeds with withdrawal with
tablets only.
Third stage of PCOS
After undergoing treatment for infertility, she has been successfully treated and is now
pregnant. Be careful during her pregnancy as she can have PCOS related pregnancy
complications!!. There is an increased incidence of
Early pregnancy loss,
Gestational diabetes,
Pregnancy Induced Hypertension
Small for Gestation babies
Fourth Presentation in later years
She is now in 40+ in age. She has had 2 children. She has not been regular in maintain-
ing herself and her lifestyle changes. And now, she presents with menorrhagia and DUB.
Bleeding is excessive and unbearable. She also complains of Excessive Weight gain.
Always focus on accomplishments rather than on activities!
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Management
Diagnosis of PCOS is conrmed by clinical history, ultrasonography and blood hormonal
evaluations. The gold standard for all patients with Obese PCOS should be weight loss,
by diet and exercise. Obesity is associated with central fat accumulation and an increased
waist to hip ratio (WHR). Weight loss (of as little as 5%of the body weight) alone can improve
the fundamental aspects of the endocrine system of PCOS and result in low circulating
androgen levels and spontaneous resumption of menses.
Given a broad outline below are guidelines in management of PCOS in all the above
mentioned clinical presentations.
Adolescent PCOS
The aim should be that the young girl or woman should not be allowed to become hyper-
estrogenic for the fear of long term complications of Syndrome X. This is most important
as there is denitive association between PCOS and Endometrial Carcinoma in later
life. The main aim of treatment should be to ensure that all long term complications are
prevented. Hence, counseling and condence boosting, along with importance of diet and
life style changes must be stressed on. To prevent hyper-estrogenic state, it is necessary to
ensure that she must get atleast 6 menstrual cycles every year.
Table 4: Management of Adolescent PCOS
For Menstrual Irregularities
Oral Contraceptive Pill with Drosperinone or CPA
Progesterone therapy cyclically
For Acne Management
Patient education and basic skin care
Medications with Topical Therapies and Systemic Therapies using Oral antibiotics &
Isoretinoin
Hormonal therapy Oral Contraceptive Pill with Drosperinone or CPA
For hirsuitism
Local Cosmetic therapy
Hormonal therapy Oral Contraceptive Pill with Drosperinone or CPA
Infertile PCOS
Here our aim has to be to ensure that we can help her ovulate and hence achieve pregnancy
as early as possible. Complications of Ovarian hyperstimualtion should be avoided and
hence all treatment should be as low dose as is possible.
Table 5: Management Options for Infertile PCOS
Life Style Modications
Diet and Weight Loss
Medical Management
Clomiphene Citrate
Hot heads and cold hearts never solved anything!
32
Letrozole
Insulin sensitizers like Metformin
Gonadotrophin therapy
GnRH agonists/ antagonists along with gonadotropins
Surgical Management
Laparoscopic Ovarian Drilling
Assisted Reproduction
IVF and /or ICSI using low dose stimulation to avoid complications of multiple pregnancy
and Ovarain hyperstimulation Syndrome(OHSS)
Table 6: PCOS- Pregnancy Management
Adequate progesterone support to avoid miscarriages
If there is insulin resistance, then continue Metformin therapy during pregnancy
Avoid multiple pregnancies
Increased vigilance for gestational diabetes, PIH and PET all throughout pregnancy and if
need low dose aspirin
Late Mainsfestations Syndrome X
This is the most important time to ensure that she is adequately treated. Control of
dyslipidemias and impaired glucose tolerance will help in preventing cardiovascular
problems and Type II Diabetes. Control of menstrual problems is important to prevent
endometrial hyperplasia and carcinoma.
Table 7: Managing Bleeding in Later age PCOS
Life Style Changes and weight reduction
NSAIDs and Traneximic acid
Evaluate the endometrium by Hysterosocpy and HPE for hyperplasia and rule out
possibility of Endometrial Carcinoma
Once conrmed that there is no carcinoma, then ensure that bleeding is controlled by one
of the following methods:
Mirena
TCRE
Hysterectomy
Conclusions
The reduced rate of ovulation is directly associated with degree of hyperinsulinemia and
hence the initial focus in treatment should be on control of insulin secretion by diet and
exercise. A BMI of > 30 kg/cm2 is rarely associated with regular cycles. Today a holistica
approach with prevention should be the basis of managing PCOS. Weight loss and life style
changes are the mainstay of successful management. Dedicated PCOS clinic which ofers
all aspects of care for patients with PCSO, from adolescence till postmenopausal along with
Assisted Reproduction and preconception counseling and advice as to how to minimize
the metabolic sequel of PCOS may be the best place for treating PCOS.
Leadership is action not position!
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Dr Rakesh Sinha
M.D.
Chief Gynecological Endo-
scopic Surgeon
BEAMS Hospitals Pvt Ltd.
Uterine Fibroids
What are broids?
Uterine broids, also known as leiomyomas, are non-cancerous
tumors of the womb or uterus. These tumors start in the
myometrium(muscle) of the uterus. They occur in nearly half of
all women over the age of 30 and this too may be underestimated as
broids have been found in 77 per cent of uteri removed for reasons
other than broids.
What causes broids ?
Fibroids only occur after puberty and shrink after menopause. The female sex hormones such as
oestrogen and progesterone are most likely involved in tumour growth. However, other growth
factors as well as some genetic factors may also be involved.
Though the causes are not known , women who have never had children, or are obese are
particularly at risk.
It is dif cult to know if broids run in families as they are so common. Women who have used the
combined oral contraceptive pill or the drug Depo-Provera as contraceptive agents are protected
against developing broids.
Are broids cancerous?
Fibroids are non cancerous. Cancer of broids (leiomyosarcoma) is very rare and begin as cancers
.Benign tumours do not transform to malignant ones.
Key Points:
Fibroids occur in more than 25% of women over 30 years of age.
Commonest cause for hysterectomy in women under 50 years.
Growth of broids depends on oestrogen and progesterone.
Benign broids do not become cancerous.
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The only sure thing is that in business there are no sure things!
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Symptoms of Fibroids
Heavy Periods (Menorrhagia)
Heavy periods occur in 30 per cent of women having broids .Tiredness, weakness and emotional
changes may occur secondary to the anaemia which results from the excessive blood loss.
Bowel and Bladder Symptoms
Pressure caused by the broids may result in bowel and bladder symptoms Rarely complete
blockage of urine may occur requiring a catheter to be passed.
Lump or Bloating
Discovery of a lump in the abdomen and / or distension of the abdomen may be the rst change
noticed. The distention may be partly due to the broid, which is rm to feel, or bowel that is
pushed and distended, which feels soft.
Sexual Discomfort or Dif culty
If the broid (s) expand the uterus and take up considerable space within the pelvis full vaginal
penetration may be prevented. This may reduce enjoyment for the female and male.
Pain
Menstrual. Period pain(dysmenorrhoea) may be due to stretching of the uterus, or the
response of trying to expel the broid , creating labour like pains.
Pressure on neighbouring organs. Back pain, or pain in the lower abdomen, may result from
pressure on the spine, pelvic bones, nerves or tissue , bowel and bladder.
Complications of Fibroids
Degeneration : Occasionally the blood supply to the broid is blocked and it undergoes
degeneration resulting in swelling and release of chemicals which can cause severe pain.
Twisting : The broid may grow outside the uterus and is connected to the uterus by a
narrow stalk, may twist on itself and cause severe pain and tenderness.
Infection: Rarely broids become infected,
which usually occurs when they are protruding
in the vagina or after childbirth.
Cancer: They are very rare ,a cancerous broid
is called sarcoma.. There may be no symptoms
to distinguish a sarcoma from a simple broid.
Sometimes a rapid increase in size may raise the
suspicion of the presence of a sarcoma.
Types of Fibroids, Symptoms and Progression
Even though 25 per cent of women above the age of 30 years have broids, only about half
experience symptoms. Fibroids may be either single or multiple and may vary from being as
small as a pea to as large as a football. Their site in the womb may also vary. They may be present
within the cavity of the uterus (submucosal), within the muscle of the uterus (intramural), or in
the outer layer and protrude from the uterus (subserosal).
Satisfying the patient is a race without finish!
37
Submucosal broids protrude inwards into the cavity of the uterus and are commonly associated
with heavy bleeding and may cause infertility.
Types of Fibroids, Symptoms and Progression
Even though 25 per cent of women above the age of 30 years have broids, only about half
experience symptoms. Fibroids may be either single or multiple and may vary from being as
small as a pea to as large as a football. Their site in the womb may also vary. They may be present
within the cavity of the uterus (submucosal), within the muscle of the uterus (intramural), or in
the outer layer and protrude from the uterus (subserosal).
Submucosal broids protrude inwards into the cavity of the uterus and are commonly associated
with heavy bleeding and may cause infertility.
Intramural broids begin as little lumps in the muscle of the uterus that grow, making the
uterus larger and distort its shape. This type of broid may play a role in heavy periods and
pressure symptoms.
Subserosal broids grow and protrude from the outer surface of the uterus, vary greatly in size,
and may be multiple.
Fibroids and Menopause The growth of broids occurs during a womans reproductive years.
After the menopause, when oestrogen production declines, broids stop growing and usually
shrink. Symptoms tend to disappear. Hormone replacement therapy may stop broids from
shrinking, and in some cases may be responsible for their continued growth and persistence of
symptoms.
An entrepreneur is one who has a sense of urgency even when there is no emergency!
38
Fibroids and Infertility
Fibroids may reduce the chances of becoming pregnant in a variety of ways:
Key Points
By causing heavy periods and subsequent anaemia resulting in ill health and tiredness.
Very large broids may bulge into the vagina and cause pain or discomfort during
intercourse.
Fibroids in the fundus of the uterus occasionally block the tubes preventing formation of
embryos
Fibroids inside the cavity of the uterus may prevent implantation of the embryo .
Multiple broids in the wall of the uterus reduce IVF success rates, perhaps by afecting the
lining of the uterus andthe implantation of the embryo..
Most broids do not need to be removed before attempting to become pregnant unless the
broid is causing infertility.
Fibroids in Pregnancy
Fibroids may not only make it dif cult to get pregnant, but they may cause miscarriage, mal-
nutrition of the foetus, abnormal position of the baby in the uterus, obstruction during labour
requiring caesarean section, and bleeding after delivery of the baby.
Key Points
Most broids do not need to be removed before attempting pregnancy.
Removal of broids before pregnancy may be required if they are large ,cause severe
bleeding, grow rapidly, or protrude into the uterine cavity.
Diagnosis
Detection and Diagnosis
Clinical Examination: Fibroids are often diagnosed during vaginal examination by the
gynaecologist at the time of a routine Pap smear/ general health checkup .
Ultrasound: The best and least expensive test to diagnose the presence of broids .The addition
of Color Doppler measures the blood ow and helps to determine the diference between
broids, adenomyosis (endometriosis inside the uterus) and some cancers.
Computerised tomography
CT is another method of assessing lumps and masses in the pelvis but is not as specic as
ultrasound and is inferior in its ability to diferentiate between the uterus and ovaries.
Magnetic Resonance Imaging (MRI)
This sophisticated X ray is most the specic imaging for the female pelvis with precision,
denition and accuracy . It may be helpful in distinguishing between broids and adenomyosis.
Management Strategy
Management depends upon size of the broid, the position of the broid in the uterus, the age of
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The heart of time management is management of self!
39
the women, the desire to conceive, and the attitude to surgery.
Symptoms of heavy bleeding, pain during periods, or pressure on the bladder, bowel and spine
usually require treatment. The anemia due to the excessive bleeding can be managed by oral
iron or intravenous iron sucrose therapy if oral iron not tolerated .
Fibroids which are growing in size may need treatment, as delay may increase the dif culty of
surgery and lead to more extensive surgery. Most often broids up to 3 cm need not be treated
unless they are in the cavity of the uterus.
In some circumstances it may be considered prudent to remove a broid even if it is not causing
any symptoms, e.g. a symptom-free 7cm broid may be dealt with laparoscopically easily, whilst
in a few years time if it doubles in size and causes symptoms the surgery is likely to be more
complex.
Prevention of Fibroids
Weight control reduction of obesity
Early child-bearing
Lactation
Oral Contraceptive Pills
No Treatment may be required
No symptoms
Small broids
After menopause
If no treatment is given regular ultrasonography should be done to monitor the growth of
broids.
Treatment may be required
Symptoms heavy bleeding, pain
Large broid in young women
Rapid growth in broid
Infertility related to broid
Suspicion of cancerous broid (sarcoma)
Drug Treatment
Gonadotrophin hormone-releasing hormone analogues (GnRHa) are the most commonly used
medical treatment for shrinkage of broids, eg :Zoladex. .They have two major disadvantages:
expense and undesirable side efects .GnRha work by decreasing the level of oestrogen,
efectively causing a menopausal state and thus hot ushes, vaginal dryness and mood swings
They should not be continued for longer than 6 months as constant low oestrogen levels can
increase the risk of oesteoporosis and fractures.
Embolization of Fibroids
Embolization is a technique used by interventional radiologists, performed under local
Dont defend the past, attack the future!
40
anaesthesia through a tiny puncture in the groin and branches of the uterine artery are
blocked.
The broid shrinks because it is starved of blood. This may prevent it from producing growth
factors which may disturb the mentstrual cycle. The shrinkage of the broid is slow and may
take up to 3 months.
Shrinkage of broids before surgery
The shrinkage efect of GnRH analogues (e.g. Zoladex) drugs is
sometimes quite dramatic but is only temporary and may not
be suf cient to overcome the ill efects the broid on fertility.
They can regrow in 3 to 6 months so the drug therapy maybe
useful for postponement of surgical removal.

Removal of Fibroids (Myomectomy)
Myomectomy, the surgical removal of broids while preserving the uterus and its child bearing
function is the denitive treatment .
Techniques of removal
1 Hysteroscopic Telescope via birth passage
2 Laparoscopic By small incisions in the abdomen
3 Laparo-hysteroscopic By a combination of 1 & 2
4 Laparotomy By an incision in the abdomen
Hysteroscopic Myomectomy
The broids protruding into the cavity are easily
detected by hysteroscopy and removed with the
help of a resectoscope .This surgery requires high
technical skill and knowledge of electrosurgery
and uid management.
Electrosurgical resection usually takes only10-30
minutes and the patient is can be discharged from
the hospital 4 6 hours after the procedure.
Laparoscopic Myomectomy
Laparoscopy or visualization of the inside of the abdominal cavity is a popular procedure used
to help in the diagnosis of many gynaecological disorders. Performed under general anaesthesia
this is the preferred method of removal of broids of 5-10 cm.
The availability of high denition cameras, xenon cold light source and high resolution medical
monitors allows magnication of the abdominal cavity in detail and precision.The harmonic
ultracision for capsule insicion and the suturing skills of the surgeon make the laparoscopic
removal of broids the desired mode of management whereby blood loss can be decreased and
Many problems cannot be solved they have to be survived!
41
the myoma bed and capsule sutured to obtain perfect haemostasis and approximation .
The use of Morcellators : an instrument which can retrieve the broid once it is separated has
revolutionized the laparoscopic management of broids .
Depending on the size and number of broids either multiport laparoscopy can be used or single
port laparoscopic surgery can be done
Key Points
3 or 4 small incisions in the abdomen
Or single incision near the umbilicus
One day stay in hospital
Return to normal activities in 3-4 days
Lesser adhesions than (laparotomy)
Similar or better results than laparotomy
It is most suitable for removal of all kinds of broids >5 cm
Larger broids can also be removed in expert surgeons hands.
Laparo-Hysteroscopic Myomectomy
When the broids are both inside the cavityand in the muscle of the uterus.
Conventional Laparotomy
An open surgery may be required for large broids when the surgeon is inexperienced with
laparoscopy .
The techniques is same as for minilaparotomy, as are the complication and results.
Blood transfusions are more likely.
The stay in hospital is for more than 3 days
Recovery takes longer.
Removal of Uterus (Hysterectomy)
There is general agreement that the only absolute indications for hysterectomy are cancer or
other life-threatening bleeding. Most other indications are relative, as they are about quality of
life issues rather than life-threatening conditions. Hysterectomy in the management of uterine
broids is only one of several choices. Sometimes it is not the best treatment option in a particular
case, other times it is.
41
If your only opportunity is to be equal then its not opportunity!
42
Key Points
Hysterectomy is not the only treatment option for broids, but in some cases it is the best
option, if:
Uterus is very large
Risk of uterine cancer is increased, e.g. in women with diabetes, obesity and high blood
pressure.
If broid is cancerous ((rare ) abdominal hysterectomy is recommended .
If denite cure is necessary and fertility is no longer required.
Laparoscopic hysterectomy results in quicker recovery & shorter hospitalization.
Price is what you pay, Value is what you get!
A UNIQUE ACHIEVMENT
Dr. Rakesh Sinha, Dr. Mrs. Manju Sinha And Dr. Chaitali Mahajan Holding
the Guinness World Record Certicate For Removing the Largest Uterus
Laparoscopically.
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Dr Rakesh Sinha
M.D.
Chief Gynecological Endo-
scopic Surgeon
BEAMS Hospitals Pvt Ltd.
Total Laparoscopic
Hysterectomy
H
ysterectomy (removal of the uterus)
is the second most frequent major
operation performed on women
next only to caesarean section.It is
considered as the last option for benign
conditions being ofered only to women above the age
of 45 years and who have completed their child bearing
.Over the past several decades new developments have
been made in the surgical approaches to hysterectomy
.The term laparoscopic hysterectomy is used to dene
various types of hysterectomy with a laparoscopic access
to the abdominal cavity.
Indications
Benign Disease
Leiomyomas: For symptomatic broids, hysterectomy provides a permanent solution to
menorrhagia and the pressure symptoms related to an enlarged uterus.
Abnormal uterine bleeding not responding to medical management. Endometrial lesions
must be excluded preoperatively or by frozen section intraoperatively if indicated.
Endometriosis: in the presence of severe symptoms with failure of other treatments and when
fertility is no longer desired.
Pelvic organ prolapse: in these cases , hysterectomy should include associated pelvic organ
supporting procedures.
Pelvic pain: A multidisciplinary approach is recommended. When the pain is conned to
dysmenorrhea or associated with signicant pelvic disease, hysterectomy may ofer relief.
Pre-invasive Disease
Hysterectomy is usually indicated for endometrial hyperplasia with atypia.
Cervical intraepithelial neoplasia in itself is not an indication for hysterectomy.
Simple hysterectomy is an option for treatment of adenocarcinoma in situ of the cervix when
invasive disease has been excluded.
Invasive Disease
Hysterectomy is an accepted treatment or staging procedure for endometrial carcinoma. It
may play a role in the staging or treatment of cervical, epithelial ovarian, and fallopian tube
carcinoma
Eagles dont flock you have to find them one at a time!
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Types of Hysterectomy
Total hysterectomy which involves the removal of the uterus and cervix only; the ovaries
and tubes are retained .
Subtotal hysterectomy where the body of the uterus is removed, but the cervix, ovaries and
tubes remain.
Total hysterectomy and bilateral salpingo-oophorectomy in which the uterus, cervix ovaries
and tubes are all removed.
Modes of Hysterectomy
Abdominal hysterectomy is performed through a long abdominal cut which may be either
horizontal incision just above the symphisispubis likefor a Caesarean section, or vertical in
the midline below the umbilicus (naval).
Vaginal hysterectomy is performed through the vagina and there are no cuts in the
abdomen..
Laparoscopically assisted vaginal hysterectomy The tubes and ovaries are separated
laparoscopically, the vault is sutured vaginally and uterus removed through the vagina
(like a vaginal hysterectomy).
Total Laparoscopic hysterectomy which can be done by multiport or single port depending
on the size of the uterus, this involves complete separation of the uterus pedicles
laparoscopically.
It is the most advanced and least traumatic mode but requires precise surgical skills,
sophisticated endoscopy equipment and for advanced anaesthesia monitoring and
management good patient outcome.
Total laparoscopic hysterectomy (TLH) is currently accepted as a safe, ef cient and
acceptable alternative to standard abdominal hysterectomy . It ofers a superior view of the
anatomy, facilitates meticulous hemostasis, enables the surgeon to perform adhesiolysis
efectively, and reduces morbidity associated with large abdominal incisions.
Instrumentation for Laparoscopic Hysterectomy
Optics:Telescope,Camera, Light source
Telescopes: telescopes have prisms which are placed in a cylindrical fashion joined by cementing
material which in combination gives a sharp magnied view
In US a Customer is king and in Japan Customer is God!
45
HDCamera : A high denition camera captures videos and converts them into digital format ,
producing a better screen resolution with good reproducible capacity.
Monitor : A high denition monitor with a wide screen angle ( 16:9) having a resolution of
1920x1200 (WUXGA).
Lightsource: Xenon light source : 350 watts which is high intensity white light contributing to
a good view during surgery
Diathermy machine with vessel sealing system
There are several options available to the laparoscopic surgeon
for securing the pedicles including bipolar diathermy, harmonic
ultracision, vessel-sealing device, endoscopic suturing
techniques, or staples.Complications such as hemorrhage,
bladder injuries, and ureteric injuries are directly or indirectly
related to the method of securing the vascular pedicles.
A good machine gives monopolar and bipolar underwater
current at low voltage and high amperage. It has vessel sealing
facility with patented temperature controlled energy delivery
system contributing to good sealing of tissue pedicles and vascular bundles with minimal
thermal damage.
Harmonic scalpel unit
This dedicated vessel sealing unit which converts kinetic energy
into thermal energy at the tissue level causing desiccation and
cutting of the tissue at the same time with minimal lateral
current spread.
Live Life before Life leaves you.
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Insuf ator (thermal)
The thermal insuf ators expels CO2 gas at body
temperature (37C) at a high ow rate which helps
in maintainance of pneumoperitonium and patient
temperature during surgery without fogging of the
telescopic lens.
Morcellator unit
This generator rotates the cutting blade at a speed of 5000
rpm and is used for tissue retrieval from the abdomen
through 12 15 mm opening.
Pre operative Preparation
All patients need basic preoperative evaluation ,investigations and preparation.Admission
is usually on the day of surgery Antibiotic prophylaxis and prophylaxis against possible
thromboembolic episodes is used appropriately.
Operative Procedure
TLH is performed under general anesthesia with advanced monitoring including spirometry
, entropy ( depth of anaesthesia ) ,capnography,gas analysis, st analysis , in addition to routine
pulse oxymetry and non invasive blood pressure monitoring .
Surgical steps
The 10-mm port is inserted under vision avoiding damage to major vessels and viscera. The
pelvis and the abdomen are inspected and any other pathology (endometriotic lesions, adhesions,
ovarian pathology etc), if present, is tackled rst. The course of the ureters is traced out at the
start of the procedure. The size, site and the number of myomas if present are assessed. The
surgery is performed through three ve mm accessory ports.
Life starts with Intense, but ends in silence,
47
The uterovesical fold of peritoneum is identied and opened from the round ligaments on
either side. The bladder is dissected down completely so that the uterine vessels on either side
can be clearly seen.
A window is created in the broad ligament close to the uterine vessels,the ascending branch
of the uterine artery identied near the isthmus and ligated at this level close to the uterus,
by transxation using 1-0 delayed absorbable suture material. The vasculature of the uterus is
thus secured and this is evidenced by the color change in the fundus, which becomes pale.
Bilateral cornual pedicles are then dessicated and cut either using bipolar diathermy or the
harmonic ultracision. The ligated uterine pedicles are cut. The uterosacrals and cardinal
ligaments are dessicated and cut.
The vaginal vault is opened & the specimen is detached completely. If ovaries need to be
removed, the infundibulopelvic ligaments are also desiccated and cut . The vaginal vault is then
sutured with No. 1 delayed absorbable interrupted gure-of-eight sutures.
The specimen is either delivered vaginally or retrieved by Morcellation .
Peritoneal lavage is given with normal saline solution..Skin is sutured with absorbable
subcuticular sutures .
Recovery Perioperative pain is managed judiciously so as to keep the patient pain free and
comfortable. The urinary catheter is removed as early as possible and oral liquids started after
peristalsis is established ,usually within six hours . The patient is discharged the following day
and called for follow-up after seven days.
Love starts with Fear and ends in tears
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Discussion
Given adequate training in laparoscopic surgery and with proper technique, TLH can be
performed successfully in most women.
Eventhough laparoscopic hysterectomy has been the subject of many controversial comments
especially when it comes to large uterus and previous cesarean sections . In skilled hands,
these patients could benet from the advantages related to minimally invasive approach such
as minimal blood loss, short hospital stay, prompt recovery, obtaining a satisfactory result.
Compared with abdominal hysterectomy there is compelling evidence indicating that denitely
provides specic benets.
Total Laparoscopic Hysterectomy should be considered instead of laparotomy in all patients
needing hysterectomy ofers minimal postoperative discomfort, shorter hospital stay, rapid
convalescence, and early return to normal activity
Myths about hysterectomy?
Hysterectomy and menopause : If the ovaries are not removed, they continue to function
and provide the oestrogen that skin, hair, bones, breasts and blood vessels need. If the ovaries
are removed, hormone replacement therapy (HRT) can provide the necessary oestrogen. It
should however be mentioned that hysterectomy may be responsible in some women for an
earlier decline in ovarian function with the development of menopausal symptoms, such as
hot ushes and night sweat, up to 2 years earlier than the average age of menopause.
Sex life deteriorates after hysterectomy : Ninety per cent of women who have a hysterectomy
nd that sex is as good, if not better, than before the operation.
Hysterectomy causes weight gain : If there is a tendency to gain weight before hysterectomy,
that tendency will persist after surgery. It is important to remember that activity level and
energy requirements will be reduced during recovery after surgery, and diet should be
adjusted accordingly until normal activity is resumed .
Pap smears need to be performed after hysterectomy : Unless the cervix has been retained,
or there was an abnormal cervical smear test in the past, there is no need to continue Pap
smears.
Friendship starts however, will remain for ever.
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Dr Gayatri Rao
D.G.O., D.N.B.
Consultant Gynaecological
Endoscopic Surgeon
Beams Hospital, Khar, Mumbai
URINARY TRACT
INFECTION IN WOMEN
U
rinary tract infections (UTIs) are the
most common bacterial infection
afecting women throughout their
lifespan. More than 50% of women will
have at least one UTI during their
lifetime; for most of these infections, patients need to
see a doctor and be treated with antibiotics.
TYPES OF UTI
Lower UTI is an infection of the lower part of the urinary tract,
which includes the bladder and the urethra. An infection of
the bladder is called cystitis, and an infection of the urethra is
known as urethritis.
Upper UTI is an infection of the upper part of the urinary tract,
which includes the kidneys (pyelonephritis) and the ureters. Up-
per UTIs are potentially more serious than lower UTIs because
there is a risk of kidney damage.
FACTORS THAT INCREASE THE RISK OF UTIs
Sexual activity often increases the risk of cystitis. About 80% of cases occur within 24 hours
following coitus.
Spermicide use, independent of sexual frequency, increases the risk of UTIs.
Menopause- lack of estrogen causes changes in the urinary tract that make it more vulnerable
to infection.
Obstructive or structural abnormalities of the urinary tract such as stulas, cystocele,
urethral diverticulum, tumors, strictures, renal stones.
Certain antibiotics that temporarily destroy the protective bacterial ora, which competes
with Escherichia coli and other microorganisms implicated in cystitis
Use of urethral instrumentation
Suppressed immune system as in Diabetes and HIV
Allergy components used in hygiene products such as soaps, creams, lotions, oils, bath salts.
Pregnancy, where the risk for developing cystitis is doubled. Physiologic bladder changes,
including decreased smooth muscle tone, increased capacity, and incomplete emptying, pre-
dispose pregnant women to vesicoureteral reux and ascending pyelonephritis. Mechanical
obstruction from the enlarging uterus also delays ureteral emptying function.
Sea is common for all, some take pearls, some take fishes and some just comeout with wet legs.
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ETIOLOGY
70-95% of both upper and lower UTIs are caused by E coli. The remainder of infections
are composed of various organisms, including S saprophyticus, Proteus species,
Klebsiellaspecies, Enterococcus faecalis, other Enterobacteriaceae, and yeast. Some species
are more common in certain subgroups, such as S saprophyticus in young women.
TYPES OF URINARY TRACT INFECTION AND THEIR SYMPTOMS-
Part of urinary tract afected Signs and symptoms
Kidneys (acute pyelonephritis) High temperature (fever) of 38C (100.4F) or above
Uncontrollable shivering
Nausea or vomiting
Pain in the back or side (ank)
fatigue
Bladder (cystitis) Cloudy urine
Need to urinate more frequently, either during the
day, or night, or both
Urinating small amounts
Pain,burning or discomfort when passing urine
An urgent need to urinate (holding urine becomes
more dif cult)
Unusually unpleasant smelling urine
Occasional blood in urine (haematuria)
Pressure or cramps in the middle of the lower abdo-
men
Abdominal pain
A feeling of tenderness around the pelvis
Back pain
Urethra (urethritis) Burning with urination
DIAGNOSIS
UTI symptoms alone (dysuria, frequency, lower abdominal tenderness or urgency) are
suf ciently reliable to conrm the diagnosis of UTI over 90% of the time.
Various tests which are to be done to conrm the diagnosis -
Microscopic urinalysis:
Elements consistent with UTI include
pyuria >10 WBCs per high power microscopic eld
erythrocytes
bacteria
Gram-stained urine is specic for UTI caused by high (105cfu/mL) bacterial counts but
lacks sensitivity for infection with lower (102104cfu/mL) colony counts.
White blood cell casts are diagnostic of upper urinary tract infection.
World is common for all but we get what we try for.
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Midstream urine culture
This remains the standard diagnostic tool. Cultures that recover more than 105 bacteria per mL
of voided urine have been considered evidence of UTI. Approximately one-fourth of women
presenting with symptoms suggestive of acute uncomplicated UTI show no bacterial growth
on urine culture.
Radiologic evaluation
Radiologic evaluation with intravenous pyelography (IVP) and cystoscopy are not required in
most women with a UTI. These tests should be reserved for women with a history of childhood
UTIs, relapsing UTIs, history suggestive of calculi or obstruction, or infection with painless
hematuria.
RED FLAGS
Gross hematuria or persistent microscopic hematuria between documented infections
should heighten the index of suspicion for underlying malignancy. Formal urologic
evaluation should be pursued.
Recurrent symptoms of cystitis in the setting of negative urine culture may suggest
mycobacterial infection, interstitial cystitis, or underlying malignancy. Pathogen isolation
with mycobacterial culture should be undertaken if there is suf cient clinical suspicion.
Pyuria in the absence of bacteriuria is suggestive of mycobacterial infection , antibiotic
Use or malignancy.
TREATMENT
Although antibiotics are the rst treatment choice for urinary tract infections, antibiotic-
resistant strains of E. coli, the most common cause of UTIs, are increasing worldwide.
Nitrofurantoin
With the incidence of uropathogen resistance rapidly exceeding for trimethoprim-
sulfamethoxazole (TMP-SMX, Bactrim, Septran) nitrofurantoin has re-emerged on the
clinical radar as viable rst-line therapy for uncomplicated cystitis. A regimen of oral
nitrofurantoinmonohydrate 100 mg , twice daily for 7 days is excellent rst-line empirictherapy
of uncomplicated cystitis.
TMP-SMX(Septran)
TMP-SMX has been a rst-line therapy for UTI since the early 1990s, when the usefulness of
beta-lactams like amoxicillin for empiric therapy was severely limited by widespread resistance.
A regimen of TMP-SMX 160/800 mg twice daily for 14 days can be used for outpatient therapy
of acute pyelonephritis in the setting of urine culture-proven susceptibility.
Beta-Lactams
The beta-lactam antibiotics share common chemical features and include penicillins,
cephalosporins, and some newer similar drugs.
Penicillins (Amoxicillin) A combination of amoxicillin-clavulanate (Augmentin) is given for
drug-resistant infections. Amoxicillin or Augmentin may be useful for UTIs caused by
See a Mistake just as a mistake, not my or His mistake
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Gram-positive organisms, including Enterococcus species and S. saprophyticus.
Cephalosporins : are also alternatives for infections that do not respond to standard treatments
or for special populations. They are often classed as rst, second, or third generation.
Cephalosporins used for treatment of UTIs include cephalexin (Phexin), cefadroxil (Odoxil),
cefuroxime (Ceftum) and cexime (Zi), among others.
Fluoroquinolones
Over the past decade uoroquinolones (ciprooxacin, levooxacin) have gone from being
reserved for multidrug-resistant or otherwise complicated UTI, to one of the most commonly
prescribed agents for empiric outpatient therapy of UTI. Ciprooxacin 500 mg twice daily for
7 days with or without an initial 400 mg intravenous dose may be used. . Other regimens used
are Noroxacin 400 mg twice a day for 5 days and Ooxacin 200 mg twice a day for 5 days.
Medications for Treating Symptoms
Phenazopyridine Phenazopyridine (such as Pyridium)
relieves pain and burning caused by the infection. The drug turns urine red or orange color,
which can stain fabric and be dif cult to remove.
Antispasm Drugs Methenamine or avoxate (Urispas) reduce bladder spasms, which may occur
with some UTIs.
LOW-DOSE CONTINUOUS ANTIMICROBIAL PROPHYLAXIS
Low-dose continuous antimicrobial prophylaxis is appropriate for women with frequently
symptomatic reinfections. It should be initiated in the setting of negativeurine culture, and
it consists of either a single daily or every other day dose of nitrofurantoin, TMP-SMX, or
cephalexin.Prophylaxis is usually discontinued after 6 months duration and only restarted if
reinfection occurs.
PRINCIPLES OF TREATMENT
Urinalysis and midstream urine culture and sensitivity should be performed with the rst
presentation of symptoms in order to establish a correct diagnosis of recurrent uti
Patients with persistent blood in urine or persistent growth of bacteria should undergo
cystoscopy and imaging of the upper urinary tract.
Sexually active women sufering from recurrent urinary tract infections and using
spermicide should be encouraged to consider an alternative form of contraception.
Prophylaxis for recurrent urinary tract infection should be undertaken only after a
negative culture 1 to 2 weeks after treatment has conrmed eradication of the urinary tract
infection.
Continuous daily antibiotic prophylaxis during a 6- to 12-month period should be ofered to
women with >2 urinary tract infections in 6 months or >3 urinary tract infections in 1 year .
Women with recurrent urinary tract infection associated with sexual intercourse should be
ofered post-coital prophylaxis as an alternative to continuous therapy in order to minimize
cost and side efects.
Vaginal estrogen should be ofered to postmenopausal women who experience recurrent
urinary tract infections.
My brings guilt, His brings Anger and Only mistake brings realization.
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Dr Shweta Raje
M.D., D.N.B.
Consultant Gynaecological
Endoscopic Surgeon
Beams Hospital, Khar, Mumbai
CHRONIC PELVIC PAIN
Understanding Chronic Pelvic Pain Syndrome
Chronic pelvic pain can be dened as intermittent or constant pain
in the lower abdomen or pelvis of at least
6 months duration, not occurring exclusively with menstruation or
intercourse and not associated with
pregnancy. It is a symptom, not a diagnosis.
Chronic pelvic pain (CPP) accounts for 10% of all visits to gynecologists.
In addition, CPP is the reason for
20 - 30% of all laparoscopies in adults.
Etiological factors in chronic pelvic pain
There is frequently more than one component to chronic pelvic pain. Assessment should aim to
identify contributory factors rather than assign causality to a single pathology.
Table 1: Etiology
Endometriosis (a condition where cells of the lining of the uterus (the endometrium) are
found elsewhere in the body, usually in the pelvis.
Adenomyosis (a condition where the endometrium is in pockets within the muscle wall of the
uterus)
Pelvic inammatory disease (PID) (an infection of the uterus, fallopian tubes and/or pelvis)
Interstitial cystitis (bladder inammation)
Musculoskeletal pain (pain in the joints, muscles, ligaments and bones)
Irritable bowel syndrome (IBS)
Depression, including postnatal depression
Previous or ongoing traumatic experiences such as sexual abuse in some women
Adhesions (areas of scarred tissue that may be a result of a previous infection, endometriosis
or surgery) Although these are common, they do not always cause pain
Trapped or damaged nerves in the pelvic area.
For some women with long-term pelvic pain none of these factors may be found
Figure 1 bowel adhesions to uterus Figure 2 Pelvic adhesions
If your only opportunity is to be equal then its not opportunity!
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Figure 3 Residual ovary after hysterectomy Figure 4 Endometriosis
Pathophysiology:
Acute pain reects fresh tissue damage and resolves as the tissues heals. In chronic pain,
additional factors come into play and pain may persist long after the original tissue injury or may
exist in the absence of any such injury. Nerve damage following surgery, trauma, inammation
or infection may play a part in this process.
Pelvic pain which is cyclical is usually gynaecological in nature
Symptoms suggestive of irritable bowel syndrome or interstitial cystitis are often present in
women with chronic pelvic pain. These conditions may be a primary cause or a component
of chronic pelvic pain.
Musculoskeletal pain may be a primary source of pelvic pain or an additional component
resulting from postural changes.
Nerve entrapment in scar tissue, fascia or a narrow foramen may result in pain and
dysfunction in the distribution of that nerve.
Addressing psychological and social issues which commonly occur in association with
chronic pelvic pain may be important in resolving symptoms.
The cardinal symptoms of dysmenorrhoea, dyspareunia and chronic pelvic pain are said to be
characteristic of endometriosis. Pelvic venous congestion has also been proposed
as a cause of pelvic pain with menstrual exacerbation. Adhesions may be caused by endometriosis,
previous surgery or previous infection.
Depression and sleep disorders are common in women with chronic pain. This may be a
consequence rather than a cause of their pain but specic treatment may improve the womans
ability to function.
Assessment
Many women present because they want an explanation for their pain. Often, they already have
a theory or a concern about the origin of the pain. These ideas should ideally be discussed in the
initial consultation.
Table 2: History
The type of the pain
Cyclical / non cyclical
What makes the pain better or worse (certain sorts of movement, for example)
Change is the nature of life, Challenge is the aim of life.
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Any associated problems that might be linked to the pain (intercourse, bladder, bowel or
psychological symptoms, for instance).
Workup
The patient is asked to keep a pain diary. This involves noting down when the pain occurs, how
severe it is, how long it lasts and the things that seem to afect it.
Table 3: Types of tests:
Pregnancy test
Pelvic Examination
Transvaginal scanning is an appropriate investigation to screen for pelvic pain
Blood investigations
Tests for sexually transmitted infections.
Transvaginal scanning and magnetic resonance imaging (MRI) are useful tests to diagnose
adenomyosis. The role of MRI in diagnosing small deposits of endometriosis is uncertain.
Diagnostic laparoscopy has been regarded in the past as the gold standard in the diagnosis
of Chronic pelvic pain. It may be better seen as a second line of investigation if other
therapeutic interventions fail. Diagnostic laparoscopy is the only test capable of diagnosing
peritoneal endometriosis and adhesions.
If the pain is related to psychological, bladder or bowel symptoms, referral to a specialist for
example, referral to a gastroenterologist for irritable bowel syndrome (IBS).
Management
Treatment for chronic pelvic pain depends on the underlying cause.
Treatment strategies for endometriosis
Treatment for endometriosis depends on several factors including the patients age, symptoms,
whether the patient wants to have children and whether there is associated subfertility. Hormonal
treatments aim to stop ovulation, allowing the endometrial deposits to regress. The efect can
be achieved with the combined oral contraceptive, progestogens, danazol or GnRH agonist, all
of, which are equally efective but have difering adverse efect proles. Other proposed causes
of cyclical pain, such as pelvic venous congestion, also appear to be well-controlled by ovarian
suppression.
Laparoscopy is done to remove/ fulgurate the endometrial deposits. Hysterectomy, with or
without removal of the ovaries, may be considered for severe symptoms that do not respond to
conservative treatment.
Response to ovarian suppression can therefore be a useful diagnostic tool.
Conservative treatments
When the cause of chronic pelvic pain cannot be identied, conservative treatments include
non-steroidal anti-inammatory drugs or a trial of the combined oral contraceptive pill
So always challenge the changes, and dont change the challenges.
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or a gonadotrophin-releasing hormone (GNRH) agonist for a period of 36 months.
Surgical treatment
Surgical treatment options which have been used if conservative measures are inadequate include
vaginal uterosacral ligament resection, presacral neurectomy (PSN) (involving total removal of
the presacral nerves) and uterine nerve ablation (UNA) (involving transaction of the uterosacral
ligaments at their insertion into the cervix by open / Laparoscopic surgical operation).
Hormone suppression for pelvic congestion syndrome: Pelvic congestion syndrome may account
for a proportion of the symptoms that women with chronic pelvic pain experience. Suppressive
hormonal therapy such as medroxyprogesterone acetate and GnRH agonists with or without
estrogen add-back are efective although the efects are not sustained once the treatment
stops.
Hysterectomy in women with chronic pelvic pain is not an efective strategy although it is an
option that some women may wish to consider.
If the history suggests to patient and doctor that there is a non-gynaecological component to
the pain, referral to the relevant healthcare professional such as gastroenterologist, urologist,
genitourinary medicine physician, physiotherapist, psychologist or psychosexual counsellor
should be considered.
Summary
Chronic pelvic pain is common afecting perhaps one in six of the adult female population.
Much remains unclear about its etiology but chronic pelvic pain should be seen as a
symptom with a number of contributory factors rather than as a diagnosis in itself.
Women often present because they seek an explanation for their pain.
The assessment process should allow enough time for the woman to be able to tell her story.
This may be therapeutic in itself. A pain diary may be helpful in tracking symptoms or
activities associated with the pain.
Conservative treatment in the form of NSAIDs or Hormonal therapy is the rst line of
management.
Treatment aiming at specic disorder is given once the etiology is established.
As with all chronic pain, it is important to consider psychological and social factors as well
as physical causes of pain. Many non-gynaecological conditions, such as nerve entrapment
or irritable bowel syndrome, may be relevant and a specialist referral is indicated in such
cases.
Changing the face can change nothing, but facing the change can change everything
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Dr Foram Mehta
M.D.
Beams Hospital, Khar, Mumbai
CERVICAL CANCER
C
ervical cancer is malignant neoplasm
of the cervix. WHO estimates that
each year over 1.30 lakh Indian women
are diagnosed with cervical cancer
and over 74,000 die of cervical cancer.
Most cervical cancers are squamous cell carcinomas,
Adenocarcinoma, arising in glandular epithelial cells is
the second most common type.
Etiology
Human papilloma virus (HPV) infection with high-risk types has been shown to be a necessary
factor in the development of cervical cancer.
Other risk factors for cervical cancer are :
Smoking
HIV infection, chlamydia infection
Stress, dietary factors
Early use of oral contraceptives
Early age at rst intercourse and rst pregnancy
Multiple pregnancies
Exposure to the hormonal drug diethylstilbestrol
Screening
Screening is looking for cancer before a person has any symptoms.
Screening schedule
( ACOG Guidelines )
When to start?
Should begin within 3 years of sexual intercourse or at 21 years.
When to discontinue?
Women aged 70 or more who have documented 3 consecutive negative cervical cytology tests.
Women who have undergone a total hysterectomy for benign condition.
Screening interval
Screening should be performed annually.
After 30 years, women who have had 3 consecutive technically satisfactory negative
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Nothing is permanent in this world not even your troubles
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cytology smears may be screened every 2-3 years.
After 30 years of age, HPV DNA testing can be combined with cytology and performed
every 3 years
Pap smear annually, regardless of the age if :
A diagnosis of cervical cancer or a Pap smear that showed precancerous cells
Exposure to diethylstilbestrol (DES) before birth
HIV infection
Weakened immune system due to organ transplant, chemotherapy or chronic corticosteroid
use.
WHO recommendation
The WHO, adopting a practical approach according to the resources of a country,
recommends that even a single smear in the lifetime between 35-50 years, if properly timed,
can reduce the incidence of invasive cervical cancer.
Tools for Screening
Gynaecological Check up
Visual Inspection with Acetic Acid (VIA)
Visual inspection with Lugols Iodine(VILI)
Pap smear
Liquid based /thin layer preparations
Colposcopy
Cervicography
Computer assisted screening
Speculoscopy- VIA with chemiluminescent light source
HPV DNA testing
Gynaecological Check Up
Normal transformation zone: Squamous epithelium is smooth and pink and columnar
epithelium appears red.
I like walking in the rain, because nobody can see my tears.
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VIA test results:
VIA Category
Clinical Findings
Test-negative No acetowhite lesions
Test-positive Sharp, distinct, well-dened, dense acetowhite areas
Suspicious for cancer Clinically visible ulcerative, cauliower-like growth
or ulcer, bleeding on touch.
Invasive Carcinoma: Raised lesion, Rolled edges, Raised white
epithelium, Abnormal vessels
VIA - Visual Inspection with Acetic Acid.
It is unmagnied visualization of cervix after application of 5% acetic acid. To look for -
Abnormal transformation zone
Areas of increased cellular density with increased abnormal nuclei and DNA content.
Mild-moderate dysplasia :
Occurs at squamo-columnar
junction as opaque white
epithelium. Aceto white
epithelium surrounds
cervical os
Severe dysplasia :
Marked acetowhite
epithelium with abnormal
raised contour.
Early cancer lesions :
Oyster shell white, Rolled
edges, Abnormal vessels,
Friable, Uneven surface.
VILI - Visual inspection with Lugols Iodine
Application of Lugols iodine solution to the cervix and visualization of cervix with the
naked eye to identify colour changes on the cervix.
The most wasted day in my life is the day when we have not laughed.
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VIA test results:
VIA Category
Clinical Findings
Test-negative Squamous epithelium turns brown and columnar
epithelium does not change colour
Test-positive Well-dened, bright yellow iodine non-uptake areas
touching the squamo-columnar junction
Suspicious for cancer Clinically visible ulcerative, cauliower- like
growth or ulcer, bleeding on touch.
Pap test exfoliative cytology test.
Reported epithelial cell abnormalities
ASCUS :atypical squamous cells of undetermined signicance
LSIL : including HPV changes and mild dysplasia/CIN 1
HSIL :including moderate and severe dysplasia, CIN 2, CIN 3,
carcinoma in situ
squamous cell carcinoma
glandular cell abnormalities
Colposcopy
Colposcopic examination is the observation of cervical epithelium under magnication (16X)
after application of normal saline, 3-5% dilute acetic acid, and Lugols iodine solution in succes-
sive steps.
Normal vascular patterns
Pre-requisites :
Not performed during menstrual period.
No sexual intercourse for 48 hours before the test.
No douche, use of tampons or vaginal
medications for 48 hours before the test.
No bimanual examination before smear.
The following samples are taken
Endocervical swab
Cervical scrap
Posterior fornix
A xative must be immediately applied to each slide
If you need help ask God, If you dont need help Thank God.
61
Abnormal vascular patterns
Human papillomavirus infection
It is very common and afects roughly 80 percent of all sexually active people, whether they
have symptoms or not. The most important risk factor in the development of cervical cancer is
infection with a high-risk strain of human papillomavirus.
More than 150 types of HPV are acknowledged to exist. Of these, the high risk strains for Ca
Cervix are Type 16 , 18 ,31
Types 16 and 18 are generally acknowledged to cause about 70% of cervical cancer cases. Together
with type 31, they are the prime risk factors for cervical cancer.
HPV DNA testing
The HPV DNA test is a newer technique for cervical cancer triage which detects the presence
of human papillomavirus infection in the cervix. It is more sensitive than the pap smear but
less specic and its role in routine screening is still evolving.
No matter how noble your intentions are
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Prevention
HPV vaccine
HPV vaccines are efective against the two strains of HPV that currently cause approximately
70% of cervical cancer.
Gardasil, is a vaccine against HPV types 6, 11, 16 & 18 which is up to 98% efective.
Together, HPV types 16 and 18 currently cause about 70% of cervical cancer cases. HPV types 6
and 11 cause about 90% of genital wart cases.
Cervarix has been shown to be 92% efective in preventing HPV strains 16 and 18 and is efective
for more than four years.
HPV vaccines are targeted at girls and women of age 9 to 26 because the vaccine only works if
given before infection occurs; therefore, public health workers are targeting girls before they
begin having sex.
Management
Patients with persistent LSIL should be treated, chiey with the use of of ce-based ablative
therapies.
Management guidelines for HSIL (CIN grade 2 or 3) are well established and recommend
colposcopy-directed biopsy with or without endocervical curettage. Cold-knife conization or
loop electrical excision procedure (LEEP) should be performed in all patients with biopsy-
conrmed HSIL in order to exclude invasive disease
KEY POINTS
Cervical cancer is the second most common cancer in women worldwide and the commonest
cancer in India.
HPV infection is a necessary factor in the development of cervical cancer. It afects roughly
80 percent of all sexually active people.
Together, HPV types 16 and 18 currently cause about 70% of cervical cancer cases.
The search for unrecognized disease by means of applied tests or examinations in apparently
healthy individuals is called screening.
Various screening methods are available. The commonest are Gynaecological Check up &
Pap smear
Cervical screening is a way of preventing cervical cancer from developing, and diagnosing
the disease at an early stage
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Winning starts with beginning
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Dr. Mandakini Parihar, MD,
DGO, FICOG
Director , Mandakini IVF Centre
1st Vice-President Elect, FOGSI
2012
Past President , Navi Mumbai
Obs & Gyn Society
Consultant, BEAMS Hospital
and Fortis Hospital
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Assisted Reproductive
Techniques (ART)
In-vitro Fertilization (IVF) and Intracytoplasmic Sperm injection (ICSI)
Dr. Mandakini Parihar
Introduction
I
nability to have children is infertility after one
year of regular unprotected coitus. Either Male
or Female or both factors may be responsible
for Infertility. About 15% of couples sufer from
infertility. In a country like ours, infertility is
not only a medical problem but a social one too. Today,
advances in reproductive medicine have helped many
couples become parents with Assisted Repro ductive
Techniques (ART). In July, 1978, Louise Brown, the
worlds rst baby was born by In-vitro Fertilization
Technique (IVF). It changed management of infertile
couples and brought hope and happiness to many
childless couples. The problem of male infertility was
conquered in 1992, with the worlds rst baby being
born with Intra-cytoplasmic Sperm injection (ICSI).
There are many diferent ways in which fertility treatment can be ofered to patients and today
with advances in ART, almost 80% of the patients can be helped with some form of Assisted
Reproduction.
Table 1 : Infertility Treatment options include
1 Simple forms of Fertility Management
a Ovulation Induction
b Ovulation induction with Planned Relations
c Ovulation induction with Intra-Uterine Insemination (IUI)
d Donor insemination
2 Assisted Reproductive Techniques (ART)
a In-vitro Fertilization (IVF)
b IVF with Intra-Cytoplasmic Sperm Injection (ICSI)
c IVF with ICSI with Surgical Sperm retrieval (TESA or PESA)
d IVF with Ovum Donation
e IVF with Embryo Donation
f IVF with surrogacy
The only disability in life is a bad attitude
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Male Factors
IN APPROXIMATELY 40% OF THE COUPLES, MALE FACTOR IS THE SOLE CONTRIBUTORY CAUSE OF
INFERTILITY. HENCE A PROPER SEMEN ANALYSIS IS VERY IMPORTANT.EXTENDED SPERM FUNCTION TESTS
MAY BE NEEDED DEPENDING ON THE INITIAL EVALUATION. A TESTICULAR BIOPSY MAY BE NEEDED IN CASES
OF AZOOSPERMIA. TODAY, IN CASES OF OBSTRUCTIVE AZOOSPERMIA, SPERM CAN BE RETRIEVED DIRECTLY
FROM THE TESTES AND PREGNANCIES ACHIEVED WITH ICSI SUING PESA OR TESA SPERMS.
Female Factors
Approximately 40 % of patients are infertile due to female factors. The common causes of
female factor infertility will need tests for proper evaluation. Hormonal prole, Uterine and
tubal factor evaluation, Monitoring of a natural cycle for ovulation and ultrasonography for
checking for other pelvic pathology along with basic routine hematology tests are needed for
the evaluation of female factors.
Male
Semen analysis and culture
Routine basic hematology
Testicular biopsy if azoospermia
Female
Routine basic hematology
Baseline hormonal evaluation on day 2/3 of period
Natural Cycle Follicular monitoring by TVS
Hysterosalpingography (HSG) or Hysteroscopy with laparoscopy and chromopertubation
for uterine and tubal testing
Ultrasound of the pelvis (USG): This is done to evaluate and identify any abnormality in
the pelvis. In certain cases we may also need 3-D USG
In-Vitro Fertilization (IVF) & Intra Cytoplasmic Sperm Injection (ICSI)
What is in vitro fertilization (IVF)?
For many couples who have exhausted traditional clinical and surgical treatments for infertil-
ity, Assisted Reproductive technologies (ART) may ofer the best hope for pregnancy. Through
these procedures, women with otherwise untreatable infertility have given birth to healthy
babies. IVF or In-vitro Fertilization means fertilization outside the body. In ICSI (Intra Cyto-
plasmic Sperm Injection), the sperm is directly injected into the egg.
Table 3 : IVF-ICSI Indications
Absent or blocked fallopian tubes ( Previous tubal pregnancy or infections, STD, or
Tuberculosis)
Endometriosis
Low sperm count or motility
Absent sperm count due to obsturction
Love looks through a telescope; envy, through a microscope
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Patients where all other treatments such as ovulation induction with intra uterine in-
semination have failed
Unexplained infertility
Advanced age
Poor ovarian reserve
Patients who want to become pregnant by the procedure of egg donation
Patients who want to become pregnant by the procedure of embryo donation
Patients who need surrogacy services for achieving pregnancy
Table 4: The main steps in the IVF-ICSI with embryo transfer sequence are
Down regulation of the pituitary to stop the inherent hormonal production which can
interfere with stimulation. This is done using either a GnRH agonist or a GnRH antagonist
for suppression.
Giving Fertility injections for growing of eggs in the ovaries. These are gonadotropin
injections using either HMG or FSH for stimulation. (Fig 1 Stimulation Protocol)
Monitor the development of follicles in the ovaries by transvaginal sonography
Administration of HCG injection (Human Chorionic Gonadotrophin) when the eggs are
mature (when follicles are about 17-19mm in size)
Collection of eggs under anesthesia (ovum Pick-up) (Fig 2 Ovum appearnace)
Obtaining the sperm from husband and providing correct conditions for fertilization and
early embryo growth. The eggs are mixed with the husbands sperms in the laboratory.
This technique is called In-Vitro Fertilisation (IVF). In the case of Intra Cytoplasmic Sperm
Injection (ICSI) the sperm is robotically injected into the cytoplasm of the egg. (Fig 3 ICSI)
Transferring the embryos into the uterus (embryo Transfer) 2-3 days after the egg collection.
Sometimes we grow the embryo till day 5 and then transfer at the blastocyst stage. Embryo
transfer of good quality embryos back to the womb, after day 2 ( Fig 4:four cell embryo) ,
day 3 (Fig 5:six-eight cell embryo) or day 5 (g 6: blastocyst stage) days after egg removal.
Figure1 : Stimulation Protocol for IVF-ICSI cycle
Problems are not stop signs, they are guidelines.
66
Figure2 : Oocyte Figure3 : ICSI Procedure
Figure 4 4 cell Embryo Figure 6 Blastocyst
Often husbands of patients undergoing treatment cycles may not be around at the time of the
IVF treatment (due to the nature of their jobs eg: expats, staying and coming from abroad, sailors
etc). In these cases the sperms are obtained earlier and frozen sperms are used for the fertilization
procedure. Occasionally, in cases of male factor infertility, donor sperm is required and this can
also be provided from a registered sperm bank.
Egg Donation
Most ART centers will ofer a comprehensive donor egg program. There are many circumstances
where the female partner is unable to produce eggs or the egg quality is very poor. These patients
can qualify for egg donor recipient program.In egg donation, eggs are borrowed from a young
Make your life a mission - not an intermission
67
woman (less than 31 yrs of age) called the donor, with her consent. These eggs are then fertilized
with the sperms of the husband of the recipient woman and the resultant embryo is inserted
into the womb of the recipient. The success rate of this procedure is in the region of 30 to 40%.
Surgical Sperm Retrieval
In cases of azoospermia it is important ot evaluate if there is sperm production in the testes and
if present, we can use these sperms by the technique of PESA (Percutaneous Epididymal Sperm
Aspiration) or TESA ( Testicular Sperm Aspiration). Hence, it is important that the testicular
biopsy must be done at the unit where ART services are available so that if present the sperm
can be frozen immediately for use in later cycle.
Complications
There are only two main side-efects of IVF-ICSI treatment and they are both temporary.
Ovarian hyperstimuation Syndrome(OHSS). This is usually seen in patients with Polycystic
ovaries and is due to the gonadotropin stimulation. It occurs in about 0.5-2% of cases. The
management is mainly by prevention. This is achieved by using low dose stimulation
protocols. If it still occurs, the manangment is intensive monitoring and adequate hydration.
In some cases, ascetic uid tapping may be needed.
Multiple Pregnancies currently the rate of multiple pregnancy is about 20-25%. Most of
them are twins, but some are high order multiple as triplets and quadruplets. This also
occurs due to multiple embryo transfers. We have now started decreasing the number of
embryos transferred to 2. With improving laboratory conditions and better culture systems,
we are hopeful that we will soon transfer only one embryo and hence be able to decrease this
incidence to less than 5%.
Success rates
Most ART units should be able to ofer success rates of about 40% in young patients. Average
success rates are between 30-40% depending on the age of the patients, the cause of infertility and
presence of other pelvic pathology.
With the availability of Assisted Reproduction in the form of IVF / ICSI many couples are able
to achieve pregnancy and fulll their dream of parenthood. It is a true miracle of medical sci-
ence to see couples get pregnancies and see these babies grow. Since 1978, 3 million babies have
been born with ART and the number is only increasing.
Figure7 : IVF-ICSI Lab Figure 8 Air Filtration Unit with ICSI Machine
Somewhere, something incredible is waiting to be known
6 8
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Dr Namrata Prabhudesai
M.D.
Consultant Radiologist
Beams Hospital, Khar, Mumbai
ULTRASOUND IN
GYNAECOLOGY
U
ltrasound or sonography has uses in
many areas of gynaecology to assess
pelvic organs. It is said that just as one
could never imagine a cardiologist
without a stethoscope, it is impossible to
imagine a gynaecologist without an ultrasound scanner.
The reasons for performing a pelvic ultrasound
Pelvic pain
Abnormal vaginal bleeding
Pelvic inammatory disease (PID)
Localizing an intra-uterine device (IUCD)
Evaluation of uterus and endometrium
Evaluation of ovaries
Adjunct to fertility treatments
Review of early pregnancy for localization and dating
Monitor growth, congenital anomalies in developing fetus
Review of mass palpated during a pelvic examination
Assessment of uterine broid
What is the principle of Ultrasound?
High frequency sound waves (Ultrasound) are passed through the human body, which reect of
the various body structures. A computer receives these reected sound waves and uses them to
create pictures of various organs.
What are the advantages of Ultrasound?
It is a non-invasive procedure
It is painless
Cost-efective
Done on OPD basis
Short duration
Free of any side-efects
Wide applications for scanning not just pelvic organs and fetuses but all parts of the
human body
Awareness is empowering
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The common types of pelvic ultrasound are
TVS (Transvaginal/Endovaginal Scan) Specially designed probes/transducers are
introduced inside the vagina to generate ultrasound images of uterus and adnexae
TAS (Transabdominal Scan) This is a per abdominal scanning technique by visualizing
the uterus and pelvic organs. A full bladder is needed for this procedure as water is a good
medium for transmitting sound waves
Doppler Ultrasound To study the vascular anatomy and vascular aberrations of the
uterus/ovaries/abnormal pelvic masses
3D and 4D Ultrasound It clearly depicts the anatomy of uterus and ovaries by means of
specialized 3D/4D probes. It has wide applications in diagnosing broids/congenital uterine
abnormalities and pressure efects on the pelvic organs by uterine and ovarian masses.
Sonohysterography A new technique to better image the uterine cavity
Therapeutic Ultrasound In this technique, ultrasound waves are used for therapeutic
benets to pelvic organs. An example of a recent therapeutic ultrasound in gynaecology is
HIFU High Intensity Focussed Ultrasound.
A Typical Ultrasound Machine
Pelvic ultrasound is preferably performed
in the rst 10 days of the menstrual cycle.
First, a transabdominal scan is done that
provides a broad perspective of organs in the
pelvis but generally not a lot of detail. Then
a transvaginal scan using a slender probe is
performed that provides detailed images
Transabdominal Procedure Of Ultrasound Transabdominal View Of Uterus and Ovaries
Dreams and dedication are a powerful combination
70
Transvaginal Procedure Of Ultrasound Transvaginal View of Uterus and Ovaries
3D Ultrasound Of Uterus
Sonohysterography
It uses an infusion of sterile saline through a soft plastic
catheter placed in the cervix in conjunction with transvaginal
ultrasound. The saline infusion distends the uterine cavity and
provides an excellent contrast to the lining, giving improved
visualization of uterine and endometrial pathology.
This technique may also be used to assess the fallopian tubes
by demonstrating uid spill into the pelvis. Colour Doppler
imaging demonstrates the movement of ultrasound contrast
medium within the tube.
Sonohysterogram
HIFU High Intensity Focussed Ultrasound.
This is a treatment ultrasound for broids and adenomyosis. A
specialized ultrasound machine generates high intensity sound
waves that are targeted at a focal point on the broidal tumor. This
raises the temperature inside the tumor mass above 80 deg C causing
coagulative necrosis and cell death. The efect is a gradual reduction in
the tumoral size. Multiple sessions are given at intervals till the patient
becomes asymptomatic secondary to regression of broid
When it is dark enough, you can see the stars
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CT and MRI in Gynaecology
Dr. Anand Parihar
Computed Tomography
The development of helical multislice CT markedly increased its
value in the diagnosis of pelvic pathology.. An entire pelvic CT
examination can be completed in less than 20 seconds and nearly
immediately reviewed as both axial and three-dimensional (3D)
reformatted images in the coronal and/or sagittal planes.
MRI
The high soft tissue contrast among pelvic organs and the ability to
generate images in any plane make MRI important diagnostic tool.
Indications:-
Congenital anomalies
Benign disease of pelvis.
Leiomyomas
Adenomyosis
Endometriosis
Benign adnexal masses
Malignancy
Cervical ,Endometrial ,Ovarian .
CONGENITAL ANOMALIES
Anomalies occur because of failure of development or fusion of the mullerian ducts as well as
failure of septal resorption once fusion has occurred. Although often initially diagnosed using
hysterosalpingography, MRI should be performed when surgical therapy is considered to more
accurately characterize the anomaly. It is particularly important to diferentiate a septate from a
bicornuate uterus, each of which requires diferent treatment ( Fig 1 & 2)
LEOMYOMA
On CT images, broids are usually of soft tissue density but may exhibit coarse peripheral or central
calcication .They enlarge and distort the usually smooth uterine contour. Enhancement pattern
is variable (g 3)
MRI is of value in the symptomatic patient when surgery and uterine salvage therapy is considered.
Fibroids are described in terms of size, location, and signal intensity. Any broid that impresses
on the endometrial canal is considered to have a submucosal component and can be a source of
bleeding.
Using T2-weighted MRI, broids can be further classied into three groups
Ordinary broids : composed of collagenous material .
We never know the worth of water till the well is dry
72
Cellular broids: contain less collagen. These broids will often respond to hormonal
therapy.
Degenerating broids: are of very bright T2 signal intensity but often contain thick septation
or wall nodules. These broids do not respond well to uterine artery embolization because of
central necrosis . There are no discriminating features between large degenerating broids
and leiomyosarcoma.
ADENOMYOSIS
Adenomyosis is a common cause of pelvic pain in women of menstrual age. Adenomyosis cannot
be diagnosed using CT.
Because of its accuracy and ease, MRI remains the test of choice. adenomyosis appears as poorly
dened low T2-signal intensity conuent with and widening the junctional zone (greater than
11 mm) .High T2-signal intensity glands are often seen within the diseased area. Occasionally,
focal adenomyosis will form a cavity with a very low T2-signal intensity hemosiderin rim.
(Fig 4 & 5)
ENDOMETRIOSIS
CT, Transvaginal US, and MRI are of use only when the diagnosis of an endometrioma is
suspected. On contrast-enhanced CT images, endometriomas may be uni- or multilocular and
are often higher in density than clear uid .
The main diferential diagnosis is that of a hemorrhagic cyst and endovaginal US is often of use
in distinguishing between the two entities.
DERMOID
On CT, a fat density mass with or without a fat-uid level is present . The high-density
Rokitansky nodule, composed of hair and other components, may oat within the centre of the
mass and calcication is often present.
On MRI,. Fat can be denitely identied and separated from blood using fat suppression pulse
sequences.The speckling artifact within the Rokitansky nodule is virtually diagnostic of a
dermoid. (Fig 6)
CYSTADENOMA
On CT,they appear as well-dened, uni- or multilocular, low-density masses. The walls and
internal septa are of varying thickness and regularity .Papillary projections of soft tissue density
may be seen within the tumor.
On MRI: Although the accuracy for distinguishing between benign and malignant ovarian
lesions improves with the addition of Gd-enhanced MR images , malignant ovarian
cystadenocarcinomas cannot be reliably diferentiated from benign cystadenomas unless
metastases are present.
TUBO-OVARIAN ABSCESS
Usually a sequelae of pelvic inammatory disease .The fallopian tube becomes dilated and
Nature is not a place to visit, it is home
73
obstructed, usually by a combination of blood and pus. The ovary is often involved in the resultant
inammatory mass.
On contrast-enhanced CT imaging, tubo-ovarian complex has the appearance of an enhancing
mass with cystic and solid components .
Although it is extremely unusual for diagnosis of tuboovarian abscess to require MRI, ndings
include free pelvic uid, a dilated fallopian tube, and complex cystic mass. It is possible that a large
abscess may mimic an ovarian neoplasm.
CERVICAL CANCER
On MR images, cervical cancer is usually hyperintense to the dark cervical stroma on T2-
weighted images. The preservation of the black ring of the cervical stroma, no matter how
thin, virtually excludes parametrial extension. These patients are candidates for surgical cure.
Those in whom the black line is broken and a mass extends beyond the expected confines of
the cervix have an 85% likelihood of parametrial invasion and are usually treated primarily
with brachytherapy. . Lymph nodes greater than 1 cm in size are positive for tumor in 70%
of cases.
In cases of advanced disease, CT is preferred . The cervix is often enlarged in the anterior-
posterior direction and may contain gas Images.Thickening of the uterosacral ligaments also
manifests extension of disease, although this can also be a result of radiation .The development
of hydronephrosis is often the result of bladder wall or ureteric invasion and upstages the disease
to IIIB.
ENDOMETRIAL CANCER
MRI is recommended when locally advanced disease is expected based on physical examination
ndings and in the patient with a dif cult physical examination due to obesity or prior radiation
or surgery.
The image is scrutinized for extension of hyperintense tumor into or through the myometrium.
Preservation of a subendometrial band of enhancement 120 seconds post injection of intravenous
contrast virtually excludes myometrial extension.
On CT endometrial carcinoma often presents as an obstructing lower uterine segment mass
with associated hemato- or pyometra. Findings of advanced disease are similar to those of cervical
cancer and consist of extension of lymphatic extension of disease to the pelvic sidewall chains and
retroperitoneum.
OVARIAN CANCER
CT and MRI are equal in diagnosis of ovarian malignancy, howevr CT is usually preferred because
it is well accepted by the patient and gives an overall view of the abdomen and pelvis .
Although equal to CT scanning in accurate staging of disease, MRI of the entire abdomen
and pelvis requires at least 45 minutes. This can be dif cult for an ill patient. MRI can be
particularly useful when searching for small-volume recurrent disease. It has also been shown
that recurrent tumor may be present and visible on MRI despite a normal CA-125 level and
physical examination.
Writing is the best way to talk without being interrupted
74
MRI OF PELVIC FLOOR RELAXATION
Pelvic oor imaging using MRI is indicated when multiple compartments of the pelvic oor are
involved and prior to repeat surgeries. Sagittal midline images using an ultrafast T2-weighted
pulse sequence with the woman at rest and at maximal strain quantify the descent of all three
compartments at once and can be used to identify enterocele, sigmoidocele, and anterior urethral
rotation and kinking.
CT and MRI can also be used for imaging of Pituitary gland in suspected cases of prolactinomas
and MRI is of great value for evaluation of breast lesions, specially in dense breasts.
Fig3 :CT. Bulky uterus with
low-density areas due to
broids One small eck of
calcication
Fig 5 :CT. Bulky mildly
heterogeneous uterus with
posterior displacement
of the cavity due to
adenomyosis rather than
broids
Fig 6: CT. Complex mass in
the pelvis typical of a dermoid
cyst (arrows). The mass is
of mixed attenuation but
contains a large amount of
fat. It has a calcied rim and
a dense area of calcication
(arrowheads) inferolaterally
due to a tooth.
Fig1&2: Uterine didelphys showing
two separate uteri and cervices
(arrows). Note the normal left
ovary (o).
Fig 3 : Multiple leiomyomas
large cervical intramural
leiomyoma (c) and smaller
intramural tumours (e).
There is a degenerating
serosal leiomyoma (d) and a
smaller serosal leiomyoma
(s) adjacent to a loculated
cystic collection due to an
associated hydrosalpinx (h). b
= bladder.
Fig 4 : Focal
adenomyosis (arrow)
b = bladder; e
= intramural
leiomyoma
When the stomach is full, it is easy to talk of fasting
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Breast Screening
Some of the common symptoms of breast cancer are---
Lump in the breast/axilla - usually painless.
Nipple bleeding/discharge/retraction/ulceration.
Alteration in skin colour and thickness
Breast cancer can be detected in asymptomatic stage by the following regular screening protocols
Monthly self-breast examination.
Clinical breast examination by health care provider.
Baseline mammograms at 35 followed by yearly mammograms after 40. They are usually
accompanied by ultrasound of the breast.
Breast lesion biopsy/FNAC for abnormal mammograms-BIRADS-III and above.
MRI of the breast and PET scan.
Thermography or NTBS scan - a newer noninvasive radiation free infrared imaging technique
that detects change in heat pattern (vascularity) due to cancer.
Dr Namrata Prabhudesai
M.D.
Consultant Radiologist
Beams Hospital, Khar,
Mumbai
W
ith urbanization the incidence of
breast cancer is on the rise in India,
the important factors being late
marriage, late or no child bearing,
absence of breast feeding, early
menopause, OC pills, HRT, stress, pollutants, alcoholism,
smoking, obesity, etc.
Breast cancer strikes 100,000 women yearly in India and
is projected to reach 250,000 by 2015 outpacing cervical
cancer. According to ICMR the incidence rate is 30-33 per
100,000 women in urban India. More importantly the
rate is on the rise in women under the age of 40.
Most cancers are detected late as patients usually come
with a palpable or visible lump. Early detection by
means of various screening modalities improves the sur-
vival rate. If detected in time the cure rate is as high as 97
%. Breast cancer can also afect males but the incidence is
very low.
Success is not in what you have, but who you are
76
Breast Self Examination
A diagram here depicts breast self-examination
Mammography
Mammography still remains a gold standard for early detection and screening of breast cancer.
It uses low dose x-rays to examine the breast tissue by a specialized mammography unit. Two
views of each breast are obtained MLO - mediolateral oblique and CC - craniocaudal.
Both the radiographs are compared. Any calcication, asymmetry, radiodensity, skin thickening,
architectural distortion etc are noted and then categorized as follows-
ACR-BI-RADS (American College of Radiology Breast Imaging Reporting And
Database Systems).
Staging
Incomplete evaluation.
Negative.
Benign.
Probably benign nding (short term follow up).
Suspicious (indeterminate).
Highly suggestive of malignancy.
Proven cancer.
A book is a gift you can open again and again
77
Mammography Procedure Diagram
MAMMOGRAMS
Typical mammograms look like this
Limitations of mammography are only radiation and discomfort experienced by some during
the procedure. Dense breasts also limit mammographic evaluation and can mask the cancerous
growth.
Mammography is also done for follow-ups in known breast cancer patients on treatment
(chemo/radiation/hormonal), mastectomy and breast implants.
Age protocols for breast screening
Age 35-40yrs Above 40 yrs
Self examination Monthly Monthly
Clinical breast examination 2-3 yrs 1-2 years
Mammography Baseline Yearly
If you think education is expensive, try ignorance
78
Ultrasound Of The Breast
It is a noninvasive high-resolution sonography of the breast that usually complements mam-
mography and improves the pick up rate of breast cancer.
Advantages of ultrasound
It is a painless procedure done on OPD basis.
It is cost efective.
Radiation free.
No preparation is required.
Useful for dense young breasts where mammography has limitations.
Can be done in young patients, as there is no radiation.
Diferentiates between solid and cystic lesions.
Ultrasound picture of a spiculated hypoechoic tall mass suspected to be malignant.
Ultrasound is excellent at imaging cysts: round, uid-lled, pockets inside the breast. Additionally,
ultrasound can often quickly determine if a suspicious area is in fact a cyst (always non-cancerous)
or an increased density of solid tissue (dense mass), which may require a biopsy to determine if it
is malignant (cancerous).
Physicians use ultrasound to evaluate breast abnormalities that have been found with screening
or diagnostic mammography or during a clinical breast exam. Ultrasound may help detect some
breast masses and is the best way to determine whether a cyst is present without placing a needle
into the area of concern to aspirate uid. Ultrasound is also useful in helping physicians guide
a biopsy (tissue sampling) to determine whether a breast abnormality is cancerous. Physicians use
ultrasound during core and ne needle aspiration biopsies (FNA) to determine where to place the
needle. Ultrasound may also be used to prove whether a suspicious area is a lymph node. However,
ultrasound does not have good spatial resolution like mammography, and therefore cannot provide
as much detail as a mammogram image. Ultrasound is also unable to image microcalcications,
tiny calcium deposits that are often the rst indication of breast cancer. Mammography, on the
The determination to win is the better part of winning
79
other hand, is excellent at imaging calcications.
MRI Of Breast
In this method, the breast is scanned in an MRI device before and after the intravascular injection
of a contrast agent (Gadolinium DTPA). The pre-contrast images are subtracted from the post-
contrast images, and any areas that have increased blood ow are seen as bright spots on a dark
background. Since breast cancers generally have an increased blood supply, the contrast agent
causes these lesions to light up on the images.
Breast MRI is more sensitive than mammogram, especially when it is performed using contrast
dye. However, breast MRI may not always be able to distinguish breast cancer from noncancerous
breast growths. This can lead to a false positive result.
MRI also cannot pick up tiny pieces of calcium (microcalcications), which a mammogram can
detect.
A biopsy is needed to conrm the results of a breast MRI.
Thermography/NTBS Scan
It is a newer noninvasive radiation-free, painless and no touch technique of breast cancer screening.
It is available at select centers in India, BEAMS Mumbai and Indore being one of them.
It detects the thermal changes in the breast due to altered vascularity in cancerous lumps by
means of dual infrared cameras which are seen as areas of altered colour signal intensity. Any
such suspicious area needs further evaluation by means of mammography, sonography etc.
With the advent of multiple sophisticated screening and diagnostic modalities,early detection and
hence reduced morbidity and mortality due to breast cancer is increasingly possible.
A resolute determination is the truest wisdom
Mission Pink Health Project of IMA Dhule
On 8th March 2011.IMA- MS Women Wing along with IMA Dhule has launched
Mission Pink Health Project Anaemia detection, treatment & prevention along with Adolescent
Health Education Programme to commemorate World Womens Day :
The features of the project were Medical Checkup., Investigations- HB, Blood Group &
RH. Counselling of girls on Anaemia, Adolescent, Sex Education by informative talks, Power
Point Presentation (CD) & Question answer session.Awareness creation with posters, slogans &
Skit.,Health kit distribution containing 100 tablets of lron, Folic Acid, Vitamin-C & Albendzole
Tablet, Protein Powder, Sanipad, Nail Cutter, Soap etc. to each girl.Record keeping with health
card & followup after three months. Special investigations for girls with severe Anaemia or any
other disorder.
Same project will be implemented throughout Maharashtra with the help respective branches
of IMA. The special educational C.D. is prepared for the project & shall be sent to all the branches.
Shirpur project is sponsored by M.L.A., Mr. Amrishbhai Patel and the same project will be
implemented throughout Maharashtra with the help of respective branches of I.M.A. Lets join
hands tighter to ght Anaemia & make Mission Pink Health a grand success!
Dr. Jaygosh Kaddu Dr. Jayesh Lele Dr. Ravi Wankhedkar Dr. Vijaya Mali
President Hon. Secretary Co-ordinator Chairperson
80
3rd April 2011: Te installation ceremony of the newly elected President Dr. Chandrakant
M. Dharia & his team was held on 3rd April 2011 from 7.00pm onwards at IMA Lawns. Dr.
Vinay Aggarwal, National President IMA HQ had graced the occasion as the Chief Guest.
3rd April 2011: Pulse Polio Programme arranged.
7th April 2011: A CME was held on WHO Day THEME: ANTIMICROBIAL RESISTANCE:
NO ACTION TODAY, NO CURE TOMORROW. Dr. Anant Gore and Dr. Sandeep
Bawdekar were the speakers.
10TH April 2011: Cardicon was organized at IMA House,
17th April 2011: HEPATOLOGY CME was organized at IMA House.
17th April 2011: A medical check up camp of senior citizens & public awareness programme
was organized by Dr. Anil Pachnekar at Nehru Nagar, Kurla (E).
24th April 2011: CME on Gynecology was organized at Bombay Hospital in Association
with GPA-GB & Bombay Hospital.
3rd May 2011: On the occasion of Asthma Day, Asthma Awareness Camp was organized
by IMA Mumbai Branch at Dharavi. More than 1000 people attended.
8th May 2011: A CME on Dermatology and Menopause was organized at IMA House.
8th May 2011: On the occasion of Mothers Day, IMA Mumbai Branch on behalf of IMA
HQ had organized free Medical Checkup Camp for women at Family Welfare Centre in
IMA House. Haemoglobin Estimation, Pap Smear, general medical checkup was done. Te
ladies were taught self breast examination. More than 50 ladies attended the camp.
10th May 2011: I had attended a meeting called by Mumbai Municipal Corporation for
quality assurance at F-South Ward in which maternal deaths during pregnancy were
discussed.
22nd May 2011 : 7th Anniversary of CME Centre of Bombay Hospital in association
with IMA Mumbai Branch and GPA-GB was celebrated at S. P. Jain Auditorium, Bombay
Hospital by conducting a Medicine Medley.
28th May 2011: A CME on Current Trends in Management of Acute Coronary Syndrome
by Dr. Debabrata Dash.
29th May 2011 : A CME on Vertigo was held at IMA House. Tere was a galaxy of
speakers ranging from Spine Surgeon, Neurologist, ENT Surgeon to Physiotherapist.
12th June 2011 : A CME on Peripheral Vascular Disease was organized at IMA House.
14TH June 2011 : I had attended a meeting of Quality Assurance Committee of Mumbai
Municipal Corporation.
25th June 2011 : A CME on Management of Pulmonary Diseases was organized.
DR. RAJENDRA H. TRIVEDI
HON. SECRETARY,
IMA MUMBAI BRANCH
REPORT OF ACTIVITIES OF IMA MUMBAI BRANCH FOR MAHIMA
FROM 1 ST MARCH 2011 TO 30TH JUNE 2011
In joy or sadness, flowers are our constant friends
81
IMA MUMBAI WEST BRANCH ACTIVITIES REPORT
HIGHLIGHTS OF BRANCH ACTIVITIES 1ST MARCH 2011 TO 15TH JUNE 2011
We regularly conduct CME programme on every Tuesdays & Tursdays. Tese
CME programmes were accredited by MMC.
We organized following seminars which were also accredited by MMC.:
1) PAST, PRESENT & FUTURE ON HEPATOCELLULAR CARCINOMA was
organized on SUNDAY, 06th March 2011.
2) A symposium on CARDIO VASCULAR DISEASES & KIDNEY on the occasion
of WORLD KIDNEY DAY was organised on THURSDAY, 10TH March 2011.
3) CARDIOVASCULAR WORKSHOP OF DIABETES programme was organised on
SUNDAY, 27TH MARCH 2011.
4) Symposium on LIVER TRANSPLANTATION was organised jointly by 1)
IndraPrastha Apollo Hospitals, New Delhi 2) Indian Medical Association -
Mumbai West Branch and 3) Indian Academy of Pediatrics Mumbai Branch on
SUNDAY, 3RD APRIL 2011 held at IMA Mumbai West Branch premises.
5) ANTIMICROBIAL RESISTANCE AND ITS GLOBAL SPREAD on the occasion
of WORLD HEALTH ORGANISATION DAY was organsied on THURDAY, 07TH
APRIL 2011.
6) BE INSPSIRED, GET INVOLVED IN TREATMENT FOR ALL on the occasion
WORLD HEMOPHILIA DAY programme was organised on SUNDAY, 17TH
APRIL 2011.
7) YOU CAN CONTROL ASTHMA on the occasion of WORLD ASTHMA DAY
programme was orgnaised on TUESDAY, 03RD MAY 2011.
8) DIABETES UPDATE 2011 was organised on SUNDAY, 22ND MAY 2011.
Cultural Sub Committee had organised interesting HANDI CRAFT
EXHIBITION on the occasion of INTERNATION WOMENS DAY on 08TH
MARCH 2011 at our branch premises and was well appreciated.
Our branch had organized and excellent ANNUAL DAY PROGRAMME on
SUNDAY, 05TH APRIL 2011 on the occasion of Installation of New Elected Team
of Managing Committee for the year 2011 2012 under the Presidentship of Dr.
Ashok Balsekar.
Following Veteran and senior members of our branch were elected has trustees :
- Dr. Akil Contractor
- Dr. Arshad Gulam Mohd.
Addition of 87 new life members from 1st April & 15th June 2011.
Medical Education Sub Committee has organised educational programme for Post
Graduate Students / Residents arrange on Saturday, 18th June 2011at Nanavati
Hospital
Medical Welfare Sub Committee had organised a
The love of gardening is a seed once sown that never dies
82
-Health for all Free yoga Sessions
-Weekend Trip to Nagothane for IMA Members on Saturday, 28th May 2011.
Information, Education & Communication Sub Committee had organised health
awareness programmes:
a) We had organised medical emerging booth on the occasion of MAHASHIVRATRI
on 02ND MARCH 2011 at Shiv Mandir Gumpha Road, Jogeshwari (E);
b) We had organised a lecture on the occasion of INTERNATIONAL WOMENS
DAY on TUESDAY, 08TH MARCH 2011 at M. W. Desai Hospital, Govind
Nagar, Malad (East). Lecture was given by a Gynaecologist Dr. Jayanti Kamat
who is a Infertility Specialist;
c) We had organized a lecture on the topic of Management of STI & RTI on
TUESDAY, 15TH MARCH 2011 at M. W. Desai Municipal Hospital, Govind
Nagar, Malad (East). Lecture was taken by Joint Director of MDACS Dr. Dilip
Kadam.
Womens Wing Sub Committee has an interesting programme of demonstration
of THAI COOKING.
Forthcoming Events :
- AN INTERACTION WITH MAHARASHTRA MEDICAL COUNCIL
programme on SUNDAY, 26TH JUNE 2011.
- Scientic programme of MEDICINE UPDATE 2011 on the occasion of
DOCTORS DAY;
- DOCTORS DAY CELEBRACTION programme on SUNDAY, 03RD JULY
2011;
- GYNAECON 2011 on SUNDAY, 24TH JULY 2011;
- TEACHERS DAY programme on 04TH SEPTEMBER 2011.
BLOOD DONATION DRIVE 2011
On the occasion of DOCTORS DAY celebrations we requested all the branches to hold Blood
Donation camp and this year the response has been overwhelming.
So far we have received conrmation from 84 branches and the detailed report we shall give in
next MAHIMA.
DR JAYAGHOSH KADDU DR JAYESH LELE DR RAJENDRA CHAUHAN
PRESIDENT HON STATE SECRETARY CONVENOR
Success is a ladder you cannot climb with your hands in your pockets
83
SR.
NO.
SUB - COMMITTEE
2010 - 2011
CHAIRMAN CONVENER MEMBER
1 ACTION SUB COMMITTEE Devendra Shirole Ghate Vijay
2 PRESS PUBLICITY Dr. J ayaghosh Kaddu Dr. J ayesh Lele Dr. Anil Laddhad
3 LEGAL CELL COMMITTEE Dr. J ayant Navarange Dr. Nisar Shaikh
4 MAHIMA EDITORIAL
BOARD
Deepak J umani Dr. Shantanu Abhyankar
5 RESOURCE & FINANCE
COMMITTEE
Dr. Akil Contractor
6 DR. MEMBERSHIP PRO-
MOTION COMMITTEE
Dr. Hozie D. Kapadia Dr. Prashant Nikhade
Dr. S. G. Shanbhag
Dr. Avinash Bhosale- Satara
Dr. J ayant Watwe - Kol-
hapur
7 RURAL HEALTH COM-
MITTEE
Dr. Ravindra Kute -
Shrirampur
Dr. Pofale - Omerga-
9423070748
Dr. I. S. Mane
Dr. S. D. Malgave - Sangli
8 MEDICAL EDUCATION
COMMITTEE & MEDICAL
ETHICS
Dr. Patwardhan Dr. J ayadhaval Bhumas
- Miraj
Dr. Lahane - Latur, Dr. Ajay
Tilwe
9 OCCUPENTIONAL
HEALTH / SERVICE DOC-
TORS
Dr. Reelkar - Chiplun Dr. Salunkhe - Satara
10 MIS Dr. Bhondwe Avinash
11 WOMENS DOCTORS
WING
Dr. Vijaya Mali Mr. J adhav - Alibag Dr. Shrenik Patil
Dr. Maya Tulpule, Dr.
Sathye - Alibag
12 CONSTITUTION COM-
MITTEE
Dr. Suhas Pingle Dr. N. N. Murkey Dr. S. C. Mehtalia
13 NEW PREMISES / BUILD-
ING COMMITTEE
Dr. Ashok Adhao Dr. Anil Suchak
14 SAVE FEMALE CHILD
COMMITTEE
Dr. Ghole Dr. Somshekhar Patil
- Miraj
15 DASS COMMITTEE Dr. Y. S. Deshpande
16 AWARDS COMMITTEE Dr. J ayghosh Kaddu Dr. Bakulesh S. Mehta Dr. Sharangpani,
17 PROJ ECTS COMMITTEE Dr. Prakash Deo
18 COORDINATION STATE -
HQ COMMITTEE
Dr. Vijay C. Panjabi Dr. Milind Naik
19 ANTIQUACKERY CELL Dr. Ghanshyam Umre Dr. Kabra Anil
20 INFORMATION & COM-
MUNICATION
Dr. Lele Dr. J umnai
21 SERVICE DOCTORS
WING
Dr. Gaikwad - Beed
22 SPORTS COMMITTEE Dr. Mangesh Gulwade
23 MEDICAL TEACHEERS
+MEDICAL EDUCATION
COMMITTEE
Dr. Patwardhan
24 Political Liason Committee Dr. Sudhir Tambe Dr. Ravi Wankhedkar Dr. Rajendra Gandhi, Dr.
Chavan - Miraj, Dr. T. S.
J agtap, Dr. Kripal Desh-
pande
25 State Training Cordinator Dr. Metan Dr. Ram Aranakar Dr. Abhyankar Kolhapur
26 Clinical Establishment Act Dr. T. C. Rathod Dr. S. Mane -
Kurundwad
27 Hospital Owner Committee Dr. Shrotri - Satara Dr. J umani - Solapur
28 Geriatric Committee Dr. N. N. Murkey Dr. Prakash Khalap
SUB - COMMITTEE 2010 - 2011
War does not determine who is right - only who is left
84
IMA MS SOCIAL SECURITY SCHEME HON. SECRETARYS REPORT
Date: 17/06/2011.
- Te Scheme was launched on 1st October 1990.
- Te Eective membership as on 31st March 2011 5423+
65added from 1st April till today.
Total No. of death since 1990 145. In the year 2011-12 No.
of deaths 03 till today & the nominees of each of 03 expired
members is paid `. 3, 79,610/-.+ `. 3000/- Refund of Advance
Deposit.
Young members, do not over look the security of family,
thinking we are too young to die.
Mishaps & deaths can occur any time unpredictably.
Te younger you join the less you pay the more you accrue benet for your
members.
Request to members of the scheme :-
- Please keep the IMA MS SSS certicate in secured place with all FFC receipts.
- Please keep your nominee informed of your membership of the scheme & how to
act in case of
Unfortunate death to get the death claim amount.
- Please note FFC 2011have been received from 4000+ members, about 1234
members have yet to pay. Please note they have to make the payment Rs. 1300 FFC
+ Rs. 100/- Late fee+ ` 2000/- Advance Fraternity Contribution = Rs. 3500/- before
31st July 2011. No excuse of notice not received will be entertained.
Te members who have joined between 1st April 2010 to 31st March 2011 are
sent the notices to pay the dierence of Rs 2000/- payable towards the increased
Advance Fraternity Contribution. Tey do not have to pay FFC 2011. Te amount
of Rs 2000/- + Rs 100/- Late Fee= Rs 2100/- is payable by each of the new members.
97 members are yet to pay this amount. Te Reminder is being sent to them to pay
the same by the earliest.
Request to the President / Hon. Secretary of each Local Branch. :-
1) Please help us to get the Life Membership status of the demanded members
urgently. If they are not registered as life member get them enrolled immediately
and inform us. In case of their being non IMA life member, in case of death their
nominees will not be considered the beneciary.
2) Please incorporate the above matters in your news bulletins / correspondence to
members.
3) On death of any member inform & inquire with IMA MS O ce, whether he / she
was member of IMA MS SSS, if yes, please help in expediting the process of sending
death claim benet to the nominee.
4) Advise members to send proper amount as mentioned above along with lled in
Success is not permanent. The same is also true of failure
85
form with Xerox of age proof & IMA Life Membership certicate in case of new
membership. We will be sending you the list of non payers, please motivate them
to pay immediately.
5) IMA MS SSS recognizes the Best Working of Local Branches for propagation of
the SSS. Please enroll larger no. & receive award for your Branch.
6) Please note change of payment schedules. From 20th November 2010
Dr. Shrikant H. Kothari
Hon. Secretary, IMA MS Social Security Scheme.
Age Group Admission Fee Advance FFC Annual Subs.
2 yrs.
Total
Up to 30 years Complete Rs. 1000/- Rs. 3000/- Rs. 200/- Rs. 4200/-
30 yrs. Complete to 40 yrs. Rs. 2000/- Rs. 3000/- Rs. 200/- Rs. 5200/-
40 yrs. Complete to 50 yrs. Rs. 3000/- Rs. 3000/- Rs. 200/- Rs. 6200/-
50 yrs. Complete to 55 yrs. Rs. 4000/- Rs. 3000/- Rs. 200/- Rs. 7200/-
55 yrs. Complete to 60 yrs. Rs. 5000/- Rs 3000/- Rs. 200/- Rs. 8200/-
8888885555555 85
Report of IMA Nagpur Branch
The membership strength has now become 2117.
In the month of May , CMEs were organized on Asthma and COPD, A diabetes Detection camp and a
Seminar on Anti Tobacco Day was also conducted
A T 20-20 match also was won by IMA Nagpur.
Inaugural function of Asthma & COPDCME. Lighting of Samai by Dr. Pradeep
Rajderkar, IMA, President, Dr. Sanjay Deshpande Chairman, CME, Dr. Kishor
Taori, Past President, IMA and Dr. Avinash Wase, Hon. Secretary, IMA.
Dr. Pradeep Rajderkar, President & Dr. Avinash Wase, Hon. Secretary IMA,
Inaugurating the Camp. Dr. Sanjay Deotale, Imm. Past Secretary, Dr. Satkar Pawar
and Mr. Raju Kaware look on.
Shri. G. J . Akarte, Kishore J aiswal, Dr. Madan Kapre, Dr. Pradeep
Rajderkar. Adv. Rajendra Rathi and Dr. Avinash Wase at the inaugural
function.

The Cricket Team of IMA, Nagpur Winner of T20-20 Match
Confidence is the companion of success
86
Report of Professional Protection Scheme
Respected Sir,
Please nd enclosed herewith brief report of professional protection Scheme IMA MS for of ce
bearer meeting to be held on 18th June 2011 at Pune. Let me take this opportunity to thanks Dr.
Shirkant Kothari, Honble Secretary, IMA MS SSS and IMA MS of ce bearers for publishing
about IMA Schemes in FFC demand notices and appeal to all the of ce bearers and local branch
President/ Secretary / IMA Activist to propogate this scheme in their local branch area to make
the scheme successful in helping members in the event of unforeseen circumstances leading to
alleged medical negligence cases. We hereby request you to identify active IMA Members from
your local district branch who are wiling to work actively for IMA MS PPS so that members can
be serviced efectively and ef ciently in the event of any litigation against the members, and
create the source of nancial support. During the year ended on 31st March 2011 5% cash back of
annual fees to IMA Maharashtra State will be Rs. 43,122/- and an equal share of annual fees will
be paid to respective local branches. (List attached)
Thanking you
Dr. Krishna Parate Dr. Anand Kate
Chairman Co-Chairman
M: 09823050572 M: 09822278590
BRIEF REPORT
Up till now the scheme has dealt with many cases and notices received by members to their
satisfaction and fruitful outcome. To name a few
1.Pathologist Satara --- Consumer redressal forum Notice for false
positive HIV test.
2.Gynecologist & Anesthetist Nagpur --- Diabetic patients legal notice.
3.Orthopaedics Surgeon, Wardha --- Legal Notice for injection abscess
4.Physician - Cardiologist, Nagpur --- MMC Notice and District Consumer
Court Case
5.Gynecologist Laproscopist, Nagpur --- Criminal JFMC Court Case for
abdominal sepsis
6. Uro surgeon, Akola --- Legal Notice for death of patient after DJ stenting
7.Neuro Surgeon Akola --- Civil Court Notice for death of Head injury patient.
8.Surgeon, Nagpur --- Death of Patient of Head injury, Case in District Consumer Forum
Dr. Krishna Parate Dr. Anand Kate
Chairman Co-Chairman
Membership Growth 31/03/2010 31/03/2011 31/05/2011
330 429 477
Renewal notices sent to all
members before 28/02/2011
8 Members renewal
fees not received as
on 13/06/2011 (List
enclosed)
Members are
being persuaded
personally to send
renewal fees at
earliest before 30th
June 2011.
No. of Deletions
during the year
(List enclosed with
reason)
Fixed Deposits 12,00,000/- 20,00,000/- 30,00,000/-
To be trusted is a greater compliment than to be loved
87
Mission Pink Health Project.
IMA- MS Women Wing along with IMA Dhule has launched Mission Pink Health Project Anaemia
detection, treatment & prevention along with Adolescent Health Education Programme on World
Womens Day 8th March 2011.
Features of Project :
1. Medical Checkup.
2. Investigations- HB, Blood Group & RH.
3. Counselling of girls on Anaemia, Adolescent, Sex Education by informative talks, Power Point
Presentation (CD) & Question answer session.
4. Awareness creation with posters, slogans & Skit.
5. Health kit distribution containing 100 tablets of lron, Folic Acid, Vitamin-C & Albendzole Tablet,
Protein Powder, Sanipad, Nail Cutter, Soap etc. to each girl.
6. Record keeping with health card & followup after three months.
7. Special investigations for girls with severe Anaemia or any other disorder.
Same project will be implemented throughout Maharashtra with the help respective branches of IMA.
The special educational C.D. is prepared for the project & sent to you.
Shirpur project is sponsored by M.L.A., Mr. Amrishbhai Patel the same project will be implemented
throughout Maharashtra with the help of respective branches of I.M.A. You are requested to implement
this project throughout the year in your area. Help of local NGO & Govt. Organsation can be taken.
Lets join hands tighter to ght Anaemia & make Mission Pink Health a grand success!
Thanking you,
Yours Sincerely,
Dr. Jaygosh Kaddu Dr. Jayesh Lele Dr. Ravi Wankhedkar Dr. Vijaya Mali
President Hon. Secretary Co-ordinator Chairperson
WEST ZONE REGIONAL CONFERENCE OF IMA CGP
HOSTED BY IMA MAHARASHTRA STATE
Friends,
President, Secretary, Of ce Bearers & Director of IMA CGP Maharashtra State, Dr. Anil
Pachnekar announces Regional Conference of IMA CGP to be held on Sunday, 18th September
2011 at HOTEL J. W. MARRIOTT from 9 am to 5 pm.
Distinguished National & International acclaimed speakers will participate for panel discussions,
debates to enlighten you on the latest perspectives in medicines.
Please keep your date with us on 18th September 2011 at Hotel J. W. Marriott for CGP IMA MS.
DR. VINAY AGGARWAL DR. D. R. RAI DR. JAYAGHOSH KADDU
National President Hon. Secretary General State President
DR. JAYESH LELE DR. ANIL PACHNEKAR DR. SHIVKUMAR UTTURE
Hon. State Secretary Director IMA CGP (MS) Organizing Secretary (MS)
Detail programme will follow soon.
Kindly register earliest in IMA Mumbai Branch or in IMA Maharashtra State.
It is a one full day conference.
Delegate charges for Mumbai Rs. 500/-.
Delegate charges out of Mumbai Rs. 300/-.
MMC ACCREDITATION CREDIT HOURS FOR CONFERENCE HAVE BEEN
APPLIED.
Hard work has made it easy. That is my secret. That is why I win
88
HFC RATES FROM 1ST APRIL 2010
WHY JOIN IMA?
1. By joining IMA you become one of the member of the largest N. G. O. in India.
2. You have an access to the very well run schemes by your state branch.
3. Medico Legal cell helps you to solve your medico Legal problems
4. Social Security Scheme (1 of Maharashtra State 2. National) run for last 15 years are a real
help in 4 case of an unfortunate death.
5. Group Health Insurance scheme is available for major illnesses & high medical expenses ,
professional protection scheme.
Please attach a copy of MMC Reg. Certicate with Life Membership form & Marriage
Certicate in case of Couple Life Membership.
BRANCH CAN COLLECT ADDITIONAL AMOUNT THAN HFC AS DECIDED BY GENERAL
BODY / MANAGING COMMITTEE FOR THE BENEFIT OF CORPUS OF THE BRANCH
IMA Mumbai West Building, 2nd Floor, Behind Chandan Cinema
J.R. Mhatre Marg, J.V.P.D. Scheme, Juhu, Mumbai - 400 049
Tel. (022) 26232965 / 65215756, Fax : (022) 26233890
Email :- imamsmumbai@yahoo.co.in / Website :- imamaharashtrastate.org
CATEGORY STATE SHARE H.Q. SHARE TOTAL
Annual Single 95 243 338
Annual Couple 131 338 469
Life Single 1420 3650 5070
Life Couple 1970 5065 7035
New Br.Formation 25 25 50
The 2nd Congress on Womens Health and Diseases under
the aegiss of IMA MS, a two day academic feast which includes
Workshops, plenary Sessions, Orations debates and panel
discussions along with rib tickling Cultural pragrammes have
been arranged in Pune The Oxford of East has been organized by IMA Pune from 8th and
9th of October 2011.
This is a golden opportunity for all health care professionals to update themselves on
various aspects of health issues of women.
Everyone is gifted - but some people never open their package
83
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