GYNAECOLOGY

Rotterdam 2003 Criteria For Diagnosis Of

PCOS/PCOD at Least 2 Out Of 3 Should Be
Present:
1. Oligo/Anovulation
2. Hyperandrogenism: Biochemical Or Clinical
3. 12 Or More Than 12 Follicles 2-9 Mm In Size
Present Within One Or Both Ovaries On USG
(NECKLACE OF PEARL PATTERN)
 Hyperthecosis (increase testosterone from the
ovaries)

Defective aromatization within the ovaries

(hyperandrogenic microenvironment within
the ovaries)

Normal aromatization in periphery

(unopposed estrogenic action as there is no
progesterone due to anovulation)
 Sr FSH & LH should always be done on Day 2 or 3
of the menstrual cycle.

Normal ratio of FSH/LH= 2:1

In PCOS the ratio is 1:2 OR 1:3

Sr FSH (done on day 2 or 3 of the menstrual cycle)

is the MARKER FOR OVARIAN RESERVE
Ovulation Induction Agents
1. Clomiphene citrate (CC)
2. Letrozole
3. Gonadotropins : HMG (Human Menopausal
Gonadotropin) (from the urine of the menopausal
women) and recombinant FSH.

Multiple pregnancies:
3-8% with CC
15-30% with Gonadotropins
Insulin resistance (IR) is considered to be the hallmark
in pathophysiology of PCOS

MC used drug = metformin

Metformin will help the patient in weight reduction and
will increase the success of ovulation induction drugs

MC side effects: nausea/vomiting and bloating (GI

upset)

Most dangerous side effect: lactic acidosis

 Laparoscopic ovarian drilling (LOD) or
laparoscopic electrocoagulation of ovarian
surface (LEOS)
 Definition: Presence of functional endometrium at
places other than uterus
(ectopic endometrial tissue)
MC sites in order of frequency:
1. Ovaries (ovarian endometriosis =
endometrioma = chocolate cyst of the ovaries)
2. POD
3. Uterosacral ligaments
Laparoscopy is the Investigation of Choice
Laparoscopy findings are:
Chocolate cysts
Powder burn spots
Matchstick burnt spots
Blueberry lesion
Red/purple raspberry lesion
White lesion
Red/flame lesion
Subovarian adhesions
Surgery:
Patients with infertility: laparoscopic ovarian
cystectomy, adhesiolysis & electrocoagulation
of endometriotic implants

Medical Management:(induce amenorrhea)

1)OC pills, DMPA ,POP, and Mirena
2) Danazol
3) GnRH analogues (most common drug used
for medical management)
 Count: 20 million/ml

Motility: 50% or more with forward

progressive motility

Morphology: 30% or more sperms

should be morphologically normal
Aspermia: absence of semen
Azoospermia: zero sperm count

Asthenospermia: less than 50% sperms with

forward progressive motility.

Oligozoospermia: count less than 20 million/ml

Teratospermia: >70% abnormal forms

 Sr. FSH level estimation helps determine
the site of pathology:
A very high FSH would indicate a testicular
cause.
A very low FSH would indicate pretesticular
(hypothalamic/pituitary)
cause.
A normal FSH would indicate a post-
testicular cause.
Indications:
1. Male factor infertility (sperm counts between 5 and 20
million/ml). If sperm count is less than 5 million/ml, IUI is
ineffective
2. Unexplained infertility (treatment of choice is
superovulation + IUI)
3. Antisperm Antibody in cervical mucus
4. Semen deposition problem
(ED/epispadias/hypospadias/penile deformities)
5. Vaginismus

Patent fallopian tube is prerequisite.

If fallopian tubes are blocked, IUI should not be done.
 Indications:
Tubal pathology/blocks
Male factor: count less than 5 million/ml

Basic steps of IVF:

Ovarian stimulation with gonadotropins
Oocyte retrieval (ovum pickup)
Fertilization: 50,000 sperms are put on each oocyte
Embryos kept in incubator for 48-72 h
ET done on day 2 or day 3 (48-72 h) after oocyte retrieval
Generally 3-4 embryos are transferred in the uterine cavity
Success rate of IVF per cycle is 30-35%
Indications:
1. Severe oligo-astheno-teratospermia
2. Repeated fertilization failure in IVF

The steps are identical to IVF (oocyte retrieval

and embryo transfer), but for fertilization, one
sperm is mechanically injected into one oocyte.
Success rate of ICSI per cycle is 30-35%.
In absence of secondary sexual characters, no menses till
the age of 14 years or
In presence of secondary sexual characters, no menses till
the age of 16 years
MC cause of primary amenorrhea:
1) Ovarian dysgenesis/Turner syndrome.
2) Rokitansky-Mayer Kustner-Hauser or Mullerian agenesis
3) Androgen Insensitivity syndrome or testicular feminizing
syndrome (AIS/TFS) .
Each and every case of primary amenorrhea karyotyping
should be done.
Non-contraceptive uses of condom include.
a. Prevention of STDs
b. Condom catheter in males
c. To cover the TVS probe
d. After vaginoplasty
e. Shivkars pack (condom tamponade) for atonic
PPH.
f. In cases of antisperm antibodies present in
cervical mucus
 CATEGORY 1 : INDICATIONS
CATEGORIES 2 & 3 : RELATIVE CONTRAINDICATIONS
CATEGORY 4 : ABSOLUTE CONTRAINDICATIONS
 First:inert devices : Lippes loop
Second: all the copper-containing
devices
Third: hormonal devices : Progestasert
and Mirena
 PROGESTASERT : 38 mg of progesterone 65
g/day.
life span = 1 year.
Increases the risk of ectopic pregnancy (as it
decreases tubal motility).
MIRENA=LNG IUD=LNG 20=LEVONOVA
Mirena : 52 mg levonorgestrel. 20gm/day. 5
years.
Failure rate= 0.09 %
1. Reduction of blood loss, which benefits
patients with anemia and DUB
2. Reduction of pain and dysmenorrhea in
endometriosis and adenomyosis
3. Beneficial effect on fibroids
5. Can be used in prevention and treatment of
endometrial hyperplasia
6. Decreases the risk of endometrial cancer.
7. Decreases the risk of PID and hence protects
against ectopic pregnancy
 STANDARD DOSE=50 MICROGRAM/pill

LOW DOSE = 30 MICROGRAM/PILL

VERY LOW DOSE = 20 MICROGRAM/PILL

 Cure of menstrual disorders:dysmenorrhea,
Menorrhagia, irregular periods
Protection against cancer: endometrial ,ovarian colon
cancer.
Benign breast diseases
Ovarian functional cysts
Fibroids
Ectopic pregnancy ( decrease PID )
Endometriosis
Acne and hirsutism (PCOS)
Premenstrual syndrome
1. Depot medroxyprogesterone acetate (DMPA)
2. Norethisterone enanthate (NET EN )
DMPA (150 mg) remains effective for 3 months.
NET EN injection is to be taken every 2 months

Failure rate : 0.1-0.4%

Benefits : SAME AS MIRENA +

DMPA prevents sickling : the best contraceptive for patients
of sickle cell anemia.
DMPA use protects ovarian cancer.
Indications:
1. Unplanned , unprotected
intercourse
2. After rape
3 Rupture or tear in the condom at
the time of intercourse
(1) inhibition or delay of ovulation,
(2) prevention of implantation (interception
= main action)
(3) prevention of fertilization .
They cannot interrupt already established
pregnancy. (cannot cause abortion)
Hormonal and Mechanical
There are two types of hormonal emergency
contraception (emergency window = 72 hours)

1. LNG-only pills (most commonly used)

One tablet of 0.75 mg LNG followed by a same dose
taken 12 h later OR Single dose of 1.5 mg
2. COC Pills (Yuzpe Regimen)

IUDs can be used postcoitally up to 5 days following

sexual exposure.
Medical method for first trimester MTP
It is now officially allowed in India up to 9 weeks
(63 days) of gestation.
Method: combination of RU486 followed by
PGE1(MISOPROSTOL)

Surgical Technique (Suction Evacuation/MVA)

It is allowed up to 12 weeks of gestation.
SECOND TRIMESTER MTP (13-20 WEEKS)
1. Misoprostol (PGE1) tablet vaginally

2. Ethacridine lactate extra-amniotically

Note: Intra-amniotic saline/mannitol/urea, etc.

are no longer used because of risk of
maternal mortality.
It can be done by laparotomy or laparoscopy.
The following are the laparotomy methods:
1. Pomeroy technique(MC): 1 in 300-400
2. Irving technique: 1 in 1000
3. Uchida technique: no failure
5. Madlener technique: 0.3-2%
6. Parkland technique: 1 in 400

Least failure rate = Uchida followed by Irwing.

Silastic bands: most commonly used for
laparoscopic tubal ligation followed by Clips.
Cautery no longer used.

Failure rate of laparoscopic TL= 0.2-1.3%.

The intra abdominal pressure during laparoscopy

surgery should be kept between 10-15 mmHg
An Isthmo-isthmic anastomosis most suitable for
reversal.

MOST SUITABLE FOR REVERSAL:

1)CLIPS
2)silastic bands
3)Pomeroy ligation

CAUTERY is least suitable for reversal

Indications for HRT:

Menopausal symptoms such as hot flushes,

vaginal dryness.

Prevention and treatment of osteoporosis

Decreased libido.

HRT is not given for primary prevention of

heart disease.
The different hormones used are:
1. Estrogen (E) and progesterone
(P) combination.
2. Testosterone + P
3. Tibolone (E,P,A)
4. Raloxifene (SERM)=DEC OP.
INC VTE , worsen hot flushes
TRUE :

Uterosacral and cardinal ligaments.

Levator ani muscle (pelvic floor)
Perineal muscles forming perineal body

FALSE:
Broad & Round ligament.
Fothergills repair (Manchester operation): Main
step is amputation of cervix.
Various complications include:
a. Primary/secondary hemorrhage
b. Repeated second trimester abortions due to
cervical incompetence
c. Preterm labor/PROM
d. Cervical stenosis
e. Cervical dystocia
f. Infertility due to cervical factor
Abdominal (Sling Surgery/Cervicopexy)
2 ends of tape anchored to :

Purandare = Rectus Sheath

Shirodkar = Sacral Promontary

Khanna = ASIS
Post surgery, the uterus becomes retroverted and the POD
becomes deep. Hence, enterocele is a long-term
complication of PURANDARE surgery.

SHIRODKAR:
a. Injury to sigmoid colon, mesentery, and ureters
b. Hemorrhage from pre sacral/mesenteric vessels
c. Intestinal obstruction
d. Injury to genitofemoral nerve
Bladder neck descent :

Bladder neck suspension procedures:

Kellys
MMK :MarchettiMarshalKrantz
Bursch
 Prolonged and obstructed labor is the MC cause of
VVF in India.

In developed countries, the MC cause is post

surgery.

Patients with VVF present with continuous

incontinence .

Method of closure of fistula: LAYER technique

 It is almost always a secondary infection, with
primary site being lungs (MC)
Hematogenous route is the MC mode of spread
Bilateral fallopian tubes are involved in almost
100% of the cases.
Ampulla is the most commonly affected.
Uterus is involved in 80% of the cases.
Cornu of the uterus is commonly affected
 Genital tuberculosis falls in category 1.

Four-drug AKT =H,R,Z,E

Four drugs are given for 2 months, and 2 drugs (H,R) are
given for 4 months

Surgery for restoration of fertility (corrective tuboplasty) is

contraindicated

IVF after completion of AKT is the treatment for infertility

Risk factors for CA cervix/CIN:
a. Young age at first intercourse (<16 years)
b. Multiple sexual partners
c. Cigarette smoking
d. Race
e. High parity
f. Low socioeconomic status
g. Human papillomavirus (HPV) infection
h. HIV
i. Immunosuppression
 If the PAP smear shows Dysplasia

Colposcopic-Guided Cervical Biopsy

If a patient presents with obvious fungating

growth on lips of cervix

Punch Biopsy.
CIN I = Wait and watch/follow up
CIN II = Cryosurgery
CIN III :
If patient wants to conserve the uterus/desirous of
further child bearing = LEEP/LLETZ
(Loop electro-excision procedure/large loop
excision of transformation zone)

If the family is complete or if the patient is not

ready for regular follow-ups :
simple hysterectomy
 Conization/cone biopsy
Diagnostic:
If there is a mismatch between cytology and
histology.
(If PAP smear is abnormal but cervical
biopsy is normal)
Therapeutic :
Stage 1A1 microinvasive cervical cancer
(in young patients, to preserve the uterus)
All stages (I-IV) are radiosensitive.
Stages of Ca cervix that are operable are 1A2, IB, and IIA.
Stages IIB-IV are not operable and have to be treated with
RT only.
1A2, IB, IIA are radiosensitive and surgically operable, but
surgery is preferred over RT for these stages for the
following reasons:
a. Preservation of ovarian function
b. Preservation of vagina for coital function
c. Psychological benefit to the patient
Ca cervix almost never spreads to ovary and so when
radical hysterectomy is done, oophorectomy is not
required.
COC,POP,DMPA,MIRENA,PREGNANCY=
PROTECTIVE
 Advancing age (average age 60 years)
Early menarche and late menopause
Family history of ovarian cancer
Incessant ovulation (greater risk if more ovulatory cycles)
Personal/family history of breast CA
Multiple cycles of gonadotropins/clomiphene citrate for
ovulation induction
BRCA 1 & 2
LYNCH 2 SYNDROME
Factors Reducing the Risk of Ovarian
Cancer:
Use of OC pills/DMPA/POP
Multiparity
Breast feeding
Pregnancy
 E.S.T/yolk sac tumor AFP

Epithelial ovarian tumors CA-125

Dysgerminoma LDH

Granulosa cell tumor INHIBIN

Serous Epithelial tumors Psammoma bodies
Clear cell tumors Hobnail cells
Endodermal sinus tumor Schiller-Duval bodies
Granulosa cell tumors Call-Exner bodies
Leydig (hilus) cell tumors Reinkes crystals
Krukenberg tumor Signet ring cells
 PREGNANCY
MENSES
ENDOMETRIOSIS
ACUTE PID
GENITAL TB
FIBROIDS
They are the MC benign tumors of uterus
MC pelvic tumors in females.
1. Estrogen-dependent tumors:
a. Early menarche, late menopause
b. Associated anovulation and PCOS
c. Growing in size during pregnancy, and following
menopause there is cessation of growth
2. Nulliparity (a uterus which does not bear a baby
consoles itself by having a fibroid)
More common in colored races

Infertility: Fibroids can cause infertility

and infertile women are more prone to
develop fibroids

Smoking is protective for fibroids.

Hyaline degeneration is the MC type, and sarcomatous
is the least common variety.

Sarcomatous degeneration occurs in 0.1-0.5% cases.

The majority of fibroids remain asymptomatic.

Menorrhagia is the classic symptom of symptomatic

fibroids.

USG is the investigation of choice for fibroids.

Drugs which decrease the size of fibroids :
1. GnRH analogs (MC used)
2. Danazol
3. Progesterone
(DMPA/Mirena/POP/low-dose OC pills)
4. Mifepristone (RU-486)