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  • 1. JEFFCOATE’S PRINCIPLES OF GYNAECOLOGY
  • 2. JEFFCOATE’S PRINCIPLES OF GYNAECOLOGY Seventh International Edition Revised and updated from the sixth edition by Pratap Kumar MD FICOG Prof. and Head, Department of Obstetrics and Gynaecology Kasturba Medical College, Manipal, Karnataka (India) Narendra Malhotra MD FICOG Consultant and Director MNMH (P) Ltd., Agra Apollo Pankaj Hospital (P) Ltd., Agra (India) President, Federation of Obstetric and Gynaecological Societies of India-2008 JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi • Ahmedabad • Bengaluru • Chennai • Hyderabad • Kochi • Kolkata • Lucknow • Mumbai • Nagpur ®
  • 3. Published by Jitendar P Vij Jaypee Brothers Medical Publishers (P) Ltd B-3, EMCA House, 23/23B Ansari Road, Daryaganj New Delhi 110 002, India Phones: +91-11-23272143, +91-11-23272703, +91-11-23282021, +91-11-23245672, Rel: +91-11-32558559 Fax: +91-11-23276490, +91-11-23245683 e-mail: jaypee@jaypeebrothers.com Visit our website: www.jaypeebrothers.com Branches • 2/B, Akruti Society, Jodhpur Gam Road Satellite Ahmedabad 380 015 Phones: +91-79-26926233, Rel: +91-79-32988717, Fax: +91-79-26927094 e-mail: ahmedabad@jaypeebrothers.com • 202 Batavia Chambers, 8 Kumara Krupa Road, Kumara Park East Bengaluru 560 001 Phones: +91-80-22285971, +91-80-22382956, +91-80-22372664, Rel: +91-80-32714073 Fax: +91-80-22281761 e-mail: bangalore@jaypeebrothers.com • 282 IIIrd Floor, Khaleel Shirazi Estate, Fountain Plaza, Pantheon Road Chennai 600 008 Phones: +91-44-28193265, +91-44-28194897, Rel: +91-44-32972089 Fax: +91-44-28193231 e-mail: chennai@jaypeebrothers.com • 4-2-1067/1-3, 1st Floor, Balaji Building, Ramkote Cross Road Hyderabad 500 095 Phones: +91-40-66610020, +91-40-24758498, Rel:+91-40-32940929 Fax:+91-40-24758499, e-mail: hyderabad@jaypeebrothers.com • No. 41/3098, B & B1, Kuruvi Building, St. Vincent Road Kochi 682 018, Kerala Phones: +91-484-4036109, +91-484-2395739, +91-484-2395740 e-mail: kochi@jaypeebrothers.com • 1-A Indian Mirror Street, Wellington Square Kolkata 700 013 Phones: +91-33-22651926, +91-33-22276404, +91-33-22276415, Rel: +91-33-32901926 Fax: +91-33-22656075, e-mail: kolkata@jaypeebrothers.com • Lekhraj Market III, B-2, Sector-4, Faizabad Road, Indira Nagar Lucknow 226 016 Phones: +91-522-3040553, +91-522-3040554 e-mail: lucknow@jaypeebrothers.com • 106 Amit Industrial Estate, 61 Dr SS Rao Road, Near MGM Hospital, Parel Mumbai 400012 Phones: +91-22-24124863, +91-22-24104532, Rel: +91-22-32926896 Fax: +91-22-24160828, e-mail: mumbai@jaypeebrothers.com • “KAMALPUSHPA” 38, Reshimbag, Opp. Mohota Science College, Umred Road Nagpur 440 009 (MS) Phone: Rel: +91-712-3245220, Fax: +91-712-2704275 e-mail: nagpur@jaypeebrothers.com Jeffcoate’s Principles of Gynaecology © 2008, Arnold All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the editors and the publisher. This book has been published in good faith that the material provided by editors is original. Every effort is made to ensure accuracy of material, but the publisher, printer and editors will not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only. First Edition : 1957 Fifth Edition : 1987 Sixth Edition : 2001 Seventh Edition : 2008 ISBN : 978-81-8448-288-1 Typeset at JPBMP typesetting unit Printed at Ajanta
  • 4. Preface to the Seventh International Edition We both, Dr Prof Pratap Kumar and Dr Narendra Malhotra feel very honoured for being asked to revise the best textbook on gynaecology by Sir Norman Jeffcoate. In the rapidly advancing age of technology and rapidly changing trends in management, diagnosis, drugs and procedures, it is of paramount importance to update books and manuals periodically. This book was earlier updated and edited by Dr Neerja Bhatla in the year 2001, an International Edition (Sixth edition), but soon the publishers felt the need for revising it within a span of five years. Prof Norman had expressed in 1974 that he had endeavoured to preserve his personal approach. We have added many new chapters and rewritten a few chapters all together trying to maintain Sir Jeffcoate’s style. We have retained the description of Professor Jeffcoate’s original case discussions, photographs and pictures. We hope that the undergraduate and the postgraduate students will appreciate our efforts to update this “Bible” of Gynaecology. Pratap Kumar Narendra Malhotra 2008
  • 5. Preface to the Fifth Edition It was inevitable that following Professor Sir Norman Jeffcoate’s retirement there would be pressure to continue to publish the Principles of Gynaecology. In the last revision in 1974 Sir Norman emphasised that he had endeavoured to preserve his personal approach, bearing in mind the objectives and principles outlined in the preface to the First Edition. In addition, some of Sir Norman’s comments in the preface to his Fourth Edition are included to emphasize the guidelines the present author has taken in an attempt to maintain the format of the Principles of Gynaecology. Much of the material presented is retained from the last edition, since it also reflects the gynaecological training of the author under Professor Jeffcoate in Liverpool. The views expressed are therefore personal ones from a pupil of Sir Norman Jeffcoate against the background of all the information available. Once given, the views expressed mean that references are excluded for the special reasons given in the preface to the First Edition. In the process of being taught obstetrics and gynaecology by Sir Norman, one was encouraged to consider all the facts about a case, to come to a conclusion and to be able to justify it. Even though a critical approach to each case was expected, we were never allowed to forget that we were dealing with a woman, mother or child with a personal problem. Indeed, Professor Jeffcoate’s personal approach was such that in a clinic with many students and postgraduates present, it was obvious that as far as the patient was concerned Sir Norman was the only person there. I have never been able to achieve the same effect, but I hope that my efforts in revising this book will be acceptable to an outstanding teacher, guide and friend. If so, then I am sure it will benefit all those who read it. Victor Tindall 1986
  • 6. Extracts from the Preface to the First Edition The book is meant to add to rather than replace clinical and tutorial instruction, so those matters which can best be taught beside the patient, or which are easy for any student to learn and understand from other sources, receive little attention. In planning the text I recalled those subjects which I myself found (and still do find) difficult to master, or on which I had to search far and long for information, and gave them disproportionate emphasis. This and other considerations resulted in a disregard for the relative importance - as judged by their clinical frequency -of different conditions. Indeed, the reader will find that quite rare conditions are mentioned, illustrated or described at length; and that all manner of asides - even some with an obstetrical flavour — creep in. This is partly because they are of special interest to me but mainly because they appeared to offer scope for presenting an attitude of mind; for discouraging loose thinking and empiricism; for inculcating a scientifically and ethically honest outlook; for emphasising the Art as well as the Science of gynaecology. I have not played safe by stating only generally accepted views, nor have I played fair by giving the differing views of various authorities. Instead, after weighing the evidence, I have attempted to reach a conclusion which satisfies me as being as rational as present knowledge allows. Without intended disrespect, mention by name of authors and workers has been avoided as a rule; references clutter up the text, destroy continuity and are hardly ever used properly. On the other hand, I have not hesitated to give my own views and have, at times, been more dogmatic than clinical experience ever really justifies. I have even gone so far as to enunciate ideas which in many respects are conjectural if not fanciful. I do not expect these all to be accepted; if they are I shall be disappointed because their object is to provoke trains of thought and discussion. In offering this book to fellow students I remember with affection and gratitude W Blair-Bell, one of the great gynaecologists of this century. He not only taught me gynaecology and a particular approach to it, he taught me to think and to write. He, more than anyone else, provided me with the stimulus and the opportunity to obtain the experience which has led to this work. Norman Jeffcoate 1957
  • 7. Acknowledgements A mammoth project like revising Sir Norman Jeffcoate’s Principles of Gynaecology requires lots of help from colleagues. We are grateful to all those who have helped us to do this mammoth job. Special appreciation and thanks are to: 1. Thank you doctors and staff of Department of Obstetrics and Gynaecology, Kasturba Medical College, Manipal, Karnataka. 2. Thank you junior doctors of MNMH (P) Ltd. and Apollo Pankaj Hospital (P) Ltd, Agra. 3. Our special thanks to the following, who have given valuable suggestions in various chapters: Prof Barun Sarkar, Prof Arun Nagrath, Dr Richa Singh, Dr Anju Sharma, Dr Alka Saraswat, Dr Jaideep Malhotra, Dr Anupam Gupta and Dr Neharikaa of Agra, Dr Sunder Rajan (Pondicherry), Dr Kavita Singh (Jabalpur), Dr Col R Puri (Jalandhar), Dr Sakshi Tomar (PGI Lucknow), Dr Maninder Ahuja (Faridabad). 4. Special thanks to Dr Pranay Shah of Mumbai for contributing Chapter on Laparoscopy and Dr Richa Saxena for editing the manuscript. We both are thankful to our families for bearing with us and sharing family time for work like this. Thank you Vidya, Dr Prabha Malhotra, Dr Jaideep Malhotra, Deepali, Deepika, Dr RM Malhotra, Kehsav and Neharikaa. We hope that our efforts will be appreciated.
  • 8. 1. A Clinical Approach to Gynaecology................................................................................................................ 1 2. Anatomy ............................................................................................................................................................... 21 3. Ovarian Functions............................................................................................................................................... 56 4. Menstruation and Other Cyclical Phenomena .............................................................................................. 79 5. Clinical Aspects of Menstruation and Ovulation ......................................................................................... 88 6. Puberty and Adolescent Gynaecology .......................................................................................................... 111 7. Conception ......................................................................................................................................................... 120 8. Spontaneous Abortions (Including Recurrent Loss) .................................................................................. 131 9. Ectopic Pregnancy ............................................................................................................................................. 142 10. Gestational Trophoblastic Disease................................................................................................................ 160 11. Breast Function and its Disorders .................................................................................................................. 174 12. Development of the Urogenital System ....................................................................................................... 189 13. Malformations and Maldevelopments of the Genital Tract ..................................................................... 196 14. Sex Determination, Asexuality and Intersexuality..................................................................................... 219 15. Injuries ................................................................................................................................................................ 251 16. Pelvic Organ Prolapse ...................................................................................................................................... 275 17. Other Displacements of the Uterus ............................................................................................................... 293 18. Torsion of Pelvic Organs ................................................................................................................................. 304 19. Infections Including STD ................................................................................................................................ 308 20. Infections as They Affect Individual Organs .............................................................................................. 333 21. Genital Tuberculosis ........................................................................................................................................ 361 22. Endometriosis and Allied States .................................................................................................................... 365 23. Polycystic Ovary Syndrome ............................................................................................................................ 384 24. Hirsutism ............................................................................................................................................................ 394 25. Epithelial Abnormalities of the Genital Tract ............................................................................................. 400 Contents
  • 9. Jeffcoate’s Principles of Gynaecology xii 26. Genital Cancers ................................................................................................................................................. 427 27. Tumours of the Vulva ...................................................................................................................................... 440 28. Tumours of the Vagina .................................................................................................................................... 456 29. Tumours of the Cervix Uteri ........................................................................................................................... 464 30. Tumours of the Corpus Uteri .......................................................................................................................... 487 31. Tumours of the Fallopian Tubes .................................................................................................................... 517 32. Tumours of the Pelvic Ligaments .................................................................................................................. 521 33. Tumours of the Ovary ...................................................................................................................................... 524 34. Chemotherapy in Gynaecological Malignancies ........................................................................................ 561 35. Radiotherapy in Gynaecological Malignancies .......................................................................................... 568 36. Immunotherapy in Obstetrics and Gynaecology........................................................................................ 573 37. Amenorrhoea, Hypomenorrhoea and Oligomenorrhoea .......................................................................... 579 38. Abnormal and Excessive Uterine Bleeding.................................................................................................. 598 39. Dysmenorrhoea ................................................................................................................................................. 617 40. Premenstrual Syndrome and Other Menstrual Phenomena ..................................................................... 627 41. Hormone Therapy in Gynaecology ............................................................................................................... 637 42. Vaginal Discharge............................................................................................................................................. 656 43. Pruritus Vulvae and Vulvodynia ................................................................................................................... 662 44. Low Backache and Chronic Pelvic Pain ........................................................................................................ 676 45. Problems of Sex and Marriage ....................................................................................................................... 681 46. Infertility and Assisted Reproductive Technology .................................................................................... 699 47. Instruments and Gynaecological Procedures .............................................................................................. 731 48. Ultrasonography in Gynaecology .................................................................................................................. 741 49. Endoscopic Surgery in Gynaecology............................................................................................................. 767 50. Contraception .................................................................................................................................................... 784 51. Sterilisation and Termination of Pregnancy................................................................................................ 824 52. Urinary Problems .............................................................................................................................................. 839 53. Menopause ......................................................................................................................................................... 862 54. Hysterectomy and its Aftermath .................................................................................................................... 884 55. Conditions of the Lower Intestinal Tract ..................................................................................................... 890 56. Preoperative and Postoperative Management: Postoperative Complications....................................... 899 57. Nutrition in Women from Adolescence to Menopause ............................................................................. 925 58. Exercise and Physiotherapy in Gynaecology............................................................................................... 946 Index ..................................................................................................................................................................... 953
  • 10. Gynaecology (from the Greek gyne, woman, and logos, discourse) is the study of woman but usage restricts it mainly to the study of the female organs of reproduction and their diseases. This is convenient although the dividing line between gynaecology and other branches of medicine is ill defined, and varies from time to time and from clinic to clinic according to advances in knowledge, to custom and to local working conditions. At one time, the breasts were wholly within the domain of the gynaecologist but now the general surgeon deals with certain breast disorders, and the gynaecologist and obstetrician with the others. The genital tract is so closely linked, embryologically and anatomically, with the urinary tract and the large bowel that certain conditions of the urethra, bladder and rectum come to a greater or lesser extent within the province of the gynaecologist. The whole endocrine system is concerned with the control of genital functions while the psyche and sex are inseparable. It may be added that, according to definition, obstetrics (the study of childbirth and its disorders) is merely one aspect of gynaecology and, in practice, the two cannot properly be separated. These points merely serve to emphasise that it is impossible to consider the reproductive system except in relation to the remainder of the body, and that it is necessary to interpret gynaecology in the widest sense. Woman is more than just a container for a uterus and ovaries. The development of the highly specialised gynaecological surgeon improves operative technique but may also engender a narrow and harmful outlook. Such a specialist can become a craftsman first and a doctor second. The woman who seeks advice for discomforts related to the genital organs is not usually in need of an operation: her need is understanding - understanding the woman as a whole - her outlook, her achievements and failures, her domestic and social, as well as sexual, problems. The care of the whole woman will be threatened by the development of subspecialties such as gynaecological endocrinology, foetal medicine, gynaecological oncology and gynaecological urology, unless proper basic training in obstetrics and gynaecology remains a prerequisite to subspecialisation. These developments are justified only in a few centres, to promote growth of knowledge and expertise; otherwise they deprive the woman of the person she can look to for help at any time, one whom she knows has a personal interest in, and responsibility for, her welfare. “Mulier est hominis confusio,- Madame, the sentence of this Latin is, ‘Woman is mannes joye and all his bits’.” - CHAUCER A Clinical Approach to Gynaecology1C H A P T E R Psychosomatic and Sociological Aspects of Gynaecology 2 Clinical Methods 2 Special Tests and Accessory Aids to Diagnosis 12
  • 11. Jeffcoate’s Principles of Gynaecology 2 Although covering all aspects of the physiology of the female genital tract, gynaecology is basically a clinical discipline and gynaecologists need to be primarily clinicians. PSYCHOSOMATIC AND SOCIOLOGICAL ASPECTS OF GYNAECOLOGY Environment can cause or aggravate physical and mental ill health; the psyche influences the develop-ment of organic disease in all parts of the body; illness begets anxiety and this in turn begets illness; the reactions of doctor, relatives and friends to illness can determine recovery or chronic invalidism. These are not new discoveries but are as old as the practice of medicine. Psychosomatic medicine and social medicine are merely new names for old arts which are practised almost automatically by the good doctor and which find an important place in gynaecology. Thus, menstruation can be inhibited for many months by a subconscious need to attract attention, by a desire for pregnancy and by a change in occupation or in living conditions. On the other hand, menstruation may be precipitated by excitement and can become regularly excessive in response to nervous tension and domestic disharmony. A woman may develop pelvic symptoms to escape the advances of her husband. Painful menstruation, painful coitus and the like frequently have fear, resentment or guilt over genital functions as their basis - inculcated possibly by impressions and experiences gained during childhood. Obesity is much more likely to be a manifestation of an anxiety state or bad habit than evidence of endocrine disturbance. Many women, when worried, find solace in eating and drinking; if they are sleepless, they have longer hours in which to solace themselves. A woman faced with unwanted responsibilities, or with any distasteful situation, may try to escape by blaming her genital organs about which there remains an air of mystery which secures for her the sympathy of other women and of the oversolicitous husband. A gynaecologist must be a psychologist although not necessarily a trained psychiatrist. If the part played by emotional and environmental factors in pelvic disease is recognised, only experience and wisdom are required to elicit them. The majority of women are unconscious of these factors in their illness and, when made aware of them by sympathetic explanation, encouragement and tact, can adjust themselves to ensure a cure. There are a few, however, who deliberately set out to deceive and go to such lengths to achieve their objective that they are not easily found out. Take for example the following rare case: A married woman aged 30 years, with two children, complained of recurrent and persistent vaginal bleeding which failed to respond to several lines of treatment. Ultimately her uterus was removed, whereupon the bleeding continued and was found to be coming from vaginal ulcers which refused to heal even when repeatedly excised. It was then proved that she deliberately injured the vagina to make it bleed. Rather than confining psychosomatic gynaecology to a single chapter, the aim in this book is to include it wherever it belongs, in the hope of placing it in its proper context. If the psychological aspects of gynaecology suffered from neglect in the past there is now some danger of their being exaggerated. In clinical practice it should be made a rule never to diagnose neurosis or a psychogenic basis for symptoms until organic disease is excluded for certain. CLINICAL METHODS The handling and examination of the patient can only be properly taught and learned in the consulting room (office) and at the bedside, and there is more than one way of doing them well. A systematic account of clinical methods is as wearisome to the writer as it is unprofitable to the reader. In this chapter, it is proposed to comment only on certain general principles and to offer suggestions for overcoming common difficulties. The diagnosis of the cause of the patient’s complaints depends on a process of detection. Some clues are worthless and misleading, others are small but important. The good diagnostician is one who quickly realises what is significant and what is not, one who will not dismiss evidence, bizarre though it may appear, if it does not fit in with preconceived ideas. Clinical intuition is no more than the capacity to take intelligent notice (sometimes almost subconsciously) of small points (Flow chart 1.1). History It is essential for the physician to communicate with a patient in a manner that allows her to continue to seek appropriate medical attention.It is necessary that a doctor listens to a patient completely and if there is a good ear to listen the diagnosis will be made easy. Not only the words used, but also the patterns of speech, the manner
  • 12. A Clinical Approach to Gynaecology 3 in which the words are delivered, even body language and eye contact, are important aspects of the patient– physician interaction. The most important evidence is always provided by the history which the patient or her relatives can give-if allowed to do so. The diagnosis can nearly always be made or reduced to one of two or three possibilities based on the history, without any physical examination. Indeed, it can often be made by telephone. Physical signs are less reliable and should mainly be used as confirmatory evidence. It is good practice never to examine the patient without having a provisional diagnosis in mind. The previous medical history, family history and the account of symptoms as given by the woman can be boring, but scrupulous attention to them saves time, trouble, special investigations and mistakes. She appreciates the opportunity to tell her story and, amongst irrelevances, invariably gives vital clues. Moreover, many irrelevances can be avoided by skilful guidance and by the occasional leading question. A garrulous old woman aged 80 years was admitted to hospital as an emergency case with the history of a sudden onset of lower abdominal pain following a fall on getting out of bed. A few leading questions did not reveal typical features of any of the ordinary abdominal crises and, as the physical signs were not remarkable, she was kept under observation for 10 days during which time her discomfort subsided. She then appeared well and was prepared for discharge home. On the day the patient was due to leave hospital, as a final check, she was referred for the opinion of a gynaecologist. She was then, for the first time, allowed to tell her own story, from which it became clear that the sequence of events was (1) pain, (2) getting out of bed, (3) faintness causing her to fall, (4) unconsciousness on the floor for a few minutes, (5) residual abdominal pain and tenderness. All that remained necessary was to recognise a faint bruise around the umbilicus as ‘Cullen’s sign’, and the picture of intraperitoneal haemorrhage was sufficiently complete to justify laparotomy. This revealed the cause to be a small and previously non-palpable sarcoma in the fundus of the uterus. Successful interrogation requires an inquisitive outlook. Why has this woman come to see me today and not 6 months ago? Why has she not had children during 3 years of marriage? What was the illness which confined her to bed for 3 months in childhood and what were its symptoms and treatment? At what time in pregnancy did the two abortions occur? How long did she breastfeed the last baby? Did she suffer fever after any of the pregnancies? How old is her husband? Is she an only child? Have her aunts got hairy faces? What operation was carried out 5 years ago? What were her symptoms at the time and what was she told? Has she a home of her own? Does she go out to work and who looks after the children while she does? Why is she worrying about a trivial symptom or is it her mother worrying on her behalf? Is she afraid of cancer or of a sexually transmitted disease? History taking also requires tact, for it is concerned with details of what some women regard as highly embarrassing topics. It calls for privacy, kindness, courtesy and a deferment of the more personal questions Flow chart 1.1: An approach to a case with gynaecological problems
  • 13. Jeffcoate’s Principles of Gynaecology 4 until confidence is established. Previous illness and confinements are usually safe grounds, although caution is necessary if a baby has been lost. A woman may find it easier to talk about menstruation than about discharge, while marital and domestic problems should come last. A matter-of-fact and coldly scientific attitude is the one most likely to encourage the patient to discuss intimate matters without embarrassment. Attention to dress, avoidance of jokes, formal behaviour and concentration on the patient and her problems are especially important to maintain the right atmosphere in a teaching clinic. Importance should be given to the Patient–Physician Relationship. One needs to listen more and talk less. Encourage the pursuit of topics important to patients. It is necessary to realise that one should minimise controlling speech habits such as interrupting, issuing commands, and lecturing. Care should be taken to understand discomfort of certain issues and become aware of discomfort in an interview, recognise when it originates in an attempt by the physician to take control, and redirect that attempt. The confidence one gives by assuring patients that they have the opportunity to discuss their problem fully is very important. Sometimes all that is necessary is to be there as a compassionate human being. If clinical findings or confirmatory testing strongly suggest a serious condition (e.g., malignancy), the gravity and urgency of this situation must be conveyed in a manner that does not unduly alarm or frighten the individual. Honest answers should be provided to any specific questions the patient may want to discuss. Often during the course of examination, some fact of which the patient is ashamed comes to light. Perhaps she is pregnant, or has been pregnant, or has had a sexually transmitted disease. Such confidential disclo- sures are to be received impassively and naturally, without sign of approval or disapproval, and the patient should not see that any record is made of them. SYMPTOMS Trivial Symptoms Whenever the symptom appears inadequate or atypical, suspect that it is a cloak for another worry. The recently married woman who complains of longstanding dysmenorrhoea is probably suffering from painful coitus. The woman without children after several years of marriage is often complaining of infertility whatever other symptoms she presents. Vague pains or insigni- ficant discharge may denote cancer phobia. Pain Exact Site and Radiation Ovarian and tubal pain is felt low in the abdomen, usually immediately above the inguinal ligament. Pain of uterine origin is diffuse and hypogastric in site, often referred to the inner aspects of the thighs but not extending below the knees. Backache of pelvic origin is in the midline, never h