Common Gynaecological Problems

1. Common Gynaecological
Problems
Dr Hsu Myat Myo Naing
MPH, MBBS
Myanmar

2. COMMON GYNAECOLOGICAL
PROBLEMS
 Menstrual problems
 Vaginal discharge
 Pruritus vulvae
 Swellings of the vulva

3. Menstrual problems
 Normal- every 21 to 35 days, 2-3 ds,
35-40 ml
 Problems
 Dysmenorrhoea
 Abnormal vaginal bleeding
 Amenorrhoea

4. Dysmenorrhoea
Primary dysmenorrhoea
 no organic or psychological cause
 diagnosis by history: teen age girls,
onset with or shortly after mens, lasts
24-48 hrs
 exam: exclude organic causes
 inves : usually not required

5. Primary Dysmenorrhoea
 Treatment- NSAIDs, reduce pain &
mens loss
 COCs, prevent ovulation
 Surgery rarely required
 Refer if not relieved

6. Secondary dysmenorrhoea
 Usually- organic or psychological cause
 History- adult life, before menses,
increases as menses approaches
 Causes- endometriosis, adenomyosis
uterine polyps, fibroids PID,
psychosexual problems

7. Endometriosis
 Def: +ce of endo tiss in sites other than
ut cavity
Adenomyosis
 Def: +ce of endo tiss confined to
myometrium

8. Endometriosis
History
 no symp in 20 %
 30-40 yrs, nullip or low parity, subfertility
 heavy irregular pds, secod dysm,
deep dyspareunia, pain
bet menses
 rectal bleed & stricture, cyclical
haematuria
 cyclical swell & pain in abdo wounds

9. Endometriosis (Cont)
 Exam: tenderness & mass in lower
abdomen
 abdo wall deposits,
 VE: tender nodules on US ligs
 tender fixed RV ut
 nodules in vagina

10. Endometriosis (Cont)
Investigations
 Laparoscopy
 Ultrasound
Treatment---
 Medical
 Surgical
Medical- Aim is to stop periods, not curative
 COC 6-9 months
 Inj. Depoprovera 6-9 months

11. Endometriosis (Cont)
 Danazol - 200-800 mg/day 6-9 months
 SE- virilizing effects: Decreased br size,
acne, oily skin, hirsutism, weight
gain, deepening of
voice, hot flushes, dry vagina
 Medroxyprogesterone acetate 30mg/day
 GnRH analogue- maximum 6 months
 REFER-if SE severe or symptoms not
relieved

12. Endometriosis (Cont)
Surgical Tm
 Conservative by laparotomy or laparoscopy
diathermised or excised, ennucleation
 Radical- TAH and BSO + excision of
endometriotic lesions
 Combined medical & surgical in severe cases

13. Adenomyosis
 History- older, multiparous women,
2ndary
dysmenorrhoea, menorrhagia
similar to fibroids &
DUB
 Examination- tender enlarged uterus
 Treatment- Hysterectomy , conserve
ovaries

14. Uterine polyps (myomatous polyps)
 History- pain in midcycle
 Examination- felt through the cx os
 Treatment- excision

15. Chronic PID
 History- repeated acute attacks, chronic
pain, 2ndry dysmenorrhoea, heavy irreg
menses, infertility, chronic vg discharge
 Examination- tender ut & adnexa, fixed
retroversion
 D/D- endometriosis

16. Chronic PID
 Investigation- Laparoscopy
 Treatment- Prolonged AB therapy 3-6
months
 Failed medical Tm- TAH&BSO (?ovs)

17. Psychosexual problems
 3rd & 4th decade, over anxiety,
emotional instability,
 2ndry dysmenorrhoea as part of PMT
syndrome

18. Abnormal Vaginal Bleeding
Types
 Excessive menstrual loss
 Intermenstrual bleeding
 Postcoital bleeding

19. Diagnostic work-up
 History-20-40 yrs, usually benign
(exclude serious Cs)
 Perimenopausal- endometrial biopsy
 Pediatric & postmenopausal- REFER
 Irregular pills, IUCD
 Pattern- regular heavy, acyclical heavy
intermenstrual, postcoital

20. Excessive menstrual loss
 too long, too frequent, too heavy, too irregular
Menorrhagia
 Def: excessive (80 ml or more) regular loss
Causes-
 physiological(normal loss but thinks heavy)
 IUD, infection(chronic PID)
 Neoplastic fibroids, Ca endometrium,
functioning ov Ts, uterine polyps
 Blood dyscrasias, psychological factors

21. Dysfunctional Uterine Bleeding
 Not due to organic lesions
 Ovulatory or anovulatory
 Anovulatory - common in extremes of
life, CHO intolerence, older obese,
endocrine d/s,
- prolonged period of amnorrhoea
followed by heavy persist Bld

22. Dysfunctional Uterine Bleeding
(Cont)
Ovulatory
 35- 45 years, abd discomfort,
 dysmenorr, dyspareunia
 cycle usually regular, but heavy

23. Management of excessive
menstrual loss
 History- as in diagnostic work-up
 Examination- anaemia, obesity,
endocrine d/os
 Investigations - Bld CP, clotting screen,
TFT & GTT if indicated
Ultrasound, endometrial biopsy if 40 & >

24. Treatment
a. Medical Tm
Anovulatory cycles
 adolescent & young, COC few months or
cyclical progestogens (medroxyprogesterone
acetate 10mg daily or norethisterone 5mg bd)
from day 15-25
 perimnopausal, cyclical progestogen (regular
withdrawal) if no withdrawal, menopause has
occured, if menopausal sympts +, HRT
containing progestogens

25. Acute Onset of Heavy Bleeding
 Control by a high dose of progestogens
& reduce slowly
 eg: northisterone
 30mg bd x 3 Ds
 20mg bd x 3 Ds
 10mg bd x 3 Ds
 5mg bd x 10 Ds
 followed by withdrawal bleeding

26. Ovulatory cycles
 more difficult to manage
 antifibrinolytic therapy, tranexamic acid
1-3 G/day
 prostaglandin synthetase inhibitors
 COCs after excluding contraindications
 Danazol 200-800 mg daily
 Surgical Tm, Hysterectomy or endo:
ablation

27. Fibroids
 Commonest Tu: of female GT
 History- peak bet 35-45 years nulliparity
or infertility may be symptomless
menorrhagia, IMB if fibroid polyp +
abdominal
swelling, complications (pain)

28. Fibroids
 Examination- mass in lower abd
 VE- mass arising from the uterus
 Diff: Dia: adenomyosis, ova: tumor,
pregnancy
 Investigations- bld CP, ultrasound

29. Treatment
 Conservative- if small, no symptoms
during
preg, near menopause
 Medical Tm- GnRH analogues
contraindications to
surgery
prior to surgery in huge fibroids
 Surgery - Myomectomy or
Hysterectomy

30. Intermenstrual Bleeding
Causes- Midcycle bleeding: Reassurance
 Premenstrual: due to defective corpus L
 Tm- progesterone supplem:
 Neoplasia: endom: or cervical polyp,
Cas
 Infective: cervicitis, infected polyp

31. Postcoital Bleeding
 Causes- Cervicitis, ectropion
 Ca cervix (most important)
 Treatment- Treat the cause

32. Amenorrhoea
Primary- No period up till 14 if no Sdry sex dev:
16 if Sdry sex dev: +
Causes:
 Developmental errors of ut, ut atresia
 Genital T obstruction: imperforate hymen,
vaginal atresia, transverse vg septum
 Chromosomal disorders - eg: Turner`s $
 Anorexia nervosa
 Management- according to the cause
 TIMELY referral

33. Imperforate hymen
CF
 Normal growth
 Intermittent abdo: pain
 Palpable lower abdominal swelling
 Difficulty in micturition
 Bulging bluish mem: at lower end of vagina
 Mn - Incision of mem: under aseptic condition

34.  Secondary- Absence of menses for 6
months(who has menstruated before)
 Causes - Physiological
before
puberty,adolescence,
during preg:[ commonest],
lactation, after
menopause

35. Pathological
 stress related amenorrhoea
 polycystic ovary syndrome [PCOS]
 hyperprolactinaemia [pituitary tumors]
 hypo/hyper thyroidism
 premature menopause [before 35]

36.  VAGINAL DISCHARGE
 Causes- Physiological [leucorrhoea]
usually mucoid or white,
increased at the time of ovulation,
premenstrual
during sexual excitement and coitus,
during pregnancy, in the female
neonate d/t maternal oestrogen

37.  Pathological causes
Premenarchal years
- poor hygiene, foreign bodies,
- thread worms, sexual abuse
Reproductive years
- infections: Candida, Chlamydia, Neisseria,
Trichomonas, Bacterial vaginosis
Herpes, Syphilis,
nonspecific infections
- neoplastic: benign as well as malignant,
usually bld stained

38.  iatrogenic: traumatic, douching, allergy
to rubber,spermicides
 RPOC [ post-partum, post-abortal]
 ectropion, urinary and fecal fistula
 psychological, idiopathic

39.  Postmenopausal years
- atrophic vaginitis [ may be blood-
stained]
- malignancy

40. History
 Features of discharge
- onset, duration, frequency,
- nature [ mucoid, serous, purulent,
bloody]
- colour [ clear, white, yellow-green,
blood-stained]
- consistency [ watery, viscid, curd like]
- amount [ scanty, copious]
- associated symptoms: pruritus, burning

41. - relationship to menstrual cycle. eg
moniliasis worse before menstruation
- hygiene practice : douching, tempons
- risk of STDs, associated UTI
- associated medical conditions. eg diabetes
- history of allergy to rubber, spermicides
- drugs: antibiotics, COCs
- cervical smear result if done

42. Physical Examination
 - a complete general and abdominal
examinat:
 -VE including urethra, speculum
examination to determine
nature and amount of discharge,
condition of the cervix

43. Investigations
 - cervical cytology, vaginal pH.
 - saline wet mount, wet mount on 10%
KOH solution
 - Gram stain, C & S: HVS, endocervical
- colposcopy if indicated

44. Treatment
 - Treat the underlying cause
 - lucorrhoea- Explanation and Reassurance
Failure of cure of vaginal discharge
 - incorrect diagnosis, use of incorrect drugs
 - Tm course too short or incorrect dosage
 - underlying cause untreated
 - lack of pretreatment explanation
 - poor compliance, SE of drugs
 - aesthetically not acceptable

45.  Possible causes of relapse
[ reappearance of same condition]
- failure to deal with predisposing
factors
- lack of attention to hygiene
measure
- other local underlying pathology,

46. Reinfection
 - sexual transmission,
 failure to treat sex partner
 - change of sex partner,
 failure of long term prophylaxis
Referral
 - suspicious cx or vg lesions
 - chronic discharge not responding to
Tm
 - Dx unclear, very anxious patient

47.  PRURIUS VULVAE
Causes- with discharge
- without discharge
Pruritus with discharge
Trichomonas vaginalis and
Candida albicans account 80%

48. Pruritus without
discharge
 Generalised pruritus ( jaundice,
uraemia,allergy,lymphadenoma)
 Skin diseases [scabies, psoriasis]
 Parasitic infections: thread worm,
pediculosis pubis
 Discharge from anus & rectum: fissure
in ano, piles,fecal incontinence

49.  Glycosuria
 Allergy:soaps, antiseptics, deodorants,
toilet preparation, under wears
 Deficiency states: Vitamin A,B , iron
 Chronic vulval dystrophies
 Chronic vascular changes:eg varicose
veins
 Psychological upsets

50.  History : onset, duration, predisposing factors
 systemic illnesses, previous treatm:
 Physical examination
General: evidence of DM, uraemia, liver failure
deficiency states
Pelvic/E: color of vulval skin, dystrophies,
if d/c +, amount, color, odour, condition
of cervix and vaginal walls

51.  Investigations
For systemic diseases if necessary
If vg d/c +, tests for Trichomonas &
Candida
Biopsy if skin changes +

52.  Management
 Treat underlying cause:eg DM, Candida
If no cause found:
loose fitting cotton underwear
to keep the vulva well aerated
personal hygiene
sedatives at night, antihistamines
ointments containing corticosteroids anfungicides
local anaesthetics s/b avoided
fungicides orally if perineal pruritus +

53.  Management of infection by Candida
albicans
Commonest cause of vg d/c
Dx by C/F and investigations
 History- intense pruritus and soreness, > at night
 VE - erythema of labia, perineum & vagina
scanty, thick, white curd-like discharge
not sexually transmitted

54.  Predisposing factors
-Pregnancy, premenstrual period
- Medical diseases: dm, iron DA
- Drugs: COCs, A/B, corticosteroids,
immunosuppresive drugs
- Adhesive tights

55.  Investigations
- discharge suspended in N saline,
mycelial filaments and spore
 - culture of swabs

56.  Treatment ( fungicides)
- Clotrimazole( canestin) 200mg vg pessaries hs X 3
Resistant cases: ( oral ketoconazole or
itraconazole)
hepetic damage must be excluded
-Genital hygiene:daily washing with bland soap &
water
Avoid close-fitting tights,washing of
underwear at 80*C,>
- Treatment of underlying causes: eg DM

57.  Trichomonas infection
C/F- itching or burning sensation, dyspareunia
- profuse, offensive, frothy, white , green or
brownish vg discharge
- oedema and congestion of vulva
- vg stuck with reddish-purple or dark-red spots
(strawberry spots)
- associated gonococcal infection common
- usually sexually transmitted

58.  Diagnosis
- from C/F, vg pH is increased
- vg d/g in N saline +ce of motile flgellated
protozoa
- culture of swabs
 Treatment
- Metronidazole 200 t.d.s X 7 Ds both
partners
(should avoid alcohol during Tm)

59.  Bacterial vaginosis
 C/F
- foul smelling profuse offensive fishy vg d/c
-VE- unusual looking (green or yellow or
foamy)- no sign of inflammation
irritation uncommon, not STI
 Tm - Metronidazole as for Trichomoniasis

60.  LUMPS and SWELLINGS of the VULVA
 Tum- From any structure of the skin (keratinized sq
ep)
 Causes- trauma: haematoma
- infections: Condylomata accuminata (viral
warts), syphilitic condylomas, boils
- retention cysts: sebaceous, epidermoid,
Bartholin, remnants of Wolffian ducts
- vascular changes: haemangioma, varicose
veins

61.  - urethral and paraurethral conditions: urethral
prolapse, caruncle, paraurethral gland cysts
 - inguinal hernia, hydrocele of canal of Nuck
 - genital prolapse
 - benign tumors: lipoma, fibroma, papilloma,
hydradinoma,(tumor
of sweat gld)
 - malignant tumors- sq cell Cas, melenoma,
sarcoma, basal cell Ca

62.  Enlargement of Bartholin`s gland
 Bartholin`s adenitis
- The gland is acutely painful and swollen
- usually due to Gonococcus
- may be due to Staphyllococcus or G -ve bacilli
- an abscess may be formed
- if the main duct is blocked= Bartholin`s cyst
 Tm- Marsupialisation for both cyst and abscess

63.  Urethral caruncle
- is a reddened area involving the
posterior margin of the urethral orifice
- usually symptom-less and found in
postmenopausal O+
- occasionally can cause bleeding and
dyspareunia
- Tm: topical oestrogens or excision or
cautery

64.  Malignancies
- progressively enlarging lumps and ulcers
associated with chronic pruritus and foul
smelling discharge
- mass is irregular, fragile ulcer with
irregular rolling edges
- enlarged inguinal lymph nodes may be
present
- biopsy is necessary to confirm the Dx
- needs REFERRAL for radical surgery