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Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
Common  gynaecological  problems
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Common gynaecological problems

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Common Gynaecological Problems

Common Gynaecological Problems

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  • 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

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