1. Mariechen Puchert 2010
Gynaecology Notes
Postmenopausal atrophic vaginitis reduces vaginal epithelial resistance to infection.
• Burning
• Itching
• Dyspareunia
• Vaginal discharge
Emphysematous vaginitis: gas-filled blisters in vagina
Toxic Shock Syndrome
• High fever
• Vomiting
• Diarrhoea
• Headache
• Irritability and confusion
• Muscle and abdominal pain
• Erythematous rash
• Hypotension
Epidermal cysts: small epithelial fragments bury underneath surface
epithelium and lead to cyst formation
CIN: cervical intraepithelial neoplasia
VAIN: vaginal intraepithelial neoplasia
FIGO Classification of Vaginal Carcinoma
Stage I Carcinoma limited to vaginal wall
Stage II Involvement of subvaginal tissues, NOT pelvic wall
Stage III Extension to pelvic wall
Stage IV Extension beyond true pelvis e.g. into bladder or rectum
Dermatological Conditions of Vulva
Dermatitis: Common dermal irritation, atopy
Lichen planus: Multiple white epithelial discolourations on vulva, non-neoplastic
Psoriasis: Scaly red plaques
Bartholin’s duct cyst
• Duct opens between hymen and labia minora
• Duct situated in bulbocavernous sinus
• Marsupialisation: dissect cyst walls and suture to vaginal walls
Differential diagnosis for ulcerative genital lesion
• Herpes genitals
• Chancroid – haemophilus ducreyi
• Lymphogranuloma venereum
• Granuloma inguinale
• Syphilis
2. Mariechen Puchert 2010
Leukoplakia White spot on ectocervix or vaginal wall, hyper or parakeratosis
Adenosis Presence of columnar epithelium on the ectocervix
Menorrhagia Excessive menstrual bleeding
Polymenorrhoea Cycle shorter than 21 days
Oligomenorrhoea Scanty bleeding or cycle longer than 35 days
Metrorrhagia Irregular bleeding at any time between periods
Adenomyosis Endometrial glands and stroma within the myometrium (>3mm)
3. Mariechen Puchert 2010
Syphilis
Treponema Pallidum
o 3 motions: corkscrew motion, contracting and expanding, kinking motion
o cultured from: chancres, skin lesions, blood, urine, condylomata lata, lymph
nodes, CSF, semen, breast milk
o can infect foetus at 8 weeks, but can cause abortion at 16 weeks
Diagnosis
Dark field microscopy
Serology
Non-specific: VDRL if negative no syphilis, if positive further tests
RPR
Specific: TPHA if positive syphilis, if negative further tests
FTA-Abs if positive syphilis, if negative no syphilis
ELISA Enzyme-Linked Immunosrbent Assay Technology
I. Primary Syphilis Chancre
II. Secondary Syphilis Condylomata Lata
III. Early and late latent phases
IV. Tertiary Syphilis Systematic involvement
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Gonorrhoea
Neisseria Gonorrhoea
o Urethritis
o Cervicitis
o Proctitis
o Pharyngitis
o Bartholin’s duct abscess
o Salpingitis
o Gonococcal septicaemia
Diagnosis
PCR (polymerase chain reaction)
Gram’s Stain
Culture (Thayer-Martin agar)
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Chancroid
Haemophilus Ducreyi
o Multiple painful small erythematous papules
o Form pustules which become bleeding ulcers
o Soft chancre, sloughy and purulent base
o Painless ulcers do occur
Diagnosis
Clinical signs
Laboratory tests – bacteriological identification
Exclusion of other ulcer-forming disease
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4. Mariechen Puchert 2010
Granuloma Inguinale
Calymmatobacterium Granulomatis
o Small painless papules
o Multiple or single
o Papule forms round, indurated, velvety granulomatous ulcer
o Beefy-red colour
o Destructive scarring and fibrosis
o Stenosis and pseudobubos
Diagnosis
DONOVAN BODIES closed safety pins within large mononuclear cells
Biopsy/scraping from base of ulcer
Giemsa, Wright or Papanicolaou Stain
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Bacterial Vaginosis
Gardnerella Vaginalis
o Itching, burning
o Discharge, malodorous
o Pregnancy-related morbidity
Diagnosis
• Typical vaginal discharge
• Vaginal pH greater than 4.5
• Positive Amine Test
• Presence of “Clue Cells”
CLUE CELLS superficial or intermediate vaginal epithelia with granulated
salt-and-pepper appearance
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Mycoplasma
Mycoplasma Hominis
o Salpingitis
o Tubo-ovarian abscess
o Miscarriage
o Chorioamnionitis
o Infertility
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Lymphogranuloma Venereum
Chlamydia Trachomatis
o Painless herpes-like lesion
o Not indurated
o Painful inguinal/femoral lymphadenopathy
Diagnosis
• Serology (micro-IF)
• PCR
• Culture (of cells, not of discharge)
5. Mariechen Puchert 2010
• Antibody staining/ ELISA
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Herpes Genitalis
Herpes Simplex
o Multiple red papules
o Papules become watery vesicles
o Watery vesicles turn yellow
o Vesicles rupture to form ulcers
Diagnosis
• Cytology
• Electronmicroscopy
• Immunofluorescence
• Serology
• Culture (Human Fibroblast Cells)
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Human Papilloma Virus Types 6 and 11
Condylomata Acuminata
o Small red, pink or brown swellings
o Become pedunculated
o HPV 16: squamous and adenocarcinoma
o HPV 18: adenocarcinoma
Diagnosis
Colposcopy (Acetic acid solution, Iodine solution)
Cervical cytology
RNA testing
Treatment
• Topical ointment
• Electrocauterisation
• Laser therapy
• Cryotherapy
• Surgery
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Trichomoniasis
Trichomonas Vaginalis
o Protozoon
o Burning discharge, dysuria, polyuria
o Dyspareunia and post-coital bleeding
Diagnosis
Smears: Wetmount, Cytological
Cultures
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6. Mariechen Puchert 2010
Candidiasis
Candida Albicans
o Discharge white, watery and thin OR cheese-like and thick
o Vulva normal OR red and oedematous
o Petechial bleeding
Promoting factors
HIV/AIDS
Anaemia
Broad spectrum antibiotic therapy
Cancer
Chlorine in swimming pools
Contraceptive pill with high oestrogen content
Diabetes mellitus
Pregnancy
Tight, insulating underwear
Traumatic coitus
Diagnosis
Wetmount smear with KOH
Culture
Treatment
Imidazole derivatives
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Pediculosis Pubis
Phthirus Pubis
o Pubic lice
o Gama benzene hexachloride lotion
o Benzyl benzoate lotion
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Pelvic Inflammatory Disease
Neisseria Gonorrhoea
Chlamydia Trachomatis
Gardnerella Vaginalis
Genital tract infection above the level of the cervical os
Risk Factors
Early sexual debut
Women <25 years
Sexual promiscuity
Low parity
Previous PID or STD
Low socio-economic status
7. Mariechen Puchert 2010
Protective factors
Oral contraceptives
Barrier contraception
Tubal ligation
Pregnancy
Diagnostic triad
1. Lower abdominal tenderness
2. Cervical excitation tenderness
3. Adnexal tenderness
AS WELL AS one of:
o Pyrexia
o Leukocytosis
o Mucopurulent cervical discharge
o Gonorrhoea or Chlamydia
Gainessville PID Classification
Investigations in PID
• Pregnancy test
• ESR
• Blood panel
• Urine dipstick
• HIV and Syphilis screening
• Pap smear
• Pelvic imaging
Sequelae
o Recurrence
o Infertility
Stage I Early salpingitis
Adnexal tenderness
Eliminate symptoms and infectivity
Stage II Late salpingitis
Pelvic peritonitis
Preserve fallopian tube function
Stage
III
Pyosalpinx
Tubo-ovarian mass
Tubal occlusion
ESR >60ml/hour
Preserve ovarian function
Stage
IV
Ruptured tubo-ovarian complex
Generalised peritonitis
Septicaemia
Preserve patient’s life
Stage
V
ADRS
8. Mariechen Puchert 2010
o Ectopic pregnancy
o Chronic pain
o Psychological
o Mortality
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Leiomyoma
Tumour of Müllerian duct origin, composed of smooth muscle and fibrous strands.
I. Submucous
II. Intramural
III. Subserous
Complications in pregnancy
• Necrobiosis with localised pain
• Recurrent miscarriage
• Premature rupture of membranes and premature labour
• Placenta Abruptio
• Intrauterine growth retardation
• Fetal malpresentation and obstruction
• Uterine inertia
• Postpartum haemorrhage
Complications in non-pregnant women
o Anaemia
o Infection
o Torsion
o Ascites
Clinical features
Age (35-45)
Infertility
Abnormal vaginal bleeding
Abdominal mass
Pain
Vaginal discharge
Uterine inversion
Pressure effects
Treatment
1. General (conservative)
2. Medical (GnRH)
3. Non-invasive surgery
4. Surgery
Indications for Surgery
o Leiomyoma larger than uterus
o Leiomyoma distorts uterine cavity
o Leiomyoma in lower part of uterus
9. Mariechen Puchert 2010
o Doubt in nature of leiomyoma
o Complications present
o Sudden enlargement of leiomyoma
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Dysmenorrhoea
Painful menstrual cramps of uterine origin
Risk factors of Primary Dysmenorrhoea
Heavy menstrual flow
Young age (<20)
Nulliparity
Early menarche
Smoking
Obesity
Family history
Stress, anxiety, depression
Management
I. Pharmacological
II. Non-pharmacological
III. Surgical
Pharmacological treatment
o NSAIDs (first line treatment)
o COCs
o Levonorgestrel IUD
o Vitamin supplements (B6, E, B1, Magnesium, omega-3, glyceryl trinitrate)
Non-pharmacological agents
• Transcutaneous Electrical Nerve Stimulation
• Acupuncture
• Heat therapy
• Lifestyle modification
• Aerobic exercise
• Psychological therapy
Surgical treatment
1. LUNA (Laparoscopic Uterosacral Nerve Ablation)
2. Dilatation of Cervix
3. Hysterectomy
Causes of Secondary Dysmenorrhoea
Endometriosis
PID
Pelvic congestion syndrome
Ovarian cyst
Leimyomata or polyps
10. Mariechen Puchert 2010
Orthopaedic conditions
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Premenstrual Tension
Disorder of nonspecific somatic, psychological or behavioural symptoms recurring in
the premenstrual phase of the menstrual cycle.
Major symptoms
• Irritability
• Bloating
• Headache
• Fatigue
• Food cravings
• Depression
Laboratory investigations
I. FBC
II. Blood chemistry
III. Serum prolactin
IV. TSH
Treatment of PMS
1. Education, support and stress reduction
2. Dietary modification
3. Nutritional supplements
4. Medical management – of physical or emotional symptoms
5. Surgical management
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Amenorrhoea
Aetiology
• Pregnancy
• Pseudocyesis
• Lactation
• Perimenarchal and perimenopausal
• Stress
• Undernutrition
• Anorexia Nervosa or weight loss
• Exercise
• GnRH deficiency
• Hyperprolactinaemia
• Hypopituitarism or compression of hypothalamus
• Ovarian failure
11. Mariechen Puchert 2010
• Ovarian tumours
• Polycystic Ovary Syndrome
• Iatrogenic
• End-organ defects
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Menopause
Biological period of permanent cessation of menses resulting from loss of ovarian
follicular function.
Consequences
o Vasomotor instability
o Urinary Tract – vaginitis, UTIs, incontinence
o Weight gain – shift to android distribution
o Skin and teeth – thinner, weaker
o Dry eye syndrome
o Osteoporosis
o Atherosclerosis
Adverse effects of oestrogen replacement
• Liver globulins
• Increased BP
• Venous thrombosis
• Glucose metabolism
• Cholelithiasis
• Cancer: breast, endometrial, ovarian, colon, rectal
Routes of therapy administration
1. Oral
2. Percutaneous
3. Transdermal
4. Subcutaneous
5. Vaginal
6. Nasal spray
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Endometriosis
Presence of endometrial tissue at sites outside the uterine cavity
1. Endometrial glands
2. Stroma
3. Haemosiderin pigment
Clinical presentation
o Dysmenorrhoea
o Pelvic pain
o Infertility
o Dyspareunia
12. Mariechen Puchert 2010
o Menorrhagia and polymenorrhoea
Extrapelvic sites
Intestinal tract
Urinary tract
Pulmonary and thoracic
Management
1. Medical
2. Surgical – conservative
3. Surgical – extensive
4. Surgical – adjunctive
Medical treatment
• NSAIDs
• COCs
• Progestogens
• Danazol
• GnRHa
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Genital Prolapse
Causes
i. Childbirth
ii. Tissue defects
iii. Iatrogenic
iv. Conditions causing raised intra-abdominal pressures
Urethrocele prolapse of urethra and underlying anterior vaginal wall
Cystocele prolapse of bladder and underlying anterior vaginal wall
Uterine prolapse prolapse of uterus and cervix
Vault prolapse
Rectocele prolapse of lower part of anterior rectal wall
Enterocele herniation of small bowel and/or omentum
Procidentia uterus and cervix appear in entirety outside introitus
Elongation colli fundus remains in position but cervix elongates
Grading of prolapse
I. Descent within vagina, but not to the introitus
II. Descent down to, but not through the introitus
III. Descent through the introitus
Aims of management
1. Eliminate symptoms
2. Restore anatomy
3. Restore function
4. Improve quality of life
13. Mariechen Puchert 2010
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Trauma and Sexual Assault
RAPE: intentional and unlawful carnal knowledge of a female, by a male, without her
consent. Minimal penetration of female sexual organs by that of a male.
Consent is not valid when...
In state of fear
Asleep
Under influence of drugs, alcohol,sedatives, narcotic agents or hypnosis
Impersonation or fraud occurs
Either party is under 16 years of age
Certified under the Mental Health Care Act (17 of 2002)
Specimens taken
o STI-testing
o Semen
o Saliva
o Blood
o Fingernail scrapings/clippings
o Foreign matter
Clinical treatments
• Prophylactic antibiotics for STDs
• PEP for HIV
• Hepatitis B vaccination
• Pregnancy prevention
• Gynaecological and surgical treatment
• Psychological and emotional services and counselling
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Sexual Dysfunction
Phases of sexual response
I. Transition
II. Desire
III. Arousal
IV. Orgasmic
V. Resolution
VI. [Refractory]
