Common gynaecological problems

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Common Gynaecological Problems

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Common gynaecological problems

  1. 1. Common Gynaecological Problems Dr Hsu Myat Myo Naing MPH, MBBS Myanmar
  2. 2. COMMON GYNAECOLOGICAL PROBLEMS    Menstrual problems  Vaginal discharge  Pruritus vulvae  Swellings of the vulva
  3. 3. Menstrual problems  Normal- every 21 to 35 days, 2-3 ds,  35-40 ml                           Problems  Dysmenorrhoea  Abnormal vaginal bleeding  Amenorrhoea
  4. 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. 5. Primary Dysmenorrhoea  Treatment- NSAIDs, reduce pain &  mens loss   COCs, prevent ovulation   Surgery rarely required   Refer if not relieved 
  6. 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. 7. Endometriosis   Def: +ce of endo tiss in sites other than  ut cavity   Adenomyosis   Def: +ce of endo tiss confined to  myometrium 
  8. 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. 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. 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. 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. 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. 13. Adenomyosis  History- older, multiparous women,                                                 2ndary  dysmenorrhoea, menorrhagia                                                 similar to fibroids &  DUB  Examination- tender enlarged uterus  Treatment- Hysterectomy , conserve  ovaries
  14. 14. Uterine polyps (myomatous polyps)  History- pain in midcycle  Examination- felt through the cx os  Treatment- excision
  15. 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. 16. Chronic PID  Investigation- Laparoscopy  Treatment- Prolonged AB therapy 3-6  months  Failed medical Tm- TAH&BSO (?ovs)
  17. 17. Psychosexual problems  3rd & 4th decade, over anxiety, emotional instability,  2ndry dysmenorrhoea as part of PMT syndrome
  18. 18. Abnormal Vaginal Bleeding Types  Excessive menstrual loss  Intermenstrual bleeding  Postcoital bleeding
  19. 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. 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. 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. 22. Dysfunctional Uterine Bleeding (Cont) Ovulatory  35- 45 years, abd discomfort,  dysmenorr, dyspareunia  cycle usually regular, but heavy
  23. 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. 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. 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. 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. 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. 28. Fibroids  Examination- mass in lower abd  VE- mass arising from the uterus  Diff: Dia: adenomyosis, ova: tumor, pregnancy  Investigations- bld CP, ultrasound
  29. 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. 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. 31. Postcoital Bleeding  Causes- Cervicitis, ectropion  Ca cervix (most important)  Treatment- Treat the cause
  32. 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. 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. 34.  Secondary- Absence of menses for 6 months(who has menstruated before)  Causes - Physiological before puberty,adolescence, during preg:[ commonest], lactation, after menopause
  35. 35. Pathological  stress related amenorrhoea  polycystic ovary syndrome [PCOS]  hyperprolactinaemia [pituitary tumors]  hypo/hyper thyroidism  premature menopause [before 35]
  36. 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. 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. 38.  iatrogenic: traumatic, douching, allergy to rubber,spermicides  RPOC [ post-partum, post-abortal]  ectropion, urinary and fecal fistula  psychological, idiopathic
  39. 39.  Postmenopausal years - atrophic vaginitis [ may be blood- stained] - malignancy
  40. 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. 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. 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. 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. 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. 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. 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. 47.  PRURIUS VULVAE Causes- with discharge - without discharge Pruritus with discharge Trichomonas vaginalis and Candida albicans account 80%
  48. 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. 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. 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. 51.  Investigations For systemic diseases if necessary If vg d/c +, tests for Trichomonas & Candida Biopsy if skin changes +
  52. 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. 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. 54.  Predisposing factors -Pregnancy, premenstrual period - Medical diseases: dm, iron DA - Drugs: COCs, A/B, corticosteroids, immunosuppresive drugs - Adhesive tights
  55. 55.  Investigations - discharge suspended in N saline, mycelial filaments and spore  - culture of swabs
  56. 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. 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. 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. 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. 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. 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. 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. 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. 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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