This document outlines the course for a gynaecology course. It will cover anatomy and physiology of the female reproductive system, gynaecological assessment, and various gynaecological disorders. Specific disorders that will be discussed include menstruation disorders, abortion, ectopic pregnancy, endometriosis, infertility, and cancers of the reproductive organs. Each disorder will be defined, types/classes described, causes/risk factors explained, pathophysiology outlined, signs and symptoms detailed, management strategies provided, and potential complications noted. The course will provide an in-depth review of female reproductive health and common gynaecological issues.

1. GYNAECOLOGY
Mbatah Jared Adams

2. COURSE OUTLINE
 Review the anatomy and physiology
 Gynaecological assessment
 Description of various gynaecological
disorders to include:
 Menstruation disorders
 Abortion
 Hydatidiform Mole
 Ectopic pregnancy

3. COURSE OUTLINE CONT…
 Endometriosis
 Infertility
 Fistula and genital prolapse
 Disorders of the vulva-pruritus vulvae,
candidiasis, Bartholin’s abscess and cyst,
vulval dystrophies, cancer of the vulva
 Diseases of the Vagina; atrophic vaginitis,
cancer of the vagina

4. COURSE OUTLINE CONT…
 Disorders of the cervix: cancer of the
cervix, cervicitis, cervical erosion,
 Disorders of the uterus: adenomyosis,
fibromyoma, cancer of the uterus
 Ovarian cyst and cancer
 Pelvic Inflammatory Disease (PID)
 Breast disorders: benign breast
tumours, breast cancer
 Polycystic ovary syndrome

5. COURSE OUTLINE CONT…
UNDER THE FOLLOWING HEADINGS
 Definition
 Types/ classes
 Causes/ risk factors
 Pathophysiology
 Signs and symptoms
 Management
 Complications

6. MENSTRUATION DISODERS
Definitions
 Amenorrhoea; absence of menstruation
 Hypomenorrhoea/oligomenorrhoea=T
his is when the period occurs on a
regular basis but is minimal
 Menorrhagia; Excessive bleeding in
amount and duration.
 Hypermenorrhoea; Excessive bleeding
in amount

7. DEFINITIONS CONT…
 Epimenorrhoea/ polymenorrhoea;
periods occurring in shorter intervals
than usual i.e. shorter than 21 days
 Dysmenorrhoea; painful menstruation
 Metrorrhagia; irregular genital bleeding.
Also bleeding between periods
 Menometrorrhagia; heavy vaginal
bleeding between and during periods,

8. AMENORRHOEA
Types
 Physiological amenorrhoea
 Pathological amenorrhoea
 Primary amenorrhoea.
 Secondary amenorrhoea.

9. ? Causes of physiological amenorrhoea

10. Causes of physiological
amenorrhoea
 Pregnancy
 Post menopause
 Lactation
 Pre-puberty

11. Causes of pathological
Amenorrhoea
 Hormonal causes- dysfunction of ovaries,
pituitary gland, thyroid gland and adrenal gland
 Nervous causes- any cause of anxiety e.g.
change of environment, occupation, fear of or
desire for pregnancy (pseudocyesis)
 Severe diseases e.g. T.B, anaemia

12. Causes cont…..
Congenital abnormalities e.g.
imperforate hymen (causes
hematocolpos and hematometra),
uterine agenesis.
Local causes e.g. hysterectomy,
oophorectomy
Drugs e.g. OCPs
Excessive weight loss

13. TREATMENT
 Treat the underlying cause
 Psychotherapy to relieve the
tension/stress
 Pharmacotherapy:
 Clomiphene(clomid)
 Human Menopausal Gonadotrophin
(HMG) and Human Chorionic
Gonadotrophin (HCG)
 Bromocriptine

14. DYSMENORRHOEA
Types
 Primary or spasmodic dysmenorrhoea-
Has no any underlying pathology
 Secondary or congestive dysmenorrhoea
– has pathological causes

15. Characteristics of primary
dysmenorrhoea
 Ussually associated with ovulatory circles.
 Usually starts on the first day of bleeding
 Common a few years after puberty
Treatment
 Analgesics
 Assess for stress and reassurance
 Adequate nutrition, rest and exercise
 Hormones that inhibit ovulation e.g. OCP
 Surgery, in the form of pre-sacral neurectomy

16. Secondary dysmenorrhoea
Causes
- Fibroids
- PID
- Endometriosis
- Adenomyosis
- Uterine prolapse.

17. Secondary dysmenorrhoea cont…
Characteristics of secondary dysmenorrhoea
 Pain may be concentrated in a specific area
 Onset usually after 20 yrs.
 Begin some days before the on set of bleeding
 It is made worse by exercise.
 Other symptoms like infertility and dyspareunia
may be present.

18. Secondary dysmenorrhoea cont…
Treatment
 Treat the underlying cause
 Administer anti-prostaglandins to relieve
the pain

19. ABNORMAL UTERINE BLEEDING
Types
 Dysfunctional uterine bleeding (non
organic) abnormal uterine bleeding
without any physical sign on
examination.
 Organic uterine bleeding- abnormal
bldeeding with an identifiable cause

20. ORGANIC UTERINE BLEEDING
CAUSES
 Adenomyosis
 IUD
 Systematic diseases e.g. coagulation disorders
 Cervical polyps
 Ectopic pregnancy
 Infection
 Trauma
 Tumours
MANAGEMENT
-Treat the cause - HB monitoring and manage anemia
-Psychotherapy

21. DYSFUNCTIONAL UTERINE
BLEEDING
 Abnormal bleeding per vaginal with no
identifiable pathology.
 Diagnosis- Ruled out the usual causes of
vaginal bleeding through uterine biopsy,
ultrasound, physical exam.
 Common at the beginning and end of the
reproductive years
 In most cases there is unovulation.

22. TREATMENT
 Combined oestrogen and progesterone
pills for 3-6 cycles
 D&C
 Surgery

23. ABORTION
DEFINITION
 Termination of pregnancy by the removal
or expulsion from the uterus of a fetus or
embryo prior to viability currently before
28 weeks of gestation.

24.  Difference between miscarriage and
abortions?

25. CLASSIFICATION
Abortions can be classified as follows:
 Spontaneous (miscarriage)
 Induced
- Therapeutic
- Criminal (illegal)

26. METHODS OF INDUCING
ABORTIONS
 Medical using misoprostol a
prostaglandin analog.
 Surgical methods;
Up to 15 weeks' gestation.
-Suction/ vacuum aspiration (MVA) or
electric vacuum aspiration (EVA);
-Dilation and curettage

27. 15th - 26th weeks
Dilation and evacuation (D&E) consists of
opening the cervix of the uterus and
emptying it using surgical instruments
and suction

28. CAUSES OF SPONTENEOUS
 Most of them are idiopathic
 Foetal causes e.g. foetal abnormality
structural or chromosomal, abnormal
attachment of the placenta.
 Maternal causes to include:
 Diseases like hypertension, malaria,
diabetes, malnutrition
 Cervical incompetence

29. CAUSES C0NT…
 Structural abnormalities of the uterus.
 Hormonal insufficiency e.g. insufficiency
production of progesterone by the corpus
luteum.
 Drugs e.g. oxytocics, cigarette smoking
and alcohol
 Trauma
 Emotional disturbance

30. CLINICAL TYPES/STAGES
 Threatened abortion
 Inevitable/ Imminent abortion
 Complete abortion
 Incomplete abortion
 Missed abortion
 Septic abortion
 Recurrent/ habitual abortion

31. Threatened abortion
Features
 Minimal bleeding
 Cervix is closed
 Uterus is of appropriate size for gestation
 Patient may feel some abdominal pain or
mild pain

32. Management
 Bed rest PRN
 Give mild sedatives e.g. phenobarbitone
 If painful administer analgesics
 Assess the amount of blood loss
 Monitor the contractions
 Reassure the patient
 Advice not to have sexual intercourse and any
heavy physical
 Advice the patient to take diet high in fibre

33. Inevitable/ Imminent abortion
 Features
 Dilated cervix
 Strong uterine contractions
 Severe bleeding
 Products of conception may be felt
through the cervical os.

34. Management
 Analgesics
 Evacuation of the uterus-MVA or D&C
 Replace blood loss if necessary
 <16 weeks evacuation of uterine.>16
weeks give oxytocin 40 units in 1L i.v
fluids at 40 drops/min to expel the
products of conception then evacuate
the uterus.

35. Incomplete abortion
 This abortion in which some products of
conception have passed (usually the fetus)
but some (usually the placental tissue) has
been retained.
Features
 Cervix is open
 Vaginal bleeding which may be moderate to
severe.
 Abdominal pain present

36. Management
 Analgesics
 If pregnancy is <16 weeks and bleeding
is light to moderate use fingers or ring (or
sponge) forceps to remove products of
conception protruding from the cervix

37.  If bleeding is heavy and pregnancy is
<16 weeks, evacuate the uterus by:
 Manual Vacuum Aspiration.Evacuation by
sharp curettage (D&C) should only be done
if MVA is not available
NB/If evacuation is not immediately possible,
give oxytocin 10 IU IM and arrange for
evacuation as soon as possible

38.  If pregnancy is >16 weeks:
 Infuse oxytocin 40 units in 1 L iv fluids
(normal saline or Ringer’s Lactate) at 40
drops per minute until expulsion of products
of conception occurs
 If necessary, give misoprostol 200 mcg
vaginally every 4 hours until expulsion, but
do not administer more than 800 mcg
 Evacuate any remaining products of
conception from the uterus

39. Complete abortion
 This is an abortion in which all the
products of conception have been
expelled
Features
 Pain is absent
 Bleeding is slight
 Cervix is closing or has closed

40. Management
 Ultra sound to confirm that the cavity is
empty
 Advice the patient to report if bleeding
recurs or develops fever
 Check HB after 24hrs
 Curettage only if bleeding persists
 Antibiotics if febrile

41. Missed abortion
 This occurs when the embryo dies but
the gestational sac is retained in the
uterus for several weeks or months.
Feature
 Uterus stops growing
 Cervix is closed
 Brownish vaginal discharge.

42. Management
 Most of them are expelled
spontaneously. Empty the uterus by
curettage if this does not happen.
 Give psychological support

43. Recurrent/ Habitual abortion
 This is used to refer to three or more
consecutive spontaneous deliveries.
 Most of these patients will have obvious
causes which include: diabetes,
abnormalities of the uterus and cervical
incompetence.

44. Septic abortion
 This is an abortion accompanied by infection
Clinical features
 Fever
 Tachycardia
 Offensive vaginal discharge
 Tenderness in the lower abdomen
 General features of abortion.

45. Management
 This is usually an emergency. The
following principles are followed;
-Replace blood lost
-Parenteral broad-spectrum antibiotics
administration. Take a cervical swab for
culture and sensitivity before
administering the antibiotics.
-Evacuation once the patient has
stabilized.

46. NURSING MX
 Monitor urinary output to rule out any renal
interference.
 Monitor vital signs-rapid pulse and high
temperature indicates severity of the infection.
Low blood pressure, rapid weak pulse and low
temp indicate shock or impending shock.

47. Management cont…
 High fluid intake to compensate fluid loss due
to fever, bleeding and also to flush the system
off toxins.
 Perform vulva toilet four hourly with antiseptic
 Administer anti-tetanus vaccine
 Position the patient in a propped up position if
not in shock. This helps to localize infection
 High protein ,high calorie diet to promote
healing

48. COMPLICATIONS OF ABORTIONS
 Haemorrhage
 Sepsis
 Perforation of the uterus
 Psychological trauma
 Renal damage
 Amniotic embolism
 Anaemia as a result of bleeding and haemolysis of
red blood cells

49. POST ABORTAL CARE
 Emergency treatment of complications
 Family planning counseling and services
 Access to comprehensive reproductive
health care, including screening and
treatment for STI, RTIs and HIV/AIDS
 Community education to improve
reproductive health and reduce the need
for abortion

50. ECTOPIC PREGNANCY
DEFINITION
 This is a condition in which the embryo
implants outside the uterine cavity e.g.
tubes (most common site), cervix,
abdominal cavity, ovary also called
extra uterine pregnancy.

51. TUBAL PREGNANCY
 Causes
 Previous inflammation in the tube e.g. acute
PID which heals with scarring blocking the
tube
 Occlusion by peritoneal adhesions e.g. after
appendicectomy
 Endometriosis in the tubes
 Congenital anatomical abnormalities of the
tube.
 Too long tubes-more than 10cm

52. PATHOPHYSIOLOGY
When the uterus has implanted in the tube, corpus
luteum remains and produces progesterone
which ensures that the endometrium is not shed
off.This causes amenorrhoea.As the embryo
continues to grow in size, it stretches the wall of
the uterine tubes causing pain.

53.  Also, the erosion of the tubal wall by
the implantation causes some bleeding
into the peritoneal cavity which also
causes irritation of the peritoneum
resulting in pelvic pain and referred
shoulder pain. Since the tubal walls are
not adopted for embryo development,
the tubal pregnancy results to one of the
following:

54. Outcomes of tubal pregnancy
 Tubal rupture.
 Tubal mole.
 Tubal abortion
 Abdominal pregnancy

55. Acute tubal rupture/ fulminating
This is sudden rupture of the tube.
Characteristics
 Sudden onset of lower abdominal pain
 Vomiting due to sudden bleeding in to the
peritoneum
 Vaginal bleeding-this may be delayed until
some hours later after the rupture.
 Pain on moving the cervix with fingers during
vaginal exam

56. Acute tubal rupture cont…
 Patient is in severe pain
 Signs and symptoms of shock to include
cold skin, rapid weak pulse, low blood
pressure
 Very tender abdomen with muscle
guarding. Signs of free fluid in the
abdomen e.g. fluid thrill and shifting
dullness

57. Chronic tubal rupture
Characteristics
 Lower abdominal pain usually marked on one side.
 Amenorrhoea
 Irregular vaginal bleeding which may be confused for
threatened abortion.
 Nausea and vomiting
 Feeling of faintness
 Anemia
 Tachycardia
 Low blood pressure
 Tenderness and guarding in the lower abdomen

58. Diagnosis
 Ultrasound
 Culdocentesis
 Urine testing for HCG

59. Management
 This is an emergency and requires immediate
medical attention.
 Start the patient on plasma expanders e.g.
normal saline as you wait for blood.
 Take blood for grouping and crossmatching
and start blood transfusion
 Administer a strong analgesic
 Prepare for an emergency laparatomy where
salpingotomy (making an opening in the tube)
or salpingectomy (excision of the affected
tube)

60. HYDATIDIFORM MOLE
The chorion degenerates in early
pregnancy and form a mass of vesicles
making the foetus fail to develop

61. Signs and symptoms
 Amenorrhoea followed by:
 Vaginal bleeding
 Passage of balloon like vesicles in brown
vaginal discharge
 Vomiting and headache
 Gross ankle oedema, high B.P and protenuria
 Larger uterus than expected
 Foetal heart sounds and parts not detectable
 Pregnancy test strongly positive

62. classification
 Complete –has no sign of embryo and
has very high risk of malignancy
 Incomplete-Has some evidence of
embryo and has a lower risk of
malignancy.

63. MANAGEMENT
Most will be expelled spontenously:
 Manage as complete abortion.
 Oxytocin
 Evacuation-gentle after 5 days
If not expelled:
Evacuate the uterus
Monitor hCG levels-Should be normal within a
week. Review weekly initially then monthly for
an year. This is to rule out metastasis

64. Complications
 Malignant change
 Hemorrhage
 Sepsis
 Pre-eclampsia
 Perforation of the uterus

65. GENITAL PROLAPSE
Definition
 This is the downward displacement of
the pelvic organs due to relaxation of the
pelvic support

66. Causes
 Chronic coughs
 Constipation
 Obesity
 Traumatic deliveries
 Menopause
 Multiparty
 Pelvic tumours
 Sacral nerve disorders
 Heavy lifting

67. CYSTOCELE
 This is the herniation of the bladder through the
anterior vaginal wall.
Classification
 Mild cystocele-the anterior vaginal wall
prolapses to the introitus upon straining
 Moderate cystocele- the vaginal wall extends
beyond the introitus upon straining
 Severe cystocele- the vaginal wall extends
beyond introitus in the resting state

68. Features
 The patient will complain of vaginal
pressure
 A protruding mass on vaginal
examination
 Urinary incontinence or incomplete
bladder empting

69. Management
Conservative management
 Insertion of pesseries or tampon in the lower
vagiana which provides temporally support.
 Kegel exercises to improve the muscle tone.
 Oestrogen administration in post menopausal
women which improves tone and vascularity of
the musculo-fascial support.
Surgical measures
 For large cystocele an anterior vagina
coloporrhaphy is done

70. Preventive measures
 Doing kegel exercises during postpartum
to strengthen the pelvic muscles.
 Avoid obesity
 Treat chronic coughs and constipation
 Avoid traumatic deliveries
 Oestrogen therapy after menopause.

71. RECTOCELE
 This is herniation of the rectum through the posterior
vaginal wall
Features
 Usually asymptomatic
 Difficult in evacuating faeces
 Sensation of vaginal fullness
 Presence of a soft reducible mass in the posterior
vaginal wall.
Management
 Posterior colpoerineorrhaphy
 Advice the patient to avoid straining activities,
coughing, constipation and vaginal deliveries after the
surgery.

72. UTERINE PROLAPSE
Classification
 1st degree- the cervix is at the mid
portion of the vagina
 2nd degree- the cervix is at the introitus
 3rd degree- the cervix is behold the
introitus

73. Features
 Sensation of fullness in the vagina
 Low backache
 Uterus may protrude at the introitus
 Bleeding if the cervix become eroded by the
drying effect
 Dyspareunia
 Leucorrhoea due to uterine engagement
 Change in micturation patterns e.g. incomplete
emptying due to bladder displacement by the
uterus.

74. Management
Medical measures
 Vaginal pessaries
 Oestrogen therapy post menopause
 Treat any underlying cause e.g. reduce weight,
malignancy, cough etc.
Surgical
 Vaginal hysterectomy
 For 1st and 2nd degrees ,and for women of
reproductive age colporrhaphy and amputation of the
cervix is done. This is referred to as the Manchester
repair

75. FISTULAE
Definition
 A communication between two internal
hallow organs or between an internal
hallow organ and the skin.
Types
 VesicoVaginal fistula
 RectoVagianl fistula

76. Causes
 Obstructed labour which causes necrosis
due to pressure by the presenting part.
 Congenital malformations
 Radiotherapy for gynaecological conditions
 Disease e.g. tuberculosis and tumours
 Surgeries

77. Features
 Dribbling of urine through the vagina for VVF
and faeces and flatus for RVF
 Large fistulas can be seen on speculum exam,
small VVF can be seen on cytoscopy
 Some patients may complain of lack of sexual
enjoyment
 Psychological amenorrhoea
 Vulval excoriation
 Social isolation

78. Management
 Some recently formed fistulas heal
spontaneously when the bladder is drained
continuously (VVF) for about 21-28 days and
also low residue diet given for the same period
(RVF)
 The fresh fistula requiring surgery should be
repaired at once while fistulas noticed several
days after injury should be repaired after 2-3
months in order to allow the local damage and
infection to settle

79. Preoperative care
 Enema on the morning of operation
 Sterilize the gut with Cabbracol 500mgs BD for
five days before RVF repair
 Antibiotics for a few days before RVF repair
 Blood for HB
 Examination under anaesthesia to note the
type
 High protein and vitamin diet to promote
healing and fitness for the operation.
 Psychological support

80. Postoperatively
 Ensure continuous drainage of the
bladder for 10-14 days
 Analgesics to relieve the discomfort
 Antibiotics to prevent infections
 High protein and vitamin diet which is
low residue
 Ensure perineal hygiene through
perineal irrigation and douching
 Liquid paraffin for RVF to avoid
constipation

81. INFERTILITY
Definition
 This is the apparent inability to achieve
conception for one year of normal
intercourse.

82. TYPES
 Primary infertility
 Secondary infertility

83. General factors affecting fertility
 Age
 Nutrition
 Health
 Drugs
 Psychological factors e.g. anxiety
 Ignorance of coitus and some cases
excessive coitus

84. Female factors affecting fertility
 Structural abnormalities e.g. Mullerian agenesis
 Tubal blockage
 Endocrine disoders
 Uterine fibroids
 Cervical hostility where the cervical mucus is
hostile to spermatozoa
 Cervical incompetence which leads to secondary
infertility due to abortions
 Endometriosis

85. Male factors affecting fertility
 Structural abnormalities e.g.
hypospadias, undescended testes
 Impotence
 Oligospermia and azoospermia

86. TREATMENT OF INFERTILITY
 Thorough assessment in order to
identify the cause and treat
 Emphasize to the couple if no
abnormality if found that pregnancy is
possible even after many years.
 Assisted reproduction-In vitro
fertilization, Artificial insemination

87. TREATMENT OF INFERTILITY
 Counsel the clients on general measures to
include
1. Good diet and exercise
2. Avoid excessive consumption of alcohol, caffeine
and tobacco.
3. Avoid excessive coitus
4. Have adequate sleep
5. Advice on weight loss if obese
6. Avoid excessive or prolonged exposure of the
scrotum to heat e.g. hot bath, tight underwear or
prolonged sitting in hot environment

88. PELVIC INFLAMMATORY
DISEASE
Definition:
 Its infection of the upper genital tract-uterus,
fallopian tubes and the ovaries.
Causative micro-organisms
 Gonococci
 Staphylococci
 Streptococci
 Tubercle bacilli
 E. coli

89. Sources
 Through blood spread e.g. Tuberculosis
 Direct spread e.g. from the endometrium
to the fallopian tubes
 Via lymph
 Ascending infection from lower genital
tract
 Introduction by contaminated
instruments e.g. during abortions and
pelvic operations

90. Clinical features
 General signs of infection e.g. fever,
malaise, vomiting, anorexia
 Lower abdominal pains
 Purulent vaginal discharge
 Vaginal bleeding may be present

91. Management
 Antibiotics
 Avoid intercourse, douches as this may worsen
the infection process
 Position in semi fowlers to enhance downward
drainage
 Analgesics
 Document the amount, type, odor etc. of the
vaginal discharge
 Maintain perineal hygiene by sitzs baths and
cleaning of the perineum frequently.

92. MANAGEMENT CONT..
 Surgery to drain abscesses in acute cases and
for removal of pelvic organs in chronic cases if
treatment is unsuccessful
 Psychological support to the client since PID
may be caused by STI, there may be guilt
feelings
 Health information provision on hygiene and
how to prevent a recurrence.
 Balanced nutrition high in fluid and proteins
 Adequate rest and exercise

93. ENDOMETRIOSIS
Def;
 Is an abnormal condition in which the
endometrial tissue is located in other tissues.
Pathophysiology
 Despite the location, the Ectopic endometrial
tissue responds to hormonal changes hence
there is cyclic bleeding in the affected organs
.This causes inflammation and scarring
resulting in adhesions formation.

94. Clinical features
 This relates to the location
 General features include
-pain that begins just before menstruation,
lasting during menstruation and some times
for a few days after
-dyspareunia
-menstrual irregularities
-infertility
-cyclic bleeding from the rectum/ hematuria etc.

95. Diagnosis
 History of cyclic bleeding e.g. from the
rectum, scar
 Pelvic examination
 Laparoscopy

96. Management
 Analgesics
 Hormonal therapy e.g. contraceptive
pills, danazol
 Surgical management-removal of the
Ectopic endometrial tissue. More radical
surgery involving removal of the uterus
and the ovaries.

97. Polycystic ovary syndrome
 Involves disruption of the menstrual
cycle and a tendency to have high
levels of male hormones (androgens)
that is causes by increased production of
luteinizing hormone.
 It gets its name from the many fluid-filled
sacs (cysts) that often develop in the
ovaries, causing them to enlarge.

98. Symptoms
 Develop during puberty and worsen with time.
Symptoms vary from woman to woman.
 Primary Amenorrhoea
 Irregular vaginal bleeding
 Unovulating.
 Masculinization or virilization. Symptoms
include acne, a deepened voice, a decrease in
breast size, and an increase in muscle size
and in body hair (hirsutism).
 Most are obese.

99. Diagnosis
Is based on symptoms.
Blood tests to measure levels of hormones
such as follicle-stimulating hormone and
male hormones are done.
Ultrasonography is done to see whether
the ovaries contain many cysts and to
check for a tumor in an ovary or adrenal
gland.

100. Treatment
 Exercise
 Decrease carbohydrate intake
 Metformin
 Clomiphene
 Other fertility drugs if above fails
 Remove unwanted hair
 OCP for those who don’t want
pregnancy.