operation

.post bt { float:left; color: $headerBgColor; font-size:100px; line-height:80px; padding-top:1px; padding-right:5px; } ssssssss


Gynaecology
 One of our colleges died earlier, please pray for her.
 It will be my pleasure to receive any notes or comments on my e-mail : dr.7oka@live.com
 Uterine size : normally hardly felt ( 7.5 X 4 X 2.5 cm in long.,transverse, A-P diameters ) . = ( 3 X 2 X 1 inch )
 Bartholin’s gland : it’s duct 2 cm long and opens between the hymen and labium minus .
 Female urethra is a tubular structure , 3-5 cm ( 4 cm ) in length , the urethral smooth muscles are innervated by sympathetic fibers ( T10,11,12 )
 Urinary bladder ; detrusor muscle have rich cholinergic parasympathetic supply ( S2,3,4)
 nerve supply of the vulva mainly from the pudendal nerve (S2,3,4) AND additional sensory nerves are supplied from the : ilio-inguinal nerve (L1) , the genital branch pf genito-femoral nerve ( L1,L2), and the posterior cutaneous nerve of the thigh .
 the vagina forming an angle 60 with the horizontal plane .
 vaginal length : the ant. Wall = 8-9 cm , the post.wall = 10 – 11 cm
 the ureter
o 25 cm in length
o pass through the cardinal ligments 1-2 cm lateral to the vagina ( lateral fornix ) ,
o about 2 cm = ½ inch ( at the base of broad ligament or lateral to the internal os or lateral to the supravaginal cervix) the ureter is crossed by the uterine artery , the ureter being below the artery ( like water under the bridge ) ,
o ureter may injured during hysterectomy during clamping the vaginal angles and the parametrium 1 cm lateral to vaginal vault .
 the isthmus is an area 4-5 cm in length that expands during pregnancy forming the lower uterine segment ( 10 cm ) in the last trimester .
 the cervix is the elongated lower part of the uterus measuring 2.5 – 3 cm .
 the cervix – body ratio is 2/1 at birth , 1/1 at puberty , and 1/3 in adults
 the position and direction of the uterus :
o anteversion : the angle between the axis of the cervix and that of the vagins is usually a right angle ( 90 d )
o anteflexion : the angle between the axis of the body of the uterus and that of the cervix is usually an obtuse ( 160 – 170 d )
 the junction between squamous and columnar epithelum at the external os is either abrupt or it may form a transitional zone 1- 3 mm known as the transformation zone .
 nerve supply of the uterus
o parasympathetic innervations are received from S2,3,4
o sympathetic innervation from T5 and T6 ( motor ) , T10 , T11,T12 and L1 ( sensory ) , both reach the uterus through branches of inferior hypogastric plexus .
 fallopian tube , each tube is about 10 cm in length and divided into four parts : interstitial part : 1 cm , isthmus : 2 cm , ampulla : 5 cm , infundibulum : 2 cm .
 nerve supply of the fallopian tubes : sympathetic and parasympathetic fibers ( sympathetic fibers arise from T11 and T12 )
 tubal pain is referred to the tubal points which lie on the lower abdominal wall ½ an inch above midinguinal points .
 ovary : measure 3 X 2 X 1.5 cm
 ovarian artery arise from the aorta at the level of the L2
 nerve supply of the ovary : the ovary is insensitive except to squeezing on P.V examination . It is supplied by sympathetic and parasympathetic nerves ( T10 and T11 ) that accompany the ovarian vessels .
 Gonadal differentiation at the six week , after week 6 fetal development will occur into either male or female .
 Testicular differentiation :
o At the seventh week : Germ cell >>> spermatogonia , sex cord cell >>> sertoli cells , both >>> seminiferous tubules
o At the eight week : local mesodermal differentiation >>> leydig cell
 Testicular sertoli cells secrete MDIF that inhibits Mullerian development start at 61 days and completed at 80 days fetus .
 External genitalia start to develop from urogenital sinus (part of the primitive cloaca ) about the 10th week of gestation
 Vagina : upper 3/4th from the lower part of the Mullerian ducts , lower 1/4th from urogenital sinus .
 The ovaries develop from the genital ridges at the level of the 10th – 11th dorsal (thoracic ) vertebrae and descend later on the pelvis .
 Uterine hypoplasia : small infantile uterus with a body to cervix ratio of 1 : 2 .
 The average menstrual cycle lasts for 3-7 days ( mean 5 days ), recurs every 24-32 days ( mean 28 day ) with average blood loss of about 30 – 50 ml/cycle. From puberty to menopause women will have around 400 menstrual cycle .
 The fetal ovary contains a maximum number of 7 million primordial follicles at mid gestation . the number the declines sharply reaching 1.5-2 million at birth , then declines gradually to reach around 400.000 primoridial dollicles at puberty. Throughout the menstrual cycles ovarian follicles become gradually exhausted until they become depleted by the time of the menopause .
 The follicular phase : last from the 1st day of menses till ovulation . it is of variable length ( mean 13 days )
 The mature Graafian follicle is about 18 – 24 mm
 The preovulatory LH peak (1-1.5 day) occurs after the level of estradiol (E2) reaches 200 pg/ml for about 50 hours
 Ovulation occurs approximately 36 hours after the onset of the LH surge and about 12 hours after LH peak
 The luteal phase extends from the time of ovulation till the onset of menstruation , and is fairly constant lasting for about 14 days .
 The life span corpus luteum is around 9 days
 In absence of pregnancy , the CL undergoes apotosis and cease to produce P by 12- 14 days after ovulation
 Placental steroidogenesis is established about the 8th week og gestation .
 The proliferative phase , the endometrial thickness grows from 0.5 mm at the end of menstruation to about 5-8 mm at the end of the proliferative phase .
 The secretory phase : the basal portion (basalis) represents 25 % of the endometrium .
 The menstruation : * regeneration and repair : start with 2 days from the onset of menstruation then complete cessation of bleeding within 5- 7 days from the start of menstruation .
 Spinbarkeit test >>> +ve in follicular phase ( threads 7-10 cm )
>>> -ve in luteal phase ( threads 3-4 cm )
 Cytology of vaginal epithlium : maturation index
o 0-30-70 >>> follicular phase
o 0-70-30 >>> luteal phase
 Puberty start by the age of 8 – 9 years and is completed by the age of 12 – 14 years .
 At initiation of puberty single nocturnal spikes of GnRH start to occur , and gradullay increase in frequency becoming nigh and day over a period of 1 – 2 years , until the normal adult frequency is achieved .
 Growth spurt : is the first sign of puberty to occur with a peak growth velocity at age of 11 years , followed by slower growth rate until cessation usually by the age of 15 years .
 The average age of menarche in Egypt is 12.5 years .
 Precocious puberty : appearance of secondary sexual characters before 8 years of age, with or without onset of menstruation .
 Delayed puberty : if no secondary sexual characters are noted by the age of 13 – 14 years or if menses is still absent by the age of 15 – 16 years .
 Menopause usually occurs between 45-55 years with a median age of 51.4 years .
 Premature menopause : menopause occurring before the age of 40 years .
 In menopause :
o there is increase in serum FSH levels , produced by the pituitary gland ( > 30 IU/ml ) followed by an increase in serum LH levels ( > 20 IU/ml )
o Endometrium becomes atrophic ( < 5 mm in thickness )
o Vasomotor symptoms of hot flushes last for 1 – 5 minutes .
 Perimenopause : the period of life that extends through the few years preceding menopause ( average of 4 years ) , and ends by the first menstrual period .
 see drugs of menopause .
 Amenorrhoea :
o Primary amenorrhoea : menstruation has never occurred by the age of 14 years without growth or development of the 2ry sexual characteristics , or by the age of 16 years , regardless of development of the 2ry sexual characteristics
o Secondary amenorrhoean : cessation of menstruation , more than 6 months , in reproductive age women , that is not due to pregnancy .
 Premature ovarian failure : due to early exhaustion of ovarian primordial before the age of 40 years leading to premature menopause . ( high FSH levels > 40 ng/ml )
 A minimum of 20 % of body fat by weight is required for initiation of menarche and maintenance of menses .
 Hypergonadotrophic amenorrhoea : elevated gonadotropins ( FSH > 20 IU/L , LH > 40 IU/L )
 Euogonadotrophic amenorrhoea : normal gonadotrophin levels ( FSH and LH of 5-20 IU/L)
 Hypogonadotrophic amenorrhoea : low gonadotrophin levels ( FSH and LH < 5 IU/L )
 Body mass index = weight in kg / height in m2 )
o Normal BMI for height = 26 or less
o Overweight = 26-28
o Obesity with excessive body fat > 28
 See drugs of amenorrhoea
 Microadenoma ( < 10 mm in size ) , macroadenoma (>10 mm in size )
 Normal prolactin level : 2.9-29 ng/ml
 See drugs of hyperprolactinaemia
 Tests for ovulation :
o Basal body temperature : ovulatory syclyes show biphasic BBT chart with a rise in temperature ( 0.2-0.3 C )
o Mid luteal serum progesterone assay :
 Is performed 7 days after ovulation , or day 21 of the cycle ( maximum CL activity )
 Levels < 5 ng/ml suggest anovulation
 Values > 10 ng/ml suggest ovulation with adequate CL function
 Levels 5-9 ng/ml suggest ovulation but with inadequate function ( LPD )
o Premenstrual endometrial biopsy : done 2-3 days prior to menstruation .
 See drugs of anovulation
 Risk for twin pregnancy ( 10 % ) and multifetal pregnancy ( 1% ) in clomiphene citrate while in pituitary gonadotropins the risk is markedly increased up to 10 – 30 %
 In PCOS there is
o abnormal LH/FSH ratio > 2:1
o by US the ovaries surrounded by small follicles ( 2-10 mm in diameters )
 US picture of PCOS may be encountered in up to 25 % otherwise normal females .
 See drugs of PCOS
 LPD : dated PEB showing secretory changes with a lag > 2 days behind that for a normal cycle .
 Infertility : failure of conception to occur after 1 year of regular intercourse , without the use of any type of contraception.
Almost 15% of couples may suffer infertility after the first year of marriage
o 15 % >>> unwanted delay in conception
o 25% >>> problems will be found in both partners .
o Male factor >>> 30-40 %
o Female factor >>> 40 -50%
o Unexplained >>>
 10-15%
 almost 50 % of these couples will conceive within 3 years without treatment
 Due to decreased ovarian reserve : deceased number and quality of oocytes ( manifested by an elevated day 3 FSH level > 10 m.IU/ml)
 Management : repeated IUI , for at least 3 cycles , may improve the chances of conception .
 Fecundabiltiy : the monthly probability of pregnancy among fertile couples . it ranges arounf 20 – 25% per cycle in unprotected intercourse .
 The cumulative pregnancy rates increase by time , reaching about 50% in 6 months , and up to 85% after one year .
 Increased scrotal temperature : 1c < body temp.
 Semen analysis = male seminogram : samples are collected by masturbation after 3-4days of abstinence from intercourse .
 Female factor of infertility :
o Ovarian factor >>> 30 – 40 % - the commonest
o Tubal & peritoneal factors >>> 30 %
o Uterine and endometrial factors >>> 5-8%
 Normal and abnormal semen parameters
Normal semen parameters
abnormal semen parameters
Volume : 2-5 ml
Low volume : < 1.5 ml
Concentration /ml : > 20 million sperm/ml
Oligospermia : < 20 million sperm /ml
Total sperm conc.: >40 million per ejaculate
Azospermia : absent sperms in ejaculate
- Percent motility : > 50% motile sperms
- Progression : >50 % Gr. 1+2 ( forwards)
Asthenospermia :
- Poor motility < 40 % motile sperm
- Poor progression < 40 % Gr.1+2
Morphology : > 30 % notmal forms ( oval head and single tail )
Teratospermia : abnormal forms > 50 %
White blood cells : <1 million /ml
Necropermia : dead spermatozoa > 50%
 Starting infertility evaluation : investigations usually start after 6 months to 1 year of regular marital life.
However if female age is > 35 years , or history reveals marked menstrual disorders or strong suspicion of tubo-peritoneal or male factor , investigations should be started immediately .
 Serum FSH & LH usually done in day 1-3 of cycle
 Hypogonadotrophic hypogonadism ( very low FSH & LH levels < 1 ng/ml)
 HSG
o 6-10 cc of urographin
o Performed 2-3 days postmenstrual .
o Improves pregnancy rates in the first 3-6 months
 The Post coital test
o Examination of cervical mucus 6-10 hours after intercourse , at time of ovulation
o Normally : > 20 progressively motile sperms / HPF .
 Steps and techniques in IVI/ICSI Procedures :
o Ovarian stimulation : injections are continued for 11-14 days until the leading follicles reach 18 mm in diameter by TVS
o Oocyte retrieval ( egg collection ) : aspiration of mature oocyte is performed 24-36 hours after hCG administration .
o Laboratory sperm egg fertilization :
 In IVF : 100,000 – 200,000 sperms are incubated with retrieved oocytes ( 4- 6 hours after collection )
o Embryo transfer (ET) : 2 – 3 days after oocyte retrieval
o Luteal phase support by progesterone after ET and continued for 2 weeks .
 Success rate of ICSI >>> 25-40%
 Dysmenorrhoea :
o Primary dysmenorrhea : it occurs in ovulatory cycles usually presenting 2-3 years after menarche , since initial cycles are usually anovulatory
 Pain starts just before or with the onset of menses and last for 24-48 hours.
 NSAID eg. Ibuprofen 400 mg t.d.s
o Secondary dysmenorrhea :
 Type of patient : mostly middle age ( 30 – 35 years ) parous women
 Premenstrual syndrome ( PMS ) :
o 50-80 % of women >>> uncomfortable premenstrual symptoms
o 5-10% >>> interfere with normal activities
o Up to 60 % >>> severe PMS + Psychiatric disorder
o Clinical manifestations : symptoms are cyclic and need to be charted over at least 2 months duration
o TTT : long acting GnRH agonists : short term ( 3 months )
 Menorrhagia : excessive bleeding during menstruation . bleeding may be increased in amount , duration , or both ( > 80 ml / cycle )
 Polymenorrhea : frequent menstruation at short intervals < 21 days of normal amount .
 DUB :
o Ovulatory DUB >>> 80 – 90 %
o Anovulatory DUB >>> 10 20 %
 Metropathia hemorrhagica : one ovary may contain a small follicular cyst ( < 5 cm )
 See drugs of DUB
 Postmenopausal bleeding : any bleeding from the genital tract occurring 6 month to 1 year after cessation of menstruation ( average age at menopause is 47-52 years )
o Pelvic TVS : a cut – off value for endometrial thickness in menopause > 5 mm is suspicious of hyperplasia, and that > 10 mm is suspicious for malignancy
 Sexually transmitted diseases :
o See drugs for infections
o all are common in young sexually active females especially < 25 years of age
 Bacterial :
 Gonorrhea :
 Symptomatic gonorrhea : symptoms usually appear 2 to 5 days after exposure , but may be delayed for up 30 days
 Disseminated gonococcal infection : < 3 % of cases
 NAAT sensitivity >>> 96.7 %
 Chlamydia trachomatis
 Susceptibility to HIV is 3 folds increased .
 Asymptomatic >>> 75 %
 PID >>> 40 %
 Microscopic examination : 20 or more leucocytes by HPF
 NAAT sensitivity >>> 85% , NAAT specificity >>> 99 %
 Complication : late onset pneumonitis in 10 %
 Chancroid
 Incubation period : 3 – 5 days
 Association with syphilis and herpes found in 10 % of cases
 Lesion : small papules >>> painful genital vulvar ulcer in 2 – 3 day
 Granuloma inguinale
 Incubation period : 8 – 80 days
 Lymphogranuloma venerum :
 Caused by c.trachomatis serotypes L1,L2,L3
 Incubation period : 3-5 weeks
 Resolve spontaneously : 2 to 6 weeks
 Complement fixation tests with titers > 1/64 indicate active infection
 Viral :
 Herpes simplex virus (HSV) :
 Incubation period : 21 days
 Resolves after 3-4 weeks
 Human papilloma virus ( HPV ) :
 Types :
o 6 , 11 >>> visible external warts
o 16,18,31,33,35 >>> CIN & external genital squamous intraepithelial neoplasia .
 Association with other STDs in almost 25 % of cases .
 Contact with infected male partners : risk of 60 – 80 %
 Maternal to fetal transmission : very rare ( 1:1000 )
 Incubation period : 6 weeks to 18 months ( mean 3 months )
 Human immunodeficiency virus ( HIV )
 Long latent incubation period : 2 month to 17 years
 Median time between HIV infection and development of AIDS in adult is about 10 years.
 The mean age at diagnosis of AIDS infection is around 35 years .
 Initial HIV exposure :
o retroviral syndrome in 70 %
o incubation period : 2-4 weeks , followed by febrile symptoms
o generalized lymphadenopathy follow in 2 weeks
 more severe disease :
o months or years later
o 30 % of cases progress to AIDS in 5 years .
 ELIZA screening for individual at risk detects > 95 % of patients within 3 months of infection.
 Without treatment the risk of transmission to the fetus >>> 15 % to 25 % while breast feeding increasing the risk of neonatal transmission >>>>>>>>>>>> 12 – 14 %
 Syphilis
 Primary syphilis :
o Incubation period : 10 -90 days
o Resolves in 2-6 weeks
 Secondary syphilis :
o Untreated chancre >>> followed in 6 weeks to 6 months
o Resolve in 2-6 weeks
 Tertiary syphilis : 33 % of untreated patients
 Female lower genital tract infections :
 Vaginal flora : anerobes are predominant with a ratio to aerobes approximately 10 : 1
 Vaginal PH : 3.8 – 4.5
 Decrease in glycogen content >>> rise in vaginal PH reaching 6.5 – 7
 Bacterial vaginosis ( BV )
 1st most common
 50 % of women attending the clinics
 Vaginal PH rising ranging 4.7-7
 50 % asymptomatic
 The positive predictive value for microscopic examination in diagnosis of BV reaches almost 95 %
 Cure rates in non pregnant women >>> 80 – 90 % at one week
 Recurrent infection may occur in up to 30 % of treated women within 3 month especially those with heterosexual contacts
 Candida vaginitis (CV)
 2nd most common
 30 % of women attending the clinics
 30 % of women may have vaginal colonization of candida albicans with no symptoms of infection
 Non ablicans strains : 20 % of cases
 Vaginal PH : normal or slightly acidic ( < 4.5 )
 Wet amount microscopic examination with saline and 10 % KOH : reveals hyphae or pseudohyphe , with budding yeast in 50 % - 70 % of women with yeast infection
 Trichomonas vaginalis vaginitis
 3rd most common
 4 anterior flagellae
 Slightly larger than leucocyte ( 20 mm in length and 10 mm in width )
 70 % encountered from male partners
 25 – 50 % asymptomatic
 Vaginal PH : is usually weak acidic ( 5- 6 )
 Normal vaginal discharge amount < 0.5 ml/day
 Saline wet amount preparation reveals numerous leukocytes and highly motile flagellated trichomonads in 70 % of cases
 Pap smear : a sensitivity approaching 60 %
 Senile ( atrophic ) vaginitis :
 Vaginal PH is usually low < 4.5
 Female upper genital tract infections :
 Microbiology of PID :
o Neisseria gonorrhea : from the cervix in 27 % to 80 % , from fallopian tubes in 13 % to 18 %
o Chlamydia trachomatis : 20 % to 40 %
 Both may coexist together in 25 % to 40 %of cases of PID
 Factors associated with increased risk for PID :
o Young ( 25-35 years ) , sexually active women >>> 85 %
o Multiple sexual partners >>> 3 fold risk
 2/3 of acute PID cases begin just after menses .
 Remote sequel and complication of PID :
o Tubal obstruction and infertility :
 11 % after 1 episode
 23 % after 2 episodes
 54 % after the third episode
o Ectopic pregnancy : rate increase 10 fold , approximately 50 % of tubal ectopic pregnancy
o Chronic pelvic pain : 20 % with acute PID , sometimes associated with dyspareunia .
 Blood tests in PID :
o Increased WBCs (Leukocytosis) : is not by itself a reliable indicator owing to its low sensitivity ( < 50 % of cases with acute PID will have a WBC count greater than 10.000 cells /ml) and its lack of specificity to PID
o Increased ESR : is a non-specific finding although elevated in > 75 % of PID cases , ( good sensitivity but low specificity )
 Laparoscopy indicated in poor response to parentral antibiotics after 48-72 hours of initiating treatment .
 Surgical treatment indicated whenever the patient doesn’t improve within 72 hour of treatment
 Vaginal drainage of pelvic abscess : if it was large in size > 8 cm .
 Chronic specific infections of the female genital tract :
 95 % of female genital TB is due to human strain .
 Sites affected in TB :
o Tubes : almost all cases
o Endometrium : 80 %
o Ovaries : 20 – 30 %
 Tuberculous follicles may be found in the endometrial stroma especially in the 2nd half of the cycle
 Antituberculous drugs last for 18 – 24 months
 Bilharziasis cause infertility in up to 40 % of patients
 65 % of cases of vaginal carcinoma were associated with bilharziasis ( Shafeek 1961 )
 Benign conditions of the vulva and vagina :
 Pruritus vulvae :
o 80 % with vaginal discharge
o 20 % without vaginal discharge
 Lichen sclerosus et atrophicus :
o Approximately 4 % of women develop invasive cancer .
 Pelvic organ prolapse (POP):
 POP occurs in nearly 12 – 30 % of women significantly increasing both by age and multiparity so that woman will have an estimated life risk of 11 % to undergo surgery for such condition.
 Multiparity : it is estimated that the risk of POP increased 1.2 times with each vaginal delivery
 The incidence of POP doubles every decade of life between the 30 – 60 years of age .
 Prolapse may develop in 2 % of nulliparous women suggesting congenial weakness of the pelvic support .
 Vaginal mesh repair : recurrence of prolapse after surgical correction may occur with up to 30 % of cases requiring a second operation within 5 years .
 Perineal lacerations :
 Management of perineal lacerations :
o Every perineal tear , however, small, should be repaired.
Primary suture is possible if done within the first 24 hours.
If the case is seen later than that, it’s considered as septic wound and left to heal by granulation.
Repair in such cases is postponed intil all signs of infection have disappeared , usually 3-6 month later.
 Pre-operative preparation of old perineal tear : the patient is admitted to hospital 3 days before the operation .
 Postoperative after care :
o The vulva is regularly washed with antiseptic solutions then dried ( at least 3 times daily )
o The vaginal pack is removed after 24 hours .
o On the 5th night the patient is given oral purgative ( as 50 ml castor oil )
 Urinary incontinence in the female :
 Parameters of normal bladder function based on cystometry :
Residual urine after voiding < 50 ml
First desire to void 150 – 200 ml
Detrusor pressure filling < 15 cm H2O
Capacity : strong desire 400 – 600 ml
 Stress urinary incontinence :
o 5 % : < 45 years
o 10 % : 45 -60 years
o > 30 % : > 65 years of age
 Surgical treatment of USI :
o Colposuspension operation eg. Burch procedure :
 Success rate 95 % after 1 year
 The longest successful follow up period ( 75 % after 15 years )
o The sling procedures :
 High success rate up to 90 %
 Shorter stay in the hospital ( 1 day )
o Kelly’s plication with anterior colporrhaphy :
 60 -70 % success rate but fall to 30 % after 5 years
o Periurethral injection of collagen :
 Long term success rate results are < 30 % after 5 year .
 Urge incontinence : second most common cause of female urethral incontinence , and accounts for 30 – 40 % of cases .
 Frequency : urination 7 or more times a day
 Vesico-vaginal fistula ( VVF ):
o Causes with incidence :
90 % - developing countries
Due to obstetric trauma
90 % - developing countries
Due to iatrogenic injury during pelvis surgery
6 %
Pelvic irradiation therapy
2 %
Secondary to pelvic malignancy
0.5 – 2 %
pelvic malignancy
0.1 – 0.8 %
Hysterectomy
 Retrograde coloured dye injection into the bladder :
o 200 ml of coloured dye
o Patients is allowed to walk for 15 – 20 minutes
 3 gauze test
 Conservative management of VVF :
o If injury to the bladder discovered during difficult labor :
 An indwelling rubber catheter should be fixed in the urethra , and left for a period of 3-6 weeks
o If injury is detected some time after labour :
 Operation for closing the fistula should not be attempted before complete tissue involution and resolution of oedema in 3 – 6 months .
 Flap – splitting operation or dedoublement : free mobilization of the vaginal flaps from the bladder over an area of 1.5 – 2 cm around the fistula .This is a most important step .
 Post operative care :
o The vaginal pack is removed 24 hours after the operation
o The catheter is never removed before 10 -14 days .
 Kidney function tests : see drugs & levels.
 Uterine leiomyomas :
o They are clinically detectable in almost 20 % of women over the age of 30 years ,
o At autopsy myomata will be present in up to 40 % of uteri examined .
 Pathology of myomas :
o Corporeal 95 %
o Cervical 1%
o Broad ligamentary 1 %
 Size : is variable , ranging from small < 1 cm seedling fibroids to huge ones .
 Cellular leiomyoma : are tumours with mitotic counts of 5 – 10 per 10 consecutive high power field ( HPF ) that lack cytological atypia. They are not considered malignant .
 Malignant transformation into leiomyosarcoma is very rare occurring in no more than 0.2 % - 0.5 % of myomas.
 Menorrhagia : is the commonest presentation – almost 30 % of cases .
 Uterine leiomyomata are unusual cause for infertility being responsible for associated infertility in only 5 – 10 % of cases and are reported as a sole cause for infertility in < 3 % of cases .
 Small myomata with a uterine size < 12 weeks are only felt within pelvis through bimanual examination .
 During expectant management repeated bimanual pelvic examination , pelvic U.S , and regular blood counts are performed every 6-12 months .
 Uterine larger than 14 weeks size is one of indication to operate symptomless fibroid as it will cause unpleasant symptoms .
 Uterine enlargement < 12 week size can be treated medically .
 Hystroscopic myomectomy used in removal of small SMM < 5 cm in diameter which protrude > 50 % in uterine cavity .
 Laparoscopic myomectomy done in limited to < 4 in number , < 6 cm in size , ,mainly SSM (rarely ISM ) , provided the uterus is < 16 weeks size .
 See drugs of fibroid.
 Recurrence of fibroids may occur in up to 27 % of cases .
 Vaginal hysterectomy if the uterus is < 12 weeks size .
 Uterine artery embolization : results in 60 % reduction in size of myomas , and control of menorrhagia in up to 90 % of cases within 8 – 12 weeks from performing the procedure .
 Laparoscopic myolysis :
o Cryomyolysis : using  180 C probe
 MRI – guided focused ultrasound : improvement of symptoms in up to 60 % of cases .
 Endometriosis :
o 10 % of women in the childbearing age
o 20 % of cases of chronic pelvic pain ( > 6 months )
o 30-40 % of women with infertility
 Risk factor : mid reproductive ages ( 25 – 35 years )
 Genetic and immunological factors : the relative risk of endometriosis is 7 % in siblings, compared to 1 % in control groups .
 CA-125 : cell surface antigen found in coelomic epithelium .
 The disease is usually progressive in 30 – 60 % of cases .
 See drugs of endometriosis
 Surgical therapy :
o Small endometriomas < 3 cm : aspirated , irrigated and the interior wall vaporized
o Large endometriomas > 3 cm : removal of cyst wall to prevent recurrence .
o Preoperative hormonal treatment : by 3 months course of GnRH.
 Extirpative surgey >>> TAH&BSO , if the ovaries were preserved recurrence rate will be high with a 15 – 40 % chance to re-operate .
 Referral for IVI/ICSI : maternal age is approaching 35 years where fertility declines sharply .
 Endometriosis tends to recur in 5 – 20 % of cases.
 Contraception and family planning :
 Prolonged lactation :
o at least 40 - 60 % of female will experience lactational amenorrhea and anovulation during the 1st 6 months of puerperium due to elevated prolactin levels
o efficacy is low giving no more than 50 % protection
 advantages of barrier methods :
o fairly reliable with failure rates < 10 HMY ( Hundred woman years )
 male and female latex condom : high pregnancy prevention rate reaching up to 97 %
 The female diaphragm and cervical cap : they should be inserted 6 hours before intercourse .
 Spermicides ( nonxynol-9 )applied 30 minutes before intercourse , failure rate are high reaching up to 30 / HMY if used alone
 Copper IUD ( Cu T 380 ) :
o is the moset commonly used type with surface are of copper 380 mm2 , it is changed every 6- 8 years .
o increases blood loss by almost 35 %
 Copper ( Cu T 200 ) + silver IUD = Nova T
 Progesterone releasing IUD ( Mirena IUD ) :
o with sustained release of levo-norgestrel ug/day , it is changed every 3-4 years .
o 70 % reduction in menstrual blood loss
 Timing of IUD insertion :
o By end of menstruation
o 4-6 weeks after delivery ( during puerperium )
o 3-4 weeks after an abortion
 Technique of IUD insertion : the long IUD threads are then then cut 2 cm from the external os .
 IUD : very low failure rate : 0.5 / HMY
 Treatment for mild to moderate bleeding : NSAID eg. Profenid 600mg tablets
 Expulsion usually occurs in the first 6 months following insertion
 Pregnancy on IUD : if the threads are :
o Visible : abortion rate 25 %
o Not visible : abortion rate 50 %
 See Hormone methods for contraception
 Premalignant lesions of the female genital tract :
 Endometrial hyperplasia :
o Simple hyperplasia :
 Risk for progression to cancer is a low as 1 %
 If atypia is present the risk of progression to cancer may reach 8 %
o Complex hyperplasia :
 Malignant potential is < 3 %
 With atypia > 25 %
 CIN usually affects women in younger age groups ( 25 – 45 years )
 Histological grading of CIN :
o CIN I : dysplastic cells occupy the basal one third ( 1/3 ) of the thickness of the squamous epithelium. Cells of the upper 2/3 show normal stratification and maturation .
 May undergoes :
 Spontaneous regression
 Remain stationary
 Slowly progressive throughout a period of 7- 10 years.
o CIN II : dysplastic cells occupy one half (1/2) of the thickness of the squamous epithelium. Cells of the upper 1/2 show normal stratification and maturation .
o CIN III : dysplastic cells occupy the full thickness thickness of the squamous epithelium without invasion of the basement membrane
 Pap smeat test : is done as an office procedure with an accuracy rate > 80 % , however it carries a small percentage of both false positive and false negative results ( 15 – 25 % )
 Coloposcopy allows inspection of the TZ with magnification up to 20 times after applying 3 % - 5 % acetic acid solution .
 Coloposcopic directed biopsies with accuracy of 85 % - 95 %
 Frequency of cervical cytology screening :
o High risk population are screened annually within 3 years from the onset of sexual activity
o Low risk population : > age of 30 , with 3 consecutive annual negative pap smears, should be screened every 3 years
o Low risk women over the age of 70 : with 3 negative pap smears in the last decade , can consider discontinuation ofPap testing at the physician’s advise .
 Vulvar intraepithelial neoplasia :
 Squamous VIN :
o Younger age than 41 years
o 1/3 of cases are asymptomatic , however VIN often presents as pruritus vulvae
o Asymptomatic cases < 50 years of age are managed conservatively , with repeated biopsies to exclude progression of the disease .
o Symptomatic cases are treated by topical steroids for 3-6 months to relieve symptoms
 Non-squamous VIN : in almost 1/3 of cases there is an associated adenocarcinoma in the apocrine gland and 20 % concomitant cervical cancer may be present .
 Malignancies of the uterine corpus :
 Endometrial carcinoma :
o The most curable gynecologic cancer owing to the fact that most of cases are diagnosed at an early stage ( > 70 % at stage 1 disease ) and if offered proper treatment it will have a high 5 year survival > 85 %
o Combined OCP has a 50 % reduction in the risk of EC due to protective progesterone effect.
 Stage II accounts for 10 – 13 % of cases .
 Grading of the tumour :
o Grade I : < 5 % solid parts
o Grade II : 5-50 % solid parts
o Grade III : > 50 % solid parts
 Increased postmenopausal endometrial thickness > 4-5 mm is an important finding that should indicate performing an endometrial biopsy procedure
 Pap smear has an accuracy rate of < 50 % in diagnosis of EC , hence is considered unreliable .
 Intracavitary irradiation : survival rate is 10 – 15 % lower than that of surgery .
 Brachytherapy : small metal cylinders are inserted in the vagina 3 weeks postoperative .
 Sarcoma of the uterus : leiomyosarcoma :
o Less than 0.2 %as a malignant transformation in benign leiomyoma
o Patients with > 10 mitosis per 10 HPF are regarded as having malignant disease .
 Choriocarcinoma :
o 60 % following evacuation of molar pregnancy
o 25 % following abortion
o < 15 % following term pregnancy
o Rarely following ectopic gestation
 Haematogenous spread : lung ( 80 % ) , vagina ( 30 % ) , liver ( 10 ) , CNS and brain ( 10 %)
 Symptom : persistent vaginal bleeding that continues for > 6 weeks
 See drugs for choriocarcinoma.
 Cervical cancer and CIN :
 Aetiologic factors
o Human papilloma virus : more than 100 HPV types
 70 – 80 % of women exposed to genital HPV , the infection is transient and cleared by immune system in 1 – 2 years .
o HSV type II
 The age incidence for cancer cervix is commonly between 45 – 55 years which is almost 10 years younger that that for endometrial carcinoma , and 10 years older than that for CIN lesion .
 Pathology :
o > 80 % >>> squamous cell carcinoma of the ectocervis
o 15 % >>> adenocarcinoma of the endocervis
 Stage 1a : invasion depth < 5 mm & width < 7 mm
 HPV vaccine :
o > 95 % effective in prevention HPV 16 , 18 , releated cervical cancer.
o Effective when given in age groups from 9 – 26 years in non–previously infected population.
 5 years survival rates after surgery alone ranges 75 – 100 % in stages from IA to IIA.
 5 years survival rates for radiotherapy alone are comparable for survival with surgery alone for stages IA-IIA disease
Low risk HPV
High risk HPV
6 , 11
16 , 18 , 31 , 33 , 35 , 45 , 58
95 % of precancerous lesion
16 : 40 – 70 % of invasive squamous carcinoma of the cervix
18 : 25 % of squamous cell carcinoma
Types 6,11,16,18 account for 70 % of all cervical cancers, and almost 90 % of cases of genital warts.
 5 years survival rates For advanced stages localized within pelvis , 50 – 80 %
 5 years survival rates for metastatic disease outside the pelvis , < 15 %
 Prognosis in cancer cervix :
o Stage IA : cure rates may reach up to 95 %
o Stage IB : 5 years survival rates may reach up to 85 % whether with surgery or radiotherapy
o Stage II : drops sharply to 5 years survival of 50 %
o Stage III : 5 years survival rates 25 %
o stage IV : 5 years survival rates 5 %
 recurrent cervical cancer after primary surgery more than 6 months
 Malignancies of the vulva and vagina :
 invasive cancer of the vulva : incidence in gradual rise reaching up to 8 %
 squamous cell carcinomas :
o is the commonest type representing almost 92 % of tumours
o approximately 5 % of cases are multifocal .
o LN node metastasis is very comman ( 30 % )
 Staging : stage I : 2 cm or less in greatest dimension
 Management :
o very early tumor in which the depth of penetration is less than 1 mm >>> groin dissection .
 prognosis : 5 years survival rates :
o stage I : 90 %
o no nodal involvement : 90 %
o nodal involvement : 50 %
o stage II : 15 %
 Non neoplastic ovarian swellings :
 Follicular cyst :
o small size ( 3 – 7 cm )
o rarely exceeds 5 – 7 cm in diameters .
 corpus luteum cyst :
o small size ( 3- 7 cm )
 theca lutein cyst
o may reach large size > 20 cm
 endometriotic cyst : Ca 125 level in serum in may be elevated in many cases , but the test is not
specific.
 Benign ovarian neoplasms :
 Epithelial ovarian tumours : 60 – 70 % of all ovarian tumours .
 Serous cystadenoma
o 10 -15 % of all tumours of the ovary
o Moderate size : 10 – 15 cm
o Papillary serous cyst : the highest malignant potential in all benign cyst ( up to 50 % )
 Mucinous cystadenoma :
o very low malignant potential < 5 %
o pseudomyxoma peritonii : 5 years survival rate is around 50 %
 Brenner tumour :
o 1-2 % of all ovarian neoplasms
o Bilateral in only 10 – 15 % of cases
o Prevalent in women > 40 years
o Small ( < 2 cm ) to moderate size
 Germ cell tumours :
 20 -30 % of all ovarian neoplasms
 In younger women < 30 years
 Benign cystic teratoma :
o 50 % of ovarian neoplasms
o Below 20 years
o Bilateral in up to 12 % of cases
o Moderate size ( 5 – 10 cm )
o Cut section : mamilla ( small solid knob < 2cm )
o Very low malignant potential < 1 %
 Struma ovarii :
o 1-4 % of cystic teratoma
o 5 % capable of producing thyroid hormone
o 5 – 10 % of tumor develop into carcinoma
 Gonadoblastoma : almost all patients will have an abnormal gonad, with absent Y chromosome in 90% of cases .
 Benign sex cord stromal tumours : < 4 % of all ovarian neoplasms
 Fibroma :
o Unilateral in > 90 % of cases .
o Mostly in women around age of 50 years.
o Meig’s syndrome in only 1 % of cases .
 Tumour marker : CA 125 , CEA and CA 19 – 19
 Laparoscopic ovarian cystectomy : in young women < 35 years.
 Malignant ovarian neoplasms :
 Ovarian cancer is generally rare before 35 years of age but significantly increase by advancing age especially with peak at 50 – 70 year old age group
 Epithelial ovarian cancers
 60 – 70 % of all ovarian cancers
 Almost 2/3 of cases being first diagnosed at stage 3
 Tumour marker : CA – 125
 Hereditary( genetic ) factor :
o 5- 10 % >>> two or more relative had ovarian or breast cancer
o Single first-degree relative >>> risk 3.6 for developing ovarian cancer.
o Three types of familial ovarian cancer :
 Site specific ovarian cancer syndrome : 15 %
 Hereditary breast/ovarian cancer syndrome : 75 %
 Lynch type II : 10 %
o Breast – ovarian cancer tumour suppressor genes BRCA1 and BRAC2
 Serous cystadenocarcinoma : bilateral in over 50 % of cases
 Mucinous cystadenocarcinoma :
o Bilateral in only 20 % of cases
o < 5 % of cases concomitant pseudomyxoma peritonii may be present
 Endometrioid tumours : in around 30 % of cases there is a coexistent second primary in the endometrium .
 Malignant germ cell tumours :
 20 – 25 %of all ovarian tuomours
 Only 5 % of germ cell tumour are malignant .
 Age incidence : > 2/3 of all malignant ovarian neoplasms in women < 30 years of age .
 Dysgerminoma :
o 1-3 % of all ovarian cancers
o Young female ( 10 – 30 years )
o 5 % occurs in patients with abnormal gonads
o Microscopically : bilateral in 10 % of cases .
 Endodermal sinus tumour :
o 1 % of all ovarian cancers
o Young female ( 19 years )
o Rarely affects women over 40 years
o coexistent teratomas are found in 20 % of patients
 malignant teratoma :
 immature teratoma :
o 1 % of all ovarian tumour
o Children uner 15 years of age
 Malignant transformation in benign cystic teratoma : < 1 %
 Malignant sex-cord stromal tumours :
 Granulosa cell tumours :
o 75 % secretes oestrogen and inhibin
o 25-50 % : endometrial hyperplasia
o 5 % : endometrial carcinoma
o 50 % : Call-Exner bodies
 Sertoli-leydig cell tumours :
o < 0.2 %
o Young women 20 – 30 years of age
o 75 % of cases will have defeminisation then virilizing effects
 Metastatic ovarian cancer :
 5 – 6 % of all ovarian cancer
 Krukenberg tumour : 30 – 40 % of metstatic cancer of the ovary
 Staging :
o Stage IIIb : tuomours with implants < 2 cm on abdominal peritoneal surface . nodes are –ve
 Primary cytoreductive surgery = initial debulking
o Leaving only residual small tumour deposits no more than 1 cm in diameter is acceptable .
o It includes excision of peritoneal deposits > 1-2 cm
 The 5 year survival rate in epithelial ovarian tumour :
o Stage I : 85 – 90 %
o Stage II : up to 80 %
o Stage III : 15-20 %
o Stage IV : 5 %
 Imaging techniques in gynecology :
 Hysterosalpingography :
o Film could be taken after 24 hours in case of infertility
o Oil soluble eg.Lipiodol ( 40 % organic iodine in poppy seed oil )
o water soluble eg.urogrphin ,the second film is taken just 20 minutes after removal of the cannula
o timing : during first week after menstruation
 Ultrasound :
o Human ear can pick up sounds with frequency between 20 and 20 thousands hertz (cycle/second)
 Endoscopy in Gynaecology :
o The abdomen is inflated to a pressure 15 mmHg using 3-5 liters of CO2
o 1 cm umbilical incision
o To perform variable types of pelvic surgery , 2- 3 other ports are being made along a line 3 cm above symphysis pubis, each of these ports are being ½ - 1 cm
 Hysteroscopy
o Distention of uterine cavity with suitable medium ( CO2 – saline-glycine 1.5 % )
o The procedure :
 Cervical dilatation :
 For diagnostic procedure : dilated to 4 mm
 For operative procedure : dilated to 10 mm
 Operative gynaecology :
o Dilatation of the cervix :
 The cervical canal is gradually dilated starting with the smallest size number 3 .
 Each dilator is left in the uterus for 1 minute then remove it and introduce larger one :
 No.8-10 for curettage
 No.12 before doing amputation of the cervix
 No.14 in spasmodic dysmenorrhea
 Laceration of the cervix are more liable to occur if the cervix is dilated over number 12
o Vaginal hysterectomy cannot be done if the size of uterus is larger than a 14 weeks
o See treat of postoperative-embolism .
o Post operative haemorrhage after vaginal surgery :
Primary haemorrhage
Occurs during the operation
Reactionary haemorrhage
After operation, within the first 24 hours after the operation
Secondary haemorrhage
Occurs On the 10th post-operative day due to sepsis
 Molecular biology :
o The human cell contains 46 chromosome ( 44 autosomes and 2 sex chromosomes ) arranged in 23 pairs. Each pair is 2 copies of the same chromosome ( one maternal and one paternal )
o Each chromosome is formed of 2 chromatids joined at a point called centromere
o Aneuploidy : nondisjunction of the 2 homologous chromosomes .
 Trisomy : presence of 3 homologous chromosomes .
 Down syndrome ( trisomy 21 )
 Triple x syndrome ( 47 XXX )
 Klinefelter syndrome ( 47 XXY )
o Polyploidy :
 Triploid ( 69 chromosome )
 Tetraploid ( 92 chromosome )
o Isochromosomes : the chromosome divides horizontally at the centromere leading to formation of 2 parts each one is formed of identical parts.
Drugs
 Menopause :
o prevention of osteoporosis : calcium intake of 1500 mg daily and vitamin D 600-800 IU/days.
o Treatment of osteoporosis :
 Bisphosphonates : orally, once/week
 Calcitonin : nasal spray
 Hormone therapy (HT) :
 Oestrogen only therapy ( in absence of progesterone )
o risk for endometrial hypeplasia and endometrial carcinoma if used more than 5 years
o Daily oral dose , sub dermal implants , or transdermal patches is used for patients with absent uterus ( after hysterectomy )
 Cyclic oestrogen/gestagen HT : adding progesterone for 12-14 days each month to continuous oestrogen therapy >>> results in monthly cyclic withdrawal bleeding AND that reduces the risk of endometrial cancer .
 Continuous combined oestrogen/gestagen HT : continuous combined HT is given daily without interruption for a period that may extebd over 1-2years
 Types of hormones used :
 Oestrogen : natural e.g conjugated equine oestrogen 0.625 mg/day or oestradiol valerate 1-2mg/day.
 Progesterone : sunthetic – smaller doses
o NB: to avoid or minimize risks of HT its use should not exceed 5 years. Only 20 % of menopausal women will require HT for only 1-2 years.
 Selective oestrogen receptor modulators : Raloxifene 60 mg /day .
 Phyto-oestrogens : plant substitutes
 Teriparatide : IM injections over a period up to 18-24 months .
 Amenorrhoea :
o Hormonal treatment :
 Cyclic combined oestrogenlgestagen : as OCP 21 days each month
 Cyclic natural or synthetic progesterone therapy : 7-10 days every month
o Hypothyroidism : thyroid extract ( eltroxin ) : 50 – 150 ug daily
 Hyperprolactinaemia :
o Bromo-ergo-cryptine 2 mg ( 1-2 tablets daily { 4-6 weeks } , until restoration of normal levels )
o Lisuride hydrogen maleate 0.2 mg ( 1-2 tablets daily , until restoration of normal levels )
o Cabergoline 0.5 mg ( ½ tablet once or twice weekly for 4 weeks )
 Drugs of anovulation
o Clomiphene citrate : 50 mg oral tablets , twice daily for 5 days starting 5th day of menstruation. Dose can be increased up to 200 mg/day ( 4 tablets )
o Tamoxifen : 10 – 40 mg daily orally ( 1-4 tablets ) for 5 days starting from the 2nd day of the cycle .
o Cyclofenil : 400 mg twice daily , orally , for 5 days starting 5th day of the cycle .
o Human menopausal Gonadotrophins = 75 IU FSH + 75 IU LH
o Purified urinary FSH : = 75 IU FSH + 1 IU LH
 Given by repeated IM injections given from mid-follicular phase of the cycle until complete follicular maturation.
o hCG : 2 ampoules 5000 m/iu each , given by IM injection as one shot after full oocyte maturation ( size of dominant follicle > 18 mm by TVS )
o metformin : 500 – 800 mg daily orally .
 PCOS :
o Obese female weight reduction of 5 -10 % of body weight .
o Cyclic gestagen therapy : for 10 day every cycle ( day 16 – 25 ) to induce a regular 28 – 30 days cycle ( e.g medroxy progesterone acetate 10 mg / day )
o Combined OCP : ( day 5 – 25 ) to establish regular cycles in cases not request pregnancy
o Clomiphene citrate : oral tablets twice daily for 5 days starting 3rd , 4th , 5th day of the cycle .
 Hirsutism :
o Plasma testosterone level ( normal = 0.2-0.8 ng/ml ) , levels > 2ng/ml suggest androgen secreting tumor .
o Free testosterone ( normal = 1-3 % of total testosterone ) it is a good index for androgenicity
o DHAS ( normal 1500 – 2500 ng/ml ) , levels > 9000 ng/ml suggests adrenal tumour .
o Corticosteroids ( dexamethasone 1-5 mg / day )
o Cypretorone acetate : used for 10 days each cycle .
 Diane 35 is an OCP that uses cypretorone acetate as a progestin and is widely used in treatment of hirsutism in females that request contraception .
o Cimetidine : 300 mg 5 times daily .
 DUB :
o Medical :
 NSAIDs :
 mefanimic acid 500 mg t.d.s
 Antifibrinolytic agents :
 Tranexamic acid 500 mg t.d.s
o Hormonal
 Oral progestins : synthetic progestins as norethisterone 10 – 20 mg/day given for 14-21 days each cycle for 3 successive cycles.
 Cyclic combined oestrogen/progestin tablets (OCP) : reduce menstrual flow by 40-70% within first 6 months
 Progesterone releasing IUD : reduce menstrual flow by 75-95% within first 3 months of its insertion .
 Treatment of bacterial STDs & PID :
Cephalosporins
Quinolones
Azithromycin
doxycycline
Gonorrhea
*Ceftriaxone 125 mg IM or
*cefixime 400 mg orally , single dose
*ciprofloxacin 5oo mg or
*ofloxacin 400 mg orally single dose
2 g orally , single dose plus doxycycline
100 mg twice daily orally for 7 days , if co-infection with chlamydia trachomatis has not been excluded.
Chlamydia trachomatis
ofloxacin 300 mg orally twice daily for 7 days , not used during pregnancy
1 g orally once
( 4 tablets 250 mg each ) , suitable during pregnancy
100 mg twice daily orally for 7 days , not used during pregnancy
Chancroid
*ciprofloxacin 5oo mg orally twice daily 7 days
1 g orally once
Granuloma inguinale
1 g orally weekly for 3 weeks
100 mg orally twice daily for 3 weeks
Lymphogranuloma venerum
100 mg orally twice daily for 3 weeks
Mild and moderate cases of PID
*Ceftriaxone ( 3rd generation ) 250 mg as single IM dose + doxycycline
ofloxacin 400 mg once daily orally / 14 days with or without metronidazole. ( 500 mg twice daily/14 days )
100 mg orally twice daily / 14 days with or without metronidazole.
Severe cases of PID
Cefoxitin , 2 g IV / 6 hours + doxycycline .
NB: oral metronidazole or clindamycin are added if an abscess is suspected
ofloxacin 400 mg IV / 12 hours + metronidazole ( 500 mg IV/12 hours )
100 mg orally/12 hours.
*Ampicillin – sulbactan 3 g IV/ 6 hours + doxycycline ( IV or orally ,100 mg 12 hours.)
 Treatment of tubo-ovarian abscess :
o Triple therapy :
 Ampicillin 2 g IV/4 hours +
 Gentamycin 2 mg/kg loading dose followed by 1.5 mg/kg maintenance dose +
 Metronidazole 500 mg IV/8 hours
o Double therapy :
 Ofloxacin 400 mg IV / 12 hours
 Metronidazole 500 mg IV/8 hours
o Single agent therapy :
 Imipenem cilastatin 500 mg IV/6 hours
 TTT of HSV : acyclovir 200 mg 5 times daily for 5 days is given within 5 days of onset of vesicles
 TTT of HPV :
o Podophyllin resin 10 % to 25 % topically applied to warts , not used during pregnancy
o Trichloroacetic acid 80 % to 90 % painting , suitable during pregnancy
 Treatment for syphilis :
Benzathin penicillin G
Aqueous crystalline penicillin G
doxycycline
Early disease , primary , secondary , asymptomatic recent contacts
2.4 million units IM in a single dose
100 mg orally twice daily for 2 weeks , in non-pregnant patients with penicillin allergy
Late disease,late syphilis or tertiary syphilis , not including neurosyphilis
2.4 million units IM every week for 3 week
100 mg orally twice , or tetracycline 500 mg orally 4 times daily , 4 weeks , in non-pregnant patients with penicillin allergy
Neurosyphilis,cases with nerologic ,ophthalmic manif.,or gummatous lesions
18-24 million units IV infusion for 10 – 14 days
Congenital syphilis,cases with history of inadequqtely treated maternal syphilis
100.000 unit/kg/day/IV/12hours for first 7-10 days of life
 Treatment of BV :
Metronidazole
Tablets, 500 mg orally twice daily for 7 days ( flagyl) or 2 gm single dose
Gel 0.75 % , 5 g ( one full applicator ) intravaginally once daily for 5 days
Clindamycin
Tablets, 300 mg mg orally twice daily for 7 days
Cream 2 % , 5 g ( one full applicator ) intravaginally once daily for 5 days
 Treatment of CV :
* Intravaginal antifungal preparations :
** Oral regimens
Butaconazole 2 % cream : 5 g for 3 days or 5 g sustained release single dose
Fluconazole : single oral dose 150 mg for treatment of uncomplicated cases
Miconazole 2 % cream : 5 g for 7 day or 100 mg vaginal suppository for 7 day or 1200 mg sustained release single dose
Ketoconazole : 200 mg twice a day for 5 days , may be used for recurrent cases , treatment can be repeated along a period of 3-6 months , for chronic cases
Clotrimazole 1 % cream : 5 g for days or 100 mg vaginal tablets for 7 days
Nystatin 100.000 unit vaginal tablets for 14 days
 Treatment of senile ( atrophic ) vaginitis : intravaginal oestrogen cream administered every nigh for 2 weeks then once weekly.
 Treatment of cervical erosion :
o Electro-cautery : 3 linear burns , coagulates the superficial epithelium over the erosion that heals within 4 weeks
o Cryo-cautery (freezing ) : for 2 mintues ,freezing to  60 C
o Endocoagulation : Semm’s coagulator, the probe is heated to 100 C
 Kidney function tests :
o Blood urea : normally 20 – 40 mg %
o Serum creatinine : normally < 1 mg %
o Serum uric acid : 4-8 mg %
o Specific gravity of urine : before and after water administration : normally high before, low after , but in chronic nephritis there is low fixed specific gravity of about 1010.
o Urea concentration test : normally urea in urine should be 2 % or over after administration of 15 gm of urea of mouth .
o Urea clearance test : it indicate the number of cubic centimeters in blood cleaned of urea per minute . Average clearance 70 – 120 % below , 50 % indicates renal impairment .
 Fibroid :
o LHRH Agonists : long acting GnRH e.g. leuprolide acetate 3.75 mg IM monthly for 3 -6 months
 Maximum reduction to nearly 2/3 of original size may be achieved within 12 weeks of therapy , however in most cases rapid growth to baseline size occurs within 12 weeks of stopping Gn-RH.
o Short term Gn-RH agonist ( 2- 3 months )
 Endometriosis :
o oral contraceptive pills :
 repeated courses of continuously administered combined OCPs ( 4-6 months each )
 prognosis : after one year recurrence rate approaches 15-25 % and pregnancy rate may reach > 25 % if the tuboperitoneal factor is not severe .
o progestogens :
 dosage :
 medroxy-progesterone acetate (MPA) : 5 mg tablets orally ( maximum 20 mg / daily ) for 90 days or
 Depot MPA IM injections 150 mg / 3 months.
o Gn-RH agonists :
 Dosage : IM depot injections given monthly or every 3 months
 Side effect : significant bone loss ( only after prolonged therapy > 6 months )
o Danazol :
 testosterone derivatives , oral tablets 200 mg given 2-4 tablets daily for 4-9 months .
 Hormone methods for contraception
 Combined oral contraceptive pills ( COC) : contain a combination of :
o Oestrogen ( ethinyl oestradiol / Ethinyl estradiol(EE) : 30 ug ) , and
o Gestagen ( synthetic progesterone ) : that may vary from :
 2nd generation ( levo-norgestrel and norethissterone )
 3rd generation ( desogestrle and gestodene )
 4th generation ( drospirenone )
Monophasic pills
Biphasic pills
Triphasic pills
Contain the same oestrogen/gestagen content in one phase
Pills contain different oestrogen/gestagen content in two phases
Pills contain different oestrogen/gestagen concentration in three phases
Started day 3-4 of the menstrual cycle and continued for 21 days , followed by a 7-day pill free period .
1st phase 10 days
2nd phas 11 days
followed by a 7-day pill free period .
1st phase 6 days
2nd ohase 5 days
3rd phase 10 days
followed by a 7-day pill free period .
* Menstruation usually occurs 3-4 days after discontinuation of the last pill
** lowest risk for venous thromboembolism ( 30-35 ug EE and progestogen
 Vaginal contraceptive ring : the ring is introduced vaginally by the patient by the end of menstrual period , left for 3 weeks then removed followed by a 7 day ring free period
 Contraceptive patches : applied to the skin of tha abdomen , buttocks , or thigh , started on the 3rd or 4th day of menses, changed on the same day every week for three consecutive weeks , followed by a 7 day patch free interval to allow for menstruation .
 Thrombo-embolic disorders : is increased due to increasd platelet adhesiveness , increased level of factor II , VII , IX , and X . the risk for DVT and pulmonary embolism is increased from 4 to 6 folds if OCP were not stopped at least 4 weeks before surgery .
 Acne : may worsen during OCP intake. If already present use Diane 30 OCP ( EE : 30 ug + cyproterone acetate 2 mg )
 Relative contraindication : age > 35 years
 Progestogen only oils ( POPS ) : inhibition of ovulation in only 60 % of cases .
 Progestogen only injectable contraception :
o eg. Depot medroxy progesterone acetate IM injection given every 12 weeks
o it is main advantage is the convenience of it’s 3 monthly dose
o vaginal spotting >>> in the first few months
o 70 % will have amenorrhea at the end of the first year
 Subdermal progestogen implants :
o Provide contraception for almost 3 years
o 20 % of women >>> no bleeding
o 50 % >>> have frequent or prolonged cycles
 Contraception for lactating females :
o Progestogen only injectables : DMPA : 150 mg IM / 3 months
 Options for emergency contraception :
o IUD insertion : within 24 – 48 hours of unprotected intercourse
o Anti-progesterone oral tablets ( mifepristone RU 486 ) taken few days
o Hormone contraceptive pills : started immediately after intercourse 4 tablets ( 2 tablets / 12 hours )
 Progestin-only high dose pills regimen : Each oral tablet contain 0.75 mg of levo-norgestrel.
 The 1st tablet should be taken as soon as possible ( within 72 hours after unprotected intercourse )
 The 2nd dose tablet is taken 12 hours after the first one
 Combined oral contraceptive pills (COC) regimen :each dose should contain at least 0.1 mg of EE & 0.5 mg of levo-norgestrel (ie. 4 tablets of the standard low-dose COCs taken together )
 The 1st dose must be taken within 72 hours after unprotected intercourse
 The 2nd dose tablet is taken 12 hours after the first one
 Low – dose COCs = 4 pills per dose
 High dose COCs = 2 pills per dose
 Treatment of endometrial hyperplasia :
o EH without atypia : synthetic gestagen : cyclic oral progestin given for 3 – 6 months
 Treatment of LSILs – CIN 1 :
o Conservative treatment : treat infection and repeat within 12 weeks as
 70 % will show spontaneous regression
 15 % may progress to high grade abnormality
 Follow up after treatment : despite the efficacy of techniques in treating CIN yet recurrence is still common and follow up by annual pap smears is recommended for around 10 years
 See drugs for choriocarcinoma :
o Methotrexate (MTX) : complete remission rates of 60 – 80 %
o MTX Folinic acid cycle regimen : IM MTX 50 mg given every 48 hours for total 4 doses + folinic acid orally taken 30 hours after each MTXinjection . cycle is repeated after 14 days till negative B-hCG is achieved.
o Follow up by repeated serum B-hCG is recommended after chemotherapy is completed until normal ( negative ) B-hCG levels are achieved for 3- 6 months.
o Surgical treatment for > 40 years age
 TAH is usually preceded and followed by chemotherapy usually in the form of MTX 1p\o mg given at day of operation and continued postoperative 4 – 5 days to prevent the risk of dissemination and development of distal metastases .
 Treatment of microinvasive carcinoma of cervix ( stage IA ) :
o < 3 mm in depth or < 7 mm in width
o TAH-BSO 5 year survival rate up to 95 %
 Wertheim’s radical hysterectomy :
o depth 3- 5 mm or width < 7 mm ( I DOUBT IN THIS )
o Remove 2-3 cm from the upper vaginal cuff
 Chemotherapy in cancer cervix :
o Weekly IV cisplatin , with nearly increase 10 % in cure rates
 Chemotherapy in ovarian cancer :
o As soon as possible after surgery , is given for 5 or 6 cycles at 3-4 weekly intervals
o Eg. Cisplatin or carboplatin alone or in combination with paclitaxel
 Postoperative thrombo-embolism :
o Prevention : subcutaneous heparin 5000 units 2 hours before surgery and then repeated 12 hourly until the patient is mobile .
o Treatment : heparin 10000 units IV every 6 hours for 48 hours , with 10 mg warfarin in the 1st day and 5 mg in the 2nd day.