Gynaecological Nursing

Biyani's Think Tank
Concept based notes
Gynaecological Nursing
(GNM)
Subita Fageria
Lecturer
Deptt. of Commerce & Management
Biyani Girls College, Jaipur
2
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Hrs. 20
Course Content
Unit-I introduction
Definition related to gynecological nursing
Sexuality
Gynecological history taking, examination and investigations
Unit-II Puberty
Definition development of sex organs in females
Menstrual cycle
Disorders of menstruation; amenorrhea, Dysmenorrhoea, Cryptomenorrhoea
Unit III Fertility and Infertility
Definition, causes both in male and female investigation and Management
Unit IV Pelvic Infections
Vulva; vulvitis, bartholinitis
Vagina: vaginitis, trichomonas vaginalis, Moniliasis
Metritis, Salpingitis, oophoritis, Pelvic abscess
Chronic, infections, cervical erosion.
Unit V Uterine Displacement and Descent
Retroversion, retroflexion
Descent of the uterus; first degree, second degree, complete procedentia
Unit VI Sexually transmitted disease and their prevention
Syphilis, gonorrhea, warts;
Acquired immun deficiency syndrome (AIDS)/HIV
Unit VII Breast Disorder
Mastitis
Breast abscess
Tumours
Malignancy
Unit VIII Benign and malignant neoplasms of Reproductive organs
Uterine polyps, uterine fibroids
Cancer: cervix, uterus
Ovarian cyst: benign, malignant
Cancer: chemotherapy, radiotherapy
Palliative care.
Unit-I
Introduction
Q.1
Define Gynecology?
Ans.
Gynecology : a branch of medicine that deals with the disease and hygiene of women:
Q.2
Name the different genital organs in female?
Ans.
Female Genital Organs
External
Genital organs
1.
2.
3.
4.
5.
6.
7.
Q.3
Mons Pubis
Labia Majora
Labia Minora
Clitoris
Vestibule
Hymen
Perineum and
Bartholin glands,
Vestibular bulbs
Mention the support of the uterus?
Internal
Genital organs
1. Vagina
2. Uterus
3. Fallopian tubes
4. Ovaries
Ans.
Support of the Uterus
Primary Supports
Secondary supports
Muscular
or Active
Fibro muscular
or Mechanical
1. Broad ligament
2. Utero-vesical fold of
peritoneum
3. Recto-vaginal fold of
1. Peluic diaphragm
1. Uterine axis
2. Perineal body
2. Pubo Cervical ligament
3. Uro-Genital
3. Transverse cervical
ligament
diaphragm
4. Utero-sacral ligaments
5. Round ligaments
Q.4
How will you proceed to examine a gynecological patient?
Ans.
I. Identification Date:
Name of patient
Age
Marital Status
Social Status
Parity
Residence
Date
Chief Complaints
peritoneum
II. History
1. Menstrual history
2. Obstetric history
3. Past medical history
4. Past Surgical History
5. Family history
6. Personal history
III. Examination : It Includes

1. General & systemic examination
2. Gynecologic Examination
1. General & systemic examination :
Body Built- thin/obese
Nutrition- Average/poor
Stature- Secondary sexual character
Pallor, Jaumdice
Teeth, gum & tonsils
Neck Palpation of thyroid glands
Oedema of Legs
Vital signs
Cardio Pulmonary & Respiratory system
Gynecologic Examination
Breast Examination
Abdominal
Examination
Tenderness
for tumour
Pelvic
Examination
Inspection
Palpation
Percussion
Auscultation
Inspection of
external
genitalia
Vaginal Examination
Rectal
Examination
Retovaginal
Examinatio
n
Other Examination:
1. Blood
General inspection
Speculum Examination
Digital Examination
Bimanual Examination
of pelvic organs
2. Urine
3. Cervical and vaginal exfoliative cytology
4. Cervical Mucous study:
(i)
Bacterial Examination
(ii)
Infertility
Post coital test (PCT)
Sperm penetration Test
Sperm cervical mucous contact test (SCMCT)
(iii)
Hormonal study
5. Imaging Study:
Ultra Sonography
Trans abdominal
Trans Vaginal
Colposcopy
X-ray
CT-Scan
MRI
Endoscope
Hysteroscopy
Laparoscopy
Proctoscopy
Sigmoidoscopy
Salpingoscopy
Culdoscopy
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Unit II
Puberty
Q.1
What is puberty & explain tanner staging and mention the abnormal puberty?
Ans.
Definition: Puberty in girls is the period which links child hood to adult. It is the period
of gradual development of secondary sexual characters.

Morphological Changes:
As described by "Tanner & marshall" five important physical changes occurs during
puberty. These are breast, public & axillary hair growth, growth in height &
menstruation. Most of the changes occurs gradually but only the menarche can be dated.
The most common order is :Beginning of growth spurt : (Start)
The larche (Breast budding changes)
Adrehnarche (Public & Auxiliary hair
Peak growth in height
Menarche (menstruation) (Important controlling factor for onset of puberty are

genetic, nutrition, body weight psychologic state, exposer to light & others.)
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Endocrinology in puberty:
Tanner Staging
According to Tanner, breast & public hair development at puberty are divided into 5
stages.
I.
Breast Development:
Stages Ist Pre pubertal stages elevation of papilla only.

Stages IInd Breast budding, palpable breast tissue areola & nipple began to enlarge.
Stages IIIrd Further enlargement of entire breast tissue.
Stage IVth Secondary mound of areola projecting above the breast tissue.
Stage Vth Secondary mound disappear in stage IVth . Adult breast with typical contour.
II.
Public hair development:
Stage Ist Pre Pubertal stage, no public hair present.

Stage IIrd Sparse, long hair on either side of Labia Majora
Stage IIIrd Darker, curled hair over the mons pubis.
Stage IVth Adult type hair covering a small area over the mons only.
Stage Vth Adult hair with a traiangle distributor covering the medial sides as the thigh.
Common disorder of the puberty:

1. Precocious puberty : before 10 years age.
2. Delayed puberty: Does not occurs 16 years of the age.
3. Menstrual abnormalities: Amenorhoea, dysmenorrhoea menorrhagia
4. Others in :
PID
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carcinoma
hirsutism
Q.2
What is meant by menarche?
Ans.
Menarche:
The first menstruation in life is called menarche. It may occur any where between 10-16 years
The peak time being 13 years. There is endometrium proliferation due to ovarian oestrogen but
when the level drops temporarily, the endomrium sheds & bleeding is visible.
Note: The first period is and anovular.
Growth: Growth in height in an adolescent girls is mainly due to hormones. The
important hormone are growth hormone, oestrogen & insulin like growth factor:
Genital organ changes :
1.
Ovaries:- Ovaries change their shape, the elongated shape become bulky & Oval.
2.
The uterine body & cervix ratio at birth is about 1:2, the ratio become 1:1 when
menarche occurs. There after the enlargement of the body occurs rapidly so that
the ratio soon become 2:1
3.
The vaginal changes are more pronounced. The vaginal PH becomes acidic
ranging between 4 to 5.
4.
The valve is more reactive to steroid hormones.
5.
The mons pubis & the labia minora increase in size.
6.
The breast changes are pronounced. Under the influence of oestrogen, there is
marked proliferation of duct system & the breast become prominent & round
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under the influence of progesterone, the development of acivni increase

considerably.
Q.3
Define menstruation? Explain the changes occurs during each menstrual cycle?
Ans.
Definition: Menstruation cycle defined as the cyclic events, changes that takes place in a
rhythmic fashtion during the reproductive period of women's life.

or
menstruation cycle is the visible menifestation of cyclic physiological uterine bleeding due to
shedding of the endometrium following invisible interplay of hormones mainly through the
HPO- axis.
The cyclic discharge of blood, mucous, epithehal and other substances from the uterus during the
reproductive life of the females at an average interval of 28 days in called menstruation.
* Changes, during, menstruation, cycle : During each menstruation cycle, series of changes
occurs in ovaries & accessory sex organs (uterus, vagina, cervix & ovary).
* These, changes, are :
1. Ovarian Changes
2. Uterine Changes
1. Ovarian Changes: The changes in the ovary occur in two phases during each menstrual cycle
these are:
i. Follicular phase : (5-14 days)
ii. Luteal phase : (15-28 days)
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i.
Follicular phase : (5-14 days): This extends from the 5th day of the cycle till the
time of volution which takes place at about 14 day. During this phase, the primordial
follicle of the ovary develops in to a graffian follicle.
Ovarian follicle: The follicle consist of ovum surrounded by epithelial cells. These
follicles gradually grow in to a nature follicles through various stages:
Primordial follicles
Primary follicle
Vesicular follicle
Mature or graffian follicle

The graffian follicle is the mature ovarian follicle on the 14 day of menstruation, the graffian
follicle is ready to release ovum.
Ovulation: It is the process in which there is rupture of graffian follicle with the discharge of
ovum in to the abdominal cavity.
ii) Luteal Phase: (15 to 23 day)
This phase extends from 15 day to 28 day of menstrual cycle. After ovulation the ruptured
follicle develop in to a yellow body called corpus luteum.
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The corpus lateum act as a secratory endocrine glands & release or secrete large quantity of
progesterone & small quantity of oestrogen. The corpus luteum degenerate as corpus luteum
menstrualis if fertilization have not occur till 26 to 28 days.
Note :Ovarian cycle

Germinal epithelium
Follicular phase
Premordial follicle
role of FSH
Primary follicle
Vasicular follicle
Grassion follicle
Luteal Phase (Role of LH)
Ovalation
Corpus luteum
If Fertilization occurs
If Fertilization does not occurs
Corpus luteum of pregnancy
Corpus luteum menstrualis
(Corpus luteum verum)

Corpus albicans
Destroy after 3 months
Or after the formation of
Destroy after 26 day of menstrual
placenta to secrete
cycle
estrogen & progesterone
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Uterine changes:
During menstrual cycle the changes in the uterus takes place in the three phases:1. Menstrual Phase (0-5 days)
2. Proliferative Phase (6-14 days)
3. Secretary phase (15-28 days)
1. Menstrual Phase: This is the phase during which bleeding occurs & its duration last
about first 4 to 5 days.
Causes of bleeding:
2 days before the onset of bleeding (26-28 days) there is sudden reduction in the release
of progesterone & oestrogen from ovary. This is responsible for menstrual changes in the
endometrium due to lack of hormones oestrogen & progesterone. The blood vessels in the
endometrium under goes severe constriction because of :
1. Sudden lack of oestrogen & progesterone which are vasodialator.
2. Action vasoconstrictor substances like prostaglandins releases from tissue of endometrium
Vasoconstriction
Hypoxia of endometrium
Necrosis in the endometrium
Necrosis of & blood vessels
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2. Proliferation phase: (6-14 days)

This phase extends usually from 5th day to 14th day as menstrual cycle.
During proliferation phase, the ovary secrets estrogen that acts on the endometrial cells. These
endometrial cells proliferate rapidly under the influence of estrogen. Thus the epthillum reappear
on the surface of endometrium with in first 4 to 7 days of prolifrative phase. This proliferation of
the cells in the endometrium is continued because of continue secretion of oestrogen till the end
of cycle. New blood vessels appear in the endometrium. At the end of proliferative phase, the
thickness of endometrium is 3 to 4 nm.
3. Secretary Phase: (15 to 28 days)

After ovulation, corpus luteum is developed in the ovary. It secretes large quantity of
progesterone & small quantity of oestrogen oestrogen causes proliferation of cells in the
endometrium (Hyper plasia) & progesterone causes further enlargement of the endometrium
(hyper trophy)
At the end of secretary phase, the thickness of endometrium is 5 to 6 nm if fertilized is a
fertilized ovum is implanted during this phase the ministerial cycle does not appear if ovum
is not fertilized menstruation occurs after this phase & a new cycle start.
Q.5 Write a short not on corpus luteum.

Ans.
Definition:A glandular yellow body developed from graffian follicle after the discharge
of ovum is called as corpus luteum.

Development of corpus luteum:
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During ovulation the graffian follicle ruptured and ovum is discharge. After the
discharge of ovum, the remaining cells of graffian follicle together form the corpus
luteum. The follicles filled with blood immediately now it is called as corpus
hemorrhagicum.
Functions of corpus lutcem:
1. The corpus luteum acts as a temporary endocrine gland secrete large quantity of
progesterone & small quantity of oestrogen.
2. The hormone secreted by corpus luctcum are very much essential for the
maintenance of pregnancy if fertilization has occurs.
3. Corpus luteum is active till placeta start secreting oestrogen & progesterone.
4. It occurs after 3rd month of pregnancy (degeneration)
5. Abortion occur if corpus luteum become inactive before the onset of hormonal
secretion from placenta.
Fate of corpus lucteum:
1. If ovum is not fertilized: The corpus luteum reaches the maximum development about 1
week after ovulation during this period. It secretes large quantity of oestrogen then it
generate into corpus luteum menstrualis.
After ward the corpus luteum menstrualis is transformed into a white scar called corpus
albicans.
2. Us Ovum is fertilized: If ovum is fertilized or pregnancy occurs, the corpus luteum
decrease in size & transformed into corpus luteum verum. This persist for 3 to 4th month.
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During this period, it secrete large amount of progesterone 8 a small amount of oestrogen
with are essential which maintaining the pregnancy.
Q.6
Mention the role of different hormones.
Ans.
Hormonal regulation of menstrual cycle:
I. Hormonal regulation of ovarian changes

(A) A follicular changes: FSH is responsible for follicular growth.
(B) Ovulation: LH is important for ovulation.
(C) Lutear phase: LH & FSH both are essential for luteal phase because they stimulate
corpus luteum to sectet progesterone & estrogen.
II. Hormonal regulation of uterine changes:
(a) Proliferative phase: Oestrogen is essential

(b) Secretary phase Progesterone is responsible
(c) Menstrual phase: Oestrogen & progesterone level should be low for menstrual phase.
Q.7
Define menopause? What are changes takes place in body at menopause? State it's `
clinical features?
Ans.
Definition: It is defined as permanent cessation of menstrual cycle at the as reproductive
life due to loss of ovarian follicular activity.

Organ changes at menopause
1. Ovary: Ovary shrink in size become wrinkled & white colour.
2. Fallopian tube: Fallopian tube showed features of atrophy.
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3. Uterus:- Uterus become smaller & the ratio between the body & cervix reverts to the
1:1.
4. Vagina: the vagina become narrower due to gradual loss of elasticity & PH become al
alkaline.
5. Vulva: Vulva shows feature atrophy.
6. Breast: Breast fat is re-absorve & nipple decrease in size.
7. Bladder & Urethra: Under go similar changes to those of the vagina "There may be
dysurea increase frequency, urgency or stress in continence.
8. Loss of muscle tone: Lead to pelvic relaxation.
9. Bone metabolism: Following menopause there is loss of bone mass about 3 to 5% per
year. This is due to deficiency of estrogen post menopausal women runs a high risk for
fracture of bone due to osteoporosis.
10. Cardio Vascular system: Risk of cardio vascular disease is high in post menopause
women due to deficiency of oestrogen.
Menopausal Symptoms:
1. Vasomotor
2. Genital & urinary
3. Psychological
4. Health Hazards
In majority, a parts from cessation of menst no more symptoms is evident is some symptoms
appear which may be grouped as follow.
1. Vasomotor:
Hot flush :
Lasts for 1-2 minutes.
Unbearable
Associated with night sweating
Disturbed sleep
Peripheral Vasodilator
Palpitation
Pulse rate : rise by 20 beasts/minutes
2. Genital & urinary:
Genital symptoms:
Dysparecimia
Atrophic virginities
Urinary symptoms:
Urgency urgency
Dysuria
3. Psychological:There is decrease frequency anxiety:
Headache,
Insomnia,
Irritability
Depression.
4. Health Haxards:
21
22
Oesteoporosis & Fracture:

Cardio vascular & cerero vascular: Increase risk as IHD, CAD, & CVA.
Dry skin & prone to damage & infection.
Q.8
Short note on hormonal replacement therapy?
Ans.
Hormonal Replacement Therapy:Objective of HRT:

The objective of HRT is to ensure the potential benefits & minimize the risk.
HRT is clearly beneficial in symptomatic women unless there is contra
indications to therapy.
HRT is also indicated even in symptoms free cases to prevent oesteoporosis,
atherosclerosis cardio vascular, disease and degenerating changes in the skin.
Indication:
1. Premature ovarian failure
2. Surgical or radiation menopause
3. Symptomatic women.
Contra Indication:
1. An diagnosed genital tract bleeding
2. Oestrogen dependant in breast cancer & endometrial cancer.
3. Active liver disease
4. Gall bladder disease
Monitoring prior to during HRT:
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1. Blood pressure
2. Breast examination
3. Pelvic examination
4. Cervical cytology
5. Pelvic USG
6. Mammography
7. Serum level of oestradiol
Drugs used in HRT:
The principle hormone used in HRT is oestrogen. This is ideal for a women who had
hysterectomy already but a women with in intact uterus only oestrogen therapy lead to
endometrial hyperplasia & even endometrial carcinoma.
Commonly used oestrogen are conjugated oestrogen.
Progesterone used are medroxy progesterone acetate
1) Oral oestrogen therapy: Oestrogen conjugated equil oestrogen 0.625 1.25 mg is
given daily for women who had hysterectomy.
2) Oestrogen & cyclic progestin: (Combined therapy) for a women with intact uterus
oestrogen is given continuously for 25 days & progestin is added for last 12-14 days.
3) Sub dermal & implants: Implants are inserted sub cateneously (SC) over the
anterior abdominal wall using local anesthesia 17-
oestrodiol implants, 25 mg, 50
mg or 100 mg are available 8 can be kept for 6 months.

4) Percutaneous Oestrogen gel: 1 gm application of gel delivering 1 mg of oestradiol
daily is to be applied on the skin over the anterior abdominal wall or thigh.
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5) Vaginal cream: Conjugated vaginal oestrogen cream 1.25 mg daily is very effective
specially when associated with atrophic vaginitis
6) Progestin: Patient with history of breast carcinoma or endometrial carcinoma
progestin may be used. It may be effective in suppressing hot flushes and it prevents
oestioporosis.
Q.9
What is meant by menstrual abnormalities?
Ans.
Menstrual abnormalities: It means menstrual disorder.

There are of following types:
1. Pre menstrual syndrome (PMS)
2. Dysmenorrhoea
3. Menorrhagia (Hypermenorrhoea)
4. Epimenorrhoea/Polymenorshoea
5. Metrorrhagia
6. Oligomenorrhoea
7. Hypomenorrhoea
8. Dysfunctional uterine bleeding (DUB)
9. Amenorrhoea
10. Mid-menstrual pain
Q.10 Define amenorrhoea write the types of amenorrhoea
& explain about
cryptomenorrhoea?
Ans. Definition: Amenorrhoea means absence of menstruation, it is a symptom not a disease
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Types of amenorrhoea:
1. Physiological amenorhoea
2. Pathological Amenorrhoea
Physiological amenorrhoea
Types of amenorrhoea
Physiological
Primary
Before Puberty
Pathological
Secondary
During pregnancy
During lactation
Following menopause
Concealed
Cryptomenorrheoa
Congenital
Primary
Real (True)
Acquired
Secondary
Cryptomenorrhoea
Definition: In cryptomenorrhoea there is periodic shedding of the endometrium & bleeding but
the menstrual blood fails to come out from the genital tract due to obstruction in the passage.
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Cause:
1. Congenital
2. Acquired
1. Congenital:
i.
Imperforated hymen
ii.
Transverse vaginal septum
iii.
Atresia of the upper third of vagina & cervix
2. Acquired:
i.
Stenosis of the cervix following amputation, deep cauterization and conization.
ii.
Secondary vaginal atresia following difficult vaginal delivery.
Clinical Features:
1. Amenorrhoea dated back from the events.
2. Periodic pain in lower abdomen.
3. Urinary symptoms: Retention of urine
4. Pelvic examination reveals the offending lesion either in vagina or cervix. The uterus is
symmetrically enlarge.
Treatment
1. Simple dilatation of cervix so as to drain the collected blood is enough.
2. In case of secondary atresia of vagina, reconstruction surgery is to be perform to maintain
the patency.
3. Dilatation of the cervix in cervical stenosis
4. A incision is required in the human to drain the blood in the case of imperforate hymen.
Q.10 Write a short note on dysmenorrhoea?

Ans.
Dysmenorrhoea:
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Definition: Dysmenorrhoea means painful menstruation

or
Dysmenorrhoea is defined as pain ful menstruation of sufficient magnitude so as to incapacitate
day to day activity.
Types of dysmenorrhoea:
1. Primary Dysmenorrhoea
2. Secondary Dysmenorrhoea
1. Primary/spasmodic/Intrinsic/functional/essential/idiopathic/dysmenorrhoea:
The primary dysmenorrhoea is one where there is no identifiable pelvic pathology. It
signifies pain due to menstruation of uterine origin.
Causes:
1. Psychosomatic factor: Due to anxiety tention.
2. Abormal anatomical & functional aspect of uterus.
3. Endocrine factor: Decrease vasopression
4. Biochemical factor
5. Elevated level of uterine prostaglandins.
6. Neurogenic factor.
Clinical Features:
The primary dysmenorrhoea usually appease within 2 years of menarche. Patient is young (18-24
years)
1. The pain begins a few houses before or just with onset of menstruation The pain is
spasmodic & confined to lower abdomen & may radiate to back & medial aspect of
thighs.
2. Systemic discomfort:
Nausea
Vomiting
Faitigue
diarrhoea
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Headache
Sometimes fainting
2. Secondary Dymsmenorrhoea:
Secondary dysmenorrhoea is normaly considered to be
menstruation associated pain occurring in the presence of pelvic pathology.
Causes:
1. Chronic pelvic infection
2. Pelvic endometrosis
3. Endometrial polyp
4. IUCD in utero
5. Uterine fibroid
6. Cervical stenosis
Clinical features:
The pain is dull, situated in the back & in front without any radiation.
The onset duration of pain depends on the pathology producing pain.
Treatment:
1. Treatment of secondary dysmenorrhoea is directed towards the under line cause such as
endometriosis or PID.
2. Antiprostaglandins such as mefanamic acid may produce some relief.
Q.12 What do you understand by menorrhegia and metrorrhagia?

And.
Menorrhagia:
Definition: Menorrhagia is defined as cyclic bleeding at normal intervals, the bleeding is either
excessive in amount (more than 80 ml) or duration or both.
I.
Organic:
1. Pelvic pathology :
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2. Systemic : Liver dysfunction, conjestive heart failure severe hypertension.

3. Endocrinal
4. Emotional upset
5. Blood Dyscrasias
II.
Functional Causes: due to disturb HPO acis.
Metrorrhagia:
Definition: Metrorrhagia is defined as irregular acyclic bleeding from the uterus in
In clinical practice the bleeding from any part of the genital tract is included under
the metrorrhagia
Irregular bleedings in the form or contact bleeding of inter menstrual bleeding in a
normal cycle is also included in the metrorrhagia.
Q.13 Write a short note on dysfunctional uterine bleeding (DUB)?

Ans. Dysfunctional uterine bleeding:Definition: DUB is defined as a state of a abnormal uterine bleeding without any clinically
detectable organic pelvic pathology.
Causes: The current concept enclosed that the abnormal bleeding is most likely due to
(i)
local causes in the endo-metrium.
(ii)
Alteration in the ratio of endometrial prostaglandins.
(iii)
The endometrial abnormalities
(iv)
Emotional influences worries anxieties.

Classification:
1. Ovular bleeding
2. Anovular bleeding
1. Ovular bleedings:
i.
Epimenorrhoea
ii.
Oligo Menorrhoea
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iii.
Functional menorrhagia
2. Anovular bleeding:
Metropathia Haemorrhagica
Threshold bleeding
Investigation:
1. History
2. Physical and systemic examination
3. Internal examination
4. A blood values
5. Hysteroscopy
6. Lapros copy
Management of DUB
General Management:
1. Rest is imposed during bleeding phase
2. Anemia should be treated
3. Clinically avidance systemic or endocrinal abormalties should be investigated & treated.
Medical Management
1. Hormonal therapy
2. Oestrogen
3. Combined oestrogen & progesterone therapy
4. Prostaglandin synthatate inhibitor
5. Anti fibrinolytic agents.
Surgical mgt:
1. Uterine curettage
2. Endometrium resection
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3. Hysterectomy
Nursing Management:
1. Assurance and psychological support
2. Fluid therapy depending upon blood loss
3. Intake & output chart therapy
4. Drug therapy: hormonal therapy
5. Maintain personal hygiene
6. Check vital signs
7. Helps the patient in daily activity of living
Q.13 What is means by oligomenorrhoea?

Ans.
Oligomenorrhoea:
Definition: Menstrual bleeding occurring more than 35 days a part and which remains constant at
that frequently is called oligomenorshoea or infrequent menses at interval longer than 35 days.
Causes:
1. Age related: During adolescence & during menopause
2. Weight realted: obesity
3. Stress and exercise related
4. Endocrine disorder commonest cause
5. PCOD (Poly cystic ovarian disease)
6. Hyper thyroidism
7. Hyper prolatinaemia
8. Androgen producing tumour
Treatment:
Treatment depends upon the causative factor such as:1. Hormonal therapy for PCOD or other endocrinal disorder.
32
2. Antituberculor therapy for tubercular endometritis.

3. Surgery for ovarian or adrenal tumour.
Q.14 Mention the role of different hormones controlling the menstrual cycle?
Ans.
Hormonal regulation of menstrual cycle:
I. Hormonal regulation of ovarian changes

(A) A follicular changes: FSH is responsible for follicular growth.
(B) Ovulation: LH is important for ovulation.
(C) Lutear phase: LH & FSH both are essential for luteal phase because they stimulate
corpus luteum to sectet progesterone & estrogen.
II. Hormonal regulation of uterine changes:
(d) Proliferative phase: Oestrogen is essential

(e) Secretary phase Progesterone is responsible
(f) Menstrual phase: Oestrogen & progesterone level should be low for menstrual phase.
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Unit III
Infertility
Q.1
What is sterility or infertility?
Ans.
Infertility:
Definition: Is a defined as a failure to conceive with in one or more years of regular unprotected
coitus.
Primary infertility denates women has never conceived
Secondary infertility indicates previous pregnancy but failure to conceive sub sequently.
Factor responsible for fertility are:

1. Healthy spermatozoa should be deposited high in the vagina.
2. The spermatozoa should be under go changes and acquire motility.
3. The motile spermatozoa should ascend through the cervix into the uterine cavity and
fallopian tubes.
4. There should be ovulation
5. The fallopian tube should be patent.
6. The spermatozoa should fertilize the ocyte at the ampulla of the tube.
7. The zygote should reach the uterine cavity after 3 to 4 days of fertilization
8. The endometriwn should be prepared for the implantation and corpus lutum should
function adequately.
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Q.2
What are the cause of female infertility?
Ans.
Causes of female infertility:
1. Ovarian factor (15 to 25%)

2. Tubal peritoneal factor (25 to 35%)
3. Cervical & uterine factor
4. Vaginal factor
I.
The ovarian factor includes:
1. Anovulation
2. Luteal phase defect
3. Lutinised unrupture follicle
1. Anovulation:
The possible causes of Anovulation:
(A) HPO- Axis Disturbance

Hypthalamus :
Obesity or weight loss
Psychological disturbances
Psychotrophic drug
Sedative oral pills
Pituitary Pituotory:
Sheihan's disease
Tumous Prolactinaemia
Ovary :
Poly cystic ovarian syndrome
Premature ovarian failure
(B) Thyroid dysfunction : Hypo/ hyper thyroidism

(C) Adrenal:
35
Hyperplasia
Tumour
Hyper andronism
B) Iuteal phase defect:

Inadequate growth and functional of corpus luteum resulting in decrease progesterone secretion
The LPD is due to:

Drug induced ovulation
Hyper thyroidism
DUB
Pelvic endometrisis
(iii) Luifenised Unruputured follicle :

In this condition the ovum is trapped inside the follicle. Which:
Pelvic endometrosis
Hyper proloctinaemia
II.
Tubal and peritoneal phase & factor :

Tubal factor:
Tubal infection
Peritubal adhesion following pelvic surgery
Infection or pelvic endometriosis
Peritoneal factor :
Mild endometriosis
Adhesion (pelvic)
III.
Cervical & Uterine factor
Uterine factor:
Uterine hypoplasia
36
Uterine fibroid
Tubercular endometriosis
Uterine synachie
Congenital male formation of uterus
Cervical Factor:
(a) Anatomical:
Congenital elongation of the cervix
Retroverted uterus
Second degree uterine descent
(B) Physiological :
Purulent cervical discharge as in chronic cervitis.
Presence of antisperm or sperm immobilizing antibodies in cervical mucous.
IV.
Vaginal factor :
Atresia of vagina
Transverse vaginal septum
Vaginitis & purulent discharge
V.
Combined factor
Advance age of male & female
Lack of knowledge about coital techniques
Dyspareunia
Anxiety
Use of lubricant during inter course
Q.3
How will you proceed to investigate a female anovular infertility?
Ans.
Investigation of female infertility:
37
Female Investigation:
I.
History:Age
Duration of marriage
History of previous married
]i. Medical history:

tuberculosis
Diabetes
STD
PID
ii. Surgical History: any abdominal or pelvic surgery.
iii. Menstrual history:
Menstrual adnormalties such as hypo, oligo, famenorrhoea.
iv.
Previous obstetrics history: It includes number of pregnancy, interval between

then & any pregnancy related complication such as premature rupture of
membrane or puerperal sepsis.
v.
Contra ceptive practice; IUCD
V. Sexual History:
Such as dysparaunia and loss of libido,
II.
Examination
1. General examination:
Obesity/weight loss
Abnormal distribution of hairs
Under development of secondary sexual characters, features of PCOD includes
hirsutism & in appropriate galactorrhoea.
2. Systemic Examination: Includes hypertension, chronic heart disease, renal disease,
endocrinopathies
38
3. Speculum examination:
May reveal abnormal cervical discharge
4. Other investigation:
Ovarian factor: Anovalation, Oligovulation, Luteal, phase defect, luteinized unruptured
follicle.
I.
Diagnosis of ovulation:
The various method use is practice to detect ovulation are:
Indirect
Direct
Conclusive
(1) Indirect: This method includes :

A. Menstrual history
B. Regular or irregular
Mild menstrual bleeding/pain/excessive vaginal discharge.

Feature of pre menstrual sgndrome or primary dysmenosshoea.
Evaluation of peripheral or end orgen changes due to oestrogen & progesterone.
b) Basal body temperature:

There is biphasic pattern of temperature variation in ovalatory cycle. There is no rise in
the temperature through out the the cycle in anovulatory cycle.
Procedure:
The pt. is instructed to take her oral temperature daily on the walking in morning
before rising out of the bed.
39
The temperature is also recorded on special chart. Day when intercourse takes
place should also be noted on the chart.
Inter Pretation:
The body temperature maintain through out the first half of cycle is raised to 0.5 to if
following ovulation. The rise sustains through out the second half of the cycle & falls
about to second day prior to the next period called biphasic pattern.
Clinical Importance:
Maintenance of BBT chart during investigation is helps in determine ovulation,
endometrial biopsy, cervical mucous study. It is also helps the couple to determine the
fertile period if the cycle is irregular.
c) Cervical mucous study:
Alteration of the physiochemical property of the cervical mucous occurs due to effect of
oestrogen & progesterone.
Disappearance of fern pattern beyond 22 days of the cycle which present in the mid cycle
is suggestive of ovulation.
Persistence of fern pattern even beyond 22 days suggest to Anovulation.
d) Vaginal cytology:
A single smear on 25 or 26 days of the cycle reveals features of progesterone effects if
ovulation occurs.
e) Hormonal estimation:
Serum progesterone estimation
Ist day 8th day
O
1mg ml
If ovulation occur
22nd day
6-8 ng/me
40
Serum LH LH surge 34 to 36 hrs before ovulation
Serum oestradiol
Serum oestradiol attains the peak rise approximately about 24 to 36 hours prior to
ovulation.
f) Endometrial biopsy:
Biopsy is to be done on 21st to 23 day of the cycle.
g) Sonography:
The feature or recent ovulation by sonography are collapsed follicle & fluid is the pauch of
douglase.
1. Direct method: Laparoscopy visualization of recent corpus luteum or detection of the

ovum from the aspirated periotinal fluid from the pouch of dongles is the only direct
avoidance of evolution.
2. Conclussive:
Pregnancy is the surest avoidance of ovulation
II)
Luteal phase defect (LPS)
BBT chart
Endometrial biopsy
Serum progesterone estimation
III)
Lutenised unruptured follicle (LUF)
Sonography, laproscopy, ovarian biopsy.
Q.4
What are the management of female infertility?
Ans.
Treatment of female infertility:

The treatment modalities in female infertility are grouped as follows:
1. Ovulatory dysfunction
2. Tubal & peritoneal dysfunction
41
3. Associated disorder like endometriosis, infections or endocrinopathy

4. Cervical factor
5. Immunological factor
6. Utero-vaginal canal
7. Unexplanined infertility
8. ART (Assisted reproductive technology)
1. Ovulatory Dysfunction:
It includes
i.
Anovalation
ii.
LPD
iii.
LUF
iv.
Anovulation
Induction of ovulation:
To facilitate effective folliculogenesis & ovulation, the following may be
prescribed.
(a) General
(b) Drug
(c) Surgery
(A) General:
Psychotherapy to improve the emotional upset.
Improvement of nutrition & weight gain
Weight reduction in obese person a in pcos.
(B) Drug
Drug used in induction of ovulation
Clomiphene citrate 50250 mg daily
HMG (FSH 75 9 U + LH 75 IU)
FSH hormone
42
HCG
GNRH analogous buserlin, goserlin
Growth hormone
Drug used in reduction of the raised level
Androgen Dexamithasone
Prolactine Bromocriptin
Insulin metformin
Drug used as substitution therapy
Hypothyroidism thyroxin
Diabetes mellitus antidiabetic drugs
Monitoring during ovulation induction

BBT (Basal Body Temperature)
Cervical mucous study
Estimation of plasma oestrogen level
Ultra sonography for growing follicles
Surgery:
(a) Surgery for PCOS
Bilateral Wedge Resection of the ovary:
Laparoscopic ovarian diathermy & lasar vaprisation as on alternative to wedge
resection.
(b) Appropriate surgery for pituitary prolactionoma
(c) Surgical removal of other ovarian & adrenal tumour.
2. Luteal phase defect:
(a) Natural progeterane Loomg thrice daily starting from the day of ovulation
(b) HCG
(c) In unresponsive cases clomiphene citrate may be tried
43
(C) Lutenised unruptured follicle :

(a) HCG
(b) Bromocriptine therapy
(2) Tubal & peritoneal factors :
The following guidelines are prescribed:

i.
Pre-operative assessment & planning for surgery has to be done by HCG & laparoscopy.
ii.
Prior counseling of the couple about the hazards of surgery & prospect of future
pregnancy should be done.
iii.
Presence of hydro salphinx or gross tubal damage requires their removal to prevent
recurrent infection IVF - ET should be considered for such a situation.
iv.
In tubercular salpingatis sugery to be with held following ant tubercular therapy.
Surgery:
Tuboplasty
3. Endometriosis & endocrinopathies:
Endometriosis with involvement of the ovary or moderate endometriosis should be
treated with drugs or surgery or both.
(A) Hormones:
(i)
Progestogens:
Medroxy progesterone acetate

DANAZOL
Gastrinone
GnRH analogous
(1) Conservative surgery:
The conservative surgery can be done by conventional
Laprotomy or by laparoscopy
The surgery includes
44
Diathermy
Laser vaporization
Resection of endometriomass
(ii)
Radial Sugary:
This is indicated in cases of severe endometriosis who have completed the family.
Radical surgery means hysterectomy with bilateral salpingo oopherectomy along
with resection of endometrial tissues.
Treatment of Endocrinopathies:Hormonal & surgery for tumour.
Cervical Factor
Cervical mucous protects sperm from the hostile environment of the vagina & also from
phagocytosis.
The cervical muscous quality can be imporved by weak alkaline douching or conjugated
oestrogen (1.25 mg orally) in the follicular phase.
Improved cases of it clotrachomatis or M. hominis, doxycycline 100 mg twice daily for
14 days is to be given to both the partners.
Cervical factor when can not be treater is over come by ART procedure.
Like IUI, IVF, or GIFT
5. Immunological factor:
In the presence of antisperm antibodies in the cervical mucous, dexamithasone
0.5 mg at bed time may be given.
6. Utero vaginal surgery:
The operations in the uterus to improve the fertility includes:
a. Myomectomy
b. Metroplasty
c. Adhesiolysis with insertion of IUCD in uterine synachiae
45
d. Enlargement of the vaginal introitus or removal of vaginal septum

e. Apart from cauterization, amputation of the cervix may have to be done
for congential elongation of cervix.
7. Unexplained infertility
It is storage that 90-80% patient of unexplained infertility become pregnant with
in 3 years without having any specific treatment.
ART should be employed.
8. Combined Factor:
The faults defected in both the partners should be treated simultaneously & not
one after the other.
Q.5
Write a short note on Assisted Reproductive Technology (ART).
Ans.
Definition:
ART includes all the prouderes that assist the process of reproduction by retrieving oocytes from
the ovary or sperm from the testes or epididymis.
Methods of ART:
1. Intra uterine insemination (IUI)
AIH (Artificial Insemination husband)
AID (Artificial insemination donar)
2. IVF-ET (Invitro Fertilization & embryo transfer)
3. GIFT (Gamete intra fallapian transfer)
4. ZIFT (Zygote intra fallopian transfer)
5. ICSI (Intra Cytouplasmic sperm infection)
Methods of sperm recovery:

1. Testicular sperm extraction (IESE)
2. Micro surgical epididymal sperm aspiration (MESA)
3. Percutaneous epididymal sperm aspiration (PESA)
46
Unit IV
Pelvic Infections
Q.1
Describe the etiology, sign and symptoms, and treatment of acute, bartholinitis?
Ans.
Acute bartholinitis:-
Definitions: Inflammation of bartholin's glands
Etiology : Causative Organism Are:

1. Mostly Gonococcus
2. Others Pyogonic Organism
Eg:
Coli
Staphylococcas
Streptococeus
Chlamydia trichomatis
Sign and symptoms :

1. Local pain at vulva
2. Difficulty in walking/setting
3. Tenderness present
4. Discomfort
5. Induration at the posterior half of the labia during palpation.
6. Mouth of the duct may be seen as it is surrounded by red areola, on pressing the gland
by fingers. Discharge secretion is seen to come out
Investigations:
1. Blood for TLC, DLC, HBQ, VDRL
2. Urine genral examination culture & sensthinity.
3. Urethral snor and gonococcus
4. Vaginal swab for culture or sensitivity.
Treatment :
1. Rest in bed
2. Hot compression over the area
3. Analgesics to relieve pain
4. Sedative if necessary
5. Systemic antibiotics like amphicillin 500 mg orally 8 hourly.
Q.2
What are the Bartholin's abscess and Bartholin's cyst?
Ans.
Bartholin's abscess:
It is the superlative condition of glands.
Bartholin's abscess is the end result of acute bartholinitis. The duet gets blocked of fibrosis and
the exudates pent up inside to produce abscess.
Bartholin's cyst: It is end result of acute barth lenities if condition is left untreated.
These is closure of the duet or the opening of an aciness.
Treatment:
Surgical Treatment :
Marsupialization : Surgery for bartholin's cyst on the inner aspect of the labia minus first
outside the hymenal ring. It also includes the vaginal wall and the cyst wall.
Medical Treatment:
1. Rest
47
48
2. Analgesics for pain

3. Antibiotic therapy
Q.3
Define trichomonas vaginitis. Describes its causes. Clinical features and

management?
Ans.
Trichomonas Vaginitis/Trichomoniasis
It is most common and generally occurs in child bearing age.

This commonest form of sexually transmitted vaginitis is the parasitic infestation of the vagina
by trichomonas vaginalis a parasite.
Causative organism:
Trichomonasvaginalis: pear shaped parasite
Mode of transmission:
Exact way of infection is not known.
It may be transmitted by:
1. Sexual contact
2. Improper personal hygiene
3. Use of toilet articles from one women of other or through examining gloves.
Clinical Features:
Age: The patient is in child bearing age.
Symptoms :
1. Thick vaginal discharge : characteristically it is sudden profuse & offensive
Frothy mucoid
Muco purulent/greenish
4. Itching and irritation inside and around the vaginal interoitus
5. Dyspareunia
6. Dysuria or frequency of micturition
49
Sign:
On speculum examination
1. The vaginal discharge is copious greenish yellow, frothy & offensive.
2. Red, swollen & tender vagina
3. "Strawberry" apprarance of cervix on speculum examination.
Treatment:
Principles :
1. To destroy the parasite by some germicide applied locally or orally.
2. Husband and wife should be treated at the same time to prevent re-infection.
Medical Treatment:
Metronidazole 200 mg thrice daily orally for 1 week.
Husband should be given the same treatment schedule for 1 week.
The husband should use condom during coitus.
If symptoms persist a second course, treatment is given after an interval of 7 days.
To prevent recurrence gives the treatment schedule to both the husband & wife for 7
days following menstruation for three consecutive cycle. In this three month period,
husband should use condom during coitus.
If metronidazole is into created, vaginal tablets containing clotrimazole 100 mg are to be
introduced in vagina for 6 consecutive nights.
It also eradicates monilial infection of vagina as well.
Q.4 What is vulvovaginitis ? What are the common causes of vulvo vaginitis?
Ans. Vulnovaginitis means inflammation of the mucous membrane or lining of vulva as well as
vagina.
It is commonest disorder during children. Due to lack of oestrogen, the vagina defense is lost and
the infection occurs easily.
50
In children, vulvo vaginitis occurs due to :

a. Gonococcal infection
b. E. coli and other pyogenic organisms.
c. Monilial and trichomonas
Main causes of vulvo vaginitis
Vulvo vagimitis
Bacterial
Parasitic
1. T. Vaginalis
Specific
Non- specific
2. Monilial Vaginitis
3. Tinia Crisis
1. Gonococcal
2. Pyogenic
orgainism
3. Tubercular
4. Salpingitis
Q.5
1. Forgotten pessary
foreign body
2. Senile vaginitis in
post menopausal
women
3. Exposure of vagina
in vaginal prolapsed
4. Pediculosis
5. Pin worm
6. Herpes simplex
Define pluic inflammatory disease (PID) Explain its causative organism and risk
factors, mode of transmission, clinical features, complication & treatment.
Ans. Pelvic inflammatory disease:

Definition:
It is the infection and inflammation of the upper genital tract organs typically involving the
fallopian tubes, ovaries and surrounding structures.
Acute PID includes :
Acute endometritis
Acute salpingitis
Clinically it is most important PID
Acute oophoritis
Acute peluic peritonitis
Tube Ovarian mass
Note: Cervicitis is not included in PID.
Cansative organism : (Polymicrobial infection)
I.
Primary organism:
N. Gonorrhoea 30%
Chlamydia Trachomatis
Mycoplasma hominis
II.
Secondary organism:
a) Anaerobic organism:
Bacteriodes species-fragalis & biuius
Peptococcus
Pepto Streptococcus
b) Aerobic organism:
Non-hemo cytic streptococcus
E-Coli
streptococcus
Staphylococcus
Mode of Transmission :
1. Through mucosal continuity & contiguity: Mostly gonococeal
2. Reflux of menstrual blood along with gonococci into fallopian tube.
3. Through lymphatic into tube: Mostly secondary organism
51
52
Clinical features:
Symptoms:
1. Bilateral lower abdominal and pelvic pain : Dull in nature
2. Irregular & excessive vaginal bleeding
3. Abnormal vaginal discharge :
Purulent or copious
Usually associated with lower genital tract infection
4. Fever, headache
5. Nausea & vomiting
6. Dyspareunia
Signs:
1. Temperature beyond 38oc
2. On abdominal palpation:
a. Tenderness on both the quadrants of lower abdomen
b. Enlarged & tender liver
3. On vaginal examination
a. Abormal vaginal discharge
b. Speculum examination show congested cervix with purulent discharge from canal
c. On bimanual examination : Bitateral tenderness on fornix palpation which increase
with movement of cervix
Complication
Immediate
1. Pelvic peritonitis or
generalized peritonitis
2. Septicaemia
Late
1. Dyspareunia
2. Chronic PID
3. Chronic pelvic pain
53
4. Hydro or pyosalphinx
5. Tubo-ovarian mass
6. Ectopic pregnancy
7. Infertility
Treatment of PID:
Preventive aspect
1. Community based approach to increase public health and awareness
2. Prevention of STD with knowledge of healthy of safer sex.
3. Liberal use of contraceptives
4. Routine sereening of high risk population.
Medical Management :
1. Bed rest
2. Analgesic
3. Out-patient therapy
Prescribe combined antibiotic therapy to the patient because infection is poly microbial in
nature.
Patient should receive oral therapy for 7-14 days (any one)
Doxycycline 100 mg twice a day
Erythromycine 500 mg thrice a day
Tetracycline 500 mg 4 times a day
For anaerobic coverage :
Metronidazole, 400 mg orally twice a day.
4. In patient therapy:
a. Patient should be hospitalized for antibiotic therapy in severe condition.
b. Provide bed rest
c. Restricted oral feeding dehydration and acidosis are to be corrected by I.V. fluids
54
d. I.V. antibiotic therapy for at least 48 hours.

Cefoxitin 2 gm IV 4 times a day for 2-4 days or
Gentamycine 2 mg/kg IV and
Metronidazole 500 mg IV every 8 hours
Surgical Management
1. Laprotomy
2. Occasionally the uterus, ovaries and fallopian tubes are removed if they are involved by the
infection.
Education During Discharge :

1. Education the patient against multiple sexual partner.
2. Educate to use condom during coitus
3. Educating the patient to avoid re-infection and the potential hazards of it.
Q.6
Write a short note on cervical erosion.
Ans.
Definition: Cervical erosion is a condition where the squamous epithelium of the ectocervix is
replaced by columnar epithelium which is continuous with the endo cervix.
Etiology:
55
Causes of Cervical Erosion
Congenital
Acquired
At birth (In 1/3rd case)
Hormonal
Pregnancy
and
Oral Pill user
Infection
(cervicitis)
Clinical Features:
Symptoms:
1. Vaginal discharge : Mucopurulent, offensive and irritant in presence of infection
2. Contact bleeding specially during pregnancy or pill user following coius or defecation.
3. Constipation
4. Ceruicitis:
Pelvic pain
Bachache
Infertility
Sign: On speculum examination:

External or of ectoceuix becomes bright red.
Non-tender non bleed to touch
56
When rubbing with gauze piece, multiple, oozing spot may be present.
Diagnosis
1. Clinical examination (Sing and symptom )
2. Colposcopy
3. Pap's stain cervical scrape cytological examination
Management
1. In pill user, the 'Pill" should be stopped
2. Advised to use barrier methods
3. For their patient, weight gain improve cervical erosion.
4. Iron therapy for anemic patient
5. Administer antibiotic in case of cervicitis.
6. Waiting for automatically healing.
7. Syergery :
In case of persistence erosion with troublesome discharge
Electrocautry
Cryosugery
Laser vaporization
Q.7
What is meant by salpingitis?
Ans.
Salpingitis:
Means inflammation of the fallopian tubes.

In salpingitis, following facts are to be borne in mind:
1. The infection is usually polymicrobial in nature.
2. Both tubes are usually affected
3. Salpingo oophoritis occurs (close association of tubes & ovaries in the involvement of both
when one is affected)
4. The tubal infection almost always affects adversely the future reproductive fuction.
57
Eausative organisms responsible for salpingitis:

Causative Organism
Sexually transmitted
Gonococcus
Mycoplasma
Chlamydia
trachomatis
Pyogenic
Tubercular
Aerobes
Anaerobes
Streptococcus
Staphylococcus
Actinomycosis
E-coli
Bacteriodes fragilis
Mycobacterion
Tuberculosis
Types of salpingitis :
1. Acute Salpingitis
2. Chronic Salpingitis
Q.8
What is leucorrhoea?
Ans.
Leucorrhoea : An increase in amount of normal vaginal secretion is termed as leucorrhoea.

or
any non bloody (excuding urine/stool), non irritant, non- infective & non offensive vaginal discharge
severe enough to stain the under garments is called leucorrhoea.
Leucorrhoea is never cause pruritis
58
Unit V
Uterine Displacement and Descent
Q.1
What are the various forms of displacement of uterus?
Ans.
The various form of displacement of uterus are :
1. Ascent : The uterus being dragged upward

2. Decent or prolapse: The uterus being depressed down ward.
3. Anteversion: the uterus titled forward
4. Retroversion: The uterus titled forward
5. Lateroversion : The uterus titled laterally
6. Anteflexion: Bent on itself forward
7. Retroflexion : bent on itself backward or at the level of internal as
8. Lateroflexion: Bent on itself laterally
9. Inversion: the uterus being turned inside out.
Q.2
Define retroversion of uterus. What are the clinical types of retroversion?
Ans.
Retroversion of uterus: When long axis of cervix and corpus are in a line & whole organs,
turn backward in relation to long axis of birth canal is called as retroversion of uterus.
Generally normalcy position of the uterus is one of antiversion & anti flexion.
Clinical types of retroversion:

1. Mobile retroversion : With or with out symptom
59
2. Immobile retroversion: Almost always with symptom

3. Retroversion in pregnancy
4. Retroversion in puerperium.
But the degree of retroverted uterus are :

1. First degree : When the fundus is vertical & pointing dowards saeral promontory
2. Second degree : When the fundus lies at the level of internal os or lie in hollow of the racrum.
3. Third degree funds lies below the level of internal os.
Q.3
How will you manage a case of retroverted uterus?
Ans.
Management/treatment of retroverted uterus:
1. Preventive Measures:
i.
To regular urination after delivery.
ii.
Provide pelvic floor exercise to maintain tone of pelvic muscles
iii.
To encourage lying in prone position for half to one hour once or twice daily until 2-4
weeks after delivery.
2. Curative Treatment:
1. Pessary
Indications:
i. In sub involution of uterus
ii. In case of unexplained infertility & recurrent early abortion.
iii. When operation is contraindicated
iv. In retroverted gravid uterus Jusact a hodge smith type of pessary after anteverting
the uterus.
If symptoms are relived then retroversion was the cause and this has to be
continued.
If symptoms persists a ring pessary is introduced.
3. Surgery :
Indication:
60
a. Fixed retroverted uterus producing backache or dyspareunia.

b. When pessary test is positive.
Principle of surgical correction is ventrosuspension of the uterus by shortening the sound ligaments of
both the sides extraperitoneally to the undersurface of the anterior sectus sheath.
Q.4 What is meant by genital prolapsed ? State the different types of prolapse.
Ans: Genital prolapse: Downward displacement of any structure of the pelvic floor constitutes
prolapsed.
or
Hermiation of pelvic organs through the vagina in called genital prolapse.
Types of genital prolapse
Vaginal
Anterior vaginal wall
uterus
Posterior vaginal wall
Utero vaginal
congenital
Ist degree
Nulliparous
IInd degree
prolapse
IIIrd degree
Urethrocele
Cystocele
Cysto urethrocele
Relaxed
Perineum
Rectocele
Vault prolapse
61
Primary
Secondary
Enterocele
Following, vaginal or abdominal,

hysterectomy
Q.5
Describe the prolapse of uterus, its causes, and treatment.
Ans.
Uterine prolapsed/prolapsed of uterus:
It means downward descent of uterus and vagina. Uterine prolapse is always accompanied by vaginal
prolapse.
It is infact a form of hernia.
Degree of uterine Prolapse:
1. First degree: Slight descent of the uterus but cervix (external OS) remain inside the uagine.
2. Second degree: External os project outside the vaginal interoitus but the uterine body remain
inside when women is straining or standing.
3. Thir degree (complete prolapse) : the entire uterus prolapses outside the vulva.
Causes of uterine prolapse:

I.
Predisposing factors :
1. Congenital or developmental weakness of the support
Anatomic and functional abnormality
2. Injury sustained during child birth (acquired factor)
a. Difficult vaginal delivery
b. Overstretching of the endopelic fascial sheath of the vagina.
c. Overstretching of perineum
d. Subinvolution of supporting structure.
e. Prolonged labour
f. Repeated & frequent child birth
II.
Activating/aggreviating factors
62
1. Increase intra abdominal pressure caused by chronic cough, constipation.

2. Malnutrition
3. Increase weight of the uterus, resulting from sub involution.
4. Traction of the uterus by anterior vaginal wall or cervical polyp.
Sign and symptoms:

Symptoms:
1. The usual symptoms is that something comes out from vagina
2. Discomfort
3. Bladder symptoms
Increase frequency & urgency
Stress in continence
Retention of urine
Painful maturation
4. Rectal symptoms
Constipation
Difficulty in passing of stool
5. Vaginal discharge
6. Bachache
7. Haemorrhage
Signs :
The type & extent of the Prolapse can be usually detected by asking the patient to bear
down or cough.
Early prolapse can be determined by palpation.
In case of utero-vaginal (UV) prolapse of 2nd & 3rd degree, the cervix will be found to lie
below the interoitus of the vagina.
Rectal examination : to differentiate rectocele & uterine prolapse:

1. Preventive measures
2. Conservative treatment
3. Surgical treatment
I.
Preventive measures:
a) Provide good antenatal care

b) Provide good intranatal care
i.
Prevent premature application of forceps
ii.
Avoid premature bearing effort
iii.
Avoid prolong second stage of labour
iv.
Perform timely & adequate episiotomy
v.
Avoidance of fundal pressure.
c) To provide good post natal care

Early ambulation
Provide pelvic floor exercise.
d) To provide General care

II. Conservative treatment: pessary treatment
III. Surgical treatment:
i. Anterior colporrhaphy for anterior vaginal wall prolapse
ii. Posterior colpo perin corrhaphy
iii. Pelvic floor repair (PER) :
Both anterior & posterior
Vaginal wall prolapse
iv. Vaginal hysterectomy with PFR
v. Repairing of vault prolapse
vi. Repair of enterocele
B) For uterine prolapse
a) Fothergill or Manchester operation:-
63
64
Dilatation of cervix
Amputation of cervix
Placement of ligament.
Q.6
What is Cystocele?
Ans.
Cystocele: It is most frequent type of genital prolapse. It is descent of urinary bladder
with anterior vaginal wall below the cervix.

Laxity of upper half of the anterior vaginal wall and herniation of bladder wall through it.
Degree of cystocele:
1. Mild degree: bladder descends in vagina below the cervix
2. Moderate degree: Bledder descends in vagina up to the vaginal introitus
3. Severe degree : ladder descends outside the vaginal introtus.
65
Unit VI
Sexually Transmitted Disease and their

Prevention
Q.1
Define sexually transmitted disease ?
Ans.
Sexually transmitted disease or STD replaced the older term veneral disease which
referred to disease transmitted only by sexually intercourse/contact.
More than 50 organism are known to spread through sexual activity.

The term sexually transmitted disease refer's any infections which is spread primarily by
the sexual activity or contact.
Q.2
What are the mode of transmission of STD's?
Ans.
Mode of transmission : STDs can be transmitted by :
1. Sexual contact most common

2. Placement HIV, syphilus
3. By blood transmission or infected needles HIV, Hepatitis, syphilus
4. Through birth canal gonococcal chlamydal, hepes.
Q.3
Ans.
Mention the sexually transmitted disease and it's agent.
66
S.No.
I.
1
2
3
4
5
6
7
8
II
1
2
3
4
5
III
1
2
IV
1
V
1
2
Sexually transmitted
Bacterial:
Gonorrhea
Syphillis
Lymphogranuloma Venerum
Non gonococal urethritis
Granuloma nguinale
Chaneriod
Non- Specific Vaginitis
Mycoplasma Infection
VIRAL
AIDS
Viral hepatitis
Herpes genitalis
Condyloma acuminate
CIN
Protozoal
Bacterial vagimosis
Trichomonas Vagimitis
Fungal
Monilial vaginitis
ECTO Parasite
Scabies
Pediculosis Pubis
Agent
Neisseria gonorrhoea
Treponema Paltidum
Chlamydia trachomatis
Trachomatis (D-K serotype)
Donavania Granuomatis
Hemophillus ducreyi
Hemophillus vaginalis
M Hominis
HIV-1 & HIV-2
Hep-B and C
Herpes simplex virus 2 (HSV)
HPV (Human papilloma virus)
HPV 16, 18 or 31
Gardnerella Vaginalis
V. Vaginalis
Candida
Amdida albicans
Sarcuptes Scabiei
Crab Louse (Phthirus pubis)
Q.4
What is meant by gonorrhoea?
Ans.
Gonorrhoea: Gonorrhoea is caused by neisseria gomrrhoea a gram negative diplococcus.
In female, the primary site of lesion in gonorrhea varies according to the age of the individual.
In adult, primary site of infection is urethra, cervix bartholini glands In children vagina.
Clinically gonorrhea may be

1. Acute
2. Chronic
Gonorrhoea can be divided into two categories : Local and disseminated
Local infection involve the mucosal surface of the cervix, urethra, & rectum, vestibular glands,
pharyx, or conjunctiva.
Disseminated or systemic infection involves bacteremia with poly arthritis, dermatitis,
endocarditis & meningitis. This infection is very common in women.
Incubation period : 3-8 days.
67
68
Unit VII
Breast Disorder
Q.1
What is mastitis?
Ans.
Mastitis means inflammation of the breast typically one or more adjacent segments are
inflammed and appear as a wedge shape area of redness and swelling. The women pulse &
temperature may rise.
Types:
1. Non-infective mastitis (Acute inflammatory mastitis)
This condition results from milk stasis. It may occurs during the early days as result of
unresolved engorgement.
2. Infective mastitis:
If milk statis remain unresolved, infection may also enter the breast via the milk ducts
and abscess formation may occur.
Causative organism: Staphylococcus aureus, S epidemidis, Streptocci.

Risk factors: Poor nursing & cracked nipplies
Q.2 Define breast cancer?

Ans.Breast Cancer:
69
Definition: Breast cancer refer's to a group of malignant disease that commonly occur in
the female breast and infrequently in the male breast.
Breast cancere is the commonest of all cancer and is the second common cause of cancer
deaths in women.
Q.3 What are the types (pathophysiology) of breast cancer?

Ans.
Types of breast cancer

Breast Cancer
Invasive
Carcinoma
1. Infilterating
Ductal carcinoma
2. Infitterating lobular
carlinoma
3. Modullary
carcinoma
carlinoma
4. Mucinous cancer
5. Inflammatory breast
cancer
6. Paget's disease
Non invasive carcinoma

(Carcinoma in situ)
1. Ductal carcinoma in
site
2. Labour carcihoma
in situ
Q.4
Mention the clinical menifestation of breast cancer?
Ans.
Breast cancer most often occur in upper outer quadrant.

The frequency of breast cancer according to location :
15%
8%
179
11%
48%
70
Sings & symptoms:

1. The mass is usually painless, non-tender, hard, non-mobile and irregular to shape.
2. 64-70 % of breast cancer is as a palpated mass found by the client.
3. 4-30 % are found by mammography.
4. When no mass in present, other physical finding are:
Nipple discharge
In duration
Heat & erythema of breast skin
Skin oedema
Q.5
How will you manage a case of breast cancer?
Ans.
Management :
I.
Women who have early small breast cancer (stage I ) may be best treated by
mastectomy or lymphectomy followed by radiation therapy.
II.
Women with locally advance stage (stage II) may be better served by having
hormonally synchrolized, chemotherapy to shrink the tumour size before surgery or
R.T. (Radiation therapy)
III.
Chemotherapy is used to treat client with positive lymphnode (stage II) locally
advanced cancer (stage III) and metastatic breast cancer (Stage IV)
Type of management
1. Radiation therapy
2. Chemotherapy (Pharmacological management)
3. Hormonal
4. Surgical management
a. Lymphectomy
b. Quadtrantectomy
c. Radical mastectomy
d. Modified radical mastectomy

e. Total/simple mastectomy
f. Extended radical mastectomy
g. Axillary node dissection
h. Surgical hormonal manipulation
71
72
Unit VIII
Benign and Malignant Neoplasm of

Reproductive Organs
Q.1
Define uterine polyp mention the different types of uterine polyp?
Ans.
Polyps are pedunculated tumors arsing from the mucosa and extending into the opening
of a body cavity.
Uterine polyp/cervical poly :

It is the pedunculated growth arising from the uterine cavity from that of the corpus or cervix
The uterine polyp may arise.
Either:
(a) From the body of uterus
(b) From the cervix
Types of uterine polyp:

1. Mucous type
2. Fibroid type
3. Fibro adenoma
4. Malignant polyp
Q.2
73
Write a short note on uterine fibroid .
Ans. Uterine fibroid : This is a benign growth from the muscular layer of the uterus.
Histologically, this tumour is composed of smooth muscles and fibrous connective tissue so
named as uterine leiomyoma, myoma, fibromyoma.
They are commonest of all pelvic tumours and 20 % of the women passes them.
Etiology and risk factors
Etiology:
A) Chromosomal abnormality
B) Hormonal dependent related to oestrogen stimulation
Risk factors:
(A) Null parity
(B) Age : between 35-45 years
(C) Mechanical stress in myometrial wall
(D) Obesity
(E) Hyper oestrogenic state
(F) Black women.
Types of fibroids :
Body (Corporeal)
Cervical
Interstitial/intramural
Cervical
Submucous fibroid
Fibroids
74
Subperitoneal or subserous
Parasitic Fibroid
Intraligamentory
Clinical features:
The most common clinical manifestations are :
1. Menstrual symptoms :
Menorrhagia
Metrorrhagia
Dysmenorrhoea
2. Weakness lethargy
3. Urinary Abnormality:
Urinary frequency
Urinary retention
4. Constipation, hydroureter, hydronephrosis, abdominal pain
5. Dyspareunia
6. Occassinally vaginal discharge
7. Abdonomal distension in case o f big fibroid.
8. Pregnancy related complication like
Abortion
Preterm labour
Intrauterine growth
Retardation (IUGR)
Treatment :_
1. For symptomatic fibroids
2. For asymptomatic
75
For symptomatic fibroids:

A. Medical management
i. Progestogens
j. Antiprogesterones
k. Antifibrinolotics
l. Prostaglandin synthetase inhibitor (PSE)
m. Danazol
n. GnRH analogues
B Surgical management:
1. Myomectomy
2. Endoscopic surgery :
Hysteroscopic
Laproscopic
3. Hysterctomy if women age is more than 40 years
II. Asymptomatic fibroid:

Observation:
Surgery
Q.3
What do you meant by R.V.F. and V.V.F.?
Ans.
RVF (Recto vaginal fistula)

Abnormal communication between the rectum and vagina with involuntary escape of flatus or
factor into the vagina is called R.V.F.
V.V.F (Vesico vaginal fistula)
It is the fistula between the urinary bladder and upper half of the anterior vaginal wall.
It is the abnormal communication between the bladder and vagina and the urine
escapes into the vagina causing the incontinence.
76
This is the commonest type of genital urinary fistula.
Q.4
Define carcinoma of the cervix write the clinical staging of cervical carcinoma as
recommended by FIGO.
And.
Carcinoma of the cervix:

It is generally a malignant epithelial growth from the mucous lining of the cervix squamous or
columnar epithelium.
The site of lesion is predominantly in the ectocervix (80%) and the rest (20%) are in the
endocervix.
Carcinoma of cervix is the most common of all genital cancers and of all cancers occurring in
women.
Carcinoma of the uterus
Carcinoma of endometrium of the
Carcinoma of the cervix
Body of the uterus
Carrinoma of the
Endocervical
Portiovaginalis comparing
Carcinama
80 % of all cervical
which account
Cancers
the remaining 20%
Clinical classification/clinical staging of cervical carcinoma:

(Recommended by FIGO (international federation of obstetrics/ gynaecology)
I.
77
Pre invasive carcinoma
Stage-o- Carcihnoma in situ or intra epithelial carcinoma
Invasive carcinoma
Stage-I Carcinoma is confined to the cervix only.

StageIa- Pre clinical carcinomia of the cervix that is those diagnosed only by microscopy.
Stage Ia1 Case of minimal stromal invasion less than 3 mm
Stage 1a2 Stromal invarsion greater than 3 mm & no greater than 5 mm & no wider than 7 mm
Stage 1b Lesion of greater dimension than stage 1a2
Stage 1b1 Lesion not exceeding 4 cm in size.
Stage 1B2 - Lesion exceeding 4 cm in size
Stage II the carcinoma extends beyond the cervix, but has not reacheds the lateral pelvic wall.
Carcinoma involves the vagina, but not the lower third.
Stage IIa No obvious parametrial involvement
Stages IIb obvious parametrial involvement
Stage III The carcinoma has reached the laternal pelvic wall (on sector examination no cancer free
space between the tumour & pelvic wall) Tumour involves the lower third of the vagina.
Stage IIIa No extension to the pelvic wall
Stage IIIb-extensive into the pelvic wall
Stage IV Carcinoma involves the mucosaof bladder of the rectum or both (carcinoma has extended
beyond the true pelvis)
Stage IV a Spread of growth to adjace organs.
Stage IVb spread to distant organs.
Q.5 What are the etiology & risk factors of cervical carcinoma.?
Ans.
Etiology / Causes
1. Early age of first pregnancy
78
2. Oral pills user

3. Tobacco smoking
4. Multiple sexual partner
5. Early sexual intercourse
6. Too many birth or too frequent birth
7. Low socio economic status
8. Poor maintenance of local hygience
9. STD
10. Previous or family history of cervical corcinoma
11. Prostitution.
Q.6
How will you treat a case of cervical carcinoma (carcinoma of cervix) ?
Ans.
Treatment of carcinoma of cervix:
1. Preventive
2. Curative
1. Preventive :
A. Primary prevention : It involves identifying the causal factors and eliminating or
preventing those from exerting their effects.
Identifying "High risk" women.
Identifying "High risk" males
Use of condom during early intercourse.
Raising the marriage age and of first birth limitation of family maintenance of
local hygiene and effective therapy of STD.
Removal of cervix during hysterectomy as a routine for benign lesion.
2. Secondary prevention: It involves identification and treating the disease earlier in the most
treatable stage by screening procedure.
II. Curative: The types of treatment employed for the invasive carcinoma are as follows :
1. Primary surgery
2. Primary radiotherapy
3. Combination therapy
4. Chemotherapy
1. Surgery: Types of Surgery
a. Radical hysterectomy
b. Pelvic exenteration
c. Laparoscopic radical hysterectomy
2. Primary radiotherapy :
Treated with ionizing Radiation using radium.
In early stage, brachytherapy technique is employes.
Radiation resources: 226 Ra (Radium) , 60 Co (Cobalt)
3. Chemotherapy: Primary treatment of cervical carcinoma.

Uses of drugs : combination of cisplatin, vinblastin, bleomycin
As an adjuvant treatment Used with surgery & R.T.
As an Neoadjuvant therapy : Drugs used before surgery/R.T.
79

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Biyani's Think Tank

Concept based notes

Concept & Copyright :

Biyani Shikshan Samiti

First Edition : 2011

Leaser Type Setted by :

Name the different genital organs in female?

Mention the support of the uterus?

2. Pubo Cervical ligament

How will you proceed to examine a gynecological patient?

III. Examination : It Includes

of gradual development of secondary sexual characters.

The larche (Breast budding changes)

Adrehnarche (Public & Auxiliary hair

Peak growth in height

Menarche (menstruation) (Important controlling factor for onset of puberty are

Stages Ist Pre pubertal stages elevation of papilla only.

Public hair development:

Stage Ist Pre Pubertal stage, no public hair present.

Common disorder of the puberty:

What is meant by menarche?

The valve is more reactive to steroid hormones.

The mons pubis & the labia minora increase in size.

under the influence of progesterone, the development of acivni increase

rhythmic fashtion during the reproductive period of women's life.

Mature or graffian follicle

Note :Ovarian cycle

If Fertilization does not occurs

Corpus luteum of pregnancy

Corpus luteum menstrualis

(Corpus luteum verum)

Destroy after 26 day of menstrual

estrogen & progesterone

Necrosis in the endometrium

Necrosis of & blood vessels

2. Proliferation phase: (6-14 days)

3. Secretary Phase: (15 to 28 days)

Q.5 Write a short not on corpus luteum.

of ovum is called as corpus luteum.

Mention the role of different hormones.

Hormonal regulation of menstrual cycle:

I. Hormonal regulation of ovarian changes

II. Hormonal regulation of uterine changes:

(a) Proliferative phase: Oestrogen is essential

Definition: It is defined as permanent cessation of menstrual cycle at the as reproductive

life due to loss of ovarian follicular activity.

Oesteoporosis & Fracture:

Short note on hormonal replacement therapy?

Hormonal Replacement Therapy:Objective of HRT:

oestrodiol implants, 25 mg, 50

mg or 100 mg are available 8 can be kept for 6 months.

What is meant by menstrual abnormalities?

Menstrual abnormalities: It means menstrual disorder.

Q.10 Define amenorrhoea write the types of amenorrhoea

& explain about

Transverse vaginal septum

Atresia of the upper third of vagina & cervix

Stenosis of the cervix following amputation, deep cauterization and conization.

Secondary vaginal atresia following difficult vaginal delivery.

Q.10 Write a short note on dysmenorrhoea?

Definition: Dysmenorrhoea means painful menstruation

Secondary dysmenorrhoea is normaly considered to be

menstruation associated pain occurring in the presence of pelvic pathology.

Q.12 What do you understand by menorrhegia and metrorrhagia?