30-GYNECOLOGY

age-vag pH
newborn=5-6

in
6w=7
before puberty=6.5-7.5
puberty-alk acid
during menstruation=6.5-7.5
reproductive age grp=3.5-4.5

s.
preg=4
late menopause=6.5-7.5

vaginal epithelium
BASal&paraBASal(small round BASophilic)-lack of any h activity, childhood uptil
puberty, postpartum, after menopause

menopause
iim
intermediate(transparent basophilic)-P, androgen, corticosteroid, OCP, birth, preg,

superCIal(large pyknotic aCIdophilic)-E, reproductive period, preovulatory period

maturat index
parabasal:intermed:superf
preg-0:95:5
ovulat-0:30:70
4a
PP, atrophic, long post menopause-100:0:0
menopause-50:50:0
child-80:20:0

estrogen(C18)
ER-uterus, vag, breast, hypothalamus, bld vess
ER-prostate, ovary
m

type
E1-estrONE-post menOpausal
E2-estraDIol-reproDuctIve age
E3-esTRIol-pReg
E4-esTETRol-pReg
source
Ai

androstenedione (aromatase,adipose ts) E1

2cell-2gonadotropin theory
FSH +granulosa cell E2 granulosa cell+ androgen theca interna cell+
LH
fetal DHEASplacenta E3,E4
bound-SHBG>albumin, free=1%, recept-intranuclear, end product-glucuronide,
uterus-nonpreg(endom-prolif),preg(uterus growth), cx
mucus-thin,watery,acellular,Spinnbarkeit, ferning(NaCl) disapp on d18MC, ferning in
preg-PV leaking,PROM, FT-motility,secretion, vag-superf/mature/glycogen rich
 cell/high karyopyknotic index, breast-ductular developm, Na/H2O retention,
cholesterol-HDL,LDL,TG(cardioprotective), bone-mineralisation,sr Ca,ur
Ca,epiphyseal closure,initiate growth at puberty, hypercoagulable state-brinolysis,
P receptor,FSH, low dose-LH,high dose-LH,GnRH
E level premature ovary failure=20pg/ml

progestogen
progesterone(natural,C21)
progestin(synth,C19-21)

in
1st gen-norethindrone
2nd-levonorgestrel
3rd-gestodene/desogestrel/norgestimate(least androgenic)
4th-spironolactone derivati-drospirone (antiandrogenic)
14-effect on lipid prole,androg effect

s.
synth in granulosa cell begin 36h bef ovulation
bound-albumin>cortisol binding prot, free=2%, receptor-intracytoplasmic, end
prod-pregnanediol, uterus-nonpreg(secretory,protective to endometrium), preg(uterus
growth,sm m relaxant,prophylax of preterm labour), cx
mucus-thick,scanty,viscous,very cellular,tack,crystallization, FT-motility,secretion,

high dose-LH,FSH,GnRH

testosterone(C19)
iim
vag-intermed cell, breast-glandular developm, Na/H2O excretion,
cholesterol-HDL,LDL, bone-no effect, coagulability-no effect, low dose-LH,FSH,

source-fem-pheriph conversion of androstenedione(50%), adr

medulla(25%),ovary(25%)
ovary-androstenedione>DHEA>testosterone
mal-Leydig cell
4a
bld testes barrier-Sertoli-Sertoli cell-separate early forms(spermatogonia) fr
spermatocyte, Leydig cell lie outside of BTB
bound-testosterone binding globulin (SHBG)>albumin, recept-intracytoplasmic, end
product-oxosteroid(ketosteroid), free-fem(1%),mal(2%), fem-appearance of pubic&
axillary hair, control of libido
Sertoli cell-MIS, testosterone binding globulin, E2, relaxin, inhibin
m

pituitary h
acidophil-GH, prolactin
basophil-LH, FSH, TSH, ACTH
recept-memb bound G prot coupled
FSHfem-granulosa cell, select cohort of follicle, formation of dominant follicle,
early MC at puberty anovulation d/t no FSH
Ai

mal-Sertoli cellSpermatogenesis
LH fem-theca cell&granulosa cell, high E2(200pg48h)LH
surge 36h ovulation, LH peak 12h ovulation, P+E2 maintain LH surge
mal-Leydig cell

GnRH(decapeptide)
source-arcuate nucleus med hypothalamus, neuron derived fr olfactory placode
pulsatile release begin at puberty
GABA,neuropeptideY, leptin,Glu,kisspeptin GnRH
 high pulse freq(1 in 60min)LH
low pulse freq(1 in 90min)FSH

hCG
source-syncytiotrophoblast, glycoprot
2subunit--non specif-LH,FSH,TSH, -LH(8AA),nonsp tm marker
t=24h, doubling time=48h(1.4-2d)
stimulates fetal testosterone

in
hPL
t=34-36h, fn-lipolysis,FFA supply,placental fn

inhibin(folliculostatin,McCullagh)
nonsteroidal H2O soluble prot

s.
source-Graaan follicle
inhibinA+B,EinhibinFSH,LH
fn-agglutinat sperm, cx mucus penetrat,egg interaction

corpus luteum

life span=14d
iim
steroidogenesis maintain-secretory phase(LH), preg(hCG)
secrete-P, E, relaxin, inhibinA

max activity-8th d post ovulation

menstruation
duration=21-35(28d)
oligomenorrhoea>35d
polymenorrhea<21d
4a
metrorrhagia-intermenstrual blding
amount80ml(35>50ml)
no. of d=2-7(5d)
menorrhagia>80ml/>7d
hypomenorrhoea<20ml/<2d

amenorrhoea
m

prim
absence menses-15y in presence of sec sex charact(SCC)
absence menses-13y in absence of SCC
sec
absence of menses for 6consec mth/3MC
Turner synd(45XO)-SHOX gene
Ai

Kallman synd(46XX/46XY)-Kall gene

Swyer synd(46XY)-SRY gene
MRKH synd-absent vag&uterus, distal FT present
androgen insensitivity/testicular feminization synd( 46XY)-blind vag, axillary&pubic
hair absent

puberty
fem(10.5y)-growth spurt(skeletal growth) thelarch pubarch(pubic hair) peak ht
vel 6mth menarch(12.5y,MC) axillary hair
 mal(11.5y)-testicular enlargem penile growth pubarch peak ht vel axillary
hair beard
precocious pub-fem(P<8y,M<10y), mal(P<9y)
delayed pub-fem(P>13,M>15y), mal(P>14y)
peak growth vel
mal=10.3cm/y-SMR4
fem=9cm/y-SMR3

menopause(World-51y,India-47y)-abs of menses for 12consec mth-Dx-sr FSH-40IU

in
on 2occ 1mth apart-FSH,LH, E, testosterone no change
premature menopause<40y
Rx of postmenopausal sympt-if uterus present-E+P, if uterus abs-E, if E c/i-SSRI

sarcoma botryoides

s.
grapelike, polypoid, bulky mass, protruding through vag in 4y girl child

PCOD/Stein Levinthal synd

stromal hyperplasia +theca cell androg SHBG free E1(total E1 norm,
E2/E1 ratio reverse) LH(persistent elevat) imbalance b/n FSH&LH(LH/FSH>2)
no dominant follicle anovulation
%of PCOD
obese=50
insulin resistance=50-75
iim
%of norm fem with polycystic ovary=25
ovarian hyperstimulation synd-Gn(human menopausal Gn)> GnRH> clomiphene
citrate
long term complication
gestational DM,PIH,multiple preg,ca endomet,CVS ds,T2DM
4a
infertility
inability to conceive even after 1y of unprotected coitus
mal factor alone=20%
mal+fem factor=40%
fem factor=40-55%
m

anovulation(40%)
test for ovulation
basal body temp-at ovulation(0.5F temp-P)
Cx mucus-thick, burn/Caramel test
vag cytology(lat vag fornix)-intermediate
endomet Bx(best)-secretory endometrium
Ai

sr P(1st, retrospective, most reliable)-D213ng/ml

ur LH-LH surge/peak
TVS(MC)
ovary-follicular monitoring-rate of growth=2mm/d, mature follicle=18-20mm,
sudden size of follicle, fluid in Douglas pouch
endometrium-periovulat-triple layer endometrium-3hyperechoic line,
Secretory-Single hyperechoic line with post enhancement
test for ovarian reserve
sr FSH(MC)-D3-norm<10IU, borderline=10-15IU, poor>15IU
 sr antiMullerian h-poor<0.5ng/ml
clomiphene citrate challenge test-sr inhibinB<45pg
antral follicular count-poor<10
inhibinB d3 MC
Rx-hMG, hCG, urofollitropin

tubal factor(20-30%)
cornual-best progn(90%)
Ix-HSG b/l cornual block laparohysteroscopy(laparoscopy+ hysteroscopy

in
cannulation+ chromopertubation) IVF
gold std-laparoscopy
Mx-distal block-mild(mbrioplasty), severe(IVF)
midsegm block-tubal ligation
reanastomosis Sx-progn-clips> Fallope ring> mod Pomeroy> cautery,

s.
isthmo-isthmic(same diam), total lth>4cm

cx factor
unfavourable mucus
antispermAb(postcoital test)-D12-14, 2h after coitus, norm-forward progression
iim
motility, antispermAb-circulation/shaking motility(norm sperm motility=1-2mm/min)
immunobead assay-antispermAb
sperm immobilization test
Mx-ovulation induction+intrauterine insemination(0.3-0.5ml process semen reach
fertilizatiin at site<5min)

uterine factor
septate-2uterus, 2cx,2 vag
bicornuate(intercornual dist>4cm, intercornual angle>60) didelphys/bicollis-
4a
2uterus, 2cx, 1vag
bicornuate unicollis-2uterus, 1cx, 1vag
MC-bicornuate unicollis> bicornuate bicollis> septate> unicornuate
reproduct outcome-arcuate> didelphis> bicornuate unicollis
ectopic preg&infertility-unicornuate
abortion-septate
Ix-saline infusion sonography(water-black), gold std-laparoscopy
m

Mx-bicornuate/didelphys-Strassman metroplasty
septate-Tompkin,Jones hysteroscopic resection of septum

male factor
fertilizable life span of sperm=72h
liquied semen=20-30min
Ai

max time to wait=60min

seminal vesicle contribute=60%
WHO-semen parameter
vol>1.5ml
pH>7.2
tot sperm count>39mill/ejaculate
sperm conc>15mill/ml
total motility>40%
progressive motility>32%
 sperm morphology>4%
vitality>58%
WBC<1mill/ml
aspermia-no ejaculate
azoospermia-no sperm in ejaculate
oligospermia<15mill/ml
severe oligospermia<5mill/ml
asthenospermia-abnorm motility
necrospermia-dead sperm

in
teratospermia-abnorm morphology
globospermia-rounded head(lack acrosomal cap)
Mx-for IVF-sperm motility-norm
for ICSI-sperm morphology-norm
mild oligospermia-IVF

s.
severe oligospermia-IntraCytoplasmic Sperm Injection(ICSI)
nonobstruct azoospermia-testicular sperm extraction(TESE)+ICSI

IVF-severe FT tube damage

ovulation induction drug+inj hCG 36h egg retreival
iim
max no. of embryo transfer=3, on D3 postfertilization, 8cell stage(blastomere), 2cm
bel fundus
in case of preimplantation Dx of genetic ds-D5(blastocyst)

preimplantation genetic Dx
polar body, blastomere(1-2), blactocyst(trophoectoderm cell)
zona pellucida pierce, material preserve HCO3 based, Ca&Mg free medium
MC technology-FISH, PCR, gene sequence, SNP(Single Nucleotide Polymorphism)
4a
March classic Asherman synd
min<cavity
mod=-cavity
severe>cavity

AUB
45yendomet sample to r/o ca endom
m

<45yOCP/P

DUB
no identif cause-anat/systemic/endocrine
80%-anovulatory, E-breakthrough bld
Mx
Ai

adolescence-OCP, tranexamic acid(antibrinolytic)

perimenopausal
a/c with bld loss
unstable-D&C+IV E
stable-high dose oral E
c/c-P/OCP

metropathia hgica(cystic glandular hyperplasia, Schroeders ds)

40-45y, 2mth heavy bld, painless, thick polypoidal, HPE-no secretory pattern, Swiss
 cheese pattern, cyclic glandular hyperplasia
Mx-P therapy

PMB
Ix TVS endom thickn 4mm no risk, 5mm high risk of malign endom
aspiration/Bx by Pipelle, Karman, Vabra aspirator(suction device)
gold std-fractional curettage

endometriosis

in
theory
Sampson(most accepted) theory of retrograde menstruation
Meyer coeloMic/Mullerian Metaplasia theory-Metaplasia of peritoneal
Mesothelium endoMetrium
HaLban theory of Lymphatic spread

s.
immune mediate-cell mediated, humoral immunity
familial-KRAS gene, 1st relative-7time
c/f-MC-pain(dysmenorrhoea> c/c pelvic pain> dyspareunia> c/c backache)>
infertility> menorrhagia
lap classic(ASRM)

mod-superf+deep
iim
min-isolate superf deposit
mild-scattered superf deposit<5cm in aggregate

severe-superf+deep+adhesion
Ix-gold std-HPE
Mx-pain-NSAID, OCP, GnRH agonist continuous, P, aromatase inh, danazole
infertilit-mild-superovulat with clomiphene citrate+ intrauterine
insemination(IUI) IVF
mod,severe-IVF
4a
adenomyosis
menorrhagia+dysmenorrhea, symmetrical growth, tender, 10-20w size uterus
Ix-gold std-HPE(PM)->1HPF deep to jn zone, >2.5mm deep to jn zone
Mx-hysterectomy

gEnITal TB
m

c/f-infErtilITy> pain> menstrual irregularity(1st- menorrhagia amenorrh>

oligomenorrh)
Ix-HSG-tobacco pouch/lead pipe app of FT, endometrial Bx, D1 menstrual bld PCR
Mx-cat I-ATT6mth, infertility-IVF

broid uterus
Ai

E+P, submucous-(0-intracavitary, 1>50%intracavitary, 2<50%intracavitary)

c/f-asympt> menorrhagia(submucous>intramural),
degeneration(hyaline>red-submucous)
subser-calcareous/calcic degeneration
pressure sympt-subserosal>intramural
ant-freq of micturition
post-retention of urine
cx broid-retent of urine
infertility-submucous
 broad lig broid
true-de novo b/n layer of broad lig-lat to ureter
false-subserosal broid outgrowth BL-med to ureter
Ix-hysteroscopy,HSG
Mx-med-low dose OCP, GnRH agonist, mifepristone, ulipristal(SPRM), aromatase inh
Sx-conserv-type0,1 submucous-hysteroscopic myomectomy
type2 submucous, intramural, subserosal-lap myomectomy
radical
subtotal hysterectomy-uterus

in
total hysterectomy-uterus+cx
pan hysterectomy-uterus+cx+FT+ovary

prolapse
De Lancey level of support

s.
1-uterosacral lig, cardinal lig-uterocervical prolapse
2-paravag ts-cystocoele
3-perineal body(m)-rectocoele
degree
1-above introitus
2-at introitus
3-outside introitus iim
Pelvic Organ Prolapse Quantication(POPQ) system-hymen
Baden Walker way classic
1/A-way upto hymen
2/B-reach hymen
3/C-way past hymen
4/procidentia-max prolapse outside, fundus palpable
Mx-
4a
nullip
mod Shirodkar abd sling Sx(psoas hook, mersilene tape, rectus sheath, good abd
tone not req)
eaRly PREg+prolapse
Ring PEssaRy(removed at 16-18w)
puerperium
ring pessary6mthSx
m

multip+complete family+want to retain MC

Shirodkar(mod Manchester Fothergill) repair
old multip+complete family
1,2-Kegel exercise
3-vag hysterectomy+pelvic floor repair
old multip+3prolapse+DM+HTN
Ai

leForte colpoclesis
old multip+3prolapse+CAD+2MI
ring pessary at level of ischeal spine

vault prolapse
posthysterectomy
Mx-abd-sacrocolpopexy(best), uterosacral suspension
vag-sacrospinous xation, uterosacral suspension
 stress urinary incontinence
Mx-BurCh Colposuspension(suspend fr Cooper lig)
MMK(suspended fr periosteum symphysis pubis)
transobturator tape>transvaginal tape

enterocoele
Mx-McCalls culdoplasty

VVF

in
Mx-Latzko procedure

MTP
1st trimest-mifepristone&misoprostol

s.
CONTRACEPTION
OCP
MOA-inh ovulation
ADR-breakthrough blding
very low dose EE20g
low dose EE<50g(35g)
high dose EE>50g
lowest possible dose EE=10g
iim
Mala N(free)=Mala D(subsiDiseD-Rs3) =(30gEE+150gLNG)21d+ [60mgFe++
fumarate(19.5mgFe++)]7d
return of fertility-3mth
Chlamydia, Candida, ca cx, hepadenoma(E)
PID, ectopic preg, ca ovary(50%), ca endometrium(60%), ca colon
no change-HCC, ca GB
4a
POP(minipill)
MOA-alteration of cx mucus
ADR-irregular vag blding
P=75g
safe period=3h
only POP India-cerazette(desogestrel)
m

MOA-inh ovulation
safe period=12h

saheli(CDRI-Lucknow)
ormeloxifene/centchroman(30mg)
MOA-inh implantation
Ai

1st 3mth 2/w f/b 1/w

injectable
DMPA
MOA-inh ovulation
ADR-irreg vag blding
150mg/3mth IM
safe per=3w
return of fertility-12mth
 sickling crisis, sz, PID
bone loss

implant(implanon)
P(ovulat)
single rod, 4cm long, S/C, 68mg(etonogestrel), 67g/d3y, nondominant arm
FR=0.01%(lowest)
norplant
6rod, 3.4cm long, S/C, fan shaped manner, 36mg LNG5y

in
IUCD
CuT380A(paraguard)
MOA-inh fertilization>inh implantation
ADR-menstrual loss(80ml), max risk of inf-1st 21d postinsertion

s.
free of cost
bead, thread, monolament, Cu 50g/d10y, coat with BaSO4(radiopaque)
SA=380mm, lth=3.6cm, width=3.2cm
postplacental<10min of placental expulsion
PP<48h,>6w
ideal time PP-6w
IUCD in preg-remove IUCD iim
emerg contracept<120h, ideal time<72h

CuT375/multiload, 5y, flexible arm, 1.8cm wide, 3.5cm lth, inf<11% risk, expulsion
rate=2.8%

III gen IUCDcontainreleasefor

progestasert-38mg P-65g/d-1y
4a
Levonova-60mg LNG-20g/d-5y
mirena(white plastic cylinder)-52mg LNG-20g/d-5y-release upto 7y-amenorrh by
6mth
skyla(LNG14)-14g/d-3y

vag/Nuva ring
E(EE 15/d)+P(etonogestrel 120g/d) kept for 3w1w free, safe period 3h MOA-inh
m

ovulation

diaphragm
latex, silicon, kept in place for 6-24h, used with spermicide(nonoxynol9-non ionic
surfactant-destroys sperm memb)
Ai

cervic cap
6-48h, used with contraceptive jelly

condom-expiry period=3y
fem condom
17cm long, FC I-polyurethane, FC II-synth nitrite, no spermicide, lubricant,
used-8times

emergency contraceptive/interceptive/morning after pill

 most effective-IUCD> ulipristal(SPRM-30mg SD <5d)> mifepristone(10-50mg SD)>
LNG(plan B 1step-2tab 750g together>12h apart<72h, effective upto 120h
MOA of horm EC-delay ovulation>inh implantation
MC-LNG pill
high dose OCP-(100g EE+500g LNG) twice 12h apart

sterilization
PP-ideal<48h, upto 7d
MC-minilaparotomy, mod Pomeroy(Parkland), isthmus, 2 site ligation, 3cm

in
destroyed, plain catgut
Pomeroy meth-1site ligation
req-consent of pt, min 1child 1y old, 22- 49y fem
interval42d(6w)
laparoscope, Fallope ring, isthmus, 2.5cm destroy, IAP=10-12mmHg, max

s.
press=15mmHg, CO2 2l, outer diam Fallope ring=3.6cm, inner diam=1cm,
thickn=2.2cm
hysteroscopic sterilisation-interstitial FT, Outer coil(nitinOl), inner coil(stainless
steel), essure, deploy in tubal ostium, outer coil larger in uterine cavity, conrmed by
HSG after 3mth
MC-lap sterilization
iim
highest eCtopic-Cautery, lowest-mod Pomeroy
highest FR-Hulka clip> bipolar cautery> unipolar cautery> mod Pomeroy
ligatn(suture)Uchida Irving> mod Pomeroy

PID
risk-sterilisation> IUCD(progestasert> mirena> CuT)>POP

contraceptFR(perfect use)FR(typical use,nothing mention)

4a
Implant-0.01-0.01
Vasectomy-0.1-0.1
Mirena-0.2-0.2
mod Pomeroy meth-0.2
DMPA-0.3-0.3
Pomeroy-0.4
Tubectomy-0.5-0.5
m

IUCD-0.6-0.6
POP-0.5-3.0
OCP-0.3-8.0
Vaginal ring(nuvaring,etonogestrel+EE) -0.3-8.0
Diaphragm-6.0-12.0
Vag sponge(today)
Ai

nullip-9.0-12.0
multip-20.0-24.0
mal Condom(latex-once)-2.0-18.0
fem Condom(polyurethane-8time)-5.0-21.0

laparoscopy
CO2=200ml/min, press=15-25mmHg
hysteroscopy
CO2=70ml/min, press=100mmHg
 colposcopy
magnication=10-30times
focal lth=30cm, part visualised-ectocx, vag, vulva, 5%acetic acid, green lter(bld
vess), abnorm vess-reticular,mosaic,punctate
colpomicroscopy
magnic=100-300times

instrument
Ayre spatula

in
Post wall-Pap smear, upper lat wall-h cytology

Babcock forceps
FT, no groove, jaw

s.
CuSCO self retaining speculum
ColpoSCOpy

cytobrush
sample fr endocx

Doyen retractor iim

retract UB during CS, retract ant abd wal

endometr Bx
best for Dx ovulation, serration on end

episiotomy scissors
blades are angled
4a
Hegar dilator
curved, graduated, blunt, no.8 pass into int os-cx incompetence(inverse Palmar test)

Karman cannula
endometrial aspiration
m

Leech Wilkinson cannula

HSG, screw, conical end

metal urinary catheter

Myoma screw
Ai

anticlock direction

ovum forceps
cup shaped end, no serration, no lock, D&C, remove product of conception 2nd
trimester

punch Bx forceps

Sims retractor
 ant vag wall, serrated end, angle b/n loop&shaft=15

Sims vag/duck billed speculum

each end different size, not self retaining

sponge holding forceps

transverse serration

UB sound

in
not graduated, lth=25cm

uterine sound
lth=25cm, tip=5cm, graduated, angle b/n tip&shaft=150

s.
vulsellum
upper end jaw, hold ant lip nonpreg uterus

Abbreviations
a-artery, AA-amino acid, abtc-antibiotic, AI-autoimmune
iim
bef-before, bel-below, b/l-bilateral, bld-blood, b/n-between, bn-benign, br-branch,
Bx-biopsy
ca-carcinoma, carb-carbohydrate, c/i-contraindication, c/l-contralateral,
conc-concentration, cong-congenital, Cx-cervix
d-day, def-deficient, ds-disease, d/t-due to, Dx-diagnosis
E-estrogen
fem-female, fr-from
gld-gland, glu-glucose
h-hormone
4a
idiop-idiopathic, i/l-ipsilateral, inf-infection, inj-injury
lig-ligament, LL-lower limb, l/t-leading to
m-muscle, maj-major, mal-male, MC-most common, met-metastasis, min-minor,
mtx-methotrexate, Mx-management
n-nerve, norm-normal
P-progesterone, pl-plasma, prot-protein, pt-patient
Rx-treatment
m

SCC-squamous cell carcinoma, sr-serum, Sx-surgery, sz-seizure

tm-tumour, ts-tissue
UL-upper limb, u/l-unilateral
vag-vagina, VC-vocal cord, vel-velocity, vert-vertebra, vit-vitamin, vol-volume
w-week, wt-weight
Xr-X ray
Ai

y-year
#-fracture
-degree

THESE NOTES ARE ONLY FOR THE PURPOSE OF GUIDANCE AND HELP
TO PG ASPIRANTS, NOT FOR COMMERCIAL OR OTHER PURPOSE. REFERENCE
HAS BEEN TAKEN FROM VARIOUS STANDARD TEXTBOOKS.