Gyne

Zelalem .B (PhD, candidate)

2024
LEARNING OBJECTIVES
• At the end of this session the student will be able to
• To understand that a detailed and structured gynecological history
• To understand that the gynecological examination will be customized
by the history to elicit the appropriate signs.
•Good communication is necessary for
the assessment of patient's condition
and treatment

•communication technique
• concentration
Trust
• Knowledge
• Kindness
• Humor
The Beginning
• Read any referral documentation, if any.
• Introduce your self in a friendly and relaxed way.
• Ensure confidentiality
• Begin with a single opening question
Initial part of the history is particularly important and
highly dependent on the skill of the Midwife.
Components of the History
Date and Time
Identification
Previous Admissions
Chief complaint(s)
History of Present Illness(HPI)
Past History
Personal and Social History
Family History
Review of Systems/Functional Inquiry
• General
• Name, age and occupation

• A brief statement of the general nature and duration of the

main complaints (try to use the patient’s own words
rather than medical terms at this stage)
• History of presenting complaint
• This section should focus on the presenting complaint, eg
menstrual problems, pain, subfertility, urinary incontinence,
etc
• Menstrual history
• Age of menarche
• Usual duration of each period and length of cycle (usually
written as mean number of days of bleeding over usual
length of full cycle, eg 5/28)
• First day of the last period
• Menstrual history
• Pattern of bleeding: regular or irregular and length of cycle
• Amount of blood loss: more or less than usual, number
of sanitary towels or tampons used, passage of clots or
flooding
• Any intermenstrual or post-coital bleeding

• Any pain relating to the period, its severity and timing of

onset
• Any medication taken during the period (including over-the
counter preparations)
Pelvic pain
• Site of pain, its nature and severity
• Anything that aggravates or relieves the pain –
specifically enquire about relationship to
menstrual cycle and intercourse
• Does the pain radiate anywhere or is it
associated with bowel or bladder function
(menstrual pain often radiates through to the
sacral area of the back and down the thighs)?
• Vaginal discharge
• Amount, colour, odour, presence of blood
• Relationship to the menstrual cycle
• Any history of sexually transmitted diseases (STDs) or recent tests
• Any vaginal dryness (post-menopausal)
• Cervical screening
• Date of last smear and any previous abnormalities�
• Sexual and contraceptive history
• The type of contraception used and any problems with it
• Establish whether the patient is sexually active and whether
there are any difficulties or pain during intercourse?
• Menopause (where relevant)
• Date of last period
• Any post-menopausal bleeding
• Any menopausal symptoms
 Previous gynaecological history
This section should include any previous gynaecological
treatments or surgery
 Previous obstetric history
• Number of children with ages and birth weights
• Any abnormalities with pregnancy, labour or the puerperium
• Number of miscarriages and gestation at which they occurred
• Any terminations of pregnancy with record of gestational
age and any complications
• Previous medical history
• Any serious illnesses or operations with dates
• Family history
• Enquiry about other systems
• Appetite, weight loss, weight gain
• Bowel function (if urogynaecological complaint, more detail may be
required)
• Bladder function (if urogynaecological complaint, more detail may
be required)
• Enquiry of other systems
• Social history
Sensitive enquiry should be made about the woman’s social
situation including details of her occupation, who she lives with,
her housing and whether or not she’s in a stable relationship
• A history regarding smoking and alcohol intake should also be
obtained
• Any pertinent family or other relevant social problems
should be briefly discussed
Examination
• Any examination should always be carried out with the patient’s
consent and with appropriate privacy and sensitivity
• A general examination should always be performed initially which
should include examining
• the hands and mucous membranes for evidence of anaemia.
• The supraclavicular area should be palpated for the presence of nodes
Abdominal examination

• The patient should empty her bladder

before the abdominal examination
• The patient should be comfortable and
lying semi-recumbent with a sheet
covering her from the
• Abdominal examination comprises
inspection, palpation, percussion and,
if appropriate, auscultation.
• Pelvic examination
 Basic Requirements of the Pelvic Examination

• Check carefully, gentle movement

• Urine evacuated before check ( urine preserved for
checkup )
• Replace the one-time pad
• Bladder lithotomy position

• Q: To avoid the menstrual period, what should you do

before check, if check is must while bleeding?
• Male MW to check best with female MW presence to
avoid unnecessary misunderstanding
 Step 1

Vulval inspection
• Vulva development and its hair
distribution
• New biological, skin lesion vulva
• Vaginal vestibule
• Hymen
• The vagina mouth
• Vaginal wall and uterine prolapse or
not
Normal Vulva
 Step 2

Check up by speculum
• Speculum forbidden without
agreement by virgin
• replacement and removal
 Step 3

Vaginal inspection
 deformity: vaginal
septum, double vagina
 new biological, ulcer,
cyst or not
 Vaginal discharge is
normal, if necessary, check
leucorrhea routine
 Step 4

Cervical inspection
 Size, color, mouth shape
 bleeding, erosion, gland cyst, polyps
 Cervical tube has hemorrhages or
exudates or not
 Cervical smear
 Cervical scraping smear
 Step 5

Bimanual examination
 Check with two fingers or one
finger into the vagina, while the
other hand in the abdomen to
help checking
 Vaginal, cervical, endometrial,
attachment, palace and pelvic
wall
 Check up Record

 The vulva: development, production type.

 Vaginal: Patency, mucosa, secretions

 Cervical: size, hardness, erosion, contact bleeding, lifting pain

 Uterine body: location, size, texture, motion, tenderness

 Bilateral accessory: mass, size, texture, motion, tenderness, and

relationship between uterus and pelvic wall
 System Review

• General
• Weakness
• Fatigue
• Anorexia
• Change of weight
• Fever
• Night sweats
 AUB
for 3rd year MW students
by
Zelalem bekele (Msc Mw)
2021

01/02/2025 3rd year MW students By ZB

Learning Objectives
At the end of this session the student will be
able to
 Describe the features of the normal menstrual cycle and the ovarian and
endometrial changes that accompany them.

 Understand the classification and causes of abnormal uterine bleeding

 Understand the evaluation of abnormal uterine bleeding in reproductive aged

women

 Management common effects of abnormal uterine bleeding

 Discuss the indications for surgical management for abnormal uterine bleeding
01/02/2025 3rd year MW students By ZB
 What is normal UB?

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Normal Menses
• Menarche: 2.3y after pubertal initiation
• Range 1-3 years
• Cycle length: 21-42 days (beginning to beginning)
• Should be regular by 2-2.5 years
• Cycles outside of 20-45 days should be considered abnormal
even in adolescents
• Duration: 3-7 days
• Average blood loss: 30 mL/cycle
• Can be 20-80mL

01/02/2025 3rd year MW students By ZB

What’s normal?
The normal menstrual Cycle

01/02/2025 3rd year MW students By ZB

 Normal Menses

01/02/2025 3rd year MW students By ZB

What volume of blood is in a soaked,
regular-sized tampon or pad?
A. 5L
B. 10 mL
C. 5 mL
D. I don’t know, I’m a dude!
E. 1 mL
 ABNORMAL UTERINE
BLEEDING (AUB)

01/02/2025 3rd year MW students By ZB

Definition
• AUB is any uterine bleeding that differs materially
from the usual menstrual cycle in
Frequency(n: 28+7)
Amount(n:20-80ml)
Duration of flow(n:3-8days)
Time of occurrence
Cycle(n: regular)

01/02/2025 3rd year MW students By ZB

Accepted terminology for common
types of AUB

 HMB: excessive menstrual blood loss

 IMB: bleeding between periods,

 PCB: bleeding after sex.

 PMB: bleeding more than 1 year after cessation of periods.

 BEO: ‘bleeding of endometrial origin’, a diagnosis of exclusion, has replaced the

term ‘dysfunctional uterine bleeding’ (DUB).

01/02/2025 3rd year MW students By ZB

Magnitude Of AUB
• Most common reason for gynecologic referrals
• 9-30% of reproductive age groups
• Common in both extremes of life: perimenarchal and
perimenopausal
• 20% in adolescents and 40% in >40yrs
• 20% of all hysterectomies
• May represent a normal physiologic state, or a sign of
serious underlying condition

01/02/2025 3rd year MW students By ZB

 Etiology of AUB

01/02/2025 3rd year MW students By ZB

If I had a coin in my palm for every women
with AUB…
48

01/02/2025 3rd year MW students By ZB

01/02/2025 3rd year MW students By ZB
Classification: PALM-COEIN
50

01/02/2025 3rd year MW students By ZB

 Structural causes (PALM)
51

A Polyps – AUB-P
• endocervical or
• endometrial

Detected by ultrasound or
sonohysterography

Often irregular, light bleeding

01/02/2025 3rd year MW students By ZB
Structural causes (PALM)
52

B Adenomyosis –AUB-A
• Controversial as a cause of
bleeding

• Diagnosed with
ultrasound, MRI,
pathology

01/02/2025 3rd year MW students By ZB

Common presenting features of
Adenomyosis
i) Women are usually parous with age usually ≥40
years

ii) HMB (70%)

iii) Dysmenorrhea (30%)

iv) Women in their reproductive age group often suffer

from infertility.
01/02/2025 3rd year MW students By ZB
 Structural causes (PALM)
54

C Leiomyoma – AUB-L
◦ Submucous
◦ Intramural
◦ Subserosal
• Diagnosed with exam,
ultrasound, MRI, CT
• Heavy, regular bleeding

01/02/2025 3rd year MW students By ZB

Endometrial Polyp or Submucosal
Leiomyoma
• Predictable vaginal bleeding with
intermenstrual bleeding

• 33-year-old woman

• Normal height and weight

Structural causes (PALM)
57

D Malignancy and hyperplasia –

AUB-M
• Diagnosed by biopsy
• Irregular bleeding

01/02/2025 3rd year MW students By ZB

 Non-structural causes COEIN
58

 Coagulopathies or bleeding disorders(von Willebrand’s

disease)
 Ovulatory dysfunction
 Endometrial
 Iatrogenic sources (medications, smoking)
 Not yet classified

01/02/2025 3rd year MW students By ZB

Coagulopathies or bleeding disorders(von Willebrand’s
disease)

• Up to 15% of patients with abnormal vaginal bleeding

(especially in the adolescent age group) have
coagulopathies.

• Review of systems may be positive for other

bleeding symptoms including epistaxis, gingival
bleeding, and ecchymoses.

• Von Willebrand disease is the most common

hereditary coagulation abnormality
Coagulopathies or bleeding disorders(von Willebrand’s
disease)

• Coagulopathies can be due to vessel wall

disorders, platelet disorders, coagulation
disorders, and fibrinolytic disorders.

• Von Willebrand disease arises from a deficiency

of von Willebrand factor (vWF), a protein required
for platelet adhesion.
Coagulopathies or bleeding disorders(von Willebrand’s
disease)

• Diagnosis.
• Positive family history and review of systems are helpful
for screening. Initial lab tests include CBC with platelet
count, PT, and PTT. The

• best screening test for Von Willebrand disease is a

vWF antigen.
Dysfunctional Uterine Bleeding (DUB)

• Dysfunctional uterine bleeding is one of the commonest

causes of excessive menstrual bleeding in women of
reproductive age.

• If the pregnancy test is negative, there are no

anatomic causes for bleeding, and coagulopathy has
been ruled out, then the diagnosis of hormonal
imbalance should be considered.

• The classic history is that of bleeding which is unpredictable

in amount, duration, and frequency (without cramping).
Iatrogenic

• Iatrogenic causes of abnormal uterine bleeding appear

to be increasing as many drugs used for cancer,
renal disease, and transplantation either mimic or
modify endogenous hormones and cause abnormal
uterine bleeding

• Drugs that can effect the menstrual cycle include

prednisone, tamoxifen, coumadin, heparin, and
Depo-Provera.
 H&P :Diagnosis
• Patients will have different ideas as to what constitutes a
‘heavy period’ Useful questions include:
• How often does soaked sanitary wear need to be changed?

• Is there presence of clots?

• Is the bleeding so heavy (flooding) that it spills over your

towel/tampon and on to your pants, clothes or bedding?

• Have you had to take any time off work due to this
bleeding?

01/02/2025 3rd year MW students By ZB

 Diagnosis: H&P
66

• History
[Link] vs Chronic
[Link] bleeding pattern
[Link] bleeding hx (incl. severity and assoc pain)
[Link]: AUB/ bleeding disorders
[Link]: warfarin, heparin, NSAID, OCP,
• Physical
[Link], hirsutism, acne
[Link] dysfunction: cold/heat intolerance, dry skin, lethargy, proptosis
[Link]:
[Link] disorder: pallor, signs of hypovolemia
[Link] exam
◦ Is it from the uterus?!

01/02/2025 3rd year MW students By ZB

Diagnosis: Labs and Imaging
67

• Labs
[Link] test (Strong recommendation)
[Link] (Strong recommendation)
[Link] screening for bleeding disorder (when indicated)
[Link]
[Link]/Chlamydia in high risk patients
• Imaging:
[Link]
[Link]
[Link]
[Link]
• Endometrial biopsy

01/02/2025 3rd year MW students By ZB

 Practice bulletin no. 128: diagnosis of abnormal uterine bleeding in
reproductive-aged women. Obstet Gynecol. 2012 Jul;120(1):197-206. doi:
10.1097/AOG.0b013e318262e320.
Uterine Evaluation

3rd year MW students By ZB

68

01/02/2025
Who should be offered EMB?
69

◦ women aged > 45 years as first-line test

◦ women with persistent bleeding refractory to medication,
regardless of age
◦ women aged < 45 years with risk factors for endometrial
cancer, such as
◦ obesity (body mass index > 30 kg/m2)
◦ nulliparity
◦ hypertension
◦ irregular menstruation
◦ polycystic ovary syndrome
◦ diabetes
◦ hereditary nonpolyposis colorectal cancer
◦ family history of endometrial cancer
01/02/2025 3rd year MW students By ZB
 EMB Considerations
70
• Consent
1. Cramping is common
2. vaginal bleeding for several days
3. vasovagal
4. pelvic infection
5. uterine perforation (1 to 2 per 1000 procedures - vs 3 to 26 per 1000 D&C)
• Contraindications
1. Active vaginal/pelvic infection
2. bleeding diathesis
3. pregnancy
• Preprocedure prep
1. Anesthesia not required, consider NSAID 30-60 min prior
2. Difficult passage - consider 200 to 400 µg misoprostol night before
(PV>PO)
01/02/2025 3rd year MW students By ZB
EMB procedure71
Am Fam Physician. 2001 Mar 15;63(6):1131-5, 1137-41.
Endometrial biopsy. Zuber TJ
• Bimanual
• Speculum then clean cervix
• +/- tenaculum (if not axial)
• Insert pipelle - stop @ resistance (avg 6-8cm)
• Pincer grasp, Pull out piston for suction
• Corkscrew combined w/ cephalic-caudal motion to sample entire endometrial surface
• Don’t remove until sampling completed
• Expel the specimen into a formalin container (replace piston)
• Consider second pass if insufficient tissue
◦ If the biopsy material looks like a dark red earthworm and does not disintegrate in the formalin,
it is likely that appropriate biopsy material has been obtained.
• Remove tenaculum, hold pressure w/ Texas swab PRN
01/02/2025 3rd year MW students By ZB
 72

Endometr
ial biopsy

01/02/2025 3rd year MW students By ZB

Management
• When selecting appropriate management for
the patient, it is important to consider and
discuss:
• the patient’s preference of treatment;
• risks/benefits of each option;
• contraceptive requirements:
• family complete?
• current contraception?
past medical history:
• any contraindications to medical therapies for HMB?
01/02/2025 3rd year MW students By ZB
 Management 74

• Medical management should be initial

treatment for most patients
• Need for surgery is based on various factors
(stability of patient, severity of bleed,
contraindications to med management,
underlying cause)
◦ Type of surgery dependent on above + desire
for future fertility
• Long term maintenance therapy after acute
bleed is controlled

01/02/2025 3rd year MW students By ZB

Medical treatments
• Mefenamic acid and other non-steroidal anti
inflammatory drugs (NSAIDs) are associated with a
reduction in mean menstrual blood loss of 20–25
percent.

• This may be sufficient in some women to restore

menstrual blood loss either to normal or to a level
which is compatible with a reasonable quality of life

01/02/2025 3rd year MW students By ZB

Medical treatments
• Benefits: Effective analgesia, hence often the firstline
treatment of choice where dysmenorrhea coexists.

• Disadvantages: Contraindicated with a history of

duodenal ulcer or severe asthma.

• Recommended dose: 500 mg p.o. to be taken

when menstruation is particularly heavy or
painful

01/02/2025 3rd year MW students By ZB

 Treatment - Acute
77

• Unstable?
[Link] dose hormones v
◦ IV estrogen – 25 mg IV q 4-6 hours x 24 hrs
• Stable
[Link] meds
◦ Monophasic OCPs – One TID for seven days, then
daily for at least one cycle
◦ Medroxyprogesterone (Provera) – 20 mg TID for
seven days, then daily for at least three weeks
◦

01/02/2025 3rd year MW students By ZB

Chronic Treatment Considerations
78

• Etiology and severity of bleeding (eg, anemia,

interference with daily activities)
• Associated symptoms (eg, pelvic pain, infertility)
• Contraceptive needs or plans for future pregnancy
• Contraindications to hormonal or other medications
• Medical comorbidities
• Patient preferences regarding medical versus surgical
and short-term versus long-term therapy

01/02/2025 3rd year MW students By ZB

Non-surgical treatment Options
79

• Hormonal methods

[Link] methods

[Link] IUD

[Link] progestin

[Link] agonists (leuprolide)

• Metformin and other insulin-sensitizing drugs for irregular

bleeding in women with polycystic ovary syndrome

01/02/2025 3rd year MW students By ZB

Surgical Management Options
80

• D&C
• Uterine Artery Embolization
• Hysterectomy

01/02/2025 3rd year MW students By ZB

 Ready to test your
knowledge?!

01/02/2025 3rd year MW students By ZB

 Case 1
82
A 35 year old female is evaluated for a 5 month history of heavy menstrual bleeding. She has
been menstruating for the last 8 days and is still going through 10 maxi pads or more daily with
frequent clots. She has fatigue but no dizziness. She and her husband would like to conceive a
2nd child next year. She does not smoke.
PM Hx: DM2

Vitals: Afebrile, BP 138/71, HR 80. BMI 40.2

Pelvic exam: moderate amount of blood in vaginal vault.

What do you want to do next?

01/02/2025 3rd year MW students By ZB

Case 1(continued)
83
urine hcg is negative. Hct 30

EMB is negative.

Pelvic u/s shows a large submucosal fibroid. You consult ob/gyn for a
myomectomy, scheduled in 2 weeks.

Which of the following is the most appropriate next step in

management?
A. Levonorgestrel IUD (Mirena)
B. IV estrogen
C. Estrogen-progesterin oral contraceptive
D. Re-evaluate in 2 weeks
01/02/2025 3rd year MW students By ZB
CASE 2
• 4 A 39-year-old G3P3 complains of severe, progressive
secondary dysmenorrhea and HMB. Pelvic
examination demonstrates a tender, diffusely enlarged
uterus with no adnexal tenderness. Results of
endometrial biopsy are normal. Which of the following is
the most likely diagnosis?
• a. Endometriosis
• b. Endometritis
• c. Adenomyosis
• d. Uterine sarcoma
• Answer C Adenomyosis, portions of the endometrial lining grow
into the myometrium, causing HMB and dysmenorrhea.

• On physical examination, the uterus is usually tender to

palpation, boggy, and symmetrically enlarged.

• The patient described here has a physical examination most

consistent with fibroids.

• Uterine leiomyomas would cause the uterus to be firm,

irregular, and enlarged.
CASE 3
• A 32-year-old woman has come to the gynaecology
clinic complaining of heavy menstrual bleeding. On
examination the uterus is anteverted and bulky. What is
the best imaging modality to further investigate her
symptoms?.
• A Abdominal ultrasound scan.
• B CT.
• C Hysterosalpingogram (HSG).
• D TVUSS
ANS
• Transvaginal ultrasound is important in this patient
with AUB and exam findings suggestive of structural
abnormality. Would consider EMB as >45 yo.
• MRI is not the primary imaging modality to evaluate
AUB, however may be used as a follow-up test after
ultrasonography

• Hysteroscopy/SIS should be done in patients with

concerning uterine cavity findings on TVUS
CASE 4
49 year old women presents to your primary care clinic with a 3 day history of heavy
menstrual bleeding. She denies dysmenorrhea but reports that her menstruation cycle
have been increasingly irregular over the past couple years, including bleeding
between periods. She is not sexually active and had a bilateral tubal ligation 10 years
ago.
Her physical exam demonstrated
normal vital signs,
no signs of hypovolemia,
no bruises.
Pelvic exam was
unremarkable for tenderness,
nodularities, or abnormal size uterus.
Cervix was normal with blood in the os.

Pregnancy test is negative and pap smear was performed and was Normal
• Which of the following is the most appropriate next step
in management of this patient?

• A. Endometrial biopsy
B. Measure serum LH and FSH
C. Pelvic U/S
D. Oral contraceptives
Answer
• Endometrial biopsy—Need to rule out endometrial cancer in
patients older than 45 with AUB
•
• Measuring LH and FSH can confirm menopause, but does not
rule
out endometrial cancer.

• Pelvic ultrasound– good with uncertain findings on pelvic exams

• Oral contraceptives are appropriate for patients with

anovulatory
bleedings. But endometrial carcinoma needs to be ruled out first
Amenorrhea
LH + CHOLESTEROL Theca Cell
side-chain
StAR
cleavage 3β

PREGNENOLONE PROGESTERONE
17 α -hydroxylase 17 α -hydroxylase

17-HYDROXY- 3β 17-HYDROXY-
PREGNENOLONE PROGESTERONE

17,20-lyase 17,20-lyase

DEHYDROEPI- 3β
ANDRONSTENEDIONE
ANDROSTERONE
17 β -HSD5

TESTOSTERONE

FSH + 5 α -R

DIHYDRO-
aromatase TESTOSTERONE
Granulosa
Cell ESTRONE
17 β -HSD1

ESTRADIOL
Amenorrhoea
• Amenorrhoea is normal.
• Pre-pubertal
• Pregnancy
• Lactation
• Post-menopausal
PRIMARY AMENORRHOEA
1. No menstruation by the age of 14 years
accompanied by failure to grow properly or
develop sec. sexual characteristics.

2. No menstruation by age of 16 when growth and

sexual development are normal.

SECONDARY AMENORRHOEA
 Secondary absence of menses for six months (or
greater than 3 times the previous cycle interval) in a
women who has menstruated before.
 Pregnancy, lactation or hysterectomy must be
excluded
 Prepubertal and post-menopausal conditions are also
to be excluded as physiological causes
CAUSES OF
AMENORRHOEA
A. Disorder of outflow tract and or
uterus

B. Disorders of ovary

C. Disorders of Ant. Pituitary

D. Disorders of Hypothalamus
 A. DISORDERS OF OUTFLOW
TRACT & OR UTERUS
1. CRYPTOMENORRHOEA
Vaginal atresia or imperforate hymen prevent menstrual loss from
escaping.

FEATURES:
 Prim. Amenorrhoea in a teenage girl with normal sexual
development present

Complaining of:
i. Intermittent lower abd. pain
ii. Possible difficulty of mict.
iii. Palpable lower abd. swelling (Haematometra)
iv. Bulging, bluish membrane at lower end of vagina
(Haematocolpus).

MANAGEMENT: INCISE MEMBRANE

2. TESTICULAR FEMINIZATION:
(Androgen Insensitivity)

 Phenotype is woman. Genotype is man

(xy)  testes are present.
 Inherited by an X-linked recessive gene…
(familial)

 Resulting in absence of cytosol androgen

receptor
FEATURES:
i. Growth and develop are normal (may be taller than
average).
ii. Breasts are large but with sparse glandular tissue and
pale areola
iii. Inguinal hernia in 50% of cases
iv. Scanty, or no axillary and pubic hair
v. Labia minora underdeveloped
vi. Blind vagina, absent uterus, rudimentary fallopian
tubes
vii. Testes in abd. or inguinal canal
viii. Normal levels of testosterone are produced.. But no
response to androgens (endog. or exogen)
ix. No spermatogenesis
x. There is  incidence of testicular neoplasia (50%)
CONSIDER THE DIAGNOSIS IN A
FEMALE CHILD:
1. With inguinal hernia
2. With 10 amenorrhea and absent uterus
3. When body hair is absent

MANAGEMENT:
 These patients are female.
 The gonads must be removed after puberty 
then HRT started

 Rare cases of incomplete test. feminization do

occur  have variable degress of
masculinization
4. ASHERMAN’S SYNDROME:

Sec. amenorrhoea following distruction of the

endomet. by overzealous curettage multip.
Synechiae show up on “Hysterography”.

MANAGEMENT:
Under G.A. breakdown intraut. Adhesions
through hysteroscopeinsert an IUCD to deter
reformation hormone therapy (E2 + P)
 DISORDERS OF PITUITARY
1. Pituitary Tumor causing “Hyperprolactinemia”
 40% of women with hyperprolactinemia will
have a pituitary adenoma

Pit. Fossa XR is necessary in all cases of

amenorrhoea – particular 20.

FEATURES:In coned view:

 Enlarge of pituitary fossa
 Double flooring of fossa
 If any of above features seen
 CT san or MRI + Assessment of visual fields
MANAGEMENT:

Bromocriptine (Dopamine agonist)

 Suppres prolactin sec.
 Correct estrogen deficiency
 Permits ovulation
  Size of most prolactinomas

 Surgical removal of tumor

 if extracellar manifestation (e.g.
press. on optic chiasma) or if patient
cannot tolerate or respond to
medical Rx.
SHEEHAN’S SYNDROME
♣ Necrosis of ant. pituitary due to severe
PPH
 Pan – or partial hypopituitarism
♣ It is rare problem today due to better
obstetric care and adequate blood transfusion
 CASE 1
• After a significant period of hypovolemic shock, the bleeding was controlled and the
vascular volume replaced. Estimates of blood loss were over 2,500 cc. The patient
apparently recovered well. However, she was unable to breast-feed and gradually noted
breast atrophy and no resumption of menses. Later, she developed constipation, slurred
speech, and moderate non pitting edema. Which of the following is the most likely
diagnosis?
• (A) acute tubular necrosis (ATN)
(B) amenorrhea-galactorrhea syndrome
(C) Asherman’s syndrome (uterine synechiae)
(D) pituitary tumor
(E) Sheehan’s syndrome (pituitary necrosis)
 Answer
• (E) Anterior pituitary necrosis from postpartum hemorrhage with significant shock will cause the
loss of gonadotropins, thyroid-stimulating hormone (TSH), and adrenocorticotropic hormone
(ACTH), generally in that order. Lack of breast milk is usually the first clue.
• Amen-orrhea may be the second sign. Sheehan syndrome is a rare occurrence when good post-
partum management prevents or adequately treats blood loss and prevents shock. ATN would have
presented early postpartum with extremely dilute urine and evidence of hypov-olemia.
• Asherman’s syndrome is the scarring of the endometrial cavity after a D&C, especially in the
situation of a postpartum hemorrhage. The symptoms are confined to postpartum amenor-rhea
with or without cramping, depending on whether it is only an
outlet obstruction. Forbes-Albright syndrome (amenorrhea-galactorrhea syndrome) is usually
associated with a pituitary tumor and not with pregnancy. Galactorrhea is also associated with this
syndrome.
CASE 2
2 During the evaluation of secondary amenorrhea in a 24-year-old
woman, hyperprolactinemia is diagnosed. Which of the following
conditions could cause increased circulating prolactin concentration
and amenorrhea in this patient?
a. Stress
b. Primary hyperthyroidism
c. Anorexia nervosa
d. Congenital adrenal hyperplasia
e. Polycystic ovarian disease
ANSWER
• The answer is A. In anorexia nervosa, prolactin, thyroid-stimulating
hormone (TSH), and thyroxine levels are normal, FSH and LH levels
are low, and cortisol levels are elevated.
• Prolactin is under the control of prolactin-inhibiting factor (PIF), which
is produced in the hypothalamus. Many drugs (e.g., the
phenothiazines), stress, hypothalamic lesions, stalk lesions, and stalk
compression decrease hypothyroidism, elevated TRH acts as a
prolactin-releasing hormone to cause release of prolactin from the
pituitary; hyperthyroidism is not associated with hyperprolactinemia.
There are many other conditions, such as
CASE 3
• A 45-year-old woman who had two normal pregnancies 15 and 18
years ago presents with the complaint of amenorrhea for 7 months.
She expresses the desire to become pregnant again. After exclusion of
pregnancy, which of the following tests is next indicated in the
evaluation of this patient’s amenorrhea?
a. Hysterosalpingogram
b. Endometrial biopsy
c. Thyroid function tests
d. Testosterone and DHAS levels
e. LH and FSH levels
ANSWER
• The answer is e. This patient has secondary amenorrhea, which rules out
abnormalities associated with primary amenorrhea such as chromosomal
abnormalities and congenital Müllerian abnormalities.
• The most common reason for amenorrhea in a woman of reproductive age is
pregnancy, which should be evaluated first. Other possibilities include chronic
endometritis or scarring of the endometrium (Asherman syndrome), hypothyroidism,
and ovarian failure.
• The latter is the most likely diagnosis in a woman at this age. In
addition, emotional stress, extreme weight loss, and adrenal cortisol insufficiency
can bring about secondary amenorrhea.
• A hysterosalpingogram is
part of an infertility workup that may demonstrate Asherman syndrome,
but it is not indicated until premature ovarian failure has been excluded.
Persistently elevated gonadotropin levels (especially when accompanied by
low serum estradiol levels) are diagnostic of ovarian failure.
FEMALE REPRODACTIVE TRACT
INFECTION
3rd Year MW
ZELALEM.B
2021
Learning objective
• At the end of this session the student will be able
to
• Understand the importance of sexually transmitted
infections (STIs) in gynaecology.
• Describe the testing, diagnosis and transmission of
common STIs and blood-borne viruses (BBVs).
• Understand that support is needed for patients to
enable them to undertake screening.
• Manage the common STIs in Gynecology
Normal vaginal discharge
The normal vaginal flora is predominately aerobic
organisms

The most common is the H+ peroxide producing

lactobacilli

The normal PH is <4.5

 Normal vaginal discharge
Normal vaginal secretions

In reproductive aged women it consists of

1-4 mL fluid (per 24 hours), white or transparent, thick or
thin, and mostly odorless.

 formed by mucoid endocervical, sloughing epithelial cells, normal

vaginal flora, and vaginal transudate.

↑ in the middle of the cycle because of (physiologic

leukorrhea)↑ in the amount of cervical mucus:
during ovulation, pregnancy and in patient using OCP.
Bacterial Vaginosis (BV)
It is caused by alteration of the normal flora, with
over-growth of anaerobic bacteria

It is triggered by ↑ PH of the vagina (intercourse,

douches)
Recurrences are common

May present with Fishy odor (especially after

intercourse) no dyspareunia
 Bacterial Vaginosis (BV)
• Clinical Picture:
• Symptoms:
• 50% may be asymptomatic
• Discharge: thin excessive greyish frothy malodorous
• Pruritis
• Signs:
• Characteristic discharge and vulvovaginitis
Bacterial Vaginosis (BV)
• Diagnosis: Amstel Criteria
1. Homogenous, grayish-whitish discharge
2. Presence of clue cells
3. PH >4.5
4. +ve whiff test(amine test) (adding KOH to the vaginal secretions will give a
fishy odor) in 70-80% of cases

“Clue cells are the most reliable predictor of BV”

 Bacterial Vaginosis (BV)
• Treatment:
• A) Intravaginal preparations;
Clindamycin cream 2% at bed time for 7 days
Metronidazole once daily for 5 days
• B) Oral regimens:
Metronidazole as a single 2 gm dose
Clindamycin 300 mg twice daily for 7 days
• C) Sexual partner should be treated if infection is recurrent

• D) During pregnancy;
Clindamycin may be used throughout pregnancy
Metronidazole may be used after the first trimester
 Trichomonas Vaginitis
• Trichomonas vaginitis is caused
by the sexually transmitted,

• Trichomonas is a flagellate
protozoan

• 60% of patients also have BV

• 70% of males will contract the
disease with single exposure
• Patients should be tested for other
STDs (HIV, Syphilis)
01/02/2025 3rd year MW students By ZB
 Trichomonas Vaginitis
• Clinical picture: Incubation period 3-28 days
• Symptoms:
• Often manifests after menstruation; vaginal pH is raised
• Profuse yellowish, frothy malodorous vaginal discharge
• Pruritis vulvae
• Vaginal soreness
• Dysparunia and dysuria
• Signs:
• Vulvitis (redness, hotness, oedema)
• Vagina: red, oedematous, tender with punctate haemorrhage (strawberry
vagina)
• Cervix: Strawberry like, sometimes eccentric erosion
• The characteristic discharge (forthy, yellowish, maloderous…….. etc)
Trichomoniasis
Trichomoniasis
 Trichomonas Vaginalis
• Diagnosis:

1. Profuse, frothy ,purulent malodorous discharge

2. It may be accompanied by vulvar pruritis
3. Secretions may exudate from the vagina
4. If severe → patchy vaginal edema and
strawberry cervix
5. PH >5
6. Microscopy: motile trichomands and ↑
leukocytes
7. Clue cells may if BV is present
 Trichomonas Vaginitis
Treatment:
Metronidazole tablets (Flagyl):
500 mg/12 h for 10 days OR
2 gm single dose
Protozole and Tinedazole:
2 gm single dose
Clotrimazole, vaginal pessaries used during pregnancy and
lactation in stead of metronidazole.
The husband should be treated at the same time
Vulvovaginal Candidiasis
• This is one of the most common genital infections

• Caused by Candida albicans in around 80–92 per cent

of cases.

• C. albicans is a diploid fungus

• Other non-albican species like [Link], C.

glabrata, C. krusei and can also cause similar
symptoms,
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Classification of Vulvovaginal
Candidiasis
Uncomplicated Complicated
• Sporadic or infrequent in • Recurrent symptoms
occurrence • Severe symptoms
• Mild to moderate • Non-albicans Candida
symptoms
• Immunocompromised,
• Likely to be Candida e.g., diabetic women
albicans
• Immuno competent
women
01/02/2025 3rd year MW students By ZB
 V. Candidiasis
• Symptoms
vulvar pruritus associated
with a vaginal discharge
pain, vulvar erythema,
and edema with
excoriations are common
vaginal discharge is
described as cottage
cheese-like.
Vaginal pH is normal (<4.5),
01/02/2025 3rd year MW students By ZB
Candidiasis
V. Candidiasis
• Diagnosis
• perineal and/or vaginal swab. Conditions such as

• Testing can be done with a Gram stain or wet film

examination and direct plating on to fungal media.

01/02/2025 3rd year MW students By ZB

V. Candidiasis
• Predisposing factors
Pregnancy,
High-dose combined oral contraceptive pill,
 Immunosuppresion,,
diabetes mellitus,
Hormone replacement therapy and
HIV-infected women have a higher predisposition to
develop vulvovaginal candidiasis.

01/02/2025 3rd year MW students By ZB

 Treatment:
• Vaginal Antifungal preparations
 Vaginal suppositories or intravaginal creams with special applicator available as
either a single dose, a 3-day course, or a 7-day course
 Agents include clotrimazole, miconazole, and tioconazole preparations

• Oral antifungal treatment

 Fluconazole; Single oral dose 150 mg, for treatment of uncomplicated cases
 Ketoconazole; 200 mg twice a day for 5 days, for recurrent cases. Treatment can be
repeated on special schedules along a period of 3 -6 months, for chronic cases.
Gonorrhea

• Gonorrhea is caused by the Gram-negative

diplococcus N. gonorrhoeae
• They attract leukocytes, commonly giving rise to
purulent discharge.

• Gonorrhea is usually sexually transmitted,

although organisms can be acquired by neonates
passing through an infected cervix, causing gonorrheal
ophthalmia

01/02/2025 3rd year MW students By ZB

Gonorrhea
• The columnar and transitional epithelium of the
genitourinary tract is the principal site of invasion.

• The organism may enter the upper reproductive tract

causing salpingitis with its attendant complications.

• Approximately 600,000 new infections occur each year

in both men and women

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Gonorrhea
• Risk factors
• age equal to or less than 25 years,
• the presence of other sexually transmitted
infections,
• a history of previous gonococcal infection,
• new or multiple sexual partners,
• lack of barrier protection, drug use, and
commercial sex worker

01/02/2025 3rd year MW students By ZB

Gonorrhea
• Signs and Symptoms
• Most affected women are
asymptomatic carriers.
• Purulent vaginal discharge.
• Urinary frequency and dysuria.
• Recovery of organism in
selective media.
• May progress to pelvic infection
or disseminated infection.

01/02/2025 3rd year MW students By ZB

Gonorrhea
• Discharge
• The vulva, vagina, cervix, and urethra may be
inflamed and may itch or burn.

• Specimens of discharge from the cervix, urethra, and

anus should be taken for culture from the symptomatic
patient

01/02/2025 3rd year MW students By ZB

 Gonorrhea
• Bartholinitis
• Unilateral swelling in the inferior lateral
portion of the introitus suggests
involvement of Bartholin's duct and
gland.
• In early gonococcal infections, the
organism may be recovered by gently
squeezing the gland and expressing
pus from the duct.
• Enlargement,
• tenderness, and
• fluctuation may develop
01/02/2025 3rd year MW students By ZB
Gonorrhea
• Anorectal Inflammation
• Anal itching, pain, discharge, or bleeding occurs
rarely.

• Most women are asymptomatic and acquire infection by

perineal spread of vaginal secretions rather than by
anal intercourse

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• FEMALE SYMPTOMS:
Symptoms may show up 2-21 days after having sex
a yellow or white discharge from the vagina
burning or pain when urinating
Bleeding between periods
Heavier and more painful periods
 Cramps or pain in the lower abdomen,
sometimes with nausea or fever
• MALE SYMPTOMS:
 Yellow or white drip/discharge from penis
 Burning or pain when urinating
 Frequent urinating
 Swollen testicles

01/02/2025 3rd year MW students By ZB

Gonorrhea
• Diagnosis
• Most affected women are asymptomatic carriers.
• Purulent vaginal discharge.
• Urinary frequency and dysuria.
• Recovery of organism in selective media.
• May progress to pelvic infection or disseminated
infection
01/02/2025 3rd year MW students By ZB
 Treatment for Gonorrhea

Antibiotics that are currently used are:

• Cefixime
• Ceftriaxone
• Ciprofloxacin*
• Ofloxacin*
• Tetracycline
• * The antibiotics should not be taken in pregnancy

• Gonorrhea and Chlamydial infection, another common STD, often infect people at the same
time. A combination of antibiotics is taken which will treat both diseases, such as:
• Azithromycin
• Ceftriaxone
• Doxycycline
• All sexual partners should be tested and treated if infected, whether or not they have
symptoms of the infection.
Prevention of Gonorrhea

• Abstinence
• Monogamous relationships
• Condom use
Herpes Simplex Virus
(HSV)
Herpes Simplex Virus (HSV)
• Commonest cause of vulvar ulcers

• Second most prevalent STD

• -HSV I –
• Mostly oro-labial, but 25-30% increasing cause of genital herpes
• HSV II –
• Almost entirely genital
• > 95% of recurrent genital lesions
• Primary infections
• Recurrent infections
• Latency
01/02/2025 3rd year MW students By ZB
Herpes Simplex Virus (HSV)
• In college students 78% HSV I
from oral contact

• HSV II, predominantly sexually

transmitted

• Usually spread from contact with

an asymptomatic partner

• Women are more susceptible

• Recurrence rate for HSV II 89%;

HSV I 45%
01/02/2025 3rd year MW students By ZB
Transmission
• Horizontal Transmission
• Intimate sexual contact
(oral/genital)
• Aerosol and fomite
transmission is rare
• Vertical Transmission
• Maternal-infant via infected
cervico-vaginal secretions,
blood or amniotic fluid at
birth
• Autoinoculation
• From one site to another
Herpes Simplex Virus (HSV)
Primary HSV Recurrent HSV

• Fever, malaise, pain, • Prodrome itch, tingling

dysuria • Malaise – mild
Groups of blisters, • Small blisters, fissures or ulcers
pustules • Duration 5 days
Extensive ulcers
Duration: 2 weeks

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Herpes Simplex Virus (HSV)

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Herpes Simplex in Women

154
Credit: Jean R. Anderson, MD
HSV: Diagnosis

 Clinical presentation
 Viral culture
 Tzanck smear/Giemsa smear
 Skin biopsy

155
 HSV: Treatment Considerations
 Antivirals
Initial episode:
Acyclovir (Zovirax) 400mg po tid x 7-10 days
Acyclovir (Zovirax) 200mg po 5 x day x 7-10 days
Famciclovir (Famvir) 250mg po tid x 7-10 days
Valacyclovir (Valtrex) 1 gm bid x 7-10 days

 Lesions may be bathed in mild soap and water

 Sitz baths may provide some relief
 Sex partners may benefit from evaluation and counseling
• Transmission is possible when lesions not present due to viral shedding
156
Syphilis
• Syphilis, a chronic systemic infection caused by
Treponema pallidum subspecies pallidum,
• Sexually transmitted and is characterized by episodes
of active disease interrupted by periods of latency.

• After an incubation period averaging 2 to 6 weeks,

01/02/2025 3rd year MW students By ZB

SYPHILIS
• Treponema pallidum
• 1st isolated from syphilitic
lesions in 1905

• STI, although may be

congenital or acquired
from blood transfusion

• Untreated syphilis is a
progressive disease

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EPIDEMIOLOGY

• Age group: 20-39 years, M:F RATIO 3:2

• 2-5 FOLD INCREASE IN TRANSMISSION OF HIV IF

EXPOSED

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SYPHILIS
Pathogenesis
[Link] enters tissues by penetration of intact mucosae or
through abraided skin

It rapidly enters the lymphatics

Widely disseminated through the bloodstream and may lodge

in any organ

Exact infecting dose not known but in animals less than 10

organisms sufficient
01/02/2025 3rd year MW students By ZB
SYPHILIS
• The bacteria multiply at the initial entry site and a
chancre, a lesion characteristic of primary syphilis
forms after an average of 3 weeks

• Painless and usually on the external genitalia, or

cervix, anus, perianal, mouth

• Heals spontaneously 3-6 weeks and 1-12 weeks

later lesions of secondary syphilis occur

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Primary Chancre

Primary
Chancre

Credit: Centers for Disease Control and Prevention (CDC)

162
Vulvar syphilitic chancres of primary
syphilis
Syphilis

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 Syphilis –
1st Stage

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Secondary Syphilis
• Variable- Malaise , fever,
sore throat
• Skin with Macular or
pustular lesions,
particularly on trunk and
extremities
• Lesions highly infectious
• Gradually resolve and period
of latent infection occurs
• I.e no clinical manifestations
but serological evidence of
disease persists
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 Secondary Stage

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Secondary Syphilis
• Relapse of lesions
common so classifical as
early(likely) or
late( recurrence unlikely)
• Those with late latent
syphilis are generally not
infectious but may
transmit to fetus or
blood remains
infectious
01/02/2025 3rd year MW students By ZB
 Third Stage – Latent Period

• All symptoms disappear so that the victim thinks

he/she is cured.

• If not received treatment the bacterium remains in

the body and begins to damage the internal organs
including the brain, nerves, eyes, heart, blood
vessels, liver, bones, and joints.

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Late Syphilis
• Not being able to coordinate muscle
movements
• Paralysis
• Numbness
• Gradual blindness
• Dementia
• Death

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Congenital Syphilis
• Depending on how long a pregnant women has been
infected , a good chance of stillbirth or a baby who dies
shortly after birth

• If not treated immediately a baby born without

symptoms can develop them within weeks

• Developmental delay or even seizures and death

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Congenital Syphilis

• Hutchinson’s teeth

• Syphilitic snuffles

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DIAGNOSIS
• CLINICAL OBSERVATIONS
• CONFIRMED BY 2 METHODS
• SEROLOGY
• MICROSCOPY- DARK FIELD
-PHASE CONTRAST

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DIRECT MICROSCOPY
• Treponems visualised
directly in freshly
collected exudate from
Primarily or secondary
lesions
Rapid diagnosis but
insensitive(commensal
treponems) may use
immunofluorescence

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TREATMENT
• Primary, secondary, or early latent
• Penicillin G benzathine (single dose of 2.4 mU IM)
• Patients with Confirmed Penicillin Allergy
• Tetracycline hydrochloride (500 mg PO qid) or
doxycycline (100 mg PO bid) for 2 weeks

• Late latent (or latent of uncertain duration),

cardiovascular, or benign tertiary
• CSF normal: Penicillin G benzathine (2.4 mU IM weekly for 3 weeks)

01/02/2025 3rd year MW students By ZB

TREATMENT
• Neurosyphilis (asymptomatic or symptomatic
• Aqueous penicillin G (18–24 mU/d IV, given as 3–4
mU q4h or continuous infusion) for 10–14 days

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CASE 1
Q1 A 20-year-old patient complains of painful vulvar ulcers present for
72 hours. Examination reveals three tender, punched-out lesions with a
yellow exudate but no induration. Which of the following is the
mo st likely diagnosis?
(A) chancroid
(B) granuloma inguinale
(C) herpes
(D) lymphogranuloma venereum
(E) syphilis
ANSWER
• (A) Very painful punched-out lesions with a yellow exudate but no
induration surrounded by an erythematous halo should suggest
chancroid.
• Each of the other conditions listed present with significantly different
symptoms and findings
CASE2
• Q2 A 17-year-old girl is seen at a local clinic desiring contraception
because she thinks she will soon become sexually active. During her
examination, an ulcerative lesion is seen in the vaginal fornix. It has a
rolled, irregular edge with a reddish-appearing granular base. The lesion is
mildly tender to palpation. This lesion is most likely which of the
following?
(A) vaginal intraepithelial neoplasia
(B) vulvar carcinoma
(C) syphilis
(D) an ulcer caused by the use of tampons
(E) genital herpes
ANSWER 2
• (D) Tampon ulcers may cause vaginal discharge or spotting but may also be asymptomatic.
• When seen on examination, they have the characteristic appearance described in the
question; rolled-edge ulcers with a granular base. They are found in the vaginal fornices and
go away after the discontinuation of tampon use.

• A herpetic lesion does not have this appearance.

• A syphilitic lesion is also unlikely if the woman has not been sexually active, but it would be
wise to screen with a rapid plasma reagin (RPR) or Venereal Disease Research Laboratory
(VDRL) test or a direct treponemum antibody testing.
• The other diseases mentioned are less likely because they are sexually transmitted or are
extremely unlikely
in a woman this age.
CASE 3
Q3 The most common reportable sexually transmitted disease (STD) in
women that can cause conjunctivitis and neonatal pneumonia is which
of the following?
• (A) gonorrhea
• (B) syphilis
• (C) chlamydia
• (D) herpes
• (E) chancroid
ANSWER3
ANSWER (C) All of the STDs listed occur in pregnancy and should be
thought of in high-risk women.
Herpes, HIV, and human papillomavirus are three viral conditions that
are also common in pregnancy. With maternal chlamydia, there is an
increased incidence of conjunctivitis and pneumonia in the newborn,
and there might be late postpartum endometritis in the mother.
.