Bedside Clinics in Gynecology Arup Kumar Majhi
INDEX
Page numbers followed by b refer to box, f refer to figure, fc refer to flowchart, and t refer to table.
A
Abbe-Wharton-Mcindoe operation 641
Abdomen 132
examination of 18
girl with swelling 502f
inspection of 19f
pain lower 785
palpation 21f
regions 19
subdivision of 20f
Abdominal distension 327
Abdominal examination 19, 84
Abdominal hysterectomy 630f
total 73f, 89f, 189, 524f, 790f, 791f
Abdominal lump
lower 43, 445
palpation of 20f
Abdominal mass 488
and ascites 22
Abdominal myomectomy, steps of 128
Abdominal sacrocolpopexy 328f, 329f
complications 330
sacrocolpohysteropexy 328
steps of 328
Abdominal sacrohysteropexy 306
Abdominal wall 712
Abdominal wound, care of 782
Abdominopelvic lump, rate of growth of 115
Abdominoperineal cases 636
Ablative procedures, methods of 169
Ablative surgery 175
Ablative therapy, result of 170
Abnormal uterine bleeding 50, 51, 51f, 109, 142, 145, 151, 152fc, 158, 158fc, 159, 159f, 162, 163, 167, 168, 168t, 171, 172, 499, 785
ablative surgery in 169
causes of 148
common causes of 149
diagnosis 159
etiology 149
hormonal agents in 166t
management of 161, 168, 170, 171
nonhormonal agents in 167t
prevalence of 145
Abortion 673, 827
incomplete 5
Abscess 819, 821
cyst 764
drainage 824
Acanthosis nigricans 14, 14f, 337, 410, 410f
Accessory glands, secretion of 597, 601
Accredited Social Health Activist 724
Acetowhite
epithelium 239
Acne 337, 444
Acquired central nervous system injury 493
Acquired immunodeficiency syndrome 255, 462
Acrosomal cap 597
Acrosome reaction 602, 603
ACTH See Adrenocorticotropic hormone
Actinomyces like organisms 686
Activin 591
Acyclovir 838
Adenoacanthoma 186
Adenocarcinoma 221, 232
cervix 221f
Adenoid basal carcinoma 221
Adenoid cystic carcinoma 221
Adenoma 658
Adenomyosis 53f, 114, 153f, 506, 528, 528f, 530, 530f, 531, 532
diagnosis 529
diffuse 529f, 530
features of 109
gross pathology 528
histopathology 529
junctional zone 529
pathophysiology 528
risk factors 529
symptoms 529
types 529
with infertility 532
Adnexal mass 39
Adnexal swelling 40
Adolescent gynecology 499
Adrenal hyperplasia, late-onset congenital 487
Adrenal steroids 613
Adrenal tumor 438
Adrenarche, premature 495
Adrenocorticotropic hormone 405, 420, 470
stimulation test 425, 469
Adrenogenital syndrome 8, 434, 436, 436f, 437, 461
Advanced epithelial ovarian carcinoma during laparotomy 88f
Advanced ovarian cancer 88
management of 90
Advanced sperm function tests 368
Agglutination reaction test, mixed 366
AIDS See Acquired immunodeficiency syndrome
AIS See Androgen insensitivity syndrome
Alendronate 620
Alli's tissue forceps 141, 141f, 309, 309f, 310, 312, 313, 321, 564, 566, 578f, 579, 680, 726, 739, 739f
sterilization 739
uses 739
Alopecia 433
history of 403
Alpha fetoprotein 96
Ambiguous genitalia 28, 439, 468, 471
cause of 468
Ambosexual hairs 433
Amenorrhea 212f, 358, 402, 408, 412, 452, 453, 479f, 482, 485, 486, 488, 570, 582, 686
cases of 390
causes of 7
secondary 407, 477, 477f, 478
in hypothyroidism, mechanism of 485
primary 8, 18, 434, 442, 443, 447, 447t, 448, 448fc, 450, 463, 505
classify 443
clinical classification of 443t
common causes 442
etiologies 441
secondary 8, 407, 474, 477, 481fc, 486f, 536
diagnosis of 479
physiological causes of 478
American Fertility Society 624
American Society of Reproductive Medicine classification 513
AMH See Anti-müllerian hormone
Aminobutyric acid 619
Amniotic cell, typing of 462
Ampulla 604
Amsel criteria 835
Anabolic steroids 422
Anagen 432
Anal incontinence 574
pathophysiology of 574
Anal sphincter
complex 574
external 573
internal 573
Anal wink reflex 299
Analgesic 521
Androblastoma 99, 488
Androgen 418, 468, 486, 589, 719
biosynthesis defect 473
blocking drugs 412
excess, evaluation of 423
insensitivity syndrome 10, 20, 434, 436, 436f, 445f, 455t, 456, 457f, 457t, 458f, 459f, 460, 460t, 471
vagina in 446f
producing tumor 488
progestogen combination 719
secreting adrenal tumors 420
secreting tumor 420, 442
sensitivity of 432
type of 457
synthesis 422f
disorders of 466
Androgenic drugs 418
Androstenedione 423, 503, 589, 613
Anemia 13, 107
common causes of 13
demonstration 13f
symptoms of 156
Anesthetic complications 773
Anesthetic drugs 708
Anesthetic hazards 708
Aneurysm needle 730, 746f
with thread 746
sterilization 746
uses 746
Angiogenesis 606
Angiogenic agents 521
Annular tubules 69, 97
Anorectal mucosa 578, 579, 579f
Anosmia 463
Anovular dysfunctional uterine bleeding 151t
Anovulation 357, 369, 486
causes of 150, 357, 412
surgical management in 377
Anovulation See also Oligo ovulation
Anovulatory bleeding 151, 151t
Antara 666f, 724
Anterior vaginal wall 300, 737
cyst 280
prolapse 293, 297, 305
retractor 34f, 726, 739, 739f
Anteversion 283
Antiandrogens 428
Antibiotic
administration 781
broad-spectrum 581
use of 781
Antidepressant drugs 620
Antidiuretic hormone 780
Antifertility vaccine 720
Antifibrinolytics 172
Antigen, detection of 838
Anti-mullerian hormone 338, 349, 351, 352, 451, 470, 612, 622
Antioxidants 597
Anti-potency pill 398
Antiprogestational agent 521
Antiprogestins 124
Antiseptic dressing 706
Antisperm antibody test 366
Antitesticular action 622
Antral follicle 407, 588
count 351, 352
Antral follicle See also Tertiary follicle
Antrum folliculi 590
Aorta, coarctation of 15, 444
Apical cystocele See also Transverse cystocele
Apical prolapse
apex 301
presence of 301
Arcuate arteries 593
Arcuate uterus 635, 635f, 800f
Arcus tendineus 285, 305
fascia 554
pelvis 285, 312
Arms of mirena 682
Aromatase inhibitor 370, 372, 413, 521, 523
Arrhenoblastoma 99, 421f, 488, 488f, 489f
hirsutism in 421f
undifferentiated 489f
virilization in 418f
Artery forceps 564
Artificial insemination
history of 394
types 394
Ascites 23f, 75
Ascitic fluid 80
ASHA See Accredited Social Health Activist
Asherman syndrome 453, 486, 506
causes 486
diagnosis 486
treatment 486
Asherman syndrome See also Uterine synechiae
Aspermia 365
Aspiration with pipelle 54
ASRM classification, limitations of 514
Assisted reproductive technology 381, 398, 520, 526
procedures 396
Association of adenomyosis and endometriosis 531f
Asthenospermia 365, 390
Asymmetric septate uterus 633
Asymptomatic fibroid 122
Atonic postpartum hemorrhage 756
Atretic cervical tissue 638
Atretic cervix, conservative surgery in 638
Atrophic vaginitis 196
Atypia 173
progesterone, absence of 174
AUB See Abnormal uterine bleeding
Autocrine defects 150
Autoimmune disease 486
Autosomal recessive genetic disorder 361
Auvard's self-retaining speculum 726f, 739, 739f
Auvard's weighted speculum 321
Axillary hair 460
less 445f
Ayer's spatula, graduated 299f
Aylesbury spatula 235
Ayre's spatula 45f, 235, 235f, 236f, 299, 731f, 748, 748f
Azithromycin 837
Azoospermia 362f, 364, 365, 367, 390, 399, 401
diagnosis 400
nonobstructive 364, 394, 399
obstructive 399
prevalence 399
treatment 400
types 399
Azoospermia See also Oligospermia
B
Babcock's tissue forceps 729, 744, 744f
sterilization 745
uses 744
Bacterial vaginosis 44, 46, 829, 835
adverse effects of 835
diagnosis of 47, 835
signs 835
symptoms 835
Baden-Walker halfway system 290
BAGSHWE regime 208
Balfour abdominal self-retaining retractor 730f
Barrier methods, types of 692
Bartholin's abscess 29, 821f, 825, 825f
causative organism 825
diagnosis 825
treatment 825
Bartholin's cyst 28, 819, 820, 820f, 821
complication 822
etiology 822
excision of 822f
operation of 764
palpation of 31f
presentation 822
treatment 822
Bartholin's duct 822
Bartholin's gland 28, 31, 819, 821
anatomy of 821
carcinoma 254
disorder of 821
Basal artery 593
Basal body temperature 341, 344, 344f
method 697
Basal cell carcinoma 254
Basal cell carcinoma See also Rodent ulcer
Basaloid 255
Basaloid See also Warty types
BASHH guideline 832
Basophilic cells 344f
BBT See Basal body temperature
Benign cystic teratoma 71, 74, 74f
Benign mucinous cystadenoma 73, 73f
Benign ovarian cyst 71, 78
malignant transformation of 77
Benign ovarian tumor 61, 71, 67f, 78, 790f
Benign serous cystadenoma 62f, 72, 72f
Bent-on-flat scissors 309
Bethesda system 228, 229, 238
Bicolis with septate vagina 630f
Bicornuate uterus 624, 631, 631f, 632f, 797
indication of surgery in 632, 798
reproductive outcome in 632, 798
Billing's method 697
Billing's method See Cervical mucus method
Bimanual examination 212, 572, 759f
Biopsy 254, 792, 837
colposcopy
with 267
without 267
from cervix 729f
Bipolar coagulation forceps 769f
Birth control
and family planning 647
history of 647
methods 648t
classification 648
Bisphosphonates 620
Bivalent vaccine 247
Black box 598
Bladder 11, 322f, 324f
filling and emptying 554
flap 553
function 302
injury 565f, 708
mucosa 545f
overactive 554, 559
pillars 322f
retraining 560
sulcus 297
Blastocyst 387f, 605f
competency 605
development of 604
formation 605
stage embryo 606
Bleeding
abnormal 613
breakthrough 147
irregular 668
pattern, type of 148
per vagina, irregular 144, 793
source of 116f
type of abnormal 155
Bleomycin 103
Blind vagina, causes of 445, 446f
Blinding 811
Blinding See Masking
Blood 828
loss, quantity of 9
sugar 536
supply and surgical importance 548
transfusion, history of 10
Blood pressure 16, 107
measurement 16
procedure of measurement of 16
Blue-domed cyst 512, 516f
Boari's flap method 553, 553f
Boari's technique 551
Body mass index 337
Bone
age 496
determination 496f
marrow density 616
mass, markers of 618
mineral density 522, 616
specific agent 621
Boney's myomectomy clamp 131f
Bonney's hood operation 130, 130f
Bonney's myomectomy clamp 129, 729f, 745, 745f
sterilization 745
uses 745
Bonney's stitch 319
Bonney's test 557
Borderline ovarian tumor 91
clinical features 91
management 91
prognosis 92
Bowel 11
injury 708
preparation 577
Bowen's diseases 268
Brain tumor, resection in 497
Breast 499
cancer 619
syndrome 10
development of 18, 448
sequence of 449f
examination of 17, 17f, 56, 211, 534, 572
pendulous 17
Breastfeeding 650
Brenner tumor 73, 73f
Broad ligament 511
clamping of 753f
cysts 137
fibroid 60, 118, 138, 138f, 139f
large 118f
hematoma 708
tumors 137, 138
Bromocriptine 374, 375, 427, 484
Broom devices 236
Bulbar conjunctiva, upper 14
Bulbocavernosus 557
reflex 299
Bulbourethral gland 597, 602f
Bulge symptoms 294, 295
Bulking agent, periurethral injection of 563
Bull's eye target 76
Burch colposuspension 562, 562f
Burch suspension 307
Buserelin 522
Butterfly incision 260f
C
Cabergoline 374, 375, 484, 521, 523
Café-au-lait spots 519
CAH See Congenital adrenal hyperplasia
CAIS See Complete androgen insensitivity syndrome
Calcified chocolate cyst 515f
Call-Exner bodies 99
Calymmatobacterium granulomatis 833
Cancer cervix 36f, 214, 216, 219f, 227, 238, 282f, 791
causes of death in 216
complications of 216
diagnosis 792
lymphatic drainage of 222
management of 223
prevention 227, 246
prognosis of 227
radical hysterectomy in 791f
stages of 216, 217t, 218f, 219
treatment of 792
Cancer 186
diagnosis of 52
predisposition 10
Cancer vulva 793
radical vulvectomy in 793f
Candida albicans 6, 44, 46, 47, 833
Candidiasis 35, 46, 47, 832
diagnosis of 47, 834
predisposing factors 834
signs 832
symptoms 832
treatment 834
Cannula 707
type of 796
Capio ligature carrier device 330
Carcinoma
breast 658
cervix 41, 209
stage of 222, 222t
in situ 228
simplex 268
undifferentiated 221
Carcinosarcoma 197
Cardinal ligaments 283
Cardiorespiratory arrest 708
Cardiovascular disease 616
prevention of 620
Cardiovascular system 16, 534
Catagen 432
Catheter 124f, 537
metal 537
rubber 537
CC See Clomiphene citrate
CEE See Conjugated equine estrogen
Ceftriaxone 781
Centchroman 650, 665, 666
contraindication 666
mechanism of action 666
pregnancy failure 666
side effects 666
Central cervical fibroid 134f136f
Central precocious puberty
diagnosis of 494
etiologies of 493
problems of 494
Centriole 598
Cerebrovascular accident 167
Cervical agenesis 637, 637f
diagnosis 637
treatment 637
Cervical anomaly, subclassification of 626t
Cervical atresia 390, 625
isolated 625
Cervical cancer 196, 227, 234
causes of 246
epidemiology of 227
etiology of 227
pathology of 220
primary cause of 232
risk factors for 227
screening 234
advantages of 234
spread of 221
stages of 220
Cervical cap 695, 695f
Cervical cap See also Check pessary
Cervical carcinogenesis 233
Cervical condyloma 241f
Cervical cytology 45f, 235, 235f, 236f, 748
by plastic broom 45f, 236f
indications of 748
method of 235
reporting system on 230t
Cervical dilators 742
set of 758f
types of 742
use of 742
Cervical ectopy 241f
Cervical erosion 213, 213f
Cervical extension, detect 185
Cervical factor 390
causing infertility 358
causes of 358
infertility 369
diagnose 359
treatment of 389
Cervical fibroid 49, 133, 133f, 134, 136f, 281f, 286f, 290f, 788f
anterior 134f
arising 133f
central 133f, 136f
clinical criteria of 135
diagnois 134
incidence of 133
investigations 135
large 30f, 787f
management of 135
myomectomy for 136
polyp 280f
posterior 134f
signs 135
specimen of large 787
symptoms 135
varieties of 133
Cervical hostility 382
Cervical intraepithelial lesion 240
system 238
diagnosis of 243
management of 243
Cervical intraepithelial neoplasia 228, 229, 229f, 232, 265
development of 231
etiology of 231
high-grade 242f
low-grade 241f
risk factors for 234
Cervical malignancy 533
Cervical mucosa
changes of 670
ferning of 346f
Cervical mucus 345f, 346, 347f, 482, 827
amount of 345
ferning 347f
method 697
study 345
Cervical myomectomy 787
Cervical neoplasia 232
Cervical polyp 134, 139f, 141f, 196, 213, 213f
Cervical pregnancy 49
Cervical smear, normal 235f
Cervical syphilitic ulcer 213
Cervical tuberculosis 213, 213f, 841, 841f
Cervicitis 390
Cervicothoracic somatic dysplasia 638
Cervicovaginal junction 322f
posterior 322f
Cervix 32, 37, 214, 237, 252, 255, 308, 322f, 460, 603, 623
abnormalities of 439, 445
amputation of 317, 318f
elongated 388
barrel-shaped 215
canalization of 638
carcinogenesis of 228
carcinoma of 217t
development of 623
dilatation of 760f, 761
double 630f
elongation of 317f, 281, 282, 282f
gradual dilatation of 759f
hypertrophic elongation 279
in colposcopy 239, 239t
large malignant growth of 279, 282
lesions of 737
lymphatic drainage 222f
normal 240f
normal looking 36f
old tear 35
palpation 37
preinvasive lesions of 228, 246
premalignant lesions of 209, 228
small procedures on 764
strawberry appearance 35
Cesarean ligation 700
Cesarean section 126
Chancroid 837
signs 837
symptoms 837
treatment 837
Check pessary 695
Chemoradiation 226
Chemotherapeutic agents 102
Chemotherapy 227
response score 103
Chhaya 663, 665f, 724
Childhood problems, history 403
Chimerism 467
Chlamydia 231, 500, 827, 829, 836
infection 47, 827, 836
diagnosis 836
signs 836
symptoms 836
treatment 837
trachomatis 47, 378, 827, 830, 833, 836
Chocolate cyst 515, 515f, 524f
before cystectomy, drainage of 524f
bilateral 511f, 524f
causes of 519
large 60
left side 518f
of ovary 803f
of right ovary 518f
Choriocarcinoma 67, 69, 93, 97, 198, 204, 204f, 205
assessment of staging of 207
diagnosis of 204
differential diagnosis 201
gynecological examination 200
history 198
investigations 201, 204
physical examination 200
provisional diagnosis 201
treatment 205
Chorionic frondosum 609
Chorionic villi 609
Chromosomal abnormalities 442
Chromosomal sex, determination of 464
Chronic pelvic pain, causes of 6
Cimetidine 429, 468
CIN See Cervical intraepithelial neoplasia
Cisplatin 103
Clear cell
carcinoma 186, 221
tumors 69
Clindamycin 835
Clitoridectomy, reduction 462
Clitoris 279, 624, 819
Clitoromegaly 419f
Clitoroplasty 462
Clomiphene 358
risks of 371
side effects of 371
Clomiphene citrate 341, 371, 413
challenge test 351, 352
indication 371
Clonidine 619
Cloquet node 257
Cloquet node See also Rosenmuller's node
Clue cell 47, 835
detection 44
CNS See Central nervous system
Coagulation disorders 712
Coast of Maine 495
COC See Combined oral contraceptive
Cochrane collaboration 811
COEIN 152f
group 153
Coffee bean 99
Cohort study 810
Coital function 450, 517
Coital history 342
Coitus interruptus 698
Coitus, vaginoplasty for 639
Cold coagulation 243
Colles' rogen deficiency 616
Color Doppler 157f
Colpocleisis 327
partial 307
Colpoperineorrhaphy
complications of posterior 316
posterior 308, 313, 314f, 317
Colporrhaphy
anterior 305, 308, 312, 317, 319, 322, 326
complications of 313
steps of 308
posterior 313
end of 326f
Colposcopy 239, 239f, 254
advantages of 239
cancer in 240t
Colposuspension 562
Combined dye test 538
Combined estrogen progesterone pill 655f
Combined formulation, concept of 653
Combined hormonal
patch 650
transdermal patches 671
Combined injectable preparation 651, 669
Combined oral contraceptive 70, 123, 156, 167, 171, 181, 504, 525, 637, 644f, 651
drug interaction 659
missing pill 659
Combined oral contraceptive pill 521, 650, 652
benefits of 657
composition of 652
effects of 657
uses of 657
Combined oral pills
benefits of 656
contraindications of 658
Combined pill 724
types of 654, 654t
Combined vaginal ring 650
Compact morula, formation of 604
Complete androgen insensitivity syndrome 473
Complete perineal tear 40, 570, 573, 575f
causes of 576
diagnosis 574
gynecological examination 572
history 570
obstetric causes 576
physical examination 571
risk factors of 576
signs 574
surgery for repair of 577
symptoms 574
systemic examination 571
traumatic causes 576
treatment of 577
vaginal examination 572
Condom 692, 816
benefit of 693
history and development of 692
Condyloma acuminata 28f, 819, 838, 838f
treatment 838
Condyloma lata 839
Condylomata 266
Condylomatous lesion, typical 241f
Cone biopsy 218, 245, 245f
Cone biopsy See also Entire lesion
Congenital adrenal hyperplasia 8, 31f, 405, 419, 419f, 420f, 434, 436, 436f, 437, 437f, 444f, 461, 465, 471
clinical presentation of 461
investigation 461
management of 462
pathophysiology 461
treatment of 462
Congenital syphilis 839
Conjugated equine estrogen 167
Conray 420 353
Conservative cryotherapy, role of 243
Continuous interlocking vicryl sutures 564
Contraception 647, 723, 802
broad categories of 648, 649
hormonal methods of 651
method of 509, 646, 648, 649
regular 673
Contraceptive 693, 724
barrier 647
methods of 692
contraindications of injectable 668
history 143, 342
methods 649
modern 722
pills 722
prevalence rate 722
regular 648, 674
services 723
sponge 696
type of 646
uses 723f
Cooper ligament 562
Copper intrauterine device 650
Copper T 675
Copper T380A 675
Copper-containing devices 677
Core biopsy 85
Cornified cells 344
Cornual pregnancy 49
Corona radiata 590
Corpora cavernosa 257
Corpus albicans 592
formation 592
Corpus cancer syndrome 12, 182
Corpus luteum 592
cyst 70
formation of 588, 592
Cortical bone 616
Corticosteroid 413, 429
Cortisol deficiency, replace 462
Crab louse 833
Cranial ends of fusion 623
C-reactive protein 828
elevated 830
Creamy discharge 214
Creamy discharge See also White discharge
CRS See Chemotherapy response score
Crude birth rate 721
Cryotherapy 132
Cryotherapy See also Laser vaporization
Cryptomenorrhea 445f, 447f, 456, 505
drainage of 636f
Cryptorchidism 360
CS See Cesarean section
Cu380A 675
Cubitus valgus 435f
Cu-intrauterine device 645
Culdoplasty techniques 332
Cumulus cells 591f, 603
Cumulus oophorus 590
Cumulus oophorus See also Discus proligerus
Cumulus separation 602
Curette material, collection of 760
Cusco's bivalve self-retaining speculum 738
Cusco's bivalve speculum 214, 299
Cusco's handling anteriorly 33f
Cusco's speculum 31, 32f, 33, 33f, 308f, 346, 726, 738f
blades of 738
Cushing's syndrome 405, 407, 408, 411, 418, 420, 424, 425, 426, 438, 439
Cu-T 380a 675f, 676f
insertion of 680
with plunger tube 645f
Cu-T
adhered with right adnexa 800f
in pelvis 800f
CVA See Cerebrovascular accident
Cyanosis 13, 107
Cyclic therapy 619
Cyclofem 669
Cyclooxygenase 609
Cyclosporine 422
Cyproterone acetate 427, 428, 653
Cyst 28, 231
excision 822, 823f
functional 70, 71
multiple 512
Cystectomy 78, 822
simple cyst following 72f
Cystic endometrial changes 174
Cystic fibrosis 340
Cystocele 35, 278, 279, 287, 288, 297, 297f, 310, 310f, 311f
displacement 288, 289f
dissected completely 310f
distension 288
midline 288, 288f
mimic 280
presence of 334, 564
repair of 312f
Cystoscopy 272, 539, 564
Cystourethroscopy 539
Cytobrush 236, 732, 748, 748f
use 748
Cytokines 608
Cytology 234
classification, systems of 238t
liquid-based 235, 236
Cytomegalovirus 833
Cytoplasmic syngamy 602
Cytoreduction 90
Cytotrophoblast 608
D
D and C
complications of 761
indications of 760
Danazol 162, 165, 167, 171, 172, 422, 468, 522
Darifenacin 561
Das's dilator 742
Das's dilator See also Hegar's dilator
Daytime urinary frequency 295
Deaver's retractor 730f
Decidua 606
basalis 593
functionalis 593
Decidual plate 609
Decidualization 606
reaction, primary 608
Decubitus ulcer 278, 294f, 302
management of 302
with pigmentation 298f
Dehydroepiandrosterone sulfate 423, 440, 480
Delayed puberty 8, 434, 435, 450
Dementia 615
Denonvilliers, fascia of 311
Density gradient
centrifugation technique 392
technique 391
Denys-Drash syndrome 466
Deoxyribonucleic acid 232, 255, 265, 843
Depilating agents 430
Depilation 431
Depot medroxyprogesterone acetate 164, 167, 168, 650, 651, 723
mechanism of action of 667
Depression
cause of 620
treatment of 620
Depressive disorders 711
Dermal papilla
destruction of 431
enzyme of 429
Dermoid cyst 74f, 76, 93, 790
Dermoid plug 74
Deslorelin 522
Desmopressin 162
Detrusor instability 554
Detrusor overactivity 554
diagnosis of 559
surgery for 564
Detrusor overactivity See also Detrusor instability
Detrusor pressure 558
Dexamethasone 370, 375, 427, 429
DHEA See Dihydroepiandrosterone
Diabetes 180, 340, 360, 616, 620
mellitus 122, 411, 411t
with vascular complications 658
Diabetic neuropathy 390
Diakinesis 586
Diamond's media 47
Diaphragm 650, 695
Diarrhea 516
Diastolic pressure 16
Diathermy
bipolar 706
unipolar 706
Diazoxide 422
Didelphic uterus 630f
Dienogest 522, 653
Diethylstilbestrol 624
exposure 234
Digital vaginal examination 480
Dihydroepiandrosterone 492
Dihydrotestosterone 423, 503
Dilatation, Frank method of 640
Diploid cells 600
Diplotene 586
Directly observed treatment short course therapy 843
Dissecting forceps 730f, 731f
Distension prolapse 288f
Distention media 775
DMPA See Depot medroxyprogesterone acetate
Docetaxel 103
Docetaxel See also Nanoparticle paclitaxel
Doderlein's bacilli 46
Dominant follicle 350f, 590, 591
Donovan bodies, detection of 837
Dopamine agonist 370, 374, 485
bromocriptine 374
cabergoline 374
indication 374
mechanism 374
pregnancy rate of 375
side effects 375
types 374
DOTS See Directly observed treatment short course therapy
Double-blind study 811
Doxycycline 354, 837
Doyen's retractor 730f
Drospirenone 421, 653
Ducreyi bacillus, culture of 837
Dye test 343, 538
Dynein bands 598
Dyschezia 516
Dysfunctional uterine bleeding 5, 142, 150, 155, 175f
abnormal bleeding in 150
diagnosis 150
endometrial pattern in 152
gynecological examination 144
history 142
pattern of bleeding in 151
types of 150
Dysgenetic testis 465
Dysgerminoma 67, 69, 93, 94
diagnosis 95
of ovary 95f
prognosis 95
treatment 95
Dyskaryosis 230
Dysmenorrhea 5, 9, 109, 112, 162, 163, 499, 509, 529, 785, 831
primary 9, 344
secondary 9, 510
severe 531f
Dyspareunia 10, 109, 155, 327, 529, 831
cause of 7, 619
deep 11
deep 510
superficial 11, 266
Dysplasia 228, 238
Dysuria 615
E
Early pregnancy
factor 608
failure 517
Ectocervix 220, 230
Ectopia vesicae 553
Ectopic pregnancy 5, 381, 629, 687, 709, 766
cause of 687
disturbed 828
Ectopic ureter 553
Edema 12, 107
demonstration 12f
vulva 12f
Edge-pairing technique 546
EFI See Endometriosis fertility index
Eflornithine 429, 431
hydrochloride 430
Eflornithine See also Vaniqa
EIN See Endometrial intraepithelial neoplasia
Ejaculation to fertilization, from 603
Ejaculatory duct obstruction 364
Ejaculatory dysfunction 390, 398
treatment of 398
Elagolix 523
Elephantiasis 837
ELISA See Enzyme-linked immunosorbent assay
EMACO regime, dose of 208
Embolism and granuloma formation 795
Embryo 608
cryopreservation of 397
donation 397
third day cleaved 387f, 605f
transfer 341, 382, 387, 387f
basic steps 383
catheter 388f
Embryoendometrial synchronization 606
Embryonal carcinoma 69, 93
Embryonal cell carcinoma 97
Embryonic bed 605
Embryonic life, period of 623
Emergency contraceptive 648, 651, 672
administration of 674
effects of hormonal 673
efficacy of 674
failure rates 674
methods 673
most common pill 672
pill 646f, 672f
Emergency pill 650, 724
Emphysema 712
surgical 773
Endocervical adenocarcinoma 36f, 221
Endocervical canal 235
by cytobrush 45f
cytobrush for 235f
Endocervix 230
Endocrinal abnormality 442
Endocrinal disorder 149
Endocrine
changes 612
during puberty 498, 498fc
disorder 361
markers 351
Endodermal sinus tumor 69, 96
Endometrial ablation 126, 132
Endometrial adenocarcinoma 185f
Endometrial biopsy 157, 160, 182, 195, 347, 843
future of 348
indications of 195
methods of 160
Endometrial cancer 12, 53f, 188f, 189f, 196, 613, 658, 793, 793f
after treatment 191
age and 180
diagnosis 181
incidence of 180
lymphatic spread of 187f
prevention of 191
prognosis 191
spread 187
types 185
with cancer ovary 189f
Endometrial carcinoma 109, 153f, 172, 176, 179, 180, 186, 187, 192
adjuvant therapy in 190
curettage of 183
differential diagnosis 179
gynecological examination 178
history 176, 181
investigations 179
physical examination 177
provisional diagnosis 179
recurrent 192
stages 187
treatment modalities of 187
Endometrial cavity 113f, 114f
pathology of 159
Endometrial cycle 343f, 589f, 606
consists of 586
Endometrial disorder, primary 150, 155
Endometrial dysfunction, primary 171
Endometrial glands 510, 594
Endometrial hyperplasia 172, 173, 173f, 174, 175f, 196, 528, 613
diagnosis 173
varieties of 173
Endometrial intraepithelial neoplasia 173
Endometrial lesion 45
Endometrial pathology 49
Endometrial polyp 51f, 113f, 114f, 159f, 161f, 196, 613, 777f
transvaginal sonography of 157f
with Doppler 113f
Endometrial receptivity 168, 606
principal regulators of 606
Endometrial sampling 157, 160, 174
Endometrial stromal sarcoma 197
Endometrial surface 111
Endometrial thickness 195, 351f, 482
Endometrioid adenocarcinoma 185, 793
ovary 90f
Endometrioid tumors 69
Endometrioma 515
aspiration of 524f
huge 514f
resection of 523
Endometriosis 60, 378, 499, 506, 510, 512, 516f, 528, 531, 712, 773f, 820
approach to 525, 525fc
cause
infertility 359
of pain in 517
classification 513, 526
clinical features 515
deep infiltrating 514
diagnosis 517, 518
etiologies 513
fertility index 514
score 514
in adolescent 503
management 503
in cervix 512
in episiotomy scar 512
in umbilicus 511
in vagina 512
in vulva 512
incidence of 510
interna 531
management 520
medical management 520
pain in 516
prevention of 520
signs of 516
sites of 511, 511f
surgical management of 523
symptoms of 516
treatment modalities of 520
variety of 531
with infertility 526fc
approach to 526
management of 526
Endometriotic implants 512
Endometritis 390
Endometrium 116, 517, 592, 608, 638, 840, 841
ablative procedure on 764
curettage of 183f
staging of carcinoma of 188t
synchronizes with 606
thickness of 594
transcervical resection of 169
Endomyometrial junction, blurring of 530f
Endopelvic fascia 283
Endosalpingeal damage, degree of 378
Endoscopic surgery 765
Endtz test 365
Engineered autologous, use of 640
Enlarged clitoris 421f, 439, 445, 459f, 480
with fused labia 28
Enterocele 287, 287f, 288, 297f, 299
demonstration of 301, 301f
formation 642
in vaginal route, repair of 317
large 287f
management of 332
Envelop cells 344
Environmental toxins 513
Enzyme
deficiency 425
immunoassay 829
Enzyme-linked immunosorbent assay test 349
EOC See Epithelial ovarian cancer
Eosinophilic cells 344f
EP See Estrogen-progesterone
Epidermoid cyst 820
Epididymal sperm aspiration 395
Epididymis 362
Epididymitis 340
Epigastrium 20
Epilation 431
Epilepsy 711
Epimenorrhea 8, 148
Epithelial cell 71
proliferation of 202f
Epithelial ovarian cancer 81, 85, 91, 102
management of early 90
prognosis of 92
Epithelial sarcoma 197, 254
Epithelial stromal tumors 68
Epithelial tumor, solid 73f
Epithelial vulvar diseases, classification of 269, 269t
Epithelioid trophoblastic tumor 201, 206, 207f
Epithelium, normal 229
Equatorial region 598
ERAS protocol 783
Erectile dysfunction 390, 398
treatment of 398
Erectile failure 398
Erythrocyte sedimentation rate 111, 828
Escherichia coli 822, 825
ESR See Erythrocyte sedimmentation rate
Estosterone-related seminopathy 601
Estradiol 349, 486, 619
early 352
releasing vaginal ring 620
valerate and dienogest 654
Estrogen 418, 588, 591, 596, 612, 613, 620, 621, 644, 647, 652, 653
and progesterone, fall of 595, 596
containing pill, lower 123, 661
contraindication to 619
cream 500, 620
dependent tumor 621
dose of 163
injectable 162
level of 596
low-dose 450
status, assessment of 480
therapy 618, 619
contraindication of 621
preparation and dose 619
route 619
Estrogenic cervical mucus 346
Estrogen-progesterone 525
combination 521
contraceptives, use of 162
treatment 487
Ethinyl estradiol 671
Ethiodol 353
Etonogestrel 521, 671
Etoposide 103
Etrograde menstruation 513
ETT See Epithelioid trophoblastic tumor
Eugonadotropic eugonadal anovulation 358
Eugonadotropic hypogonadism 442
Eunuchoid habitus 452
Euprolactinemia 375
European Society for Pediatric Endocrinology 463
Excessive discharge, cause of 112
Excisional biopsy 254
External cervix, Ayre's spatula for 235f
External genitalia 28, 31f, 437f, 624
examination 445, 469
inspection of 27, 572
palpation of 31, 338, 509, 572, 575
prepubertal 451f
External sphincter, repair of 580
External vagina, palpation of 31
Extrafascial hysterectomy, total 189, 190
Ezy-pill 663, 724
F
Facies and skin, examination of 14
Fallope ring 705
Fallopian tube 80f, 343, 460, 511, 623, 700, 709, 753f, 785, 840
and ovary, tuberculosis of 841f
cancer 104, 104f
diagnosis 104
management 104
survival rate 104
carcinoma 49
Falloposcopy 357
Falope ring 706
False capsule 119
Familial hereditary factors 122
Family planning and contraception 644
Family Planning Programs 721
Family planning, natural 696
Fatty degeneration 120
FDA See Food and drug administration
Fecundity 339
Federation of Gynecology And Obstetrics menstrual parameters 146t
Feinberg-Whittington media 47
Female condom 650, 694, 694f
advantages 694
disadvantages 694
efficacy and failure 694
types 694
Female external genitalia 27f, 819
inspection of 27f
Female factor infertility, causes of 340
Female gender, assignment of 471
Female genital system, development of 622
Female genital tract 718
deposition in 602
Female genital tuberculosis 48, 826, 840
differential diagnosis 842
etiopathogenesis 840
pathology 840
prevalence 840
signs 842
symptoms 842
Female infertility
management of 369
uterovaginal surgery in 388
Female metallic catheter 725f, 735, 735f
catheterization 736
complications 736
uses 735
Female pseudohermaphrodite 466, 467
Female rape victim, medical examination in 814
Female reproductive tract 604f
development of 622fc
Female sterilization 650, 699, 709
clients undergoing 710
efficacy of 709
failure of 709
health benefits of 709
Femidom 694
Feminizing genital surgery 472
Feminizing surgery 472
Femoral canal 821
Femoral vessels 261
Fenton's operation 401, 764
in tight hymen 388
Fern test 345, 346
Ferriman-Gallwey scoring system 424, 424f
Fertility awareness method 650
advantages of 697
disadvantages 697
failure rate of 697
Fertility awareness-based methods 696
Fertility control 647
Fertility indicators 721
crude birth rate 721
total fertility rate 722
Fertility rate, total 722
Fertility sparing
conservative management 192
surgery 89
Fertilizable lifespan of oocyte 604
Fertilization 590, 604, 604f
informations of 598
processes during 368f
acrosome reaction 368f
penetration 368f
sperm oocyte fusion 368f
zona binding 368f
Fesoterodine 561
Fetal androgen excess 466
Fetal growth restriction 609
Fetiform teratoma 71
Fetoplacental origin androgen excess 466
FGT See Female genital tuberculosis
Fiberoptic lighting system 705
Fibroid 118, 172, 194, 613
cystic degeneration of 121f
fatty degeneration of 120f
occurs, rapid growth of 115
operation on 763
polyp 36f, 139, 141, 279, 280, 282
types 153f
varieties 115f
Fibroid uterus 60, 105, 109, 111, 112, 803f
abdominal examination 107
cause of infertility in 112
diagnosis 110
differential diagnosis 109
gynecological examination 107
history 105
investigations 108
management 122
physical examination 106
systemic examination 107
vaginal examination 108
Fibroma 102, 820f
Fibromyoma 109
Fibroplant 674, 690, 691
Fibrous histiocytoma, malignant 254
FIGO See International Federation of Gynecology and Obstetrics
Filshie clip 706
Fimbrial cysts 137
bilateral 137f
Finasteride 427, 428
First polar body 587, 590
Fistula 550
diameter of 542
malignant 533
margin scar tissue 544
operative 537
situated 584, 585
varieties of 540f
rectovaginal 540f
urethrovaginal 540f
vesicouterine 540f
vesicovaginal 540f
Fitz-Hugh-Curtis syndrome 827, 836
Flagella, typical 47, 834
Flap splitting method 544, 545f
Fluid
balance 559, 779
choice of 781
deficit 775
management, postoperative 780
principles of quantity of 781
thrill 24
demonstration of 24, 25f
Flushing curette 727, 743f
use of 743
Flutamide 427, 428
Focal adenomyosis 529f, 530
Focal endometriosis 529
Foley's catheter 356, 545f, 565f, 726, 736, 736f, 750, 824
sterilization 736
tourniquets of 129
uses 736
Follicle
cohort of 588
mature 590
maturing multiple 373f
primary 588
secondary 587, 588
Follicle stimulating hormone 162, 338, 343, 358, 441, 443, 481, 588, 611
increase of 613
Follicular cyst 70
Follicular depletion 612
Follicular development 591
Follicular phase 588
Food and drug administration 123, 237, 371
Formation of morula 604
and blastocyst 604f
Formerly true hermaphroditism 467
Fornices 41
Fornix
anterior 40
posterior 40
Fothergill's operation 306308, 313, 317, 318f, 320, 332
complications of 320
indications of 317
steps of 317
Fothergill's operation See also Fothergill's operation
Fothergill's stitch 319, 319f, 320f
Four drug regime 844
Fourchette 819
Fourth generation progestin 653
Frasier syndrome 466
Freedase 30, 662
Fresh frozen plasma 780
FSH See Follicle stimulating hormone
Functional cyst, varieties of 70
Functional hypothalamic amenorrhea 488
Fundal invagination 632
Fundal submucous large fibroid 116f
Fundus, invagination of 632
G
Gabapentin 619
Galactorrhea 361, 403, 482
amenorrhea syndrome 483
history of 337, 342
without prolactinemia, causes of 483
Galstaun's chart 496
Gamete intrafallopian transfer 396
Gardnerella vaginalis 6, 46, 827, 833
Gartner's duct cyst 30f, 35, 279, 280, 280f, 282, 820
Gelastic seizures 493
Gellhorn 304f
Gem cell malignancy 97
Gender assignment 470
Genetic analysis, indication of 367
Genetic causes 493
Genetic diagnosis, preimplantation 397f
Genetic disorder 10, 341
screening of 397
Genital fistula 539
classification 539
milestones of 541
Genital herpes 838
diagnosis 838
signs 838
symptoms 838
treatment 838
Genital hiatus 300f
Genital malignancies 82
Genital organs, development of 622
Genital prolapse 41, 274, 280, 290f, 294, 582, 630f
etiologies 274
examination 278f
Genital tract function 450
Genital tuberculosis 840
Genital wart 232, 838
virus 833
Genitalia
internal 460
musculinised external 466
Genitourinary fistula 536, 642
classification 539, 540
diagnosis of 536, 538
Genuine stress incontinence 554
Germ cell tumor 71, 74, 69, 92, 93, 103, 790
classify 92
diagnosis of 93
malignant 93, 95
mixed 67, 97, 502f
treatment of 94
varieties of 92
Gestational carrier surrogacy 388
Gestational choriocarcinoma 203, 204f
development of 203
Gestational trophoblastic disease 49, 71, 202
classification of 202
Gestational trophoblastic neoplasia 9, 202, 207f
chemotherapy for 208
survival rate in 208
treatment of 207
Gestrinone 171, 521, 522
GHRH See Growth hormone releasing hormone
Gilliam's type operations 388
Glands 594
Glandular and stromal growth 594
Glandular cell 230
Glandular lumen 594
Glassy cell 221
Glucose tolerance test 411
abnormal 404
Glycerin-acriflavine 334
GnRH See Gonadotropin-releasing hormone
Gonadal differentiation 464
Gonadal dysgenesis 443, 451, 465
mixed 467, 471
partial 465
pure 459
Gonadal examination 468
Gonadal regression 465
Gonadectomy 457f, 472, 473t
timing of 472
Gonadoblastoma 95
Gonadotropin 358, 367, 370, 372, 413, 447, 595
dose of 373
indications 372
induction 373
preparations of 372
regimens 373
regulators 591
risks 373
use 601
Gonadotropin releasing hormone 162, 168, 358, 370, 383, 414, 429, 450, 470, 482, 492, 521, 522, 525, 595, 601, 612, 637, 719
agonist 123, 165, 427
analogs 370
antagonist 522
protocol 383
stimulation test 497t
Gonococcus infection 827
Gonorrhea 44, 835
diagnosis 47, 836
signs 836
symptoms 836
treatment 836
Goserelin 522
Gossypol 719
Graafian follicle 587, 588, 590
Graft rejection 642
Gram stain 48
Gram-negative diplococci 44
intracellular 47, 836
Granuloma inguinale 837
signs 837
symptoms 837
treatment 837
Granulosa cell 70, 589, 591, 595
tumor 69, 97, 98, 98f, 496f, 497f
diagnosis 99
Grasping forceps, varieties of 769f
Grave's disease 270
Groin dissection 262f
Groove sign 837
Growth hormone releasing hormone 498
GTN See Gestational trophoblastic neoplasia
GTT See Glucose tolerance test
Gunshot lesion 519
Gynandroblastoma 97, 102
Gynecological disease 10
diagnosis of 49
Gynecological emergencies 121
Gynecological examination 4, 156, 439
Gynecological history, past 10
Gynecological malignancy, common 180
Gynecological perineum 28, 573, 819
Gynecological problems 499, 628
common 499
Gynecological surgery 10, 541, 763
abdominal 10
routine postoperative management in 778
Gynecology
imaging in 44, 49
investigative procedures in 44
operative 749
Gynecomastia 361, 362f, 459
Gynefix 690
200 IUD 690
330 IUD 690
H
Haemophilus ducreyi 833
Hair
balding loss of 444f
duration of survival of 432
follicle, structure of 431f
loss, permanent 431
phases 432, 432f
physiology 431
removal
laser-assisted 430
physical methods of 430
structure 431
types 432
HAIR-AN syndrome 409, 410f, 424, 479f
Hamartoma 493
Hand instruments 768, 769f
grasper 769f
monopolar hook 769f
scissors 769f
Hanging drop test 771
Haploid 587
Hart line 253
Hasson technique 771
Haultain's technique 762, 762f
Hawkin-Ambler's cervical dilator 727, 742, 742f
hCG See Human chorionic gonadotropin
Heart disease, complicated 712
Heavy bleeding per vagina 212f
Heavy menstrual bleeding 8, 9, 105, 142, 146, 147, 151, 154, 167, 168, 528, 529, 531f
causes 8
Heavy menstrual bleeding See also Menorrhagia
Hegar's cervical dilator 727, 742f
Hegar's dilator 742
Hematochezia 516
Hematocrit estimation 146
Hematogenous spread 187, 221
Hematometra 49, 445f, 447f
Hematuria 507
Hemiuterus, pregnancy in left 630f
Hemorrhage
secondary 327
severe 128
Hemostasis 129
Heparin, low-molecular-weight 782
Hepatic artery ligation 208
Hepatic metastasis 85f
Hepatitis
B virus surface antigen 390
C virus 390
Hereditary nonpolyposis colorectal cancer 10
syndrome 180, 194
Hermaphrodite, true 466, 467
Herpes simplex 231
virus 255, 833
Heterogenous structural pattern 174
Heterologous sarcoma 197
High-arch palate 452f
High-body mass index 614
HIPEC therapy 103
Hirsutism 14, 14f, 337, 402, 412, 415f, 418, 419f, 432, 444, 444f
basic factors for 418
causes 418
common causes 418
evaluation 423, 426
management 417, 426
medications causing 421, 422t
therapy 427, 427t
treatment 504
Hitrelin 522
HMB See Heavy menstrual bleeding
Hodge-Smith pessary 731, 746, 746f
Homogeneous thickened endometrium 174
Homologous recombination deficiency 103
Hormonal contraceptive 143, 653
Hormonal suppression 427
Hormonal treatment 170
without hysterectomy 192
Hormone 404, 492, 532, 618
changes in menopause 613
pill 655, 656
estimation 349
in infertility workup 348
first 612
history of 156
in infertility 349
levels 367t
noncyclic 414
producing 97
profile 366
replacement therapy 181, 618
synthesis 420f
therapy 473, 616618, 620, 621
in menopause 621
indications 190, 473
risks 621
role 620
Horseshoe-shaped incision 643
Host cells 232
HPO See Hypothalamic-pituitary-ovarian
HPV See Human papilloma virus
HSG See Hysterosalpingography
Hulka-Clemens spring clip 706
Human body, fluid compartments in 782
Human chorionic gonadotropin 158, 207f, 492, 592
Human epididymis protein 4 65
Human immunodeficiency virus 231, 234, 390
testing 843
Human leukocyte antigen 462
Human papilloma virus 239, 241f, 255, 265, 505, 658
infection 228, 232, 255
high-risk 255
role of 232
testing 234, 237, 243
transmission of 232
types of 232
vaccine 246
Husband's semen analysis 338
Hyaline degeneration 120
Hybrid leiomyomas 117
Hydatidiform mole 202f, 204, 208
partial 203f
Hydrocortisone 422
replacement therapy 488
Hydropic degeneration 202f
Hydroxyprogesterone 405, 420, 480
Hydroxysteroid dehydrogenase 419
Hymen 623
HYPEC 103
Hyperandrogenemia 415fc, 419
Hyperandrogenic-insulin-resistance acanthosis nigricans syndrome 409
Hyperandrogenism, causes of 405, 411
Hyperestrogenemia 486
Hypergonadotropic hypoestrogenic anovulation 358
Hypergonadotropic hypogonadism 442, 460
anovulation 358
Hyperinsulinemia 414, 415, 415fc
degrees of 411
testing of 411
Hyperkalemia 469
Hyperlipidemia 616, 620
Hyperplasia 613
atypical 173
complex 173
simple 173
with atypia, simple 173
Hyperprolactinemia 158, 340, 358, 360, 374, 413, 474, 477, 482484
bilateral galactorrhea in 479
causes 483
effects 484
incidence 482
treatment 484
secondary 485
without galactorrhea, causes of 483
Hypertension 180, 360, 616
uncontrolled 658
Hyperthermia 560
Hypertrichosis 418
medications causing 421, 422t
Hypertrophic cervix with leukoplakia, prolapse with 282f
Hypertrophy 35
clitorial surgery for 472
Hyphae, typical 834
Hypochondrium
left 20
right 20
Hypoglycemia 462
Hypogonadotropic hypogonadism 340, 358, 372, 434, 437, 437f, 443, 462
amenorrhea 442
causes of 462, 462t
Hypomenorrhea 8, 147, 148
Hyponatremia 462
Hypo-osmotic swelling test 365, 368
Hypoplasia 456, 466
Hyposmia, presence of 463
Hypospadias 459f
sever 390
Hypothalamic amenorrhea 474, 481
Hypothalamic hamartoma 493f
Hypothalamic-pituitary
compartment 414
ovarian 151, 171, 414, 415fc
Hypothalamus 462
arcuate nucleus of 595
Hypothesis 807
Hypothyroidism 158, 340, 358, 403, 413, 474, 485f
Hypoxia, postoperative 782
Hysterectomy 126, 128, 169, 172, 174, 245, 328, 532, 749, 756
clamp 728, 744, 744f
sterilization 744
uses 744
complications of 756
consent of 128
extended 749, 750
indications 245, 755
radical 749, 750
specimen 197f
steps 786
total 750
subtotal 749, 785
supracervical 749, 750
time of 756
total 79, 749, 785
type 224, 224t, 749, 750
Hysteroflator 775
Hystero-laparoscope 357
Hysterosalpingo-contrast-sonography 356
Hysterosalpingography 54, 54f, 341, 353, 794, 794f, 796, 797, 797f, 798, 798f, 800
advantages 354
cannula 354f, 731f, 747, 747f
indications of 747
catheter 356f
complications of 795
contraindication 356, 795
disadvantages 354
indications of 795
Hysteroscope 705, 774, 775t
ambulatory, office, outpatient 774
complications 776
contraindications of 776
distention media 775
indications 774
procedure 776
Hysteroscopic guided biopsy 157
Hysteroscopic metroplasty 634
Hysteroscopic myomectomy 127
Hysteroscopic septal resection 634f, 777f
Hysteroscopic surgery 765
Hysteroscopic telescope 733f
Hysteroscopy, procedure of 776f
Hysterosonography 52, 159
Hysterosonosalpingography 50
I
Iatrogenic dissemination 513
Iceberg sign, tip of 75
Idiopathic hirsutism 422
Idiopathic hypogonadotropic hypogonadism 463
Idiopathic precocious puberty 493f
IGFBB See Insulin like growth factor binding protein
IHD See Ischemic heart disease
IHH See Idiopathic hypogonadotropic hypogonadism
Iliac artery, common 124f
Iliac fossa
left 20
right 20
Iliac lymph nodes, external 257
Iliac spine, anterior superior 262f
Iliococcygeus
arises 284
colpopexy 306
Iliopectineal ligament 562
Imipramine hydrochloride 561
Immature cells, presence of 229
Immature teratoma 71, 93, 95, 96f
prognosis 96
treatment 96
Immotile cilia syndrome 340, 361, 598
Immotile sperm, diagnosis 368
Immune tolerance 609
Immunofluorescence 829
Immunological factors 369
Immunological test 368
Immunoperoxidase staining 365
Immunosuppression drug 234
Imperforate hymen 28, 30f, 445f, 446f, 456, 456f
Implanon 650, 669
Implantation 586, 605, 606
failure 412
luteolysis, absence of 596
morphological steps of 607
process 607f
window 606
Impotence 390
In vitro fertilization 341, 348, 382, 386, 526, 844
basic steps 383
steps 385f
Incontinence
contribute to 556
of stool, causes of 7, 575
of urine, causes of 7
pessaries 560
true 553
Infection
postoperative 642
prevention, postoperative 781
Infertility 335, 339, 340, 360, 412, 531, 794, 831
abdominal examination 338
and ectopic pregnancy 832
D and C in 761
diagnosis of 403
differential diagnosis 339
evaluation, part of 348
gynecological examination 338
history of 335, 531f
in endometriosis 517
incidence of 339
investigations 338
ovarian volume 49
physical examination 337
provisional diagnosis 339
secondary 341
treatment 797
types 339
unexplained 382, 394
vaginal examination 338
with endometriosis 382
relation of 517
workup 349
Inflammatory bowel syndrome 510
Inflammatory skin, chronic 265
Inflatable cushion 555
Infracoccygeus sacrocolpopexy 306
Infracoccygeus vaginal sling needle, posterior 306, 330, 331f
Infundibulopelvic ligament 80, 80f, 551
clamping of 753f
suture of 751f
Inguinal canal 821
Inguinal glands, bilateral 793f
Inguinal incision left side, after repair of 262f
Inguinal lymph group, superficial 257
Inguinal lymph nodes 252
Inguinal lymphadenectomy 793
Inguinal nodes, deep 257
Inguinofemoral lymphadenectomy 261
bilateral 260f
Inhibin 612
A 591
B 591
decrease of 613
Injectable contraceptives 666
advantages 667
depo-provera 666
depo-subQ provera 666
disadvantages 668
efficacy or failure rate 667
sayana-press 666
side effects 668
types 666
and formulation 666
Insemination 393
artificial 400
Insler score 345
Inspection and speculum examination 271, 278
Instruments 725, 757f, 774
cervical dilator 757f
falope ring 769f
female metallic catheter 757f
for laparoscopic ligation 705f, 769f
identify 725
loader 769f
multiple teeth vulsellum 757f
pusher 769f
scope 769f
Sims' speculum 757f
sponge holding forceps 757f
tong 769f
trocar cannula 769f
uterine
curette 757f
sound 757f
Insufficient follicular development 151
Insulin 418
resistance 411
sensitizing agents 370, 412, 413, 427, 429, 504
Intercourse, painful 615
Intermenstrual bleeding 8, 116, 116f, 140, 142, 147, 154
International Federation of Gynecology and Obstetrics 86, 207f, 258
Interval debulking surgery 90
Intestines, tuberculosis of 841f
Intra-abdominal pressure 570
Intracesarean insertion 690
Intracytoplasmic sperm injection 394, 395f
advantages of 396
indications of 394
procedure of 395
results of 396
sources of sperm in 395
Intraepithelial neoplasia 232, 268, 269
Intramural fibroid 121f
Intramural fundal fibroid 117f
Intramural single fibroid 116f
Intraperitoneal chemotherapy 102
dose of 103
Intraperitoneal exfoliation 187
Intraperitoneal hemorrhage 121
Intraperitoneal implantation 221
Intrauterine contraceptive device 11, 46, 143, 158, 645, 648, 674, 686f, 689f, 723, 795, 800, 800f, 802f
advantages of 678
complications of 684
copper containing 674, 677, 679
frameless 674, 690f
hormone releasing 674
inert 674
levonorgestrel 674
misplaced 685f, 803f
noncontraceptive uses 679
pregnancy with 686
progesterone 674
removal 687
steps of insertion 680
types 674
Intrauterine device 647, 663, 691, 724
Cu-T 380a 724
multiload Cu-375 724
Intrauterine insemination 389, 394f, 526
cannula 393f
donor 390
indications of 390
set-up 392f
steps of 390fc
Intrauterine progestogen releasing systems 164
Intravenous
antibiotics 781
chemotherapy dose 102
fluid 779
pyelogram 454, 639
pyelography 539
role of 539
Introitoplasty 500
Invasive cancer 229f
cervix 237
in colposcopy 240
Invasive carcinoma, development of 233fc
Invasive disease, staging of 219
Invasive mole 203, 204
Invasive tumors 269
Invasive vulvar cancer 258
Involution, stage of 592
Ipsilateral renal anomaly syndrome 629, 631f
Iron therapy 161
Irritable bowel syndrome 507, 521
Irving technique 703, 703f, 704
Ischemic heart disease 167
IUCD See Intrauterine contraceptive device
IUI See Intrauterine insemination
IVF See In vitro fertilization
IVF-ET See In vitro fertilization and embryo transfer
J
Jaundice 14, 107
history of 658
Jones metroplasty, modified 640
K
Kallmann syndrome 358, 438, 441, 443, 463
Kartagener's syndrome 361f, 364, 598
Karyotype 447, 503
abnormal 451
XY 460
Kegel's exercise 303, 560
Kelly placenta forceps 732f
Kelly's forceps 688, 688f, 689f
before withdrawal of 689f
Kelly's operation 562
Kelly's plasty 307
Keratinocyte function 417
Ketoconazole 427, 429
Keyes punch biopsy 254, 267
Khanna's abdominal sling operation 327
Kidney, palpation of 20, 21f
Kiss ulcer 253, 253f
Klinefelter syndrome 340, 361, 362, 362f, 400
diagnosis 401
karyotype 400
phenotype 400
prevalence 400
semen analysis 400
treatment 401
Koch's disease 575
Koch's peritonitis 60
Kocher's artery forceps 728f
Koilocytosis 232
Korotkoff phase 16
Kroener's fimbriectomy technique 704, 704f
Krukenberg tumor 101, 101f, 791, 791f
histology 101
management 102
prognosis 102
Kustner's operation 763
L
Labia
fusion of 500f
majora 624, 819
minora 624, 819
normal 279
Labial adhesion 500, 500f
Labial agglutination 500
Labial fusion 419f
Lactational amenorrhea method 698, 722, 723
advantage 698
disadvantages 698
failure rate 698
Lactobacillus 826
LAM See Lactational amenorrhea method
Landon's bladder retractor 730f, 745, 745f
sterilization 746
uses 745
Landon's retractor 300, 322, 323f, 324f
Lane's tissue forceps 728, 744, 744f
Lanugo hair 432
Laparoscope, telescope of 733f
Laparoscopic chromopertubation test 357
advantages 357
disadvantages 357
Laparoscopic dye test 357f, 773f
Laparoscopic hysterectomy, total 766
Laparoscopic ligation 705
set 733f
Laparoscopic myomectomy 127, 127f, 766, 773f
Laparoscopic ovarian drilling 377, 413, 413f, 766, 773f
Laparoscopic procedure 770
Laparoscopic radical hysterectomy 226
Laparoscopic sterilization 705
advantages of 707
disadvantages of 707
Laparoscopic surgery 382, 765
advantages of 765
contraindications 766
diagnostic 766
disadvantages of 766
hand instruments 768
indications 766
informed consent 770
Laparoscopic uterine artery occlusion 132
Laparoscopic vaginoplasty 455, 640
Laparoscopy 350, 797, 829
chromopertubation test 343
complications of 773
diagnostic 447
in endometriosis, role of 518
late complications 774
perioperative complications 773
role of 115
surgical 766
Laparotomy 84f, 127, 497f, 800f
complication of 708
steps of 79
LARC 691
Latent syphilis 839
Lateral sulci, absence of 289f
Latzko vaginal repair 546
Lawson Wilkins Pediatric Endocrine Society 463
Lax perineum 287, 288
Le Fort's operation 307, 327
procedure 327
Le fort's operation See also Colpocleisis 327
Leg raising test 22
Leg veins 15, 107
Leiomyoma 117f, 119, 153f, 154
in sonography 113
microphotograph of 119f
subclassification system 117
Leiomyomatosis 112
Leiomyosarcoma 120, 197, 197t, 254
Leprosy 360
Leptotene 586
Lesion 252
bilaterality of 65
nonuterine local 148
types of 519
Letrozole 358, 370, 372
Letrozole See also Aromatase inhibitors
Leucorrhea, causes of 46
Leukocytes 365
Leukocytosis 828
Leukocytospermia 365
Leukoplakia 239
history of 248
vulva 28f
Leukorrhea 45
pathological 46
physiological 46
Leuprolide 522
acetate 165, 167
Levator ani muscle 284, 315
Levonorgestrel intrauterine system 521, 523, 645, 650, 676, 676f, 677f
mirena 676f
Levonorgestrel-releasing intrauterine system 164, 168, 171
Leydig cell 600
LH See Luteinizing hormone
Libido 619
decreased 615
Lichen sclerosus 265, 270
diagnosis 270
etiology 270
symptoms 270
treatment 270
Life table method 650
Ligament
anterior longitudinal 329
pubocervical 311
pubourethral 554
Ligation, complications of 708
Lipid profile, abnormal 404, 410
Lipoma 819f
Lippes loop 675
Lithotomy position 566, 759f
Liver 20
cirrhosis 658
disease 360
active 658
palpation of 21f
LNG-IUS See Levonorgestrel-releasing intrauterine system
Long-acting reversible contraceptive 691
advantages of 691
contraindications 692
Longitudinal vaginal septum 637
diagnosis 637
treatment 637
L-ornithine decarboxylase 429
Low back pain 831
Lower abdominal pain, chronic 831
Lower uterine segment cesarean section 2
LUCS See Lower uterine segment cesarean section
Lugol's iodine 237, 243
application of 242f
Lumbar region 20
Lump abdomen 55, 100f, 488f
case of 55
differential diagnosis 58
gynecological examination 56
physical examination 56
provisional diagnosis 58
Lump lower abdomen, causes 7, 58
Luteal follicular transition 588
Luteal phase defect 347, 348
diagnosis 348
management 348
Luteal-placental shift 592
Luteinized unruptured follicle 348
Luteinizing hormone 338, 343, 358, 441, 481, 492, 591
midcycle 588
secretion 655
Luteolysis 592
Lymph node 222t, 225f, 257, 270, 792f
degree of 257
dissector 732f
draining 792
involvement 265
paracervical 223
parametrial 223
superficial 262f
supraclavicular 84
Lymphadenectomy 190, 226, 226f
provision of 225
Lymphatic spread 85, 187, 221, 256
Lymphedema 837
Lymphogranuloma inguinale 837
signs 837
symptoms 837
Lymphography 255
Lymphovascular space involvement 222
Lynch syndrome 82, 181, 192, 194
cancers 192
M
Mackenrodt's ligament 283f, 285, 313, 318, 318f, 319, 325, 325f, 551, 752f
clamping of 755f
tightening of 317
Mackenrodt's stump 326
Macroadenoma 484
Macroprolactin 483
Madlener technique 704
Magic pill 647
Makler counting chamber 364f
Mala N 655f, 656, 663, 724
Male condom 646f, 650, 692, 692f, 724
advantages 693
contraindication 694
disadvantages 693
efficacy and failure rate 693
nirodh 724, 663
Male contraception, hormonal method of 718
Male contraceptive 717, 719
Male factor infertility
etiologies of 340
management of 389
Male gender, assignment of 471
Male genital
system, development of 622
tract, normal anatomy of 713f
Male hair pattern 419f
Male infertility 360
assessment of 366
causes of 340, 360, 360t
medical management in 389
Male pseudohermaphrodite 465467
Male reproductive tract 602f
Male sterilization 712
medical eligibility criteria for 717
Male subfertility 366, 368
treatment for 389
Malignancy index, risk of 65t
Malignant melanoma 254, 271, 819
vagina 272f, 273f
Manchester operation 320
Marshall's test 557
Marshall-Marchetti colposuspension 562
procedure 562
Marsupialization 824, 824f
Masking 811
Mass, causes of 40
Maternal origin androgen excess 466
Matrix metalloproteinase 608, 609
Maturation index 618
Mayer-Rokitansky-Küster-Hauser syndrome 434, 435, 435f, 453, 453f, 455t, 465, 625, 638
incidence of 639
investigations 639
treatment plan 639
Mayo's operation 323f
Mayo's scissor 729f
Mcburney's point 772
McCall culdoplasty 306, 307, 332
Mccune-Albright syndrome 494
Mcindoe technique 641
Mcindoe vaginoplasty 642f
Mcindoe-Reed operation 639
Medical abortion 700
Medical management in incontinence, role of 560
Medical termination of pregnancy 341, 647
ligation 700
Medroxyprogesterone acetate 167, 168
Meigs' syndrome 64, 75, 102
Meiosis 586
Membrana granulosa 590
Menometrorrhagia 147
Menopausal hormone therapy 618
Menopausal symptoms 522, 620
Menopausal syndrome 167
Menopausal transition 610, 611, 612, 619, 621
women in 617
Menopausal women 617
Menopause 8, 286, 610, 612, 621
and cyclic therapy 619
consequences of 613
effects of 613, 614t
established 612
management of 610, 618
physiology of 612
premature 10
transition, endometrium in 613
Menorrhagia 8, 9, 11, 105, 146, 147, 499, 510
causes of 111
Menorrhagia See also Heavy menstrual bleeding
Menstrual abnormality 5, 486, 831
types of 407
Menstrual blood loss 146
Menstrual calendar 146
Menstrual cycle 596, 611
normal 664
Menstrual disorders 499
Menstrual function 450
irregular 487
Menstrual history 7, 275, 536
Menstrual pattern, types of abnormal 147
Menstrual period
final 611
last 106, 210, 336, 570
Menstruation 151, 497f, 586, 595
bleeding phase 595
cessation of 610
control of 441fc
normal 146
occurs 595
physiology of 592
Mesenteric cyst 43, 60
Mesh, placing of 331f
Mesosalpinx 325
Mesovarium 80, 80f
Meta-analysis 811
Metabolic syndrome 415, 416
diagnostic criteria of 416
management of 416
monitoring for 416
prevalence of 415
Metal catheter 736, 758f
Metallic clip, application of 718
Metallic malleable uterine sound, graduated 727, 740f
Metaplasia theory 513
Metastasis over peritoneum 89f
Metastatic ovarian tumor, secondary 791
Metastatic tumor 254
secondary 101
Metformin 375, 429
dose 375
indication 375
mode of action 375
side effects 375
Methyldopa 422
Metoclopramide 422, 780
Metropathia hemorrhagica 174
mimicking 70
Metroplasty in septate 388
Metrorrhagia 8, 140, 147, 148
cause of 112
Metrorrhagia See also Intermenstrual bleeding
Metzenbaum scissor 309
Microadenoma 484
Microinvasive disease, staging of 218
Microprolactinoma bromocriptine 375
Microsurgery 381
principle of 381
Microwave ablation 170
Micturition
cycle 554
cystourethrography 559
mechanism of 554
Midluteal serum progesterone 349
Midurethral sling 562, 563f
Mifepristone 124, 521
side effects 124
Migraine aura 658
Milestones of Family Planning Program 724
Mini pill 663
Minilaparotomy 703
Minimally invasive surgery 765
Minoxidil 422
Mirabegron 561
Mirena 676f
insertion 683f
made ready 682f
introducer withdrawn gently 683f
method of insertion of 682
with applicator 164f, 645f
Missed progesterone-only pill, management of 665t
Missing pill, management of 660t
Missing string, causes of 801
Mistimed pregnancy 723
Mitra's operation 226, 792
Mittelschmerz 344
Miya hook 330
Molar pregnancies 202
Molluscum contagiosum 838
treatment 838
virus 833
Monophasic pill 654, 655
Mons pubis 819
Mood disturbances 614
Mood symptoms 620
Morning after pill 672
Mosaic pattern 239
Mosaic turner syndrome 443, 451
Mosquito forceps 728f
tip of 500
Motile protozoal organism 834
Motor apparatus 598
MPA See Medroxyprogesterone acetate
MRKH See Mayer-Rokitansky-Kuster-Hauser syndrome
Mucinous cystadenoma ovary 73f
Mucinous tumors 68
Mucous polyp 139
Müllerian agenesis 443, 453
Mullerian anomaly 49, 53, 455, 456, 499, 627, 800
classification 624, 624f
system for 625, 626f
development of 622
diagnosis of 627
effects of 627
gynecological problems 627
management of 505
prevalence of 626
surgery on 764
surgical methods in 640
Müllerian duct 623
aplasia 638
incomplete development of 625
syndrome 466
Müllerian hypoplasia 624
Müllerian knob 454, 638
Müllerian origin 623
Müllerian ridge 454
Mullerian structure 459, 473, 622
Müllerian tumor 197
Müllerian, renal, cervicothoracic somite syndrome 454
Multichannel cystometrics, procedure of 558
Multiload
375 with inserter tube 645f
copper 375 675, 675f
Cu-375 663, 675, 676f
procedure of insertion of 682
technique of insertion of 682f
Multilocular cyst 65
Multiloculated mucinous cystadenoma 73f
Multinucleated syncytiotrophoblast 204f
Multiphasic pill 654
Multiple fibroid 118f
after myomectomy 132f
in parous woman 787f
Multiple gestation 373
Multiple pregnancy, risk of 371
Multiple sclerosis 360
Multiple small follicles 480f
Multiple small hypoechoic cysts 50f, 406f, 407
Multiple teeth vulsellum 141f, 727f, 740, 740f, 759f
uses 740
Mumps 360
Musculo-muscularis 380f
Musset's classification 633
Mycobacterium tuberculosis 827
Mycoplasma hominis 378, 827
Myohyperplasia 175f
Myoid cells 600
Myolysis 126, 132
Myoma 109, 114
bed
after enucleation 131f
closing of 129f, 132
enucleation of 131f, 137
puncture 132
screw 729f, 745, 745f
sterilization 745
uses 745
stalk of 129f
traction of 131f
Myomatous erythrocytosis syndrome 112
Myomectomy 126128, 128f, 130f, 137, 169, 172
disadvantages 132
open 128
risks 128
routes 127
Myxoid degeneration 121
N
Nabothian follicle 231
Nafarelin 522
Nanoparticle paclitaxel 103
NATAZIA 654
National Institute for Health and Care excellence 561
National Institute of Health 405, 406
Nausea and vomiting, postoperative 780
Necrozoospermia 364, 365
Needle holder 730f
with ratchet 769f
Needle suspension 563
Neisseria gonorrhoeae 47, 378, 500, 827, 830, 833
Neoadjuvant chemotherapy 88, 90
Neocervix 320f
creation of 638
formation of 317, 320f
Neoplasia
degree of 229
high-grade 232
Neoplastic disease 658
Nerve damage, magnetic stimulation for 560
Nestorone 653
Neurological disorders 390
Neurological systems 17
Nexplanon 670
Nexplanon
method of insertion of 670
rod 670f
with applicator 670f
NICE See National Institute for Health and Care excellence
NIH See National Institute of Health
Nipple, examination of 211, 572
Nitrous oxide 243
No touch technique 680
Nocturnal penile tumescence 361
Nomegestrol 653
Nongestational choriocarcinoma 97
Nonhormonal agents 719
Nonhormonal antiresorptive agents 620
Nonhormonal drug 170, 619
Nonlactating puerperal mother women 664
Nonneoplastic epithelial disorders 268
Nonoxynol-9 696
Non-postabortal women 656
Nonscalpel vasectomy 713, 714f, 715f, 763
dissecting forceps for 732f
Nonsexual hairs 432
Nonsteroidal anti-inflammatory drugs 54, 143, 162, 167, 521, 525
Nonsteroidal oral contraceptive 649
Nontouch technique 689f
Norelgestromin 203 671
Norethisterone enanthate 667
Norethynodrel 653
Normal menstrual bleeding, mechanism of 151
Normal ovulatory menstrual cycle, regular 612
Normozoospermia 365
Norplant 2 rods 669f
Norplant system 669, 691
NSAIDs See Nonsteroidal anti-inflammatory drugs
Nuclear syngamy 602
Nucleic acid amplification technique 836
Nulliparous 5
cervix 240f
prolapse 286, 286f
women 286
Nuvaring combined hormonal ring 671f
O
Obesity 158, 486, 616
Obligate intracellular bacterium 836
Obstetric fistula 533
Obstetric history 2, 2t, 106, 156, 210, 275, 336
past 9
Obstructed hemivagina 629, 631f
Obstructive azoospermia 364, 394
Obstructive pulmonary disease, chronic 813
Obturator device, composite set of 568f
Obturator fossa 226f
OC See Oral contraceptive
Office aspiration biopsy 182
OHSS See Ovarian hyperstimulation syndrome
Olaparib 103
Oligo ovulation 369
Oligoasthenospermia 390
Oligoasthenoteratozoospermia 365
severe 394
Oligomenorrhea 8, 147, 148, 402, 407, 408, 479f
Oligoovulation
causes of 412
surgical management in 377
Oligoovulation See also Anovulation
Oligospermia 364, 367, 390
Oligozoospermia 365
severe 367
Omentum, part of 685f
Ondansetron 780
Oocyte 386f
cryopreservation of 397
depletion 613
donation 397
maturation inhibitor 588
mature 590, 591, 591f
pick-up 603
primary 586, 588, 591
secondary 587, 588, 590, 591
Oogenesis 587f
process of 586
Oogonia, atresia of 587
Oolemma 367
Oophorectomy 78, 79, 421f, 756
fallopian tube 81
pedicle in 80
Oophoropexy 77
Operation theater 767, 767f
arrangement in 767
set-up 767, 767f, 768f
Operative hysteroscope 733f
instruments 775f
Ophthalmoscopic examination 17
Opportunistic salpingectomy 81, 709
Oral conjugated estrogen, low-dose 619
Oral contraceptive 168, 427, 428, 652
contraindications of 658
pills 11, 170, 524, 652
Oral pill, types of 662
Oral progesterone 166
regimen of 163
Oral progestins 162
Orchidectomy estrogen therapy 458
Orchitis 340
Original Papanicolaou classification, grades of 237t
Orilissa 523
Ormeloxifene 665, 724
Osteopenia 616
Osteoporosis 615
prevention and treatment of 620
treatment of 620
Otoxynol-9 696
Outflow tract obstruction 453
Ovarian androgen production, stimulation of 414
Ovarian apoplexy 70
Ovarian arteries 593
Ovarian cachexia 12f, 83f
Ovarian cancer 81, 82, 104
early stage 88
family history of 83
investigations of 83
prevention 709
prognostic factors for 92
risk factors for 82
screening 82
stages 86, 87f, 86t
Ovarian cycle 343f, 589f
Ovarian cyst 23f, 59f, 79f, 789f
following cystectomy 789f
large 23f, 515
unilateral multiloculated 73f
management 81
rupture 77, 77f
torsion 75, 76f
Ovarian cystectomy 78, 78f, 763, 773f, 789, 790f
specimen 497f
Ovarian development, disorders of 466
Ovarian drilling 764
Ovarian endometrioma 519
cystectomy of 526
laparoscopic visualization of 518
management of 524
wall of 515
Ovarian endometriosis, types of 515
Ovarian failure 481
primary 413
Ovarian follicles
depletion of 613
developments of 588
Ovarian function 517
Ovarian hormones 589f, 591
cyclical changes of 343f
Ovarian hyperstimulation 383
controlled 370, 383
protocols of controlled 383
Ovarian hyperstimulation syndrome 50, 71, 370, 375, 376f
diagnosis of 376
pathophysiology of 376
prediction of 377
prevention 377
risk of 413
signs 376
symptoms 376
treatment of 376
Ovarian hyperthecosis 409
Ovarian insufficiency, primary 474, 486
Ovarian ligament 80, 80f, 325, 753f
Ovarian malignancy 41, 81, 102
operation on 763
pleural effusion in 85
Ovarian masses, causes of 68
Ovarian morphology 406, 407f
Ovarian neoplasm 93, 423
adolescents 502
children 502
classify 68
types of 502
Ovarian pathology 49
Ovarian pedicle, clamping of 80f
Ovarian pregnancy 9
Ovarian reserve 349, 350, 612
diagnose 352
markers of 351
Ovarian response, monitoring of 374
Ovarian steroids 595
Ovarian stimulation 391
Ovarian teratoma, classification 71
Ovarian tissue, cryopreservation of 397
Ovarian torsion, feature of 76f
Ovarian tumor 55, 59, 62, 75, 84f, 421f, 789
benign features of 66t
bilateral 791f
malignant 89f
common variety of 71
complications of 75
diagnosis of 61
in pregnancy 103
malignant 53f, 67f, 83, 84f, 85f, 790f, 791
features of 66t
management 502
operations 763
pedicle of 80f
surgery in 503, 789
torsion of 5
type of 66
Ovarian vascularity 351, 353
Ovarian volume 351, 353
Ovary 420
advantages of keeping 756
before ovulation 350f
benign cyst of 789
chocolate cyst, right 531f
dermoid cyst of 74, 74f
disadvantages of keeping 756
immature teratoma of 96f
malignant tumor of 96
specimen, dermoid cyst of 790f
thecoma fibroma of 102
tumors of 68f
Overactive bladder
causes 555
drugs in 560
Ovulation 371, 588, 591
cervical mucus, after 345f
detection of 342, 343
diagnosis of 342, 343
disorder of 150
inducing drugs 358
induction 370, 413
indication of 370
inhibition 670
medical induction of 370
physiology of 343, 586
Ovulatory bleeding 151, 151t
Ovulatory dysfunction 158, 370, 390
management of 370
Ovulatory follicle 588
Ovulatory heavy menstrual bleeding, treatment of 163
Ovum forceps 725, 734, 734f
sterilization 734
uses 734
Oxybutynin 561
P
Pachytene 586
Paclitaxel 103
Pad test 557
Paget's cells 270
Paget's disease 265, 268, 269
Pain management, postoperative 781
PAIS See Partial androgen insensitivity syndrome
Palm 152f
group 153
Palm-Coein classification 152, 152fc
Palmer's point 771
Palpation 20, 298
deep 20
superficial 20
Pap smear 45, 45f, 235, 235f
abnormal 235f
screening 157
Pap stain, role of 184
Pap test 45
Papanicolaou
classification 237
grades 237
slide method 236
system 238
test 42, 45
Papanicolaou test See also Papanicolaou test
Papillary cystadenoma 76
Paraaortic lymph node 223
dissection 89f
Para-aortic lymphadenectomy 189
Para-aortic nodes 257
Paracrine defects 150
Paracrine regulation, defective 601
Paracrine regulators 591
Paramesonephric ducts 623
unfused 623
Parametrial involvement 215
Parametrial resection 224
Pararectal space 330
Parasitic cyst 77
Parasitic fibroid 117, 118
Parathyroid hormone 620
Paravaginal defect 299
large 307
repair 308
Paravaginal fascia 562
Parent to Child Transmission Program, prevention 830
Parkland technique 704, 704f
Parovarian cyst 137
Paroxetine 619
Partial androgen insensitivity syndrome 456, 456f, 459, 459f, 471, 473
Patent tubes, bilateral 54f, 354f
PCOS See Polycystic ovary syndrome
Pearl formula 645
Pediatric gynecology 499
common problems in 499
Pegylated liposomal doxorubicin 91
Pelvi-abdominal cavity 62
Pelvic abscess 49, 327
Pelvic adhesion 531f
Pelvic brim 551
Pelvic causes 147
Pelvic cavity, spillage of dye in 354
Pelvic discomfort 135
Pelvic endometriosis 41, 511, 512, 524f
Pelvic examination 36, 557, 711
Pelvic fascia 284
Pelvic floor
exercise 303, 555
musculofascial structures of 578
repair 307, 321
strengthening 560
Pelvic genitalia examination 445
Pelvic infection 327, 708
natural barrier of 826
Pelvic inflammatory disease 49, 115, 378, 750, 826, 830
clinical features
of acute 828
of chronic 831
features of 826
indications of surgery in 831
investigations for chronic 832
management of acute 829
organisms responsible for 827
pathology
of acute 827
of chronic 828
risk factors 827
stages 828
types 826
Pelvic inflammatory disorder 5
Pelvic lymph nodes 223
Pelvic lymphadenectomy, indication of 189
Pelvic mass, evaluation of 67
Pelvic nodes 257
Pelvic organ prolapse 7, 35, 274, 275f, 282f, 292, 292b, 294, 295, 308, 615, 731f, 747f
abdominal examination 277
anatomical classification of 287
case 302, 305
classification 287
diagnosis of 294
differential diagnosis 279
etiologies of 286
four degree classification 290
grades of 289
gynecological examination 277
history taking 275
local clinical examination 296
management of 302
physical examination 276
pregnancy with 333
prevention 333
quantification 291f
system 290
stages of 290, 292, 292b
surgery in 305
symptoms 294
theory 288
three degree classification 289
vaginal examination 277
Pelvic organ prolapse-Q 290
classification 290
grading 293
grid 292
measurements 291t, 292, 292b
site-specific 291
staging, demonstration of 299
system, advantages of 293
Pelvic pain 5, 137, 155, 163, 499
acute 5
characteristics of 6
chronic 516, 517
deep 214, 516
midcycle 344
of different origin, characteristics of 6t
Pelvic part of ureter, blood supply of 548
Pelvic structures, relation of 284f
Pelvic tuberculosis 378, 712, 796, 841f
clinical presentation of 842
diagnosis of 843
Pelvis 511, 616
computed tomography scan of 53f
heaviness of 135
mass in 39
sonography of 496
X-ray 800f
Penetrating injury 582
Penile urethra 461
Percutaneous epididymal sperm aspiration 396f
Peri-implantation genetic diagnosis 397
Perimenopausal woman 46
Perineal body 300f
repair of 580
tone of 278, 299
Perineal fistula 28, 30f
Perineal muscle 315, 316f
Perineal pouch 643
Perineal skin 316f
Perineal stitches 580f
completed 580f
Perineal tear 28, 573
during delivery, prevention of 576
old complete 7f, 572f
repair of complete 764
types of 573
Perineorrhaphy 313, 577
method of 578
Perineum 257, 297, 575
deficient 28
structure of 576
Periodic abstinence 696
Peripheral precocious puberty 496
Peritoneal patches, yellow brown 519
Peritoneum
loose uterovesical fold of 751f
uterovesical fold of 323f, 754f
Permanent contraception 699
Persona 699
Pessary
placing of 746
test 302, 557
Pfannenstiel incision 327, 750
Phasic pill 655
Phenazopyridine hydrochloride 538
Phenothiazines 422
Phenotype 408
sex determination 464
Phenotypically female 460
Phenytoin 422
Photophobia 560
Phytoestrogens 619
Phytoprogestogens 619
Pill 661
biphasic 654
combined 663
containing
drosperinone 661
gestodene 661
emergency 663
extended 661
natazia 661
selection of 661
triphasic 654
zoely 661
Pinopodes 606
PIPAC 103
Pipelle
advantages of 54
biopsy 54, 54f, 160f
device, disadvantages of 160
disadvantages of 54
Pituitary adenoma 438
Pituitary downregulation 123
Pituitary hormones 589f, 591
cyclical changes of 343f
Pituitary tumors 358
Placenta 609
accreta 609
percreta 609
Placental polyp 140
Placental site trophoblastic tumor 201, 206f, 207f
Plant products 719
inhibiting spermatogenesis 719
Plastic vaginal mold 643f
Platelet aggregation 595
Platinum refractory 90
Platinum resistant 90
Platinum sensitive 91
Platinum-based chemotherapy 104
Pleural effusion 75
Plucking 430
Pneumoperitoneum 705, 771
POCSO Act See Protection of Children from Sexual Offences Act
POF See Premature ovarian failure
Polar body, second 588, 590
Polycystic ovarian disease 49
Polycystic ovarian morphology 50f, 406f
Polycystic ovarian syndrome 9, 122, 148, 151, 171, 180, 402, 405, 407f, 410f, 413f, 414, 415f, 415fc, 416, 438, 443, 474, 479f, 480f, 486f, 495, 499, 590, 766, 773f
adolescent 504
diagnostic difficulties 504
causes of 412
complications of 408
diagnose adolescent 411
diagnosing adolescent 411
diagnosis of 406
diagnostic criteria 405, 406t
differential diagnosis 433
etiology 409
incidence 409
management 413
adolescent 412, 504
pathophysiology 414
phenotypes 408, 408t
Polycystic ovary
bilateral 406f
diagnosis 357f
Polyembryoma 69, 93
Polyhedral cells, large 95f
Polymenorrhagia 8
Polymenorrhea 8, 147, 148
Polymenorrhea See also Epimenorrhea
Polymerase chain reaction 838, 843
Polyostotic fibrous dysplasia 494
Polyp 35
malignant 140
types of 139
Polyspermia 603
Pomeroy technique 701, 704, 701f
ligation by 701f
Pomeroy's procedure 700
Poor ovarian reserve, treatment of 353
POP See Pelvic organ prolapse
Population, percentage of 722f
Portio vaginalis 30f
Postabortal ligation 700
Postcoital bleeding 149
Postcoital contraception 672
Postcoital test 358, 368
Postcoital test See also Sims-Huhner test
Postmenopausal
atrophic cervix 242f
bone 616
woman 46, 184, 616, 790f
Postmenopausal bleeding 8, 176, 179, 193196, 215
causes of 193
common causes of 8, 179, 193
Postmenopause 612
Postoperative advice 716
Postpartum hemorrhage 2, 532
Postpartum intrauterine contraceptive device 646, 687, 688f, 732f
advantages of 687
insertion, timing of 688
program 723
Postpartum
ligation 700
sterilization 700
Postradiation fistula 585
Post-tubal sterilization syndrome 709
Potential tumor, low malignant 91
Pouch of Douglas 40, 134, 322f, 323f, 338, 351f, 509, 511
peritoneum in 323f
Powder burn 519
Power house 598
PPH See Postpartum hemorrhage
PPIUCD See Postpartum intrauterine contraceptive device
Prader staging 469
Preantral follicle 588, 589
Precocious puberty 490, 493f, 495
cause 496
classify 493
gonadotropin
dependent 493
independent 493, 494
incomplete 498
significance of incomplete 495
Prednisolone 429
Preeclampsia 609
Pre-ejaculatory prostatic fluid 698
Preinvasive lesion 265
of cervix, management protocol of 246fc
Premalignant endometrial hyperplasia 154
Premature ejaculation, treatment options of 399
Premature ovarian failure 341, 358, 413, 474, 477, 486
causes 486
diagnosis 487
therapy 487
Premature rupture of membranes 2
Premenopausal parous woman 785
Premenstrual spotting 344
Premenstrual syndrome 344
Preovulatory cervical mucus 346f
Preovulatory follicle 588
Prepubertal age, bleeding in 145
Prepubertal girl 501
Prerectal fascia 315, 579
plicated 315f
repair of 578, 579f
Prescribing pill 659
Primary invasive cancer cervix, management of 223t
Primary tumor, assessment of 220
Primordial follicle 587, 588
development of 586
Primordial germ cells 95f
Primordial gonads 622
Proapoptic agents 521
Procidentia 286f, 290
with pigmentation 298f
Progestational agent 653
Progesterone 123, 124, 174, 190, 349, 462, 588, 596, 612, 613, 619, 621, 652, 653
antagonist 521
challenge test 482
containing pill, lowest 661
effect of 344f, 347f
injectable 164
level 592
luteal-phase 163
only contraceptives 668
only injectable contraceptive 666
secretion 596
therapy 175
vaginal ring 671, 671f
Progesterone-only pill 181, 646f, 650, 663
advantages of 664
composition 663
contraindication 665
disadvantages 665
failure rate 665
mechanism of action 663
missing 664
side effects 665
timing for starting 664t
Progesterone-only preparation 163
types 651
Progesterone-receptor modulators, selective 521
Progestin 468, 652, 671
interventions 621
newer 653
only pill 647
replacement study trial 621
second generation 652
Progestogen 422, 521, 619, 644
discovery of 647
Prolactin 349, 404, 418
measurement of 484
nadir, time of 484
structure of 483
types of 483
Prolapse surgery 332
Proliferative endometrium 347f, 593f
PROM See Premature rupture of membranes
Pronuclei, formation of 604f
Prophylactic antibiotic 354
Prophylactic surgery, role of 83
Propionibacterium acnes 417
Prostaglandin 609
synthase enzymes 609
Prostatic secretions 597
Prostatitis 340
Protection of Children from Sexual Offences Act 814
Protruded cervix 333
Pruritus 533, 536
Psammoma bodies 72
Pseudo broad ligament 137
cyst 137f
fibroid 117, 138, 788f
small 138f
Pseudocapsule 119
Pseudocapsule See also False capsule
Pseudocervical fibroid 134
Pseudodecidua 594
Pseudo-Meigs syndrome 113
Pseudomucinous cystadenoma 76
Pseudomyxoma peritonei 77
Psoraleas 422
PSTT See Placental site trophoblastic tumor
Puberche 495
Pubertal development tanner staging, sequence of 499
Puberty 493
sequence of development of 448
Pubic hair 421f, 460, 499
development, sequence of 449f
growth of 450
normal 460
Pubic tubercle 262f
Pubocervical fascia 283, 285, 305, 311, 311f
repair of 311f
Pubovaginal sling 563
Pudendal artery, external 261
Pudendal nerves 554
Puerperal sepsis 10
Puerperal women 656
Pulmonary embolism 711
Punch biopsy forceps 216f, 729f
Purandare's abdominal sling operation 327
Purandare's sling 306
Pyelonephritis 294
Pyknotic nuclei 344
Pyometra 49, 192, 193f, 194
causes of 192
diagnosis 193
drainage of 193f
management 193
Pyridium 538
Q
Q-tip test 300, 557
Quadriphasic pill 654
Quadrivalent vaccine 247
Quinacrine pellets 705
Quinagolide 374
R
Radical complete vulvectomy 260f
Radical hysterectomy 223, 225, 792, 764, 773f, 792
components of 792
modified 190
steps of 225
Radical vaginal trachelectomy 226
Radical vulvectomy
complications of 263
steps of 261
Radiofrequency ablation 172
Radiofrequency-induced thermal ablation 169
Radio-radial delay 15
Raloxifene 620
Randomized control trial 810, 811
Rape 814
legal guidelines on 814
Rape victim
examination of 814, 815
female attendant 815
medical examination 814
valid consent 815
Reactive oxygen species 368, 597
Rectal and rectovaginal examination 84
Rectal buttonhole tear 574
Rectal examination 41f, 362
Rectocele 287, 288, 297, 298f, 299
and lax perineum 314f
presence of 334
repair of 315f
Rectovaginal area, examination of 212
Rectovaginal examination 41f, 215
Rectovaginal fistula 553, 582, 582f, 583f
acquired 582
causes of 582
congenital 582
diagnose 584
location 584
management 584
prevention 584
probe test 584
signs 584
symptoms 584
treatment 584
Rectovaginal septum 41
Rectovaginal space, dissection of 579f
Rectum and prerectal fascia 579f
Recurrent ovarian cancer 90
Red lesion 28, 519
References 809
harvard style 809
vancouver style 809
Reflexes 299
Regimen
A 829
B 830
Reid colposcopic index 240
Reifenstein syndrome 459, 466
Renal angle tenderness 17
Renal failure 214, 360
Reproductive ageing workshop, stages of 611, 611t
Reproductive disorder 415
Reproductive function 450, 460
Reproductive tract infection 830
Research 804
Reserpine 422
Respiration 15, 107
Respiratory depression 708
Respiratory disease, chronic 360, 361f
Respiratory system 17, 534
Retrograde ejaculation 390, 399
treatment options of 399
Retrograde pyelography 539
Retroversion, correction of 746
Retroverted gravid uterus 736
Retroverted uterus 37, 38f
Rhabdoid tumor, malignant 254
Rhabdomyosarcoma 197
Rhomboid-shaped incision 317
Ribonucleic acid 47
Ring forceps 734
Ring pessary 302f, 303f, 304f, 583f, 731f, 747, 747f
use 747
Risedronate 620
Ritu mala cycle-beads 697f
Ritumala 696
Rizzoli's operation 585
RMNCH +A 724
Robotic myomectomy 128
Robotic surgery 765, 777
Rodent ulcer 254
Rokitansky protuberance 74, 75
Rokitansky-Küster-Hauser syndrome 8, 359, 446f, 454f
Rosenmuller's node 257
Round cells 365
Round ligament 325, 511
suture of 751f
RTI See Reproductive tract infection
Rubber catheter 758f
simple 129, 726f
Rubber drain, corrugated 732f
Rubin's cannula 343
Rubin's test 343
Rucaparib 103
Rudimentary horn, pregnancy in 629
RVF See Rectovaginal fistula
S
Sacrocolpohysteropexy 329, 329f
Sacrocolpopexy 307, 328, 328f
Sacrohysterocolpopexy 307
Sacrospinous colpopexy 306, 307
Sacrospinous ligament 307, 330, 331
fixation 330, 330f
complications 330
steps 330
right 330
Saline infusion sonography 52, 52f, 157f, 158, 159, 356
advantage to 52, 161
contraindications 52
disadvantages 52
procedure 52
role of 159
Salpingectomy 756
during hysterectomy 756
Salpingo-oophorectomy 7880, 80f, 763, 788f, 789f
bilateral 73f, 78, 79, 79f, 189, 190, 524f, 749, 785, 790f, 791f
left-sided 489f
unilateral 96, 100
Salpingoscopy 357
Salpingostomy 379f
Salt-losing crisis 461
Salvage chemotherapy 91
Sampson's implantation theory 513
Sarcoma botryoides 271
Sarcomatous change 120
Sarcomatous change See also Leiomyosarcoma
Sayana-press 666f
Scalp hair 432
asynchronization of 432
Scar endometriosis 512f
cause of 512
Schauta's operation 225, 792
Schiller positive 237
Schiller's test 235, 237
Schroeder's disease 174
Scissor, curved 729f
Schuchardt incision 546
Sebaceous cyst 820
Secondary sexual characteristics, development of 492
Secretory endometrium 347f, 594f
transformation of 606
Segesterone acetate 671
Selective estrogen receptor modulator 124, 181, 370, 620
Semen 363f
analysis 362, 363, 401
computer-assisted 363, 368
collection 391
and analysis 363
composition 597
epididymis 597
prostatic secretion 597
testicular secretion 597
cryopreservation 397
donor 390
ejaculated 596f
fructose in 365
normal composition of 596
parameters 363t
preparation, swim-up technique of 392f
volume 364
Semen analysis See also Azoospermia
Seminal plasma, functions of 597
Seminal vesicle
congenital absence of 364
secretion of 364
Seminiferous tubule, cross section of 600f
Seminopathy, severe 390
Septate uterus 624, 633, 633f, 634, 798f, 799
complete 51f, 633f
diagnosis 633
normal-shaped 631
treatment 634
Septum, transcervical resection of 640
Serkal syndrome 466
SERM See Selective estrogen receptor modulator
Serous carcinoma 221
Serous cystadenocarcinoma 790
Serous cystadenoma
large 79f
ovary, microphotography of 72f
simple 76
Serous tumors 68
Sertoli cells 600
Sertoli-leydig cell tumor 99, 99f, 100f, 488, 488f, 489f
clinical presentation 100
treatment 100
Sertoli-stromal cell tumor 69, 99
androblastoma 97
Serum 157, 469
17-hydroxyprogesterone 488
estradiol level 481
follicle-stimulating hormone 492
inhibin B 352
prolactin 484
level of 483
testosterone 420, 435, 436, 480, 503
total 423
Sessile subserosal fundal fibroid 115f
Sex chromosome 464, 465
Sex cord 69
stromal tumors 97
tumor 69, 97
Sex hormone-binding globulin 415, 613
Sex steroid secreting tumor 494
Sexual behavior, change of 246
Sexual character, secondary 14, 337, 436, 445
Sexual development
diagnose disorder of 468
disorder of 434, 463, 465t, 467t
management of disorder of 504
Sexual differentiation 464
diagnosis of 470fc
disorder of 463, 464, 468, 470fc, 471t, 503
Sexual dysfunction 459, 615
treatment of 619
Sexual hairs 433
Sexual history 342, 361
Sexual history See also Coital history
Sexual orientation 470
Sexually transmitted
disease 10, 46, 265, 266, 678, 827, 832
history of 256
infections 48, 826, 830, 832, 833t
Sharman's curette 727, 743f
SHBG See Sex hormone-binding globulin
Sheehan's syndrome 358, 407
Shield chest 435f
Shigella 500
Shirodkar's abdominal sling operation 327
Short stature 435f
Sigmoidoscopy 272
Signet-ring appearance 101
Silastic ring 706f, 707
Sildenafil 398
citrate 398
Sildenafil See also viagra 398
Silicone plugs, solid 718
Simpson pain 181
Sims' double-bladed posterior vaginal speculum 737
Sims' position 542, 542f
Sims' posterior vaginal speculum 214, 308, 321, 726f, 737f
application of 758f
Sims' saucerization 546
Sims' semi-prone position 26, 26f
Sims' speculum 27f, 31, 33, 34f, 214, 297, 299, 300, 301, 537f, 542f, 737, 738
advantage of 738
disadvantages of 737
double-bladed 32f
insertion of 33
perineum 535, 537
Sims' triad 541, 737
Sims-Huhner test 358
Single tooth
tenaculum 131f
vulsellum 319f, 727f, 740, 740f
uses 740
Sinovaginal bulb 623
SIS See Saline infusion sonography
Skin 263f
and mucosa, non-neoplastic epithelial disorders of 268
and mucous membrane 823f
changes 615
grafting, inlay split-thickness 641
pigmentation of 14
SLE See Systemic lupus erythematosus
Sling operation 306
Smear plastic spatula 236
Snail shell 76
Socrates 6
Solid ovarian mass, triad of 75
Solifenacin 561
Sonohysterography 52, 159
Sonohysterosalpingogram 356
advantages 356
Soy products 619
Space-filling pessary 303
Spatula 236, 748
Speculum examination 31, 35, 212, 251, 537, 572
Spencer wells variety 728f
Sperm 364f
abnormalities, nomenclature related 365
cells, immature 365
centrifugation damage 393
centriole 598
cervical mucus contact test 359, 368
chromatin structural assay 368
concentration 364
DNA integrity test 368
dysfunction 368
ejaculation 602f
fertilization 601
function 517
test 367, 368
head, structure of 598f
maturation 719
morphology 365
motility 364
oocyte fusion 602, 603
penetration assay 368
preparation 391
techniques 391
transport 601
viability test 368
vitality test 368
zona pellucida binding tests 368
Spermatic fascia, external 715
Spermatids 600
Spermatocyte
primary 600
sequence of 599f
secondary 599f, 600
Spermatogenesis 586, 599f, 600, 601
hormonal control of 600, 601fc
Spermatogonia 599, 599f, 600
A 599
B 599
Spermatozoa 600
ejaculated 597
mature 365f, 597f, 599f
structure of 597
Spermiation 600
Spermicidal
agents 696
gels 648
Spermicides 696
Spermiogenesis 600
Sphincter
external 578
internal 578, 579
support 555
urethrae 555
Sphincteric defect, intrinsic 555
Sphincteroplasty 577
method of 578
Spinal cord
injury 390
involvement 214
Spinelli's procedure 763
Spinnbarkeit test 345, 346, 346f
Spinnbarkeit test See also Thread test
Spironolactone 427, 428, 468
Spleen 20
palpation of 21f
Sponge holding forceps 141f, 299, 725, 734, 734f
Squamocolumnar junction 230, 230f, 231f, 235
Squamous cell 221, 230
carcinoma 214, 215f, 221, 221f, 232, 254, 255, 819
in situ 269
hyperplasia 265
Squamous elements, malignant 186
Squamous intraepithelial lesion
high-grade 240, 243, 269
low-grade 240, 243
Squamous metaplasia, normal 242f
Squatting position 26
Standard adjuvant chemotherapy 102
Staphylococcus 825
STDs See Sexually transmitted diseases
Stein-Leventhal syndrome 409
Stem cells 599
Stenosed vagina 41
Stenosis with dyspareunia 636
Sterilization
certificate of 712
reversal, steps in 382
type of 706
Steroid
cell tumors 69
contraceptives 662
hormones 591, 612
Steroidal contraceptives 651, 652fc
STIs See Sexually transmitted infections
Stitch removal scissors 732f
Straight scissor 729f
Straight scissor See also Mayo's scissor
Strassman metroplasty 640, 641f
Strassman technique 632, 798
Stratum basalis 592
Stratum compactum 592
Stratum spongiosum 592
STRAW staging system 611t
Streak gonad 451
Streak ovary 465
Streptococcus 825
Streptomycin 422
Stress incontinence 298, 301, 313, 327, 554, 557, 615
demonstration of 301
diagnosis of 556
management of 308
operations of 764
pathophysiology of 555
risk factors for 555
surgical options in 562
Stress urinary incontinence 294, 560
sign of 554
treatment of 560
Stress urodynamic study 558
Stroke-thromboembolic disorder 658
Stroma 510, 594
Stromal tumors 69
Struma ovarii 71
Stumdorf's stitch 319
STUMP 196
Subcutaneous goserelin acetate 165
Subcutaneous tissue 262f, 578
and skin, repair of 580
remove 262f
Subdermal implants 669
advantages 670
Submeatal sulcus 297
Submucosal fibroid 112, 114f, 116, 116f, 784, 784f, 786f
Submucous leiomyoma endometrium 113
Subseptate uterus 388, 634f
Subserosal fibroid 117, 117f, 787f
Subserous myoma 628
Subzonal sperm insertion 396
Suction irrigation cannula 769f
Supernatant fluid 392
Surrogacy 388
indications 388
issues of 388
reproduction by 639
Swab holding 734
Swab holding See Ring forceps
Swab test 538
Swabbing 758f
Swelling of vulva 28
benign 819
classifications of 819
infective 819
malignant 819
neoplastic 819
traumatic 819
Swim-up technique 391
Swiss cheese 175
Swyer syndrome 94, 451, 460t, 459, 466, 471
Syndromic case management 830
Synopsis 805
Synthetic androgen 522
Synthetic steroid ethisterone 165
Syphilis 231, 360, 839
diagnosis 839
primary 839
secondary 839
signs 839
symptoms 839
tertiary 839
treatment 839
Systemic disorder 149
Systemic examination 4, 16
Systemic lupus
disease 147
erythematosus 167, 270
T
Tadalafil 398
Tamoxifen 181, 190, 371
Tampon test 538
Tanner's staging 28, 449f, 499
of breasts 448
of pubic hair 450
Target therapy 103
TE See Thromboembolism
Tear, fourth-degree 574
Telescope 769f, 774
Telogen 432
effluvium 432, 433
Temporary colostomy 585
Tenesmus 516
Tension-free vaginal tape 562, 563f, 565f
advantages of 568
guidewire 565f
needle 565f, 733f
surgical procedure of 564
Teratomas 69, 93
Teratozoospermia 365, 390
Terminal hair 432
Tertiary follicle 590
Tertiary follicle and preovulatory 590
Testes 362
determining factor 622
Testicular biopsy, role of 367
Testicular differentiation disorder 471
Testicular feminization syndrome 434, 436, 438, 455t, 456
Testicular regression syndrome 465
Testicular tissue 622
Testicular volume, normal 367
Testosterone 422, 440, 447, 460, 492, 622, 719
deficiency of 601
deficient 451
low-oral dose of 601
use of 601
Theca cells 589
Theca externa 589, 590
Theca interna 589, 590
Theca lutein cyst 71
Thecoma 102
Thelarche, premature 494
Thermal balloon therapy 169
Thermogenic hormone 344
Thread test 346
Threadability test 346f
Three drug regime 844
Thromboembolic complications 263
Thromboembolism 167
Thyroid
disorder 10, 485
gland 361
examination 444
hormones 418, 485
stimulating hormone 111, 341, 404, 440, 481
tumor 71
Thyroxine 111, 370
Tibolone 619
Tightening fascial layer 311
Tinidazole 835
Titanium, alloy of 705
Tolterodine 561
Tongue 14, 107
Tonsils 14, 107
Topical retinoids 417
Torsion 121
notorious for 790
Total hysterectomy, specimen of 79f
Towel clip 729f
Toxic reaction 708
Toxic test 828
Trachelectomy 223, 226, 764
procedure of 226
selection criteria of 226
Tranexamic acid 123, 161, 162, 172
Tranquilizers 401
Transabdominal scan 195
Transcervical sterilization 704
Transdermal combined hormonal patch 671f
Transdermal estradiol 619
Transdermal patch 521, 651
Transitional cell epithelial tumors 69
Transitional epithelium 548
Transobturator needle and tape 566f
Transobturator procedure 562
Transobturator tape 566f, 567f
advantages of 568
surgical procedure of 566
Transperineal ultrasound 302
Transperitoneal approach 547
Transrectal ultrasound 369
Transureteric anastomosis 551
Transureteric ureteroureteric anastomosis 551f
Transvaginal combined hormonal ring 671
annovera 671
nuvaring 671
Transvaginal sonography 113f, 158, 174, 183, 406f, 518f, 530f, 593f, 628, 685f, 802f, 803f
advantage to 161
Transvaginal ultrasonography 49f, 50f
role of 51
Transverse cystocele 328
Transverse fascia 327
Transverse müllerian ridge 638
Transverse sulcus 297
Transverse vaginal septum 456, 625, 635, 635f, 636f
diagnosis 636
management of 636, 636t
types 635
Trendelenburg position 703
Treponema pallidum 819, 833, 839
Tretinoin 417
Trichomona
with four flagella 47f, 834f
vaginalis 6, 46, 500, 833, 834
Trichomoniasis 35, 46, 47, 834
diagnosis of 46, 834
signs 834
symptoms 834
treatment 835
Triiodothyronine 111
Trilayered embryo transfer 350
Triple-blind study 811
Tripterygium wilfordii 719
Triptorelin 522
Trocar 705, 707
cannula 705f
placement 771
Troglitazone 429
Trophoblast, intermediate 204f
Trophoblastic tumors 201, 202
Trospium 561
Trransverse vaginal septum lower third 499f
True broad ligament
cyst 137f
fibroid 138
TSH See Thyroid-stimulating hormone
Tubal block
bilateral 797
causes of 359, 378, 796
Tubal defect, unilateral 390
Tubal disease 49
classification of 378
Tubal embryo transfer 396
Tubal factor cause infertility 378
Tubal factor infertility 359, 369, 378, 379, 382
surgery for 379
treatment of 379
Tubal function 517
assessment of 378
diagnosis of 378
Tubal hyperemia 830
Tubal insufflation test 343
Tubal ligation 378, 699, 700f, 701f, 709
approaches of 700
failure rate of 704
pomeroy method of 702f
Tubal obstruction, bilateral 390
Tubal patency test 353, 747, 773f, 794
methods of 343
negative in 796
Tubal pregnancy 766
Tubal reconstructive surgery 763
Tubal sterilization
complications of 708
techniques of 703
Tubal surgery 382
Tubectomy 712, 763
Tubercular vaginoperineal fistula 842f
Tuberculosis 10, 360, 575
diagnose 480
drug dosage for 844, 844t
Tuberculous growth 36
Tubo-ovarian mass, large 60
Tubotubal anastomosis 380f, 381, 382
Tubular coagulation 706
Turner and Klinefelter syndromes 465
Turner syndrome 8, 10, 12, 15, 17, 94, 434, 435, 435f, 440, 443f, 444, 451, 451f
classic stigma of 451
clinical presentation of 451
height in 453
investigations in 453
management of 453
TVS See Transvaginal sonography
U
UAE See Uterine artery embolization
Uchida technique 703
Ulcers 28
Ulipristal acetate 124
Ultrasonography
approach of 49
in gynecology, role of 49
three-dimensional 803f
Ultrasound markers 351
Umbilical endometriosis 511f
Umbilical hernia 712
Umbilical region 20
Unicornuate uterus 627, 628f
adverse impacts of 628
diagnosis 628
management 629
pregnancy in 629
Unification operation 798
Unilocular ovarian mass 72f
Ureaplasma urealyticum 827, 833
Uremia 216
Ureter 119
course of 549f
injury of 550, 551
types of injury of 550
Ureteric catheter 552, 552f
Ureteric course, pathologies altering 551
Ureteric fistula 540
management of 551
Ureteric injury
diagnosis 550
management 550
prevention 551
Ureteroureteric anastomosis 552f
Ureterovaginal fistula 548
causes of 549
diagnose 550
incidence of 548
Ureterovesical anastomosis 551, 552, 552f, 553
procedure of 552
with bladder flap 553f
Urethra 31, 819
catheter introduced 537f
compressor 555
external 537
outer layers in 555
related swelling 821
Urethral fistula 540
Urethral gland 597
Urethral meatus, external 564, 566
Urethral mucosa, coaptation of 555
Urethrocele 278, 287, 297, 312
Urethrocystometry 558, 559
Urethrovaginal sphincter 555
Urge incontinence 554
causes of 555
Urge urinary incontinence, drugs in 560
Urinary bladder, full 59f
Urinary collective system 638
Urinary diversion 547
Urinary follicle-stimulating hormone 372
Urinary frequency 615
Urinary human menopausal gonadotropin 372
Urinary incontinence 533, 553
management of 559
types 553
Urinary luteinizing hormone monitoring 349
Urinary meatus, external 553
Urinary pregnancy test 480
Urinary problems 615
Urinary retention 560
management 736
Urinary sphincters, artificial 563
Urinary symptoms 275, 294
Urinary system 534
changes in 294
Urinary tract
infection 307, 327, 614, 615
lower 553
Urinary β-human chorionic gonadotropin 157
Urine
analysis 536
examination 536, 558
hyponatremia 469
in gynecology, retention of 735
trough urethra 298
Urodynamic studies, indications of 558
Uroflowmetry 558, 559
Urogenital sinus 623, 624
Urogenital sinus origin 623
Urografin 353
Uterine anomaly
classification of 625t
role of cerclage in 635
Uterine artery
crossing ureter 225f
embolization 53, 124, 124f, 125, 168
advantages 126
complications 126
contraindications 125
indication of 125
ligation 750
Uterine bleeding
diagnose abnormal 158
Uterine cavity 161, 683f
curette of 759f, 760f
Uterine curettage, role of diagnostic 205
Uterine curette 183f, 727, 743, 743f, 758f
flushing curette 743
sharman's curette 743
types of 743
use of sharp 743
Uterine descent 287f, 297f
Uterine didelphys 624, 629, 630f, 631
Uterine dressing forceps 728, 743, 743f
Uterine duplication 632
Uterine factor
causing infertility 359
diagnosis 359
Uterine fibroid 39, 60f, 62, 63, 112, 119, 120, 121, 528, 711
cause of pain in 112
common associations of 120
complications of 121
degenerations of 120
diagnosis of 114
etiology of 122
myomectomy in 388
nomenclatures of 109
pregnancy with 141
risk factors of 122
types of 117t
Uterine fibromyoma 43
Uterine fundus
arteriovenous malformation in 206f
cupping of 281f
Uterine inversion 116f, 762f
surgery for chronic 762
Uterine leiomyoma 112, 118
incidence of 122
management options of 111
types of 116
Uterine lesions 148
Uterine manipulator 705
Uterine mass 39
Uterine origin 158
Uterine perforation 684
detect 761
Uterine polyp 139
clinical presentations of 140
management of 141
Uterine prolapse 7, 7f, 279, 281, 288, 297f, 298
three degree of 289f
Uterine rupture 629
Uterine sarcoma 176, 197f
staging of 197
Uterine septum 640
Tompkins procedure in 640
Uterine sound 740
sterilization of 741
uses 741
Uterine synechia 474, 486
adhesiolysis for 388
Uterine tamponade 168
Uterine transplantation 639
Uterine unification, surgical techniques of 633
Uterine vessels 224, 754
clamping of 752f, 754f
stump of right 325f
Uterocervical canal 281, 741
Uterosacral stump 326
Uterovaginal
fistula 638
problems 369
prolapse 288
Uterovesical pouch 322
Uterus 119, 215, 460, 603, 638, 751f, 796, 801
abnormalities of 439, 445
adenomyotic 528
after hemisection of 136f
and vagina, complete absence of 453f
anteverted 36, 38f
chronic inversion of 279, 281, 282
descent of 297
development of 623
didelphys 630f
different positions of 38f
double 630f
holding forceps 730f
incision over 129
inversion of 281f
length of 741
management preserving 306
palpation of 38
preserving operation 317
prolapse of 287
removal of 755f
sarcoma of 197
serosal coat of 129f
simple canalization of 638
supports of 283, 284f
third degree retroversion of 388
with vagina, implantation of 638
UTI See Urinary tract infection
V
Vaccines types 247
Vagina 252, 255, 623, 842
closure of upper part of 439
congenital anomaly of 35
creation of new 640
development of 623
double 630f
epidermal cyst of 280f
longitudinal septum of 637f
methods of creating 639
supports of 283, 284f
transection of 755
Vaginal agenesis 28, 30f, 41, 446f, 638, 638f
complete 625
Vaginal anomaly, subclassification of 626t
Vaginal approach 306, 307, 544, 763
advantages of 543
Vaginal atresia 446f
Vaginal bleeding 501
causes of 501
diagnosis 501
history of 214
irregular 209
treatment 502
undiagnosed 658
Vaginal blunt manipulator 328
Vaginal cancer 34f, 248, 271, 271f
diagnosis of 271
risk factors 271
types 271
Vaginal contraceptive films 692
Vaginal cord
canalization of 623
invaginates 623
Vaginal cuff, closure of 755
Vaginal cytology 344, 344f
Vaginal devices 560
Vaginal diaphragm 695f
and spermicide 695
advantage 695
disadvantage 695
Vaginal dilatation 636
Vaginal dilators 639f
Vaginal discharge 5, 6, 275, 295, 538, 831
causative organisms of 48, 48t
evaluation 45
examination 44
excessive 538
test 829
Vaginal disinfection 577
Vaginal dryness 615
prevention 619
Vaginal endometriosis 512
Vaginal epidermal cyst 820f
Vaginal examination 25, 212, 509, 535
sequence of 27
Vaginal factors causing infertility 359
Vaginal fibroma 29f, 280f
Vaginal hysterectomy 139f, 286f, 308, 321, 326f
during 332
laparoscopic-assisted 766
Vaginal introitus 28, 436f, 819
Vaginal length, total 300f
Vaginal ligation
advantage 708
contraindications of 708
Vaginal lubricants, water-soluble 620
Vaginal mucosa 278, 312f, 313, 315, 319, 320f, 326, 580f
approximated 316f
cut 312f
portion of 312f, 319
redundant portion of 311
repair of 311f, 578
separation of 309f, 314f
Vaginal myomectomy 128
Vaginal opening, absence of 439, 445
Vaginal pessary 303, 747
complications 303
indications of 303, 747
types 303
Vaginal prolapse 288
Vaginal ring 521, 651
Vaginal rugae, presence of 299
Vaginal rugosity 297
Vaginal septum 28, 31f, 630f
low transverse 635f
removal of 388
Vaginal space, creation of 642f
Vaginal speculum, posterior 33f, 680, 738
Vaginal sulcus, lateral 297
Vaginal tubal ligation 708
Vaginismus 11, 401
cause 401
management 401
Vaginoplasty 455, 639, 643f
methods of 455, 639, 640
using amnion 455
Vaginouterine prolapse 288
Valsalva maneuver 299
Valvular disease, complicated 658
Vaniqa 430, 431
Vanishing testes syndrome 466
Vardenafil 398
Varicocele 360
Vascular endothelial
cell growth factor 606
growth factor 150
Vascular pattern, atypical 239
Vascularity inside ovarian malignancy 50f
Vasectomy 340, 650, 712, 713f, 718
clients, eligibility of 716
Vasography 369
Vasomotor symptoms 614
treatment of 618
Vasopressin injection 129
Vault of vagina 328f
after removal of uterus 752f
Vault prolapse 288, 306f, 328
management of 288, 306
Vecchietti's technique 455, 639
VEGF See Vascular endothelial growth factor
Vellus hair 432
Venous thromboembolism
history of 619
postoperative 782
Verbal descriptor scales 6
Veress needle 705, 706
insertion of 771
Vertical incision 129
Vescicovaginal fistula 9
repair 545f
flap splitting method of 545f
method of 545f
Vesical fistula 540
Vesicocervical fascia 310, 322
Vesicocervical junction 308, 321
Vesicocervical ligament 310f
Vesicovaginal fistula 7, 34f, 533, 543f, 582
case of 542
classification of 540
etiological causes of 541
healed 543f
management of 547
irrepairable 547
repair of 545f
treatment of 543
types of 540
Vestibular anus 585
Vestibular bulb 819
Viagra 398
Vicryl delayed absorbable suture, pack of 731f
Videocystourethrography 559
VIN See Vulvar intraepithelial neoplasia
Violin string 836
Virchow's gland 84
Virgin, rectal examination for 480
Virilism 418
Virilization 480
degree of 469
risk of ongoing 472
Visual detection 243
Visual field defect 361
Visual findings 829
Vitality test 368
Vitamin
D 620
E 619
von Willebrand disease 154, 499
Vulva 842
and vagina, examination of 194
atrophied 279
cancer of 254
carcinoma of 248, 258t
growth over 250f
hamartoma of 821f
itching around 533, 536
lymphatic drainage of 256f
lymphatics of 256
operations on 763
palpation of 31f
preinvasive lesion of 248, 265
sebaceous cyst of 29f
structures of 819
swellings of 28, 819
Vulvar cancer 30f, 255, 265
etiogenesis of 256
incidence of 255
lesion 254
management of 259
mode of treatment 259
prognosis of 264
risk factors of 255
spread 256
stage 258
stage-wise treatment of 261, 261t
surgery, types of 259, 259t
survival rate of 264t
treatment of 259
varieties of 254
Vulvar candidiasis 29f
Vulvar carcinoma 819
diagnosis of 252
lesions of 265
prognostic factors of 265
Vulvar discomfort, chronic 270
Vulvar dystrophy, chronic 268
Vulvar growth 253f
Vulvar growth See also Kiss ulcer
Vulvar injury 501f
Vulvar intraepithelial disease 268
Vulvar intraepithelial neoplasia 255, 265, 266, 269
categorization of 266, 266t
classification of 266
diagnosis of 266
Vulvar lesion, cases of 254
Vulvar lipoma 29f
Vulvar lymphatics 257
Vulvar sarcoma, varieties of 254
Vulvar squamous cell carcinoma, prognosis of 264
Vulvar swelling 266
Vulvar tissue, after removal of 263f
Vulvar warts 28f, 29f, 819, 838f
in pregnancy 820f
Vulvar warts See also Condyloma acuminata
Vulvectomy 263, 763
incision, simple 260f
radical partial 260f
simple 260f, 267f
simple partial 259
Vulvitis, acute 819
Vulvodynia 270
diagnosis 270
treatment 270
Vulvoscopy 254
Vulvovaginal candidiasis 832, 832f
Vulvovaginitis 500, 501
cause 500
diagnosis 501
symptoms 500
treatment of 501
W
Walthard bodies 73
Wandering fibroid 117
Ward mayo's operation 133f, 305, 308, 313, 321
complications of 327
Warty types 255
Water test 771
Watery discharge 212f
Weight loss 370
Wertheim's clamp 732f
Wertheim's operation 223, 791f, 792, 792f
White discharge 214
White lesion 28, 519
Whorl appearance 119f
William's vaginoplasty 643f
William's vulvovaginoplasty 455, 639, 643
Withdrawal bleeding 147
Withdrawal method 698
advantage 698
disadvantage 698
failure rate 698
Withdrawal method See also Coitus interruptus
Withdrawal technique 681
Wolffian structure 464, 622
Women's health initiative 616
World Health Organization 830
Wound
dehiscence 263, 708
hematoma 708
infection 708
X
X-ray pelvis, straight 802f
X-ray plate 800
XXY karyotype 400f
XY sex reversal 466
Y
Y chromosome 459, 471
deletion 340
short arm of 622
Yeast-like organism 47
Yersinia 500
Yolk sac tumor 69, 96
Young's syndrome 360
Z
Zoledronic 620
Zona
dissection, partial 396
hatching 607
pellucida
bind to 367
loss of 607
penetration 602, 603
reaction 603
recognition 602
Zygote 396
intrafallopian transfer 396
Zygotene 586
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Chapter Notes

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1Gynecological History Taking, Examination and Investigations

Writing a Gynecology CaseChapter 1

 
STRUCTURE OF HISTORY WRITING
A case should be written under the following broad headings:
  1. Patient's particulars
  2. History
  3. Physical examination including systemic examinations
  4. Gynecological examinations
  5. Investigations supplied or required
  6. Summary of the case
  7. Provisional diagnosis
  8. Differential diagnosis
 
DETAILED PARAMETERS UNDER THE BROAD HEADINGS
 
Patient's Particulars
  1. Name:
  2. Age:
  3. Address:
  4. Occupation:
  5. Married/Unmarried:
  6. History of infertility:
Bed no.:
Date of admission:
Date of examination:
  1. Husband's occupation:
  2. Socioeconomic status:
  3. Religion:
  4. Parous/nulliparous:
 
History
  • Chief complaint/complaints:
  • History of present illness:
  • Menstrual history:
    • Last menstrual period (LMP)
    • Duration of menstruation
    • Interval in days
    • Age of menarche
    • Regularity of cycle
    • Pain during period/If pain relation with menstruation
    • Amount of bleeding
    • Clot
      Intermenstrual bleeding (IMB)
      Heavy menstrual bleeding [HMB (Menorrhagia)]
      Menopause or not—any postmenopausal bleeding
      If amenorrhea—primary or secondary
  • Obstetric history (Table 1):
    • Parity
    • Living issue (LI): Write “Nil” in nulliparous
    • Last child birth (LCB)
      Table 1   Obstetric history
      Serial no.
      Year and month
      Pregnancy events
      Labor events
      Mode of delivery
      Puerperium or postabortal period
      Baby
      1.
      • Duration of pregnancy
      • Antenatally cared or not
      • Complications if any
      • Treatment
      • Spontaneous or induced
      • History of PROM
      • History of prolonged labor
      • Vaginal delivery with/without episiotomy
      • Forceps/ventouse
      • LUCS—Indications
      • Place of delivery
      • Who conducted delivery?
      • Uncomplicated or complicated, e.g. PPH, sepsis, nonunion of episiotomy wound
      • History of blood transfusion
      • Hospital stay
      • History of intake of Rh anti-D immunoglobulin in Rh negative mother
      • Living or dead
      • If dead—still birth—or neonatal death. If still birth fresh or macerated
      • Birth weight
      • Condition at birth
      • Sex
      • Breastfeeding
      • Immunization
      Abbreviations: PROM, premature rupture of membranes; LUCS, lower uterine segment cesarean section; PPH, postpartum hemorrhage.
  • 3Past history:
    • Medical
    • Gynecological
    • Surgical
  • Family history:
  • Marital or sexual history:
  • Functional history:
    • Bowel
    • Bladder
    • Sleep
    • Appetite
  • Personal history:
    • Personal hygiene
    • Smoking/alcohol
  • Contraceptive history:
  • Drug history:
    • History of any drug allergy
    • History of intake of corticosteroids, antiepileptic or other drugs (previous or present).
 
Physical Examination
Patient-alert, conscious and cooperative
  • Build
  • Nutrition
  • Height
  • Weight/body mass index (BMI)
  • Edema
  • Pallor
  • Cyanosis
  • Jaundice
  • Clubbing
  • Tongue, teeth, gum, and tonsil
  • Secondary sexual character
  • Facies and skin—presence of excessive pimple, hirsutism and acanthosis nigricans
  • Neck veins
  • Neck glands
  • Leg veins
  • Pulse
  • Respiration
  • Temperature
  • Blood pressure.4
 
Systemic Examination
  • Central nervous system
  • Cardiovascular system:
    • Auscultation of heart
  • Respiratory system:
    • Auscultation of chest
  • Gastrointestinal system (during abdominal examination):
    • Liver
    • Spleen
  • Examination of other systems:
    • Examination of back and spines skeletal system
    • Neurological examination
    • Ophthalmoscopic examination
    • Urinary system
  • Examination of breasts and nipple
  • Inspection
  • Palpation.
 
Gynecological Examination
  • Abdominal examination:
    • Inspection
    • Palpation
    • Percussion
    • Auscultation
  • Vaginal examination
  • Inspection and palpation of external genitalia
  • Speculum examination
  • Bimanual examination
  • Rectovaginal examination and rectal examination.
 
Summary of the Case
 
Investigations Supplied or Required
 
Provisional Diagnosis
 
Differential Diagnosis (D/D)
5
 
DISCUSSION OF THE POINTS ESSENTIAL FOR PROPER CASE TAKING AND WRITING
The following descriptions will be of immense help to write a clinical case in proper way.
 
Patient's Particulars
  • Age: Dysfunctional uterine bleeding (DUB) is more common in menarcheal age and perimenopause whereas abnormal bleeding in reproductive age is mostly pregnancy-related bleeding. The average age of cancer cervix is 35–45 years and that of endometrial cancer is 55–70 years (mean 60 years). Age is no bar in ovarian malignancy but is more common in elderly or in younger age group.
  • Address: If the patient is not in a position to tell her address properly one should write—rural, urban, urban slum or semiurban.
  • Parous/Nulliparous:
    • Parity means only previous pregnancy/pregnancies reaching beyond the age of viability.
    • Nulliparous: No history of any conception. Gravida means a pregnancy state both present and past irrespective of the period of gestation (not relevant in gynecological case).
    Cancer cervix and genital prolapse are more common in multiparous and endometrial cancer and endometriosis are mostly found in nulliparous or low parity women.
  • It must be mentioned whether woman is a widow.
 
History
  • Chief complaints: When the patient has definite chief complaints then write them in chronological order. If there is no definite complaint, it is to be enquired for which problem she was brought to hospital. The duration and character of symptoms with associated features if any and exaggerating or relieving factors should be recorded.
  • History of present illness:
    • Elaborate the chief complaints with onset, duration, severity, etc.
    • Mention the important negative points
    • Mention any other relevant symptoms.
    Detailed queries related to the individual clinical cases are discussed in respective chapters. However, some important aspects of gynecological history should always be enquired like pelvic pain, vaginal discharge, menstrual abnormality and abnormal uterine bleeding, presence of urinary/fecal incontinence, something coming down per vagina, patient presenting with lump abdomen which are outlined below.
Pelvic pain
    • If there is any pelvic pain, it should be enquired in detail and its relation with menstruation or association with bladder and bowel function should be searched for. The important causes of acute pelvic pain of gynecological origin are acute pelvic inflammatory disorder (PID), torsion of ovarian tumor, ectopic pregnancy, incomplete abortion and dysmenorrhea.6
    • Causes of chronic pelvic pain are endometriosis, adenomyosis, symptomatic leiomyoma, chronic pelvic infection, pelvic adhesions, etc. In pelvic pain, bowel and urologic cause must be considered.
    • The characteristics of pelvic pain of different origin can be expressed by a mnemonic—SOCRATES—these are site, onset, character, radiation, associated feature, timing, exacerbating factor and severity to diagnose the cause as below in Table 2.
Table 2   Characteristics of pelvic pain of different origin (SOCRATES)
Origin
Site
Onset
Character
Radiation
Associated features
Timing
Exacerbating factors
Severity
Uterine
Midline
Prior period
Cramping
Thigh and lower back
Vaginal bleeding
Along with period
Nonspecific
Variable
Ovarian
Any iliac fossa
Acute, intermittent
Gripping
Groin, shoulder (if ascitis)
Pregnancy, ovarian cyst, irregular period
Cyclical
Positional
Severe
Pelvic infections/or adhesions
Lower abdomen, prominently one side
Gradual, acute or chronic
Shooting, gripping
Not specific
Fever, vaginal discharge, history of surgery
Acute, may be cyclical
Examination, coitus, movement
Severe intermittently
Endometriosis
Not definite
Gradual or sudden
Cramping, shooting
Not specific
Subfertility
During period
Cyclical, coitus
Variable
    • Pain is a subjective symptom and very difficult to quantify because it depends on individual's pain perception. To quantify discomfort pain scales have been developed which includes visual analog scale (VAS) and verbal descriptor scales (VDS).
    • In visual rating scale 0—no pain, 1—mild pain, 2—moderate pain and 3—severe pain.
Vaginal discharge
    • In case of discharge per vagina its amount, character, color, odor, presence of blood, associated with itching or not and relation with menstrual cycle are enquired. Association of itching with white discharge is mostly due to candidiasis/or trichomoniasis.
    • The causes may be physiological, infective, early cancer cervix or idiopathic, etc. Before ovulation, there is physiological excessive cervical mucus discharge which is clear, transparent, copious and stretches like egg white and after ovulation the discharge becomes thick and less in amount. Infective causes are candidiasis, trichomoniasis and bacterial vaginosis.
    • The most common is candidiasis caused by Candida albicans, a fungus. In candidiasis, it is creamy white, thick curdy discharge associated with marked vulvar itching and soreness. In trichomoniasis (caused by protozoa Trichomonas vaginalis), the discharge is fishy-odor, frothy, clean, sometimes yellowish green and associated with vulvar soreness and itching. In bacterial vaginosis (caused by Gardnerella vaginalis) the discharge is clear, homogeneous, whitish-gray and fishy smelling. In cancer cervix discharge may be mixed with blood.7
Causes of dyspareunia: See below.
Causes of something coming down per vagina
    • Pelvic organ prolapse [uterine prolapse (Fig. 1), cystocele, rectocele, and enterocele], Gartner's duct cyst, cervical polyp, chronic inversion of uterus, elongation of cervix and cervical growth (details in Page 279, Chapter 10).
zoom view
Fig. 1: Uterine prolapse
(63 years parous postmenopausal woman presenting with something coming down P/V)
Causes of incontinence of urine
  • Vesicovaginal fistula (VVF), ureterovaginal fistula (UVF), stress incontinence and urge incontinence (details in Page 553).
Causes of incontinence of stool
  • Old complete perineal tear (CPT) (Fig. 2), rectovaginal fistula (details in Page 575).
Causes of lump lower abdomen
  • Full bladder, pregnancy, ovarian tumor (Fig. 3) uterine fibroid, large TO mass, Koch's peritonitis, etc. (details in Page 58)
Causes of amenorrhea
  • Primary amenorrhea, secondary amenorrhea and menopause (see below).
  • Menstrual history
    Examples:
    • Last menstrual period (LMP): First day of last menstrual period.
    • Age of menarche: 12 years.
    • Duration of menstruation: 4–5 days.
    • Interval in days: 28 ± 2 days.
      zoom view
      Fig. 2: Old complete perineal tear (CPT)
      (24 years woman presented with incontinence of stool with history of home delivery 1 year back)
      zoom view
      Fig. 3: Large ovarian tumor with ascites
      (32 years nulliparous woman married for 11 years presented with huge abdominal swelling. Subsequently, it was found to be a metastatic papillary serous cystadenocarcinoma of ovary)
    • 8Regularity of cycle: Regular/irregular.
    • Pain during period: Present, if present severity and relation with period.
    • Amount of bleeding: Average, scanty or heavy.
    • Clot: Present or not—occasionally.
    • If there is IMB character of bleeding whether continuous, intermittent, spotting, etc.
    • Any medication taken during period.
Menorrhagia
  • Menorrhagia means excessive menstrual bleeding (>80 mL/cycle) in duration and/or amount where cycle length is normal. It is now named as “heavy menstrual bleeding” (HMB).
  • Important causes of HMB are DUB, fibroid uterus, adenomyoma, endometriosis, PID and hereditary blood disorder (for details see Page 147).
Hypomenorrhea
  • Hypomenorrhea is defined as reduced flow either in amount or in duration or in both with cycle length normal (see Page 148).
Polymenorrhea or epimenorrhea (see Page 148)
  • Polymenorrhea or epimenorrhea is characterized by short cycle (<24 days) resulting in frequent menstruation and, when associated with menorrhagia, it is called polymenorrhagia.
  • When cycle length is long, more than 38 days, the condition is called oligomenorrhea.
Metrorrhagia
  • Metrorrhagia refers to the IMB (Intermenstrual bleeding)—bleeding between periods suggesting hormonal, endometrial or cervical pathology.
  • In recent International Federation of Gynecology and Obstetrics (FIGO) classification all above terminologies are abandoned except “HMB and IMB”.
Postmenopausal bleeding (PMB) (see Page 193)
  • Bleeding per vagina after 1 year of permanent cessation of menstruation is called “postmenopausal bleeding”.
  • Common causes of PMB are atrophic endometrium (the most common cause), endometrial cancer, cancer cervix, endometrial hyperplasia, endometrial polyp and decubitus ulcer.
Menopause
  • Menopause is declared at a point in time after 1 year of cessation of menstruation.
Primary amenorrhea
  • Absence of menses by 13 years of age with no visible secondary sexual characteristic development or absence of menses by 15 years of age in the presence of normal secondary sexual characteristics.
  • Important causes are constitutional delay (delayed puberty), Turner syndrome, Rokitansky-Küster-Hauser (RKH) syndrome, androgen insensitivity syndrome and adrenogenital syndrome (congenital adrenal hyperplasia).
Secondary amenorrhea
  • The absence of menstruation for 6 months in a patient who had previously regular menses or absence for at least three previous cycles in a woman with previous irregular cycles.9
  • Common causes of secondary amenorrhea encountered are ovarian pregnancy, polycystic ovarian syndrome (PCOS), hypothalamic and hyperprolactinemia.
Dysmenorrhea
  • Cyclical pain during period incapacitating to the woman from normal activity is called “dysmenorrhea”.
  • In primary dysmenorrhea no identifiable cause is detected and most intense just before and during period.
  • Secondary dysmenorrhea is due to endometriosis, adenomyosis, PID, outlet obstruction, endometrial polyp and submucous fibroid.
Q. How will you assess the quantity of blood loss?
The different methods which are suggested are:
  1. Measurement of Hb from sanitary napkins
  2. Hb and hematocrit estimation
  3. Number and type of pad or tampons and amount of passing clot and by using a scoring sheet
  4. By maintaining menstrual calendar and putting the symbols against each day.
Clinically, it is said to be HMB or menorrhagia when there is:
  1. Less than or equal to 3 hourly pad change,
  2. Change of pad at night time
  3. More than 21 pads per cycle
  4. Passage of clots greater than 1 inch
  5. More than 80 mL blood loss in each menstrual period
  6. Clinical anemia (for details see chapter of AUB).
  • Past obstetric history: Write in the tabular forms.
    • Write “nil” if patient is nulliparous.
    • Endometriosis and endometrial cancer is common in nulliparous whereas in multiparous there is more chance of pelvic organ prolapse and cancer cervix.
    • Any history of infertility (mention if conception after treatment)
    • Write in chronological order the followings: Term delivery, preterm delivery,
    • History of abortion (spontaneous or induced including MTP, place of termination), ectopic pregnancy and hydatidiform mole. PID may be sequel of unsafe abortion. Undiagnosed bleeding may be due to incomplete abortion or due to gestational trophoblastic neoplasia (GTN).
    • In vescicovaginal fistula (VVF), there may be history of obstructed labor. CPT is common in home delivery.
  • Past history
    • Past medical history
      The following medical histories are important:
      • » Diabetes—Obese diabetic woman is high-risk subject for endometrial cancer
      • » Hypertension
      • » Bronchial asthma10
      • » Thyroid disorder—menstrual abnormality, amenorrhea, and infertility are common
        • Hyperprolactinemia with/without galactorrhea may cause amenorrhea and infertility
      • » Tuberculosis: In genital tuberculosis, there may be history of pulmonary tuberculosis.
      • » Renal disease
      • » Cardiac disease
      • » Epilepsy/Seizure disorder
      • » Rheumatic fever
      • » Sexually transmitted diseases (STD)/PID/puerperal sepsis
      • » History of blood transfusion
      • » History of chemotherapy and radiation
      • » History of coagulation disorder in young girl may present with abnormal uterine bleeding (von Willebrand disease)
    • Past gynecological history
      • » Gynecological disease: History of PID, STDs, pelvic pain, endometriosis, and genital prolapse.
      • » Gynecological surgery:
        • Abdominal: Hysterectomy, myomectomy, and oophorectomy
        • Vaginal: Vaginal hysterectomy (VH) with/without PFR, VVF repair, Fothergill's operation, amputation of cervix, and CPT repair.
    • Past surgical history
      The following are to be enquired for:
      • » Cholecystectomy
      • » Appendicectomy
      • » Any laparotomy
        History of anesthetic difficulties in previous surgery.
  • Family history
    The following family histories are relevant:
    • Medical disorder
      • » Diabetes
      • » Hypertension/dyslipidemia/ischemic heart disease
      • » History of birth of baby with congenital anomalies or chromosomal disorder
      • » Tuberculosis
      • » Blood dyscrasia.
    • Genetic disorder: Androgen insensitivity syndrome, Turner syndrome, premature menopause may run in family.
    • Cancer predisposition in family: Breast, endometrial and ovarian cancer. Risk of endometrial cancer occurs in hereditary nonpolyposis colorectal cancer (HNPCC) group. BRCA mutation carrier may suffer from breast cancer syndrome.
  • Marital and sexual history
    Sexual history is very important so far as infertility is concerned.
    • Dyspareunia means pain in intercourse.11
    • Causes of deep dyspareunia are pelvic endometriosis, prolapsed ovary and pelvic infection.
    • Superficial dyspareunia is usually due to introital infection or trauma. Vaginal dryness is common cause of dyspareunia in menopause.
      • » Vaginismus is pain on penetration due to involuntary contraction of pelvic floor mostly of psychological origin.
  • Functional history
    It should be taken in details, e.g.
    • Bowel: Constipation is common in enterocele and cervical fibroid. Tenesmus is found in deep endometriosis. Pelvic abscess may cause diarrhea. History of bleeding piles, etc.
    • Bladder: History of stress incontinence, frequency and retention of urine.
      Retention of urine may be due to pelvic organ prolapse, cervical fibroid and in cryptomenorrhea due to imperforate hymen.
    • Sleep
    • Appetite: Sudden loss of weight and anorexia is common in ovarian malignancy. In young girl, loss of weight with anorexia and amenorrhea may occur in anorexia nervosa.
  • Social history
    This is taken in very sensible way. Her occupation, her living standard, whether she is in a relationship, any pertinent family or social problem, wherefrom she will get support if surgery is advised, especially in case of elderly woman. Any addiction for drug, smoking and alcohol is enquired.
  • Contraceptive history
    Duration and types are to be enquired. Past history of sterilization, use of oral contraceptive (OC) pills and intrauterine contraceptive device (IUCD) or any other methods used are to be enquired. IUCD may cause menorrhagia, OC pills break through bleeding and LNG-IUS is associated with amenorrhea.
  • Drug history
    History of intake of steroids, antihypertensive, antidiabetic, anticoagulants, thyroxine and any other hormone like estrogen. Estrogen and aspirin should be stopped before surgery. Estrogen therapy may be a cause of abnormal uterine bleeding. History of drug allergy should always be asked for.
 
Physical Examination
  • Build
    It can be expressed as average/short stature/tall stature. Build is actually a “skeletal framework” of a person.
  • Nutrition
    It can be expressed as average/good/poor or malnourished/looks obese.
    Nutrition is clinically assessed by (a) measuring the skinfold thickness between index or middle finger or by calipers, (b) by seeing the mid upper arm circumference (<22 cm—malnourished, >30 cm—likely obese), (c) mid-thigh circumference and (d) examining the features of vitamin deficiency.12
    Typical cachectic look is a feature of ovarian malignancy (Fig. 4).
  • Height
    Measured either in centimeter or foot and inches.
    When large measuring scale is not available in the examination hall ask the patient to stand by the side of any wall, mark the highest point and measure from floor to this point with your measuring tape.
    Short stature may be due to Turner syndrome. Other physical stigmas are looked for.
  • Weight: Write in kg. Assess overweight or thin/underweight.
    Body mass index (BMI) = Weight in kg/Height in meter2
    BMI <18.5—Underweight, 25–29.9—Overweight, >30—Obesity
    Obesity with menstrual abnormality in young girl may be due to PCOS. Middle-aged women with obesity, hypertension and diabetes are subjects for corpus cancer syndrome (endometrial cancer).
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    Fig. 4: Ovarian cachexia
  • Edema
    Write as “present” or “absent”. Pitting edema or nonpitting edema like myxedema.
    • Primary sites to examine:
      • » Just above the medial malleolus elicited by pressing with the tip of right thumb at least for 15 seconds (Fig. 5)
      • » Anterior surface of the lower third of shin bones
      • » The dorsum of foot.
    • Other sites:
      • » Facial edema
      • » Over the sacrum
      • » Parieties (abdomen)
      • » Over the vulva (Fig. 6).
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        Fig. 5: Edema demonstration
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        Fig. 6: Edema vulva
  • 13Anemia
    Present or absent—mild, moderate or severe
    • Primary site to see:
      • » Lower palpebral conjunctiva—Retract both the lower eyelids at a time and tell the patient to look upward (Fig. 7)
    • Other sites:
      • » Dorsum and tip of the tongue
      • » Soft palate
      • » Nail beds
      • » Palm and soles
      • » Skin.
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        Fig. 7: Anemia demonstration
Anemia and pallor are not synonymous. Anemia is one cause of pallor. Pallor may be due to anemia or shock of any origin.
You can write pallor instead of anemia on physical examination.
Clinically, anemia is categorized as mild, moderate and severe and may not be associated with laboratory findings always. The arbitrary gradings are:
    • Mild: 10–10.9 g%;
    • Moderate: 7–<9.9 g%;
    • Severe: <7 g%
    • Very severe: 4 g%.
In case of AUB status of pallor reflects the severity of bleeding.
The common causes of anemia are iron deficiency, AUB, repeated pregnancy, bleeding piles, thalassemia and hook worm infestation.
  • Cyanosis
    Absent/Present. Types: Peripheral/Central.
    • Sites to detect cyanosis:
      • » Peripheral:
        • Tip of nose
        • Ear lobule
        • Outer surface of lips, cheek and chin
        • Tips of fingers and toes
        • Nail beds
      • » Central:
        • Tongue
        • Inner surface of lips
        • Gum, soft palate, cheeks
        • All sites of peripheral cyanosis.14
  • Jaundice
    Expressed as Present/Absent
    • Sites to detect:
      • » Upper bulbar conjunctiva: The patient is asked to look downward and upper eyelids are retracted to see the bulbar conjunctiva well.
      • » Under surface of tongue
      • » Soft palate
      • » Sole and palm
      • » Skin.
        Jaundice is always checked in sunlight near an open window.
  • Clubbing
  • Tongue, teeth, gum and tonsils
    Write healthy or any specific lesion present.
    • The mouth is examined for features of malnutrition like glossitis, stomatitis, presence of any septic focus like tonsillitis and caries teeth.
  • Examination of secondary sexual characters
    Breasts, axillary hair and pubic hair—This is important in primary amenorrhea and intersex.
  • Examination of facies and skin
    Excessive pimples over face, excessive growth of hair over face and other body areas (hirsutism) (Fig. 8), acanthosis nigricans (pigmentation of skin) (Fig. 9) are features of androgen excess commonly PCOS.
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    Fig. 8: Hirsutism
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    Fig. 9: Acanthosis nigricans
    21 years unmarried girl presented with long cycle interval menstrual period, obesity and hirsutism
  • 15Neck veins
    Generally examined to see whether these are engorged or not.
  • Neck glands
    The neck is examined for presence of any enlarged gland. Supraclavicular glands are palpated for enlargement. Virchow's gland (enlarged left supraclavicular, also known as Troisier's sign) may be palpable in advanced ovarian malignancy.
    Thyroid gland is also inspected and palpated for any enlargement or any other pathology.
  • Leg veins
    Note the presence of tortuosity of veins, varicose veins or presence of any pigmentation or ulcer. Prominent leg veins are features of ovarian malignancy.
  • Pulse
    • Radial pulse is palpated at the wrist, lateral to the flexor carpi radialis tendon by the pulp of three fingers with the patient's forearm semipronated and wrist slightly flexed.
      Write:
    • Rate: Normal rate is 60–90 beats per minute (bpm). Less than 60 bpm is called bradycardia and tachycardia is rate of more than 100 bpm.
    • Volume: It reflects pulse pressure. Volume can be expressed as normal, low volume or large (increased) volume. Feeble indicates very low volume pulse. Increased volume is seen in advanced age, arteriosclerosis, hypertension, anemia and thyrotoxicosis. Low pulse volume occurs in LFV, hypovolemia and peripheral arterial disease.
    • Rhythm: Regular or irregular.
    • Any special character: Character refers to the waveform or shape of the arterial pulse.
    • Other pulses: Other than radial pulse brachial, carotid, femoral, popliteal, posterior tibial and arteria dorsalis pedis can be palpated in special situations.
    • Any difference of upper and lower limb pulses:
      In Turner syndrome, pulses of both upper and lower limbs should be examined. In Turner syndrome, there may be congenital coarctation of aorta which is narrowing of aorta distal to the left subclavian artery and pulses of upper limb are usually normal with reduced lower limb pulses which are delayed in relation to pulses of upper limb, i.e. radiofemoral delay. Radiofemoral delay can be checked by palpation of radial and femoral artery simultaneously. Radio-radial delay is found in presubclavian coarctation of aorta.
  • Respiration
    • Rate: —/min
    • Rhythm:—
    • Type: Abdominal or thoracic
    • Any special variety: —
  • Temperature
    Temperature is best recorded by thermometer.16
  • Blood pressure
    • Expressed as systolic/diastolic mm of Hg.
    • Normal BP is defined as less than 130/85 mm of Hg (British Hypertension Society). Optimal BP is less than 120/80 mm of Hg.
Importances of blood pressure measurement in gynecological practice:
(1) BP measurement is a routine procedure to assess the general health of a woman, (2) may be associated with some gynecological diseases like AUB and endometrial cancer and (3) also as a part of preoperative evaluation for surgery.
 
Procedure of Measurement of Blood Pressure
Patient should take rest at least for 5 minutes before measurement.
Position of the patient
BP can be measured either in sitting or lying down posture in relaxed attitude supporting the patient's arm comfortably at the level of heart. The sphygmomanometer cuff is applied over the upper arm, with the center of the bladder on brachial artery. There should not be no tight clothing constricting the upper arm; loose thin clothing usually makes no difference.
Systolic pressure
Systolic pressure is first assessed roughly by palpation of radial pulse or brachial pulse after inflating the cuff till it becomes impalpable. In auscultation technique, diaphragm is placed gently over the brachial pulse which is situated medial to the biceps Brachii tendon, over the elbow joint. The cuff is initially inflated to a pressure 20–30 mm of Hg higher than the estimated systolic pressure determined by palpation. Then the cuff is deflated 2 mm/sec until a regular tapping sound (Korotkoff phase I: K1) is heard. Blood pressure is read to the nearest 2 mm of Hg.
Diastolic pressure
The cuff is deflated slowly until the sounds disappear. The pressure is recorded as diastolic pressure at which the sound completely disappears (Korotkoff phase V: K5). Sometimes muffled sounds persist (Korotkoff phase IV: K4) and do not disappear, then the point of muffling (K4) is taken as diastolic pressure.
It is better to measure BP in both arms. If different the higher one is considered and noted.
Size of BP cuff
The bladder should be at least 80% of the length and 40% of the width of upper arm circumference. A standard adult cuff has a bladder 13 cm × 30 cm and suits an arm circumference of 22–26 cm. In obese patients with an arm circumference of more than 32 cm may give false high readings in normal sized cuff, therefore larger cuff (bladder 16 cm × 38 cm) or thigh cuff (20 cm × 42 cm) is needed for those patients.
 
Systemic Examination
  • Cardiovascular system
    Palpation of precordium and auscultation of heart are done in different areas.
    Write: Palpation of precordium: No abnormality detected.17
    Auscultation: Normal heart sounds.
    If any lesion is detected or suspected detailed examination of different areas is done and noted.
    In Turner syndrome, there may be coarctation of aorta.
  • Respiratory system
    • Position of trachea
    • Palpation, percussion and auscultation done on both sides. Pleural effusion may be present due to abdominal ascites.
      Write:
      No abnormality detected
      Breath sounds are normal
      No adventitious sound.
      If any abnormality is detected—then write in detail.
  • Gastrointestinal system
    Liver and spleen are palpated routinely for any enlargement and tenderness (see below).
    Write: Not enlarged or just palpable or enlarged (fingers as the measurement is).
  • Other systems
    • Neurological systems:
      • » Higher function
      • » Cranial nerves
      • » Sensory function
      • » Motor function
    • Ophthalmoscopic examination—not done.
    • Urinary system
      • » Kidney
      • » Renal angle tenderness: Renal angle tenderness is elicited at the junction of lower border of 12th rib and lateral (outer) border of erector spinae (see Figs 22 and 23, Page 21).
 
Examination of Breasts
  • Inspect the skin, areola, nipple, sizes of breasts and local swelling in different positions: (a) arms resting on thighs, (b) arms pressing on hips, (c) arms over the head and (d) leaning forward to make breasts pendulous. Compare both sides for any asymmetry (Figs 10A to D).
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    Figs 10A to D: Examination of breasts. (A) Arms resting on thighs; (B) Arms pressing on hips; (C) Arms over the head; (D) Leaning forward to make breasts pendulous
    18
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    Figs 11A and B: Palpation of breasts in lying down position. (A) With head on one pillow; (B) Patient's hand under the head on the side
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    Figs 12A to C: Palpation of each breast systematically
  • Breasts are palpated in lying down position. With head on one pillow and patient's hand under the head on the side to be examined (Figs 11A and B).
  • Palpate each breast systematically (Figs 12A to C) over all the quadrants from periphery toward nipple. Presence of any lump and tenderness is noted. If there is any mass its characteristics are noted (size, position, consistency, fixity, surface, margins, inflammation and tenderness). Palpate the nipple for any abnormality or discharge—watery, bloody or milky (galactorrhea). Palpate also the axillae for any extension of breast (axillary tail) between thumb and finger and presence of nodes. Palpate also the supraclavicular group of lymph nodes.
  • In case of primary amenorrhea, development of breast is staged according to Tanner's staging (see Fig. 19A, Chapter 13, Page 449).
 
Per Abdominal Examination
Before gynecological examination (abdominal and vaginal) the following preparatory procedures are done.
  • Ask the patient to evacuate her bladder
  • Always keep one female attendant/chaperone19
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Fig. 13: Inspection of the abdomen: Position of the patient—dorsal supine position with partial flexion of knees and thighs
  • Stand on right side of the patient (Figs 13 to 15)
  • Explain the patient what you are going to do
  • Make dorsal supine position, head is supported by a small pillow—Partial flexion of knees and thighs facilitate relaxation of abdominal muscles (Figs 13 to 15).
  • Abdomen is exposed fully and other parts are covered well.
 
Gynecological Examination
  • Abdominal examination
    Regions of abdomen (Fig. 16)
    Abdomen is subdivided into nine regions by two horizontal and two vertical lines or planes (Fig. 16). The upper horizontal line joins the tips of the 9th costal cartilages on either side and the lower horizontal line is drawn from highest points of the iliac crests (transtubercular). The vertical lines on either side are drawn vertically upward from midclavicular points.
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Fig. 14: Inspection of the abdomen
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Fig. 15: Position of the patient—dorsal supine position with partial flexion of knees and thighs
20
 
Inspection (see Figs 13 and 14)
  • Contour of abdomen
  • Condition of skin
  • Condition of umbilicus—everted/flushed/inverted
  • Presence of any scar and its description
  • Presence of any lump or fullness of the abdomen. Both in ovarian tumor and ascites abdomen is enlarged. In case of ascites flanks are also full and in ovarian tumor center is only fulI (see below). In ascites enlargement of abdomen is equal in both sides laterally, but in ovarian cyst enlargement on two lateral sides are usually unequal.
  • Presence of sites of hernia—coughing impulse if any
  • Enlarged inguinal lymph nodes, testes in inguinal region (androgen insensitivity syndrome).
 
Palpation
Palpation is done by flat of the hand and finger movements must be gentle and from metacarpophalangeal joints and not interphalangeal joints (Figs 15 to 18).
  • Superficial palpation: By superficial palpation temperature, tenderness, parietal edema, localized lump, divarication of recti and fluid thrill are elicitated.
  • Deep palpation: Abdomen is palpated deeply with flat of the dominant hand as well as the fingers while patient is asked to breathe quietly. All the surgical areas (Fig. 16) of the abdomen are palpated symmetrically either clockwise or anticlockwise starting from the right hypochondrium for any mass or enlarged organ. It is better to palpate the region at the end which is tender. Sometimes in difficult palpation like in obesity and ascites, etc. the left hand is placed over right hand to feel deeply.
  • Liver and spleen are palpated (Figs 19 to 21): Patient is asked to take deep breath during palpation.
  • Palpation of kidney: The site of kidney is palpated and renal angle is elicited keeping hand behind near the junction of lateral border of erector spinae and lower border of 12th rib (Figs 22 and 23)
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Fig. 16: Subdivision of abdomen into nine regions by two horizontal and two vertical lines or planesAbbreviations: RH, right hypochondrium; E, epigastrium; LH, left hypochondrium; LF, left flank or lumbar region; LIF, left iliac fossa; H, hypogastrium or suprapubic region; RIF, right iliac fossa; RF, right flank or lumbar region; UR, umbilical region.
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Fig. 17: Palpation of abdominal lump
21
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Fig. 18: Palpation of abdomen
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Fig. 19: Palpation of liver
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Fig. 20: Palpation of spleen
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Fig. 21: Palpation of spleen
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Fig. 22: Palpation of kidney
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Fig. 23: Palpation of kidney
  • 22All surgical areas are palpated—presence of any lump, tenderness, rigidity and muscle guarding are looked for.
  • Rebound tenderness is elicited by complain of severe pain abdomen after giving pressure over the abdomen and then taking off the hands suddenly.
  • In presence of any lump note its:
    1. Site
    2. Shape
    3. Size
    4. Surface
    5. Margins
    6. Consistency
    7. Tenderness
    8. Mobility.
  • In pelviabdominal mass note whether lower margin can be reached or not. If it is not reached you can write “cannot get below the lump”. In pelvic mass, it can be moved from side to side, but difficult to move vertically.
  • Inguinal area is palpated to look for enlarged lymph nodes and if any its character is noted.
  • How would you test a lump is parietal or intra-abdominal?
    • Leg raising test: Any mass whether it is intra-abdominal or parietal is determined. Patient is asked to lift up both extended legs together on lying down position. In case of intra-abdominal mass, it will disappear and in case of intraparietal it will be prominent.
  • How would you determine a lump is retroperitoneal or intra-abdominal?
    • Knee elbow position to rule out retroperitoneal lump—in intra-adominal lump, it will be prominent and in case of retroperitoneal mass, it will become not prominent.
 
Percussion
  • Percussion can differentiate abdominal mass and ascites.
  • In ascites midline (A) is resonant, flanks are dull on percussion, and “shifting dullness” is positive (Fig. 24A).
  • Whereas in mass like ovarian tumor without ascites midline (A) is dull on percussion and flanks are resonant (Fig. 24B).
  • If ovarian cyst is associated with gross ascites the midline will be resonant, flank is dull (Fig. 24C) and “shifting dullness” becomes positive.
  • Fluid thrill is present in huge ascites and is also present in large ovarian cyst and in encysted fluid.23
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    Figs 24A to C: (A) Only ascites; (B) Large ovarian cyst; (C) Ovarian cyst with huge ascites
    24
    Demonstration of shifting dullness (Figs 25 to 27)
  • In supine position, percuss from the midline out to the flanks. Any change from resonant to dull is noted along with the areas of dullness and resonance. Finger on the site of dullness is kept and patient is asked to turn on to her side and a pause of 10–30 seconds is given. Then again percussion is done. If the dull and tympanic areas are reversed “shifting dullness” is said to be positive.
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    Fig. 25: Percussion on midline in dorsal position
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    Fig. 26: Percussion from midline towards the flank in dorsal position
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    Figs 27A and B: Demonstration of shifting dullness: (A) Dorsal position; (B) Lateral position
    Demonstration of fluid thrill (Figs 28 and 29)
  • It is done when abdomen is tensely distended. The palm of the left hand flat is placed against the left side of the patient's abdomen. The patient or an assistant is asked to place of the edge of hand on the midline of abdomen. The right side of the abdomen is flicked by a finger of right hand, if a ripple is felt against left hand “fluid thrill”, is said to be present.25
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Fig. 28: Demonstration of fluid thrill
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Fig. 29: Demonstration of fluid thrill
 
Auscultation
  • Intestinal peristaltic sound is usually heard. Fetal heart sound is excluded in any lump abdomen. Absent peristalsis indicates peritonitis and increase peristalsis is heard in intestinal obstruction.
 
Vaginal Examination
  • Preparatory procedures
    • Ask the patient to evacuate her bladder before examination except in case where there is history of stress incontinence.
    • Woman will lie in dorsal supine position, thigh flexed and knee flexed keeping the feet on extended foot rests so that buttock comes to the margin of table which facilitates the introduction of speculum (Figs 30 and 31). Some schools prefer to do it in dorsal lithotomy position (Fig. 32) which is not comfortable for the patient and not practiced in all setup.
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      Fig. 30: Dorsal supine position
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      Fig. 31: Dorsal supine position
    • 26Keep one female attendant/chaperone
    • Stand on right side of the patient near the leg ends
    • Ask the patient what you are going to do and take consent for that. In case of minor, consent from legal guardian is taken.
    • Examination is done in good light.
  • Other positions in different situations
    • Sims’ semi-prone position: Left lateral position with left leg extended and right thigh and knee partially flexed (Fig. 33). This position is very useful for inspection of lesions of anterior vaginal wall lesion like VVF using Sims’ speculum to retract posterior vaginal wall (Figs 33 and 34) and rectal examination.
    • Squatting position: This position is sometimes necessary for proper visualization of genital prolapse if not demonstrated in dorsal position. Even genital prolapse sometimes needs standing position to visualize well (see Figs 40 and 41, Chapter 10, Page 296).
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      Fig. 32: Dorsal lithotomy position
      Hence, the different positions for gynecological examinations are:
      1. Dorsal position (see Figs 30 and 31)
      2. Dorsal lithotomy position (see Fig. 32)
      3. Sims’ semi-prone position (see Fig. 33)
      4. Left lateral position (Fig. 35).
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Fig. 33: Sims’ semi-prone position (Left lateral position with left leg extended and right thigh and knee partially flexed)
27
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Fig. 34: Sims’ speculum to retract posterior vaginal wall to visualize the anterior wall
 
Sequence of Vaginal Examination
  • Inspection of external genitalia
  • Palpation of external genitalia and vagina
  • Speculum examination
  • Bimanual examination.
 
Inspection of External Genitalia
Inspect the vulva visually (Fig. 36) one by one the following structures (Fig. 37):
  • Labia majora and labia minora
  • Clitoris
  • Urethra
  • Fourchette
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Fig. 35: Left lateral position
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Fig. 36: Female external genitalia
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Fig. 37: Inspection of the female external genitalia
  • 28Vaginal introitus
  • Bartholin's gland
  • Anus
  • Gynecological perineum.
Observe for any discharge, lesions, ulcers, scratch mark, discoloration, redness, any growth, swelling of vulva like sebaceous cyst, enlargement of clitoris, ambiguous genitalia, old perineal tear, and protruding masses like genital prolapse.
In primary amenorrhea, pubic hair distribution is noted with Tanner's staging (see Fig. 19B, Chapter 13, Page 449).
Patient is asked to cough to note any stress incontinence, or to watch for impulse on coughing of any mass.
 
Observations of External Genitalia and Probable Causes
  • Red lesion—contact dermatitis, tinea cruris
  • White lesion—leukoplakia (Fig. 38), lichen sclerosus et atrophicus, squamous cell hyperplasia, squamous cell carcinoma
  • Papules—molluscum contagiosum, condyloma acuminata (vulvar warts) (Figs 39 and 40)
  • Cyst/Swelling—lipoma (Fig. 41), sebaceous cyst (Fig. 42), indirect inguinal hernia, Bartholin cyst (Fig. XX)/abscess (Fig. 43), vulvar fibroma (Fig. 44)
  • Ulcers/erosion—Herpes, chancre
  • Discharge—Trichomonas, candidiasis (Fig. 45), bacterial vaginosis
  • Large growth—Vulvar cancer (Fig. 46)
  • Deficient perineum—complete perineal tear (see Fig. 2)
  • Protruding mass through introitus—pelvic organ prolapse (see Fig. 1), cervical polyp, cervical fibroid (Fig. 47), chronic uterine inversion, elongated cervix, Gartner duct cyst (Fig. 48)
  • Perineal fistula (Fig. 49)
  • Vaginal agenesis (Fig. 50)
  • Imperforate hymen (Fig. 51)
  • Vaginal septum (Fig. 52)
  • Enlarged clitoris with fused labia (Fig. 53) (congenital adrenal hyperplasia).
Swellings of vulva including Bartholin cyst are described in Chapter 32.
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Fig. 38: Leukoplakia vulva
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Fig. 39: Vulvar warts (condyloma acuminata)
29
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Fig. 40: Vulvar warts
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Fig. 41: Vulvar lipoma
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Fig. 42: Sebaceous cyst of vulva
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Fig. 43: Bartholin abscess
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Fig. 44: Vaginal fibroma
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Fig. 45: Vulvar candidiasis
30
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Fig. 46: Vulvar cancer
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Fig. 47: Large cervical fibroid from portio vaginalis
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Fig. 48: Gartner duct cyst
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Fig. 49: Perineal fistula (tubercular)
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Fig. 50: Imperforate hymen
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Fig. 51: Vaginal agenesis
31
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Fig. 52: Vaginal septum
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Fig. 53: External genitalia in congenital adrenal hyperplasia (CAH)—enlarged clitoris with fused labia
 
Palpation of External Genitalia and Vagina
Digital examination is done to palpate the vulva and vagina for accurate diagnosis of the lesion and presence of tenderness. Urethra and Bartholin gland are squeezed to express any discharge. Bartholin gland is situated in posterior third of introitus deep to bulbospongiosus on two lateral sides (Figs 54A and B).
In genital prolapse cervix is dragged. Uterus is palpated to determine the degree of prolapse. Perineal body and levator ani are palpated to assess the tone (details in Chapter 10).
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Figs 54A and B: (A) Palpation of vulva; (B) Palpation of Bartholin cyst (left side)
 
Speculum Examination
Speculum examination is usually done in dorsal position (lithotomy by some school) with a bivalve Cusco's speculum (Fig. 55) or single or double bladed Sims’ speculum (Fig. 56) before bimanual examination.32
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Fig. 55: Cusco's speculum
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Fig. 56: Double-bladed Sims’ speculum
 
How to Introduce Cusco's Speculum?
  • After separating the labia with left thumb and index finger (Figs 57 to 61) transverse blades of Cusco's speculum (lubricated by jelly) is introduced in anteroposterior direction (as vaginal introitus is anteroposterior slit depressed from side to side) and is then rotated 90° to bring the transverse blades transversely (upper part of vagina transversely enlarged).
  • During introduction one should be cautious that speculum does not touch roughly the urethral meatus which is very sensitive.
  • After opening the blades cervix is well visible (Figs 60 and 61). If cervix is not visible speculum is angled 30° to visualize cervix as in anteverted uterus (most common) cervix lies posterioly.
  • Lateral vaginal walls and cervix are visible well with Cusco's speculum. Both anterior and posterior vaginal walls are not visible as obscured by two blades.
  • The handle of the Cusco's speculum can be kept anterior (Fig. 61) or posterior (Fig. 60) which will be convenient for proper visualization for cervix. The retaining screw can be tightened to allow the speculum self-retained without any support.
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Fig. 57: Diagrammatic representation of introduction of Cusco's speculum
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Fig. 58: Showing separation of labia with left thumb and index finger for introduction of Cusco's speculum—transverse blades of Cusco's speculum is introduced in anteroposterior direction and is then rotated 90° to bring the transverse blades transversely
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Fig. 59: Introduction of Cusco's speculum
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Fig. 60: Introduction of Cusco's speculum (Handling posteriorly—commonly used)
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Fig. 61: Cusco's handling anteriorly (Occasionally needed)
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Fig. 62: Single bladed posterior vaginal speculum
 
Insertion of Sims’ Speculum
  • To visualize the anterior vaginal wall Sims’ speculum either double bladded (see Fig. 56) or single bladded (Fig. 62), is used, best in Sims’ semiprone left lateral position (Fig. 63A) but can be done also in dorsal supine position (Fig. 63B) provided back of the patient is brought to the edge of table.
  • Like Cusco's speculum Sims’ speculum may also be needed to insert laterally first and then to rotate 90° posteriorly to retract the posterior vaginal wall.
  • With this instrument anterior vaginal wall, lateral vaginal wall and cervix are visualized.
  • If there is cystocele, it is retracted with anterior vaginal wall retractor (Fig. 64), to visualize the cervix and vault of the vagina (Figs 64 and 65).
  • In Sims’ position, the lesion of anterior vaginal wall like VVF (Fig. 66) or cystocele is well visualized. After introduction of speculum the structures are seen and findings are noted.34
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Fig. 63A: Introduction of Sims’ speculum—Sims’ position
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Fig. 63B: Introduction of Sims’ speculum—dorsal supine position
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Fig. 64: Anterior vaginal wall retractor
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Fig. 65: To see the enterocele by retracting the posterior vaginal wall by Sims’ speculum and retracting the anterior vaginal wall by anterior vaginal wall retractor
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Fig. 66: Vesicovaginal fistula (VVF). Catheter is seen through the fistula opening
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Fig. 67: Vaginal cancer
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Findings of Vagina on Inspection and Speculum Examination
What to see?
Findings of vagina
Vagina is noted for character of mucosa, its moistness, any abnormal discharge, any infection, any lesion or growth
  • Normal finding—the mucosal color is pink, there is small mucous discharge. In reproductive age, vagina is rugosed
  • In postmenopausal period, vaginal mucosa becomes atrophied, dry and there may be features of senile vaginitis
  • In candidiasis, there is creamy white, thick curdy discharge. In trichomoniasis the discharge is fishy-odor, frothy, clear and sometimes yellowish green, whereas in bacterial vaginosis the discharge is clear, homogeneous whitish-gray and fishy smelling.
  • Vaginal wall becomes keratinized, pigmented and even ulcerated in pelvic organ prolapse
  • There may be nodules and/or papules in condyloma acuminata, chancre and in vaginal carcinoma. Reddish polypoid nodule is seen in vaginal adenosis and adenocarcinoma. Large growth in vaginal carcinoma may occasionally be visible (Fig. 67)
  • Gartner's duct cyst is usually situated on anterolateral wall of vagina. Cystocele is situated on anterior vaginal wall and rectocele on posterior vaginal wall.
Any congenital anomaly of vagina is also noted (see Fig. 52)
 
Cervical Findings on Speculum Examination
What to look for?
Findings of cervix
  • Cervix is inspected for its color, any discharges, character of external os, tear, hypertrophy, cervicitis, erosion, ectropion, entropion, cervical polyp—mucus or fibroid, cyst, Nabothian cyst and growth
  • Normal findings: Normal cervix is deep pink in color. External os is pinhole or round in nulliparous and it is transverse slit like in multiparous (Fig. 68A). The squamocolumnar junction is situated in between the pink squamous epithelium of ectocervix and bright—red columnar epithelium of the endocervix and situated near the external os at reproductive age. Preovulatory cervical mucus is clear, transparent, abundant and stretchable
  • Old tear of cervix is usually sequel of vaginal delivery. Polyp may be mucous, fibroid or placental (rarely). Fibroid polyp (Fig. 68B) may originate from cervix or may arise from uterus and protrudes through external os. Hypertrophy is common in uterine prolapse. Cervix becomes wide and barrel shaped in endocervical cancer
  • Discharge—like that of vagina (candida, trichomonas and bacteria vaginosis). There may be mucopurulent cervical discharge in STDs like gonorrhea and chlamydia. Strawberry appearance of cervix can be seen in trichomoniasis due to punctate hemorrhagic spots36
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Fig. 68A: Normal looking cervix
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Fig. 68B: Fibroid polyp
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Fig. 69: Cancer cervix—endocervical adenocarcinoma
What to look for?
Findings of cervix
  • Cervix
  • Malignant growth: The cervical carcinoma may be ulcerative, cauliflower or hypertrophic (Fig. 69)
  • Tuberculous growth (rare) of cervix may mimic cancer cervix (see Fig. 7, Chapter 33).
Cervical smear is taken for PAP smear from the surface of cervix by Ayer's spatula and from the cervical canal by cytobrush. If there is any discharge that should be collected for microscopical examination. PAP smear should be taken before vaginal examination.
 
Bimanual Examination (Pelvic Examination or Bimanual Examination)—Procedure
  • Index and middle fingers of gloved right hand is introduced gently through the vagina after retracting the labia minora with left thumb and index finger after using any lubricating jelly until the cervix is palpable (Figs 70 to 75).
  • In anteverted uterus (which occurs in most of the cases) cervix is directed posteriorly and so anterior lip is touched first (Fig. 76).
  • When the uterus in midposition touching of both lips of cervix together are likely (Fig. 77).
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Fig. 70: Examining fingers
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Fig. 71: Per vaginal examination—index and middle fingers are introduced by retracting the labia
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Fig. 72: Bimanual examination—left hand over the suprapubic region
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Fig. 73: Bimanual examination—left hand over the suprapubic region
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Fig. 74: Bimanual examination
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Fig. 75: Bimanual examination
  • In retroverted uterus (15%) cervix is directed anteriorly, so posterior lip is palpated first (Fig. 78).
  • Cervix is palpated first. Then the other hand is placed over the patient's abdomen over the suprapubic region to do the bimanual examination to palpate the uterus and the fornices (two lateral, anterior and posterior) to note the findings.
  • The different positions of uterus are anteverted (most common), midposition and retroverted (15%) and is shown in Figure 79.
 
Bimanual Examination and what to see
Palpation of cervix
Findings
Cervix is palpated to note size, consistency, mobility, and to diagnose any pathology, whether there is any bleeding on touch and cervix is moved to note any tenderness
Bleeding on touch may signify malignancy.
Tenderness on movement is found in:
  • Ectopic pregnancy and
  • Acute pelvic inflammatory disease
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Fig. 76: Bimanual examination in anteverted uterus (anterior lip of cervix is felt first)
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Fig. 77: Bimanual examination—uterus in mid- position (both lips of cervix is felt together)
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Fig. 78: Bimanual examination—in retroverted uterus (posterior lip of cervix felt first)
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Fig. 79: Different positions of uterus. (A—anteverted, B—mid-position, and C—retroverted)
 
Bimanual Examination and what to see
Palpation of uterus
Findings
The other hand is placed over the patient's abdomen over the suprapubic region and tried to reach behind the uterus and uterus is palpated in between the two hands keeping fingers both in anterior fornix and posterior fornix to note:
  • Position
  • Size
  • Shape
  • Consistency
  • Mobility
  • Any tenderness
Normal uterus is firm in consistency and size is 7.5 cm × 5 cm × 2.5 cm, anteverted, and anteflexed with good mobility.
Uterus is uniformly enlarged in:
  • Pregnancy
  • Hematometra
  • Pyometra
  • Endometrial carcinoma.
  • Fibroid
  • Adenomyosis
  • Endometrial polyp
Uterus is irregularly enlarged in fibroid uterus.
Mobility of uterus is restricted in
  • PID
  • Endometriosis
  • Malignancy
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Bimanual Examination and what to see
Mass in pelvis
Findings
Palpated bimanually—Internal fingers are directed to the fornices toward the abdominal fingers to palpate any mass in between
If there is a mass it is uterine origin or adnexal origin—How will you understand?
Uterine mass usually lies in midline whereas adnexal mass on any lateral fornix
If any mass is palpated, first it is assessed whether it is separated from the uterus or not.
  • If there is a cleft in between the uterus and the mass it is most likely adnexal mass (commonly ovarian tumor) (Figs 80A and B). And in uterine fibroid there is no such cleft (Figs 81A and B).
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Figs 80A and B: Cleft (groove) in between the uterus and the mass indicate mass is adnexal origin commonly ovarian tumor
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Figs 81A and B: There is no cleft (groove) between the mass and the uterus which is not separately palpable indicating mass originating from uterus, likely to be fibroid
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Bimanual Examination and what to see
Findings
  • On movement of the cervix upward if the mass also moves, the origin of mass is uterus and in that case if uterus is pushed down cervix also moves down.
Lateral fornix: Palpation
Normally fallopian tubes and ovaries are not easily palpable. Normal ovaries can be palpable in very slim patient and if palpable a characteristic painful sensation of ovary occurs
Adnexal swelling in lateral fornix may be:
  • Ovarian tumor
  • Tubo-ovarian mass
  • Chocolate cyst of ovary
  • Broad ligament tumor
  • Paraovarian or fimbrial cyst
  • Ectopic pregnancy
Posterior fornix is palpated for any, nodule, mass, tenderness or any collection
Causes of mass or nodule in posterior fornix (in pouch of Douglas)—may be due to:
  • Retroverted uterus
  • Prolapsed ovary
  • Posterior lower uterine fibroid
  • Tubo-ovarian (TO) mass
  • Mass of rectovaginal wall.
The typical nodular structure in POD may be:
  • Metastatic nodule of ovarian cancer
  • Endometriosis
  • Tuberculosis
  • Scybella (hard stool)
Fluctuating mass in posterior fornix—may be due to collection of blood or pus
Anterior fornix: What are the masses you may get on anterior fornix?
The masses in anterior fornix are due to:
  • Ovarian cyst (commonly dermoid)
  • Fibroid uterus
  • Chronic ectopic
  • Broad ligament fibroid
  • Mass related to urinary bladder
 
Rectal Examination and Rectovaginal Examination
Procedures
Findings
Rectovaginal area (gynecological perineum) —inspection and palpation
It is a wedge-shaped area extending from fourchette to anus. Average normal length is 4 cm (see Figs 36 and 37).
Length is reduced in perineal tear and to some extent in posterior vaginal wall prolapse. In complete perineal tear gynecological perineum is almost absent and replaced by a horizontal bridge of rectovaginal septum and incontinence of stool (see Fig. 2).
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Rectal Examination (Rectoabdominal)
Procedures
Done by gloved index finger lubricated with jelly (Fig. 82).
Gynecological indications of rectal examination are:
  • Cancer cervix
  • Posterior vaginal wall prolapse
  • Endometriosis
  • Ovarian malignancy
  • Adolescent girl
  • Primary amenorrhea (Vaginal agenesis)
  • Stenosed vagina
Findings
Carcinoma cervix
In carcinoma cervix: (a) involvement of parametrium and lateral pelvic wall is felt better, (b) shape of cervix can be assessed, and (c) involvement of rectal mucosa can be diagnosed
Genital prolapse: To differentiate between rectocele and enterocele
Pelvic endometriosis: Involvement of uterosacral ligament and POD (nodular)
Ovarian malignancy: Metastatic nodule in POD
In young virgins: In absence of ultrasonography.
Rectal examination has become less important nowadays due to the availability of ultrasound
In vaginal agenesis rectal examination helps to identify the presence of uterus
In stenosed vagina pelvic examination is done by rectoabdominal method.
 
Rectovaginal Examination
It is done by keeping index finger in vagina and middle finger in rectum (Fig. 83)
Rectovaginal examination is done to palpate rectovaginal septum, POD, posterior surface of uterus, fornices and uterosacral ligaments
It can differentiate the enterocele and rectocele (see Chapter 10, Page 301) and any lesion in rectovaginal septum like endometriosis or growth can also be diagnosed
Piles, rectal polyp and cancer can be detected. Tone of perineal body can be assessed.
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Fig. 82: Rectal examination
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Fig. 83: Rectovaginal examination
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INVESTIGATIONS SUPPLIED OR REQUIRED
Investigations are done for two purposes:
  1. Firstly for confirmation of diagnosis and to assess the extent of disease and
  2. Others for preoperative investigations for patient's surgical fitness.
These are:
  • Routine preoperative investigations: Routine blood examination—Hb%, TC, DC, and ESR, blood sugar (fasting and postprandial), renal function test (urea and creatinine), urine—routine examination and culture, liver function test, serology (hepatitis B and C, HIV) X-ray chest, ECG.
    Papanicolaou test (PAP test) is done routinely in gynecological cases.
  • Investigations in gynecology which are done for the confirmation of diagnosis and/or to assess the extent of disease as suggested by clinical diagnosis are given in Chapter 2 (see Page 44).
 
SUMMARY OF THE CASE
Summary will contain the following points:
  • Patient's profile and complains
  • Significant or relevant history—positive and negative
  • Important physical examination findings including vital signs (always write vital signs even if they may be normal)
  • Gynecological examination findings
  • Investigations supplied or required.
 
EXAMPLE OF WRITING A SUMMARY (SAMPLE SUMMARY)
Mrs XY aged 35 years parity three, living issue 3, tubectomy done 4 years back was admitted on ____ with complain of lump abdomen progressively increasing for last 3 months duration. Her LMP was ______, period is regular, almost monthly interval and duration of 4–6 days. She has no pain abdomen or any other significant symptom. There is no significant past and family history.
On general examination, her height is 5 feet, weight 54 kg, GC—average, Pallor—mild, edema—nil, neck glands not enlarged, Pulse ___/min, BP____ mm of Hg (or may write normotensive) and any other positive findings. Breasts examination revealed no abnormality.
On abdominal examination, there is a lump lower abdomen almost globular, corresponding to 24 weeks pregnancy size, surface smooth, well-defined margin, nontender and mobile. Shifting dullness is negative and there is no fluid thrill, no Braxton Hicks contraction, no fetal parts palpable and fetal heart sound not audible.
On pelvic examination revealed a large pelviabdominal mass separated from the uterus which is of normal size and retroverted.
In investigating report her hemoglobin level is 11 g%, blood group—A positive, CA 125-21 U/mL, USG is suggestive of ovarian cyst of 20 cm × 15 cm size with uterus of normal size without any ascites.43
 
PROVISIONAL DIAGNOSIS
A case of ovarian tumor probably benign in nature in a 35-year multiparous woman.
 
DIFFERENTIAL DIAGNOSIS
Write the differential diagnosis like in case of lower abdominal lump—it will be uterine fibromyoma, mesenteric cyst, full bladder and pregnancy, etc. (see Chapter 3, Page 59).