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June 25, 2024
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Primary medical and rehabilitative care for women with non-specific inflammation of the female genital organs, for non-inflammatory diseases and after gynecological surgery. The task of family doctor. Clinical examination.

 

INFLAMMATORY DISEASES OF FEMALE GENITALS

 

The rate of inflammatory diseases is over 60% of all gynecologic diseases and about 30% patients of female hospitals have the inflammatory processes of genital organs. Especially the quantity of the inflammatory diseases has enlarged because of the increased sexual activity at the young age, permissive sexual attitude, prostitution. Those at the highest risk are young unmarried women with multiple sex partners. Primarily inflammatory diseases affect human fertility because of infections of the female upper genital tract and their sequel. Women with persistent virus infection are at particular risk for cervical dysplasia and intrauterine fetal death.

Normal flora has a significant role in defense against infection by genital pathogens. The female genital tract, especially the vaginal secretions, contain from 108 to 109 bacteria per gram of fluid examined. Lactobacilli produce lactic acid from glucose keeping the vagina at an acidic pH (3,8-4,2). Glycogen is metabolized by vaginal epithelial cells to glucose, which then serves as a substrate for Lactobacillus.

Normal vaginal microflora contains: Lactobacillus (70-90%), Staphylo-coccus epidermalis (30-60%), diphteroids (30-60%), Hemolytic Streptococci (10-20%), nonhaemolytic streptococci (5-30%), Escherichia coli (20-25%), Bacte-roides (5-15%), Peptococcus (10-60%), Peptostreptococcus (10-40%), Clostri-dium(5-15%).

Presence of pathogenic flora without inflammation isn’t a sign of patho­logic processes.

It is considered that normal vaginal flora is represented by Lactobacillus. But not only Lactobacillus acidophilus provide the self-cleaning of the vagina. The normal vaginal ecosystem of reproductive age women contains 7 kinds of Lactobacillus: L acidophilus (42,8%), L. Paraeasei, L. Fermentum, L. Plantarum (10-18,6%), L.cateforme, L.corineformis, L. Brevis (2,5-5,7%), H2O2producing Lactobacillus may play an important role in acting as a natural mierobicide within the vaginal ecosystem.

     Variation in vaginal colonization by Lactobacillus and other organisms could relate to estrogen level metabolism products of vaginal microflora, vaginal pH, and the type of Lactobacillus initially colonizing the vagina. Many endogenic and exogenic factors may change the balance of the vaginal ecosystem. Some vaginal microorganisms may cause the inflammation in certain conditions. Both vaginal and cervical epithelial cells have the capacity to convert glycogen to glucose, which is further metabolized to lactic acid. Vaginal acidity depends on adequate levels of estrogens as well as the presence of lactic acid-producing bacteria such as Lactobacilli. Concentrations of lactobacilli are probably important determinants of vaginal pH as well. The increased concentration of lactic acid producing bacteria in the vaginal fluid may result in a lower pH which determines decreased susceptibility to infection. Estrogens have a direct effect on the number of organisms and composition of the bacterial flora. The mucosal surface provides protection from invading pathogens. Mucous may act to eliminate a variety of pathogens or antigens. Mucous also serves for attachment of immunoglobu-lin A, lysozyme, lactoferrin and other biologically active substances. Mucous in the female genital tract is under hormonal control. Any abnormalities with low estrogen secretion and decreasing of estrogen level with age may damage defense mechanisms of the female genital tract. Using of contraceptives, shower can effect into vaginal ecosystem by changing vaginal pH, altering the vaginal fluid by direct dilution.

            Chronic unspecific inflamation disease of internal sexual bodies organs that belong to the most widespread gynecological pathology. There can be  consequences of the transfer of acute form of inflammation process, and also can display a primary of current chronic illness. The absence of the expressed clinical picture or significant anatomic changes is frequently united with gradual infringement of the main biological function of the female organism. In other cases the rough changes are observed which require operative intervention and worsens the forecast concerning restoration of the functions of the internal sexual organs. Treatment, which should be received by the sick woman should be duly, appropriately developed in the circuits and principle stage.

Bartholinitis

Bartholinitis is an inflammation of Bartholin’s gland (large gland of vaginal vestibule). It may be caused by Staphylococcus, E.coli and N. gonorrhea. Any type of the pathogen initiates ductal inflammation and obstruction that can lead to Bartholin’s abscess. There can be serous, serous-purulent, or purulent inflammation.

Obstruction of the opening of the main duct into the vestibule leads to abscess formation. Infection of Bartholin’s glands can lead to secondary infections, abscess or cyst formation (fig 1). When the gland becomes full and painful, incision and drainage is appropriate. Patients with abscess usually require abscess incision with insertion of the catheter in abscess cavity. Recurrent infection from vaginal flora and mucous cyst formation are common sequelae of bartholinitis. If the infection of gland is caused by N.gonorrhea specific antibacterial treatment is prescribed.

Vulvitis

Vulvitis is a vulvar inflammation. It may be primary and secondary. Primary vulvitis is caused by local irritants (including feminine hygiene sprays, deodo­rants, tight-fitting synthetic undergarments in women with obesity or diabetes mellitus. Secondary vulvitis are caused by accompanying discharge from vagina.

 

      I.          Vestibulitis. Inflammation, pain and tenderness probably due to up-regulated nerve supply in the vestibular area.

                  A.          Etiology. Although the true etiology is unknown, vulvar vestibulitis syndrome is strongly associated with candidal infection.

                  B.          Clinically. There is entry dyspareunia, erythema and point tenderness of the vestibule, primarily at the base of the hymenal remnant.

                  C.          Treatment may include long-term oral antifungal therapy, topical steroids, or surgery. Mycolog-II (nystatin + triamcinolone) is frequently very effective.

   II.          Vulvovaginitis. All types of vaginitis may produce vulvar itch, irritation, dyspareunia, or dysuria. Evaluation includes history, exam, microscopic exam of secretions with saline and KOH (wet prep obtained from vaginal vault) and vaginal pH with Nitrazine. Consider a UA to rule out UTI, and cervical cultures for infection with gonorrhea and chlamydia if indicated. Obtain a Pap if not done recently, since HPV is also sexually transmitted.

                  A.          Candidal vaginitis.

1. Etiology. Candida albicans, other Candida species (such as glabrata), Torulopsis species, other yeasts. Not generally sexually transmitted, although in refractory cases treatment of the partner may be needed. Precipitating factors include systemic antibiotic therapy, pregnancy, high-dose estrogen oral contraceptives and tight- fitting undergarments. Recurrent infections may occur in uncontrolled diabetes mellitus, immunosuppression (HIV, corticosteroid use). Asymptomatic colonization does not require treatment.

2. Discharge. Discharge is nonmalodorous, thick, white cottage cheese-like and adheres to vaginal walls.

3. Diagnostic tests. Wet mount: pseudohyphae or budding yeast cells. Wet mount is insensitive (65%-80%); if wet mount is negative, consider empiric treatment for typical pruritus without a watery discharge. Vaginal pH is normal (<4.5). Reserve fungal cultures for recurrent/resistant cases.

4. Treatment.

a. Vaginal suppositories can be used at bedtime for 3 days: clo- trimazole 200 mg (100 mg x 2), miconazole 200 mg, or terco- nazole 80 mg. Single dose treatments are also available (e.g., 1200 mg of miconazole)

b. Vaginal creams are used at bedtime for 7 days: clotrimazole 1% 5 g, miconazole 2% 5 g, or terconazole 0.4% 5 g.

c. Oral: One dose of fluconazole 150 mg PO is effective. Itraconazole 200 mg PO QD for 3 days may also be used.

d. Recurrent or resistant cases may require 10-14 days of topical or oral therapy, followed by suppressive therapy with clotrimazole 500 mg vaginal suppository or fluconazole 100 mg PO once weekly. Clotrimazole and miconazole are available OTC; terconazole is prescription and should be reserved for resistant disease. Encourage cotton underwear.

e. In pregnancy, use creams for 7 days and avoid oral therapy.

Candida Vulvovaginitis

Candida is the second most common diagnosis associated with vaginal symptoms. It is found in 25% of asymptomatic women. Fungal infections account for 33% of all vaginal infections.

Patients with diabetes mellitus or immunosuppressive conditions such as infection with the human immunodeficiency virus (HIV) are at increased risk for candidal vaginitis. Candidal vaginitis occurs in 25-70% of women after antibiotic therapy.

Symptoms. The most common symptom is pruritus. Vulvar burning and an increase or change in consistency of the vaginal discharge may be noted.

Physical examination

Candidal vaginitis most often causes a nonmalodorous, thick, adherent, white vaginal discharge that appears “cottage cheese-like.” The vagina is usually hyperemic and edematous. Vulvar erythema may be present. The normal pH level is not usually altered with candidal vaginitis. Microscopic examination of vaginal discharge diluted with saline (wet-mount) and 10% KOH preparations will reveal hyphal forms or budding yeast cells. Some yeast infections are not detected by microscopy because there are relatively few numbers of organisms. Confirmation of candidal vaginitis by culture is not recommended. Candida on Pap smear is not a sensitive finding because the yeast is a constituent of the normal vaginal flora.

Treatment of candida vulvovaginitis

For severe symptoms and chronic infections, a 7-day course of treatment is used, instead of a 1 day or 3 day course. If there is vulvar involvement, a cream should be used instead of a suppository.

Most C. albicans isolates are susceptible to either clotrimazole or miconazole. An increasing number of nonalbicans Candida species are resistant to the OTC antifungal agents and require the use of prescription antifungal agents. Greater activity has been achieved using terconazole, butoconazole, tioconazole, ketoconazole, and fluconazole.

                  B.          Bacterial vaginosis (BV).

         1.          Etiology. Polymicrobial (Gardnerella vaginalis, Mycoplasma hominis, Prevotella, Mobiluncus, Bacteroides, etc.). Not generally considered sexually transmitted but rare in those not sexually active. BV suggests (but does not prove) sexual abuse in the proper population. BV can lead to premature delivery, chorioamnionitis and postpartum endometritis; however, it is not clear that treatment prevents these complications.

         2.          Discharge. Thin, white, or dull gray, homogeneous malodorous discharge that adheres to the vaginal walls.

         3.          Diagnostic tests. 3 of 4 criteria: (1) Elevated pH (>4.5), (2) positive whiff or amine test when KOH applied to vaginal secretions, (3) clue cells seen on saline wet mount, (4) homogenous discharge noted.

         4.          Treatment.

          a.          Oral: Metronidazole 500 mg PO BID for 7 days or 2 g PO as single dose; clindamycin 300 mg PO BID for 7 days.

         b.          Vaginal: metronidazole 0.75% gel 5 g per vagina BID for 5 days or clindamycin 2% cream per vagina QHS for 7 days.

          c.          Pregnancy. During the first trimester avoid oral therapy; use vaginal metronidazole (avoid vaginal clindamycin–higher rate of preterm delivery), but treatment probably does not prevent preterm labor. After the first trimester, use metronidazole 250 mg PO BID for 7 days or 2 g PO as single dose; or clindamycin PO as above.

         d.          Treatment of male partner(s) does not reduce the rate of recurrence (although condom use will).

C.                                        Trichomonas vaginitis.

    1.     Etiology. Trichomonas vaginalis, a protozoan that is sexually transmitted.

    2.     Discharge. Copious, yellow gray or green, foamy, malodorous discharge.

    3.     Diagnostic tests. Elevated pH (>4.5). Presence of mobile, flagellated organisms and leukocytes on wet mount.

    4.     Treatment.

     a.     Metronidazole 2 g PO as a single dose, or 500 mg PO BID for 7 days. Treat partner as well. Vaginal metronidazole is not effective. For multiple treatment failures (reinfection excluded) use metronidazole 2 g PO QD for 3-5 days.

    b.     Pregnancy. During the first trimester, use clotrimazole 100 mg vaginal tabs QHS x 2 weeks. Then retreat in the second trimester with 7 day metronidazole regimen.

   D.     Contact irritant/allergic vaginitis. Itching, burning, soreness, variable discharge, with or without erythema. By definition, an evaluation for other etiologies is negative.

    1.     Etiology. Obtain a careful history to identify the offending agent, such as menstrual pads, chemicals (soaps, laundry detergent, spermicides, perfumes, feminine hygiene products, etc), latex condoms, antifungal creams.

    2.     Treatment: avoid the irritant, use bicarbonate sitz baths, topical vegetable oil. Avoid corticosteroids, which cause burning and atrophy.

   E.     Atrophic vaginitis. Predominantly in postmenopausal women, may also occur during lactation or with progesterone-only contraceptives.

    1.     Clinically. Epithelium has few rugae and is inflamed and dry, producing itching, dyspareunia, spotting and urinary symptoms. May have significant vaginal hemorrhage especially in the elderly. Vaginal pH.6.0. Wet mount may show increased cocci and coliforms, small round parabasal cells, PMNs.

    2.     Treatment is estrogen, either oral estrogen replacement therapy or topical estradiol 0.01% cream 2-4 g daily for 1-2 weeks, then half the dose for 1-2 weeks, maintenance dose is 1 g 1-3 times per week. Another option is conjugated estrogen cream 2-4 g daily (3 weeks on, 1 week off) for 3-6 months. If estrogen is contraindicated may use glycerin/mineral oil preparations (Replens) symptomatically. If symptoms do not resolve with hormone or antifungal therapy, biopsy is indicated.

   F.     Chronic purulent vaginitis has been reported which is an exudative vaginitis, with purulent discharge and an elevated vaginal pH due to replacement of normal flora with gram-positive cocci and occasional vaginal spotted rash. Responds to clindamycin cream.

III.          Cervical Infections. Most commonly Neisseria gonorrhoeae and Chlamydia trachomatis.

                  A.          Range of symptoms. From asymptomatic to mucopurulent cervicitis; may have associated urethritis or infection of Bartholin’s glands.

                  B.          Evaluation. Pelvic exam; look for purulent, yellow or green cervical discharge, >10 WBC/oil field on cervical smear, and check gram stain for gram-negative intracellular diplococci (GC). Cervical cultures for GC/Chlamydia should be done. Consider a Pap smear if none recently.

                  C.          Collecting specimens. Collect cervical culture for gonococcus culture first, since this organism will be found in the mucus. Endocervical cells are needed for Chlamydia, which is intracellular. For both specimens use an endocervical swab held in the cervix for 30 seconds. Twirling the Chlamydia swab will increase yield. See Chapter 8 for treatment.

                  D.          Routine screening is recommended in high-risk groups such as sexually active teens and women <25 or with new or multiple sexual partners. DNA-based screening tests of vaginal secretions or urine specimens are also available.

IV.          Urethritis. Causes for urethritis with negative UA include low colony-count UTI (up to 30% of culture proven UTIs have a negative UA), N. gonorrhea, C. trachomatis, Mycoplasma species, Ureaplasma urea-lyticum, Trichomonas vaginalis, herpes simplex, Candida, interstitial cystitis, contact sensitivity (to soaps, feminine hygiene products, latex condoms, spermicides, etc). PCR of voided urine can detect Chlamydia. See Chapter 8 for more information.

   V.          Proctitis and Proctocolitis can also be due to sexually transmitted infections such as N. gonorrhoeae, C. trachomatis, and herpes simplex virus when receptive anal intercourse or oral-anal contact is practiced.

VI.          Syphilis, Genital Herpes Simplex, and Other STDs. See Chapter 8.

Endocervicitis

Endocervicitis is the inflammation of mucosa layer of the endocervix. Bac­teria cause infection of the columnar epithelium. Chlamidia trachomatis, Myco-plasma, Trichomonada vaginalis, N. Gonorrhoeae, viruses, Candida, E.coli, Staphylococci cause endocervicitis.

Cervix is constantly exposed to trauma during childbirth, abortion.The abundant mucus secretion of the endocervical glands both with the bacterial ascend from the vagina creates a situation that is advantaging to infection.

The inflammatory process is chiefly confined to the endocervical glands. The squamous epithelium of the exocervix may be involved into the process called acute exocervicitis. The extent of endocervical involvement as compared with exocervical one appears to have some relation to the infecting agent.

Chronic cervicitis manifestation is cervical erosion. Erosion indicates the presence around the cervical os a zone of infected tissue that has a granular appearance. It implies the loss of superficial layers of the stratified squamous epithelium of the cervix and overgrowth of infected endocervical tissues.

The inflammatory process stimulates a reparative attempt in the form of an upward growth of squamous epithelium, causing some of the ducts of the endo­cervical glands to be obstructed. Retention of mucus and other fluid within these glands results in the formation of Nabothian cycts. These cysts are endocervical glands filled with infected secretion. Their ducts become secondarily included into the inflammation and reparative processes.

    The most important in the diagnosis of chronic cervitis is the exclusion of the malignant process. Before the begining of treatment, examination with colposcope should be carried out. The cervicitis may appear as a reddish granulation raised above the surrounding surface, giving the impression of being papillary.

A Papanicolaou smear should be obtained and suspicious areas should un­dergo biopsy.

Treatment. Acute cervicitis is treated with appropriate antibiotics (it depends on bacterial agent). Local treatment of acute phase is a real danger of dissemination of infection. Laser therapy is used in treatment of acute and chronic cervicitis.

Electocautherization is the traditional treatment of chronic cervicitis, especi­ally with erosion, cervical ulcers or ectropion. Nowadays cryosurgery or laser surgery has replaced electrocautherization.

Acute endometritis

Acute endometritis is an inflammation of endometrium (mucus layer of ute­rine). It may occur in such cases as: endometritis after uterine curettage or suction and puerperal endometritis. Endometritis is caused by bacterias, viruses, mycoplasmas. The most frequent the associations of 3-4 anaerobic bacteria and 1-2 aerobic are the main reason of endometritis.

Anaerobic bacteria compose a part of the normal cervicogenital flora. There are two known mechanisms which cause anaerobic infection: antibiotic selection that preferentially inhibits aerobic bacteria and tissual trauma that occurs after surgery which reduces the redox potencial. Anaerobes produce odorous metabolic products.

Uterus has endometrium factors of local immunity. There are T-lymphocytes and other factors of cellular imunity in endometrial stroma. Lymphocytes and neutrophiels normally appear in the endometrium in the second half of menstrual cycle; their presence does not necessarily constitute endometritis. The appearing of plasma cells represents immune response, usually to foreign bacterial antigen. The organism should be cultured before applying of antimicrobal therapy. As anaerobes compose a part of normal flora, deep tissual cultures not contaminated by surface bacteria are required. Forty eight or more hours are required for anaerobe recovery, and treatment usually is based on clinical signs. There are nonspecific and specific endometritis. Specific endometritis is caused by M. Tuberculosis, N. Gonorrhea, Chlamidia trachomatis, Actinomyces.

     Clinic. Fever is the characteristic feature in the diagnosis of endometritis, and it may be accompanied by uterine tenderness. If the infection has spread to the parametrium and adnexa, tenderness may be present there as well. Temperature elevation is probably proportionate to the extention of the infection and when confined to the decidua, the cases are mild and there is minimal fever. Chills may accompany fever. Women usually complain of abdominal pain. There is tenderness on one or both sides of the abdomen and parametrial tenderness is elicited upon bimanual examination. The uterus is lightly enlarged.

A leukocytosis and increased erythrocyte’s sedimentation rate is revealed in patient’ blood test. In some cases acute endometritis may become a chronic one.

Treatment. Various choices of initial antibiotic therapy are used. Most of them are successful. Single-agent therapy has the benefit of easy administration; Cephalosporins such as Cefotetan and Cefoxitin are commonly used. A combi­nation of Ampicillin and Aminoglycoside is also popular. The combination of Clindamycin with Gentamicin or Metronidasol with Unasyn (Ampicillin with Sulbuctam) and Gentamicin is applied. It is desirable to provide additional antibi­otic coverage if there has beeo responce within 48 to 72 hours. Intravenous antibiotic therapy is continued until the patient is asymptomatic and afebrile period lasts for at least 24 hours.

Local uterine douching with antiseptic solution of chlorhexidin or furacilin has a good effect. In some cases uterine curettage is performed after temperature normalization.

Chronic endometritis

Chronic endometritis is a sequale of untreated acute endometritis or nona-dequate treatment of postabortion orpurperal endometritis. The chronic endomet­ritis sometimes is associated with the use of intrauterine device (IUD). In some cases it may occur without acute stage.

Clinic. The chronic endometritis results from organisms that are normally in lower genital tract (Protei, E. Coli, Staphylococcus, Mycoplasma). Bacteria that can be recovered are usually of low pathogenicity, but more virulent intra­uterine bacteria occasionally cause the serous purulent’ discharge, abnormal uterine bleeding and moderate uterine tenderness. Diagnosis is based on anamnesis and clinical manifestation. It could not be diagnosed unless plasma cells are found in the endometrium. Ultrasonography can identify gas vesicules in uterine cavity, hyperechogenic places (local fibrosis, sclerosis) in basal layer of endometrium.

Treatment. A complex treatment is used. It includes a medicines for curing of accompaning deseases, desensibilisative medicines and additional general health measures, vitamines.

Physiotherapy has an important role. It improves pelvic hemodynamics. Diathermy on lower abdomen, electrophoresis with copper, zinc, ultrasound, inductothermy, laser radiation are used. If during physiotherapy the process becomes strained antibiotic therapy is recomended. While remission antibiotic using is not proved.

Physiotherapy promotes to activation of hormonal ovarian function. If effect is not enouph than a hormonal therapy is used (taking into account the patient’s age, term of deseases, degree of ovarian hypofunction). Health resort treatment is effective (balneologic therapy, mudcure resort).

                                                  Salpingoophoritis              

Salpingoophoritis is the inflammation of the uterine tubes and the ovaries. Salpingoophoritis is the most frequent among all pelvic inflammatory deseases. Most cases of oophoritis are secondary to salpingitis. The ovaries become infected by the purulent material that escapes from fallopian tube. If the tubal fimbriae are adherent to the ovary, the tube and ovary together may form a large retort-shaped tubo-ovarian abscess.

Most patients with salpingoophoritis have lower abdominal, adnexal ten­derness (unilateral or bilateral) purulent cervical exudate or purulent vaginal discharge.

Clinic. There are four stages of salpingoophoritis. The first — salpingitis without irritation (inflammation), of the peritoneum, the second— with signs of peritonitis, the third with occlusion of uterine tubes and tuboovarian abscess and the fourth is the rupture of tuboovarian abscess. During bimanual examination adnexal inflammatory mass is revealed.

The diagnosis of salpingoophoritis is based on the history, physical exami­nation and laboratory tests. Besides that additional ultrasonography and laparoscopy can be used.

Laparoscopy provides the most accurate way to diagnose the inflammatory process and its stage. It should be used in cases when the diagnosis is unclear, especially in patients with severe peritonitis, to exclude a ruptured abscess and appendicitis. Besides diagnostic laparoscopy is used to provide treatment pro­cedures.

Ultrasound can be used to distinguish the presence of an abscess from an inflammatory mass within the adnexal mass. It may also be helpful in defining mass in the obuse patient or if the bimanual examination is unsatisfactory because of the excessive tenderness.

Treatment. All patients with acute salpingoophoritis should be hospitalized. Adequate therapy of salpingitis includes the assessment of severity, antibiotic treatment, additional general health measures.

Before the culture test performing the antibiotic therapy is provide with broad spectrum antibiotics. The most effective is the combination of Clindamicm with Chloramphenicol, Gentamicin and Lincomicin, Doxycyclin, Clacid, Cefobid, Cyfran, Claforan, Dalacin С and Unasyn.

When anaerobic agents are suspected metronidazol should be used, in severe cases intravenously, After temperature normalization and cessation of peritonitis signs antibacterial therapy is continued for 5 days. Detoxycation is indicated and is provided by using of 5% glucose solution, polyglucin, reopolyglucin, solutions of proteins, correction of pH balance by using of 4% solution of Sodium bicarbo-nates. Among physical methods of treatment cold on the lower part of the abdomen is used. Appropriate antibacterial treatment is combined with laparoscopy active drainage.

The tuboovarial abscess is drained of pus by puncture and rinsed with bacteri-ostatic solution and local application of antibiotics. In subacute stage aloe, ultra­violet radiation, authohaemotherapy is used. They prevent the chronic processes.

     Chronic salpingoophoritis. In most cases chronic salpingoophoritis is the sequale of non treated acute process. Chronic stage of the process is characterized by tubal occlusion with periovarial adhesions, tubal dysfunction.

Clinic. The main complains of the patient are: mild tenderness in lower part of abdomen that becomes severe during menstruation. Pelvic nerves have more painful sensitivity (pelvic plexitis, ganglionevritis due to chronic inflammation). In some cases menstrual dysfunctions such as oligomenorrhea, polymenorrhagia, algodismenorrhagia occur. Changing in uterine tubes and hypofunction of ovaries lead to infertility or miscarriage. Secretory dysfunction like vaginal discharge or cervical exudate may be observed as a clinical finding of colpitis or endocervitis. Some patients complain of low libido, painful coitus, dysfunction of urinary bladder, liver tenderness.

Menstrual dysfunction (menorrhagia or metrorrhagia) is the most frequent symptom of chronic salpingoophoritis as a sequel of disorders of neurohomoral regulation of menstrual function. Metrorrhagia often occurs after cessation of menstruation and then the differential diagnosis should be made in case of ectopic pregnancy.

Diagnosis. Correct history taking (reveal of inflammation after abortion, delivery or dilatation and curettage) makes it possible to suspect the chronic inflammatory process. Primary chronic salpingoophoritis is found in more than 60% of cases. Some information gives physical examination and laboratory tests. Bimanual examination gives nonspecific information. Enlargement, consistency and degree of adnexa mobility should be examined. Sometimes because of peri-tubal and periovarian adhesions the sizes and mobility of adnexa are changed.

Additionally, ultrasound and laparoscopy, hysteroscopy should be held. Tomography or endoscopy may be used. Laparoscopy is the most informative diagnostic method to differentiate salpingoophoritis, external endometriosis, uterine myoma with inflammatory changes, cysts. Disorders of adjacent organs (bladder, intestine) while serous inflammation is present without structural changes. But women with disorders of urinary tract, gastro-intestinal tract must be additionally examined (urography, irrigoscopy).

Treatment of chronic salpingoophoritis is provided with minding of patho-genesis and clinic. Antibiotics are indicated in acute period, when there are signs of inflammation.

Nonsteroidal antiinflammatory drugs (Voltaren, Butadion) are prescribed. To stimulate immune system immunomodulators are used: (Decaris, T-activin). FIBS, aloe, autohaemotherapy are also used. Analgesia both by medicines and by reflextherapy is of great importance. Physiotherapy is conducted in hospital while in case of acute process and remission it can be used in ambulatory conditions. Ultrasound has analgetic and fibrinolityc influence and is prescribed in sinusoid and modulate of high frequency. Laserotherapy is also used. To escape chronic salpingoophoritis the acute salpingoophoritis must be treated in proper way and the quantity of abortion should be reduced.

Parametritis

Parametritis is an inflammation of parametrium. Inflammation of the whole pelvic cellular is called pelviocellullitis. According to international statistics these diseases are classified as acute parametritis or pelvic phlegmona.

Infection agents may be staphyloccocus, streptoccocus, E.coli, etc. It can be caused by one microbic agent or microbe association. It occurs after pathologic delivery, abortion, operation on genitals. The main way of infection spreading is lymphogenic. Morphologically parametritis is characterized by all signs of inflam­mation: dilation of blood and lymphatic vessels, peripheral edema, exudation. There are 3 stages in course of parametritis (infiltration, exudation, firming). Exudation may be serous, and very rarely it is purulent. Sometimes it undergo resorbtion and dissolves, sometimes a fibrose connective tissue grows and leads to uterine dislocation to the side of previous inflammatory process.

Clinic. Moderate tenderness in lower parts of abdomen, in back, high body temperature (38-39°C), tachicardia are found. Signs of peritoneal irritation and diminished or absent bowel sounds, especially associated with ileus, indicate more serious infection, including the possibility of abscess formation. Fever is a characteristic feature in the diagnosis of metritis and it is accompanied by uterine tenderness. Bimanually before or behind on left or right side of the uterus infilt­ration may be palpated. It is firm and immovable. Infiltration is classified into anterior, posterior and lateral.

Treatment begins from using antibiotic of broad coverage against a variety of common microorganisms and is usually prescribed without cultures.

Various choices of initial antibiotic therapy are used. Most of them are suc­cessful. Cephalosporins such as Cefotetan and Cefoxitin are commonly used. A combination of Ampicillin and Aminoglucoside and also the combination of Clindamycin with Gentamicin are used.

A bottle with ice on the lower part of abdomen is used in case of infiltrative stage of disease. Bio stimulators should be prescribed. Management of a persistent pelvic abscess includes drainage by colpotomy, or laparotomy. Intraabdominal rupture of pelvic abscess is a surgical emergency. Sepsis may occur in association with pelvic infection, with or without frank abscess formation. Phisiotheraputic precedures are used for rehabilitation.

Tuboovarian abscess

  Tuboovarian abscess (TOA) may occur as a complication of salpingoopho-ritis. It begins from acute purulent salpingitis when all layers of uterine tubes arc involved into the process. The tubes characteristically become swollen and redden as the muscularis and serosa are inflamed. If exudate drips from the fimbriated ends of the tubes a pelvic peritonitis is produced then it can give rise to peritoneal adhesions. The swollen and congested fimbriaes may adhere to one another and produce tubal occlusion. The fimbriae may occlude tubes producing permanent tubal infertility. The swollen and congested fimbriae may adhere to ovary, trapping the exudate in the tube and giving rise to pyosalpinx or if the ovary becomes infected, a tuboovarian abscess. The mucosal folds may adhere to one another forming gland-like spaces that are filled with exudate. If the infection subsides after agglutination of the fimbria and closure of the peripheral end of the tube, secretion accumulates and distends the tube, forming pyosalpinx. Each recidive of chronic salpingoophoritis has more clinical manifestation and is treated with difficulty. TOA is associated with IUD, microbe association, chronic salpingoophoritis.

Intoxication in case of TOA leads to liver disorders. Decreasing of albumin-globulin index is observed while the level of general proteins is normal for a long time. The degree of these disorders depends on the time of duration of the process.

Clinic. Clinic of TOA depends on the volume of purulent damage of adnexa, duration of the process, disorders of adjacent organs. There are some syndromes which are divided into local syndrome (pain, purulent discharge, peritoneal symptoms and palpation of tuboovarian mass).

Inflammatory-intoxicative syndrome includes fever, tachycardia, nausea, vomiting. Luecocytosis, decreasing of albumin-globulm index, C-reactive protein are observed in blood. Immune syndrome (decreasing of lymphocytes and mono-cytis in blood) is found.

Syndrome of adjacent organs disorders (dysuria, urinary frequency, menstrual disorders) is also possible.

Severe lower abdominal pain occurs, pelvic peritonitis may be present. Pain can irradiate to back, pelvic bottom, in the chest. In such cases the examinations should be performed to exclude pneumonia, pancreatitis, cholecystitis. Muselar defance which prevents abdominal palpation in the lower quadrants, adnexa are tender to various degrees and cervix movement may cause pain in case of bimanual examination. The adnexa often are either adherent to the posterior aspect of the uterine or prolapsed in cul-de-sac, which may pull the uterine into a retroverted position. TOA is characterized by pain and tenderness, fever or chills, tempera­ture rises up 39°C, blood pressure decreases. Abdomen takes part in breathing, and it is painful in lower parts. In blood analysis elevated white blood count (9-10×107 1) erythrocytes’ sedimentation rate more than 30mm/hour, positive C-reactive protein, decreasing of albumin-globulin index till 0,8 are observed.

Sometimes there can be urinary syndrome with proteinuria, leucocytuna. There may be disorders of filtrative kidney’ function, even unuria. Changing of albumin-globulin index and hypofybrinogenemia characterizes the liver dys­function.

Diagnosis is based on clinic, bimanual examination, laboratory analyses and additional methods of investigation (ultrasound, laparoscopy).

Treatment Tuboovarian abscess is treated by antibiotics, desensibilisative and nonsteroidal antiinflammatory medicines, detoxication and immunostim-mulation. Best of all one should combine taking of penicillin with tetracyclins. When anaerobic infection is suspected metronidazole is used. Daily punctions of tuboovarian abscesses are indicated to remove purulent containts.

Indications to surgical removal of tuboovarian abscess are:

    abscence of efficiency of complex treatment with usage of punctions during
2-3 days

    suspicion on tuboovarian abscess perforation; volume of surgical intervention
depends on process’ spreading, woman’s age and extragenital pathology.

Pelvic Inflammatory Disease (PID)

      I.  General. PID is an infection that may involve the uterus, fallopian tubes, ovaries, and pelvic cavity, and may produce tubo-ovarian abscesses.

   II.  Pathogenesis. Usually sexually transmitted but may occur after uterine instrumentation. Often polymicrobial, with ascending infection initiated by N. gonorrhoeae or Chlamydia trachomatis, and secondary infection by other organisms including Mycoplasma species, Ureaplasma urea-lyticum, Bacteroides, Enterobacteriaceae, Streptococci, gram-negative enterics, other anaerobes.

III.  Predisposing Factors. Multiple sexual partners, non-barrier contraceptive use (especially IUD), transvaginal instrumentation of cervix and uterus, recent menstrual period, current STD infection, history of PID or douching.

IV.  Diagnosis.

A.    Differential diagnosis. Appendicitis, ectopic pregnancy, septic abortion, endometriosis, hemorrhagic corpus luteum, ovarian cyst, adnexal torsion, inflammatory bowel disease, mesenteric lymphadenitis, pyelo-nephritis, or other intra-abdominal processes. See acute abdomen in Chapter 15, surgery, for a more complete discussion of abdominal/ pelvic pain.

B.    Evaluation. Abdominal and complete pelvic exam. Obtain UA, CBC, pregnancy test, Gram stain of cervical discharge, and appropriate cultures: endocervix, rectum, urethra, blood, and peritoneal fluid as indicated. Obtain Pap if none recently.

C.    Criteria for diagnosis.

      1.Primary criteria: must have all three. (1) lower abdominal tenderness with or without rebound, (2) cervical motion tenderness, (3) adnexal tenderness. Additionally, there should be no other pathology that explains the symptoms. The primary criteria alone are sufficient to treat for PID!

      2.Secondary criteria used to confirm the diagnosis: (1) temperature >38.3° C, (2) abnormal vaginal discharge; (3) adnexal mass on bimanual exam or ultrasonography, (4) WBC >10,500/mm3; (5) elevated ESR or CRP; (6) endocervical Gram stain with gram-negative intracellular diplococci, positive rapid assay for Chlamydia, or other documentation of GC or Chlamydia infection; (7) diagnostic laparoscopy or endometrial histology; (8) culdocentesis with WBCs and bacteria

   V.  Treatment. Because of the risk of infertility, treat all patients meeting the primary criteria presumptively while awaiting cultures even if no secondary criteria are met.

                       A.          Outpatient therapy if temperature is less than 38° C, WBC<11,000/mm3, minimal signs of peritonitis, active bowel sounds, able to tolerate PO, good compliance likely.

      1.Ofloxacin 400 mg PO BID x 14 days plus metronidazole 500 mg PO BID x 14 days. Alternative: Ofloxacin as above plus clindamycin 450 mg PO QID x 14 days or Ceftriaxone 250 mg IM x 1 dose plus doxycycline 100 mg PO BID x 14 days. Reevaluate in 48-72 hours. May also elect IV therapy.

      2.Single-dose azithromycin is not adequate therapy for Chlamydia in the setting of PID.

B.     Inpatient therapy if suspected abscess, pregnancy, temperature greater than 38° C, WBC >11,000/mm3, unable to take PO medication, peritonitis, no response to oral antibiotics within 48 hours, unclear diagnosis, inability to comply with outpatient treatment and follow-up. Some authorities admit all adolescents with PID.

1.     Cefotetan 2 g IV Q12h plus doxycycline 100 mg IV/PO Q12h or cefoxitin 2 g IV Q6h plus doxycycline 100 mg IV/PO Q12h until improvement. Follow with doxycycline 100 mg PO BID to complete 14 days.

2.     In IUD-related infection, suspected abscess, or procedure-related infection: clindamycin 900 mg IV Q8h plus gentamicin loading dose 2 mg/kg IV followed by gentamicin 1.5 mg/kg Q8h until improvement. (Adjust gentamicin dose in renal insufficiency. Can also use single daily gentamicin dosing.) Adding ampicillin 1 g IV Q6h to clindamycin and gentamicin appears to improve efficacy in the setting of abscess. Alternative: ofloxacin 400 mg IV Q12h plus metronidazole 500 mg IV q8h. Follow as outpatient with doxycycline 100 mg PO BID or clindamycin 450 mg PO QID to complete 14 days, follow-up in 7 days.

Complications. Infection rarely remains confined to fallopian tubes, and peritonitis is common. Acute complications include rupture of tubo-ovarian abscess, adnexal torsion, Fitz-Hugh-Curtis syndrome (perihe-patic GC) and septicemia. Long-term complications include an increased risk of ectopic pregnancy (6-10 times), infertility (20%), and bowel obstruction secondary to adhesions.

 

Prophylactic medical examination of non-inflammatory diseases

Uterine myoma

Uterine myoma (fibromyoma, leiomyoma) — is a benign tumor which con­tains varying amounts of muscle and fibrous elements.

Concerning gynecologic diseases benign tumors are found in 10-25% of all the cases, although during the last years the tendency of increasing the quantity of these tumors is observed. The myoma arises seldom in young women. The risk of disease grows after 35-40 years, at the age which is close to climacterium. Later beginning of menstrual function, irregular menstrual cycle, high frequency of induced abortions are present in the past history of the patients. Therefore, 35-40 years women are patients at risk for uterine fibromyoma.

Tumor histogenesis and structure. Uterine myoma belongs to tumors, which are growing from mesenchyma. It has three consecutive stages in its morpho­genesis. They are:

    active region of growth formation

    growing of tumor without differentiation

    growing of tumor with differentiation and maturation

 

The areas of growth are formed mainly around the vessels. These regions are characterized by a high level of metabolism and increased capilary and tissual permeability which stimulate the tumor growing. Uterine fibroid has in its development parenehymal-stromal features of that layer, from which it has been educed, therefore the parenchyma and stroma ratio in a tumor is different. Leiomyoma is developed at predominance of muscle elements, in the structure of fibromyoma fibrous tissue is predominant. The consistency of tumor depends on fibrous and muscle tissue ratio: the more there are muscle fibers, the more the tumor is mild at palpation.

    Myomas are classified according to histologic structure as myoma, fibro­myoma, angiomyoma and adenomyoma. According to the speed of growing there are the tumors which are growing slowly and quickly. According to histogenesis peculiarities there are distinguished simple and proliferative myomas. Proliferative myomas contain much more atypical muscle elements, where is a great number of plasmatic and lymphoid cells and increased mitotic activity. The incidence of proliferative myomas happen twice more often in the patients with fast growing tumors. Very often uterine fibroids arise in places of complex interlacing of muscle fibers of uterus — near tubal angles, on uterine center line. The myoma is charac­terized by the effusive growing. As compared with cancer fibroids they move apart tissue without destroying it. Tumor is growing simultaneously with tissue mass surrounding it.

Uterine fibroids have few veins, basic amount of vessels is situated in pseudo-capsule. Uterine fibroids’ lymphatic system is atypical without absorbent vessels. Uterine fibroids are deprived of nervous terminals, choline and adrenergic nervous frames.

According to their location in the uterus myomas are    classified into:

   subserosal  subperitoneal uterine fibroids, which are growing under the outer serosal layer of the uterus, may have a wide or thin pedicle. It has been estimated that 10-16% of all myomas are subserosal ones

   interstitial (intramural, intraparietal)  — uterine fibroids, which are growing within the muscular wall of the uterus, their frequency is 40-45%

   submucosal)—-uterine fibroids which are growing under the uterine mucous into the uterine cavity, their frequency is 20% of all the patients

   atypical forms of uterine fibroids location: retrocervical myoma grows from the posterior surface of the uterine cervix, it is situated within a retrocervical fat; paracervical myoma grows from the lateral part of uterine cervix, it is situated in the paracervical fat; intraligamentary myoma grows from the uterine body or cervix within the broad ligaments.

The fibromyoma can have one fibroid (nodulosus fibromyoma), many fib­roids (multiple fibromyoma) and diffuse growth (diffuse fibromyoma).

Hormonal status of the patients with fibromyoma. They are considered hormonally depend tumors because the growth of these tumors is related to estro­gen production. In the majority of cases these patients have an hormonal dys­function of ovaries which is characterised by anovulatory cycles, corpus luteum insufficiency. It leads to hyperestrogenemia and lowering of progesterone level. Small cystic changes in ovaries occur due to hormonal disordes. Uterine endo-metrium and myometrium are under the influence of estrogenic hormones. Their excessive amount in blood can lead to endometrial hyperplastic processes and cystic changes in myometrium. Recent researches have shown that in patients with fibromyoma even with normal level of estrogenic hormones in a peripheral blood the contents of estradiol in uterine vessels is higher, than in other parts of vascular system.

Such local hyperhormonemia leads to pathological hypertrophy of myomet­rium. Not only sexual hormones synthesis, metabolism and interaction impair­ment, but also the state of the myometrial receptors especially large activity of the estrogen receptors as compared with progesterones receptors, take part in a pathogenesis of uterine fibromyoma.

Fibromyoma grows slowly without any proliferative changes at presence of small cystic changes in ovaries with nonsignificant hyperestrogenemia. FoUicular cysts of appreciable sizes have been found in the patients with fast growing fibromyoma with the presence of proliferative centers in it.

Fibromyoma growing depends on its type, location, blood supply and pa­tient’s age. Fibromyoma grows quickly in young patients, particularly during pregnancy, as the fetoplacental complex synthesizes large amount of estrogenic hormones, which are tumor stimulating growing factor. Quite often fibromyoma accelerates its growing in climacterium, when there is a rearrangement of wo­man’s hormonal system. Ovaries undergo polycystic degeneration at that time. When the menstrual function is over then the menopause and processes connected with it develop. Production of estrogenic hormones decreases, fibromyoma growth is retarded, uterine fibroids undergo involution. These processes develop due to the decreased pituitary gland gonadotropic function and changing of estrogenic effects into androgenic.

Clinic. Clinical manifestation of fibromyomas depends on uterine fibroid’s location, size of tumour, rate of its growing, and also presence of complications.

Of the most myoraas there are not any symptoms at the initial stages. Tumor should be revealed during the routine maintenance or when consulting the gyneco­logist for some other reason. The symptoms associated with uterine fibroids frequently make women seek for a medical advice.

The main symptoms are pain, bleeding, sensation of pelvic heaviness in the lower part of the abdomen, progressive increase in pelvic pressure, infertility, frequent urination, pressure on the rectum. These symptoms most commonly occur during the excessive growth of tumor, and sometimes they testify develop­ment of secondary degenerative or inflammatory changes in fibromyoma tissue.

Menstrual function in the patients does not variate in case if tumor is sub-serosal because attached to the uterus by only a stalk or on a wide basis under a peritoneal integument and it is practically outside of uterine borders. Therefore, uterine contractile function does not suffer, the mechanism of menstrual bleeding is also not disturbed. Pain symptoms may be the result of rapid enlargement of myoma, pressure of large tumors on the adjacent viscera, in areas of tissue necrosis,or subnecrotic ishemia which contribute to alteration in myometrial responce to prostaglandines. Occasionaly, such complications as torsion of pedun-culated myoma, uterine fibroid necrosis, uterine fibroid adhesion with parietal viscera can occur resulting in acute pain.

Another spectrum presentation includes patients with atypical (subperitoneal) location of uterine fibroids: the tumors from the anterior wall of the uterus and antecervical location  can press upon urinary bladder and cause dysuric signs; pressure on the ureters (as they traverse the pelvic brim) leads to hydroureter and sometimes to hydronephrosis. Retrocervical location of uterine fibroid due to intensive growing can spread in all small pelvic, compressing rectum and provoking constipation. Due to extremely large tumors, pressure on the pelvic vessels may result in hemorrhoids, edema or varicosities of the legs. Uterine fibroids of such location can irritate the nervous plexuses of small pelvis and cause pain which irradiates into the lower extremities.

Intraligamentary tumor during its growing moves apart the broad ligament of the uterus. As the ureters are passing in the lower areas of parametrium, the tumor results in pressure upon ureters leading to hydroureters or hydronephrosis. Excessive bleeding (hypermenorrhagia) and development of progressively heavy menstrual flow that lasts longer than the normal duration (polymenorrha-gia), may result from the increased surface area of the endometrium when intra­mural tumors enlarge and distort the endometrial cavity. Large tumors, especially multiple myomas make mechanical interference with the blood supply to the endometnum, and the presence of intramural rumors may interfere with the ability of the uterus to contract and effectively occlude blood vessels at the time of menstruation.

Cyclic menstruation is present but it is painful (algomenorrhea).

Submucosal location of uterine fibroid is characterized by cramping cyclic menorrhagia which has been changed into acyclic bleeding. Monthly appreciable bleeding leads to the secondary iron deficiency anemia.

Uterine myoma is frequently connected with the other gynecololic and extra-genital diseases. They are obesity (64%), diseases of cardiovascular system (60%), diseases of stomach, intestine, liver (40%), idiopathic arterial hypertension (19%), neuroses (11%), endocrinopathy (4,5% of the patients).

Characteristic dystrophical myocardial changes called “myom’ heart” result from the secondary anemia and chronic hypoxia and are often found in patients with fibromyoma. Liver function is frequently broken in these patients. Probably, these changes are the result of steroid hormones metabolism dysfunction. Hyper­trophy of the left ventricle, myocardial dystrophy, ischemic heart disease, idio pathic arterial hypertension are also present in these patients. In most of the patients after fibromyoma removal the arterial pressure is reduced to the normal level. This fact confirms the idea of pathogenetic connection of fibromyoma with changes in myocardium and rising of arterial pressure.

Diagnosis. History of the patients includes hereditary predilection (myoma in mother and other reproductive organs tumors in close relatives); menstrual dysfunction, late beginning of menarche and metabolism infringement (obesity, diabetes mellitus). Reproductive dysfunction (infertility, pregnancy loss), induced abortions (mucous and myometrium trauma should lead to endometrial receptor device changes),extragenital diseases, which caused endocrine and ovarian disordes, in particular can be present in these patients.

Bimanual examination in uterine fibromyoma has characteristic signs. It includes the presence of a large midline mobile pelvic mass with the regular contour. The mass usually has a characteristic “hard” feel or solid quantity.

Additional methods of investigation are used for confirmation of the diag­nosis. They are: uterine sounding (enlargement of endometrial cavity of the uterus, rough relief, presence of submucous fibroids are revealed) and curettage of uterine cavity (relief changes, presence in uterine cavity of submucous fibroid, endomet­rial hyperplastic processes). Nevertheless, these methods for diagnosis are not recommend to use routinely, as they can lead to submucous fibroid trauma.

Hysterography gives a possibility to diagnose submucous nodes which distort the cavity of the uterus.

Hysteroscopy may be used to evaluate the enlarged uterus by directly visuali­sing the endometrial cavity. The increased size of the cavity can be found and submucous fibroids can be visualized.

Laparoscopy is applied seldom, mainly to make differential diagnostics of subserous fibroid and ovarian tumor, and also for diagnosis of such complications as torsion of pedunculated myoma and fibroid’ necrosis.

Submucosal uterine ibromyoma (Hysteroscopy)

Pelvic ultrasonography is the most common method to confirm the uterine myomas presence. The ultrasonographer may suggest location, quantity, size of uterine fibroids, their sructure, presence of destructive changes. Dynamic obser­vation enables to supervise efficiency of the conservative therapy, tumor growing, or, on the contrary, its reduction under the influence of treatment.

Uterine fibroids’ complications

Prolapse of submucous fibroid (cervical protruding myoma)

Submucous fibromyoma is accepted by uterus as an ectogenic body. Fibroid descent to the inferior portion of uterus, irritating the isthmus receptors. It results in myometrial contractions, cervical dilation and uterus pushes out fibroid into vagina. Pedunculated tumor is connected with uterus. If pedicle is short, it can result in difficult complication — oncogenetic inversion due to prolapse of the submucous fibroid. Speculum examination should be performed for confir­mation of this diagnosis: cervical protruding myoma is visible.

Treatment Submucous tumor can be easily removed by the incision of long pedicle by clamping the base through the cervix. The pedicle is then ligated. Such removal of fibroid can lead to uterine perforation when the pedicle is short and wide. These patients need hysterectomy.

Torsion of uterine fibroid

Torsion of uterine fibroid is a very common in subserous location. Clinically it is characterized by cramping pain, signs of peritoneal irritation, fever, urinary frequency and symptoms of rectal pressure. In this situatioecrosis and infection are common.

Surgical treatment. Myomectomy is more commonly done when abdominal myoma location. Myomectomy should be the operation of choice in case of single subserous pedunculated tumor. A clamp should be put on the lower place of torsion. One should remember that it is dangerous to untwist the tumor. For most of patients the treatment should be total or subtotal hysterectomy.

Uterine fibroid’ necrosis

Necrosis of uterine fibroid results from blood supply disorder of the tumor, occuring due to rapid growing, pregnancy, mechanical accident, and postmenopausal atrophy. It leads to tumor edema and pseudocapsule hemor­rhages.

Clinically it is characterized by cramping pain which enforces during palpation. Signs of peritoneal irritation are found. Fever and leukocytosis accompany severe degeneration.

Treatment is surgical removal.

Uterine fibroid’ suppuration

Uterine fibroid’s suppuration arises primarily very seldom. Sometimes it is a result of necrosis. Submucous and interstitial uterine fibroids may be suppurated. The serious septic state demands supracervical hysterectomy (subtotal) or total hysterectomy.

Pseudocapsule’ and uterine fibroid’ vessels rupture

Pseudocapsule’ and uterine fibroid’ vessels rupture happens very seldom. It is accompanied by severe pain, signs of intraabdominal hemorrhage (hemorrhagic shock).

Malignant degeneration of uterine fibromyoma

The malignant degeneration of uterine fibromyqma in sarcoma arises in 5-7% of cases.

Uterine myoma and pregnancy

Pregnancy at fibromyoma of uterus comes mainly at subserous and interstitial location of uterine fibroids. Submucous fibroids manifest with pregnancy progressing.

Diagnosis of pregnancy in such patients represents appreciable difficulties. The test for pregnancy and ultrasound examination are necessary, because only with their help it is possible to establish the duration of gestation. Abortions and premature labors frequently happen in the patients with fibromyoma. Approximately half of women can bear a child. During the pregnancy there is a threat of its interrupting as the result of fibroid blood supply disorder (its necrosis, pseudocapsule hemorrhage). The function of urinary bladder and rectum is broken. Fetal position is frequently incorrect—oblique or transversal one. Breach presen­tation is common if the myoma does not let the fetal head get into pelvic inlet. Preterm rupture of amniotic fluid, primary and secondary dystocia of labor are common.

Cesarean section should be performed if the nodes are placed behind the course of the genital canal and block the plane of pelvic inlet. Vaginal delivery is recommended in all other cases of labor. Postpartum hemorrhage happens in the third period of labor (in case of placental implantation in the area of uterine fibroid), therefore it is necessary to perform manual removal of placenta and manual revision of the uterine cavity. Hypotonic bleeding in early puerperal period is a very dangerous complication that appear as the result of uterine contractile dysfunction. Uterine involution and regress of fibroid take place in the late puerperal period.

Uterine fibroid should undergo involution until their complete regress in women with high-grade lactation during the further duration of puerperium.

    Fibroids

    Fibroids are round growths that develop in the uterus. They are almost always benign, or non-cancerous. Fibroids range in size from as small as a pea to as large as a melon. They are also called leiomyomas or myomas.

Fibroids are very common, affecting an estimated 20 to 50 percent of all women. They are most likely to affect women in their 30s and 40s, and for reasons we don’t understand, occur more frequently in African-Americans. Many women with fibroids have family members who also have them.

Some fibroids grow steadily during the reproductive years, while others stay the same size for many years. All fibroids should stop growing after menopause. If your fibroids grow after menopause, you should consult your doctor.

Usually, fibroids cause no symptoms and don’t require treatment. But if symptoms occur, you should seek medical attention.

At UCSF, the Comprehensive Fibroid Center offers a wide range of treatments. There are many effective ways to treat fibroids, and the type of treatment chosen will depend on the severity of your symptoms and the fibroid size, number and location. Your preference and desire for future childbearing also enters into the treatment discussion. Not all treatments are recommended for all women.

Fibroids are round growths that develop in the uterus. They are almost always benign, or non-cancerous. Fibroids range in size from as small as a pea to as large as a melon. They are also called leiomyomas or myomas.

Fibroids are very common, affecting an estimated 20 to 50 percent of all women. They are most likely to affect women in their 30s and 40s, and for reasons we don’t understand, occur more frequently in African-Americans. Many women with fibroids have family members who also have them.

Some fibroids grow steadily during the reproductive years, while others stay the same size for many years. All fibroids should stop growing after menopause. If your fibroids grow after menopause, you should consult your doctor.

Usually, fibroids cause no symptoms and don’t require treatment. But if symptoms occur, you should seek medical attention.

At UCSF, the Comprehensive Fibroid Center offers a wide range of treatments. There are many effective ways to treat fibroids, and the type of treatment chosen will depend on the severity of your symptoms and the fibroid size, number and location. Your preference and desire for future childbearing also enters into the treatment discussion. Not all treatments are recommended for all women.

    Types of Fibroids

Fibroids can grow in different parts of the uterus:

·        Pedunculated fibroids are attached to the uterine wall by stalks.

·        Subserosal fibroids extend outward from the uterine wall.

·        Submucosal fibroids expand from the uterine wall into the uterine cavity.

·        Intramural fibroids develop within the uterine wall.

Different types of fibroids are associated with different symptoms. For example, submucosal fibroids typically cause heavy periods. In contrast, subserosal fibroids are more likely to push against the bladder, causing frequent urination.

      Causes of Fibroids

     Doctors and medical researchers do not know what causes fibroids to develop. There is evidence that the female hormones, estrogen and progesterone, can make them grow. During pregnancy, when the hormone levels are high, fibroids tend to increase in size. After menopause, when the hormone levels are low, fibroids stop growing and may become smaller.

Fibroids
Diagnosis

Usually, fibroids are found during a routine gynecologic visit with a pelvic examination. A pelvic exam allows the doctor to feel the size and shape of the uterus; if it is enlarged or irregularly shaped, fibroids may be present. Or, you may notice new symptoms and inform your doctor.

If your doctor thinks you may have fibroids after performing the exam, there are several tests that can confirm the diagnosis. The first is usually an ultrasound. The other tests are more specialized and are only performed if needed to guide treatment options. Below is a brief description of each type of exam.

·        Ultrasound Many women are familiar with ultrasound from pregnancy, when it is used to evaluate the growing fetus. Ultrasound is also a safe and reliable way to look for fibroids. In the test, sound waves are used to create a picture of the uterus and ovaries. Ultrasound does not use radiation.

The procedure takes between 30 to 60 minutes. The initial portion of the exam is performed with the transducer on the abdomen. Conducting gel is placed on the skin, which feels wet and cool. The transducer is moved around as the technologist takes pictures of the uterus and ovaries. 

The second portion of the exam is performed internally. You will need to empty your bladder first. A special ultrasound probe will then be placed in the vagina. It is usually not painful and is inserted like a tampon. Close-up pictures are then taken of the uterus, endometrium (the lining of the uterus) and ovaries. The radiologist reviews all the pictures and will report the results to your doctor.

·        Saline Hysterosonography This is also an ultrasound procedure which uses no radiation. The exam helps us better visualize the inside of the uterus and endometrium. Submucosal fibroids and polyps can easily be identified by this method.
The exam takes about half an hour. It is often performed right after the woman finishes her menstrual period. A small catheter is inserted through the cervix and a small balloon is inflated to hold it in place. Sterile saline is injected into the uterus and ultrasound pictures are taken. During the procedure you may experience some cramping, similar to menstrual cramps. The cramps may last for a short time after the procedure — this is normal.

·        Magnetic Resonance Imaging (MRI) — MRI is more expensive than ultrasound but gives doctors a reproducible, detailed picture of the number, size and exact location of the fibroids. Not all women with fibroids need an MRI. All patients that are being evaluated for a uterine artery embolization will get one, however. MRI uses a large, special magnet to take pictures of the body. The test does not use radiation.

The exam takes about 45 to 60 minutes, during which time you are asked to remain still. Before the study begins, an intravenous (IV) line is placed in your arm. You then lie down on a moveable bed. The big magnet is shaped like a donut, through which this moving bed passes. Contrast material is injected through the IV and pictures are taken of the pelvic area. These images will be reviewed by a radiologist who will report the findings to your doctor.

·        Hysteroscopy — Diagnostic hysteroscopy is another procedure for seeing inside the uterus. The test can be performed in a doctor’s office or in an operating room. Submucosal fibroids and polyps can be easily identified with this test. It takes 30 minutes to complete.

For the test, you will lie on your back with your feet in gynecology stirrups. A speculum is placed in the vagina. A long, slender telescope, called a hysteroscope, is gently inserted through the cervix into the uterine cavity. For ideal viewing, sterile saline or CO2 gas is introduced through the hysteroscope to inflate the cavity. Images of the lining of the uterus, the openings of the fallopian tubes, polyps and submucus fibroids are displayed on a TV monitor. Women experience mild cramps during the procedure. Taking ibuprofen (Advil, Motrin) one hour before the procedure can alleviate the discomfort.

    Fibroids Treatment

    Treatment for fibroids can range from no treatment at all to surgery. Unless fibroids are causing excessive bleeding, discomfort or bladder problems, treatment usually isn’t necessary.

    If you have fibroids, you should be evaluated periodically to review symptoms, and to monitor the fibroid and uterus size with abdominal and pelvic examinations. If you don’t have symptoms, routine pelvic ultrasounds have very little benefit. Fibroids are likely to grow each year until menopause, but this isn’t an indication that you need treatment, unless the change is accompanied by disabling symptoms.

The following are treatment options for fibroids:

       Medications

Currently, the medications available for fibroids can temporarily improve symptoms but do not make the fibroids go away. For women with heavy bleeding, it is worth trying medication before undergoing a surgical procedure. Women with pressure symptoms caused by large fibroids won’t benefit from any medicines currently available.

   There are several promising new drugs on the horizon that will treat the fibroids themselves, not just the symptoms.

     Contraceptive Pills and Progestational Agents

    Women with heavy menstrual periods and fibroids are often prescribed hormonal medications to try to reduce bleeding and regulate the menstrual cycle. These medications will not shrink fibroids or make them grow at a faster rate.

If the medication has not improved your bleeding after three months, consult your doctor. Women over the age of 35 who smoke should not use oral contraceptives.

     GnRH Agonists (Lupron)

     GnRH agonists are a class of medications that temporarily shrink fibroids and stop heavy bleeding by blocking production of the female hormone, estrogen. Lupron is the most well known of these drugs. Although Lupron can improve fibroid symptoms, it causes unpleasant menopausal symptoms such as hot flashes. Long-term use can cause bone loss.

Lupron is recommended only for very specific cases. It may be recommended if you have heavy bleeding and serious anemia, and would need a blood transfusion during fibroid surgery. If you take Lupron for two to three months before surgery, your periods may temporarily stop and eliminate the need for a blood transfusion. Lupron also may be recommended if you have very large fibroids — greater than 10 to 12 centimeters — prior to fibroid surgery. Lupron should not be used solely to shrink fibroids unless surgery is planned, because fibroids will re-grow to their original size as soon as you stop taking Lupron.

      Intrauterine Devices (IUD)

    Although IUDs are typically used to prevent pregnancy, they have other benefits as well. An IUD that releases a small amount of hormone into the uterine cavity can decrease bleeding caused by fibroids.

An IUD can be inserted during a routine office appointment.

     Myomectomy

    A myomectomy is an operation to remove fibroids while preserving the uterus. For women who have fibroid symptoms and want to have children in the future, myomectomy is the best treatment option.

      Myomectomy is very effective, but fibroids can re-grow. The younger you are and the more fibroids you have at the time of myomectomy, the more likely you are to develop fibroids again in the future. Womeearing menopause are the least likely to have recurring problems from fibroids after a myomectomy.

A myomectomy can be performed several different ways. Depending on the size, number and location of your fibroids, you may be eligible for an abdominal myomectomy, a laparoscopic myomectomy or a hysteroscopic myomectomy.

·        Abdominal Myomectomy During this operation, an incision is made through the skin on the lower abdomen (a “bikini cut”). The fibroids are removed from the wall of the uterus, and the uterine muscle is sewn back together using several layers of stitches. You will be asleep for the procedure. Most women spend two nights in the hospital and four to six weeks recovering at home.

·        Laparoscopic Myomectomy In a laparascopic myomectomy, four one-centimeter incisions are made in the lower abdomen: one at the belly button, one below the bikini line near the pubic hair, and one near each hip. The abdominal cavity is filled with carbon dioxide gas. A thin, lighted telescope is placed through an incision so the doctors can see the ovaries, fallopian tubes and uterus. Long instruments, inserted through the other incisions, are used to remove the fibroids. The uterine muscle is then sewn back together, the gas is released and the skin incisions are closed.

You will be asleep for the procedure. The recovery is shorter than for an abdominal myomectomy — typically, women spend one night in the hospital and two to four weeks recovering at home.

·        Hysteroscopic Myomectomy Only women with submucosal fibroids — fibroids that expand from the uterine wall into the uterine cavity — are eligible for this type of myomectomy. Fibroids located within the uterine wall cannot be removed with this technique.

During the procedure, you will lie on your back with your feet in gynecology stirrups. You will most likely be asleep for the procedure. A speculum is placed in the vagina and a long, slender telescope is placed through the cervix into the uterine cavity. The uterine cavity is filled with fluid to lift apart the walls of the uterus. Instruments passed through the hysteroscope are used to shave off the submucosal fibroids.

This is an out-patient procedure, and you may go home after several hours of observation in the recovery room. Most women spend one to four days resting at home to recover.

Read more about myomectomy.

     Hysterectomy

Hysterectomy is a major surgical procedure in which the uterus is removed. Many women choose hysterectomy to definitively resolve their fibroid symptoms. After hysterectomy, menstrual bleeding stops, pelvic pressure is relieved, frequent urination improves and new fibroids cannot grow. A woman cao longer become pregnant after a hysterectomy.

The ovaries are not necessarily removed during a hysterectomy. Generally, if a woman is in menopause or close to menopause, the ovaries are removed. The ovaries may also be removed if they look abnormal or if the patient wants to decrease her chance of developing ovarian cancer later in life. In pre-menopausal women, removal of the ovaries can cause hot flashes, vaginal dryness and other symptoms. You should discuss the pros and cons of ovarian removal with your doctor.

There are several hyterectomy surgical approaches: a vaginal hysterectomy, an abdominal hysterectomy and a laparoscopic hysterectomy. The choice of procedure will depend on the size of the uterus and several other factors.

·        Vaginal Hysterectomy A vaginal hysterectomy is performed by removing the uterus through the vagina, rather than through an incision on the abdomen. To be eligible for a vaginal hysterectomy, your uterus cannot be too large.

You will be asleep for the procedure. Most women stay two nights in the hospital. The recovery involves significant pain for 24 hours and mild pain for 10 days. Full recovery usually takes four weeks.

·        Abdominal Hysterectomy In an abdominal hysterectomy, the uterus is removed through a horizontal incision on the lower abdomen, called a “bikini cut.” If the uterus is very large or if there is a scar from an earlier operation, it may be necessary to make a vertical incision instead.

A total abdominal hysterectomy means removing the uterus and the cervix. Women who have had abnormal pap smears are usually encouraged to have their cervix removed. A subtotal or supra-cervical hysterectomy means removing only the upper part of the uterus. Women who retain their cervix may have less bladder leakage and vaginal relaxation later in life; however, this has not been scientifically proven. Women who have had a supra-cervical hysterectomy will continue to need periodic pap smears. In addition, some women will have monthly spotting or light bleeding if endometrial glands are still embedded in the cervical tissue.

You will be asleep during the procedure. Most women spend three nights in the hospital and six weeks recovering at home. Some women experience a complication that results in a longer recovery time.

·        Laparoscopic Hysterectomy This is a new procedure in which the uterus is removed through very small incisions on the lower abdomen. The cervix remains in place. Women with large fibroids or a large uterus may not be candidates for a laparoscopic hysterectomy. 

In the procedure, four one-centimeter incisions are made in the lower abdomen: one at the belly button, one below the bikini line near the pubic hair, and one near each hip. The abdominal cavity is filled with carbon dioxide gas. A thin, lighted telescope is placed through an incision so the doctors can see the ovaries, fallopian tubes and uterus. Long instruments, inserted through the other incisions, are used to remove the uterus. A special instrument is used to cut the uterus into smaller segments for removal through the small incisions. At the end of the procedure, the gas is released and the skin incisions are closed.

You will be asleep during the procedure. Most women spend one night in the hospital and two to four weeks recovering at home.

Read more about hysterectomy.

Uterine Artery Embolization (UAE)

Uterine artery embolization is a relatively new procedure and an alternative to open surgery for fibroids. Embolization is a technique that blocks the blood flow to the fibroid or fibroids, causing them to shrink and die. This also often decreases menstrual bleeding and symptoms of pain, pressure, urinary frequency or constipation.

UAE is performed in a radiology suite rather than an operating room, by an interventional radiologist. An intravenous (IV) line will be placed before beginning the procedure, and you will be sedated. You will remain awake, but sleepy, throughout the procedure.

A needle is placed in an artery in your leg, at the groin crease. A small catheter is then placed into the artery and X-rays are taken of the arteries — a test called anarteriogram — that supply the fibroids. The catheter is then used to select these arteries and slowly inject particles called polyvinyl alcohol, which are the size of a sand grain. The particles block the flow of blood. After the left and right uterine arteries are embolized, another arteriogram is performed to confirm the procedure is complete.

Afterward, you must rest in bed for six hours, lying flat with your leg straight. The amount of pain patients experience varies. The most significant pain usually occurs immediately following the procedure and over the next six hours. Patients usually stay overnight in the hospital, so we can monitor the arterial access site and provide adequate pain control. You will be discharged the next morning. Most women can return to full activity in a week.

When blood flow to the fibroid is blocked, the fibroid gets no oxygen and will begin to die. This process happens over days to months. During this time the fibroid shrinks by about 40 to 50 percent and the uterus by about 30 to 40 percent. Our experience and the scientific literature suggest that symptoms will improve in 80 to 90 percent of patients. For some, UAE is ineffective. Serious complications occur in less then four percent of patients

 

TREATMENT OF UTERINE MYOMA

Treatment of fibromyoma should be operative and conservative.

Indications to operative treatment are: myomatous uterus larger than 12-week of pregnancy, acceleretion of tumor growing, presence of such symptoms as pain, bleeding, secondary anemia; myoma’s complications; suspicion on malignant degeneration and combining with endometriosis and endometrial hyper-plasia. Operative treatment is performed in case when the patients have contra­indication to hormonal treatment. These contraindications are: thromboembolism and thrombophlebitis, varicose phlebectasia, hypertension, operation concerning malignant tumors in the past, no effect from hormones.

Surgical interventions are divided into radical and conservative — plastic ones.

Conservative treatment of uterine fibromyoma has been confirmed patho-genetically and is directed on correction of hormonal state, treatment of anemia and metabolic dysorder, inhibition of tumor growing.

Indications. Conservative treatment is recommended at any age, ir case of myoma duration with poor symptoms or without any symptoms, at presence of contraindications to operative treatment.

Conservative therapy includes a diet with the usage of products, which contain A,E,K,C vitamins, such microelements as copper, zincum, iodum, iron; antianemic therapy; vitamin therapy; uterotonic drugs for decreasing of menstrual hemorrhage; iodium drugs should provoke inhibition of estrogenic secretion at ovaries: 0,25% solution of potassium iodide should be taken in a dose of 15 ml once or twice per day continuously during 6-10 months. It is nessesary to combine iodium drugs with phytotherapy — 60 ml of potato juice per day. Electrophoresis of 1-2% solution of potassium iodide is commonly used. 40-60 procedures are needed for the treatment course.

Hormonal therapy. Gyfotocyn is given intramusculary in the dose of 1 ml during 12-15 days since 5-7 day of menstrual cycle during 6-8 cycles. This medicine is recommended at menorrhagia of the patient at any age.

Androgens could be applied at uterine myoma in the period of perimeno-pause. Its effect can be achieved by pituitary gland suppresion. Androgens can result in reduction of uterine size, endomerial atrophy, ovaries follicular de pressing. Methyl androstendiolum is prescribed 50 mg per day during 15 days in the follicular phase of reproductive cycle for 3 to 4 months. Methyltestosterone is administrated in 2 pills under the tongue three times per day during 20 days with 10-day time-out for at least 3 months.

In case of small sizes of myoma and severe menstrual hemorrhage at the women older than 48-year menostasis is recommended: Testosteron propionate in a dose of 50 mg/week for the first 2 weeks, then 50 mg/twice a week for the next 2 weeks, and 50 mg once per week until the general dose of 1000 mg should be taken after the arrest of bleeding or uterine curettage.

Hestagens have been used in uterine fibromyoma because of its antiestro-genic effect. First line progestines are Progesterone in a dose of 5-10 mg intramusculary once per day for 10-12 days in luteal phase of a reproductive cycle or 2 ml 12,5 % solution of 17- Hydroxyprogesterone Capronate intramusculary on 12-14 day of a cycle for at least 3 months are prescribed.

The second line progestines are Noretisterone acetas, Norcolutum that have been taken from the 5-th till the 25-th day of menstrual cycle in the patients of reproductive or climacteric age with menstrual dysfunction and uterine myoma combined with endometrial hyperplasia.

Various progestine preparations should be given according to the standard regimen: since the 5-th till 26-th day of a menstrual cycle or since the 5-th day after uterine currettage. Such hestagens of prolonged action as Depo-Provera— 150 mg once per month or 50 mg once per week for at least 3-6 months should be taken.

Pharmacologic removal of the ovarian estrogen source can be achieved by suppresion of the hypothalamic-pituitary ovarian axis by the use of gonadotropin-releasing hormone (GnRH) agonists. Buzerelinum, gozerelinum and gestrinol belong to the essentially new medicines that are a gonadotropin-releasing luteal hormone agonists. Buzerelinum in a dose of 200 mg is administrated subcutane-ously for the first 14 days of reproductive cycle, then endonasal prescription in the dose of 400 mkg per day for 6 months. Zoladex-Depo is applied subcuta­neous in a dose of 3,6 mg once a month for at least 6 months. This treatment is commonly used for 3 to 6 months before the planned hysterectomy, but it can also be used as a temporizing medical therapy until the natural menopause comes. GnRH agonists caot only result in reduction of uterine size, but also lead to a technically easier surgery with significantly diminished blood loss.

 

Endometriosis

      I.          Definition. Endometriosis is the presence of functioning endometrial tissue outside its normal location, most frequently on the ovaries, uterosacral ligaments, cul-de-sac, and occasionally uterovesical peritoneum. However, it may occur elsewhere including nasal mucosa, lung or even brain. It is estrogen-dependent and generally regresses after menopause or oophorectomy.

   II.          Pathogenesis. Several factors may play a role including retrograde transport and implantation, metaplastic transformation of “coelomic” peritoneum, lymphatic or hematogenous dissemination, immunological defects, genetic predisposition.

III.          Evaluation

                       A.          History.

              1.    The most common symptoms associated with pelvic endometriosis are dysmenorrhea (66%), deep dyspareunia (33%), infertility (60%), and low back pain or chronic pelvic pain that worsens with menses. May have premenstrual spotting and menorrhagia. Dysmenorrhea often precedes menses and lasts throughout the period.

              2.    Less common symptoms include dyschezia (painful defecation), diarrhea, intermittent constipation, cyclic abdominal pain, dysuria, urinary frequency and hematuria.

              3.    One-third of women with endometriosis are asymptomatic and even extensive disease may be asymptomatic.

                       B.          Physical examination.

          1.    Fifty percent of women have a normal clinical examination.

          2.    Findings will be accentuated in early menses and may include a fixed, tender, retroverted uterus; tender nodules along the uterosacral ligaments (with obliteration of the cul-de-sac); nodules on the back of the uterus and cervix; unilateral or bilateral fixed asymmetric adnexal masses. Rectovaginal exam is important to assess the posterior uterus and cul-de-sac.

          3.    Up to 10% of teens with endometriosis have congenital outflow tract obstruction.

                       C.          Diagnostic aids:

          1.    Laparoscopy should be done to confirm the diagnosis if treatment will be more extensive than under “mild disease” below since the clinical diagnosis may be wrong 30% to 40% of the time. Laparos-copy will help assess the extent and stage of the disease as well as tubal patency. Patient-assisted laparoscopy can improve the diagnostic yield.

          2.    Ultrasound may be helpful with a large pelvic mass, but cannot visualize small implants or differentiate types of cystic lesions.

IV.          Management: Medical treatment of endometriosis cannot restore fertility (see section on Infertility), but may help with pain or dyspareunia. Pain recurs after treatment in 53%.

     A.        Mild disease. Usually the diagnosis will be suspected but not confirmed, since laparoscopy is usually not indicated. Treatment can include observation and NSAIDS. Additional treatment includes:

      1.        Combination oral contraceptives, given for at least 6 months. Response rate is 75%.

      2.        Depo-Provera 150 mg IM Q3 months. Return to fertility may be delayed after discontinuation.

     B.        Treatment options in moderate disease. Diagnosis should be confirmed by laparoscopy prior to initiating therapy.

              1.“Pseudomenopause.” Danazol is a synthetic androgen that suppresses gonadotropins and causes amenorrhea. Side effects include vasomotor symptoms such as atrophic vaginitis, weight gain, fluid retention, migraines, dizziness, fatigue, depression, decreased HDL, acne, hirsutism, and potentially irreversible voice changes. Danazol 200 or 400 mg PO BID for up to 6 months. Begin on the first day of menstruation. Use a barrier contraceptive the first month: female fetuses may be adversely affected. Response rate is 84%-92%.

              2.“Pseudopregnancy.” Continuous oral contraceptives: use a standard monophasic formulation. Side effects as per OCP. Have the patient take one active pill every day continuously, beginning on the third day of menstruation. When breakthrough bleeding occurs, increase to two pills daily for 5 days, then return to a single pill daily. If necessary, may use up to 3-4 pills daily, although nausea may limit therapy. Maintain amenorrhea for 6-9 months: 80% of patients will experience improvement of symptoms.

              3.Progestin therapy is useful if pseudopregnancy is not tolerated or is contraindicated. Side effects include breakthrough bleeding, depression, irritability, lipid changes. Initiate therapy during menses. Progestins appear to be as effective as other treatments.

               a.Depo-Provera 150 mg IM Q3 months, may increase to 200 mg IM Q month x 4 months if needed to produce prolonged amenorrhea. Return to fertility may be delayed after discontinuation.

              b.Medroxyprogesterone 10-30 mg PO QD is an alternative.

              4.Conservative surgery to laparoscopically remove extrauterine endometrial tissue is often performed at the time of laparoscopic diagnosis. May also use pharmacotherapy from 6 weeks before to 3-6 months after surgery. Recurrence rate is 19% over 5 years.

                       C.          Severe disease.

                                            1.          Definitive surgery. Hysterectomy and bilateral oophorectomy. Recurrence rate is 10% over 10 years.

                                            2.          GnRH agonists such as leuprolide acetate (IM), goserelin (SQ implant) or nafarelin (nasal spray) induce an artificial menopausal state. Side effects are similar to menopause, including decreased bone mineral density. Response rate is 90%.

DYSFUNCTIONAL UTERINE BLEEDING

A dysfunctional uterine bleeding (DUB) is the bleeding, not associated with organic diseases of women’s genitals, interrupted pregnancy or systemic diseases of the organism.

The dysfunctional uterine bleeding can appear at any age. Depending on the time of their onset juvenile bleeding (at child age and in period of pubescence), bleeding of reproductive period, climacteric bleeding are classified. DUB are the manifestations of initial stages of neuroendocrinological diseases, especially of blood diseases. Most frequently the dysfunctional uterine bleeding appear in young women during the formation of menstrual and reproductive function. In early reproductive phase as a damaging factor are frequently the situations, connected with mental and physical overload. Chronic stress and diseases of adaptation are the pathological background on which the lesions of hormonal status develop.

In women of reproductive age me oasiu сайке oi dysfunctional uterine bleeding are inflammatory diseases. Late reproductive phase, or premenopause, comes in women at the age over 35. At this age even moderate irritants, which earlier were not the reasons of menstrual function disorders, can become starting mechanism for development of cyclic system activity dysfunction.

Disease etiology is associated with unfavourable affects of environment, psychic stresses, lesions of the ovaries’ and other endocrine glands function.

Dysfunction of hypothalamus-pituitary-ovaries-uterus system cause violation of follicle maturing. Depending on the fact that ovulation comes or not, the bleeding can be ovulative and anovulative.

Classification of dysfunctional uterine bleeding according to pathogeneses:

I. Ovulative (two-phased) according to the type of:

    hypoestrogeny

    hypogestageny

    hyperestrogeny

II. Anovulative (monophased) according to the type of:

    hypoestrogeny

    hyperestrogeny

According to onset time: cyclic (those, that come in term of next menses, but differ from it with amount of lost blood and duration); non-cyclic (appear out of menses or continue with interruptions during all the cycle).

According to patient’s age: juvenile, of reproductive age, climacteric, menopausal bleeding.

Non-ovulate uterine bleeding

Follicle atresia is a disorder of menstrual cycle, that manifests in cyclic uterine bleedings through regular time intervals, but ovulations are absent. Follicle begins its development, reaches some maturity degree, but ovulation does not come, Luteal body does not appear, follicle undergoes reverse development. There is no regular hormones’ excretion (oestrogens-progesteron), secretory changes do not come in endometrium. Disease is followed by hypoestrogeny.

 

PRINCIPLES OF CONSERVATIVE TREATMENT OF DYSFUNCTIONAL UTERINE BLEEDING

General therapy:

    effect on central nervous system

    symptomatic therapy

    antianaemic therapy

1. Action on central nervous system: work and rest order, that exclude a possibility of physical and mental overloading; psychotherapy, sedatives and vitamin therapy is prescribed.

2. Symptomatic therapy: uterotonics to arrest the bleeding and for 3 days after bleeding arrest — Gifotocin, Oxytocin, Pituitrin 0,5-1 ml i/m 2-3 times per day are used; Methyl ergo me thrin 0,02% 1 ml i/m. Medicines there are streng­thening vascular wall and improving blood coagulation should be taken: Calcium gluconate 0,5 g three times a day or Calcium chloride 10 ml of 10% solution i/v; a-aminocapronic acid inside 0,1 g per kg of woman’s body weight in 4 hrs. (10-15 g per day) during 3 days, on the 4th day they use 12 g, further accordingly 9,0; 6,0; 3,0 g per day; Dicinon in pills 0,5-0,75 ml per day or 1-2 ml of 12,5% solution; Rutin, Ascorutin, Ascorbic acid.

3. Antianaemic therapy: they take Ferrum tabulated preparations or Ferrum-Lek i/m or i/v; erythrocytes mass or fresh citrate blood is transfused when it is necessary.

Hormonal therapy. Its tasks:

    haemo stasis

    regulation of menstrual cycle

    bleeding relapse prophylaxis

    ovulation induction and normalization of menstrual cycle

1. Estrogens haemostasis.

Mechanism, of action: due to injecting of big doses of Estrogens into organism, a suppression of Folithropin synthesis in pituitary gland; acceleration of endomethrium proliferation; decreasing of vascular walls permeability; retar­dation of fibrinolysis takes place by feed-back mechanism.

Method’s disadvantages: necessity of using of comparatively big doses causes ovulation blockade; the so called “break bleeding” appear at fast dose decreasing.

Indications: DUB of juvenile and reproductive age by hypoestrogeny type; anaemia and necessity of fast haemostasis; any term and duration of bleeding.

Method of realization: Folliculin on 0,1-0,2 mg each 3-4 hrs. inside; Folliculin 10,000-20,000 UA i/m in 3-4 hours; estradiol-dipropionate 0,1% solution 1 ml in 3-4 hours. Haemostasis comes in 24 hrs. After the bleeding arrest the preparation taking should be continued gradually decreasing the dose.

2. Haemostasis by gestagens.

Mechanism of action is based on secretory transformation of endomethrium and desquamation of its functional layer (“medicinal”, “hormonal curettage”); influence on vascular wall; increasing of platelets and Proconvertin amount.

Indications: short bleeding duration; absence of anemia and of immediate haemostasis necessity.

Gestagens haemostasis arrests bleeding or decreases ii after progesterone introducing for 3-5 days, then it is increased again and continues for 8-9 days. This is caused by hormone action mechanism. At first secretory transformation of endometrium takes place (in this time bleeding decreases or stops), and then there is desquamation of its functional layer (bleeding becomes stronger again).

Methods of realization: 1% solution of Progesterone 3-5 ml for 3 days; Pregnin 0,04 (2 tabl.) sublingually 3 times a day; Primoluton-depo, Primolut-Nor.

Disadvantages of the method: absence of fast haemostasis; impossibility of use for anaemic patients after prolonged bleeding.

3. Haemostasis by androgens.

Mechanism of action is caused by suppression of hypothalamus and pituitary gland function; blocking of follicle development in ovaries; antiestrogenic influence — suppression of proliferation in endomethrium; uterine vessels contracting; in myomethrium (increassing of contractive activity).

Indications: DUB of hyperestrogeny type in climacteric age; uterine blee­ding with contra-indications for estrogens prescribing (tumor in anamnesis, uterine fibromyoma, mastopathy).

Methods of realization: Testosteroni propionas 1 ml of 1% solution 2-3 times a day i/m during 2-3 days, then Progesterone 10 mg a day i/m during 6 days; Testosteroni propionas 1 ml of 5% solution 2 times per day i/m during 2-3 days, then dose is decreased to 2 times per week. Later they prescribe Methyltesto-sterone 15 mg per day during 2-3 months.

Disadvantages of the method: it can be used only for women at the age over 45 before the artificial menostase; long application gives virilyzing and anabolic effect.

4. Haemostasis by synthetic progestines (SPP).

Mechanism of action: blocking of hypothalamus-hypophysis system and decreasing of foliberin and luliberin secretion; continuated haemostatic effect is caused by action of estrogens and secretory transformations of endomethrium under the influence of gestagen component of the preparations.

Indications: DUB in any age period.

Method of realizing: one of monophase SPP is prescribed in dose of 1 tabl. in 3-4 hours for hemostasis, then during the 10 days the dose is decreased 1 tabl., daily up to 2 tabl. per day and later on the support dose should be 1 tabl. per day. Therapy course is 21 day from the reception of the first pill.

Disadvantages of the method: great amount of contra-indications (hormone sensitive tumors, acute liver and bilious pass ways diseases, acute trombophle-bitis, tuberculosis, rheumatism, chronic renal diseases).

5. Haemostasis with estrogens and gestagens combination.

Mechanism of action is caused by estrogens effect (cause endomethrium proliferation) and gestagens effects (secretory transformation of endomethrium takes place).

DYSFUNCTIONAL UTERINE BLEEDING

A dysfunctional uterine bleeding (DUB) is the bleeding, not associated with organic diseases of women’s genitals, interrupted pregnancy or systemic diseases of the organism.

The dysfunctional uterine bleeding can appear at any age. Depending on the time of their onset juvenile bleeding (at child age and in period of pubescence), bleeding of reproductive period, climacteric bleeding are classified. DUB are the manifestations of initial stages of neuroendocrinological diseases, especially of blood diseases. Most frequently the dysfunctional uterine bleeding appear in young women during the formation of menstrual and reproductive function. In early reproductive phase as a damaging factor are frequently the situations, connected with mental and physical overload. Chronic stress and diseases of adaptation are the pathological background on which the lesions of hormonal status develop.

 

ECTOPIC PREGNANCY

Pregnancy is called ectopic when it fertilized ovum implants outside the borders of uterine cavity.

Ectopic is one of the most serious gynecological diseases, because its interruption is followed by considerable intraperitoneal bleeding and needs emergency service.

Etiology. Anatomic changes in tissues of uterine tube that appear in the result of inflammatory processes are the main causes of the violation of ovum transport and ectopic pregnancy. Inflammation of mucous membrane, its edema and presence of inflammatory exudate in acute and chronic stages may cause dysfunction of uterine tubes. After this adhesions and closing of ampular end of the tube are formed. Damaging of muscular layer and changes in innervation of the tube lead to changes of its peristalsis and delay of fertilized ovum passing through it. Considerable anatomic changes in tubal layer or adjacent tissues cause abortions, operative interventions into the organs of true pelvis. Ectopic pregnancy frequently happens in women with genital infantilism, endometriosis, tumor of the uterus and uterine adnexa. Usage of intrauterine contraceptives increases the risk of ectopic pregnancy. There are scientific datas that toxic influence of exudate in tube at its chronic inflammation causes speed-up trophoblast maturing, that’s why the proteolitic enzymes activize, and implantation comes before ferti­lized ovum enters the uterus. In case of the slow development of trophoblast an ovum is implanted in lower uterine (placenta praevia) segments or outside uterine cavity —- in its cervix (cervical pregnancy).

Classification of ectopicpregnancy. Depending on that, where a fertilized ovum has implanted tubal pregnancy, ovarian pregnancy, abdominal pregnancy, pregnancy in rudimentary uterine horn, mtraligamentaory (between folds of wide uterine ligament) and cervical pregnancy are distinguished.

In majority of cases (98,5 %) the tubal pregnancy occurs. Interstitial preg­nancy happens in interstitial portion of tube, isthmic — in isthmus and ampullar — in ampullar portion (fig. 2).

According to clinical duration unruptured and interrupting ectopic pregnancy are distinguished. Interrupting of ectopic pregnancy happens by type of tubal abortion or by type of uterine tube rupture.

                         

Fig. 2. Locaiozation of fertilized ovum in ectopic pregnancy:

1 — abdominal, 2 — tubal: 2a — interstitial; 26 — isthmic; 2b — ampular; 3 — ovarian; 3a — in a cavity of follicule; 3b — on ovarian surface; 4 — intraligamentory; 5 — cervical

Duration of ectopic pregnancy. After implantation of fertilized ovum in woman’s organism there appear changes, typical for normal uterine pregnancy: yellow pregnancy body is developed in ovary, decidual membrane is generated in uterine, uterus becomes soft and enlarges under the influence of ovarian hormones. All these signs are typical for pregnancy. The chorionic gonadotropin is also produced. One can find gonadotropin by means of appropriate researches. Pregnancy test is positive. Women have presumptine pregnancy signs: nausea, appetite changes and so on.

A fertilized ovum, that has been implanted into endosalpinx, goes over the same development stages, as in case of uterine pregnancy. The chorion villi are generated. At first they grow into mucous layer of the tube, then, without finding sufficient conditions for development, they grow into its muscular layer. While the size of fertilized ovum increases, the walls of tube stretch. The chorion villi, invading deeper, bring on its destruction. A layer of fibrinoid necrosis is generated. For Werth’s figure of speech, “a fertilized ovule digs in tube wall not only nest for oneself, but the grave”. The wall of uterine tube caot create favourable conditions for fetal development, that’s why within 4-7 weeks interrupting of ectopic pregnancy takes place.

Tubal pregnancy is interrupted for type of uterine tubal rupture or for type of tubal abortion, depending on the method the embryo is going out into abdominal cavity. In case of rupture of uterine tube destruction of its wall takes place in the result not of mechanical tension and rupture, but in the result of corrosion by chorion villi. At pregnancy interrupting for type of tubal abortion exfoliating of the embryo from tube walls and its passing into abdominal cavity through the ampular end takes place.

Unruptured ectopic pregnancy

Difficulty of diagnosis is connected with absence of symptoms which differ ectopic pregnancy from the uterine one. Sometimes women can feel uterine pain in the tower part of abdomen. During bimanual research one can palpate the enlarged tube, but sometimes it is not possible to do that because only at the end of the second month the tube reaches the size of an ovum and soft elastic consistence gives no possibility to palpate it distinctly.

A differential diagnosis of unruptured ectopic pregnancy is made in case of uterine pregnancy of early terms, cyst, ovary cystoma and hydrosalpinx.

Elastic organ is palpated in case of either ovarian cystoma near the uterine or in case of unruptured tubal pregnancy, in which uterus is not enlarged, reaction to the chorionic gonadotropin (CG) is negative. There is no ischomenia.

In case of hydrosalpinx in adnexal region elastic organ is also found, but uterine is not enlarged, women do not complain on ischomenia, reaction on CG is negative.

Diagnosis difficulties appear owing that uterus continues to enlarge because of the development of decidual envelope and hypertrophy of mucose fibres, but uterus falls behind in dimensions typical for the certain pregnancy term.

Tests for chorionical gonadotropin determination in such cases give a possibility to establish the pregnancy presence, but they don’t give answer to the question about its localization. In some cases one can make diagnosis of unruptured ectopic pregnancy with ultrasonic research. In this case embryo is absent in uterine cavity. The diagnosis can be confirmed by means of laparoscopy (fig. 4). Urgent hospitalization for complex examination and supervision is necessary in case when there is suspicion for unruptured ectopic pregnancy. The patient has to stay under the careful supervision of medical personnel. One should inform a doctor in case when there appear some changes in woman’s state, especially when there are the symptoms typical for internal bleeding.

                       


 

Fig.3. Unruptured ectopic pregnancy in ampular portion of tube

 

After entering stationary it is necessary to define blood type, and also rhesus-factor of the patient immediately.

Tubal abortion

Clinic. In case of tubal abortion exfoliating of an embryo from tube wall and its passing into abdominal cavity take place (fig.3). The clinic of tubal abortion is displayed by colicky pain, that is localized in one of iliac parts and irradiates into thigh, rectum and sacrum. Sometimes pain appears in supracla-vicular part — frenicus-symptom. If embryo drives out from the tube at once, sometimes it is followed by considerable bleeding, giddiness and loosing of consciousness. Sometimes exfoliating of embryo ceases for a while, pain stops disturbing, however the pain is soon renewed. This can repeat once or twice, then the tubal abortion lasts for a long time. Blood, that outflow from the tube, accumulates in cul-de-sac and causes the feeling of pressure on rectum.

Discharge from external genitals have spotting character, and is brown in colour. Sometimes the scraps of decidual membrane can go out and sometimes decidual membrane goes out wholly.

Diagnosis. The diagnosis of tubal abortion is not very simple. Carefully studied past history is of a great importance. Doubtful and probable signs of pregnancy are present. Anaemia is common due to intensive blood loss, arterial pressure decreases abruptly and pulse accelerates. Abdomen is flatulent, its par­ticipation in breathing act is limited. In lateral abdominal parts blunting percussion sound is determined, during palpation there are the symptoms of peritoneal irritation.

Fig. 3. Tubal abortion

 

During speculum examination is revealed cyanosis of vaginal mucosa and uterine cervix, typical are the secretions, described previously. At bimanual examination one can find that uterus is enlarged, but it does not correspond to menstruation delay term, isthmus allotment is soft, cervix motions are painful. In adnexa region from one side one can palpate an organ of elastic consistence with unclear contours. Back vault is smoothened or even prominent.


Differential diagnosis of tubal abortion. In the cases, when there is no considerable intraperitoneal bleeding, tubal abortion should be differentiated with uterine abortion in early term, exacerbation of salpingo-oophoritis, dysfunctional uterine bleeding and cystoma cms torsion.

At uterine abortion there is a permanent colicky pain, that irradiates into lumbar part. Discharge is bright or dark red coloured.

At tubal abortion pain is periodic, colicky, ordinarily it is followed by diz­ziness, and irradiates into rectum.

When percussion blunting of sound in lateral part of the abdomen is found in ectopic pregnancy and tympan is in case of uterine abortion.

Secretions from vagina in tubal abortion appear after pain attact, they are dark, of poor amount, in case of uterine abortion they are bright red and consi­derable.

   General woman’s state in tubal abortion does not correspond to external hemorrhage, but in uterine abortion it does. Bimanual examination in case of tubal abortion gives a possibility to find a formatioearby the uterus, uterus does not correspond to pregnancy term, whereas in case of uterine abortion uterine size correspond to pregnancy term and ovaries are not altered.

There are some differences between the inflammatory process of uterine adnexa and tubal abortion. In case of inflammatory process there are no menses delays, reaction on CG is negative.

Unlike tubal abortion pain during this disease appears gradually, there is no dizziness. Pain is not colicky, but permanent.

In case of tubal abortion with a long abortion duration one can observe subfebryle temperature, whereas in case of acute uterine adnexa inflammation temperature is high in most cases.

Some blood loss at tubal abortion gives rise to BP lowering, in inflammatory process BP is normal. In case of abortion pulse is higher, temperature rises rarely.

In case of tubal abortion abdomen is slightly flatulent, but soft and painful during palpation on one side, during percussion blunting sound is observed in lateral departments. In case of inflammatory process examination of abdomen gives the identical symptoms, however there is no blunting of percussion sound.

Bloody secretions in inflammatory processes of ovaries can be rarely found. Unlike the secretions of tubal abortion, they are bright, sometimes with purulent admixtures.

During bimanual examination enlargement of uterus with unclear adnexa contours from one side testifies about tubal abortion rather than about inflam­mation of ovaries, in which uterus is not enlarged and ovaries are palpated as enlarged from both sides. Often in tubal abortion sagging of back vault is found.

In spite of great amount of differences, which give a possibility to make a differential diagnosis between tubal abortion and inflammatory process of ovaries, sometimes it is very hard to distinguish them. US and specially culdocentesis are importent in such case. In case of tubal abortion during puncture blood is received and in inflammatory processes one can get serous or a purulent liquid.

If one couldn’t manage to specify diagnosis and the general woman’s state is satisfactory, they hold on resolvent and hemostatic therapy during 5-7 days with careful clinical supervision. In tubal abortion all phenomena (colicky cha­racter of pain, bloody secretions) progress and at inflammatory process improve­ment of general state is observed.

Tubal abortion differs from cystoma crus torsion. In case of cystoma torsion there is no menses delay, reaction on chorionic gonadotropic is negative, bloody discharge and signs of internal bleeding are absent. Cystoma torsion is found by abdomen palpation. US and sometimes endoscopy is used as individual method.

Differential diagnosis between tubal abortion and appendicitis. In appendicitis a patient does not complain of menses delay, there are no signs of pregnancy. At tubal abortion pain is periodic, colicky, with one side localization. In appendicitis it apears at first in epigastria, and lateral then it localizes in right iliac region and it is accompanied by nausea and vomiting, that are rare in case of tubal abortion. Bloody excretions and signs of internal bleeding are absent. Palpation of the abdomen in acute appendicitis expresses tensity of the front abdomen, whereas in case of tubal abortion it is insignificant and sometimes it is absent. The Schotkin-Blumberg’s and Rovzing signs testifies acute appendicitis while frenicus-symptom is absent. During bimanual examination in case of acute appendicitis uterus and ovaries are not enlarged. If much time has passed since the beginning of the disease, one caot always palpate them because of irritation of pelvic peritoneum. An infiltrate is palpated above and it is not possible to reach it through vagina.

A blood analysis in case of appendicitis gives leucocytosis with shift to the left, there is no anemia, whereas at tubal abortion blood picture is typical for anemia. After all, a culdocentesis can be a diagnostic criterion.

When clear differentiation is impossible, it is necessary to make laparotomy.

Tubal rupture

Clinic. Tube rupture develops more frequently in that case, when pregnancy is localized in isthmus or interstitial department. Clinics displays by severe internal bleeding, shock and acute anaemia.

Disease begins after menses delay with acute pain in lower abdomen, which appears suddenly. It is localized in iliac areas and irradiates into rectum and sacrum. This pain is followed by momentary loosing consciousness. After this patient remains adynamic. During the attempt to get up she can lose her cons­ciousness again.

Patient has all signs typical for internal bleeding: acute pallor, cold sweat, coldness of lower limbs, feeling of weakness, sometimes there is a threadlike pulse. The abdomen is flatulent, its participation in breathing act is limited. There is blunging of percussion sound in lateral abdominal region. Palpation of the abdomen is very painful. There are signs of peritoneal irritation.

Fig. Tubal rupture

Diagnosis. During .speculum examination cyanosis of mucous membrane of vagina is found. Bloody excretions are present, though not always. They are dark-coloured and look like coffee-grounds.

At bimanual examination cervical motion is always painful, there appears bulging and acute pain of the posterior pouch. Uterus body is enlarged insignifi­cantly and along its side painful organ with unclear contours can be palpated, sometimes it is pulsatory. One should remember, that it is not always possible to palpate uterus and ovaries because of acute pain during gynecological exami­nation.

Following signs can help in diagnosis of ectopic pregnancy:

   Laffon s sign — consecutive shift of pain feelings: at first in suprabrachial
part, then shoulder, then pain spreads into back part, scapulars, under sternum

   Elecker ‘s sign — abdominal-ache presence, that is followed by its irradiation
into shoulder and scapulars on tubal rupture side

   Gertsfield’s sign — urging to urination appears during tubal rupture moment

   Kulenkampf’s sign — intensive pain during percussion of anterior abdomenal
wall

At vaginal research such signs are determined:

   Landau s sign —- intensive pain during speculum or fingers inserting into
vagina

   Golden s sign — uterine cervix pallor

   Bolt’s symptom — acute pain during an attempt to displace uterine cervix

   Gudell’s sign — soft consistence of cervix

   Promptov ‘s sign — woman feels acute pain during an attempt to displace
uterus up by inserted into vagina and rectum fingers. At appendicitis examina­
tion per rectum causes pain in rectouterine pouch

Goffman ‘s sign — uterus displacement into contrary from altered tubal side.

During examination uterus easily comes into normal position, and when

examination is over it returns into its previous position At long blood presence in abdominal cavity its partial resorbtion takes place and transformed bilirubin deposits in skin cells. That’s why there appear such signs:

    Gofshteter s sign — presence of blue-green or blue-black colouring of skin iavel region

    Kuschtalov’s sign — yellow skin colouring of palms and soles, specially in fingers area

At tubal rupture clinic of internal bleeding progresses, that’s why, after careful taking of anamnesis, doctor can make a diagnosis at once. However intensity of internal bleeding depends on the individual placing of vessel which feed a tube and some patients after its rupture, in spite of abdominal-ache, giddiness, do not apply to a doctor at once. At the same time, lack of expressed symptoms can bring doctor into mistake, illness progresses. That’s why for confirmation of diagnosis of interrupted ectopic pregnancy culdocentesis, during which blood is received should be made obligatorily. However it is necessary to remember, that in 10-15% of all cases a culdocentesis does not confirm the diagnosis. In the case, if general patient state is not satisfactory, endoscopic examination should be done.

Diagnosis of ectopic pregnancy:

    history taking

    physical examination with typical symptoms

    pe’vic examination

    test on pregnancy

    ultrasonic diagnostics

    culdocentesis

    in complicated cases culdoscopy or laparoscopy are performed

Management. Each woman with suspicion on ectopic pregnancy should be hospitalized and must stay in stationary until clinical confirmation or refuse of suspicion on ectopic pregnancy.

 

It’s very important to inform patients how to find the cause of the problem.

Pay attention to contains of the information and notice the way we produce it.

Many women have pain in their pelvic region at some point in their fives. Each woman responds to pain in her own way. Some women are bothered by pain more than others. You should discuss any pain with your doc­tor, but even more so if it disrupts your daily life, if it worsens over time, or if you’ve noticed a recent increase in pain.

Finding the cause of pelvic pain can be a long process. Often there is more than one reason for the pain, and its exact source can be hard to pin down.

This pamphlet explains:

      Some causes of pelvic pain

      How it is diagnosed

How it is treated

 

 

Problems in your reproductive organs may cause chronic or acute pain. Some pelvic pain, though, may be caused by problems in other parts of your body.

Causes of Pelvic Pain

The type and nature of pelvic pain—whether it comes and goes or is constant, whether it is short term or long term—will help your doctor detect the prob­lem. Pelvic pain is often caused by a mix of factors. Some of them are described here.

Acute Pain

Acute (sharp) pain starts over a short time (a few minutes to a few days). It often has one cause. Most often an exam and some tests can pinpoint the cause. Acute pain is a warning that something has gone wrong. The causes of acute paieed to be looked into and treated promptly.

Infection. Pelvic pain can be caused by an infection or inflammation. The infection does not have to be in the reproductive organs to cause pelvic pain. The source of the pain may be the bladder, bowel, or even the appendix.

Pelvic inflammatory disease (PID) is a broad term used to describe infection of the uterus, fallopian tubes, and ovaries. Most cases of PID are thought to come from sexually transmitted diseases (STDs). An STD is a disease spread through sexual contact. If an STD that affects the cervix is not treated, the infec­tion can travel into the uterus and tubes and cause PID. Symptoms of PID include fever and pain in the lower stomach. The pain is often a mild ache, but it can be severe.

Vaginal infection (vaginitis) can sometimes be painful, mainly during and after sex. Many kinds of organisms can cause vaginal infections.

Infections of the urethra, bladder, or kidneys (uri­nary tract infections) may cause pain, too. Patients often feel pain during urination and a strong and frequent urge to urinate even when little urine is there. When pain is also felt in the back, the infec­tion may have spread to the kidneys.

All of these causes of pain may require a visit to your doctor. A history will be taken, you will have a physical exam, and some tests may be done.

Ovarian Cysts. Sometimes a cyst may form on an ovary. A cyst is a sac filled with fluid. It is somewhat like a blister. Some cysts on the ovaries form as a result of the normal process of ovulation (release of an egg from the ovary). Often a cyst begins fairly quickly but goes away within a day or two. Some cysts can last a long time. These cysts are often felt as a dull ache or heaviness. Sometimes they cause pain during sex. Sharp pain can occur if a cyst leaks fluid or bleeds a little. This may happen around the middle of the menstrual cycle.

A pelvic exam often will detect a cyst. In some cases, pelvic ultrasound (a test in which sound waves are used to view the internal organs) is needed to be sure. Most small cysts will go away by themselves. Rarely, more severe, sharp, and constant pain hap­pens when a large cyst twists. Large cysts and those that don’t go away on their own within a few months may need to be removed by surgery.

Ectopic Pregnancy. A tubal or ectopic pregnancy is one that starts outside the uterus, often in one of the fallopian tubes. This happens most often in women who have some damage to their tubes. The pain often starts on one side of the abdomen after a missed period. Vaginal bleeding or spotting may occur with the pain. This problem needs urgent care and may require surgery. An ectopic pregnancy can lead to bursting of the tube and bleeding inside the abdomen. This can threaten your life.

Chronic Pain

Chronic pain can be either intermittent (it can come and go) or constant (it is there most of the time). Intermittent chronic pain often has a distinct cause. Constant chronic pain may be caused by more than one problem. An illness may start with intermittent pain that becomes constant.

   Dysmenorrhea. Dysmenorrhea is a case of long-term, intermittent chronic pain. Although some mild pain is common during a woman’s menstrual period, some women have severe pain with their periods, it may be caused by prostaglandin, a hor­mone made by the lining of the uterus (endometri-um). It causes spasms or cramping of the uterus.

Endometriosis and Adenomyosis. Sometimes men­strual cramps can be a sign of disease. If they get worse over the years or stay strong beyond the first 1 or 2 days of flow, they may be due to a disease such as endometriosis or adenomyosis.

The cause of endometriosis and the reasons for pain during the menstrual cycle are not known for sure. Endometriosis often makes menstrual cramps worse. It can also cause pain at times other than during the menstrual cycle. Sometimes sex is pain­ful. How severe the pain is, though, does not de­pend on the amount of endometriosis present. For instance, a small amount of endometriosis may cause a lot of pain, and a large amount may not.

   Adenomyosis occurs when the endometrium buries itself in the muscle wall of the uterus. This can cause menstrual cramps. It also can cause pressure and bloating in the lower abdomen before pe­riods and more bleeding during periods.

    Ovulation Pain. Pain that is felt around the time of ovulation is sometimes called mittelschmerz (Ger­man for “middle pain”). Ovulation occurs in the middle part of the menstrual cycle. Pain can range from a mild pinch or twinge to something more severe. It can occur every month in some women. It is intense only now and then, though.

Constant Chronic Pain

Some women may feel pain almost every day. This may mean that a problem has gotten worse. Or it could mean that a person has become less able to cope with pain. The pain may then get worse even though the disease that started the problem hasn’t changed.

Not being able to deal with pain is more likely when the pain disturbs work, physical activities, sexual relations, sleep, or family duties. Not know­ing the cause of the pain can make it more stressful because you might fear severe illness.

When pain has been present for a long time, it affects your mental and physical health. In seeking the cause for pelvic pain, your doctor may ask you questions about the pain and its effect on your life and your emotions.

Other Causes of Pain

Adhesions or scar tissue can form as a result of the healing process. Scar tissue causes the surface of or­gans and structures inside the stomach to bind to each other. Endometriosis, surgery, or a severe infection such as PTD can cause adhesions or scar tissue. Adhesions can involve the uterus, tubes, ovaries, and bowels. They can attach any of these structures to each other or to the sides of the pelvic area.

Fibroids may grow on the inside of the uterus, on its outer surface, or within the wall of the uterus. It is not known for certain what causes fibroids. Estrogen is thought to play a role in their growth, though.

Fibroids often cause no symptoms. When symp­toms do occur, they may include heavier or more frequent menstrual periods and pain or pressure in the stomach or lower back. Fibroids attached on a stem may become twisted and cause more acute symptoms.

Other causes of lower abdominal and pelvic pain include:

    Diverticulitis (inflammation of a pouch bulging
from the wall of the colon)

    Irritable bowel syndrome (a condition that may
cause alternating bouts of diarrhea and consti­
pation and often seems to be related to stress)

    Kidney or bladder stones

    Appendicitis

    Muscle spasms or strain

Diagnosis

Because there are so many causes of pelvic pain, your doctor may use many tests to ruie out likely causes of your pain. Al­though it may seem complex and time-consuming, this approach is the best way to find out what is causing the pain.

Your doctor may ask you to keep a journal in which you describe the exact nature of the pain (see box). What you write down can help to rule out certain causes. Bring it with you when you see your doctor.

Your doctor may consult with or refer you to other specialists. It depends on what your doctor suspects may be the cause of the pain. The specialists may include doctors who deal with problems of the gastrointestinal, urinary, or neurologic systems.

Physical Factors

The evaluation begins with an exam. Cultures and blood tests are sometimes needed to look for infec­tion.

Other studies are sometimes useful to find the cause of pain. They are often less helpful for evaluating chronic pain than for other gynecologic conditions, though. They include:

    Ultrasound: A test in which sound waves are reflected off the internal organs, producing an image that can be viewed on a screen

    Computed tomography (CT): A type of X-ray that shows internal organs and structures (sometimes called a “CAT scan”)

    Magnetic resonance imaging (MRI): A method of viewing internal organs and structures by using a strong magnetic field Intravenous pyelography (1VP): A type of X-ray taken after fluid is injected into a vein and excreted by the kidneys

    Barium enema: A solution given through the rec­tum that helps problems in the colon show up on X-rays

Sometimes these tests are referred to as “imag­ing studies.” This is because they are all used to make an image of the inside of the body, using sound waves, X-rays, or other techniques. These studies cannot always detect endometriosis or adhesions, which may be a cause of chronic pelvic pain.

Laparoscope

 

 

Laparoscopy is the best way to assess endome­triosis and some other problems, in this type of sur­gery, a slender device that transmits light is inserted through the navel while you are under anesthesia. This allows the doctor to see inside the body. Some­times, treatment can be done at the same time. A doctor cannot be certain of a       diagnosis of endome­triosis unless surgery is done.

Psychologic Factors

Being in pain can put great strain on a woman and those close to her. Women who have depression in their family or who had a difficult childhood (espe­cially when sexual abuse was involved) are more likely to have chronic pain.

For these reasons, your doctor may ask many questions about you and your family to see if there is a need for emotional help. Sometimes the doctor may suggest that you get counseling.

Mood and pain may be chemically linked in the brain. Chemical changes may make the brain less able to cope with pain or may block out pain sig­nals. Treatment of chronic pain can sometimes be improved by using antidepressant medications. Antidepressants alter these signals.

Treatment

Acute pain or intermittent chronic pain often in­volves treatment of one specific condition. Treat­ment of constant chronic pain is not like that. Your doctor may talk to you about a few factors that may add to the pain, but may not know which one is the main cause. Treatment may involve a few medi­cations at once, nondrug treatments, or surgery.

Medications

If you have had a problem such as a urinary tract infection or vaginitis before and it has come back, your doctor may prescribe medication over the phone. Most often, antibiotics or vaginal creams will reduce the pain of an infection within 1 or 2 days. Severe PID, though, may require days of treatment in the hospital. With some kinds of STDs, your sex partner must also be treated, even if there are no symptoms.

Drugs that reduce inflammation, such as ibuprofen, can be used to lessen the pain of dys-menorrhea. These drugs block the making of pros-taglandins, which cause the uterus to contract. Ibuprofen can be bought over the counter. If it does not work, prescription drugs may help.

For other problems, treatment with hormones may help. Combination oral contraceptives (birth control pills) can be used to relieve pain from men­strual cramps. Other hormones can shrink some types of growths, such as endometriosis, fibroids, and certain types of benign tumors. Fibroids often return to their former size, though, when treatment is stopped.

Antidepressants have been used in some patients with pelvic pain when other treatments have not worked. They can help break the cycle in which the pain and the depression add to each other. The pain seems to be made more intense by depression.

Most people try to use as little pain medication as they can. When treating chronic pain, it is better to use a nonnarcotic pain medication as part of a routine. It is not a good idea to wait until the pain is severe before you take it. Pain medication may only take the edge off the pain. It may not get rid of it. It is best to avoid strong narcotic medication. It can lead to addiction or the need for higher doses.

 

     Ovarian Cysts

      Many women will be diagnosed with an ovarian mass or cyst at some time in their lives. An ovarian cyst is a closed sac within the ovary that contains fluid or solid material.

    The majority of ovarian cysts in pre-menopausal women will be “normal” cysts, related to development of the egg in the ovary and ovulation. These cysts will almost always go away over time. Sometimes cysts are found because a woman is having pain or discomfort, and sometimes they are felt during a When a cyst or mass is found in a woman who is still having normal periods, it is important to monitor it to see if it gets smaller or resolves over the course of four to six weeks. An ultrasound, an imaging test that uses sound waves to create a picture of the inside of the body, is an accurate and painless way to monitor an ovarian cyst. Cysts that get smaller between two different ultrasounds usually require no further treatment.

Ovarian cysts that don’t get significantly smaller or disappear over the course of a month or two are more likely to be tumors. These tumors are generally benign, or non-cancerous, especially in younger women. Sometimes ultrasound or other imaging tests, such as an MRI, can determine that the cysts are non-cancerous. If they are also small and don’t cause any symptoms, they can often just be monitored periodically. If a cyst is larger, or if it is difficult to accurately determine the kind of cyst, it will most likely need to be removed surgically.

routine pelvic examination.

        Ovarian cysts or masses can often be removed via laparoscopy, a surgical technique that uses several tiny incisions in the abdomen. Sometimes, if the cyst is quite large or if a woman is older, it is better to do the operation through a larger abdominal incision.

     Often just the cyst or mass can be removed, leaving the ovary in place, but sometimes it is necessary to remove the entire ovary. If an ovary is removed, the other remaining ovary will take over the function for both ovaries, so menstrual periods and fertility generally aren’t affected.

Transvaginal Ultrasound

Definition

Transvaginal ultrasound is a type of pelvic ultrasound. It is used to look at a woman’s reproductive organs, including the uterus, ovaries, cervix, and vagina. Transvaginal means across or through the vagina.

See also: Pregnancy ultrasound

    Alternative Names

Endovaginal ultrasound; Ultrasound – transvaginal; Sonohysterography; Hysterosonography; Saline infusion sonography; SIS

     How the test is performed

You will lie down on a table with your knees bent and feet in holders called stirrups. The health care provider will place a probe, called a transducer, into the vagina. The probe is covered with a condom and a gel. The probe sends out sound waves, which reflect off body structures. A computer receives these waves and uses them to create a picture. The doctor can immediately see the picture on a nearby TV monitor.

The health care provider will move the probe within the area to see the pelvic organs. This test can be used during pregnancy.

In some cases, a special transvaginal ultrasound method called saline infusion sonography (SIS), also called sonohysterography or hysterosonography, may be needed to more clearly view the uterus.

This test requires saline (sterile salt water) to be placed into the uterus before the ultrasound. The saline helps outline any abnormal masses, so the doctor can get a better idea of their size.

SIS is not done on pregnant women.

How to prepare for the test

You will be asked to undress, usually from the waist down. A transvaginal ultrasound is done with your bladder empty.

How the test will feel

The test is usually painless, although some women may have mild discomfort from the pressure of the probe. Only a small part of the probe is placed into the vagina.

Why the test is performed

Transvaginal ultrasound can help diagnose the cause of certain types of infertility, pelvic pain, abnormal bleeding, and menstrual problems. It can show the lining of the uterus (endometrium). The test may reveal:

·        Ovarian cysts

·        Ovarian tumors

·        Pelvic infection

·        Uterine fibroids

·        Uterine lining polyps

·        Thickened uterine lining in cases of postmenopausal bleeding

Transvaginal ultrasound is also used during pregnancy to monitor the growth of the fetus, listen to the unborn baby’s heart beat, and to check for ectopic pregnancy and other potential problems.

Normal Values

The pelvic structures or fetus are normal.

Note: Normal value ranges may vary slightly among different laboratories. Talk to your doctor about the meaning of your specific test results.

What abnormal results mean

An abnormal result may be due to many conditions. Some problems that may be seen include:

·        Birth defects

·        Cancers of the uterus, ovaries, vagina, and other pelvic structures

·        Infection, including pelvic inflammatory disease

·        Non-cancerous growths of the uterus and ovaries (such as cysts or fibroids)

·        Twisting of the ovaries

Some problems or conditions that may be found specifically in pregnant women include:

·        Ectopic pregnancy

·        More than one fetus (twins, triplets, etc.)

·        Miscarriage

·        Placenta previa

·        Placental abruption

·        Shortened cervix, which increases the risk for preterm delivery or late miscarriage

·        Tumors of pregnancy including gestational trophoblastic disease

What the risks are

There are no known harmful effects of transvaginal ultrasound on humans.

Unlike traditional x-rays, there is no radiation exposure with this test.

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