23:00 Sun21 May + ‘Menstruation © Number of follicles vary throughout life, These are (© Primontial follicles: 6-7 millions at 20 weeks of 1U Life, which isthe maximum © 1-2millionsatbirth © 3.4lakhsat puberty © Atotal ofaround 400-450 are ut MENSTRUAL CYCLE ‘Onuation oon woman's life | =e Day of mental ye Case 1: Women in whom Fertilization Oceurs © Fimbria Ovarica is the extra long fimbria which takes up oocyte. Life of oocyte in the body is 24 hrs to 48 hrs (best answer 24hrs) © Sperms fertilize oocyte in ampulla and the embryo reaches the uterine cavity on 3“to 4" day of ovulation ‘+ IMPLANTATION WINDOW: Implantation on secretary or ripened endometrium oceurs on 6" to 9° day after ovulation (0r20*1024* day of the menstrual cycle ‘= Progesterone is responsible for secretory endometrium ‘which is formed by Corpus luteum (Follicle) + Estrogen is responsible for proliferatory endometrium (source follicle) (Case2: Women in whom Fertilization does not take place ‘© Oocyte dies in 24-48 hours followed by degeneration of compus luteum, ‘© Corpus luteum begins to degenerate at 9*to 10"day © Complete degeneration at 14* to 15* day followed by shedding ofendometrium ‘+ Progesterone withdrawal endometrium ‘* Uterine contractions to expel menstrual blood cause dysmenorthea ‘+ Normal length of Cervix —+ 3.5 to 4em (Short Cervix —» 2.5, em) ‘+ Mittleshmerz/ mid eycle pain: This occurs due to blood & debris (from follicle) collected into Pouch of Douglas at the time of ovulation responsible for shedding of Dysmenorrhea (Pain of Menstruation) coms During ovulation prostaglandins are released due to rupture / 1] MENSTRUATION Of follicle which causes contractions of uterine muscle to Allow cervix o open for passage of shed endometrium These contractions eauses pain Cased: Anovulatory Cycles ono «These are characterized by the following differences from ovulatory cycles © NoMITTLESHMERZ/ mid cycle pain © NoProstaglandins, shed endometrium keeps collecting in ‘uterus —+ intermittent recoil of uterus —+ blood comes out —+irregular bleeding © Painless (due to no or less prostaglandins) & Important information ‘© Anovulatory eyeles are irregular and painless, ovulatory ceyclesare regular & painful Dysmenorrhea ‘Types Primary/Spasmodic Dysmenorrhea ‘+ Pain starts 30 min before onset of periods and stays 10 hrs postonset ‘+ Seen innormal women, women with fibroids Congestive/ Secondary Dysmenorrhea ‘+ Painstarts3-4 days priorandstays throughout menses ‘+ seeninPID & endometriosis Membranous Dysmenorrhea ‘+ Fibrinolytic system in uterus is responsible for less! non cclumpingof blood ‘+ Total absence of fibrinolytic system: here the endometrium is shed like cast of endometrial cavity. Thus due to clumping of blood, there are more contractions, causing more pain coasi7 wuprofen, naproxen, mefenamic acid 2. Anti Spasmodics: dicyclomine, drotaverine, hyoscine 3. Combined oral contraceptives + With use of OCPs, cycles becomeanovulatory, hence pain free 4, Surgical dilatation of cervix: Helps dysmenorthea as drainage of blood is better. Thus parous women have lesser spasmodic dysmenorthea as cervix stays patulous after delivery. 5. Pre sacral nerve ablation —+ Laser or thermal resection of hypogastric plexus 6. GnRH analogues» Willstop the periods tiBasic Definitions of Menstrual Cycle Length of Menstrual Cycle: Normal length ofthe eycleis28 7 Days. + Polymenorthea is defined ns cycle length < 21 days, while Oligomenonthea iseyclelengthot> 38 days . oosee Duration ‘© Normal duration oflow is 2-7: ‘© Hypomenorthea is defined as period lasting <2 days while Menorthagiais when period lasts>7 days Amount ‘© Nommal flow is 30-50 mlpereycle © Excessive blood lossis> 80 ml defined as menorthai Terminologies + Polymenorrhagia: <21 days & >80ml ofblood loss © Metrorrhagia: Irregular cycles superimposed on regular cycles orintermenstrual bleeding/ spotting * Menometrorrhagia: Irregular acyclical bleeding (Ca Cervix, Polyp) ‘+ Metropathia Hemorrhagica ‘+ Ih is characterized by prolonged amenorthea of 2-3 months followedby heavy withdrawal © Usually occursina women> 40 yrs (© This occurs in an anovulatory cycle, due to absence of progesterone, the endometrium isnon secretory and there is excessive hyperplasia of endometrial glands, which Jeadstoheavy withdrawal. © Itis diagnosed by curettage & microscopic examination which reveals Cystic Glandular Hyperplasia (CGH) or [SWISS CHEESE ENDOMETRIUM with very less stroma © Itisaselflimited condition © Curettageisalsocu Physiology of Menstruation nn (TF Mntnatgtns "eon 5 cat j (pret sone . iif ke. G i Tests for Ovarian Reserve © GnRH releases in pulsatile fashion: 60 minutes in follicular phase and 90 minutes in luteal phase low to Remember Faster (60min) in Follicular phase Longer (90min) in LUTEAL phase (© Granulosa cell of follicle are sex cord cells which produce estrogen © Antral follicles: these are lui filled follicles out of which 6-7 are recruited every month Tacaa (1000) one eter Toman et a = | ru i & i ‘Women have set number of follicles, which exhaust every ‘month and are over by menopause thus perimenopausal ‘women have iregular eycles due to OLD follicles ‘+ Fate of Reproduction During Perimenopausal Period: cycles, are commonly anovulatory, oocyctes are of poor quality, hence less chances of fertilization. Even if fertilization cccurs, embryos are of poorer quality and hence abort. risk of abortionisupto 40%after 40 years. ‘+ > 35 yrs Pregnancies + ELDERLY GRAVIDAS indicated for © LEVELIIscanning (© Triplemarkers, dual marker (© Amniocentesis: ous ANTRAL FOLLICULAR COUNT: lower the AFC, lesser the ovarian reserve, Itis around 6 to 7 in young women and around 1 inolder women, OVARIAN VOLUME: lower the ovarian volume, lower the reserve, It is around 3.5 x 2.5 x 3em in younger women and around 1x 15x leminolder, * AGE: ovarian reserve decreases with advancingage + ESTROGEN: lowertheestrogen, lower the reserve © FStI:higherthe FSH, lower the reserve. In younger women it is around 2t061U, while in older women itis> 1SIU. ANTI MULLERIAN HORMONE: it is made from granulosa cells of ovary, with lower AMH, ovarian reserve is poorer. nel& Important Information © Purpose of FSH —+ Estrogen production, + Purpose of LH —+ Progesterone proition Good indicators ofovartan reserve = AFC © FSH AMI [single best for assessment] EB Important information + Normal FSH 2-610 + > 10LU—+ Suggestive of Menopausal women + >401U + Diagnostic of Menopause hormone levels Ovarian events Flete level i i 1 Ovarian Powine wane 1113 a5 47 19 2423. 25-27 291 Menstruation Folia phase Newt oye (Prostrate pase) ore Maintainance of Pregnancy + Syncytiotophoblast of the embryo starts to make HCG, ‘hich issimilarto LH which maintains corpus luteum E& important information Pregnancy is exclusively mai LUTEUM upto 6wks ‘© Corpus luteum remains up to 12wks in pregnancy © Bycorpus luteum & placenta + from 6-12 weeks © Only by placenta ~v after 12 weeks © Luteo-placental shi ined by CORPUS, weeks Corpus 12weeks Luteo Primary placentation Hee ro Day Implications of Menstrual Physiology ‘+ Hyperemesis is maximum at 66° day [9 wks + 3days), ‘matches HCG peak «Prevention of abortion: This can be done by progesterones and HCG + Spinuharkiet stretchability: cervical mucus stretchabilty whieh i¢maximumat 14th day ‘* Ferning/arborizing pattern: Cervical mucus on drying forms: Ferning/arborizing pattem which is due to presence of NaClerystals + FERTILEPERIOD © Lifespan of sperm © Lifespanofovum = —+2448hhrs + SAFEPERIOD ——-+Before 11" day & after 16° day. If ‘a woman had intercourse on 24th day of cycle: The cervical ‘mucuss oo thick for fertilization, and there isno oocyte: asa result fertilization doesn't occur. Even if embryo forms, no implantation occurs ‘+ BILLING METHOD is a natural method of contraception. Itisbased on cervical mucus physiology © Thin and stretchable cervical mucous implies wet days and intercourse done on these days can lead to pregnancy, thusis ean be avoided for contraception. ‘+ PROGESTERONE PILLS [POP]: Mechanism of action for contraception © Progesterone given from start of the month makes cervical mucus on 14* day thick & viscid, sperm cannot penetrate easily. © Progesterone inhibits LH surge causing anovulation © Makes endometrium hyper secretory and thus unfavorable for implantation. Endometrium is thus out of phase endometrium wherein pinopods areinternalized © Failurerate—+ 1102% = II*10 16" day Ths Hormonal Management of AUB oan ‘+ I" Tine hormonal management of abnormal uterine bleeding is PROGESTERONE which stabilizes endometrium in a physiological way ‘+ Next line of managementis ESTROGEN, however leads to heavier withdrawal* First line of drug in acute SEVERE Menorthagia is ESTROGEN Controlled Ovarian Hyperstimulation ——eia911 Egg collection Give multiple FSH injection from beginning of the cycle, thus many follicles willbe recruited ‘On 14* day, under general anesthesia & take all oocytes from the follicles withthe help of TVS ‘Take few of best oocytes & fertilize with sperm in test tube, thus an embryos formed Embry@ is implanted back inthe uterus Excess embryos can be stored in liquid N2 (- 196° c] for frozen embryo transfer, which may be required later, I*IVFbaby + LOUISE BROWN [1978] "IVE done by -+ STEPTOE & EDWARDS. In 2010, Noble prize was given to EDWARDS} PREVIOUS YEAR QUESTIONS @ Q. Day 20 of menstruat eyele fas in which phase?(NEET 2019) A. Menstrual phase B. Follicularphase €. Ovulationphase D, Luteal phase Q. In this graph of menstrual eyele, Which alphabet shown is suggestive ofovulation? {EMGE.2020) Tote otal " SAS ate AA BB /C.O DM Q. Inthis graph of normal menstrual eycle, X represents? (FMGE 2019) ALLH B.FSH C. Estrogen D. Progesterone Q.f1CGisstuctrallyand functionally similarto (INI CET 2021) A. Prolactin Bun c.acTH D. Oxytocin +23:01 Sun 21 May . = 70% me } : + *) CROSS WORD PUZZLES | Crossword Puzzle ‘Across 1 pain occurs at the time of ovulation “7 2, Cycle length of less that 21 days is known as CaM || bys 1, The best test for ovarian reserve is hormone ; COO) 2 eycles are painless LT I 3 {ype of dysmenorrhea is seen in endometriosis O11 OeSMALL GIRLS +2] Puberty Normal Puberty + Normal age of puberty is 10-12 years in girls « Firstsignof puberty isphysical growth © Specific events of puberty 1, Thelarche: Orbreast growthis the first specifi sign 2. Pubarche/adrenarche: Pubic and axillary hair 3. Linear growth spurt: Height increases 4, Menarche: Periods start woos EB important Information «First sign of puberty: Physical growth, ‘First specific sign of puberty: Thelarche Delayed Puberty ‘© Noperiods till 13 years without pubic/ axillary hair ‘+ Or:Noperiods till 1S years with normal axillary/ pubic hair mas0 Early Puberty ‘© Onset of puberty at9 years orearlier Precocious Puberty ‘© Onset of puberty 8 years orearlier wom Pre-Pubertal Vaginal Bleeding ‘+ Neonatal vaginal bleeding (© Itis usually due to maternal estrogens. Counselling must bedonetoavoidanxiety + Pre-pubertal vaginal bleeding: Canbe ducto © Severe UTI Rectal bleeding because of constipation ‘Anal fissures IBS Physical abuse: especially with vulvo-vaginal symptoms. orsevere bleeding Condyloma (© Lichen sclerosus: can be seen in young girls also: due to Jess estrogens and dry vulva © Foreign body: purulent bloody, can do a PR and milk out FB mou ° ° ‘Vaginal Discharge in a Pre-Pubertal Girl cams ‘Inflammation and iritation: Causes vaginal discharge while vaginitis is MENSTRUAL PROBLEMS IN YOUNG AND E& tmportant Information ‘In prepubertal girls vaginitis is always secondary to vulvitis, while in adolescent and adult women, vaginitis ‘occurs primarily © Sexualal Specially ifthere isa foreign body ‘+ Mostly mixed organisms: Streptococcus, rarely Shigella ‘Treatment © Topical estrogens for around 4 weeks (short term): makes vulva sof reduce irritation © Antibiotics © Focusonhygiene Precocious Puberty one Definition * Periods in the absence of secondary sexual characters, 8 years orbefore ‘+ Presence of pubichair growth before 7 years ‘© Breast growth before 6 years (U/LorBI/L) ‘+ Precocious puberty leads to premature closure of epiphysis leadingto nadequateheight Etiology ‘© Mostcommonly idiopathic © CNSllesions like hypothalamic hematoma Tests © Raised LH/FSH> 1 ‘Treatment ‘+ GnRH analogues (depot form) cause desensitization! down regulation of pituitary receptors ‘© Growth hormone has acontroversial role Vaginal Tumors ‘+ Most common in pre-pubertal age: Embryonal Rhabdomyosarcoma (grape like clusters) ‘Trauma ‘© Any gitl presenting with vaginal trauma, we must rule out sexualabuse ‘+ Another cause may be acci +a Pelvic Masses in Young Girls ‘© Germcell tumorsinpre-pubertal © Dysgerminoma © Demmi © Yolksaetumors ‘© Embryonal ‘Pregnancy ‘+ Functionaleysts © Follicular (© Corpustuteateyst oun Adolescent Bleeding Patterns Normal and abnormal patterns ‘+ During first 2-5 years of periods: Anovulatory eycles. These cycles are irregular (delayed 21-45 days cycles), with mean duration of 7 days + >80mliscalledexcessive . * Definition of abnormal bleeding in adolescents is cycle length> 45 days or <21 days with bleeding for> 7 days Management of anovulatory bleeding + Firstlineistranexamicacidand NSAIDS ©. Hormones used may be COC which give artificial eycles or Progesterones: 10 days regime (for 10 days from day 14)or5 days regime * Noendometrialbiopsy EE Important Information ‘* Noendometrial biopsy for puberty menorthagia Evaluation * Alsorule out the following (© Hematological abnormalities: Von Villebrands © Infections: Chlamydia, STD © PCOS (© Anatomical defects like Transverse vaginal septum or tulerine anomalies like Didelphys ‘Ask Vo sexual activity: Adolescents tend to hold back information about sex and avoid using contraception. This leads to increased chances of unwanted pregnancies andunwanted abortions ° Long Term Menstrual Suppression 3000 Indications © Coagulopathy ‘© Malignancy requiring chemotherapy ‘+ Developmental disabilities ‘Treatment ‘+ Progesterones such as Norethindrone or Medroxyprogesterone. ‘Side effects include metrorrhgia (mid cycle spotting) ‘+ Long term COC given continuously or may give break once in3-4months ‘+ DMPA: Causes endometrial atrophy. Side effects include bloating, mood swings * GnRH analogues cause amenorrhea by downregulation of pituitary ‘+ LNG-IUCD (MIRENA): No systemic side effects, causes atrophy 20h a23:02 Sun zi May a 7 unm} &) CROSS WORD PUZZLES B Crossword Puzzle Across 1. ‘Thefirstspecifie sign of puberty is 2. In a prepubertal girl presenting with vaginal bleeding, a historyot____mustalwaysberledout fist in 3. The most common cause of precocious puberty is. E TO Down 1. The most common cause of vaginal bleeding in a neonatal girlispresence of maternalgove ouneimay + —] OVARIAN HYPERS (BAKERS DOZEN) Controlled Ovarian Hyper Stimulation ‘+ This means trying to get many eggs in one eycle to chances of conception with IVF ‘Understand with example: ‘+ Eachegemakes 150-200pgestradiol © 200 x 15 eggs = 3000 pg of Estra hyperstimulation ‘+ 20040 eges=8000 pe of Estradiol: ovarian hyperstimulation + >3500pgof Estradiol leads to © Vascularendothelial I: controlled ovarian growth factor 1 Vascular Permeability © Renin, prorennin © Angiotensin 1 Vascular Permeat Intravascular Compartment 4 Fluid shifts ———> Hemoconcentration + PCV>45 or> 55 packed cell volume [HCT]-33, ‘Third space collections 4 Ascites ‘Thrombo embolic phenomenon ‘+ Pleuraleffusion i © Pericardialeffusion + Renal Emboli + Edema ‘© Cerebral Emboli + Hepatic Emboli * Limb Emboti * Torsion Rupture of ovary Hemorrhage Pre Disposing Factors eoyo23 ‘Inj HCG [Initiating factor] [used for rupturing the follicle] © Vascularendothelial growth factor ‘© Renin, prorenin ‘© Angiotensin ‘+ HCGalong with hese3 leadstoCOH MIMULATION SYNDROME 70% Moderate abdominal pain Nausea + vomiting Ultrasound evidence of ascites Ovarian size usually 8 « 12 em Severe O1SS Clinical ascites (+ hydrothorax) Oliguria (< 300 mV/day oF < 30 mV’) Hematocrit > 0.45 Hyponatremia (sodium < 135 mmol) Hypo-osmolality (osmolality <282. mOsm/kg) ‘+ Hypoproteinemia (serum albumin < 35g) © Ovarian size usually >12 em Critical OHSS + Tense asciteslarge hydrothorax Hematocrit > 0.55 White cell count > 25000/ml Oliguria/anuria Thromboembolism ‘Acute respiratory distress syndrome ‘+ Nopregnancy isadvised in severe & critical OHSSas HCGis, expected to rise further if patient gets pregnant. Embryos are frozen and are transferred on day 20 of next cycle (day 6after ovulation). * Canallow pregnancy in mildand moderate OHSS Management Avoid pregnancy insevere & critical forms ‘+ Remove luidsby tappingascites & effusion ‘© Give oral fluids [Mild, moderate forms] IV Fluids for fluid replacement © NaCl, DNS [erystalloids] © Albumin, Dextran, starch [colloids] mize E& important Information Inj HCG given for follicle rupture, is the most important culprit and triggering factor for OHSS ‘© Abdominal bloating ‘© Mild abdominal pain © Ovarian size usually <8 em EE / 10 E important Information © Colloids will hold the uid inthe Intra-vascular space and are thus important for management of OHSS wo2v01 Occurrence ‘© Most commonly seen in 13-15% of patients on Clomiphene Citrate © However more severe forms are seen with Gonadotropins: Inj, HMG [Human Menopausal Gonadotropins, Inj. FSH recombination y i 1023:02 Sun Zi May si 70% + = *2 CROSS WORD PUZZLES B Crossword Puzzle Across 1. Adnigcommonly associated with OHSSis, 2. Classification of severity of OHSS commonly used | Down U 1. IV fluids which hold fluid in intravascular space in OHSS are 2. Ovary size of 7 em withoutascitesis, form of OHSS CLIT ttzsuz sun zi may Fai vee + 44] TESTS OF OVULATION Tests of Ovulation twoois 6, Serlal Cervical MucusStudles vos ‘Tests the effects of progesterone ‘* Spinnbarkeit& ferning is due to estrogen: This is max around 1. Basal body temperature: risesby 0.5° Fasprogesteroneisa day 14 thermogenic hormone ‘+ Loss of spinnbarkeit& ferning are dueto progesterone. 2. S.LH:> 15 1Uissuggestive ofovulation . S. progesterone on day 21, if >3nghml is suggestive of ovulation 4, Serial USG: Follicular monitoring done in OPD isthe usual ‘method used, start follicular monitoring on day 9 onwards Understand with example « Follicular monitoring started on day 9, you observed increasing follicular size serially on day 11, 13, 14 and then oon day 16 the follicle shrunk: this implies ovulation occurred between day 14-16 5. Premenstrual Endometrial Biopsy on day 21 # Tocheck secretory changes ‘© When the difference biw observed & expected changes is> 2 days, it implies Luteal Phase Defects, which is an important cause ofinfertility, EB important information + Spinnbarkeit and ferning of cervical mucous are NOT suggestive of ovulation. + Loss of spinnbarkei ovulation. and ferning are suggestive of 7. Diagnostic Laparoscopy: It is not usually done for diagnosing ovulation. However laparoscopy done for any reason, if shows yellow punctum on ovary is suggestive of ovulation we ff —_—_ R —— FEehSegnaton= 70%me) >} PREVIOUS YEAR QUESTIONS @ ——$—_— ins Q.A 30-year-old nulliparous lady, married for 5 years came for infertility treatment, Her tests for ovulation reveal that she is Q.A32-year-old woman visits an infertility clinic with regular cycles of 28 days, What shouldbe the test for ovulation? (AIMS 2020) ovulating regularly and normally. Which of the following A. SerumLHatday 21 suggests that ovulationhastakenplace? (FMGE2020) B, Serum progesterone at day 21 A. High FSH / C. SerumLHatday 14 B. Lowbasal body temperature D. Serumestrogenat day 21 C. Highestrogen D, High progesterone JUMP TO < > 3B /292 lext topic Previous topic Next top2sus yun at may + a *2 CROSS WORD PUZZLES @ Crossword Puzzle Across 1. The Hotmone responsible for rise in body temperature after \ ovulationis__— = A Down moccteto 1. Endometrial biopsy should be done in phase of menstrual cycle 2. Feming of cervical mucousis due to . 3. The extreme stretchability of cervical mucous is known as Saher qq choo JUMP TO < > “p92 Previous topic Next topic23:03 Sun 21 May + Endometriosis Etiology: Retrograde Menstruation voto ‘© Proposed by Samsons [Sampsons Implantation Theory}: endometrium also goes out through tubes (retrograde) and ‘implants on ovary, ligaments, bowel «© 701080% ofall womenhave retrograde menses © 5.10% of all women who have poor immunity & inereased estrogenecity would develop endometriosis Ageof Presentation # Brdtoth decade [25-35 yrsofage] tenor very specific © USG,MRI Mostcommonsiteisthe ovary ‘Second most common sites Pouch of Douglas Bowel Lang [periodic hemoptysis] XeetPrteensl Eyes [Periodic sub conjunctival hhemorthage] Pathology Powder Burn Lesions/ Blue Spots * Chocolate Cyst of Ovary: endometrium sheds in ovary and ince it cannot come out, keepscollectiig to forma cyst ‘Scarring & adhesions with fallopian tube: inthe process of healing -causes Infertility by impairing oocyte pick up by fimbria VICARIOUS MENSTRUATION oats Symptoms * Chronic pain ‘© Acute monthly exacerbation presenting as severe congestive dysmenorrhea ‘© Deep dyspareunia © Menorthagia Infertility © Altered tubo-ovarian relation by adhesion, impairing oocyte pick up © Decreased frequency of intercourse due to dyspareuni © Poor ovulation ©. Embryotoxic Endometriotic Deposi eoaKon 5 ENDOMETRIOSIS ADENOMYOSIS =» Poor quality embryos ~» Reduced implantation = Increased risk of Abortion Treatment Surgical Rx # Adhesiolysisforadhesions ‘+ Cystectomy forchocolate cysts of ovary ‘©. Ablation for deposits: Fulgration of Deposits may be done by Thermal ablation or Laser . + 60-70%Recurrence + Other options: hysterectomy om Medical Management cos 1. INJ Depo medroxy progesterone acetate 150 mg once in 3, months ‘+ Creates pseudo pregnancy state as progesterone stabilizes endometrium Atrophy of endometrium occursin3-4 months of Rx . Tab Danozol ‘Androgen have anti estrogenic action, thus cause faster atrophy © Side Effects include hirsutism which is a reversible change. Changes of virlization, which are permanent include breast atrophy, hoarsness of voice and clitromegaly. ‘The first sign to stop treatment with Danazol is thus hoarsness of voice 3. Combined oral contraceptive pills ‘+ These cause anovulatory cycles which are painless ‘+ Limits endometriosis by causing amenorthea when given continuously. . GnRH Analogues: Depot or Continuous Form ‘+ Leuprolin, Naferelin, Gosertin + Normal GnRH secretion is pulsatile, Here, GnRH is givenas depot continuous form causing excessive stimulation of pituitary, ultimately causing desensitization/ down regulation of pituitary receptors + Atrophy ofendometrium & Important tnformation ‘+ Medical management aims at stopping the periods tll the patient conceives or completes her family, when COCS can bestarted23:03 Sun 21 May + Understand withan example {Q.25yrswith chocolate cyst Surgery is done: what next? ‘Ans. Medical management til eonception Management protocol # Pregnancy, due to amenorrhea limits endomettiosis. The patient should be encouraged to complete her family after Which she should be started on COCPS. These can be prescribed as 21 x 4 packs, given for 84 days continuously, such that patient willhave petiods once in 90 days © GnRH analogues: when given for more than 6 months, estrogen dependent osteoblastic action will stop while estrogen independent osteoclastic action continues, this results in osteoporosis. Add Back Regime; to be started if GnRH are to be given for longer than 6 months which includes low dose estrogens and RALOXIFINE [selective estrogen receptor modulator] Adenomyosis/ Endometriosis Interna oasis ‘© Adenomyosis is seen in, multiparous women over 40 yrs of age and inabout 30% ofhysterectomy specimens + It is also known as Endometriosis intema, which impl endometriosis within uterus in the muscle layer. ‘+ Moccurs due to disruption of endometrial-myometral border due to repeated pregnancies, hence associated with ‘multiparity. Presentation ‘+ Menorthagia ‘+ Progressive dysmenorrhea ‘+ Infertility in young women (Rare) ‘+ Uterus is uniformly enlarged & < 14 weeks size of pregnant uterus [14cm], in contrast fo asymmetrically enlarged uterus infibroid. F10% Dingnosis 1. USG,MRI ‘© Subenddometrial halos present 4 Hetero echoic deposits inuterine myometrium + IM defined hypoechoic areas are seen as Lakes of Endometrial Blood © Junetional zone b/w endometrium & myometrium which notmally is $-8 mm is increased to > 12 mm and is diagnostic of adenomyosis onasat cous 2. Uterine Blopsy/ Post Hysterectomy Uterine Analysis ‘+ Endometrial glands within uterine muscles isa pathognomic sign + Localized adenomyosis looks similar to fibroids, however fibroids have pseudocapsule while adenomyosis has adiffuse border. ‘Treatment 73104 ‘+ Menorthagia can be managed with NSAIDS and Hormones + For young women, not suitable for hysterectomy, hormonal therapy may be given in the form of COCPs for longer duration or IUCD’s with progesterone [mirena] o less commonly localized excision + Surgical Management of Menorrhagia can be done by Dilatationand Curretiage + © Overallbestireatment hysterectomy €& important information ‘+ Most definitive treatment ofadenomyosisishysterectomy? Q 18-year-old girl presents with partial transverse vaginal septum with dysmenorrhea and chronic pelvic pain, Which ‘ofthe following isthe likely complication? (NELT2021) A. Endometriosis B. Tubo-ovarianabscess C. Dermoideyst D. Theca lutein cyst Q.Awoman withendometriosisislikely to suffer from? (INECET 2021) A. Infertility and dysmenorrhea B. Infertility andiregular vaginal bleeding, C. Dysmenorthea and Irregular vaginal bleeding D. dysmenorthea and Vaginal discharge Q.A nulliparous 29-year-old woman presents with infertility. On examination, werus is felt to be normal in size-but is retroverted and fixed. Also, there is tendemess in posterior ‘vaginal fornix. Diagnosis? (FMGE2020) A. Adenomyosis B, Endometriosis C. Fibroid uterus D. Ovarianmalignancy PREVIOUS YEAR QUESTIONS Q. 29-year-old nulliparous lady presented with endometriosis, ‘and infertility. On laparoscopy there were severe pelvic ‘adhesions and uterus had bowel stuck to its fundus with dense ndhesions, The ovaries were eystic each around 6-8 cms in size and stuck to each other (kissing ovaries). What is thenext line of management? (FMGE2020) A. Gn analogues B. OCs Hysterectomy with oophorectomy D. B/L.eystectomy with adhestolysisand plan for IVF QA 38-year-old P3L3 woman presents with secondary dysmenorthea and on USG there is uniform enlargement of ‘ulerus upto 10cms. What is the provisional diagnosis? (FMGE 2020) ‘A. Adenomyosis B. Fibroid C. Leiomyoma D. Endometi+ 2. cRoss worD PUZZLES B Crossword Puzzle Across 1. ‘The gold standard for diagnosis of endometriosis 2. ‘The most common cause of unexplained infertility Down I aa 1. The drug. __i8 used for treatment of endometriosis and causes hirsutism 2. ‘Themost common site of endometriosis is 3. The definitive treatment of adenomyosis is TTTTTtT E eeepo Menopause mo.20 ‘© The average age of menopause is $2 years (51 years), while the average age of menopause in India is 47-48 yeats. The range is 40 -S8 years ‘© FSH> 1Oissuggestive of menopause © FSH> 40 isdiagnostic of menopaus © FSH> 40 before 40 years of age is premature ovarian failure Featuresat Menopause duc to lack of Estrogens * Skin is smooth, supple, glistening due to subcutaneous collagen which is maintained by estrogen. Atmenopause low collagen, skinbecomes lax and loose, ‘+ Voice: There ishoarseness of voice ‘+ Brain: after menopause, woman may have mood swings, depression, reduced anger threshold, anxiety, insomnia, ‘+ Hot flushes: occurrence of hot flushes coincides with LH © There is an increase in NA, serotonin, dopaminergic pathways, which causes vasodilatation in brain causing a flash of heat from brain oneck to back © Around 75% menopausal women get hot flushes © Thisis seen in up to 1-2 years in most women, can go upto 1O years © Ahot flush isnot just because of estrogen deficiency but due toestrogen withdrawal EE important information ‘* Hot flushes are important indication for HRT ‘© Due toestrogen withdrawal ‘© Bones: there is an increased risk of fractures due to osteoporosis as there is more osteoclastic activity and less osteoblastic activity. These fractures include: ‘©. Vertebral compression fractures [MC] © Wrist fractures, (© Femurfractures E& important information ‘© Most common fractures due to menopaus compression fractures vertebral ‘© Hair: Vellous hair are sof, thin and light, while terminal hair ‘are hard, thick and dark. At menopause, there are more terminal hair asthe pilosebaceous unit is more under control ofandrogens HORMONAL REPLACEMENT THERAPY (SWEET SIXTY-SIXTEEN!) ‘+ Pelvis: there isincteased risk of fractures ofhip bone © Vagina: the normal PH of vagina is acidic wl protectivengains! infections. re However glycogenisconverted to» Monosaccharides tactic acid 1202, © No Estrogens makes pHf alkaline due to reduced lactobacillus. This increases anaerobic infections causing vaginitis, vulvtis, urethritis, UTE © PID [Pelvic Inflammatory Disease] © Dry alrophic vagina also leads to decreased sexual activity leart: Risk of Coronary artery disease increases. ‘At40 years, man: woman (risk of CAD): 9:1 © At60 years, 1 « Pelvicorgan prolapse: © Ligamentous support + Round ligament: maintains anteversion + Mackenrodt/ cardinal/ transverse cervical: best ligament support = Uterosacral + Pubocervical Supports ofthe uterus ‘© Muscular support: levator ani/ pelvic diaphragm: best support > Puborectalis > Pubococeygeous = lliococeygeous E& Important Information ‘Best overall support of uerus: pelvic diaphragm ‘+ Best ligamentous support: transverse cervicabss nw ‘© Tone of these muscles is maintained by estrogen, which is Jostat menopause: increases prolapse ‘Main reason of prolapse is abnormal conduct of labour, but prolapse occursat menopause due to loss ofestrogenic tone23:03 Sun Z1 May . EB important information ‘* Most important indications for HRT: hot flushes and osteoporosis : Hormone Replacement Therapy Investigations beforestarting HRT o2sat ‘© LFT [Liver function ests] + FpPsugars ‘Lipid profile SerumFSH (© Todiagnose menopause ‘© To monitor HRT [if given to younger women (premature ovarian filure)] + CBC ‘* Mammography ‘© USG: check Endometrial lining, if < 4 mm, HRT can be started, however if $ mm, then patient needs an evaluation firstby biopsy. * Papsmear * ECG ‘* BMD assessment: DEXA scan: Dual X ray Absorptiometry. Todiaenoseosegporsis © Tscaté#éthpare to woman of 30 yrs T+1 (oT (normal) + Osteopenia:T-1 toT-2.5 + Osteoporosis:> 72.5 Contraindications to HRT ‘Abnormal liver function CADorCVA DVT/ Thromboembolism Undiagnosed vaginal bleeding 1/0 Breast cancer on32:50 07 FI10% # 1/O endometrial cancer Endometriosis Fibroids * Porphyrias Drugs for Hormone Replacement Therapy 3800 1. ‘Tab Estradiot:|-2 mg/day add 2. tahConfoyted Equa Patropen: 0.623 } Pogesrone to 1.25 mg/day E& Important Information ‘+ High dose estrogen given for HIRT should be given with progesterone to protect from endometraleancer 3. Tab Tibolone: it is a synthetic estrogen which has a progestational metabolite present. The dose given is 2.5 mp/day 4, Serm [Selective Estrogen Receptor Modulators] ‘© Raloxifene: dose given is 60 mg/day. Its estrogenic on bone and anti-estrogenic on brain, therefore it is contraindicated forhotflushes. E& Important Information * Raloxifene is not to be given in menopausal women with hot flushes ‘© Bazedoxifene: doseis20mg/day 5. lant Estrogens: these are saferbutlesseffective 6. Bisphosphonates ‘+ These form thenon hormonal treatment of osteoporosis ‘+ Various drugsand doses are: © Alendronate: 70mg/ week © Risedronate: 35 mg/ week © Ibandronate: 150 mg/ month ‘© Zolendronic Acid: 5 mg/ year ‘+ Majorside effects include gastrointestinal intolerance, which can be reduced by taking on empty stomach with lots of water and patient must then sit upright for half hour immediately after. E& important Information ‘Treatment for osteoporosis * Bisphosphonates: Late osteoporosis> 60 years ‘© Estrogens: At around 50 years, prevention and treatment, Doc 7. Calcitonin ‘* Miacalcin: Dose given is2001U as an intranasal putt alcous oun er may aa + Itactsby reducing osteoclastic action 3. -Parathormone Extract Teriparatide Includesnew bone formation 9. Denosumab Monoclonal antibody: against k-B ligand ‘Treatment of Hot Flushes asia ‘+ Estrogen: Itis the drug of choice, howeverittakes some days toact ‘+ Estrogen 0.45 mg+bazedoxifene 20 mgcan beused ‘© Clonidine Hydro Chloride: Is given for acute relief as 100 200g OD. Itdecreases vasomotor flushing ‘© Alprazolam: Given in doses of0.25~0.5 mg foracuterelief ‘+ SSRI [selective serotonin reuptake inhibitors} ‘© Paroxetine: 7.5mg/day ‘© Fluoxetine: 10-20mg/day (© Takes 6-7 days foraction Senco ee vm Rolein Coronary Artery Disease ns036 EB important information Estrogens are cardioprotective © HRTISNOTCARDIO PROTECTIVE # Ciltostart HRT—+CAD © Initial few years (upto 10 years)—+ Cardio protective © Long term— increase risk of CAD Roleof HRT in Vaginal Atrophy sn * Local estrogens are better, such as estriol cream (evalon), with lesser syst effects. + local DHEA application + Oral ospemifene, whi dyspareunia is a SERM, helps to reduce E& important Information ‘+ Start HRT only after I year of menopause23:04 sun zi may + = *) CROSS WORD PUZZLES @ ™~ e Crossword Puzzle Across iH The main cause of ahot fash isestrogen 2. __is a SERM used for the treatment of menopausal r symptoms a L1 3, Menopause causes ofbone moto 4, Mosterucial ligament of pelvic supportis, +f 1 Down a 1. The drugof choice forhot lashes is 1 ea+ ~ + Normal Ovary + Normatovary: 3x 3.5x2.Sem # Almmond-shaped * Rough surface due toscarsby ovulation Nilliparous Ovulationinduction Early menarche Latemenopause Perincaltale Ashestosexposure ° Moreovulation; more sears oooce0 Ovarian Epithelial Cancers Etiology Sears © T scars — Epithelium-+ over healing — Epithelial ovarianCA i ‘+ Associated with Mutationsin ‘© BRCA1 [Onchromosome 17] ‘© BRCA2[Onchromosome 13] ‘+ Familial Predisposition © Two 1 degree Relatives with cancers (breasV ovarian! endometrial) -+35-40% chance © One I" degree Relative and one 2” degree relative: 210 10 times chances ae FecSbomaion ‘© 70% of all ovarian cancers are surface epithelial ovarian cancers ‘+ Age group: 6th Tthdecades ‘+ Mostly bilateral ‘+ Associated with 1 CA 125: Prognostic indicator (nota good diagnostic indicatoras tis not very specific) ‘© Significant values in a postmenopausal women:> 35 ‘© Premenopausal women:> 200 ‘© Clinical features : abdominal mass (big abdominal masses are however mostly benign) and usually present with vague GI symptoms such as abdominal bloating, distension, indigestionete Diagnosis ‘+ USG features of malignancy TVS>TAS © Bilateral Surface imregularities Cystic +solid areas together (variegated) Seplate tumors: regular, thick Ascites present oo0° Ef 23 7 II OVARIAN TUMORS Hick of malignancy Index ‘A. Menopausal status Premenopausal : 1 Postmenopausal 1B. Ultrasound features No features :0 ‘© Muttitoculated One feature : 1 © Solid areas >I feature :3 © Bilateral masses © Ascites © Metastasis: C.CA 125 levels Absolute levels RMI=AXBXC <25: low risk 25-250. moderate risk >250:: high risk Refer Table 7.1 ‘© Human epididymal protein 4 (HEA) : > 94% specificity, no effect with endometrioticcyst __ * ROMAscore: Riskof Malignancy Algorithm Pre-menopausal PI : 12 + 2.38 x LN(HES) + 0.0626 x LN (Cal25) Post-menopausal PI : 8,09 + 1.04 x LN(HE4) + 0.732 x LN (CA125) ROMA (%) : 100 X Exp PY (1+ Exp PI) ROMA cut off: 7.4% for premenopausal 25.3% postmenopausal ‘Treatment ‘© Staging Laparotomy + Optimal Debulking © Vertical Midline incision Paramedian incision © Ascites for cytology for malignant cells, (if no ascites, then take peritoneal washings of POD, paracolic gutters, BIL hemidiaphragms with 50-100 ml NS and send for cytology) ‘© Assess pelvis, Abdominal organs, extent of malignancy, spread inaclockwise direction © Peritoneal biopsy © Scrape both hemidiaphragms © Supracolic omentectomy © Retroperitoneal lymph node sampling (pelvic and para- aortic) © Optimal Debulking © Remove the involved ovary in young patient or total hysterectomy with bilateral salpingectomy in an old woman © Removeall visibletumors CT+ © Residual eancer<1 emisoptimal debulking coast © Lesser post operative morbidity and better response to J ermaerany & Important Information «Normal ovary is radiosensitive, All ovarian tumors sndioresistant «Exception: Dysgerminoma: very radiosensitive Ovarian CancerStaging mans ‘© Stage: Ovarian Involvement (© A-One ovary involved © B-Bothovariesinvolved Guidelines: Management of Ovarian Cancer iene Barly Low Stage 1A, 1B, Surgical staging > Gr Surgical spill risk low grade High Stage 1C; high Surgical staging + adjuvant risk grade chemotherapy Uterus, fallopian tubes ‘Advan Stage ILJILIV Maximal cytoreduction + © IB-otherpetvic omgans ced adjuvant chemotherapy ‘Stage It: Abslominal Visceral Involvement © IIIA; Retroperitoneal lymph node involvement 3 A\()-<10mm 3 Ai-> 10mm & Important Information ‘+ Maximal cytoreduction means removal of entire pelvic © IIIA, Microscopic abdominal visceral involvement tumor + resection of metastasis © IIB Macroscopic involvement <2em ‘© Optimal debulking : <1 cm of residual lesion superficialliver | Fertility sparing surgery : done for younger women &espleen (unilateral salpingo-oophorectomy) : for stage 1A with involvement low grade or borderline tumors © IIICMacroscopic involvement>2em ‘© Neo-adjuvant chemotherapy : Stage III and IV with * StagelV massive ascites, pleural effusion, unresectable tumor. It ©. IVA:Malignant pleural effusion increases chances of optimal debulking. © IVB:Deep/ parenchymal liver & spleen deposits, Inguinal lymph node involvements ‘Types of Epithelial Ovarian Tumors ‘© Highlighted ones are new changes in staging = MC[75%) # Olderage group (Chemotherapy: + Bilateral Platinum Based 1. Epithelialovarian tumor Types 1. Cyclophosphomide # Serous Cystadenoma [me type] ‘Adreomycin ‘© Unilocular Plains Cis © B/Lin>s0% Carbo © Mostly malignant © Surface growth present } Betterchoice (© Psammoma Bodies present in 40-45% 6 Cellsare lke fallopian tube b. Platins Taxol 2. GermCell Tumors osnis a. Vincristine EEE Bleoycin latins b. Bleomycin } Etopside Better Choice Platins 3. SexCord Tumors was © Surgery alone will suffice mostly Serous Cystadenoma cf 24ie fn Psammoma Body + Mucinous Cystadenoma fo Lessmalignant © BILin 10% (© Multilocular © Pseudomyxoma peritonei: Mucinous cystadenoma ruptures to release mucin in peritoneal cavity which heals with peritoneal fibrosis —> Severe hypoproteinemtia > MC cause in ovarian tumor—+ mucinouseystadenoma > MC cause (Overall): Appendiceal cancer * Cellsare like cervix + BrennerTumor Mode of transitional cells, Nests: Walthard Inclusions Puffed Wheat Type Benign Rubbery inconsistency Cellsarelike bladder Associated with post menopausal bleeding ‘Associated with Pseudomeig syndrome — Pseudomeig syndrome is mely due o Brenner tumor 00000000 ‘* Fibroma Ovary ‘© Any other ovarian tumor: # Ascites ‘MC brenner ‘© Pleural effusion © Ascites « Pleural effusion © Endometroid Tumor © Endometrial type of collections © 6-78% of epithelial ovarian tumors © Clear cell carcinom tumor Very rare but very malignant © Poor prognosis © Large cuboidal cells with clear cytoplasm:hobnail appearance (protruding nucleus into the lumen) Iso known as mesonephroid ovarian 7 -m Cells‘Tumors © Younger age group © Unilateral ‘Teratomas [MC] ‘© Malignant [10% of teratomas} ©. Dermoid /Benign cystic teratoma [90%of teratomas] © All3 germlayers present ~ Endoderm Bone, teeth ~ Mesoderm Sebaceous secretion — Ectoderm Hair, Endocrine glands © 10-15%arebilateral & Important Information ‘+ Dermoids can have malignant transformation + Sq. cell carcinoma ‘+ Demmoids are MC tumors of pregnancy ‘+ Demnoids are MC tumors of torsion Dermoid Dysgerminoma Me germcell malignaney [40-45%] ‘Only B/L germcell malignancy (10-15%) Associated with dysgenetie gonads Large fleshy tumor Mostly malignant: Poor prognosis TT23:04 Sun 21 May + © Seminoma Type Cells ‘Large polygonal cells with o»Glearaytoplasm & dark stained nucleoli with onBiachioBick tirangement ‘Seminoma Cells Associated with © TLDH © Placental alkaline Pot © Alpha feo protein: Not increased Yolk Sac/ Endodermal Sinus Tumor & Embryonal Tumors ‘Common Features © Young women & girls ‘+ Poor prognosis ‘© Alpha feto protein © 11 anti trypsin * HCG ‘© Schiller Duval bodies: vessels with tumor cells ‘around in a cystic space Sex Cord Tumors Granulosa Cell Tumors [MC] #1 Estrogens © Precocious puberty © Menorrhagia © Endometrial cancer onstsa4 ee 26 Carl Exner Bodies © Marker: Inhibin © Carl Exner Bodies . jan secondaries prior to systemic Sertoli Leydig Tumors/Arrhenoblastomas © Hirsutism: Male pattern baldness/ excess hair growth: reversible : Permanent changes © Hoarsness © Breastatrophy © Clitoromegaly + Oligomenorthea toamenorthea © Benign ‘© Rapidonsethirsutism Hirsutism ois: ‘© Rapid Onset: Seen in ovarian oradrenal tumors ‘© Puberty Onset: Seen in congenital Adrenal Hyperplasia ‘© Adult Onset: Seen in PCOS ‘© Causes: 25% + Idiopathic + 75% —+2° (MC —+ PCOS) Eb Important Information ‘+ MC cause of Hirsutism: PCOS and not idiopathic Non-Neoplastic Ovarian Cysts ‘Follicular Cyst: follicle that didn't rupture © Corpus Luteal Cyst ‘© Theca Lutein Cyst—+ ditt HCG —+ Seen in molar pregnancy, twinpreg. © Hemorthagie Cyst ozo Management + Resolvesby themselves —» Conservative Management + MCovarian tumor of pregnancy —+ Dermoid> serous cyst smal [< Sem] & asymptomatic —» No Rx required large [> 10¢m] & asymptomatic —» Remove it in 2nd trimester + If diagnosed in 3rd trimester —» Remove wit in 1-2 wks after J23:04 Sun 21May + 4 delivery,candoa laparoscopy + Ifdoingacesarean section—+ Remove at the time of CS Krukenberg Tumor + Secondaries to ovary (Most commonly from Ca stomach > Cabreast) Signet ing cells Bilateral Finn tosolid May haveeystic degenerations ‘Ovary retainsits shape Borderline Epithelial Ovarian Tumors Features © Epithelial hyperplasia, micropapillary projections, surface iny, tufting ‘Tumor Markers vem Mitotic activity present Nuclear atypia present Detached cell clusters present Nodestructivestromal invasion Epithet + Dysgerminoma +H. Granulosa cell Endodermal sinus + Embryonal Tumor + Ey Choriocarcinoma ie Teratoma + NEE fT / 27 + + § Alpha-1 Anti trypsin is specific + =Table 7.1 : RMLI=USMSCA- — U=0(0 parameters) MEI (premenopausal Not applicable i 12s U=1.(1 parameter) M=3 (postmenops / U=3(2 parameters) ‘ RMITL=U*XMXCA- U1 (0 or 1 parameter), Me! (pre-menopausal) Not applicable las U=4(2 parameters) M=4 (postmenopausal) RMIIIl=UxM*CA- —U=1 (or I parameter) M=! (premenopausal) Not applicable 125 U=3(2 parameters) ‘M=3 (premenopausal) RMIIV=UxMxSx — U=1(orl parameter) M=I(premenopausal) S1(<) CA-125 U=4(2 parameters) " M=4 Postmenopausal) s-2(7) er 283.U% Sul Te ? Q.Match the Column (INICET 2021) A. Dysgerminoma 1. Inhibin B. Epithelia cell tumor 2. ARP C.Granulosa cell tumor 3. Bela HCG D. Choriocarcinoma 4.LDH E, Yolk sac tumor S.CAA125 AL AABS.CHD3,E2 C. A2B4,CD3ES D. A4,B2.C-1,D3,E5 Q.Anadnexal mass is palpable during bimanual examination in an asymptomatic woman . The next investigation to be done is? (GIPMER 2019) A. CA-125 B. Trans vaginal sonography C. MRI D. CTabdomen and pelvis: PREVIOUS YEAR QUESTIONS Q. During a laparotomy of a 60 year old woman, a: mass is seen next fo the uterus as shown in the picture. What is this mass likely tobe? (FMGE2020) ‘A. Ovarian cancer B, Hydrosalpinx . Fibroid D. TBadnexa Q. All of the following are good treatment options for ‘management ofovarian cancers, Except? (FMGE2020) A, Debulkingsurgery say 29 B. IV chemotherapy . Intraperitoneal chemotherapy D. Radiotherapy2s.ua suit zt may + : &2 CROSS WORD PUZZLES a f Crossword Puzzle TTTTTTtT COLO E11 Across 1. Most common type of ovarian malignancies are__inorigin 2. LD Hand alkaline phosphatase are raised in Down 1, Brenner tumor with pleural effusion with ascitesisknown as syndrome seve Psammonnabodiesare foundin__cystadenoma EGDHe'Aalevoblastomas are associated with changes of __ of MgSO4asatocolyticin preterm labor is 0 30oe TIC OVARIAN SYNDROME + 8 POLYCYS ; Polycystic Ovarian Syndrome ‘© Also called as Stein Levinthal Synurome, Almost 15-20% women (1/5") have PCOS and it is the most common endocrine disonderofreprxtuctive age women. 4 Itisalsothe most common eause of hitsutism EB important information ‘© MC cause of hirsutism is PCOS (75%) and not Idiopathic as%) + Other causes: CAH, ovarian tumors, Cushing's ete Diagnosis: Rotterdam’s Criteria 0338 “Any 20f3 Accepted for diagnosis by ESHRE, AFS, FOGSD) 1. Clinical or Labevidence of hyperandrogenism 2. Anovulation as suggested by imegular cycles 3. USG features of PCOS © Polycystic ovaries haveno cysts, smooth surface of ovary ‘© Multiple small follicles arranged in periphery (Necklace of pearls), 2-6mm ( 20:such follicle per ovary Thick stroma «Slightly enlarged ovary, ovarian volume>10mL(LXWXH * —_ oe PET biochemical) ‘* PCO mompbology * Ovarian dysfunction Type3 ‘+ HA (clinical/biochemical) ‘+ PCO morphology ‘© Mostcommon: type I (70%) ‘© Ovarian dysfunction Typed © Ovarian dysfunction © PCO morphology Pathophysiology meaner > ut © FSH —+ Estrogens © LIf=+ Progesterone Revise normal phystology + Follicle matures at day 14 (20 mm) —+200 pg estradio!—+ LH surge ~+ ovulation —» corpus luteum —» progesterone —> secretory endometrium —+ corpus luteum dies — progesterone withdrawal —+ period ‘© LIT surge occurs —» small follicle -> doesn't rupture — estrogen keeps increasing and no progesterone—+ endometrium keeps proliferating: Anovulation “+ Associated Infertility + Endometrium sheds due to ischemic withdrawal (Endometrium outgrows its blood supply): Oligomenorthea, Amenorthea (amenorrhea here is defined as missed 3 cycles ‘orno periods for months) ‘* High estrogen > LH very high, FSH is low LH: FSH ratio >2:1 or>3:1(classical) ‘+ High LH acts on stroma of ovary—+ High Androgens (Androstenedione/ Testosterone) —+ SHBG binds to androgens + Low SHBG and High Free Androgens —* Hirsutism E& important information ‘+ High estrogens do not convert to androgens in perigher Androgens convert to estrogens in periphery by aromatase enzyme * Cause of small follicle: Insulin resistance at ovarian receptorlevel ‘+ Noglucose uptake —> less follicle growth» small follicle ‘© Insulin Resistance, Obesity © High F. Insulin 25 mlU) © FGlucose: Insulinratiosa.S * Polygenic inheritance /+~— ‘Overexpression of 7hydroxylase enzyme Cutaneous markers of Insulin resistance: Acanthosis Nigreans: dark shiny, velvety erural deposits (nape of neck, cubital fossa, groin, MC: vulva) ail ¢ HAIR-AN: Hyperandrogenism, Insulin resistance, acanthosis nigricans ‘© Metabolic Syndrome’ Syrudrome X fo Waist +> 38 inches (0 THGlycerides +> 150mpial © HDL —+ 130/85 mm Hg © Fasting glucose 110-126 © 7SemsOGTT 2hrvalues +> 140-199, © Atleast ormore + increased risk of CAD + Longtermconsequences © DM © HTN ‘© Caendometrium © Caovary Trestment 03s:10 Anovulation Treatment ‘+ Weight reduction leads to ovulation [in 30% cases], loss of ‘even 5-10% weight increases insulin sensitivity and can regularizecycles Insulin sensitizer [metformin] causes ovulation in 30% ‘cases, however itis not firs ine treatment Clomiphene Citrate causes ovulation in 80% cases out of ‘which pregnancy may be achieved in 40% cases. co Excess estrogens in PCOD gives negative feedback on hypothalamus causing low FSH and thus less follicle ‘development. Clomiphene acts as hypothalamic estrogen receptor blocker, thus causing high FSH and follicle development Itis given from day 2-6 in doses of 50 mg-250 mg and is ‘combined with follicular monitoring Side effects include vasomotor flushing, headache, visual scotomas The incidence oftwinning is 8-10% Mild-moderate OHSS, cysts ° ‘Aromatase Inhibitors —> Letrozole 1"line Drug] © It inhibits conversion of androgens to estrogens. This causes less negative feedback to hypothalamus which increase FSH and thus follicular development © Letrozole (vs Clomiphene) “> Higher birth rate > Less multiples ~ Better endometrial health (CC is anti-estrogenic on endometrium) =» Better cervical mucous =» Lesseranomalies > Lesser abortions » Lesser OHSS Inj Recombinant FSH 4+ Inj emma Menopausal Gonadotropin LI+ FSH) Irregular Cycles‘Treatment cons © Combined Oral Contraceptive Pills (drug of choice): gives, antificial cycles, give foras longas regular eyclesare desired + Progesterone Pills: makes endometrium secretory © For 10days(From 14° day/mid cycle) © ForS days (day 20-25) Hirsutism’Treatment oosi3s 1.Anti-Androgens + Spironolactone(1" * Cyproteroneacetate ‘© Finasteride © Flutamide ine drug]: 50-100mg/day 2, Cosmetic Treatment For hair—+ Prevents Depression = a u's [ No Progesterone then lsc Alton Understand with example: ‘Young girl with irregular eyetes and acne, hirsutism: COC + ‘eyproterone ‘Estrogen: proliferates endometrium secretory endometrium inti-androgen: has inherent progesterone action, sowe don'tneed to give progesterone Give: estrogen+ eyproterone/ drosperinone Surgical Treatment; Laparoscopic Ovarian Drilling: 005227 ‘© Itisused fornonresponclers ‘© Muses cautery to burn ovarian stroma, and drill 4-6 holes. ‘Thick Stroma in PCOD increases local production ofzsva sun zi may +.7 androgens, this makes follicles harder, Ovarian drilling decreases androgenic stroma such that there is better response to ovulation inducing drugs ultimately resulting in better follicular growth Laparoscopic ‘Ovarian Deiling OO Cp SO OS) 0090 yar 33 vm E& important information ESHRE recommendations + Rotterdam'scriteria for diagnosis + USG criteria: now changed to 20 small follicles (rather than 12) Emphasison weight loss COC for menstrual irregularities ‘Metformin for metabolic features Letrozole DOC for PCOS infertility aye Lifestyle Modifications ‘+ Healthy eating and regular physical activity + S-10% weight oss ‘Adhere lifestyle interventionsTr, } PREVIOUS YEAR QUESTIONS & $$$ Q. For PCOD all of the following are options for ovulation induction, EXCEPT? (AlIMS 2020) A. Ovariandrilling B, Ulipristal C. Letrozole . Clomiphene citrate a 3423:05 Sun ZI May 1m CROSS WORD PUZZLES @ Crossword Puzzle a 5 CITT TT BET EEE TY 13 35 Across 1. ‘The most common eause of hirsutism ina30 year old woman is. 2. Thedrugof choice for ovulation inductionin PCODis, 3. Insulin isseeninPCOD Down 1. Themost common ovarian defect in PCODis, 2. The hypothalamic estrogen receptor blocker used for inducing ovulationis, J23: ue 21May ‘ ERVICAL CARCINOMA + 9 || ceRVIC Cervical Careinoma ‘Most common cancer of women in India is Ca Breast, w! the most common gynecological cancer of women in India| Cacervix HPV infection is associated with around 99% of cervical cancer Sereening wooo ‘© Itisdone forasymptomatic women andis done by: ‘+ PapSmear: ‘© Itistaken by Ayre'sspatula, thasa sensitivity of about 47 062%. ‘Screening has brought down the incidence of Ca Cervix by 75-80% & incidence of death by Ca cervix by around 70% ‘Use of eytobrush and cytobroom has increased sensitivity upto 90%, by prevention of drying artefacts prevented. ‘This method washes the smear in fixative and filters out cells. ‘This method is called Liquid Based Cytology. it ensures 290% cellsare utilized for cytology. ‘routine paps smears taken with Ayre spatula, placed on a slide and fixed with 95% ethanol by immediately placing the slide in he Coplinjar. Siteof taking papssmear © Cervical smear is taken from the Transformation zone oF the are between old and new squamo-colurmnar junc ‘The endometrium is composed of columnar cells while vagina & ectocervix is made of squamous cells, the junction of the two is known as the squamocolumnar junction. © TZismore proneto infection by HPV (and thus cancer) as the cellsare continuously dividing her, Etiology and risk factors omi230 ‘¢ HPV infection (Human Papilloma Virus) E& important Information © 16:MC ‘© Elaborate £6, £7 onco-proteins a transformation zone © 18:Mostmalignant HIVI&2 HSV 1&2 Commercial sex worker ‘Women with many partners Partner with STD 1% 36 Multiparous Immuno compromised Low socio Zeonomic status Sok: Early intercourse [<16,yr5] (0 TZ is Located at 1.7 to 2.3 em from the external Os changes location with age group. Early intercourse increases noof years of exposure of TZ to HPV as TZ gets cexternalized earlier Post partum/puerperal time & tmportant information ‘* HPV infection is self limiting (in most cases) in 9-15 months. On Arsen ‘Time todo Pap Smear ‘Any woman>21 yrsof age ‘Any women3 yrs after Ist sexual exposure (in India) From 21 to 29 years, sexually active women should have cytology every 3 years From 30-65 yrs: Co-TEST [PAP + HPV]: if negative then 5 yearly ifonly cytology done, then once in 3 years ifeytology isnegative ‘Afler 65 yrs: No more PAP, if3 cytology are neg TESTarenegative or2Co- Cervical Dyplasia on243 Classification of cervical dysplasia Pym Eiimne nen © CINI -<1/3rd abnormal Low Grade Lesion © CINIL -> 1rd to <2/3rd High Grade Lesion abnormal © CIN Il -> 2/3rd abnormal ‘© CIS - All cells are abnormal Management of C ones Sym toy * CINI> CINII — CaCERVIX, CIN Inota precursor of Ca cevin. In case of CIN I & CIN I, 65-80% will regress spontaneously, however high grade lesions are precursor of CaCervix ‘© CIN [can be followed up with 6 monthly PAP smear along. with antivirals & antibiotics. HPV DNA mustbe done, + IFCIN I persists for > 2 yrs, we must continue surveillance and an ablative or therapeutic procedure must be planned CT+~ Management of CIN II & CIN Il (HSIL/ High Grade Intrepithelial Lesion) (03036 inst step is a colposcopy biopsy as the cervix is normal ooking, so we need touse some agents and magnification EB important Information ‘© First step after CIN III is seen on paps smear is confirmation of diagnosis by COLPOSCOPIC [Vagino Scopic] BIOPSY © Colposcopy biopsy procedure 6 Acetic acid application to coagulate the proteins of the rapidly dividing areas which appear Acctowhite. Biopsy {snow taken fromacetowhiteareas © Schiller iodine [LUGOL IODINE] application stains the slycogen rich areas which appear Mahogany Brown, biopsy is now taken from unstained areas or lugol's negative areas. © Inthe absence ofavailabilty ofcolposcopy VIAA (Visual Inspection under Acetic Acid) or VILI (Visual inspection ‘under ugoT'siodine) may be done + Results of Colposcopic Biopsy fo Invasive cancer Cx: Rxby Radical hysterectomy © Biopsy proven CIN II is treated by LLETZ (Large Loop Excision of Transformation Zone) or LEEP (Loop Electro surgical Excision Procedure) Other Options ‘© Conization: not usually done ‘© Problem with conization: It leads toa short cervix which causes cervical incompetence leading to recurrent abortions. Itmay cause stenosis of cervix which may lead toinfertility ‘©. Canbe done ifcolposcopic Biopsy is inconclusive ‘Surgical Conization (If>35 yrs) Hysterectomy (If> 40 yrs) Cryocauitery Laser ablation: However requires training & experience Symptoms of CA Cervix oosni2 ‘Abnormal bleeding Post coital bleeding, is most common, (Note: in newly married couple post coital bleeding can be due toa post cotal tear most commonly located in Posterior Vaginal fornix) Foul smelling discharge Pyometra: Dirty vaginal discharge Post-menopausal bleeding Cancercachexia ‘Cancer pain Uremic symptoms aoa 7 Mx of Post Coltal Bleeding + Doalocal examination, rule outany lesion, take biopsy ifany obvious growth is seen. If the cervix appears normal, do Colposeopic Biopsy (nota paps smear) Indications for colposcopy biopsy ‘© CINIII cervical intraepithelial neoplasia} ‘© C1Sfeareinomainsitu) ‘# AlS(AdenoCa)/ endocervical curettage ++ Hysterectomy ‘© VINIII: Superficial excision/ laser ablation Staging Clinical Staging Done with P/Speculumexamination /Vaginal examination / Rectal examination [fr parametrium] ‘© Cystoscopy [forbladder] Procto sigmoidoscopy Imaging: USG, CT, MRI, PET CT EB Important Information «Imaging has now been added for clinical staging of ca cervix. PET CT is best amongst imaging, for clinical staging Stage © I-Limited to Cervix © IA-MicroscopicCancer —>A,-<3mmdepth Transverse + @ Removed from SA,-3-5mmdepih J Spread<7mm staging ‘© IB-Clinical/ macroscopic > BL-<2em:can consider fertility preservation > B2-2-4em > B3->4em Stage ‘+ IIA-Upper Vagina lnvolved (IIA, —+<4.em;1LA,—>4em) ‘© IIB--Parametrial involvement but short of pelvic side wall Stage ‘+ IA-Lower 1/3" vaginal involvement ‘© IIIB - Parametrial involvement till the pelvic side wall [Hydronephrosis +] E& Important Information ‘* MC Stage of Ca cervix presentation in India ~» STAGE Ill + Pelvic lymphnodes involv Imaging (PET CT Pelvilymphnodesinvolved Huse # C, -ParaAorticlymphnodesinvolved re guiredBladder & Bowel Involvement © IVB-Distant Metastasis EB important Information © Cervix doesn't drain into inguinal lymph nodes + Cervical cancer involving endometrium does not change staging ‘© Most commonly involved: anterior ip * Downstaging is done for planning nvm when clinical staging is doubtful ian Treatment protocol ‘© Forall stages: Radiotherapy is good © Stagel—I1A,: Radical Hysterectomy ‘© Stage A,:Chemo Radiation Management of Ca cervix TAL obturator) a2 3mm If detected in first Trimester give radiotherapy, fetus abort “If detected in second Trimester, try 0 check for Viability and planaccordingly. Fesiogmteon+~— ? Q. Which ofthe following is the most common cause of death in CarcinomaCervix? JIPMER 2019) A.Uremia B. Metastasis C.Bleeding D.Sepsis Q. Stepsof preparing paps smear are? (aNICET2021) A. Vaginal wall retraction — serape ectocervix — Thin smear—Fix the tide B. Scrape cctocervin —vaginal wal retraction —Thinsmear— Fixthestide . Vaginal wall retraction — scrape ectocervix — Thick smear —Fixtheslide 'D. Vaginal wall Retraction —serape ectocervix —Thin smear Q. Cervical cancer screening is must for? (AlIMS 2020) A, Women> 65 yearsofage B. Woman< 5 yearsofage C. Woman between 21-65 years of age D. Allteenagers Q.Which ofthe following proceduresis done using following (INICET 2021, AIIMS 2019) A. Dilatation and curettage PREVIOUS YEAR QUESTIONS gravida, presenting with post coital ion shows anormal vagina with normal ‘on USG. Next stepin management? (AIMS 2019) ‘A. Pap smear 1, Colposcopy Blopsy . Cryotherapy D. Per vaginal examination QA 25 year woman presents with Wo post coital bleeding. Speculum examination showed following appearance. What isthe diagnosis? (FMGE2020) \.- Cervical fibroid Cacervix . Cervical polyp ). Nabothianeyst ). Which ofthe following types of HPV is least associated with cervical malignancy? (GIPMER2019) A. Type 16 B, Type31 C. Type33, D. Typed B. Cervical biopsy Q. 16 year old girl, not sexually active, came for vaccination C. Papsmear ‘against cervical eancer. Which vaccine tobe given? D. Endometrial aspiration (AMS 2019) A. Gardasil omaha, Q..A30 year old woman who is P2L2 underwent a screening —_B. Rubavac Sosaoeennen PAP smear. The cytology report came out tobe carcinoma in C. Biovac situ. Whatisthenextstepinmanagement? (AIIMS2020) —_D, Tap A. Colposcopy biopsy B. Hysterectomy C. Follow upafter 6 months D. Radiotherapy Wf 40tims CROSS WORD PUZZLES @ € si Crossword Puzzle Across 1. Sereening forcervical cancerisdoneby smear Cy Dow Cy 1, __ bleeding is the most common symptom of cact 2. ‘The bivalent vaccine against ca cervix available in India is u CITT 3. The most common histological type of cervical cancer is __eell CLOTTTT Stet er+ + Post Menopausal Bleeding © Anybleedingafter 1 year of menopause ‘© The two very important causes are Ca cervix and Ca endometrium aoa Difference between symptoms of CA Cervix & CA Endometrium ESE] + Post coital bleeding © Postmenopausal bleeding mo, + regular vaginalbleeding * Post menopausal © Pyometra bleeding * Cacachexiaisnotseen here ‘Irregular vaginal * Obese,DM,HTN Bleeding ‘+ Foulsmell discharge + Pyometra ‘+ Cancercachexia ‘+ Uremia,pelvie pain 10 |! POST MENOPAUSAL BLEEDING yay a2 eoasst G sof Post Menopausal iHeeding EQ tmportant tnformation ‘+ MC cause of PMB in India: Ca cervix (MC presentation of ceacervix, however, is postcoital bleeding) ‘© MCeauseof post menopausal bleeding Cacervix ‘© MCeauseof PMB in world: ca cervix + MC cause of post-menopausal bleeding [western] © Endometrial atrophy (60-80%] HIRT (30%) CAendometriu (10%) Endometrial hyperplasia [10%] Polyps [10%] + Endometrial Atrophy causes senile Endometrtis which may bleed intermittently+ ¥) CROSS WORD PUZZLES @ € li Crossword Puzzle Across 4 WV _bleeding is the most common presentation of o cetvicaleancer ceancer is the most common cause of postmenopausal bleeding in ndia 2 0 3. biopsy is the best test for evaluation of uterus in postmenopausal bleeding Ct is thin endometrial associated with postmenopausal bleeding, EepetsiogmatconVulvarCancer + 2.5% ofall genital tract malignancies of women in India © Age group: presents at approximately 68 yrs © Associated with Field phenomenon: associated with cancers of surroundling structures like Ca vagina, Ca Cetvix (27%) ‘© Association with Syphilis, LGV, Granuloma inguinale, HIV, immunosuppression ‘Types ‘Squamous cll earcinoma 92%): ‘Melanoma [2-4%]:2ndme ‘© Basalcellcarcinoma [2-3%]:3ndmost common Squamous Cell Carcinoma EN nizing Youngerage group © Olderage group ‘= Multifocal lesions © Unifocal lesions + Predisposing factors Predisposing factors © HPVI6, © NoalwHPV © VIN © alw lichen sclerosis © Smoking/ Alcohol © a/w squamous hyperplasia Sites e000 ‘© Labia majora is the most common site (60%), followed by clitoris, whichis the second most common (15%) Presentation © Growth which is exophytic and ulcerative ‘© Pruritis is the most common symptom, associated with Itch- scratch cycle © Cancercachexia © Caneerpsin Diagnoss conan + Wedgebiopsy © Key’sbiopsy ¢ Ifesionis es than 16m don excisional biopy,if21 emdo snincisans biopey VULVAR CARCINOMA Lymphatic Drainage of Vulva ‘+ Lymphatic of vulva cross over the midline ‘+ Pelvie group of lymph nodes isnot involved. If itis involved, itisconsttuted asdistant metastasis ‘+ Most common group involved is Inguino-femoral ‘+ Lymph node involvement is suggestive of poor prognosis, ‘without LN involvement treatment has 90% success rate, Which reduces to<40% iflymph nodes are involved ‘Radical vulvectomy + B/L Inguino-femoral LAD is a very extensive surgery and is associated with 50% wound breakdown and surgery related mortality of 40% ‘+ Sentinel lymphnode biopsy © Sentinel LN for vulva is inguino-femoral. Sentinel lymph node mapping is done by Tecnitium 99/ isosulphane blue dye, which is injected to find out the first draining LN. a biopsy ofthis LN is done, ifinvolved doradical LADalso, else only vulvectomy. (© The major advantage of this technique is that it limits morbidity, by reducing extent of surgery. oniss0 + Limited to Vulva TA 6 Size:<2em, invasion < Imm 1B. gs Stage 1 + Adjacent organ involvement >2em, invasion > Imm © Lower 1/3 rd vagina © Lower 1/3 rd of urethra © Anus Stage IIL ‘© Inguino femoral LN involvement Il Ai © OneLN:>Smm All 6 One or two LN: <5 mm Il Bi TwoLN:>Smm_ Bil « 3 ormore LN: <$ mm. MC « LN involvement © , with extra ‘capsular spread IV Ai © Upper urethra, upper vagina, rectal involvement, growth fixed to pelvic bone i 6 Fixed or ulcerated LN + Distant metastasis Pelvie LN+ «Staging of all cancers in gynae done surgically except Ca cervix whi isdonectinically EB important information ‘© Involvement ofpelvic LN inCa vulvais StagelV ‘Treatmer Stage 1A.» Limited to Vulva © Size <2ems, © Invasion < Imm StagelB « Stagell + Stage II « StagelV « ‘Size > 2.ems Invasion < Imm Any size: Spread to Lower 1/3 urethra, Lower 1/3 vagina, ‘Anus Inguino-Femoral LN positive IVA: Upper Urethra, Upper Vagina, Bladder, Rectum Pelvic side wall IVB: Distant Metastasis Pelvic LN oomat Wide Local excision + Sentinel Lymph Node Biopsy Sentinel LN Biopsy vulvectomy + LN removal Radical Local Excision © Central Lesion: BIL LAD © Lateral Lesion: U/L LAD (2m from midline) Radical Vulvectomy Plus B/L LAD Radiation + Surgery + LAD Radiation + Surgery +LAD Chemotherapy + Bleomycin + SFU Prognosis: Yenr Survial wos © Ca vulva without Inguino femoral LN involvement has 90% 8-year survival while Ca vulva with Inguino femoral LN involvement has 50% 4 Gtoinrecurrence isasso iated with Poor Prognosis, ee a+7 EE &2 CROSS WORD PUZZLES @ Crossword Puzzle Across 1. ____ groupoflymph nodes are not involved in vulvar cancer shaded LoL 2 lymph node biopsy is done for vulvar cancer for H detection of lymph node involvement during surgery Coo Down | 1, __ isthe most common presenting symptom of vulvar LC ‘cancer U 2. ____¢elleareinomais he most common histopathological typeof vulvarcancer OTTsee + 12 || Fisroins Fibroids © tis the most common tumor of women overall, Also known, asLeiomyoma © Iisalso the most common eause of hysterectomy around the world. Etiology and Risk Factors, ‘© Fibroids are seen in as many as 30% of all women. This incidence rises toabout + Awomanis2.Stimesmorelikely to get affected ifone female relative as fibroid, ‘* Associated with chromosomal abnormality in 40% such as, 12-14 Translocation, 12 Trisomy and 7 deletion ‘© Scen in nulliparous women + Associated with an increase in Estrogen & Progesterone 0% in women >$0 years, EB important Information. roids are not seen before puberty or afler the ‘menopause due tothe absence of estrogen. + Obese women + Redmeat eaters + Increase in Growth Factors © Transforming growth Factor B © Platelet derived growth Factor © Epidermal growth Factor ©. Vascular Endothelial Growth Factor (VEGF) Pathology wosar + Fibroids are monoclonal smooth muscle cell tumors, they always start in intramural area of the muscle layer like Whorls of smooth muscle cells surrounded by pseudocapsule. This fibroid present inthe intramural area is treated as the foreign body by the uterus. Uterus responds by contracting to push the fibroid either outwards (subserosal fibroid) or inwards (submucosal fibroid) Figo Classification on06a7 Type 3; 100% intrarmural but touches the cavity. Type 2:>0% intramural and a part in cavity or submucosal Type 1:<50% intramural and rest incavity + Type: Pedunculated orintracavitary or submucosal + Type S:>S0% intramural and res in serosa (subserosal) ‘+ Type 6: <50M% intramural and res in serosa (subserosal) «Type 7: Subserosal Pedunculated Type 8: Parasitic fibroid (Detached fibroid that may be stuck {othe diaphragm or omentum) andl cervical fibroid ‘Type2-5: Part ofthe fibroid is present both in cavity (Type 2) and in the serosa (Type 5) and this is known as Hybrid Fibroid a f Type 3, Type 2 & Type 6 fibroid Type 0 Fibroid rr ‘Type 8 Fibroid aS ra, ne is 3-5 Hybrid Fibroid ae Re ‘ = =eSymptoms emis * Pain © Dysmenorthea: may present with both congestive & spasmodic type ‘© Compression of vital organs such as ureter, causing hydronephrosis © Torsion © Degeneration > Most common degeneration: Hyaline degeneration + Caleific degeneration aka “Womb stone” + Cystic degeneration id degeneration + Necrotic/infections degeneration EB important Information ‘+ MC degeneration in pregnancy: Red degeneration, Itstarts, in" trimesterand the treatment isconservative, + Rarest degeneration: Sarcomatous/malignant degeneration ‘+ Menorthagia (Most common symptom) due to increased endometrial surface area, also due to ineffective contraction, while uterus attempts to expel out the fibroid treating it as a foreign body. There is also increased pelvie congestion as a result of increased vasodilator prostaglandins, causing ‘dysmenorrhea. + Infertility © Uterine factors: Increased uterine contractility resulting in increased expulsion of embryos due to decreased implantation thus causing increased chances of abortion © Tubal factors: due to blocked tube especially at comua and also duetostretched tubes ‘© Bowel & Bladder symptoms © Posterior fibroids ean cause constipation © Increased frequency/hesitancy of urination © Urine retention: Commonly caused by posterior cervical fibroid pushing the uterus forward Diagnosis costa * USG © MRI: thisis the best imaging technique for fibroid, and isalso used for fibroid mapping. Endometrial biopsy must be done to rule out endometrial hyperplasia which occurs dueto increased estrogen. Principles of Treatment 03338 ‘© A small fibroid 10 em) with or without pain or bleeding or sar 48 infertility requires treatment as an asymptomatic large fibroid may undergo torsion, compaction, degeneration, compression of bladder and bowel or it can detach (parasitic fibroid, Medical Management cosn0 «NSAIDS: Reduce pain & bleeding + Tranexamic acid; Reduces bleeding * GnRh analogues (Leuprolin, Goserlin) cause downregulation of pituitary, such that no FSH, LH are made, causing amenorthea, these drugs reduce the size and ‘vascularity of fibroid, therefore are beneficial when given prior to surgery, to minimize blood loss. * GnRh antagonist (cetorelix, ganirelix) these cause direct suppression of pituitary and amenorthea ‘¢ Milepristone: Acts as “Anti-growth” (anti-progestin) agent towards fibroid growth, * Ulipristal: Selective progesterone receptor modulator, it has pure antagonist action on progesterone receptor inuterus, Newer Methods was Uterine artery embolization with PVA particles (Poly Vinyl Alcohol) and preferably>35 years « HiFU: High Frequency Focused USG + MRgFUS: MR guided focused USG * Intrauterine progesterone devices (MIRENA - levenergosterol IUCD) resulting in atrophy of the ‘endometrium ‘+ Myolysis needle: Electrocautery or laser needle is used to cause lysis of muscle, Surgical Management cman ‘+ Hysterectomy for patient who completed family and can be done eitherby open technique or laparoscopy ‘+ Myomectomy is preferred for those planning pregnancy. Open technique may be used for any size, while Laparoscopic myomectomy, which is a more skilled procedure, may be done for smaller fibroids. Criteria for laparoscopic myomectomy include, 3-4 fibroids with size < ‘Sem orone fibroid < 15 emcanbe removed. Its preferred for types 7,6,5-~ Pre-Requisites for Myomectomy © Hb>10gm ‘+ Normal semen analysis Techniques for reducing blood lows Pre-operative GnRhhtherapy Intra-op use of Uterine clamp, Tourniquet and Injection of vasopressin Pitressin) Minimal fimbrial tube handling ‘Minimal incision on the Avoid posterior uterine wall incision —» fixed retroversion Jeading to infertility Avoid opening the cavity Criteria for Hysteroscopic Myomectomy Fibroid inside the uterus with size<3em Type |, Ooreventype2 fibroids canbe removed Distention of uterus using fluids may be required for visualization and manipulation, (© Fluid ean escape into peritoneal cavity or into circulation, Hence Non-etectrolyte media 500- > 1500m1 (alyelne) 750m Electrolyte media (saline) 1000m1 2500m! 4+ Glycine (non-conducting media) can be used with unipolar rent solution (conduct electricity used with bipolar current ol Side effects of fluid overload in operative hysteroscopy 1065s Pulmonary edema Cerebral edema Cardiac failure Hyperammonemia (glycine) Hyponatremia Death yay 49 Myoma screw ‘Myoma clamp+ >} PREVIOUS YEAR QUESTIONS Q. AdS-year-old multipara lady has singe fibroid detected on routine USG. The fibroid iin fet palpable clinically and is found to be 14-16 ems in size. The patient is currently asymptomatic, Whatisthenext ine of management? (AUIMS 2020) A. Notreatmentas asymptomatic B, Myomectomy CC. Hysterectomy D, Medical management ee /6/ sa-~ *) CROSS WORD PUZZLES B Crossword Puzzles a fee Bahu HT | Across 1. Preferred route of removal ofatype8 fibroids by degeneration is the most common type of degeneration seen in fibroids Down 1. ‘The drug injected into the muscle layer during myomectomy toreduce blood lossis 2. Preferred route of removal ofa submucous fibroid, type 0 and, Lisby : 3. Type & fibroids tat detach from the uterus and fall into peritoneal cavity are called-~ 43 | + 13 || HYSTERECTOMY Hysterectomy Classification Total/ Subtotal Abdominal Vaginal Withor without U/L or BA Salpingo Oophorectomy Emergency’ Planned Obstetric indication’ Gynecotogi Laparoseopic/ Open’ robotic ‘oon indications. Indications «Fibroid uterus [40-45% [me] Endometriosis [15-20%] Prolapse [15%] Dysfunctional uterine bleeding Pelvic inflammatory Disease ‘Chronic Pelvic Pain emote Pre-Requisites * Consent ‘+ ruleout pregnancy ‘© Papsmearexamination + arrangeblood ‘© Precautious measures For Venous thromboembotism: leg exercises, DVT pump ‘INDUCTIVE Antibiotics [within | hr of anaesthesia] onasas ‘Complications Intra OP Injuries to Bowel, Bladder & vessels. ‘© Ureter Injury EE important Information in a hysterectomy, me site of injury —» at the site of Crossing the Uterine artery ‘© Overall, me site of injury —> atthe Pelvic Brim Post OPComplic Hemorrhage: (© Immediate hemorshage is easily visualized and there are signs of hemodynamic compromise such as tachycardi ‘hypotension, shock, even in concealed hemorshage such ‘as when bleed is retroperitoneal © Reactionary hemorrhage is seen in first 24 hrs and is due toslippage of ligature © Secondary 86h fer. 24 hrs upill2-3 weeks and is due toinfectidis’™*” yas 52 Wound Infections [4-6 % cases) ‘Cul Vault Cetttitis [vaginal cuff] Urinary Retention may occur due to bladder hypotonia Ureteric Injury: presents with post op Flank pain. The next step is todo USG/CT for diagnosis followed by acystoscopy {olocalise the block. One can attempt ureteric catheterization followed by repa Bladder Injury which may result in a vesico vaginal fistula or auretero vaginal fistula «Prolapse of Fallopian Tube through the vault # Cuff Dehiscence or breakdown of the vault wherein patient must be adviced to not have intercourse for 6 weeks aroscopic Hysterectomy coms LAVH [Laparoscpic Assisted vaginal Hysterectomy]: Some part of surgery is done laparoscopically and some part vaginally. This may include ‘+ Diagnostic laparoscopy +Vaginal Hysterectomy ‘+ Adhesiolysis + Vaginal Hysterectomy + Resectionof Adnexae ‘© Uterine vessels are resected afer bladder mobilization Total Laparoscopic Hysterectomy is done entirely by laparoscopic approach 2 ‘Types of Hysterectomy Key Removed = 1. Subtotal hysterectorny 2 Total hysterectomy 3. Total hysterectomy with bilateral ‘salpingo- oophorectomy 4. Wertheim’s hysterectomy_Atwsterectomy can be performed trough the vagina othe abdomen Preservation of Ovaries woss0 # Ovaries must be conserved at feast till 50 yrs. If Surgical oophorectomy done < $0 yrs, there are more chances of coronary Artery Disease by 65 yrs Hrophylaetle Oophoreetomy wo2s32 «It is to be done for familial cancer syndromes, BRCAI & RCA II mutations as first degree female relatives having CABreast, CA ovary, CA ovary have a 10-50% lifetime Risk ofhaving ovarian cancer.+ ? Q.A woman on second post operative day afer hysterectomy, shows distended abdomen, Which of the following is the ‘most ike electrolyte abnormality that may be found? (EMGE 2020) A. Hyperkalemia B. Hypokalemia . Hypematremia D. Hyponatremia Ee PREVIOUS YEAR QUESTIONS Q..47 year old woman presented with a uterine fibroid with rmenorthagia and is planned for hysterectomy. Anaesthetst classified her as moderate risk in view of a severe heart disease, What procedure should NOT be performed? (FMGE 2020) A. Non decent vaginal hysterectomy B, Total abdominal hysterectomy . Total laparoscople hysterectomy D, Subtotal abdominal hysterectomy&) CROSS WORD PUZZLES i @ Crossword Puzzle Across |. The most common indication of doing a hysterectomy is 2. Post op urinary retention in patient of hysterectomy most commonly oceurs dueto bladder Down 1. Autetetic injury is hysterectomy would cause pain in the 2, Mostdefinitivemanagementofadenomyosisis_____* (ARR Eee em el 55-~ 14 II {14 | GaMproceEnesis Gametogenesis 0030 ‘© SPERMATOGONIA 4754", SPERMATOZOA (4n0) Spermiogenesis + SPE SS” SPERMATOZOA SPERMATID Gyr 8 ‘© Spermiation: Release of sperms from Sertoli cells into Lumen of semeniferous tubules Inthe testes LH acts on Leyaig cells to proluce testosterone. ‘This testosterone along with FSH acts on Sertoli cells lining the semeniferous tubules to produce spermatocytes. Sperm Pathway Testis [250-290 lobules present] 4 ‘Seminiferous Tubules (70% of testes) 4 Rete Testis, t Epididymis [sperms are stored] 412-6 days (attain motility) VAS Deferens [more motile sperms] 4 Fjaculatory Duct 4 Urethra 1 Penis ‘+ Alkaline secretions from seminal vesicles along with acidic, secretions from prostate, enter ejaculatory duct which ultimately makes semen slightly alkaline. This counters vaginal ci Structure of Testis Mtoe aonat fore far nrnace sate icon Structure of Testis, ye ‘© Sertoli cells are tightly packed to keep blood away from lumen of semeniferous tubules, this forms the Blood-Testes- Barrier Spermatogenesis comes 56+ ‘© spermatogonia gives riseto4 sperms ‘© Formation of spermatozoa from spermatid include: © Condensation of nucleus occur © Formationoftil occur © Motility © Acrosomal cap [Golgi apparatus] Oogenesis wou Oogenesis fost termaten * t Piney &o) we ; / © a — 5 = Meiosis tt ® OF . eT 35, ‘© 1 oogonium gives rise to 1 ovum & 3 polar bodies [extra genetic material) ‘© Oogonia starts forming from 8wks of [UL 1 en 4 6-7 million at 20 wks: 1-2 millionat Birth 3-4 lakhat puberty 1 endo yee © Oocyte is resting in prophase I [1" Meiotic division] at the aa ‘© Meiosis | completed at the time of ovulation [puberty] ‘* Secondary oocyte & 1 polar body released (at the time of an © Secondary oocyte is arrested in Metaphase II [meiosis II] till fertilization © Afier fertilization, 2nd polar body & ovum are released Se eee el protectedundergoes atresia ocet 3 polar bodies ‘ontna0 Stages of Development of Oocyte ima tee 26h te ‘waco ‘© After ejaculation, Sperms reach posterior fornix of vagina 2 ‘min ampulla Capacitation of Sperms 2030 + Itisthe potential to fertilize oocyte and takes place in cervical mucus and proximal F. Tube (Differently given in books: single best answer: Fallopian tube) ‘© Steps responsible for capacitation © Influx ofCat ions ‘© Tyrosine phosphorylation ©. Removal finhibitory mediator [cholesterol] ‘Acrosomal cap One sperm gets insi [Golgi apparatus} L | Acrosome breakdown Cortical granules released in Release acrosin to fertilize perivitelline space of oocyte oocyte (Penetrate zona 1 pellucida of oocyte) This reaction makes the 1 ‘oocyte impermeable again ‘Acrosin (Hyaluronidase) will soften the zona pellucida (Acrosome reaction)zou sun ermay $a wi PREVIOUS YEAR QUE: ° Q. Testosterone isseereted by? A. Leydigeett B Sertolicetts C. theca uteincells D, Gramtosa cell (EMGE 2019) 18 58 “oye STIONS @ Q. Sequential order ofsperm formationis? —__(ATIMS2019) ‘A. Spermatocyte, spermatid spermatogonia, spermatozoa B, Spermatid, spermatocyte, spermatogonia, spermatozoa . Spermatid, spermatogonia, spermatocyte, spermatozoa D. Spermatogonia, spermatocyte, spermatid, spermatozoa CLzs sunziMay ed 68% CROSS WORD PUZZLES B Crossword Puzzle ITT) TTT} TTT) 7 9 59 Across 1, Formation of spermatozoa from spermatids is known as 2. Potential to fertilize an oocyte by a sperm is acquired in the fallopian ubeandisknownas Down 1. First polarbody isreleased atthe time of. 2. Second polar body isreleasedat the time of. Dtun oun er may : + \ + Mullerian Defects ‘© 0.5% of all women have Mullerian defects. These are often associated with renal defects in 15-30% Presentation ‘© Infertility ‘© Recurrent pregnancy loss ‘* Abnormal menstrual cycles ‘© Amenorthea Formation of Internal Genitalia oon ‘© Female internal genitalia are derived from Mullerian/ Para Mesonephiric Duct * Male internal geni Mesonephric/Gartner Duct are derived from Wolffian/ 1. Mullerian Duct Derivatives © Uterus “oneno0 Structures Uterus Cervix Fallopian tubes Upper 4/5" of vagina Ovaries Lower 1/5* of vagina avKe Derived from Mullerian/Paramesonephric ducts Genital ridge Urogenital sinus = Cervix ‘+ Fallopian tubes = 4/5" vagina (© Lower 1/Sth derived from Urogenital Sinus (or split as 223" and 1/3") © Ovaries are derived from Genital Ridge + Renal pelvisandureter Wolffian Duct Derivatives Epididymis Vas deferens ‘Seminal vesicles Renal pelvisandureter ooaias ccc op (EE / 15 |! MULLERIAN ABNORMALITIES Female Genital Tract Development 0s + The obliterated mesonephric duct fuses on the upper lateral ‘vaginal wall and gives remnants above & on sides of ovary oophoron and Paraoophoron NA _ Mulierian duct Mesonephvic duct Epoophoron Paraoophoron| Urogenital sinus ‘+ Gartner Duct and eyst: Wolffian duct obliterated at lower end is called Gariners duct and a collection in upper lateral vaginal wall is a Gartner cyst. A Gartner duct cyst is mostly asymptomatic, simple cyst and is treatedby simple excision # Bartholin's gland and cyst: It occurs in Barton's gland! ‘greater vestibular gland, © The cyst is located at anterior 2/3% and posterior /3* Junetionof vulva, © Bartholin’s gland functions to keep vagina moist during intercourse © epithelium of gland is columnar, epithelium of duct stratified squamous and epithelium of terminal part of duct: transitional © Bartholin’s abscess occurs as a result of a blocked duct causing mixed infections of aerobic and anaerobic (MC Staph aureus.) it is very painful and is treated by Marsupilization under GA wherein we incise and evert edges to cause exteiorization of cavity o keep itdrained, © Preferably do not excise Bartholins gland/eyst 6 7 60 eeTa Mutlerian Duct Anomalies 1830 Imperforate Hymen ‘© These result from arrested development in the form of fusion ‘iol a mullerian anomaly as all Mullerian structures are defects: which can be vertical or lateral, or can be due to ‘normal, rather itis cannulation defect of vaginal opening. failure of resorption of septum © Presentation: (0 Hidden menstruation occurs called as eryptomenorthea. 1, Vertical Fusion Defects const ‘This may present with Hematometra oF blood in uterus ih hematocolpos - blood in vagina, due to regular menstruation and thus there is also cyclical pain every month, corresponding to the period while there is no external bleeding and patient presents with primary samenorthea eee ‘0 Can rarely present with (ifiAati? FetentiGh: Hematocolpos ‘compresses urethra against pubic symphysis ‘© Classical presentation: young girl with primary amenorthea withacute retention of urine P ‘© Due to outflow obstruction, there is retrograde menstruation leading to increased risk of endometriosis, Lateral Fusion Defects cow 1. Didelphys + Usually associated with good reproductive outcome + Requiresno treatment # Inpregnancy however there i increased incidence of breech presentation and preterm labour + Increased incidence of retrograde menstruation leading to increased risk of Endometriosis Presentation. Cryptomenorrhea cossso * This implies hidden menstruation, which means ‘menstruation is occuring but menstrual blood is not coming. ‘ut due to outflow obstruction in conditions like: © Transverse vaginal septum © Vaginal atresia, Double vagina Vagina tube © Cervical vaginal atresia, © Imperforate hymen 2. Unicornuate uterus ‘This type as the worst pregnancy outcome andis associated with abortions and Preterm labour + Non communicating rudimentary hom leads to retrograde ‘menstruation causing endometriosis . imperforate Hymen Unicorrwate OC —X—X—X—X_,,,£,.3. Septate uterus © Theentire uterine cavity fuses while justa septum remains ‘* This type requires surgery more commonly than bicornuate asitisassociated with Infertility and recurrent abortions © Inpregnancy itis associated with transverse lie Septate 4, Bicornuate uterus ‘+ Theuterine cavity has two horns ‘+ This is associated with recurrent abortions, which forms an ‘+ Inpregmancy it is associated with Breech transverse lie and Preterm labour Bicomuate Septate Vs Bicornuate Uterus 0302s & Important Information Septate terusis the most common Mullerian anomaly ‘+ On Hysterosalpingography, both septate & bicornuate| uterus looks similar * USGand MRI to aid in differentiation a # Angle <75 deg: Acute» Angle > 105 dé ‘© Fundus flat '* Fundus concave ** Distance b/w hors <4em _» Distance b/w horns > 4em. ‘¢ Endometrium to fundus >» Endometrium to fundus < Smm Smm 1 @ 62 Oe Important Information Best way to distinguish b/w septate & bicornuate uterus, ‘* Diagnostic Laparoscopy + Hysteroscopy # MRI [Best imaging method] + Treatment 6 Septate uterus» Hysteroscopic septal resection © Bicornuate -» Unification surgery [Strassman's or Jone's Metroplasty) Image Discussion ons4s HSG of unicomuste weres Impertorate Hyman- = 68%) ystoroscoie view of pate eras Eshere Classification was + European society for Human Reproduction & Embryology Class UoINormal uterus Class U1/Dysmorphic uterus a. T-shaped b.Infantile _c. Others lass U2/Septate uterus Class U3/Bicorporeal uterus ome rubato a. Partial W « W re cavity a. With b. Without a. With cavity Vz ¥ a ~ . Rudimentary THM rudimentary Bl b. Without Class US/Unclassified cases23:2 sun zi may - + \ ) ? Q.17yrold git came with complain of primary amenorrhea & cyclical abdominal pain, On a per abdominal examination & midline abdominal swelling seen with some side to side mobility, Per rectal examination reveals bulging mass in vagina, Diagnosislikely is? A. Imperforate hymen B, Transverse vaginal septum C. Complete Mullerainagenesis D. Vaginal agenesis (NEET 2020) Q. 16-year-old girl presents with cyclical abdominal pain, She ‘has not menstruated so far. What is your diagnosis? (FMGE2020) A. Bartholincyst B. Sub-urethral polyp C. Sebaceous cyst D. imperforate hymen (/ PREVIOUS YEAR QUESTIONS Q. Which of the following is the last common in didelphys uterus? (NEET2021) A. Preterm labour DB, Transverselle ©. Endometriosi D. Abortions Q.24 yrold with married life o yrs visits infertility clinic with vo recurrent abortion. On further workup, she found to be having septate uterus. Which surgery has better reproductive ‘outcome? (NEET 2020) ‘A. Straussmann metroplasty B, Tomkins metroplasty C. Transcervical hysteroscopic resection of septum D, Jonesmetroplasty Q. 25-year-old woman presents with midline septum in the ‘uterus, Which ofthe following is the management? (NEET2021) A. laparoscopic metroplasty B. Hysteroscopie septoplasty ‘Galllgrinemetroplasty * OeEaparoscopic septoplasty ‘Q. Unicomuate wterusean be diagnosed by? A. xray pelvisand laparoscopy B, Xraypelvisand HSG .Falloposcopy and HSG D. Laparoscopy and HSG (INICET 2021) Q. 25-year-old female with primary infertility came to hospital \with USG finding of uterine anomaly. Which ofthe following isused for confirming diagnosis? (NEET 2021) A. TVS B. Hysteroscopy +laparoscopy C. Laparoscopy D.HSG Of 64eoue ae + ‘CROSS WORD PUZZLES @ Crossword Puzzle Across 1. ‘The mostcommon type of uterine anomaly is_ 2. Septal resection i best performed by Down 1. Treatment of imperforate hymen isby 3. Wolffianductooblteratedat lowerendiscalled duct F I eh ee 65oe al +16 Management of Abnormal Uterine Bleeding, Non-Hormonal Management ‘© NSAIDS: includes drugs like ibuprofen, mefenamic acid ‘which inhibit vasodilator prostaglandins, redicing pain and bleeding in uterine blood vessels, These now form the first line drugs formanagementof AUB, ‘Tranexemic Acid: it inhibits conversion of plasminogen to plasmin andisthe first line drug formanagement of AUB, Bleeding, ‘e030 mest Fibrin Plug, Plasminogen [RANEXAMIC ACID] ABNORMAL UTERINE BLEEDING (ITS A DOWNPOUR})- = 68% am Understand with example Patient presents with bleeding on 30 Aug with LMP of 28 July. Cou have been an ectopic pregnancy, which occurred asfollows #28" July: Last menstrual Peri 4 11" August: Ovulated (Untercourse) 4 Embryo implanted on fallopian tube on 17* August t 28* August missed her period 4 30" August bleeding occurred Fibrinolysis ¢—Plasmin Rebleeding Hormonal Management Progesterone: Sbilizesthe Endometrium Estrogen: Forms new endometrial glands: better for acute severe menorthagia, Note: Estrogen withdrawal is heavier than Progesterone Withdrawal Combined Oral Contraceptive Pills Danazol/Androgens: Leads to Endometrial atrophy GnRH Analogues: down regulation of Pituitary IUCD Levonorgestrol [MIRENA] nant Surgical Management coo26 ‘+ Therapeutic Curettage/ Hemostatic Curettage/ Dilatation ‘& Curettage [DNC] BIL Uterine Artery Embolization by PVA [poly vinyl Alcohol] Particles Endometrial ablative procedures: preferred in older women, causes amenorthea. These are alternative to hysterectomy and canbe doneasOPD procedure (© Trans cervical Resection of Endometrium (TCRE]: Rollerball © Micro Wave Method © Thermal Method: 87°C x8 min EB important information ‘* MC Fate of ectopic pregnancy —> Vascular inefficiency ‘embryo degeneration drop in progesterone shedding of decidua (cause of vaginal bleeding in ectopic) ‘Other outcomes ofectopic pregnancy © Tubalabortion © Rupture: Much rare PALM-COEIN classification olyp A: Adenomyosis L:Leiomyoma ‘M: Malignancy C: Coagulation defect 0: Ovulatory dysfunction E: Endometrial hyperplasia trogenic N:Notyetclassified. DUB [Dysfunctional Uterine Bleeding} oo33.s8 Conditions 03700 © Anovulatory DUB © Seen inextremes of age groups such as Pubertal Girls and Peri menopausal women, where in cycles are mostly * Hysterectomy anovulatory,hence iregular © Metropathia Hacmorthagica: Bleeding oecurs every 2.5 ~ Causes oot 3 months with heavy bleeding, usually in women > 45 Firststepisto rule out pregnancy related causes years. Dilatation and curettage is both diagnostic and therapeutic a23:12 Sun 21 May ‘©. Most common type of DUB is anovulatory. In 65% with anovulatory DUB, the Endometrium is Hyperplastic © Ovulatory DUB onan (© Decreased Corpus Luteal Function 1 Irregularripening 1 Premenstrual spotting/ Bleeding, sores 67 = bE% © Increased Corpus Luteum Function (Persistence of CLof Previous cycle) t Iregularshedding J Post menstrual spotting/ Bleeding23:12 Sun 21May i) ? Q Which of the following is the first Tine management for Abnormal uterine bleeding in adolescent age group? (IPMER 2019) A. Oral contraceptives B. Tranevamic acid C. Progesterone D, Endometrial Biopsy Q.35-year-old female attends gynae OPD with excessive bleeding since 6 months, not controlled with non-hormonal drugs. USG and clinical examination reveals no abnormality. Nextstepis? (NEET2020) ‘A. Endometrial ablation B, Endometrial sampling C. Hysterectomy D. Hormonal therapy PREVIOUS YEAR QUESTIONS or Oem Q.45-year-old female with 3 months menorthagia. USG showing 2 em submucosal fibroid, First line of management is (NEET2019) A. OCPfor3 months B, Progesterone for3 months C. Endometrial sampling D. Hysterectomy 723:12 Sun 21 May oe = 68% &) CROSS WORD PUZZLES @ Crossword Puzzle Across 1. Irregular shedding of endometrium presenting as LITT ‘postmenstrual spotting is seen with, ofcorpus luteum 2. Most common cause of irregular bleeding in pubertal girls is TT ELTITT Down 1. Androgen that causes endometrial atrophy and is used in AUBis. 2. Androgen that causes endometrial atrophy and is used in AUBis, 3, First cause to be ruled out in any woman of reproductive age presenting with heavy vaginal bleedingis, ay OT OTE a] 69