Summary Gynaecology Disease

,Chapter 1 – Basic Principles of Gynecology

Female Reproductive Anatomy

 Uterus
o Origin: Fusion of two Mullerian/PMN Ducts (NB: Wolffian in men requires androgens)
o Major structures:
 Fundus  Above fallopian tube entrance
 Cornu  Fallopian tube entrance
 Corpus  Body
 Isthmus  Joints uterus + cervix
 Cervix  Exit into vaginal canal
o Layers:
 Endometrium  Highly vascular for implantation
 Myometrium  For uterine contractions
 Serosa  Smooth surface for easy sliding of abdominal contents
o Ligaments:
 Cardinal  At base of broad ligament, contains uterine artery + vein
 Uterosacral  Originates at lower end of uterus, attaches to sacrum
 Round  Originates at uterine horn (near FT), moves inferior, circles back into deep ing
ring, continues toward labia majora where its fibres spread
 Broad  Folds widely over all gyne organs and acts as mesentery
o Position:
 Anteverted (50%)
 Mid-position
 Retroverted
 Oviducts/Fallopian Tubes (uterus  ovaries)
o Segments:
 Interstitium (at cornu)
 Isthmus  Proximal tube (near uterus)
 Ampulla  Middle tube
 Infundibulum  Distal tube (near ovaries)
o Function:
 Facilitate migration of sperm proximal uterus-tube
 Facilitate migration of zygote distally  tube-uterus
o Attachments: Medial – uterus, Lateral – pelvic side wall, Inferiorly – broad
ligament
o Blood supply: Implicated in ectopic
 Ascending uterine artery
 Ovarian artery
 Ovaries
o Function:
 Contain oocytes within follicles (follicle  graffian follicle [maturest + release oocyte] 
corpus luteum  corpus albicans [degenerating form])
 Produce hormones (estrogen from FOLLICLE,
progesterone from CORPUS LUTEUM)
o Attachments: Ligaments suspend ovaries
 Ovarian ligament (to uterine fundus)
 Suspensory ligament (to pelvic side wall)
 Mesovarium (to broad ligament)

,Gynecological Procedures  Hx, Abdo Ex, Vaginal Ex + Swab + Smear, Urine dip + preg, Blood, TV-USS,
Hystersalpingogram + Hysteroscopy, Laproscopy

 USS
o Trans-vaginal (preferred)
 Indication: Lower abdominal investigation (Pro: High resolution; Con: Invasive)
o Trans-abdominal (ONLY for after 12wk pregnant i.e. 2nd trim onwards, otherwise TV)
 Indication: Abdominal investigation (Pro: Non-invasive; Con: ↓resolution)

 Liquid Based Cytology (LBC)
o Indication: Prevent cervical cancer in >25
o Method: Samples taken and placed in formalin
 Transformation zone brushing
 Endocervix brushing
 Endocervix = Columnar, Ectocervix = Squamous
 @ Puberty the vagina + cervix grows causing ENDOcervix to grow OUT into the
vagina, and these cells which grow out are exposed to acidity of vagina and
subsequently undergo squamous metaplasia
 At menopause the vagina shrinks and these cells re-enter the endocervix and
then undergo COLUMNAR METAPLASIA as they are not exposed to the acidic
vaginal environment
o LBC vs Pap:
 Advantages of LBC:
 Single layer of cells
 Air-drying eliminated
 HPV test on residual cells in solution (if necessary)
 Problems with Pap Smear:
 80% cells discarded with brush therefore could be non-representative sample
 Obscuring elements/artifacts may be present (e.g. from air drying)

 Colposcopy
o Indication: Abnormal LBC considered to be moderate-to-high risk
o Method: Binocular view of cervix to localise abnormal epithelium to biopsy + histological
assessment (rather than cytological as in LBC)  ACETIC ACID or LUGOL’S IODINE
o Interpretation: Need to see T-Zone in full as this is where most cancers occur
 Satisfactory: T-Zone does NOT enter endocervix (i.e. columnar epithelium present)
 Unsatisfactory: Some or all of T-Zone enters endocervix

 Loop excision – remove tissue for treatment (treat cervical dyskaryosis)
o Method: Cut out abnormal tissue identified w/ colposcopy (using electric loop wire)
o Adv: Removal of abnormal/cancerous tissue; Sample can be sent for histological diagnosis
o Follow-up: LBC

 Cone Biopsy – remove tissue for diagnosis/treatment (diagnose/treat cervical dyskaryosis grade)
o Method: Surgical procedure under LA/GA where cone shaped specimen obtained w/ scalpel
 Wide-shallow cone
 Narrow-deep cone
o Complications:
 Cervical insufficiency  Large sample
 Cervical stenosis  Inappropriate healing

, Cone used when LBC demonstrates abnormal cells within endocervix, but colposcopy does not find these
cells (i.e. does not stain with acetic acid); must cone out the endocervix to determine location of these
abnormal/pathological cells – otherwise if cells are visible loop is always done

 Cryotherapy
o Method: Freeze tissue w/ liquid nitrogen or CO2  destroys abnormal tissue
 Watery vaginal tissue released 2-3wk later
o Follow-up: LBC

 Hysteroscopy
o Method: Often done under GA!
 Scope inserted through previously dilated cervix to see endometrial cavity
 Dextran fluid infused through scope to distend uterine cavity for visualisation
 Side ports utilised for biopsies or resections (e.g. of submucous fibroids, polyps)
o Indications:
 Endometrial polyps
 Asherman’s syndrome
 Evacuation of RPOC
 Investigation for PMB + Biopsy

 Hysterosalpingogram (HSG)
o Method: Cannula inserted through endocervix, radio-opaque dye injected, x-rays taken
o Indications: Determine tubal anatomy
 Tubal blockage (e.g. PID adhesions – dye NORMALLY spills into abdomen, but won’t)
 Rupture (e.g. ectopic – spillage occurring not at right location i.e. in middle)
 Infertility work-up

 Laparoscopy
o Method: Open abdomen for diagnosis or therapy
 Diagnose + Treat: Chronic pelvic pain (e.g. endometriosis, tubal adhesions [PID])
 Treat: Ectopic resection

 Vulvar biopsy
o Indication: Any unknown vulvar lesion
o Method: Punch biopsy

 Endometrial Biopsy
o Indication: Post-menopausal bleeding (most common)
o Method: Pipelle biopsy (blind, done in clinic), hysteroscopy + biopsy

 Dilation + Curettage (D+C)
o Method:
 Dilate cervix using metal dilators or prostaglandins
 Insert curette to scrape/suction endometrium and remove lots of tissue for pathology

 Hysterectomy
o Indication: Diagnosis + Therapy
o Method: Remove uterus and cervix (total hysterectomy) abdominally or vaginally
 Radical hysterectomy  Uterus, cervix and broad ligament (if concerned re: regional
lymph node mets)