SECTION 1: GYNECOLOGICAL HISTORY TAKING, EXAMINATION AND INVESTIGATIONS

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Thomasina Williamson
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1 Contents SECTION 1: GYNECOLOGICAL HISTORY TAKING, EXAMINATION AND INVESTIGATIONS Chapter 1: Writing a Gynecology Case 1 Structure of History Writing 1 Detailed Parameters Under the Broad Headings 1 Discussion of the Points Essential for Proper Case Taking and Writing 5 Investigations Supplied or Required 42 Summary of the Case 42 Example of Writing a Summary (Sample) 42 Provisional Diagnosis 43 Differential Diagnosis 43 Chapter 2: Investigative Procedures in Gynecology and Imaging in Gynecology 44 Investigations 44 Imaging in Gynecology 49 Role of Ultrasonography in Gynecology 49 Role According to Symptomatology 50 Procedures Under Ultrasonography Guidance 50 Computed Tomography Scan 53 Magnetic Resonance Imaging in Gynecology 53 Positron Emission Tomography 53 X-ray Its Role in Gynecology 54 Pipelle Biopsy 54 SECTION 2: CLINICAL CASES Chapter 3: A Case of Lump Abdomen (Ovarian Tumor) 55 History Taking 55 Physical Examination 56 Gynecological Examination 56 Summary of the Case (Sample) 57 Investigations Supplied or Required 58 Provisional Diagnosis 58 Differential Diagnosis 58 Management of a Case of Benign Ovarian Cyst and Tumor 78 Ovarian Cancer 81

2 xvi Bedside Clinics in Gynecology Recurrent Ovarian Cancer 90 Borderline Ovarian Tumor (Synonym: Low Malignant Potential Tumor) 91 Germ Cell Tumors 92 Sex Cord Stromal Tumors 97 Chemotherapeutic Agents Used in Ovarian Malignancy 102 Fallopian Tube Cancer 103 Chapter 4: A Case of Fibroid Uterus 105 History Taking 105 Physical Examination 106 Systemic Examination 107 Gynecological Examination 107 Summary of the Case (Sample) 108 Investigations Supplied or Required 108 Provisional Diagnosis 108 Differential Diagnosis 109 Wandering and Parasitic Fibroid 118 Broad Ligament Fibroids 118 Microscopical Features 119 Degenerations of Uterine Fibroid 120 Management of Fibroid Uterus 122 Cervical Fibroid 133 Broad Ligament Cysts and Tumors 137 Uterine Polyp 139 Chapter 5: A Case of Abnormal Uterine Bleeding (Dysfunctional Uterine Bleeding) 142 History Taking 142 Physical Examination 143 Gynecological Examination 144 Summary of the Case 144 Dysfunctional Uterine Bleeding 150 PALM-COEIN Classification for Causes of AUB by FIGO How to Approach a Case of AUB? 158 Management of AUB 161 Endometrial Hyperplasia 172 Chapter 6: A Case of Endometrial Carcinoma (Including Postmenopausal Bleeding) and Uterine Sarcoma 176 History Taking 176 Physical Examination 177 Gynecological Examination 178 Investigations Supplied or Required 179 Summary of the Case (Sample) 179 Provisional Diagnosis 179 Differential Diagnosis 179 History 181 Examination 182

3 Contents xvii Investigations 182 Staging 188 Management 190 Pyometra 193 Postmenopausal Bleeding 194 Sarcoma of the Uterus 196 Chapter 7: A Case of Choriocarcinoma 198 History Taking 198 Physical Examination 200 Gynecological Examination 200 Summary of the Case (Sample) 201 Investigations Supplied or Required 201 Provisional Diagnosis 201 Differential Diagnosis 201 Classification 202 Diagnosis 204 Staging/Scoring 207 Treatment 207 Chapter 8: A Case of Carcinoma Cervix and Premalignant Lesions of Cervix 209 History Taking 209 Physical Examination 210 Differential Diagnosis 213 Diagnosis 214 Staging 216 Pathology 220 Lymphatic Drainage and Spread 222 Treatment 223 Prognosis and Survival 227 Premalignant Lesions of Cervix 228 Cervical Carcinogenesis 233 Colposcopy 239 Management of Premalignant Lesions of Cervix 243 Protocol of Management 246 Human Papilloma Virus Vaccine 246 Chapter 9: A Case of Carcinoma Vulva, Preinvasive Lesion of Vulva and Vaginal Cancer 248 History Taking 248 Physical Examination 249 Systemic Examination 250 Gynecological Examination 250 Summary of the Case (Sample) 251 Investigations Supplied or Required 251 Provisional Diagnosis 251

4 xviii Bedside Clinics in Gynecology Differential Diagnosis 251 Diagnosis of Vulvar Carcinoma 252 Management of Vulvar Cancer 259 Prognosis of Vulvar Cancer 264 Preinvasive Lesions of Vulva 265 Vulvar Intraepithelial Disease 268 Vaginal Cancer 271 Chapter 10: Pelvic Organ Prolapse (Genital Prolapse) 274 Genital Prolapse 274 History Taking 275 Physical Examination 276 Gynecological Examination 277 Summary of the Case (Sample) 279 Investigations Supplied or Required 279 Provisional Diagnosis 279 Differential Diagnosis 279 Supports of Uterus and Vagina 283 Etiologies of Pelvic Organ Prolapse 286 Anatomical Classification of Pelvic Organ Prolapse 287 Grading Systems of Pelvic Organ Prolapse 289 POP-Q 290 Surgicopathological Changes in Pelvic Organ Prolapse 294 Diagnosis of Pelvic Organ Prolapse 294 Management of Pelvic Organ Prolapse 302 Conservative Management 303 Vaginal Pessary 303 Surgery in Pelvic Organ Prolapse 305 Which Treatment When? 307 Operative Details of Pelvic Organ Prolapse 308 Anterior Colporrhaphy 308 Posterior Colpoperineorrhaphy 313 Fothergill s Operation (Manchester Operation) 317 Ward Mayo s Operation (Vaginal Hysterectomy with Pelvic Floor Repair) 321 Le Fort s Operation (Colpocleisis) 327 Purandare s Abdominal Sling Operation (1956) 327 Shirodkar s Abdominal Sling Operation (1960) 327 Khanna s Abdominal Sling Operation 327 Abdominal Sacrocolpopexy, Sacrocolpohysteropexy 328 Sacrospinous Ligament Fixation 330 McCall Culdoplasty 332 Prevention of Pelvic Organ Prolapse 333 Pregnancy with Pelvic Organ Prolapse 333 Chapter 11: A Case of Infertility 335 History Taking 335 Physical Examination 337

5 Contents xix Gynecological Examination 338 Investigations Supplied or Required 338 Summary of the Case (Sample) 339 Provisional Diagnosis 339 Differential Diagnosis 339 Approach a Case of Infertility 341 Diagnosis or Detection of Ovulation 343 Ovarian Reserve 350 Tubal Patency Test 353 Anovulation 357 Cervical Factor Causing Infertility 358 History and Examination of Male Partner 360 Semen Analysis 362 Hormones Profile in Assessment of Male Infertility 366 Reactive Oxygen Species 368 Management of Female Infertility 369 Management of Ovulatory Dysfunction 370 Ovarian Hyperstimulation Syndrome 375 Surgical Management in Anovulation/Oligoovulation 377 Tubal Factor Infertility 378 In Vitro Fertilization and Embryo Transfer 382 Surrogacy (Gestational Carrier Surrogacy) 388 Management of Male Factor Infertility 389 Intrauterine Insemination 389 Intracytoplasmic Sperm Injection 394 Treatment of Erectile and Ejaculatory Dysfunction 398 Azoospermia 399 Klinefelter Syndrome (47,XXY) 400 Vaginismus 401 Chapter 12: A Case of Polycystic Ovarian Syndrome and Hirsutism 402 History Taking 402 Physical Examination 403 Gynecological Examination 404 Investigations Supplied or Required 404 Summary of the Case (Sample) 405 Management Outline in a Case of PCOS 412 Outline the Management of Adolescent PCOS 412 Management of PCOS in Elderly 413 Pathophysiology of PCOS 414 Metabolic Syndrome 415 Hirsutism 418 Exogenous Pharmacological Agents Causing Hirsutism 421 Medications Causing Hirsutism and Hypertrichosis 421 Idiopathic Hirsutism 422 Androgens with Sources 422 Evaluation of Hirsutism 423

6 xx Bedside Clinics in Gynecology Ferriman-Gallwey Scoring 424 Laboratory Investigations 425 Further Investigations 425 Imaging 425 Summary of Recommendation for Evaluation of Hirsutism 426 Management of Hirsutism 426 Summary of Recommendation of Treatment 430 Physiology of Hair 431 Differential Diagnosis of PCOS 433 Chapter 13: A Case of Primary Amenorrhea and Disorder of Sexual Development 434 Introduction 434 Writing a Case of Primary Amenorrhea 438 Diagnostic Approach in Primary Amenorrhea 448 Tanner Staging of Breast Development 449 Tanner Staging of Pubic Hair Development 450 Discussion of Individual Cases 450 Delayed Puberty 450 Turner Syndrome 451 MRKH Syndrome 453 Androgen Insensitivity Syndrome 456 Swyer Syndrome 459 Congenital Adrenal Hyperplasia (Adrenogenital Syndrome) 461 Disorder of Sexual Development (Intersex) 463 Sexual Differentiation 464 Classifications of DSD 464 Diagnosis 468 Management of DSD 470 Chapter 14: A Case of Secondary Amenorrhea 474 Introduction 474 History Taking 475 Physical Examination 476 Gynecological Examination 476 Investigations Supplied or Required 476 Summary of the Case (Sample) 477 Provisional Diagnosis 477 Differential Diagnosis 477 Approach to Diagnose a Case of Secondary Amenorrhea 481 Hyperprolactinemia and Amenorrhea 482 Thyroid Disorder and Amenorrhea 485 Polycystic Ovarian Syndrome 485 Obesity and Menstrual Abnormality 486 Asherman Syndrome (Uterine Synechiae) 486 Premature Ovarian Failure (Also Called Primary Ovarian Insufficiency) 486 Late-Onset Congenital Adrenal Hyperplasia 487

7 Contents xxi Functional Hypothalamic Amenorrhea 488 Amenorrhea in Androgen-Producing Tumor 488 Chapter 15: A Case of Precocious Puberty Pediatrics and Adolescent Gynecological Problems 490 A Case of Precocious Puberty 490 History Taking 490 General Survey 491 Systemic Examination 491 Gynecological Examination 491 Investigations Supplied or Required 492 Summary of the Case 492 Provisional Diagnosis 492 Differential Diagnosis 492 Diagnosis of Precocious Puberty 496 Treatment 497 Onset of Puberty 498 Pediatric and Adolescent Gynecology 499 Common Gynecological Problems in Pediatric and Adolescent Group 499 Labial Adhesion 500 Vulvovaginitis 500 Vaginal Bleeding in Prepubertal Girl 501 Ovarian Neoplasms in Adolescents and Children 502 Endometriosis in Adolescent 503 Disorder of Sexual Differentiation 503 Adolescent Polycystic Ovary Syndrome 504 Preventive Gynecology in Pediatrics and Adolescent 505 Chapter 16: A Case of Endometriosis and Adenomyosis 506 History Taking 506 Physical Examination 508 Gynecological Examination 508 Investigations Supplied or Required 509 Summary of the Case (Sample) 509 Provisional Diagnosis 509 Differential Diagnosis 510 Sites 511 Classification 513 Clinical Features 515 Ovarian Endometrium 519 Treatment 520 Approach to Endometriosis 525 Endometriosis and Infertility 526 Adenomyosis 528 Diagnosis 529 Managment 532

8 xxii Bedside Clinics in Gynecology Chapter 17: A Case of Vesicovaginal Fistula and Urinary Incontinence 533 History Taking 533 Physical Examination 534 Gynecological Examination 534 Summary of the Case (Sample) 535 Investigations Supplied or Required 536 Provisional Diagnosis 536 Differential Diagnosis 536 Summary of Diagnosis 539 Management of VVF 542 Ureterovaginal Fistula 548 Anatomy and Course of Ureter 548 Ureteric Injury 550 Management 551 Urinary Incontinence 553 Mechanism of Micturition 554 Pathophysiology of Stress Incontinence 555 Diagnosis of Stress Incontinence 556 Management of Stress Incontinence 559 Chapter 18: A Case of Old Complete Perineal Tear 570 History Taking 570 Physical Examination 571 Gynecological Examination 572 Summary of the Case (Sample) 573 Complete Perineal Tear 573 Types 573 Diagnosis 574 Causes and Prevention 576 Treatment 577 Rectovaginal Fistula 582 Causes of RVF 582 Diagnosis of RVF 584 Management of RVF 584 SECTION 3: REPRODUCTIVE PHYSIOLOGY Chapter 19: Physiology of Ovulation, Menstruation, Spermatogenesis and Implantation 586 Physiology of Ovulation 586 Physiology of Menstruation 592 Normal Composition of Semen 596 Structure of Spermatozoa 597 Physiology of Spermatogenesis 599 Fertilization and Blastocyst Formation 603

9 Contents xxiii Implantation 605 Placentation 609 Chapter 20: Menopause and its Management 610 Menopause Definition 610 STRAW Classification 611 Physiology of Menopause 612 Apex of Menopause 614 Evaluation of Menopause 617 Management of Menopause 618 Current Recommendation of Hormone Therapy 621 Chapter 21: Development of Genital Organs and Müllerian Anomaly 622 Development of Male Genital System 622 Development of Female Genital System 622 Müllerian Anomaly Classification 624 New Classification System 625 Prevalence of Müllerian Anomalies 626 Effects of Müllerian Anomalies 626 Diagnosis of Müllerian Anomaly 627 Unicornuate Uterus 627 Uterine Didelphys 629 Bicornuate Uterus 631 Septate Uterus 633 Arcuate Uterus 635 Transverse Vaginal Septum 635 Longitudinal Vaginal Septum 637 Cervical Agenesis 637 Vaginal Agenesis 638 Mayer-Rokitansky-Küster-Hauser Syndrome 638 Surgical Methods in Müllerian Anomaly 640 SECTION 4: BIRTH CONTROL AND POPULATION DEMOGRAPHY Chapter 22: Family Planning and Contraception 644 Common Viva Questions on Contraceptives 644 History of Birth Control 647 Classification of Birth Control Method 648 Pearl Index 649 Failure Rates of Individual Methods 650 Hormonal Methods of Contraception 651 Combined Oral Contraceptives Pills 652 Progesterone-only Pill 663 Centchroman 665 Injectable Contraceptives 666 Subdermal Implants 669

10 xxiv Bedside Clinics in Gynecology Combined Hormonal Transdermal Patches 671 Transvaginal Combined Hormonal Ring (Nuvaring) 671 Progesterone Vaginal Ring 671 Emergency Contraceptives 672 Intrauterine Contraceptive Devices 674 Postpartum IUCD 687 Frameless IUCD 690 Long-acting Reversible Contraceptive 691 Barrier Methods of Contraceptive 692 Male Condom 692 Female Condom 694 Fertility Awareness-based Methods 696 Permanent Contraception 699 Tubal Ligation 699 Laparoscopic Sterilization 705 Nonscalpel Vasectomy 713 Male Contraceptives 717 Antifertility Vaccine 720 Chapter 23: Demography and Family Planning Programs in India Present Scenario 721 Magnitude of the Problem 721 Fertility Indicators 721 Contraceptive Prevalence in India Modern Contraceptive Usages 722 Unmet Need in India Magnitude 723 Spacing Method Need of the Day in India 723 Milestones of Family Planning Program in India 723 Contraceptives Available at Present Through Government of India 724 SECTION 5: INSTRUMENTS AND OPERATION Chapter 24: Identify the Instruments Know Your Instruments 725 Instruments at a Glance 725 Sponge Holding Forceps (Also Called Swab Holding or Ring Forceps) 734 Ovum Forceps 734 Female Metallic Catheter 735 Foley s Catheter 736 Sims Double-bladed Posterior Vaginal Speculum 737 Single-bladed (Universal) Posterior Vaginal Speculum 738 Cusco s Bivalve Self-retaining Speculum 738 Auvard s Self-retaining Speculum 739 Anterior Vaginal Wall Retractor 739 Allis Tissue Forceps 739 Multiple Teeth Vulsellum 740

11 Contents xxv Single Tooth Vulsellum 740 Uterine Sound 740 Cervical Dilators 742 Uterine Curette 743 Uterine Dressing Forceps 743 Lane s Tissue Forceps 744 Hysterectomy Clamp (Straight/Curve) 744 Babcock s Tissue Forceps 744 Myoma Screw 745 Bonney s Myomectomy Clamp 745 Landon s Bladder Retractor 745 Aneurysm Needle with Thread 746 Hodge Smith Pessary 746 Ring Pessary 747 Hysterosalpingography Cannula 747 Ayre s Spatula 748 Cytobrush 748 Chapter 25: Operative Gynecology 749 Hysterectomy 749 Dilatation and Curettage 757 Surgery for Chronic Uterine Inversion 762 List of Other Gynecological Surgeries with Page Numbers 763 Preoperative Assessment of a Patient Undergoing Gynecological Surgery 764 Chapter 26: Endoscopic Surgery: Laparoscopic/Hysteroscopic/Robotic Surgery 765 Laparoscopic Surgery 765 Hysteroscope 774 Robotic Surgery 777 Chapter 27: Routine Postoperative Management in a Gynecological Surgery 778 SECTION 6: SPECIMEN Chapter 28: Specimens 784 Uterine Fibroid Cervical Fibroid Pseudo Broad Ligament Fibroid 788 Ovarian Cyst Dermoid Cyst 790 Malignant Ovarian Tumor 790 Krukenberg Tumor 791 Specimens of Cancer Cervix (Radical Hysterectomy) Endometrial Cancer 793 Vulvar Cancer 793

12 xxvi Bedside Clinics in Gynecology SECTION 7: IMAGING Chapter 29: Hysterosalpingography Plates, X-ray Plates with IUCD and Other Imaging 794 Hysterosalpingography X-ray Plate with Intrauterine Contraceptive Device USG Plates with IUCD Other Imaging 803 SECTION 8: MISCELLANEOUS Chapter 30: Research Questions for Students 804 Chapter 31: Examination of a Rape Victim: Procedures and Protocols 814 Rape and Function of a Doctor 814 Purpose of Medical Examination in Female Rape Victim 814 Prerequisites for Examination of Victim 815 Examination and Note of Findings 816 Health Advice for Rape Victim 817 Some Practical Problems 817 Chapter 32: Swellings of Vulva: Bartholin s Cyst and Abscess 819 Classifications of Swellings of Vulva 819 Bartholin s Cyst and Abscess 821 Excision of Bartholin Cyst 822 Marsupialization 824 Bartholin Abscess 825 Chapter 33: Pelvic Inflammatory Disease, Sexually Transmitted Infections and Female Genital Tuberculosis 826 Pelvic Inflammatory Disease 826 Sexually Transmitted Infections 832 Female Genital Tuberculosis 840 Index 845

Question Bank III - BHMS

Question Bank III - BHMS Sub:- Ob/Gy -Paper-II 1. Give the definition of Puberty. 2. Enumerate five important physical changes evident during puberty. 3. Write down the vaginal changes during puberty.