Cervical effacement & dilatation

Intractable intracoital pain, syncope and collapse during sexual intercourse

Vaginal hysterectomy first steps

Hand drawn diagram

Vaginal hysterectomy steps

Non PID causes of Ectopic pregnancy

Many patients ask me whenever I met up a client with a diagnosis of Ectopic pregnancy, what is the cause and why did this happen?
My usual answer use to be asymptomatic PID.
But my observations are that, eventhough PID may be the common cause of Ectopic pregnancy, but many took it by surprise. So that made me to keep a close eye on Non PID causes of Ectopic pregnancy.
If the Ectopic pregnancy is on the right side, then chronic appendicitis with adhesions should be thought of.
If the Ectopic pregnancy is on the left or right, then active endometriosis should be thought of.

Vaginal hysterectomy -- Tips and tricks

The most important step in vaginal hysterectomy is safe dissection of the bladder and pouch of Douglas.

1. The initial incision on cervix begins circumferentially at the reflection of the vaginal mucosa onto the cervix.
2. The position and depth of this circumferential incision is very important because they determine access to appropriate planes that will lead to opening of Utero vescial fold of peritoneum and Pouch of Douglas peritoneum.
3. Anteriorly appropriate location of the incision is at the site of the bladder reflection. The lower end of bladder reflection on the prolapsed cervix is indicated by a CREASE or SULCUS formed in the vaginal mucosa when the cervix is pushed slightly inward or back into the vagina. This can also be achieved by moving the cervix in and out of the vagina and at the same time try and identify the sulcus or the groove between the vagina and bladder reflection bulge. If this location is still not identified, one should make the incision low rather than high to avoid the potential bladder injury. Downward traction on the cervix and counter-traction by the retractors help to determine the appropriate depth of the incision. This incision should be continued down to the cervical stroma. Once the appropriate depth of the incision is reached, the vaginal tissue will fall away from the underlying cervical tissue because there is distinct plane between these two tissues.

Ovarian reserve assessment

Ovarian reserve

1. Pattern of menstrual cycle assessment (regular /irregular)
2. Antral follicle count
3. Serum FSH (menstrual Day 2-5)
4. AMH – Produced by the ovary and does not fluctuate. At menopause can become undetectable.

Fundamental basis : women with good ovarian reserve have sufficient production of ovarian hormones from small follicles early in the menstrual cycle to maintain FSH at a low level. In contrast, women with a reduced pool of follicles and oocytes have insufficient production of ovarian hormones to provide normal inhibition of pituitary secretion of FSH, so FSH rises early in the cycle. The constant relationship between the number of follicles and circulating antimullerian hormone exists only after the age of 25 years. The recognition

that antim€ullerian hormone (AMH) is produced by preantral and small antral follicles with serum concentrations reflecting both the number of these small growing follicles and the primordial pool (1–3) now allows the opportunity for the study of aspects of these

earlier stages and factors influencing development, as well as the investigation of their relationship with fertility.

Perform basal cycle day 3 FSH

A normal result is not useful in predicting fertility, but a highly abnormal result ( FSH >20 mIU/mL) suggests that pregnancy will not occur with treatment involving the woman's own oocytes. A day 3 FSH concentration and a value less than 10 mIU/mL suggestive of adequate ovarian reserve, and levels of 10 to 15 mIU/ml borderline

Perform cycle day3 Estradiol :  a cycle day 3 estradiol level, although there are conflicting data as to whether it is predictive of ovarian reserve and the response to ovarian stimulation (a value <80 pg/mL suggestive of adequate ovarian reserve

Antral follicle count (AFC) : Number of antral follicles (defined as follicles measuring 2 to 10 mm in diameter). On transvaginal ultrasound, a low AFC ranging from 4 to 10 antral follicles between days two and four of a regular menstrual cycle suggests poor ovarian reserve. Although AFC is a good predictor of ovarian reserve and response, it is less predictive of oocyte quality, the ability to conceive with IVF.

Anti-müllerian hormone (AMH) — Anti-müllerian hormone (AMH) is expressed by the small (<8 mm) preantral and early antral follicles. The AMH level reflects the size of the primordial follicle pool. In adult women, AMH levels gradually decline as the primordial follicle pool declines with age. AMH is undetectable at menopause.

serum AMH levels correlate strongly to antral follicle count and are more accurate than age and other conventional serum markers (FSH, E2, inhibin B) in predicting preovulatory oocyte supply in response to ovulation induction. Relative to the  conventional ovarian serum makers, AMH appears to vary significantly less throughout the menstrual cycle.

The circulating AMH also changes across the lifespan, with initial increases during childhood, then a distinct fluctuation around the time of puberty, followed by a secondary increase during the next decade to a maximum at around age 25 years. After the age 25,  AMH undergoes a relentless decline to values below the levels of assay sensitivity between ages 40 and 45 years. This consistent decline in AMH from age 25 years is now firmly established.

After 25 years there is an uninterrupted and strong positive correlation  betweenAMHand decreasing follicular recruitment as the pool of nongrowing follicles declines and eventually becomes exhausted at the menopause. It is this decline in follicular recruitment, albeit associated with

a maximal proportion of the available follicles achieving maturation, that results in a smaller number of follicles achieving the later stages of follicular development, which underlies the decline in AMH and explains the close relationship between AMH and egg yields seen in the IVF setting.

Antimullerian hormone is produced by growing follicles up to approximately 8 mm in diameter. Under normal circumstances much of the increase in circulating AMH arises after puberty.

PCOS and AMH : Women having PCO differ from those with normal ovaries by having slightly higher mean serum androgens or AMH levels. PCOs in normal women are not a morphological variant of normal ovaries but rather represent a functional entity that may be considered as a silent form of PCOS for which serum AMH could be the best marker. In conclusion, for the definition of PCOS, serum AMH appears as a sensitive and specific parameter that would probably be easier to reproduce from one to another centre than the follicle count, as the latter is highly dependent on the evolving quality of the machines and/or the operator skill.  The threshold for AMH proposed  to suggest the presence of Polycystic ovaries is 35 pmol/l (or 5 ng/ml).

Ulipristal acetate and Uterine fibroids

Ulipristal marketed as, a progesterone receptor antagonist (PRA). It acts by depriving uterine fibroids of growth stimulation due to progesterone.

The treatment consists of one tablet of 5 mg to be taken orally once daily for up to 3 months, and it should be started during the first week of a menstrual cycle. There are no data available on treatment with a duration longer than 3 months or on repeat courses of treatment. Therefore, treatment duration should not exceed 3 months.

The benefits with Esmya are its ability to reduce fibroid-related bleeding, anaemia and fibroid size. Ulispristal showed better efficacy compared to placebo (a dummy) at reducing bleeding and anaemia, but only moderated efficacy with regards to fibroid volume reduction.

The most common side effects are amenorrhea, endometrial thickening and hot flush.

Chronic Vaginal Discharge -- Management considerations

Vaginal discharge that is difficult to treat: Management consdierations

 Physiological discharge

It is normal and healthy for women of reproductive age to have some degree of vaginal

discharge. The quantity and type of cervical mucus changes during the menstrual cycle as a

result of hormonal fluctuations. Prior to ovulation, estrogen levels increase, altering cervical

mucus from non-fertile (thick and sticky) to fertile (clearer, wetter, stretchy and slippery). After

ovulation, estrogen levels fall and progesterone levels increase; cervical mucus becomes

thick, sticky and hostile to sperm. The vagina is colonised with commensal bacteria (normal vaginal flora). Rising estrogen levels at puberty lead to colonisation with lactobacilli which metabolise glycogen in the vaginal epithelium to produce lactic acid. Thus the vaginal environment is acidic and normally has a pH≤4.5. Other commensal bacteria include anaerobes, diphtheroids, coagulase-negative staphylococci and α-hα-haemolytic streptococci. Some commensal organisms can cause a

change in discharge if they ‘overgrow’. These include Candida albicans, Staphylococcus

aureus and Group B streptococcus.

Commonest Causes of Altered Vaginal Discharge in Women of Reproductive Age?

There are three common causes of altered vaginal discharge in women of reproductive age:

1.      Infective (non-sexually transmitted)

a.      Bacterial vaginosis

b.       Candida

2.      Infective (sexually transmitted)

a.      Chlamydia trachomatis

b.      Neisseria gonorrhoeae

c.      Trichomonas vaginalis

d.      Herpes simplex virus

3.Non-infective

• Cervical polyps and ectropion
• Genital tract malignancy
• Allergic reactions.

4. Non-sexually transmitted infections

Bacterial vaginosis

BV is the commonest cause of abnormal vaginal discharge in women of reproductive age.2

Reported prevalence varies and may be influenced by behavioural and/or

sociodemographic factors.3–5 It can occur and remit spontaneously and is characterised by

an overgrowth of mixed anaerobic organisms that replace normal lactobacilli, leading to an

increase in vaginal pH (>4.5).  Gardnerella vaginalis is commonly found in wommen with BV but the presence of Gardnerella alone is insufficient to constitute a diagnosis of BV because it is a commensal organism in 30–40% of asymptomatic women. Other organisms associated with BV include Prevotella species, Mycoplasma hominis and Mobiluncus species.

 BV is considered to be ‘sexually associated’ rather than truly ‘sexually transmitted’. There is some evidence that consistent condom use may help to reduce BV prevalence,7,14–16 although one study

suggested this may only be in women who were BV-negative at baseline.15

Vulvovaginal candidiasis (VVC)

VVC is common among women of reproductive age. It is caused by overgrowth of yeasts;

C. albicans, in 70–90% of cases, with non-albicans species such as C. glabrata in the

remainder. The presence of candida in the vulvovaginal area does not necessarily require

treatment, unless symptomatic, as between 10% and 20% of women will have vulvovaginal

colonisation.

Candidiasis occurs most commonly when the vagina is exposed to estrogen, therefore it is more common during the reproductive years and during pregnancy. An episode of VVC is

often precipitated by use of antibiotics.Immunocompromised women20,21and women with

diabetes are predisposed to candidiasis. VVC does not appear to be associated with

tampons, sanitary towels or panty liners when they are used appropriately.24

As Vulvovaginal candida can be found in non-sexually active individuals, it is not classed as an STI.

3.2 Sexually transmitted infections

Chlamydia trachomatis

Chlamydia trachomatis, the most common bacterial STI in the UK, is usually asymptomatic in

women (approximately 70%). However, women may present with vaginal discharge due to

cervicitis, abnormal bleeding (postcoital or intermenstrual) due to cervicitis or endometritis,

lower abdominal pain, dyspareunia or dysuria.

Neisseria gonorrhoeae

Gonorrhoea is an STI caused by Neisseria gonorrhoeae. Up to 50% of women will be

asymptomatic. Common symptoms may include increased or altered vaginal discharge and

lower abdominal pain. It can also be a rare cause of heavy menstrual, postcoital or

intermenstrual bleeding due to cervicitis or endometritis.25

Trichomonas vaginalis

TV is a flagellated protozoan that causes vaginitis. Women with TV commonly complain of

vaginal discharge and dysuria (due to urethral infection).

TV is always sexually transmitted and is a rarer condition than BV or VVC.

Herpes simplex

Women with cervicitis due to herpes simplex virus infection may occasionally present with

vaginal discharge.

 Other causes of vaginal discharge

Other causes of vaginal discharge include foreign bodies (e.g. retained tampons or

condoms), cervical ectopy or polyps, genital tract malignancy, fistulae and allergic reactions.

Exclusion of infective and other causes can help confirm that a vaginal discharge is

physiological.

There is some association between methods of contraception and vaginal discharge. Women complaining of vaginal discharge should be asked about current and past contraception.

Douching is the process of intravaginal cleaning with a liquid solution. Some women use the

practice of douching as part of their general hygiene or cultural practice. Data suggest that

douching changes vaginal flora and may predispose women to BV, although not all

studies have reported this finding. Overall, the evidence suggests that douching should be

discouraged as there are no proven health benefits.

.

Women with cervical ectropion may complain of increased physiological discharge. Ectopy is a

normal finding in women of reproductive age but treatments such as acidic gel, silver nitrate

cauterisation, laser or cold coagulation are occasionally used in a gynaecology setting for

symptomatic relief of vaginal discharge or postcoital bleeding. There is a lack of robust

evidence for the effectiveness of these treatments in reducing vaginal discharge. Cervical

pathology must be excluded prior to treatment, and women’s should be informed of potential

risks of treatment and the fact that discharge symptoms may initially worsen before there is

any improvement. evidence as to whether the use of hormonal contraception increases the risk of VVC.

 One study has suggested that the progestogen-only injectable may reduce a woman’s susceptibility

to recurrent VVC, possibly because of its anovulatory effect and relative hypoestrogenism.

Women using Combined hormonal contraception who have recurrent VVC may wish to consider alternative contraception but there is a lack of evidence to show whether there is any benefit from switching to a lower dose combined preparation or a progestogen-only method, other than the injectable.

The Cu-IUD has been identified as a possible risk factor for acute or recurrent VVC, but there

is no consistent evidence of an association. There is some evidence to demonstrate that

yeasts adhere to IUDs and the combined vaginal ring (CVR). Combined vaginal ring users have been

reported as experiencing more vaginal irritation and discharge compared with combined pill

users. However, a study of the effect of CVR use on vaginal flora showed no increase in

numbers of inflammatory cells or pathogenic bacteria.

Although cervical cytology slides from levonorgestrel-releasing intrauterine system (LNG-IUS)

users have shown increased presence of candida with time from insertion, rates of

symptomatic infection did not change significantly.

Bacterial vaginosis

Oral combined contraception and condoms have been associated with a reduced risk of

BV, whilst BV is more common in users of the Cu-IUD. The association between BV and

use of the LNG-IUS is unclear. The progestogen-only implant and injectable may be

associated with a decreased risk of BV.Women using CHC who experience recurrent VVC may wish to consider switching to an alternative method of contraception. Women with a Cu-IUD who experience recurrent BV may wish to consider switching to an alternative method of contraception.

8 Personal Hygiene and Vaginal Discharge

Personal hygiene measures can be advised for women who are prone to vaginal discharge

and/or pruritis (e.g. regular changing of sanitary protection, avoidance of douching and of

potentially irritant chemicals in toiletries, antiseptics, wipes, so-called ‘feminine hygiene’

products, washing powders, fabric dyes, and so on). RCOG guidance contains patient

information on general care of the vulval skin, including use of emollients and soap substitutes

which prevent dryness and loss of the skin’s natural barrier functions.Women experiencing vaginal discharge can be advised to avoid douching and local irritants as part of general management.

Health professionals should be aware that the most common causes of altered vaginal

discharge are physiological, BV and candida, but STIs and non-infective causes must be

considered. Table 1 Summary of signs and symptoms of infective causes of vaginal discharge

Sign/symptom Bacterial vaginosis Candida Trichomoniasis

Discharge Thin Thick white Scanty to profuse

Odour Offensive/fishy Non-offensive Offensive

Itch None Vulval itch Vulval itch

Other possible symptoms Soreness Dysuria

Superficial dyspareunia Lower abdominal pain

Dysuria

Visible signs Discharge coating the Normal findings Frothy yellow discharge

vagina and vestibule or Vulvitis

Vaginitis

No vulval inflammation Vulval erythema Cervicitis

Oedema ‘Strawberry cervix’ (ectocervix

Fissuring sometimes resembles the surface of

Satellite lesions a strawberry)

Point-of-care test: vaginal pH >4.5 ≤4.5 >4.5

Abnormal Uterine Bleeding

Unscheduled  vaginal bleeding—bleeding that occurs outside  the normal menstrual period or the regular withdrawal bleed associated with the combined oral contraceptive pill—is a common reason for women of  reproductive age to attend specialist care.It is also referred to as intermenstrual bleeding

No touch technique of Hysteroscopy

First do vaginoscopy.

Use betadine iodine to clean in the beginning

Close the vaginal opening with the other hand so that you create a water seal.

Ask the Anaesthesist for a head down position, so that water is held in the vagina longer.

In the beginning one can go up to the posterior fornix and then withdraw slightly to see a smooth surface of posterior wall of cervix.

In a parous woman, external os appears like a fish mouth.

If Betadine used to cleanse the vagina, usually some betadine will stain the cervical glands and this will be very obvious and will help to enter the cervical os.

There is a small possibility that the internal os may appear similar to one tubal ostia, so one may infact say this as a unicornuate uterus. Before concluding this one can spend little bit more time and  hydro-distend the uterine cavity and a gentle nudge will negotiate the hysteroscope into the uterus.


Video

Video 2

Uterine polyps :Management considerations

 In both pre and postmenopausal women, endometrial polyps lose their apoptotic regulation and overexpress estrogen and progesterone receptors, thus avoiding the usual control mechanisms.
 Endometrial polyps are present in approximately one-quarter of symptomatic pre and postmenopausal women.
Half of the premenopausal women present with menorrhagia; other presentations include postmenopausal bleeding, prolapse through the cervical ostium, abnormal vaginal discharge and breakthrough bleeding during hormonal therapy.

 Increased incidence of endometrial polyps in women on hormone replacement therapy (HRT) and tamoxifen (8-36%), which acts as a selective receptor modulator and estrogen agonist on the endometrium. The influence on endometrial polyps seems to be through estrogen, on which endometrial polyps depend. However, endometrial polyp formation appears to be related to the type and dosage of the estrogen and progestogen in HRT; in particular, a progestogen with high anti-estrogenic activity may have an important role in preventing the development of endometrial polyps.

Diabetes, hypertension and obesity are independent risk factors for the development of endometrial polyps. Predictors of malignancy or premalignancy in endometrial polyps : a size of >10 mm postmenopausal status abnormal uterine bleeding a polyp diameter A polyp of >18 mm in asymptomatic women increased the risk of malignancy there is a higher incidence of concurrent endometrial hyperplasia with endometrial polyps,13, 14 especially in women on hormone replacement.

 Hysteroscopic markers for malignant endometrial polyps include surface irregularities such as necrosis, vascular irregularities and whitish thickened areas, which are indications for obtaining a histological diagnosis.

 Fertility and endometrial polyps Large or multiple endometrial polyps can contribute to infertility and increase the risk of miscarriage.Hysteroscopic polypectomy will improve the rate of spontaneous conception regardless of size or number of polyps, which may be due to the normalisation of endometrial implantation fayctors

Treatment of endometrial polyps: The risk of malignant transformation of endometrial polyps is low, but they should be removed when detected, as excision allows for both histological diagnosis and effective treatment of abnormal uterine bleeding patterns and excessive menstrual loss; in addition, endometrial polyps in postmenopausal women are more likely to be malignant when symptomatic

What to do with asymptomatic and incidental finding of endometrial polyps?

Asymptomatic and incidental endometrial polyps should be treatedause for endometrial polyps   In both pre and postmenopausal women, endometrial polyps lose their apoptotic regulation and overexpress estrogen and progesterone receptors, thus avoiding the usual control mechanisms.


  Endometrial polyps are present in approximately one-quarter of symptomatic pre and postmenopausal women.   Half of the premenopausal women  present with menorrhagia; other presentations include postmenopausal bleeding, prolapse through the cervical ostium, abnormal vaginal discharge and breakthrough bleeding during hormonal therapy.   Increased incidence of endometrial polyps in women on hormone replacement therapy (HRT) and tamoxifen (8-36%), which acts as a selective receptor modulator and estrogen agonist on the endometrium.   The influence on endometrial polyps seems to be through estrogen, on which endometrial polyps depend. However, endometrial polyp formation appears to be related to the type and dosage of the estrogen and progestogen in HRT; in particular, a progestogen with high anti-estrogenic activity may have an important role in preventing the development of endometrial polyps.   Diabetes, hypertension and obesity were independent risk factors for the development of endometrial polyps.   Predictors of malignancy or premalignancy in endometrial polyps :   a size of >10 mm postmenopausal status abnormal uterine bleeding a polyp diameter A  polyp of >18 mm in asymptomatic women increased the risk of malignancy there is a higher incidence of concurrent endometrial hyperplasia with endometrial polyps,13, 14 especially in women on hormone replacement.   Hysteroscopic markers for malignant endometrial polyps include surface irregularities such as necrosis, vascular irregularities and whitish thickened areas, which are indications for obtaining a histological diagnosis.   Fertility and endometrial polyps   Large or multiple endometrial polyps can contribute to infertility and increase the risk of miscarriage.Hysteroscopic polypectomy will improve  the rate of spontaneous conception regardless of size or number of polyps, which may be due to the normalisation of endometrial implantation fayctors   Treatment of endometrial polyps:   The risk of malignant transformation of endometrial polyps is low, but they should be removed when detected, as excision allows for both histological diagnosis and effective treatment of abnormal uterine bleeding patterns and excessive menstrual loss; in addition, endometrial polyps in postmenopausal women are more likely to be malignant when symptomatic   What to do with asymptomatic and incidental finding of endometrial polyps?   Asymptomatic and incidental endometrial polyps should be treated. Algorithm for management of endometrial polyps.                     Whether to avulse blindly or resect hysteroscopically?   There is good direct and circumstantial evidence that hysteroscopic resection of endometrial polyps under vision is safe, simple and superior to blind techniques:   There is a possibility that malignant cells can be missed if one uses blind technique of avulsion Hysteroscopic resection avoids excessive cervical dilatation, which is when uterine perforation and creation of a false passage usually occur With the blind avulsion technique, recurrence rate of 15% and none with resection technique. Polyps>2 cm require piecemeal removal, a longer operating time and multiple instrument passes through the cervix. In those cases removal under general Anaesthesia is advisable,  but small-diameter hysteroscopic morcellators can also be considered.. Algorithm for management of endometrial polyps. Whether to avulse blindly or resect hysteroscopically? There is good direct and circumstantial evidence that hysteroscopic resection of endometrial polyps under vision is safe, simple and superior to blind techniques: There is a possibility that malignant cells can be missed if one uses blind technique of avulsion Hysteroscopic resection avoids excessive cervical dilatation, which is when uterine perforation and creation of a false passage usually occur With the blind avulsion technique, recurrence rate of 15% and none with resection technique. Polyps>2 cm require piecemeal removal, a longer operating time and multiple instrument passes through the cervix. In those cases removal under general Anaesthesia is advisable, but small-diameter hysteroscopic morcellators can also be considered.