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Diseases of the Female Reproductive System. Part MINISTRY OF EDUCATION AND SCIENCE OF UKRAINE Tutorial preraped by: State Higher Educational Institution “UZHGOROD NATIONAL UNIVERSITY” N.Y. Lemish – assistant professor of the department of obstetrics and MEDICAL FACULTY gynecology of medical faculty, Uzhgorod national university DEPARTMENT OF OBSTETRICS AND GYNECOLOGY O.O. Korchynska – doctor of medical sciences, professor of department of obstetrics and gynecology, medical faculty, Uzhgorod national university Authors: As.Prof. Lemish N.Y. Ph.D, prof. Korchynska O.O. Edited by: chief of the department of obstetrics and gynecology state higher educational institution “Uzhgorod national university”, doctor of medical sciences, prof. Malyar V.A. Diseases of the female reproductive system. Reviewers: Part II. Y.Y. Bobik – doctor of medical sciences, professor, the head of department of maternal and neonatal care, faculty of postgraduate study and Tutorial for practical lessons of gynecology for students of the 5th course of preuniversity preparation, State higher educational institution “Uzhgorod national university” medical faculty S.O.Herzanych – doctor of medical sciences, professor of department of obstetrics and gynecology, medical faculty, State higher educational institution “Uzhgorod national university” Approved by the Academic Council of the medical faculty, protocol № 1 from « 25 » september 2015 year. Uzhgorod - 2015 © Lemish N.Y., Korchynska O.O. 1 2 ABBREVIATIONS MC – Menstrual cycle COC – combined oral contraceptives CONTENTS IUD – intrauterine device PV – per vaginum Abbreviations IUI – intrauterine insemination 1. Background and premalignant diseases of female genitalia ................................. 6 AIH – artificial insemination husband 2. Malignant diseases of female genitalia ............................................................... 15 AID – artificial insemination donor 3. Pelvic inflammatory diseases .............................................................................. 41 IVF – in vitro fertilization 4. Acute abdomen in gynecology ............................................................................ 56 ICSI – intracytoplasmatic sperm injection 5. Infertility .............................................................................................................. 68 GIFT – gamete intrafallopian transfer 6. Family planning ................................................................................................... 73 ZIFT – zygote intrafallopian transfer STDs – sexually transmitted diseases LAM – lactational amenorrhea method 3 4 PREFACE 1. Background and premalignant diseases of female genitalia According to the resolution of the World Assembly of health care of UN Background and premalignant diseases of vulva from 1995 the preservation of the reproductive health is established on the global Non-neoplastic epithelial disorders of vulvar skin: level by the WHO as a priority branch 1. Lichen sclerosus According to WHO statistics for 2012 cervical cancer contributed to almost 2. Squamous cell hyperplasia 8% of all cancers (excluding non-melanoma skin cancer). This tutorial 3. Other dermatoses Etiology: acknowledges the students with prophylactic measures, early diagnosis of 1. Traumatic factors background, premalignant and malignant diseases of female genitalia. 2. Autoimmune (thyroid disease,pernicious anemia, diabetes) The knowledgement of the symptoms, diagnosis, differential diagnosis of 3. Allergic (cosmetics, synthetic underwear, fragnances) basic diseases and acute states in gynecology is compulsory for every doctor 4. Irritation nowadays. 5. Nutricional (deficiency of folic acid, vit. B12, riboflavin) 6. Infection( fungus) 7. Methabolic 8. Systemic (heparic, haematological) 9. Drugs (β blockers, angiotensin converting enzyme inhibitors) Squamous cell hyperplasia of the vulva Squamous cell hyperplasia (SCH) is an abnormal growth of the skin of the vulva. It usually occurs before the menopause. The signs and symptoms. The main symptom is itchiness around the vulva, which may be pink or red, or have raised white patches. SCH usually affects the hood of the clitoris, the outer lips (labia majora), the groove between the outer and inner lips (labia minora) and the back of the entrance to the vagina. The affected skin may also extend to the thighs. Scratching causes thick, hardened patches on the vulva to appear. Diagnosis. A biopsy (under local anaesthetic) is often performed to diagnose this problem as many things can trigger itching on the vulva. Treatment. The symptoms generally stop with the correct treatment. The most common treatment is with powerful steroid creams. These should be used sparingly twice a day for several weeks. In over 90% of cases, steroid creams, usually combined with a moisturiser, relieve the symptoms of itching. Once the symptoms have been relieved, a simple moisturiser (called an emollient) can maintain remission. A small amount of women find benefit from a simple moisturiser. An alternative treatment is with a drug called tacrolimus, however this has side effects such as burning and soreness and requires careful surveillance and as yet remains very much a second line treatment. Patients can help themselves by avoiding potential irritants such as perfumed soap, biological detergents, fabric conditioners, talcum powder etc. Shaving might also lead to irritation. 5 6 Lichen sclerosus advised if a person has any narrowing of the vaginal opening. An operation to Lichen sclerosus is an uncommon skin condition. It used to be called lichen widen the opening of the vagina is occasionally needed in women with severe sclerosus et atrophicus, but it is often now just called lichen sclerosus. It most lichen sclerosus which has caused narrowing of the vaginal entrance commonly affects the genital skin (vulva) of women. Less commonly it affects Other dermatoses: Vulvar Crohn’s disease, psoriasis etc. other areas of the skin. It can occur at any age but most commonly occurs Condiloma accuminata is caused by HPV infection. Almost 50 types of following menopause menopause. HPV is known nowadays. Mostly on the external genitalia they are caused by the 6 th and 11 types. Types 16, 18, 31, 33 along with the development of the condiloma can cause cell atypia, dysplasia cancinoma in situ and invasive cancer. Premalignant lesions. They include the vulvar intraepithelial neoplasia. VIN I – corresponds to mild cellulal atypia. The lesion is limited to the deeper one-third of the epithelium VIN-II – corresponds to moderate cellular atypia. The lesion is limited upto middle-third of the epithelium VIN-III – corresponds to severe cellular atypia and carcinoma in situ. The abnormal cells involve whole thickness of the epithelium. There is no stromal invasion. Diagnosis. Clinics (pruritus vulvae, lump or bleeding from a vulvar ulcer, symptomless), local examination a lesion in vulva with white, grey, pink or dull red colour, raised from the surface and often multifocal), cytologic screening (not Fig.1.1 Lichen sclerosus of vulva useful and not reliable), biopsy. Treatment. Generally conservative management (since only 10 pecrent Distribution. The entire vulva is involved, lesion encircles the vestibule, it proceed into cancer). Medical (fluorinated steroid ointment), local excision, laser involves clitoris, labia minora, inner aspects of labia major and the skin around the therapy, cryo surgery and LEEP, simple vulvectomy. anus. It is usually bilateral and bisymmetrical. It does not involve the vestibule or extent into the vagina or anal calan. Background and premalignant diseases of the cervix Etiology. The cause is possibly an autoimmune disease. This is when the Papanicolau classification of the smears: body's immune system attacks a part of the body. This causes inflammation and Grade I – normal cells damage to the affected part of the body. In people with lichen sclerosus the genital Grade II- slightly abnormal, suggestive of inflammatory change, repeat smear area of skin may be attacked by some parts of the immune system which then after treating the infection causes inflammation. However, this has not been proved and it is not known what Grade III- a more serious type of abnormality, usually indicative of need for triggers lichen sclerosus to develop. biopsy Clinics. Dyspareunia, sleepleness, dysuria, the skin looks white and is thin. Grade IV – distinctly abnormal, possibly malignant and definitely requiring Difficulty with mictirition and even retention of urine may happen, narrowing of biopsy vaginal introitus, subepithelial haemorrhages due to scratching. Grade V – malignant cells seen Diagnosis. Appearance, clinics, biopsy (hyperkeratosis, paraceratosis, acanthosis, presence of inflammatory cells). Erosion of the cervix Treatment. A strong steroid ointment or cream, a moisturising (emollient) Is a condition in which the squamous epithelium covering the vaginal cream or ointment instead of soap to clean the genital area. This is also soothing. portion of the cervix is replaced by columnar epithelium which is continuos with Avoid bubble baths, scented soap, detergents, perfumes, etc, to the genital skin that lining the endocervix. (vulva) of women. These may irritate the skin and make symptoms worse. Lubricants are useful during sex if having sex is painful. A vaginal dilator may be 7 8 Ectropion A cervix which has been badly lacerated during childbirth shows the condition of ectropion which tends to evert the endocervical canal. Chronic cervicitis usually accompanies ectropion, and the main symptom is
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