GYNAECOLOGY

SMAHRT NOTES
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1) Anatomy of pelvic floor [19, 15, 05, 2000]
a. Pelvic diaphragm [12]
Ans.
 Pelvic Floor is formed by the
pelvic diaphragm, which in
turn is formed by the levator
ani and coccygeus muscles
with their covering fasciae
 The pelvic diaphragm is a
muscular partition between
the pelvic cavity above & the
perineum below
 The two levator ani are the
wide curved, thin sheets of
muscles. They slope from the
side wall of the pelvis toward the median plane where they fuse with each other to form the
gutter-like floor of the true pelvis
 Functions of Pelvic Diaphragm:
 The pelvic diaphragm provides principal support to the pelvic viscera and has a sphincteric
action on the rectum and vagina
 Assists in increasing the intra-abdominal pressure during defecation, micturition & parturition
 Openings in Pelvic Diaphragm:
1. – It is a triangular gap between the anterior fibres of the two levator ani
muscles. It transmits the urethra in male, and the urethra and vagina in female. The hiatus
urogenitalis is closed from below by the urogenital diaphragm
2. – It is a round opening between the perineal body and the anococcygeal raphe. It
provides passage to the anorectal junction
 Injury of pelvic diaphragm can occur during difficult childbirth  it becomes weak  can no longer
support the pelvic viscera  uterine prolapse and rectal prolapse
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2) Perineal body & it’s clinical importance [19, 07, 98]
Ans.
 Perineal body is a wedge-shaped
mass of fibromuscular tissue situated
in midline at the junction of
urogenital triangle (anterior perineum) and
anal triangle (posterior perineum) between
the lower ends of vagina and anal
canal

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 Location: It lies about 1/2 inch (1.25 cm) in front of the anal margin close to the bulb of penis in
male and the posterior wall of the vestibule of vagina in female
 Clinical Importance:
 Perineal body can be damaged during difficult childbirth or cut inadvertently during episiotomy
 The perineal body is examined by inspection and by palpation. Two fingers are placed in the
vagina and flexed laterally; the thumb being applied externally over the labium majus, the
levator muscles can be palpated with a remarkable ease and the site of the hiatus urogenitalis
can be assessed. On asking the patient to contract her pelvic floor muscles, the tone of these
muscles can be estimated.
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1. Transformation Zone of Cervix [17]

Ans.
 It is also known as transitional zone where the squamous epithelium lining the vagina merges with
the columnar epithelium of the endocervix.
 Here, due to constant cellular activity, the cells are highly sensitive to irritants, mutagens and viral
agents such as HPV 16, 18 etc. that can eventually lead to dysplasia and carcinoma cervix.
 In Pap smear, this area is scraped and its cells are studied for the nuclear changes to screen cervical
cancer
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2. Course of Ureter in pelvis [16]
Ans.
 The pelvic portion of the ureter is 13 cm long and 5 mm in
diameter
 In the pelvis, it passes over bifurcation of common iliac 
first it runs downward, backward and laterally along the
anterior margin of the greater sciatic notch  On the pelvic
floor, it pierces Mackenrodt's ligament  forms ureteric
canal  the ureter is crossed by the uterine artery above
and the uterine plexus of veins below  Opposite to the
ischial spine, it turns forward and medially to reach the
base of the urinary bladder, where it enters the bladder wall obliquely.
 Identification of ureter: The ureter is identified in life by its thick muscular wall which undergo
worm-like peristaltic movements, especially when it is gently stroked or squeezed.
 Renal Colic: Violent muscular contractions precipitated by the presence of stone in the lumen of
the ureter (ureteric calculus) produce such a severe spasmodic pain that immediate treatment is
required
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3. Wolffian duct [11]
Ans.
 Wolffian duct (aka mesonephric ducts) form the definitive genital ducts in under the
influence of testosterone from Leydig cells
 Wolffian duct anomalies in Females: The upper portion of the Wolffian duct may at times dilate to
form a paraovarian cyst, and the lower portion forms a Gartner cyst.

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1) Graafian follicle [19]
a. Mature graafian follicle [12]
Ans.
 Follicularization is a process by which a primordial follicle is converted into a Graafian follicle. It can
be seen as early as 32nd week of IUL
 The mature Graafian follicle is spheroidal or ovoid in shape
 Parts of Graafian Follicle:
 Theca interna – these cells are derived from stroma cells of
the ovarian cortex  produce hormones (estrogen & progesterone)
 Granulosa cell layer – within the theca interna
 Cumulus oophorus – projection of accumulated granulosa cells
within the cavity of Graafian follicle
 Ovum – it lies within the Cumulus oophorus
 Corona radiata – radially arranged granulosa cells around the
ovum
 Changes taking place during the development of graafian follicle are:
 Follicular cavity becomes larger and distended with fluid
 Theca interna becomes prominent
 Ovum attains maximum size
 Zona pellucida becomes thick
 Corona radiata becomes prominent
 The number of follicles that develop into a Graafian follicle in any one cycle depends upon the
levels of FSH and LH as well as the sensitivity of the follicles.
 ln a spontaneous normal menstrual cycle, only 1 dominant follicle develops into a Graafian follicle
resulting in a single ovulation on the 14th day of menstrual cycle
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2) Vaginal cytology [01, 83]
Ans.
 Vaginal epithelium displays cyclical changes in response to the ovarian hormones
 These changes can be studied cytologically by scraping this portion of the vaginal epithelium and
staining it with .
 The vaginal cytology during the different phases of the menstrual cycle is as follows:
– basophilic cytoplasm of vaginal squames, Endometrial debris, WBC & RBC
– acidophilic cytoplasm;  cornification index
(max estrogen) – cornification index is the highest
– squames become clumped together in clusters. They are less mature, the
cytoplasm is now largely basophilic, and the nuclei are bigger
– Cytoplasm is basophilic. There is lack of cornification.
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1. Luteal phase defect [10]

Ans.

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 Luteal phase defect refers to inadequate growth and function of the corpus luteum due to
defective folliculogenesis
The lifespan of corpus luteum is shortened to less than 10 days  inadequate progesterone
secretion  hinder implantation  Infertility
Causes of LPD: Drug induced ovulation, older women,  FSH and/or LH,  prolactin, subclinical
hypothyroidism, pelvic endometriosis, dysfunctional uterine bleeding etc.
Diagnosis of LPD:
 BBT chart – Rise of temperature sustains less than 10 days
 Endometrial biopsy done on 25–27th day of the period reveals the endometrium at least 3 days
out of phase
 Serum progesterone estimated on 8th day following ovulation is < 10 ng/ml
Treatment of LPD:
Natural progesterone as vaginal suppositories 100 mg t.i.d starting from the day of ovulation till
menses.
If menses fail to appear after 14 days  UPT  if UPT is +ve  continue the same till 10th
week of pregnancy
In unresponsive cases – try clomiphene citrate – it FSH which may improve folliculogenesis and
normal corpus luteum formation

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1. Menstruation – Define, physiology w.r.t. ovarian, endometrial & endocrine cycle [21, 20]
a. Menstrual regulation [09, 2000, 98]
Ans.
Definition: Menstruation is the visible manifestation of cyclic physiologic uterine bleeding due to
shedding of the endometrium following invisible interplay of hormones mainly through
hypothalamo-pituitary-ovarian axis
Duration of menstrual cycle is usually 28 days. But, under physiological conditions, it may vary
between 20 and 40 days
Physiology of Menstruation: During each menstrual cycle, the following cyclical changes occur:
Ovarian cycle: Changes in the ovary during each menstrual cycle occur in two phases:
:
 It extends from the 5th day of the cycle until the time of ovulation {14th day}
 Maturation of ovum with development of ovarian follicles takes place during this phase.
 Ovarian follicles are glandular structures present in the cortex of ovary.
 Under the influence of FSH & LH the follicles gradually grow into a matured follicle through
various stages: Primordial folliclePrimary follicle Vesicular follicleMatured follicle or
graafian follicle. {Refer 1st SQ of ‘Normal Histology’}
– it extends between 15th and 28th day of menstrual cycle. During this phase,
corpus luteum is developed. {Refer 2nd SQ}
Endometrial cycle: During each menstrual cycle, along with ovarian changes, uterine changes
also occur simultaneously in 3 phases:
– After ovulation, if pregnancy does not occur, the thickened endometrium
is shed or desquamated {due to sudden  estrogen & progesterone} along with blood and fluid
{menstruation or menstrual bleeding}; lasts for about 4 to 5 days.
– extends from 5th to
14th day of menstruation;  Endometrial
cells proliferate rapidly {reach 3-4mm
thickness}; It corresponds to the follicular
phase of ovarian cycle.
– extends between 15th
and 28th day  endometrium becomes
thicker due to E + P; It corresponds to the
luteal phase of ovarian cycle
Endocrine cycle – “Menstrual regulation”:
 The regulatory system functions through the hormones of hypothalamo-pituitary-ovarian axis.
 Pulsatile secretion of GnRH from hypothalamus  FSH & LH from anterior pituitary  Ovarian
hormones: Estrogen and progesterone  -ve feedback on GnRH, FSH & LH  After Luteolysis,
there is sudden  estrogen & progesterone  Pulsatile secretion of GnRH from hypothalamus.
 GnRH secretion depends upon 2 factors:
External factors like psychosocial events, which act on hypothalamus via many brain centers
-ve feedback effects of ovarian hormones
 FSH – It stimulates the recruitment and growth of immature ovarian follicles.

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  LH – It triggers ovulation and sustains corpus luteum
 Estrogen secretion reaches the peak twice in each cycle; once during follicular phase just before
ovulation and another one during luteal phase.
 Estrogen is responsible for the growth of follicles.
 Estrogen & progesterone act together to produce the changes in uterus, cervix and vagina
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1) Corpus Luteum [05, 01]

Ans.
Corpus Luteum is a glandular yellow body, developed from the ruptured graafian follicle after the
release of ovum.
It remains in the ovary till the end of the menstrual cycle (if the ovum is not fertilised)
Functions of Corpus Luteum:
 It Acts as a temporary endocrine gland – secrete large quantity of progesterone
 If pregnancy occurs, corpus luteum remains active for about 3 months, i.e., until placenta develops
Fate of Corpus Luteum:
 If the ovum is not fertilized  corpus luteum becomes smaller and involuted  gets
transformed into a whitish scar called corpus albicans (via Luteolysis)
 If ovum is fertilized  pregnancy occurs  corpus luteum persists for about 3 months. After
this, placenta starts secreting these hormones and corpus luteum degenerates

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1. Dysmenorrhea – Define, types, causes, C/F & Mx [18, 09, 08]
a. Primary dysmenorrhoea. [16]
b. Causes of spasmodic dysmenorrhoea. [15, 10]
c. Congestive dysmenorrhoea & it’s causes [14, 03]
Ans.
Definition: Dysmenorrhea refers to cases of painful menstruation of sufficient magnitude so as to
incapacitate day-to-day activities
Types: 2 types –

Uterine Pain is due to  tension in pelvic tissue

myometrial due to:
hyperactivity Cervical stenosis, chronic PID, pelvic
Causes in ovulatory endometriosis, pelvic adhesions,
cycle adenomyosis, uterine fibroid,
endometrial polyp, IUCD in utero etc.
Female in reproductive age (> 30 yrs)
 Young female with complaints of pain with complaints of pain during
during menses since 1-2 years after menses for the past few months
menarche. {initially no pain bcz of anovulatory cycles} Pain occurs much before the onset of
 Pain begins a few hours before or just menses & remains even after the
Clinical
with the onset of menstruation onset of periods
features  Pain is spasmodic in nature and Pain is congestive in nature &
confined to lower abdomen’ maybe intensity keeps on increasing
 a/w psychological factors {Progressive dysmenorrhea}
 Pelvic examination will be NORMAL. Pain is localised
Pelvic pathology present
 Give reassurance - Pain gradually on
its own after some physical activity or
marriage or childbirth  Treat the cause
Mx
 NSAIDs – inhibit PG synthesis
 OCP – make the cycle anovulatory
 Mirena IUCD / Vaginal rings can be given
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2. Post-menopausal bleeding – causes, inv. & DDx [17, 16, 15, 14, 07, 04, 01, 2000]
Ans.
Bleeding per vagina following established menopause is called postmenopausal bleeding
Causes & DDx:
Infections: TB; pyometra; Senile endometritis; Senile vaginitis
Fibroids & Abnormal Uterine Bleeding
Genital malignancy - Carcinoma of the cervix, endometrium, vagina, vulva & Fallopian tube;
Granulosa cell tumor of the ovary

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 Withdrawal bleeding following estrogen intake
Retained and forgotten foreign body such as pessary or IUCD.
Uterine polyp & Decubitus ulcer
Bleeding from urinary tract (bladder carcinoma) or anal canal (haemorrhoids)
Investigations:
First confirm that it is vaginal bleeding and not bleeding per rectum or hematuria
Take detailed history regarding –
Age of menopause, Menstrual pattern prior to menopause
Sensation of something coming out of the introitus
Drug history: Intake of estrogen; Irregular intake of HRT; Use of Tamoxifen etc.
Family history of genital malignancy
Urinary problems like dysuria or frequency of urination
General examination – Look for obesity, HTN, Enlarged groin /supraclavicular lymph nodes;
breast mass etc.
Per abdomen – Look for any lumps or adnexal mass
PV examination – Look for prolapse, visible cervical growth
Bimanual examination
Special Investigations: TVS-USG, Saline infusion sonography (SIS), Pap smear, Hysteroscopy,
Endometrial biopsy, CT and MRI
Other tests: thyroid function tests, CA 125 levels
Treatment:
If cause if found  treat accordingly
If no cause is detected  put under observation or regular follow-up if the bleeding is less
In recurrent or continued bleeding cases – go for Laparotomy TAH + BSO
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3. Dilation and Curettage (D&C) – procedure, indications & complications. [08, 62]
Ans.
D & C is an operative procedure whereby dilatation of the cervical canal followed by uterine
curettage is done.
: The patient is to empty the bladder prior to operation
Under General anesthesia/ diazepam sedation
Patient in lithotomy position  Local antiseptic cleaning and draping  Bimanual examination
 Posterior vaginal speculum.
Grasp the anterior lip of the cervix with an Allis tissue forceps
Uterine sound is introduced to confirm the position & to note the length of uterocervical canal
Cervical canal is dilated & is made steady by traction of the vulsellum.
After the desired dilatation  Uterine curette either in
clockwise or anticlockwise direction starting from the
fundus down to internal os.
Vulsellum and the speculum are removed
The curetted material is preserved and sent for histological
examination.
:�
:

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 Immediate Complications: Injury to the cervix, Uterine perforation, Injury to the gut & Infection.
Late complications:
 Cervical incompetence due to injury to internal os  recurrent mid-trimester abortion
 Uterine synechiae due to injury to uterine muscle  secondary amenorrhea
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1) Premenstrual Syndrome (PMS). [16]

Ans.
 Premenstrual syndrome (PMS) is a psycho-neuroendocrine disorder of unknown etiology, often
noticed just prior to menstruation.
 It should fulfil the following criteria (ACOG):
Not related to any organic lesion.
Regularly occurs during the luteal phase of each ovulatory menstrual cycle.
Symptoms must be severe enough to disturb the life style of the woman or she requires medical
help.
Symptom-free period during rest of the cycle. When these symptoms disrupt daily functioning,
they are grouped under the name premenstrual dysphoric disorder (PMDD).
 Clinical Features: �
 Treatment:
General measures – Assurance, Stress management, Diet
manipulation, avoid salt, caffeine & alcohol.
Non-hormonal: Anti-depressant drugs, Diuretics,
Pyridoxine, SSRIs, etc.
Hormonal – OCPs
Suppression of ovarian cycle – GnRH analogues
TAH + BSO – in patients with recurrence of symptoms and approaching to menopause
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2) Menopausal symptoms [14, 05]
a. Post-menopausal symptoms [03]
Ans.
Menopause means permanent cessation of menstruation at the end of reproductive life due to loss
of ovarian follicular activity. It is the point of time when last and final menstruation occurs
Menopausal Symptoms:
Vasomotor symptoms – “Hot flush” – sudden feeling of heat followed by profuse sweating.
Urogenital atrophy  dyspareunia and dysuria
Recurrent UTIs and stress incontinence
Osteoporosis and fracture
Cardiovascular disease
Cerebrovascular disease
Psychological changes – anxiety, headache, insomnia, irritability, dementia, dysphasia &
depression
Skin and Hair – thinning, loss of elasticity; “Purse string” wrinkling around the month and “crow
feet” around the eyes are the characteristics
Dementia and cognitive decline.

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 Management:
Counselling: Every woman with postmenopausal symptoms should be adequately explained about
the physiologic events. This will remove her fears, and minimize or dispel the symptoms of anxiety,
depression and insomnia. Reassurance is essential
Treatment:
 General measures – Assurance, Stress management, Diet manipulation, avoid salt, caffeine &
alcohol. There should be adequate calcium intake (300 mL of milk);
 Non-hormonal: Calcium supplements; Vitamin D supplements; Calcitonin; Bisphosphonates etc.
 Hormonal – HRT {refer next section}
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3) Cryptomenorrhea [10, 09, 08]
Ans.
Cryptomenorrhea is a condition where the menstrual blood fails to come out from the genital tract
due to obstruction in the passage.
Congenital causes Acquired causes
:�
 Imperforate hymen Stenosis of the cervix
:  Transverse vaginal following amputation, deep
 If the site of obstruction is low septum cauterization and conization.
down in the vagina, the  Atresia of upper-third of 2° vaginal atresia
accumulated blood  vagina and cervix. following difficult vaginal delivery.

hematocolpos → hematometra → hematosalpinx

 If the obstruction is at the cervix  hematometra → hematosalpinx.
 Hematocolpos produces marked elongation of the urethra → retention of urine
:
Periodic lower abdominal pain in patient aged about 13–15 (congenital type)
Amenorrhea dated back from the events
Retention of urine
O/E: Uniform globular mass in the hypogastrium; Vulval inspection reveals the bulging hymen.
:
Cruciate incision of the hymen and drainage of blood
Dilatation of the cervix in cases of stenosis via reconstructive surgery.
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4) Pyometra [05, 04, 89]
Ans.
Collection of pus in the uterine cavity is called pyometra

Obstetrical —The only condition is following infection of lochiometra.

Gynaecological —
(a) Carcinoma in the lower part of the body of uterus.
(b) Endocervical carcinoma
(c) Senile endometritis
(d) Infected hematometra following amputation, conization or deep cauterization of cervix
(e) Tubercular endometritis.
Causative organisms: coliforms, streptococci or staphylococci. Rarely, it may be tubercular.
:
 The patient complains of intermittent blood-stained offensive discharge per vaginum.

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 Pain in lower abdomen.
 Per abdomen: suprapubic swelling felt. It is cystic & may be tender.
is confirmed by dilatation of the cervix when pus escapes
Pelvic ultrasonography reveals distended uterine cavity with accumulation of fluid within
Exclude the malignancy by specific tests
: the pyometra is drained by simple dilatation of the cervix.

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1. Benefits and side effects of Hormone replacement therapy. [21, 2000]
a. 2 indications & 2 contraindications in HRT [18]
Ans.
Hormone replacement therapy (HRT) is used mainly for suppressing the perimenopausal
syndrome of vasomotor instability, psychological disturbances as well as in preventing genital
atrophy and osteoporosis.
Indications (Benefits) of HRT:
Relief of menopausal symptoms (hot flushes, dyspareunia, vasomotor instability etc.) –
especially in women < 60 years of age
Perimenopausal women with menopause-related complications like cardiovascular disease,
osteoporosis, stroke, Alzheimer disease and colonic cancer
in young women – Ex: Gonadal dysgenesis in adolescents
due to surgery (tubectomy, hysterectomy etc. – compromise the blood
supply to ovaries) or radiotherapy and chemotherapy for cancer
Contraindications (side effects) of HRT:
 Breast cancer, uterine cancer or family history of cancer
 Uterine fibroids – the fibroids may enlarge in size
 Previous history of thromboembolic episode
 Liver and gall bladder diseases
 Migraine
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2. Uses of progestogens (Progestogens are synthetic forms of progesterone) in gynaecology. [20, 08]
a. Uses of progesterone in gynaecology (at least 4) [20, 16]
Ans.
– Progesterone challenge test – to investigate pathological amenorrhea
– these are:
1) Contraception – Examples are:
 Minipill (oral)
 Depomedroxyprogesterone acetate (DMPA) (injectable)
 Levonorgestrel: Emergency contraception
 Vaginal ring containing levonorgestrel
2) Abnormal uterine bleeding, Dysmenorrhoea, premenstrual tension syndrome etc.
3) Luteal phase defect (LPD)
4) Endometriosis – Progestogens cause atrophy of the ectopic endometrial tissues
5) Endometrial hyperplasia & Endometrial carcinoma (with steroid receptors)
6) Hormone replacement therapy (HRT) – progesterone is used with estrogen
7) Postponement of menstruation – 5-mg norethisterone t.i.d. starting 3 days prior to anticipated period
: Undiagnosed vaginal bleeding, Breast cancer,
Thromboembolism etc.
Nausea, vomiting, headache, water retention, weight gain, mastalgia,
cramps in legs, DVT, pulmonary embolism, Breast cancer, LDL.

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 Medroxyprogesterone acetate causes bone loss
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3. Prostaglandins [07]
Ans.
Prostaglandins has luteolytic effects on the ovary  hence prevents implantation and brings about
menstruation.
PG causes myometrial contraction and vasoconstriction
PGE2 produces myometrial contraction but causes vasodilatation
PGI2 (Prostacyclin) causes myometrial relaxation and vasodilatation
– Ex: mefenamic acid – are given in
dysmenorrhea, abnormal uterine bleeding
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4. Human chorionic Gonadotrophins. [04]
Ans.
hCG is a glycoprotein secreted by the Syncytiotrophoblast & it contains 2 linked subunits – α and β.
α unit contains 92 amino acids similar to LH, FSH & TSH.
β unit contains 145 amino acids, and has a specific biological activity in pregnancy
hCG is commonly detected by UPT (urine pregnancy test)
: it supports early pregnancy
:
1) In habitual (recurrent) abortion - hCG provides support to the embryo
2) In Luteal phase defect (LPD) {aka CLPD – corpus luteal phase deficiency}
3) IVF programme: hCG is given when the follicular size reaches 20 mm  follicular rupture 36-38
hours following injection  give support in implantation and endometrial vascularization

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1. Indications of Laparoscopy in Gynaecology [19, 17]
a. Diagnostic laparoscopy & it’s indications [19, 05, 04]
b. Minimally Invasive Surgery in Gynaecology. [16]
Ans.
Minimal invasive surgery (MIS) implies avoiding a large skin scar, minimal handling of pelvic and
abdominal organs, less pain and thereby fast recovery.
Few examples of MIS:
Thoracoscopy – to diagnose and treat conditions in the chest.
Hysteroscopy – (refer 2nd SQ)
Endoscopy THE VAAR
Arthroscopy
Angioplasty
Robotic Surgery
Vaginal access minimally invasive surgery (VAMIS) – requires no abdominal incisions at all. It is
used to perform hysterectomy, fibroid debulking, pelvic mass removal etc.
Laparoscopy
Indications of Laparoscopy

– tubal patency, adhesions, PCOD

GIFT in infertility
– PCOD, size, volume, adhesions
PCOD drilling; to puncture the cyst
Pelvic endometriosis
Ovarian cystectomy
Pelvic tuberculosis
Lymphadenectomy in cancer cervix, ovary
Chronic pelvic pain
LUNA – Laparoscopic uterine nerve ablation
– nature of tumor
LAVH - Laparoscopically assisted vaginal hysterectomy
(benign/malignant) & staging
Myomectomy, Removal of hydrosalpinx &
– to detect malformations
pyosalpinx
To detect ectopic pregnancy
Stress urinary Incontinence
Prior to induction of Ovulation
Ectopic pregnancy
Prior to IUI & IVF
Tuboplasty
Prior to tuboplasty to study the feasibility
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2. Tubal patency test [21, 19, 13, 05, 99]
a. Hysterosalpingography / Hysterosalpingogram [HSG] & it’s complications [14, 11, 2000]
b. Hysteroscopy – indications & complications [13, 11, 07, 04]
c. Chromopertubation [07, 96]
Ans.
Indication of Tubal patency test – to evaluate the female partner of infertile couple
 Tubal patency tests should be done in the preovulatory phase of the menstrual cycle
 Avoid it in post-ovulatory phase – since it might disturb the implanted ovum & may also cause pelvic endometriosis.
Tubal patency tests include the following:
refers to visualization of the uterine cavity and the fallopian tubes
after injecting a radio-opaque dye in uterine cavity

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 Indications (apart from investigating the infertility) of HSG:
To assess tubal patency after tuboplasty operation
To detect uterine malformations (unicornuate, bicornuate, septate uterus, fibroids)
To know the position of IUD (whether lying inside or outside the uterine cavity)
To diagnose cervical incompetence
To confirm the diagnosis of secondary abdominal pregnancy
Incidental diagnosis of submucous fibroid or an uterine polyp or hydrosalpinx etc.
Timing of HSG: HSG is done between D6 and D10 of the cycle.
Antibiotic prophylaxis - Doxycycline 100 mg PO BD is given, beginning the day before HSG and
continuing for 5 days.
Complications of HSG: Flaring up of pelvic infection, pelvic pain, peritoneal irritation, vasovagal
attack, Intravasation of dye within the venous or lymphatic channels (seen in tubercular
endometritis) uterine perforation etc.
– it uses ultrasound to evaluate tubal patency & uterine cavity; it is
safer & preferred over HSG
It is a laparoscopic visualisation of the pelvic structures (uterus,
fallopian tubes and ovaries) & injection of methylene blue through the cervix to visualise the spill
of dye. It is done to verify the findings when HSG has shown blocked tubes & to establish the
patency of the tubes. (Refer 1st SQ)
– Hysteroscopy, Falloscopy, Ampullary & fimbrial salpingoscopy,
Fertiloscopy etc.
Hysteroscopy: it is an operative procedure done to visualise the uterine cavity with the aid of
fibreoptic telescope
The uterine distension is achieved by CO2, normal saline or glycine
Indications of Hysteroscopy:
Diagnostic Hysteroscopy – to detect uterine polyp, submucous fibroid, missing threads of IUD,
uterine synechiae etc. & to visualize transformation zone when colposcopic finding is
unsatisfactory
Operative Hysteroscopy - Removal of pedunculated fibroid, large polyp Fallopian tube
cannulation, TCRE, Asherman’s Syndrome etc.
Diagnostic hysteroscopy should be performed in the postmenstrual period for better view without
bleeding
Complications of Hysteroscopy – they can due to:
Distension media  Fluid overload, Hyponatraemia, Pulmonary edema, cerebral edema,
Ammonia toxicity due to excess glycine absorption, embolism (CO2).
Operative procedures Uterine perforation, hemorrhage, injury to abdominal organs etc.
Others—Infection, Hematometra and pyometra, anaesthetic complications, etc.
----------------------------------------------------------------------------------------------------------------------------------------
3. Colposcopy [11, 01]
Ans.
Colposcope is a binocular microscope, mounted on a stand, designed to magnify the surface
epithelium of the vaginal part of the cervix including entire transformation zone.
It is different from cytology since cytology identifies the patient having cervical neoplasm,
colposcopy identifies the site where from biopsies are to be taken.
Procedure:

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  Place the patient in lithotomy position; Visualise the cervix using a Cusco’s speculum
 Examine cervix & vagina with a colposcope
 Wipe the cervix gently with 3% percent acetic acid & examine again (Acetic acid causes
coagulation of nuclear protein which is high in CIN)
Indication: to detect CIN, Condyloma, papilloma etc. & to obtain accurate biopsies in women with
+ve pap smears
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4. Schiller' s Test [04, 92]
Ans. This test was done to take biopsy of cervix when colposcopy was not available
 : by using iodine solution (Schiller’s 0.3% or Lugol’s 5%), multiple punch biopsies are
taken from the unstained areas.
 Stained areas (normal) appear brown due to presence of glycogen
----------------------------------------------------------------------------------------------------------------------------------------
5. Diagnosis of ovulation [02, 2000]
Ans.
 : In a 28-day cycle, ovulation can occur between 12th & 16th day.
 is a micro-computer measure the levels of LH in the morning urine  red light shows
probable ovulation
 : Progesterone exert a thermogenic effect on the body. Therefore, record
BBT daily in the morning & plot on graph. The day of temperature shift indicates the time of
ovulation.
====================================================================================

1. Fractional Curettage [12, 08, 04]

Ans.
Fractional curettage is a modification of D&C where initially, curettings are obtained from
endocervical canal before dilating the cervix, followed by cervical dilatation and curettage from the
whole endometrial cavity·
Specimen obtained from endocervical canal is separately sent for histopathology in addition to
endometrial curettings
Indication: This procedure is done in a suspected case of endometrial cancer to know whether the
disease has spread downwards to involve endocervix.
----------------------------------------------------------------------------------------------------------------------------------------
2. Uses of Sim’s speculum [04]
Ans.
Sim’s speculum is the most commonly used instrument in gynaecological practice for exposure of
cervix to –
 obtain Pap smear or cervical biopsy
 catch it’s anterior lip before minor and major operations on cervix, endocervix or endometrium
: Help of an assistant is needed if some procedure is to be performed (since it’s NOT
self-retaining)
: autoclaving/ boiling in water/ placing in glutaraldehyde solution (Cidex) for
at least 15 minutes.

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1) Classification of uterine anomalies [19]
a. Uterus didelphys [10]
b. Development of uterus and common anomalies [07, 06, 98]
c. Bicornuate Uterus [07]
Ans.
:
The uterus is formed from the uterovaginal canal (fused, caudal vertical parts of the
paramesonephric ducts).
The primitive uterus soon differentiates into 2 parts: (a) body and (b) cervix.
In fetus, cervix is larger than the body of uterus.
The initial angular junction between the two
paramesonephric ducts becomes a convex dome and
forms fundus of uterus.
Myometrium of the uterus is derived from surrounding
mesoderm.
:
: Müllerian agenesis/Hypoplasia—segmental
: Unicornuate uterus
There is complete lack of fusion of the Müllerian ducts with a double
uterus, double cervix and a double vagina
: There are two uterine cavities with single/double cervix
: Septate uterus
Arcuate uterus
: Diethylstilbestrol
(DES)-related abnormality.
Problems faced:
Gynaecological:
Dysmenorrhea, AUB,
dyspareunia, Infertility etc.
Obstetrical: recurrent abortions, cornual pregnancy, preterm labour, incidence of
malpresentations, prolonged labour, Retained placenta & PPH etc.
Renal tract anomalies: seen in association with uterine anomalies in 40% cases.
Diagnose:
 Passage of a sound can diagnose two separate cavities.
 Hysterography, hysteroscopy, USG, MRI, Laparoscopy – to confirm
Treatment: Unification operation –
 Abdominal metroplasty could be done either by excising the septum (Strassman, Jones, and
Jones) or by incising the septum (Tompkins).
 Hysteroscopic metroplasty is more commonly done. Resection of the septum can be done
either by a resectoscope or by laser

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2) Imperforate hymen [15, 03, 02]
a. Hematocolpos [12, 07]
b. Hematometra [01]
Ans.
It occurs due to failure of disintegration of the central cells of the
Müllerian eminence that projects into the urogenital sinus
:
Cryptomenorrhea – As the uterus is functioning normally, the
menstrual blood is pent up inside the vagina behind the hymen.
Blood distends the vagina – Hematocolpos & the uterine cavity
{Hematometra}
In neglected cases, blood distends even the fallopian tubes –
Hematosalpinx
:
Remains unnoticed until the girl attains the age of 14–16 years
Periodic lower abdominal pain, which may be continuous, primary amenorrhea and urinary
symptoms, such as frequency, dysuria or even retention of urine {due to elongation of the urethra}
Suprapubic swelling;
Vulval inspection reveals a tense bulging bluish membrane
Rectal examination reveals the bulged vagina
– Ultrasonography reveals hematometra and hematocolpos
– Cruciate incision is made in the hymen with patient lying on Bed with head end raised
----------------------------------------------------------------------------------------------------------------------------------------
3) True Hermaphroditism [14]
Ans.
True hermaphroditism in humans is defined as the simultaneous presence of both testicular and
ovarian tissue in a single individual.
: It is probable that fertilization by a sperm carrying one ‘X’ chromosome, which contains
some male determining material from ‘Y’ gives rise to this condition..
:
 Ovotestis on each side (commonest).
 Testis on one side, ovary on the other.
 Testis or ovary on one side and ovotestis on the other.

Ambiguity of external genitalia

The internal structures depend on the degree of differentiation of the associated gonad on that
side
75% develop gynecomastia and nearly 50% menstruate
:
 Sex chromatin is usually positive.
 Karyotype is usually 46, XX (70%); rest are 46, XY & rarely mosaic XX/XY.
 Confirmation of diagnosis is by gonadal biopsy.

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1) Androgen insensitivity syndrome [18]
Ans.
Androgen Insensitivity Syndrome (Testicular Feminization) is a disorder of sexual development
(male intersex) which is inherited as a X-linked recessive gene.
Pathogenesis: Either, there is lack of androgen cytosol receptor or the receptor is defective
(mutated).
Clinical presentation:
Phenotypic female with primary amenorrhea or infertility
Absent or sparse axillary and pubic hair
There is eunuchoidal tendency (long arms, big hands and feet)
Gonads (testes) are either placed in the labia, or inguinal canal or intra-abdominal
External genitalia look like female. Breast development is adequate
Vagina is short and blind. Uterus and tubes are absent (due to the effect of AMH)
Investigations:
Sex chromatin is negative.
Karyotype is 46, XY.
Hormonal panel:
Serum testosterone is within average for normal males.
Serum E2 level is high normal for males.
Serum LH level is normal or slightly elevated.
Confirmation of diagnosis is by Gonadal Biopsy – it reveals Seminiferous tubules with Leydig cells
and Sertoli cells. Spermatogenesis is absent
Management:
 Appropriate counselling is done
 The individual should be reared up as a girl & the ectopic gonads (testes) are to be removed to
avoid the risks of gonadal malignancy
 After gonadectomy, long-term estrogen replacement therapy should be prescribed for its effect on
vaginal epithelium, osteoporosis and cardiovascular system
----------------------------------------------------------------------------------------------------------------------------------------
2) Hirsutism – causes and management [17]
Ans.
Hirsutism is the excessive growth of androgen dependent sexual hair (terminal hair) in facial and
central part of the body that worries the patient.
Causes
 Ovarian – PCOS; Sertoli-Leydig cell tumor; Lipoid cell tumor etc.
 Adrenal – Adrenal hyperplasia; Cushing’s syndrome etc. APO EPO
 Obesity – insulin resistance and androgen excess
 Exogenous (drug therapy) – OCPs, Androgens, anabolics, phenytoin, diazoxide, cortisone, etc.
 Postmenopause
 Pituitary tumor – secreting Excess ACTH or Excess GH

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  Idiopathic: Increased sensitivity to androgens
Management:
 Investigate the cause based on history & specific examination
 Weight reduction—is an important step of management
 Drugs – to suppress or neutralize the excess androgen action
Anti-androgens (Cyproterone acetate, Flutamide, Finasteride)
Progestins in OC pills inhibits 5 α-reductase activity in the skin
Dexamethasone: It acts by suppressing pituitary-adrenal axis
 Surgery to remove the source of androgen – Ex: tumour of ovary/adrenal/pituitary
----------------------------------------------------------------------------------------------------------------------------------------
3) Turner’s syndrome [11, 10, 05]
Ans.
It is a cytogenetic disorder involving sex chromosomes
3 types of karyo­typic abnormalities:
Missing of an entire X-chromosome → 45 X karyotype
Structural abnormalities of X-chromosomes {translocations, deletions etc.}
Mosaics – Ex: 45 X/46 XX or 45 X/46 XY
Clinical Features:
Adult women with short stature, primary amenorrhea and sterility.
At puberty, normal secondary sex characteristics fail to develop.
Webbed neck, low posterior hairline, wide carrying angle of the arms (cubitus valgus), broad
chest with widely spaced nipples and hyperconvex fingernails.
Infantile genitalia, inadequate breast development, and little pubic hair. The ovaries are
converted to fibrous streaks.
Pigmented nevi become prominent as the age advances
Cardiovascular anomalies like coarctation of aorta etc.
Development of autoantibodies → hypothyroidism.
Investigations: to confirm the clinical diagnosis
 Sex chromatin study is negative
 Serum FSH and LH are elevated
 Serum E2 is very low.
 Autoantibodies may be present
Management: Exogenous growth hormone (GH) - to increase the height; Low dose estrogen &
management of hypothyroidism with appropriate counselling
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4) Klinefelter’s syndrome [11, 09]
Ans.
It is a cytogenetic disorder involving sex chromosomes.
characterized by 2 or more X-chromosomes and 1 or more Y chromosomes {47 XXY karyotype} due
to nondisjunction during the meiotic divisions in one of the parents.
Regardless of the number of extra X-chromosomes (even up to 4), the Y-chromosome results in a
male phenotype.
: made after puberty and hypogonadism is a consistent finding. Barr body is seen

Tall and thin with relatively long legs (eunuchoid body habitus).
At puberty, testes and penis remain small with lack of secondary male characteristics.

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 Female characteristics include a high-pitched/deep voice, gynecomastia, and a female pattern
of pubic hair.
Hypogonadism, reduced levels of testosterone, remarkably high levels of FSH and LH.
Azoospermia → infertility
incidence of type 2 diabetes and Mitral valve prolapse.
risk for breast cancer, extragonadal germ cell tumors and autoimmune diseases such as SLE.
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5) Adreno genital syndrome [09]
Ans.
: It is an autosomal recessive disorder.
It occurs due to inborn error of adrenal steroid metabolism – 21-hydroxylase (95%) and rarely due
to 11-hydroxylase or 3β hydroxy steroid dehydrogenase deficiency  cortisol  ACTH 
stimulates the adrenal to produce excess androgens  virilization of female
:
 Ambiguity of sex at birth {enlarged clitoris, penile urethra, hypospadias etc.}
 Hirsutism and amenorrhea may be the presenting features around puberty
:
USG – shows presence of uterus, fallopian tubes, and vagina. The gonads are ovaries
Sex chromatin study reveals positive Barr body
Karyotype is 46, XX
 Serum levels of 17 hydroxy-progesterone
Salt loosing syndrome – low sodium & chloride; high potassium {due to aldosterone deficiency}
Urinary excretion of pregnanetriol and 17 Ketosteroids
:
Hydrocortisone 10–20 mg/m2 body surface area per day – to suppress the excess ACTH secretion
Mineralocorticoid (fluorocortisone) – in cases with 21-hydroxylase deficiency
Replace salt loss
Long-term therapy with corticosteroid is essential to suppress the adrenocortical hyperfunction
Surgery for Neonate:
Reconstructive surgery includes clitoroplasty and vaginoplasty
Vaginoplasty is recommended with the onset of puberty
Prophylaxis: Prenatal diagnosis is possible with chorion villus sampling at early weeks (9–12) of
pregnancy using DNA probes – reveals  levels of 17 hydroxy-progesterone

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1) Monilial vaginitis & it’s treatment [21, 12, 11, 07, 06, 04, 02]
a. Candidal vaginitis. [17]
Ans.
Vaginitis refers to inflammation of vagina caused by a
disruption in the normal bacteria
Monilial vaginitis {Moniliasis} is caused by Candida albicans
– patient presents with intense pruritis &
vaginal discharge which is thick, curdy white and in flakes,
(cottage cheese type) often adherent to the vaginal wall
:
 Wet Smear of vaginal discharge in KOH mount
 Culture in SDA
:
Corrections of the predisposing factors should be done
Local fungicidal preparations – Ex: Nystatin, clotrimazole, miconazole, econazole are used in the
form of either vaginal cream or pessary.
The treatment should be continued even during menstruation
Husband should also be treated & should use condoms until the wife is cured
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2) Trichomonas vaginitis – C/F, Dx & Mx [15, 12, 08, 07, 03]
Ans.
Vaginal trichomoniasis is the MCC of vaginitis in the childbearing period.
: It is caused by Trichomonas vaginalis, a pear-shaped
unicellular flagellate protozoon. �
: sexual contact, the male harbours the infection in
the urethra and prostate.
: patient presents with sudden profuse and offensive vaginal
discharge {greenish-yellow} often dating from the last menstruation. A/w
itching, urinary symptoms.
The vaginal walls become red and inflamed with multiple punctate hemorrhagic spots
{‘strawberry’ appearance}
- hanging drop preparation to identify trichomonas
: Tab. Metronidazole 200 mg thrice daily for 1 week
Alternatives: A single dose regimen of 2 g metronidazole; Tinidazole single 2 gm dose PO
Husband should also be treated & should use condoms until the wife is cured
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3) Treatment of gonorrhoea. [2000]
Ans.

Adequate therapy for gonococcal infection and meticulous follow up are to be done till the patient
is declared cured.

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 Treat adequately the male sexual partner simultaneously. Use condom till both the sexual partners
are free from disease
To avoid multiple sex partners.
:

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1) Syndromic management of STIs (Sexually Transmitted Infections). [16]

Ans.
Syndromic approach to STD:
Many different agents cause STDs.
But, some of these agents give rise to
similar clinical manifestations.
Since 1990 WHO has recommended
syndromic approach to STDs.
It is a scientifically derived approach using
flowcharts & it is more cost-effective than
diagnosis based on laboratory tests
STD Kits: �
Advantages of Syndromic Approach:
Through this approach, a health worker at
the most peripheral level without using
laboratory support, can diagnose
reproductive infections and accordingly
prescribe treatment or advise referral of the patient
Disadvantage of Syndromic Approach: - Over-treatment in some patients (esp. in vaginal
discharge)
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2) Differences between Trichomonas & Monilial vaginitis. [10]
Ans.

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----------------------------------------------------------------------------------------------------------------------------------------
3) Uses of metronidazole in gynaecology. [04, 03]
Ans.
To treat Trichomonas vaginitis
To treat Bacterial Vaginosis
In management of PID

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1) Acute PID – Define, etiopathology, causative organisms, C/F, Dx & Mx [21, 20, 15, 12, 11, 08, 07]
a. Acute salpingitis – causes & treatment. [03, 2000]
Ans.
: PID is a spectrum of infection and inflammation of the upper genital tract organs
(uterus (endometrium), fallopian tubes, ovaries), pelvic peritoneum and surrounding structures
PID can be either endometritis, salpingitis, oophoritis, pelvic peritonitis or tubo-ovarian abscess.
: PID occurs due to ascending of infection from the cervicovaginal canal to the
pelvic structures
Acute PID is usually a polymicrobial infection caused by organisms ascending upstairs through
mucosal continuity & rarely blood borne (Ex: Genital TB).
Causative organisms:
Sexually transmitted – Gonococcus (MCC of acute PID), Chlamydia, Trichomonas & Mycoplasma hominis
Pyogenic – Aerobes, Staphylococci, Streptococci, E. coli
Anaerobes – Bacteroides fragilis, Peptococcus, Clostridium, Actinomyces
Tubercular salpingitis
Risk factors:
Menstruating teenagers, Multiple sexual partners, IUD users, high prevalence of STD etc.
Procedures like endometrial biopsy, uterine curettage, hysterosalpingography etc.
PID is almost always bilateral  gross destruction of the epithelial cells, cilia and microvilli 
edema & hyperemia  build of exudate within the lumen  Depending upon the virulence, the
exudate may be watery (hydrosalpinx) or purulent (pyosalpinx).
The exudate pours through the abdominal ostium  pelvic peritonitis and pelvic abscess or may
affect the ovary (the organisms gain access through the ovulation rent)  tubo-ovarian abscess
Protective factors – they prevent ascend of infection – Examples are: Use of Condoms, OCPs (produce thick mucus plug), Monogamy,
Pregnancy etc.

:
Symptoms Signs
B/L lower abdominal and pelvic pain which Fever > 38.3 °C
is dull in nature Tenderness on both sides of lower
Fever, headache, N & V abdomen; Adnexal tenderness
Abnormal vaginal discharge The liver may be enlarged and tender.
Thick purulent  Gonorrhea PV examination:
Thin watery  Chlamydia a) Abnormal vaginal discharge
AUB b) Speculum examination shows purulent
Dyspareunia & secondary dysmenorrhea discharge from cervical canal
Pain in the right hypochondrium due to c) Cervical motion tenderness (also seen in
fibrous band in perihepatic space (Fitz- ectopic pregnancy)

Hugh- Curtis syndrome) may occur in 5–10 d) Bimanual examination reveals bilateral
% cases of acute salpingitis tenderness on fornix palpation
: Acute appendicitis, Diverticulitis, Cholecystitis, Ectopic gestation, septic abortion, Twisted
ovarian cyst & Ruptured endometriotic cyst.

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 – According to NACO guidelines, Syndromic Mx of PID is done in which Dx is made
based on history & examination findings with UPT-ve {if UPT is +ve then  ectopic pregnancy}
– Yellow kit {Kit 6}: Doxycycline 100mg BD for 14 days + Metronidazole 400mg
BD for 14 days + Cefixime 400mg OD for 1 day
If yellow kit fails to resolve the symptoms  Go for Laparoscopy {Gold Standard for the Dx of
PID} to check for Peritoneal fluid
Violin string appearance on Laparoscopy = Fitz-Hugh- Curtis syndrome.
Scoring for Conception {Boer Meisel score} – can be checked by Laparoscopy
(since PID is sexually transmitted) – Grey kit {Kit 1}: T. Azithromycin 1g + T. Cefixime
400mg taken ONCE. same as gonorrhea
:
 To drain pelvic abscess
 Pocket of pus in peritoneum
 Ruptured TOA {tubo-ovarian abscess}
 In Chronic PID
: according to CDC
UPT – to r/o ectopic
CBP – reveal WBC
ESR; CRP;
USG – it shows “Beads on string appearance; Waist sign & Cogwheel sign” + Adhesion in tube
& peritoneal cavity.
Cervical and high vaginal swab culture
Blood Culture (if there are features of septicaemia)
Urine can be tested by PCR for chlamydial infection.
Urethral swab culture should be done, if gonorrhoea is suspected
Endometrial biopsy – reveal endometritis
Laparoscopy – Gold Standard test
– in long term, PID can lead to  Infertility {MC}; Ectopic pregnancy;
Hydrosalpinx; Chronic pelvic pain; Recurrent PID etc.

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1. Discuss the DDx of mass in right iliac fossa in a 25 years old woman. How will you treat genital
tuberculosis? [05, 03, 02]
Ans.
DDx of mass in right iliac fossa: �

Treatment of Genital TB:

:�

 The modern therapy consists of

rifampicin, isoniazid,
pyrazinamide & ethambutol for
initial 2 months, followed by
rifampicin & isoniazid biweekly for another 4 months
 Caution: Avoid OCPs + Rifampin; Pyridoxine (B6) 10 mg daily prevents peripheral neuritis
 Drugs Used in Resistant Cases – Kanamycin, Cycloserine, para-amino salicylic acid, Ethionamide
& Capreomycin
 HIV-TB patients should also receive Highly Active Antiretroviral Therapy (HAART) therapy
: persistence of pyosalpinx, pyometra, fistula, pain & menorrhagia
Types of Sx: Drainage of pyometra; Fistula repair; TAH + BSO; etc.
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1. Asherman’s Syndrome. [19, 15, 06]

Ans.
following D&C (done in postpartum period or for missed abortion) is known as
Asherman’s Syndrome. Rarely, it follows tubercular endometritis
: Menstrual abnormalities like hypomenorrhea, oligomenorrhea or amenorrhea & Infertility
:
Progesterone challenge test is negative
Hysterosalpingography (HSG) shows honeycomb appearance
Hysteroscopy reveals the extent of adhesions directly – IOC as it is both diagnostic & therapeutic
: Hysteroscopic Adhesiolysis  Insert IUCD Cu T to prevent adhesion formation 
Estrogen + Progesterone to rebuild endometrium

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1. Post operative care after repair of complete perineal tear. [14]
Ans.
 Non-residual diet is given from 3rd day onwards; the full diet is given on 6th day.
 Bowel should not be moved for about 4-5 days.
 Lactulose 10 mL BD beginning on the 2nd day and increasing the dose upto 30 mL on the 3rd day –
to soften the stool.
 If the patient fails to pass stool  compound enema (olive oil or liquid paraffin, glycerine and
normal saline, each 4 oz) can be given by a rubber catheter.
 Antibiotics (cefuroxime 1.5 and metronidazole 500 mg – IV) – to cover the perioperative period.
 Intestinal antiseptics should be continued for about 5 days
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2. Causes of Complete perineal tear [13]
Ans.
Tear of the perineal body involving the sphincter ani externus with or without involvement of the
anorectal mucosa is called Complete Perineal Tear
: Over stretching or sudden stretching of the perineum during child birth.
Direct injury on the perineum by fall may lead to trauma on the perineum
to the extent of CPT

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1. Vesical fistulae – etiology, types and diagnosis [05]
a. Etiology of VVF (Vesico Vaginal Fistula) [16, 13, 11, 07, 06]
b. Three swab test [15]
c. Types and causes of genitourinary fistula. [10]
Ans.
Genitourinary fistula is an abnormal communication between the urinary and genital tract either
acquired or congenital with involuntary escape of urine into the vagina.
Types of Genitourinary fistula: �
:
: This is the MC type of Genitourinary fistula in which
there is communication between the bladder and the vagina
and the urine escapes into the vagina causing true incontinence
:
Obstetrical causes:
obstructed labor  ischemic necrosis of bladder  infection  sloughing  fistula
Instrumental vaginal delivery  trauma  fistula.
Abdominal operations such as Caesarean hysterectomy
Gynecological causes:
Surgical injury  anterior colporrhaphy, abdominal hysterectomy for benign or malignant
lesions or removal of Gartner’s cyst.
Traumatic— stick used for criminal abortion, fracture of pelvic bones or due to retained and
forgotten pessary.
Malignancy—Advanced carcinoma of the cervix, vagina or bladder
Radiation  ischemic necrosis of bladder
Infective—Chronic granulomatous lesions such as Vaginal TB, LGV etc. may produce fistula
: it is made from typical history and local examination {true incontinence}
Three swab test:�
3 cotton swabs are placed in the
vagina—one at the vault, one at the
middle and one just above the
introitus & methylene blue is instilled
into the bladder  patient is asked to
walk for about 5 minutes.

:
 Preventive – Care to be taken to avoid injury to the bladder during Obs or Gynae surgery
 Immediate management: continuous catheterization for 6–8 weeks may help spontaneous closure
of the fistula tract.
 Appropriate counselling
 Local repair of the fistula is the surgery of choice.
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2. How will you manage a case of vaginal fistulae? [02]

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 a. Rectovaginal fistula. [09, 08]
Ans.

Definition: Abnormal communication between the rectum and vagina with involuntary escape of
flatus and/or feces into the vagina is called rectovaginal fistula (RVF)
Causes:
Congenital causes – The anal canal may open into the vestibule or in the vagina
Acquired causes
 Obstetrical causes: Incomplete healing of CPT; Obstructed labor & Instrumental injury
 Gynaecological causes: Incomplete healing of old CPT; trauma during vaginal tubectomy, Fall on
a sharp pointed object, Malignancy of the vagina (common), cervix or bowel, Radiation etc.
Diagnosis: it is made from typical history and local examination {Involuntary escape of flatus and/or
feces into the vagina}
 Confirmation may be done by a probe passing through the vagina into the rectum
 Sigmoidoscopy and proctoscopy for taking biopsy of fistula edge
Treatment:
 Preventive: Good Intranatal care, identification of CPT and its effective repair. Care to be taken to
avoid injury to the bladder during Obs or Gynae surgery
 Definitive surgery for fistulas:
 Situated low down—to make it a complete perineal tear and repair it as that of CPT.
 Situated in the middle-third —repair by flap method {transvaginally}.
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1. Define Genuine Stress Incontinence (GSI) – Etiopath, C/F & Dx [16, 14, 04]
a. Clinical diagnosis of stress incontinence. [13]
Ans.
: Genuine stress incontinence (GSI) is defined, according to the international continence
society (ICS) as involuntary urethral loss of urine when the intravesical pressure exceeds the maximum
urethral pressure in the absence of detrusor activity.
: GSI is strictly an anatomic problem.
In the normal continent woman, the bladder neck and the
proximal urethra are intra-abdominal and above the pelvic
floor
GSI occurs due to Descent of the bladder neck and proximal
urethra��
Risk factors: elderly female, obesity, pregnancy, postmenopausal, Following surgery like anterior
colporrhaphy, local repair of VVF or bladder neck surgery
: escape of urine with coughing, sneezing or laughing;
Stress test—When the patient is asked to cough, a few drops of urine are
seen escaping from the external urethral meatus. If the escape is not detected
in supine position, the examination is to be conducted in standing position
�.
: done to confirm the diagnosis & r/o other pathologies�
:�

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----------------------------------------------------------------------------------------------------------------------------------------
2. Urinary incontinence – types & DDx [10, 05, 03]
Ans.

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1. Indications for continuous bladder drainage. [03]

Ans.
Urethral Caruncle
Repair of Vesico Vaginal Fistula
Urethrovaginal Fistula
Vaginal/abdominal hysterectomy
In radical hysterectomy
In simple Vulvectomy
Urinary retention due to pelvic tumor/retroverted gravid uterus

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1. What are the causes of male infertility? Write the normal values of seminal analysis. How will you
treat oligospermia? [13]
a. Semen/seminal fluid analysis. [14, 12, 11, 08, 04, 02] 21
b. Male infertility. [04]
c. Causes & investigations for Azoospermia. [2000]
Ans.
Normal values of seminal analysis:

Oligospermia – Sperm count is less than 20 million per ml.

Azoospermia: No spermatozoan in the semen

V2 PCF TRAM

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2. Define primary infertility. Mention the causes of female infertility. How do you manage a case of
anovulatory infertility in a women aged 30 years. [12]
a. Ovarian causes of infertility. [10]

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 b. 'Sterility in the female’ – causes, inv. & treatment [04, 02]
c. Tubal factors in sterility. [02]
Ans.
 Infertility is defined as a failure to
conceive within one or more years
of regular unprotected coitus.
 Primary infertility denotes those
patients who have never conceived
 Causes of Female Infertility:

----------------------------------------------------------------------------------------------------------------------------------------

1. Tests for ovulation. [16, 14, 04, 03]

a. Methods of detecting ovulation. [06]; Fern test. [02]
Ans.
Tests for ovulation �
– Mid-menstrual bleeding (spotting) or pain or
excessive mucoid vaginal discharge (Mittelschmerz syndrome).
– take oral temperature daily on
waking in the morning before rising out of the bed;
 There is “biphasic pattern” of temperature variation in ovulatory cycle.
 If pregnancy occurs, the rise of temperature sustains along with
absence of the period
 In anovulatory cycle, there is no rise of temperature throughout the cycle
– Disappearance of fern pattern is suggestive of ovulation {due to effect of E&P}
– Maturation index shifts to the left
– reveals secretory activity of the endometrial glands
during mid cycle can precisely measure the Graafian follicle just prior to
ovulation – The features of recent ovulation are collapsed follicle and fluid in the pouch of Douglas.
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2. Hydrosalpinx. [12]
Ans.
Collection of mucus secretion into the fallopian tube is called hydrosalpinx
: It is usually the end result of repeated attacks of mild endosalpingitis by pyogenic
organisms of low virulence but highly irritant – Ex: Staphylococcus, E. coli, Gonococcus, Chlamydia
trachomatis, etc.
– Ultrasound & Colour Doppler {TVS} – Sausage-shaped complex cystic structure with
reduced resistance index (RI) in the adnexal region.
: Formation of tubo-ovarian cyst; Torsion; Infection from the gut & Rupture
:
 Surgical options {if pain}: salpingectomy can be done via laparoscopy
 IVF is the main line of treatment of infertility caused by hydrosalpinx
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3. Post coital tests. [04, 03]
a. Pre requisites of Post coital test. [13]
Ans.
PCT is an infertility investigation which is done to assess the quality of cervical mucus and the ability of
sperm to survive in it.
Principle of PCT:
 Examination of the cervical mucus is done few hours (within 8–12 hours) after sexual intercourse
 Presence of at least 10 progressively motile sperm per high power field signifies the test is normal.
PCT has got poor predictive value. Moreover, the test procedure is inconvenient and embarrassing.
Routine postcoital test is not recommended
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4. Uses of condom in Gynaecology. [02]
Ans.

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1. Intra uterine insemination. [17]

Ans.
 IUI is done to bypass an abnormal endocervical canal and
to place increased concentration of motile sperms close to
the fallopian tubes.
 Indications: �
-------------------------------------------------------------------------------------------------------------------------------------
2. Ovulation induction. [15, 03, 2000]
Ans.
It can be done by the following measures:
:

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 Psychotherapy to improve the emotional causes, if any.
Reduction of weight in obesity as in PCOS cases. This facilitates spontaneous ovulation.
:
 To stimulate ovulation – Ex: Clomiphene citrate, Letrozole, recombinant hCG, GnRH analogues etc.
 To correct Biochemical Abnormality – Ex: Metformin (insulin sensitiser) for insulin resistance
 Substitution therapy – Ex: Thyroxine for Hypothyroidism
: some options are:
Laparoscopic ovarian drilling (LOD) or laser vaporization – for PCOS
Surgery for pituitary prolactinomas
Surgical removal of virilizing or other functioning ovarian or adrenal tumor
Salpingography to remove any proximal tubal block

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1. Emergency contraception. [17, 15, 06, 2000]
a. Post coital contraception. [09, 05, 01]
Ans.
Post-coital contraception: (or "morning after" or Emergency contraception or interceptives) is
recommended within 72 hours of an unprotected intercourse, rape or contraceptive failure
Mode of action: The hormones may delay ovulation if taken soon after intercourse, cause corpus
luteolysis, changes in cervical mucus and endometrial atrophy
2 methods are available:
– especially a copper device within 5 days.
– the options are:
Levonorgestrel {LNG} 0.75 mg tablet {1st dose within 72h & 2nd dose within 12h of the 1st dose} -
Mifepristone 10 mg once within 72 hours – competitive antagonist of progesterone
Ulipristal 30 mg within 5 days – progesterone receptor modulator.
Centchroman - Two tablets (60 mg) taken twice within 24 hours – Antiestrogenic
Prostaglandins – vaginal suppositories – not routinely used
Emergency Contraceptive Pills (ECPs) are provided by the trained ASHAs, ANMs etc. at door step (in
pilot districts), Village level, Subcentre & higher levels
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2. Methods of second Trimester MTP. [17, 16]
a. Indications for MTP. [15]
Ans.
The Medical Termination of Pregnancy Act, 1971 lays down:
The conditions under which a pregnancy can be terminated (5 indications).
The person or persons who can perform such terminations (Registered Medical Practitioner)
The place where such terminations can be performed (at places approved by the Government).
Indications to terminate a pregnancy under the MTP Act, 1971:
1) Medical – where continuation of the pregnancy might endanger the mother's life.
2) Eugenic – where there is substantial risk of the child being born with serious handicaps
3) Humanitarian – where pregnancy is the result of rape
4) Socio-economic – where actual or foreseeable environments (whether social or economic) could
lead to risk of injury to the health of the mother, and
5) Failure of contraceptive devices SHE - FM
Period of gestation must be 'less than 20 weeks'
Need opinion of 2 doctors if MTP is performed after 20 weeks (to avoid female infanticide) & it
should be carried out in a place fully equipped with anaesthesia and an operation theatre to handle
any complication.
The written consent of the guardian is necessary before performing abortion in women under 18
years of age, and in lunatics even if they are older than 18 years.

Methods of second Trimester MTP:

Medical methods: by using abortifacient drugs

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  Prostaglandins {PGE2} given vaginally, intra-amniotic, extra-amniotic or IM
 Extraovular instillation of drugs such as ethacridine lactate
 Mifepristone and Misoprostol - Commercially it comes as MTP kit having combipack tablets of
mifepristone 200 mg one tablet and misoprostol 200 mcg 4 tablets (800 mcg).
 Combined Methods – used frequently – Ex: Emcredil plus PG
Surgical evacuation – D&C
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3. Methods of contraception. [16]
a. Non hormonal contraceptives. [10]
Ans.
A method which allows intercourse & yet prevents conception is called a contraceptive method

Labial Adhesions - 19/17

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4. OCPs – MOA, Benefits & Contraindications. [15, 13, 08, 07, 03]
a. Non contraceptive benefits of oral contraceptives. [14]
Ans.

Combined Oral Pills (Ex: Novelon, Yasmin, Ovral-L etc.) block pituitary secretion of gonadotropin →
prevent the release of the ovum from the ovary.
Progestogen-only
Preparations render the A. Nonserious B. Side effects that
C. Serious complications
cervical mucus thick and side effects appear later
scanty and thereby inhibit Leg vein thrombosis
sperm penetration. They 1) Weight gain, and pulm. embolism
also inhibit tubal motility a) Nausea and acne and ↑ Coronary and
and delay the transport of vomiting body hair Cerebral thrombosis
the sperm and of the ovum b) Headache 2) Chloasma resulting in
to the uterine cavity c) Breakthrough 3) Pruritus vulvae myocardial infarction
bleeding or 4) Precipitation of or stroke
: Cancer of the spotting diabetes Rise in BP
breast and genitals; liver d) Breast 5) Mood swings Cervical Cancer
disease; history of tenderness and mental Benign hepatomas
thromboembolism; cardiac depression Gallstones
abnormalities; congenital Ectopic pregnancies
hyperlipidaemia; undiagnosed abnormal uterine bleeding.

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 : Age over 40 years; smoking; Mild HTN; chronic renal disease; epilepsy; migraine; nursing
mothers in the first 6 months; DM; gall bladder disease; history of infrequent bleeding, amenorrhoea,
etc.
Apart from preventing unplanned pregnancies, OCPs give protection against at
least 6 diseases: enign Breast Disorders including fibrocystic disease and fibroadenoma, varian
cysts, ron-deficiency anaemia, elvic inflammatory disease, ctopic pregnancy and varian cancer.
----------------------------------------------------------------------------------------------------------------------------------------
5. Mention indications for female sterilization. Add a note on mini-lap tubectomy. [14, 07, 06]
a. Failure of female sterilization. [12]
b. Interval sterilization. [09]
c. Puerperal sterilization. [04]
Ans.
Indications for female sterilization:
Family planning purposes – in multiparous women
Psychiatric problems.
Eugenic- repeat fetal malformations, haemophilia, Rh incompatibility, Wilson’s disease, Tay-Sachs
disease and Ma1-fan syndrome
Medicosurgical indications (therapeutic): During 3rd time repeat cesarean section or repair of
prolapse operation & co-morbidities – to avoid the risks involved in the future childbirth process.
:
Puerperal sterilization - done within 24–48 hours following delivery. Hospital stay and rest at home
following delivery are enough to help the patient to recover simultaneously from the two events,
i.e. delivery and operation.
Interval sterilization - done beyond 3 months following delivery or abortion. The ideal time of
operation is following the menstrual period in the proliferative phase.
– Tubectomy {resection of fallopian tubes}
When the tubectomy is done through a small abdominal incision along
with some device, the procedure is called mini-lap
Procedure:
Local anaesthesia  small incision (0.5 – 0.75 inch) on
abdomen  introduce the retractor into abdomen
Introduce the uterine elevator transvaginally  elevate
the uterus seize the thube by the artery forceps
Select a technique of tubectomy {Pomeroy’s, Uchida,
Irving, Madlener, or Kroener’s fimbriectomy} on one
side & repeat on the other side. �
The peritoneum is closed by purse string suture isthmic portion
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6. Laparoscopic sterilization. [13, 04, 02]
Ans.
 This is done in the interval period, concurrent with vaginal termination of pregnancy or 6 weeks
following delivery
 The tubes are occluded either by a silastic ring (silicone rubber with 5 % barium sulfate) or by
Filshie clip made of titanium lined with silicone rubber.

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7. Injectable contraceptives. [12]
a. Injectable hormonal contraception. [09]
Ans.
The Injectable contraceptives commonly used are depomedroxy progesterone acetate (DMPA) and
norethisterone enanthate (NET-EN).
: Both are administered IM (deltoid or gluteus muscle) within 5 days of
the cycle. The injection should be deep, Z-tract technique and the site not to be messaged.
: DMPA in a dose of 150 mg every 3 months (WHO 4 months) or 300 mg every
6 months; NET-EN in a dose of 200 mg given at two-monthly intervals.
:
(1) Inhibition of ovulation — by suppressing the mid cycle LH peak
(2) cervical mucus becomes thick and viscid thereby prevents sperm penetration
(3) Endometrium is atrophic preventing blastocyst implantation.
:
 It eliminates regular medication as imposed by oral pill
 It can be used safely during lactation; No estrogen related side effects
 Menstrual symptoms, e.g., menorrhagia, dysmenorrhea
 Can be used as an interim contraception before vasectomy becomes effective
 The non-contraceptive benefit – the risk of PID, endometriosis, ectopic pregnancy, ovarian
cancer, endometrial cancer, salpingitis, iron deficiency anemia & sickle cell problems
:
Chance of irregular bleeding and occasional phase of amenorrhea – Return of fertility after their
discontinuation is usually delayed for several months (4–8 months).
Loss of bone mineral density (reversible)
Overweight, insulin resistant women may develop diabetes.
Other side effects are: weight gain and headache.
: Women with high risk factors for osteoporosis
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8. IUCDs – MOA, types, side effects & complications [15, 12, 08, 06, 03]

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 a. 2nd generation IUCD. [10]
b. Copper- T 200. [07]
Ans.
IUDs are not recommended for women who have not had children or who
have multiple partners, because of the risk of PID and possible infertility
Types of IUD - 2 types: Non-medicated and Medicated
(Bioactive).
Types of IUDs Specific Points
1. Non- They appeared in different shapes and sizes
Medicated Aka 1st Gen IUDs Ex: Lippes Loop (Double-S-shaped) – It contains a small
(inert) IUDs amount of barium sulphate to allow X-ray observation
 Copper has a strong anti-fertility effect →possible to develop
Copper IUDs smaller devices which are easier to fit, even in nulliparous women
(2nd Gen IUDs)  Earlier devices: Copper – 7 & Copper T – 200
 Newer devices:
2. Medicated (Numbers in the name
• Variants of the T device {i) Cu-T- 220 C {ii) Cu-T-380 A or Ag
refers to the surface area
(Bioactive) IUDs of the copper on the • Nova T
device)
(They have less side • Multiload devices (i) ML-Cu-250 {ii) ML-Cu-375
effects) ⇨ Ex: T-shaped devices – Progestasert & LNG-20
Hormone-releasing {Levonorgestrel = Mirena)
(3 Gen IUDs)
rd
⇨ Hormones are released slowly into the uterus
⇨ LNG-20 has an effective life of 10 years
 In India, under the National Family Welfare Programme, Cu- T - 200 B & Cu-T-380 A are being used.
Mechanism of action of IUDs
 IUDs cause biochemical changes in the endometrium and uterine fluids→ impair the viability of the gamete and thus reduce
its chances of fertilization.
 Medicated IUDs produce other local effects that may contribute to their contraceptive action.
Advantages of IUDs:
1. Simplicity, i.e., Insertion takes only a few minutes
2. Once inserted IUD stays in place as long as required
3. Inexpensive
4. Contraceptive effect is reversible by removal of IUD
5. Virtually free of systemic side-effects a/w hormonal pills
6. Highest continuation rate, and
7. There is no need for the continual motivation required to take a pill
daily or to use a barrier method consistently.
Contraindications
 Absolute: suspected pregnancy, pelvic inflammatory
disease, vaginal bleeding of undiagnosed aetiology, cancer
of the cervix, uterus or other pelvic tumours & previous
ectopic pregnancy
 Relative: anaemia, menorrhagia, history of PID since last
pregnancy, purulent cervical discharge, fibroids &
unmotivated person
Side-Effects And Complications
Increased Vaginal Bleeding -can lead to Iron-deficiency
anaemia – seen esp. with non-medicated IUCDs.

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 Pain – may manifest as low backache, cramps in the lower abdomen and occasionally pain down the
thighs. Pain could also be due to infection. Pain is more commonly observed in nullipara
Pelvic inflammatory disease (PID) – due to introduction of bacteria into the uterus during IUD insertion.
 The organisms include Gardnerella, Anaerobic streptococci, Bacteroides, Coliform bacilli and
Actinomyces.
 Even one or two episodes of PIO can cause infertility (by permanently blocking the fallopian tubes).
Therefore, young women should be fully counselled on the risks of PID before choosing an IUD.
Uterine perforation – IUD may migrate into the peritoneal cavity → intestinal obstruction, peritoneal
adhesions.
Pregnancy - failure rate of IUD in the first year is approximately 3%. About 50% of uterine pregnancies
occurring with the device in situ end in a spontaneous abortion
Ectopic pregnancy – symptoms are lower abdominal pain, dark & scanty vaginal bleeding or
amenorrhoea.
Expulsion – usually occurs during the first few weeks following insertion or during menstruation. In
general, expulsion in itself is not a serious problem, but if expulsion is unnoticed, pregnancy may occur.
Fertility – PID is a threat to woman's fertility.
Mortality - is extremely rare & usually follows complications like septic spontaneous abortion or
ectopic pregnancy
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9. Vasectomy. [11, 05, 2000]
Ans
 It is a permanent sterilization operation done in the male where a segment of vas deferens of both
the sides are resected and the cut ends are ligated
 Selection of candidates: Sexually active and psychologically adjusted husband having the
desired number of children is an ideal one
 It is commonly done at present in India
 : simple operative technique, can be done as an outdoor procedure & minimal
complication.
 : Additional contraceptive protection is needed for about 2–3 months following
operations; Frigidity or impotency when occurs is mostly psychological
 : They are given to ensure normal healing of the wound and
the success of the operation:
To avoid taking bath for at least 24 hours after the operation
To have the stitches removed on the 5th day after the operation
To wear a T-bandage or scrotal support (langot) for 15 days and to keep the site clean and dry.
To avoid cycling or lifting heavy weights for 15 days
The patient should be told that he is not sterile immediately after the operation; at least 30
ejaculations may be necessary before the seminal examination is negative.
To use contraceptives until aspermia has been established.
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10. Barrier Contraception. [05, 03]
a. Advantages and disadvantages of condoms. [04]
Ans.
Barrier Contraception aka "occlusive" methods of contraception

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 of these methods is to prevent live sperm from meeting the ovum.
Barrier methods Specific Points
 Latex Allergy
Condoms
 Failure rates for the condom are mainly due to incorrect use.
(Ex: Nirodh)
 Can be used with Spermicidal Jelly
 It is a pouch made of polyurethane, which lines the vagina
Female condom  It is an effective barrier to STD infection
 Spermicidal jelly is not usually needed
1. Physical  It is a shallow cup made of synthetic rubber or plastic
Methods material.
Diaphragm
(Aka Dutch cap).
 It is a vagina barrier held in position partly by the spring
tension and partly by the vaginal muscle tone
 A spermicidal jelly is always used along with the diaphragm
- It is a small polyurethane foam sponge saturated with the
Vaginal sponge spermicide, nonoxynol-9
- Trade Name: TODAY
Foams Foam tablets, Foam aerosols Spermicides are "surface-active
2. Chemical
Creams, jellies agents" which attach
Methods Squeezed from a tube
and pastes themselves to spermatozoa
Suppositories and inhibit oxygen uptake and
{Spermicides} Inserted manually
Soluble C-films kill sperms
:
They are easily available, safe and inexpensive; easy to use; do not require medical supervision
Absence of side-effects associated with the "pill" and IUD.
Protection from STDs
:
They are less effective than either the pill or the loop.
They are only effective if they are used carefully – Ex: Condoms may slip off or tear during coitus
Condoms may interfere with sex sensation locally
Physician maybe needed to demonstrate the technique of inserting the diaphragm into the vagina
Toxic shock syndrome can occur if diaphragm is left in the vagina for long periods.
Spermicides have a high failure rate, they must be used before each intercourse & may cause mild
burning or irritation, besides messiness
No spermicide which is safe to use has yet been found to be really effective
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1. Progesterone only pill. [16]

a. Mention the advantages of mini pill. [14]
Ans.
POP is devoid of any estrogen compound
It has to be taken daily from the first day of the cycle and at the same time of the day.
It contains very low dose of a progestin in any one of the following forms — LNG 30 µg,
norethisterone 350 µg, desogestrel 75 µg or norgestrel 75 µg.

Advantages of Minipills Disadvantages of Minipills

Side effects attributed to estrogen in the combined pill are  Acne, mastalgia,
totally eliminated headache, breakthrough

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 No adverse effect on lactation  can be prescribed in lactating bleeding, or at times
women “Lactation Pill” amenorrhea
Easy to take as there is no “On and Off” regime  Simple cysts of the ovary
Can be prescribed to patient having (medical disorders) HTN,  Failure rate is about 0.5–2
fibroid, diabetes, epilepsy, smoking and history of per 100 women years of
thromboembolism use
 the risk of PID and endometrial cancer.
----------------------------------------------------------------------------------------------------------------------------------------
2. Triphasic pills. [11]
Ans.
 It is an attempt to minimize undesirable side effects of OCPs on lipid metabolism.
 In these preparations, the hormonal doses of each compound vary over the course of the cycle.
 Example: Triquilar tablets — First 6 tablets contain 50 mcg LNG and 30 mcg of ethinyl estradiol;
next 5 tablets contain 75 mcg LNG and 40 mcg ethinyl estradiol; the last 10 tablets contain 125
mcg LNG and 30 mcg ethinyl estradiol. It has to be taken like conventional ‘pills’.
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3. Enumerate various methods of tubal sterilization? [10]
Ans.
Laparotomy
Minilaparotomy
Vaginal route
Laparoscopy
Hysteroscopy
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4. Complications of tubectomy. [04]
Ans.
Immediate complications – hemorrhage, injury to the rectum, related to the anesthesia etc.
Late Complications: Incisional hernia, Chronic pelvic pain, Congestive dysmenorrhea, AUB, Post-
ligation syndrome {Pelvic pain, menorrhagia & cystic ovaries} & Alteration in libido
Chance of failure & reversibility – Informed consent must be obtained after adequate counselling

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1. Unruptured tubal pregnancy – Diagnosis & Treatment [02]
a. Surgical management of ectopic pregnancy [21]
medical Mx of ectopic - 22
b. TVS (Transvaginal Sonography). [09]
Ans.

- Failure of rise in hCG by two

folds in 48 hrs is suggestive of an ectopic pregnancy
– it reveals an empty uterine cavity,
an adnexal mass with free fluid in the peritoneal cavity
Blob sign – a blood clot with the trophoblastic tissues.
Bagel sign - empty gestational sac in the fallopian tube
reveals  vascularity (fireball
appearance)
– Aspiration of the Pouch of Douglas – it reveals 2-5 mL of non-clotting blood
– Ex:  placental protein 14; progesterone
Laparoscopy
:
 The surgical treatment comprise salpingectomy, partial salpingectomy, salpingostomy and milking
of the tube
 Conservative tubal surgery – done only if the contralateral tube has been removed or is diseased 
recurrent abortion
 Early diagnosis is the key to conservative
management

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1. Pelvic Hematocele. [11]

Ans.

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A profuse haemorrhage causes blood to collect in the pouch of Douglas to form a pelvic haematocele.
: ruptured tubal gestation
: the swelling pushes the uterus forwards 
elongation of urethra & retention of urine.
 An irregular swelling can be felt through the posterior fornix in
the pouch of Douglas
 If the pelvic haematocele gets secondarily infected, the patient
develops slight fever
: Pelvic abscess; Retroverted gravid uterus

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1. Diagnosis of choriocarcinoma. [09]
Ans.
Choriocarcinoma is a highly malignant tumor arising from the chorionic epithelium
 The diagnosis is based on clinical features and histological evidence when available.
 Clinical Features: ovarian enlargement; Small, hemorrhagic tumor with early hematogenous
spread to lungs, brain, liver etc.
 Histological evidence: composed of cytotrophoblasts and
syncytiotrophoblasts; mimics placental tissue, but villi are
absent
  Serum β-hCG level,
 X-ray of lungs as well as CT scan of lungs and brain, &
ultrasound scan of liver and pelvis
 Staging: �
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2. Treatment of Chorio carcinoma. [05, 04]
Ans.
–
Chemotherapy alone is
successful in curing 85 % of
patients �
Surveillance During & After
Therapy: Serum hCG value
monitoring every week →
once negative → every 2 weeks for 3 months → every month for 1
year → every 6–12 months for life or at least 3–5 years
the no.
of courses of chemotherapy
Preventive measures –
Ex: Selective
hysterectomy in
hydatidiform mole over
35 years
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1. Methotrexate {uses in Gynaecology} [16, 14, 13]

Ans. It is an anti-metabolite {folate antagonist} – prevents reduction of folic acid to folinic acid by
inhibiting the enzyme dihydrofolate reductase.
Used in ectopic pregnancies, choriocarcinoma & carcinoma of ovary & cervix
Side Effects: megaloblastic anemia, stomatitis, vomiting, alopecia, hepatic/pulmonary fibrosis
Folinic acid is to be administered simultaneously to prevent serious side effects

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1. Secondary Amenorrhea (incl 4 causes) [14, 08, 02]
a. Investigations in secondary Amenorrhoea. [05]
Ans.

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2. Primary Amenorrhoea. [12, 06, 04, 02]
Ans.
{Refer the Management from
“Infertility”}

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1. Hypomenorrhea. [16]
Ans. It refers to regular menstruation which lasts for only 1-2 days with scanty blood loss
Etiology: hypoplastic uterus, genital TB, partial Asherman syndrome, OCPs & near menopause

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1. Abnormal uterine bleeding – Define, causes & Mx in various age groups [19, 17, 15, 10]
a. Causes for menorrhagia in fibroid uterus [20]
b. Puberty Menorrhagia & it’s Mx [14, 09]
c. Menorrhagia – Define, causes, DDx & Mx in a 30-year-old woman with 2 children [12, 11, 08, 05]
d. Dysfunctional uterine bleeding – etiology, pathogenesis, types, Dx & Tt [13, 12, 06, 04]
Ans.
Definition of AUB: AUB refers to either menstrual bleeding which is abnormal in volume,
regularity, timing,
frequency or a non-
menstrual uterine bleeding
(ex: PCB, IMB, PMB etc.)
Menorrhagia is defined as
cyclic bleeding at normal
intervals; the bleeding is
either excessive in amount
(> 80 mL) or duration (>8
days) or both.
Causes of AUB: �
Causes of Menorrhagia:
 Pelvic Causes: Pelvic
congestion, PID, Uterine
fibroids, Adenomyosis,
Endometriosis
 Hormonal causes: Metropathia haemorrhagica
 Contraceptive use: IUCD, Progestogen-only pills, post-tubal sterilization
 General Causes: Coagulopathy, hypothyroidism, Genital TB, Blood dyscrasia etc.
Causes for menorrhagia in fibroid uterus: Whenever the uterine endometrial surface is enlarged,
the bleeding surface is increased, contributing to excessive bleeding
Investigations in AUB case:
Lab investigations: CBP, UPT, serum ferritin, thyroid profile & coagulation profile (BT, CT, PT, aPTT
etc.)
Imaging:
USG – Transvaginal ultrasonography (TVS) is preferred
Doppler ultrasonography – if AV malformation is suspected
MRI – to differentiate between fibroid & adenomyoma
Hysteroscopy or SIS – to rule out intra-cavity lesions
Endometrial tissue sampling by D&C or endometrial aspiration

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 Management of AUB in various age groups:
 General measures to improve
the health status of the patient -
Advice proper diet, adequate
rest during menses, vitamins
and protein supplements and to
maintain a PBAC (Pictorial Blood
Assessment Chart – to know the
extent of blood loss).
 Treat the cause (PALM-COEIN)
 For mild Bleeding – Reassurance
+ IFA supplements + NSAIDs (mefenamic acid 500 mg t.i.d.)
 For moderate bleeding – cyclical Combined OCPs or Progesterone only pills
 For severe bleeding –
 If vitals are unstable  D&C or i.v. estrogen
 If vitals are stable  High dose estrogen & progesterone pills
----------------------------------------------------------------------------------------------------------------------------------------

1. Metropathia haemorrhagica. [13]

a. Cysto-glandular hyperplasia. [01]
Ans.
Aka Cystic glandular hyperplasia or Schroeder’s disease
It’s a type of AUB – seen in premenopausal women
Etiology: estrogen with concomitant phase of amenorrhea for about 6–8 weeks
After a variable period, however, the estrogen level falls resulting in endometrial shedding with
heavy bleeding  painless anovulatory DUB
Medical Management: Medroxyprogesterone acetate; Mefenamic acid & Tranexamic acid
Surgical Management: Uterine curettage; Endometrial ablation/resection; Hysterectomy

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1. Prolapse uterus – Define, etiological factors, symptoms & Mx in a multiparous lady [16]
a. Causes & Mx of uterine prolapse in a women aged 45 years para 6 & living 6 [19]
b. Non-surgical management of genital prolapse. [13]
c. Mx of 3rd degree uterine descent with cystocele, rectocele & enterocoele in 45 y/o women [11]
d. Nulliparous prolapse & it’s Mx [09, 06, 03, 02, 01]
e. Treatment of third degree uterovaginal prolapse in a 35 years old female. [08]
f. DDx of 50 y/o woman presents with a mass per vagina; Aetiology of Genital prolapse; Principles
of Ward-Mayo’s operation [07]
g. Uterovaginal prolapse in a 30 y/o multipara – etiology & Mx [05]
h. 3rd degree uterovaginal prolapse in a 32 years old patient – inv. & treatment [04]
Ans.
Herniation of an organ from its normal anatomic position is known as Prolapse.
Etiological factors of prolapse:
Atonicity – seen in Menopause, Congenital weakness of the supporting structures (in nulliparous women)
Birth injuries – due to Premature bear down efforts prior to full dilatation of the cervix,
Prolonged labour, Perineal tear, Pudendal nerve Injury, instrumental delivery, Multiparity, Big
baby etc.
Other causes – intra-abdominal pressure, Chronic bronchitis etc.
:
‘Something protruding outside vagina’, backache, dragging pain in pelvis
Aggravated by straining, coughing & by heavy work; Relieved on lying down
lf there is a large prolapse, the external swelling may cause inconvenience to her during walking
Vaginal discharge, decubitus ulcer & bleeding can be seen
Incomplete evacuation of bladder or frequency of micturition
Stress urinary incontinence – Involuntary escape of little amount of urine during any act a/w 
intra-abdominal pressure such as coughing, sneezing, change of posture or lifting heavy weight
If there is large cystocele  Difficulty in micturition, and the more they strain, the more difficult it
becomes to pass urine. (Patient will be able to pass urine by repositioning prolapse in vagina with
the help of a finger. This is termed as "splinting".
Rectal symptoms are less remarkable, and constipation is rare
Coital difficulties
:
Assess the degree of prolapse – make the patient stand/squat & ask her to cough
A composite examination — inspection and palpation – is required to arrive at a correct diagnosis.
Look for Stress urinary incontinence
– measure length of cervix, degree of uterine descent and associated prolapse of
anterior and posterior vaginal walls.
: CBP, hemogram, CUE, blood urea, blood sugar, Chest X-ray, ECG etc. – to
decide on her fitness for surgery.
help in localizing the defects in the supporting structures:
Transperineal and vaginal ultrasound reveal defects in the levator ani muscles
Transrectal ultrasound is useful to confirm the presence of enterocele

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 : Vulval cyst, Gartner cyst, cysts of ant. Vaginal wall, urethral diverticula etc.

 Kinking of ureter  renal damage

 UTI
 Cancer of vagina at the site of decubitus ulcer

 Staging: �
 Prevention of prolapse:
 Antenatal physiotherapy
 Proper supervision and management of the second stage
of labour
 Episiotomy – if indicated
 Interval between pregnancies
----------------------------------------------------------------------------------------------------------------------------------------

1. Fothergill’s repair operation. [10]

Ans.

----------------------------------------------------------------------------------------------------------------------------------------

1. Decubitus ulcers (of cervix) [11, 03, 02]

Ans.
 Decubitus ulcers in prolapse refer to ulceration of prolapsed tissue due to friction, congestion and
circulatory changes in the dependent part of the prolapse.
 Treatment: Reduction of prolapse + Daily vaginal packing (with tampons soaked in glycerine and
Acriflavine solution or Betadine) for 7-14 days.
 DDx: Ca cervix

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1. Aetiology and investigations of Pruritus vulvae. [14, 04, 02, 2000]
Ans.

----------------------------------------------------------------------------------------------------------------------------------------
2. Vulval dystrophies. [10]
Ans. Aka as nonneoplastic epithelial disorders, vulvar dystrophies represent a spectrum of atrophic &
hypertrophic
lesions caused
by a variety of
conditions
resulting in
circumscribed
or diffuse
'white
lesions'.

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1. Causes of white discharge per vaginum? How will you investigate & treat such a case? [04]
a. Leucorrhoea & its causes [08, 02]
Ans.

----------------------------------------------------------------------------------------------------------------------------------------

1. Bacterial vaginosis. [14, 13, 05]

a. Clue cells. [11]
Ans.
was previously thought to be Gardnerella vaginalis (Haemophilus vaginalis).
: malodorous creamy vaginal discharge
:
(i) Recurrent infection leading to PID.
(ii) Development of PID following abortion or
(iii) vaginal cuff cellulitis following hysterectomy
(iv) Pregnancy complications: 2nd trimester miscarriage, PROM, preterm birth, endometritis.

 Amsel’s 4 diagnostic criteria are:

1) Homogeneous vaginal discharge.
2) Vaginal pH > 4.5 (litmus paper test).
3) Positive whiff tests
4) Presence of clue cells (> 20% of cells).
 Clue cells: A smear of vaginal discharge is prepared with drops of normal saline on a glass slide and
is seen under a microscope. Vaginal epithelial cells are seen covered with these coccobacilli and the
cells appear as stippled or granular. At times, the cells are so heavily stippled that the cell borders
are obscured. These stippled epithelial cells are called “clue cells”
 Gram-stained vaginal smear: Presence of more Gardnerella with few or absent lactobacilli.

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 Metronidazole — 200 mg orally thrice daily for 7 days.
 Clindamycin cream (2%) and metronidazole (0.75%) gel are recommended for vaginal application
daily for 5 days to prevent obstetric complications.
 The patient’s sexual partner should be treated simultaneously.
----------------------------------------------------------------------------------------------------------------------------------------
2. Use of pessary. [04]
Ans. Pessary is a small soluble block that is inserted into the vagina to treat infection or as a
contraceptive

----------------------------------------------------------------------------------------------------------------------------------------

1. Common Vaginal Infections. [16]

Ans.
 Gonococcal
 Trichomonal
 Monilial
 Chlamydia
 Bacterial vaginosis

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1. Fibroid uterus – C/F, complications. Write the management of Fibroid uterus in a multiparous
woman. [16, 14, 10]
a. Medical & Surgical Mx of Fibroid uterus [21]
b. Treatment of fibroid uterus in the age group of 30-40 yrs [20]
c. Types of fibroids. [06]
d. Fibroid polyp. [04]
Ans.
Fibroid is the commonest benign tumor of the uterus. It is
aka uterine leiomyoma, myoma or fibromyoma.
:�
:

Symptoms Signs
 Asymptomatic - majority
 Menstrual abnormality in  Pallor
submucous or interstital  The tumor may not be
fibroid sufficiently enlarged to be felt
 Dysmenorrhea & Dyspareunia per abdomen
 Infertility  Swelling is dull on percussion
 Recurrent pregnancy loss  Bimanual examination reveals
(miscarriage, preterm labor) the uterus irregularly enlarged
 Pressure symptoms by the swelling felt per
 Lower abdominal or pelvic abdomen
pain

 Regular supervision in asymptomatic cases – look for increase in size

 Investigations to confirm Dx – Ultrasound and Color Doppler (TVS);
MRI; Laparoscopy; Hysteroscopy; HSG; Uterine curettage
 Investigations for pre-op assessment: routine + IV pyelography to
know the ureter anatomy
 Medical Management:
 To minimize blood loss – Antiprogesterones
{Mifepristone}; GnRH agonists; LNG-IUCD
 Surgical Management: Myomectomy,
Embolotherapy & Hysterectomy:
 Myomectomy is the enucleation of myomata from
the uterus leaving behind a potentially functioning
organ capable of future reproduction. Myomectomy
can be done via Laparotomy, Laparoscopy or
Hysteroscopy
 Embolotherapy: Uterine artery embolization (UAE)
 avascular necrosis shrinkage of fibroid.

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 Hysterectomy in fact, is the operation of choice in symptomatic fibroid when there is no valid
reason for myomectomy. There is no chance of recurrence
----------------------------------------------------------------------------------------------------------------------------------------

1. Principles of Myomectomy. [17]

Ans.

----------------------------------------------------------------------------------------------------------------------------------------
2. Complications of myomectomy. [13]
Ans.

Hemorrhage—intraperitoneal from the uterine wound – due to imperfect haemostasis during

surgery.
Injury to bladder and ureter—specially with cervical and broad ligament myomas.
Injury to the Fallopian tubes—during incision and suturing.
Injury to bowel.
: recurrences, persistence of menorrhagia, pregnancy rate etc.
----------------------------------------------------------------------------------------------------------------------------------------
3. Red degeneration of Fibroid uterus. [15, 04]
Ans.
Red degeneration (carneous degeneration) occurs in a large fibroid mainly during 2nd half of
pregnancy and puerperium.
The cause is not known but is probably vascular in origin
Cut section of the tumor  raw-beef appearance with cystic spaces {due to the presence of
hemolysed red cells and hemoglobin}
The odor is often fishy due to fatty acids
Partial recovery is possible and as such called necrobiosis.
----------------------------------------------------------------------------------------------------------------------------------------
4. Infertility in Fibroid uterus. [09]
Ans.
Infertility in Fibroid uterus can occur due to the following factors:

Distortion of the uterine cavity  difficult sperm ascent

Fibroids prevent rhythmic uterine contraction during intercourse  impaired sperm transport
Menorrhagia and dyspareunia
Defective nidation due to endometrial involvement
- Cornual block due to position of the fibroid
: Anovulation
: Endometriosis

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1. Endometriosis – pathology, symptoms, signs, Dx & medical Mx [15, 14, 03]
a. Treatment of endometriosis [17, 04, 2000]
b. Chocolate cyst. [16, 14, 10, 08, 07, 05]
c. Management of severe pelvic endometriosis. [09]
Ans.
Endometriosis is defined as the presence of ectopic endometrial tissue at a site outside of the uterus.
 : 30 – 40s
 : Ovaries (MC), uterine ligaments, rectovaginal septum, cul de sac; chocolate cyst of the ovary,
pouch of Douglas, appendix lungs etc.
 :
1) The regurgitation theory: It proposes that endometrial tissue implants at ectopic sites via
retrograde flow of menstrual endometrium.
2) The benign metastases theory: It states that benign endometrial tissue can spread to distant
sites (lung, brain) from uterus via blood vessels & lymphatic channels.
3) The metaplastic theory: It states that endometrium arises directly from coelomic epithelium.
4) The extrauterine stem/progenitor cell theory: It proposes that stem/progenitor cells from the
bone marrow differentiate into endometrial tissue.
 : Overproduction of prostaglandins & estrogen enhances the survival and persistence
of endometriotic foci.
 :
 Severe dysmenorrhea, dyspareunia & pelvic pain;
Menstrual irregularities; Infertility
 Chocolate cysts or endometriomas: Distorted ovary with
large cystic masses filled with brown fluid

 : Ovarian endometrioid & clear cell carcinomas

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1. Adenomyosis & it’s treatment [13, 12, 11, 06, 05, 04, 2000]
Ans.
Presence of endometrial tissue within the myometrium.
 unknown; It may be related to repeated childbirths, vigorous curettage or excess of
estrogen effect
 Parous women > 40 yrs. with Irregular & heavy menses; colicky dysmenorrhea,
dyspareunia & pelvic pain
 Investigations to confirm Dx – Ultrasound and Color Doppler
(TVS – swiss cheese pattern); MRI;
 Medical Mx is not beneficial – hence, it is mainly
surgical.
 Conservative surgery – Ex: Adenomyomectomy
 Hysterectomy – in parous and aged women.
 : Endometriosis
----------------------------------------------------------------------------------------------------------------------------------------
2. Endometrial biopsy. [03] vsq 22
Ans.
Endometrial biopsy can be
done using the Sharman
curette as an outpatient basis
Indications: �
 To detect evidence of
ovulation — by seeing the
secretory changes in the
endometrium
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1. Complications of vaginal hysterectomy. [19, 15]

Ans.

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2. Abdominal hysterectomy – Indications & 4 complications. [14, 12]
a. Post operative complications of hysterectomy. [04]
Ans.

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1) Conization. [13]
a. Cone biopsy & it’s indication [21, 02]
b. Cervical Biopsy. [08, 05]
Ans.
It is an operation which involves removal of cone of the cervix which includes entire
squamocolumnar junction, stroma with glands and endocervical mucous membrane
Indications: Conization is done as diagnostic and therapeutic purpose in CIN:
Unsatisfactory colposcopic findings.
Inconsistent findings—Colposcopic, cytology and directed biopsy
Positive endocervical curettage.
When biopsy cannot rule out invasive cancer from CIS
Procedure: It is conventionally done with cold knife. Currently, it is being done with the help of
CO2 laser used as scalpel under colposcopic guidance.
The excised cervical tissue is sent for histological examination
Complications: Secondary hemorrhage, Cervical stenosis, Infertility, Cervical incompetence
leading to recurrent miscarriage, Mid-trimester abortion or preterm labor.
----------------------------------------------------------------------------------------------------------------------------------------
2) Cervical erosion and its treatment. [10, 07, 06, 01]
Ans.
Cervical erosion {aka Cervical ectopy} is a condition where the squamous epithelium of the
ectocervix is replaced by columnar epithelium, which is continuous with the endocervix. It’s not an
ulcer.
Cause: Estrogen excess {seen in neonate, pregnancy & pill user}
Clinical features:
Symptoms Signs
 Vaginal discharge – may be due to 2° infection Per speculum—There is a bright red area
 Contact bleeding surrounding and extending beyond the
 Associated cervicitis  backache, pelvic external os in the ectocervix
pain & at times, infertility.
Complications – delicate columnar epithelium is more vulnerable to trauma and infection.
Management:
Pap smear – to exclude malignancy
In pill users, the ‘pill’ should be stopped and barrier method is advised.
Persistent ectopy with troublesome discharge should be treated surgically {to destroy columnar
epithelium} by—(i) thermal cauterization, (ii) cryosurgery and (iii) laser vaporization
----------------------------------------------------------------------------------------------------------------------------------------
3) Ectropion of cervix [21, 03]
Ans.
Cervical Ectropion means that soft cells from inside of the cervix move to the
outside
: seen in chronic cervicitis  thick cervical mucosa with tissue edema
 thick tissues tend to come out through external os.

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 : the lips of the cervix will curl upwards and outwards to expose the red looking
endocervix
:
Pap smear – to exclude malignancy
Treat the infective cause of chronic cervicitis (if found)
Correct the ectropion by deep linear burns
----------------------------------------------------------------------------------------------------------------------------------------
4) Bartholin’s cyst. [12, 02, 01]
Ans.
Bartholin’s cyst {aka vulval cyst} form near the opening of the vagina on either side of the labia.
The cause may be infection or trauma followed by fibrosis and occlusion of the lumen
Clinical Features:
 Local discomfort and dyspareunia.
 Examination reveals swelling on either side of the labia, it’s medial projection makes the vulval cleft
‘S’-shaped; The cyst is fluctuant and not tender
Treatment: Marsupialization is the gratifying surgery for Bartholin’s cyst

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1. Carcinoma cervix – C/F, Dx, staging, screening & Mx. [21, 19, 15, 13, 12, 11, 10]
a. HPV virus [21]
b. CIN [20]
c. Pap smear [19, 12, 06, 04, 99]
d. Management of CIN III. [16]
e. Prevention of cervical cancer mortality [10]
Ans.

High-risk HPV (16, 18, 31, and 33); Low-risk HPV types 6 and 11
Social factors: Smoking, Dietary deficiencies.
Multiple sexual partners, Use of OCPs & High parity.
Persistent infection by high-risk strains of HPV;
High-risk HPV produce E6 and E7 proteins → ↑ destruction of p53 and Rb →
increases the risk for CIN.
:
 Classification:
CIN I: More common – Majority regress spontaneously. Not a premalignant lesion.
CIN II & III: Less common. High risk of progression to invasive carcinoma. Considered as a
premalignant lesion.
Carcinoma in situ (CIS) involves the entire thickness of the epithelium.
 CIN classically progresses through CIN I, CIN II, CIN III, and CIS to become invasive squamous cell
carcinoma.
 Morphology:
 Immature squamous cells show koilocytic atypia – Nuclear alterations with an associated perinuclear halo
 Nuclear alterations: in size, hyperchromasia, coarse chromatin granules, & variation in
nuclear shape

 Age: 45yrs
 Histologic subtypes: Squamous cell carcinoma (MC); Adenocarcinoma (2nd MC) & Adenosquamous
carcinoma
 Cause: High-risk HPVs; 2° risk factors include smoking and immunodeficiency
 Gross: Fungating or infiltrative mass

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 Micro.
A. Squamous cell carcinoma: Nests of malignant squamous
epithelium, either keratinizing or nonkeratinizing, invading
underlying cervical stroma.
B. Adenocarcinoma: Proliferation of glandular epithelium
composed of malignant cells with large, hyperchromatic
nuclei.
 C/P: Abnormal bleeding P/V, esp. postcoital bleeding, or
cervical discharge
 Spread:
 Local – Urinary bladder, ureters, rectum & vagina
 Distant – Liver, lungs & bone marrow
 Inv.: Pap test; Colposcopy; Biopsy
 Comp.: Ureteral obstruction, pyelonephritis & uremia
 Preventive measures:
1) Vaccination against HPV
 Antibodies generated against types 6 and 11
protect against condylomas
 Antibodies generated against types 16 and 18
protect against CIN and carcinoma.
2) Screening: With Pap test & HPV DNA testing
3) Colposcopy guided biopsy of abnormal mucosa
The goal of screening is to catch dysplasia (CIN) before it develops into carcinoma.
– gold standard for screening.
 Cells are scraped from the
transformation zone using a
brush and analyzed under a
microscope to identify
cytologic abnormalities.
 Dysplastic cells are classified as
low grade (CIN I) or high grade
(CIN II and III).
 Limitations of the Pap smear
include inadequate sampling of
the transformation zone (false -
ve screening) and limited
efficacy in screening for
adenocarcinoma.
by PCR
of the cervix and vagina (If the Pap test shows abnormal cells)
 Application of acetic acid to the cervix highlights abnormal areas
 After confirmation by tissue biopsy, women with LSIL can be followed up with repeat smears.
 HSILs are treated with excision and follow-up smears for life.
Cone biopsy, speculoscopy etc. can also be done
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1. HPV vaccine [21]

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Ans.
Vaccination against HPV
 Antibodies generated against types 6 and 11
protect against condylomas
 Antibodies generated against types 16 and 18
protect against CIN and carcinoma.

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2. Screening & staging of carcinoma breast [18]
Ans.
{Refer Systemic Surgery}
----------------------------------------------------------------------------------------------------------------------------------------
3. Lymphatic drainage of the cervix. [14]
Ans.

From cervix, on each side the lymph vessels drain in

3 directions:
a) Laterally, the lymph vessels drain into external
iliac and obturator nodes by passing parametric
tissue, few of these vessels are intercepted by
paracervical nodes
b) Posterolaterally, the lymph vessels drain into
internal iliac nodes by passing along the uterine
vessels
c) Posteriorly, the lymph vessels drain into sacral
nodes by passing along the uterosacral ligaments

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1. FIGO staging of endometrial carcinoma [19]
Ans.
FIGO Staging for Endometrial Carcinoma 2009
Stage I <50% myometrial invasion
(Tumour confined to
UTERUS)
≥ 50% myometrial invasion
Stage II Cervical stromal invasion
Tumor invasion into serosa or adnexa
Stage III
Vaginal or parametrial involvement
(Local spread)
Pelvic node involvement
Paraaortic node involvement
IVA Tumor invasion into bladder or bowel mucosa
Stage IV
IVB Distant metastases or inguinal lymph node involvement
----------------------------------------------------------------------------------------------------------------------------------------
2. How will you treat endometrial cancer? [07]
Ans.
:
For Stage 1: TAH + BSO
For Stage 2 & 3 – Type 2 (Wertheim’s) hysterectomy is done {instead of TAH} + pelvic & para-aortic
lymph node dissection
For Stage 4 – Debulking surgery + pelvic & para-aortic lymph node dissection
– except in Stage IA
Ex: Brachytherapy for vaginal vault – to avoid local metastasis
: carboplatin + paclitaxel for 6 cycles – given in stage III & IV (along with Radiotherapy).
prolong remission and improve quality of life - Medroxyprogesterone
acetate (MOPA) 1 g weekly or 200 mg orally daily.
Prevention of Endometrial Cancer:
Adding progestogen for 12 days in HRT  risk of endometrial hyperplasia & cancer. Tibolone also reduces the risk
Mirena IUCD
OCPs
The complete treatment of PCOS avoids the risk
Prefer Raloxifene over tamoxifen
Periodic USG to study endometrial thickness in a woman on tamoxifen
----------------------------------------------------------------------------------------------------------------------------------------
3. Predisposing causes for Endometrial carcinoma. [05]
Ans.
1) Long-term unopposed oestrogen
2) Oestrogen-producing tumour
3) Nulliparity, infertility & Menstrual irregularity
4) Obesity
5) Tamoxifen
6) Early age at menarche & Late age at menopause
7) White race, older age, Higher income and education
8) H/o type 2 DM, HTN or thyroid disorder

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1. PCOS (Polycystic Ovary Syndrome) / PCOD [16, 09]
a. Cystic Ovary. [04]
Ans. PCOD is a heterogeneous, multisystem endocrinopathy in women of reproductive age with the
ovarian expression of various metabolic disturbances and a wide spectrum of clinical features such
as obesity, menstrual abnormalities and hyperandrogenism.
Diagnosis –Rotterdam
criteria
 Ultrasound is
diagnostic of PCOS
 Investigations to
detect the associated
endocrinopathies {Ex:
thyroid tests}
Treatment:
Lifestyle changes – weight reduction, avoid smoking, etc.
To regulate menstruation – OCPs
To treat hirsutism – Anti-androgens
{Dexamethasone}; Clindamycin oint. for acne
To manage infertility – Clomiphene Citrate or
Letrozole {Aromatase inhibitor}
To manage insulin resistance – Metformin or
Acarbose
Surgery is reserved for cases where medical therapy fails or for infertile woman
 Surgery comprises laparoscopic chilling or puncture of not more than 4 cysts in each ovary
either by laser or by unipolar electrocautery
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1. Clomiphene Citrate. [03]

Ans. Clomiphene Citrate: It is a non-steroidal compound &
has antioestrogenic effect. �
Uses:
1. For the treatment of infertility due to anovulation.
Cyclical therapy is recommended. Clomiphene should
not be used for >6 cycles because of risk of ovarian
cancer
2. Assisted reproduction therapy (ART) and gamete intrafallopian transfer (GIFT) technique
3. Male infertility: It is used to ↑the sperm count & testosterone secretion.
A/E: hot flushes, nausea, vomiting, headache, loss of hair, hyperstimulation syndrome multiple
pregnancies, ovarian cyst, ovarian malignancy, weight gain, breast discomfort etc.

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1. Complications of ovarian tumour/cyst + Dx of twisted ovarian tumour? [17, 05, 04, 02]
a. Torsion of ovarian tumor/cyst. [15, 06, 04, 03]
Ans.
Predisposing factors for Torsion – They initiate axial
rotation
 Trauma.
 Violent physical movements.
 Contractions of pregnant uterus.
 Intestinal peristalsis.
Features & Diagnosis: �
Treatment
 Analgesics to control pain
 Laparotomy/Laparoscopy should be done at the earliest –
The clamps are placed prior untwisting the pedicle to minimize dislodgement of the thrombi
 Treat complications {if any}
----------------------------------------------------------------------------------------------------------------------------------------

1. Functional ovarian tumour. [10, 09]

Ans.
Also known as Sex cord-stromal tumors – They can be:
Estrogen producing tumors Androgen producing tumors
Sertoli-Leydig cell tumors; Leydig cell
Examples Granulosa cell tumors; Thecomas
tumors
 Precocious pseudopuberty in
Clinical pediatric patients.
Virilization
Presentations  Postmenopausal bleeding in
postmenopausal patients
Management {Refer 1st LQ of Ovarian Cancer}
----------------------------------------------------------------------------------------------------------------------------------------
2. Dysgerminoma. [01]
Ans. “Malignant germ cell tumor of ovary.” Ovarian counterpart of testicular seminoma. Mostly
unilateral.
 Commonest malignant germ cell tumor
 Age: 20-30s
 Predisposing conditions: Gonadal dysgenesis
 Clinical features are not specific for the tumor
 Treatment:
 Systemic chemotherapy is the treatment of choice, where fertility is to be preserved, even in
the presence of metastatic disease. {Regimens – BEP, VBP & VAC}
 In young patient – to preserve fertility – laparotomy for surgical staging and unilateral salpingo-
oophorectomy is done
 Association: Benign cystic teratoma

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1. Dermoid cyst. [11, 08, 07, 04, 01] 22 as SQ

Ans.
Mature (Benign) Teratoma (Dermoid Cyst): MC germ cell tumor of ovary. It consists of well-
differentiated parts derived from two or three germ layers. Tumor mimic tissues normally
produced by the germ cells. Depending on gross features, it can be Cystic or Solid. Tooth structures
& area of calcification may be seen within the wall
 Age: Young women.
 Origin: From ovum after 1st meiotic division
 Micro.:
 Cyst wall is lined with stratified squamous epithelium with underlying sebaceous glands & hair
shafts.
 Cartilage, bone, thyroid & neural tissue may be found.
 Comp.: Malignant transformation to squamous cell carcinoma (Rare)
 Paraneoplastic syndrome: Inflammatory limbic encephalitis
 Associations: Mucinous cystadenoma; Dysgerminoma
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2. Differentiating features of benign and malignant ovarian tumour. [09]
Ans.

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1. Classify ovarian tumors. What are the clinical features? How do you manage a case of malignant
epithelial ovarian Tumour? [09]
a. Malignant Ovarian Tumour & it’s investigations [06, 03]
b. Germ cell tumour of ovary. [02]
Ans.
WHO classification of ovarian tumours: �
Clinical Features of ovarian tumours:
clinically present late with vague
abdominal symptoms (pain and fullness) or signs of
compression (urinary frequency)  poor prognosis
: Often produces estrogen;
presents with signs of estrogen excess
Prior to puberty – precocious puberty
Reproductive age – menorrhagia or metrorrhagia
Postmenopause - endometrial hyperplasia with
postmenopausal uterine bleeding
– produce androgen  hirsutism
and virilization
corresponds to the seminoma of the testis & is a/w LDH & hCG
(Yolk Sac Tumour): seen in young girls; one the fastest growing; a/w
AFP & Schiller-Duval bodies
– tumor resemble placental tissue – but NO villi; it is a/w  hCG
– aka Dermoid cyst or Benign cystic teratoma - It contains sebaceous material
with hair & Teeth, bone, cartilage, thyroid tissue and bronchial mucous membrane on the wall
Monodermal or Highly specialised teratoma - aka - consists of thyroid tissue 
may develop thyrotoxicosis
– maybe a/w with ascites and hydrothorax = Meigs syndrome
Malignant Ovarian Tumours:
: 20% of ovarian tumour are malignant
Of all the malignant tumours, 90% are epithelial in origin, 80% are primary in the ovary and
20% secondary from breasts, GIT & colon.
More common among nulliparous women
Hereditary (familial) ovarian cancer occurs in 2 forms –
1) Hereditary breast ovarian cancer syndrome (BOC) – seen due to BRCA1 & BRCA2 gene mutations
2) Hereditary nonpolyposis colorectal cancer (HNPCC) – autosomal dominant; It is due to mutations in 3 DNA
mismatch repair genes (MLH1, MSH2 and MSH6).
Majority of epithelial ovarian cancers are NOT familial or hereditary

Symptoms Signs
Surface Epithelial tumors clinically present On General Examination: Cachexia, pallor,
late with vague abdominal symptoms Jaundice, U/L non-pitting edema of leg etc.

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 (pain and fullness) or signs of compression On Per Abdomen – enlarged liver, mass in
(urinary frequency)  poor prognosis hypogastrium with irregular surface etc.
Loss of appetite with a sense of bloating after meals. On PV exam –
Gradually, more pronounced symptoms Vulvar edema;
appear like: rapid abdominal sweeling, Uterus may be separated from the mass
sudden weight loss, respiratory distress etc. felt per abdomen;
Nodules felt in the uch of Douglas
Ascites (in Meigs syndrome)
:
(after the capsule is broken) – to adjacent organs such as tubes, broad ligament,
intestines, omentum and uterus
: multiple deposits are formed on the peritoneal surfaces specially in the pouch
of Douglas, in the omentum, diaphragm, retroperitoneal nodes etc.
– to paraaortic and superior gastric nodes. The left supraclavicular nodes are
enlarged To CONFIRM  “cul-de-sac” aspiration  Cytologic examination
– to malignancy   CA-125 with a pelvic mass
lungs, liver, bones, etc. To DETECT  Mammography.
the Primary  Gastroscopy/colonoscopy
: Site Barium meal X-ray
�  Chest X-rat – to r/o pleural effusions & chest metastasis
 Barium enema – to detect any lower bowel malignancy.
:
To identify  USG – to detect involvement of the contralateral ovary
Surgery – the options the extent  CT scan – for retroperitoneal lymph node assessment & for staging
are as follows: of lesion  MRI – to detect the nature of ovarian tumor
Early-stage disease:  PET scan – more sensitive than CT or MRI
In young woman:  Intravenous pyelography
U/L oophorectomy (fertility sparing surgery) → Routine follow up and monitoring → Completion of
family → Removal of the uterus and the other ovary
In Elderly woman → TAH + BSO
Advanced stage disease: Exploratory Laparotomy → Cytoreductive or debulking surgery.
Adjuvant Chemotherapy: carboplatin + paclitaxel every 3 weeks for 6 cycles after the Sx.
Radiotherapy – is less importance currently. Earlier radioactive phosphorus (32P) was instilled into the peritoneal
cavity which led to Bowel complications.
Gene and molecular therapy – under research
– Genetic screening for BRCA 1 & BRCA 2; Use of combined OCPs; CA-125 in
serum; Prophylactic oophorectomy along with hysterectomy in ‘high risk’ women etc.
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1. Krukenberg tumor. [13, 07]

Ans.
Krukenberg tumor is a metastatic adenocarcinoma of the ovary.
Primary sites: Almost all metastasize from the stomach. Few arise in the breast or colon.
Mode of spread to the ovaries: by retrograde lymphatics – stomach  superior gastric lymph
nodes  ovary.
Clinical presentation:
Metastatic tumors from the GI tract can be a/w sex hormone (estrogen & androgen) production.

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 Patient may present with postmenopausal bleeding.
Macroscopic appearance for diagnosis:
 The tumor is usually bilateral, solid with smooth surfaces.
 There is NO tendency of adhesion (i.e., capsule remains intact) & are freely movable in the pelvis
 The tumour retains the shape of the normal ovary & the cut surface has waxy consistency
Histological picture: The mucin within the epithelial cells compresses the nuclei to one pole,
producing ‘signet ring’ appearance.
Prognosis: it is poor. Median survival being less than a year
Management: (refer 1st LQ – Malignant ovarian tumour)
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2. Grading of ovarian malignancy. [06]
Ans.
FIGO Staging for Carcinoma of the Ovary 2014
Stage I Tumour limited to one ovary; No ascites
(Tumour confined to Tumour involves both ovaries; No ascites
ovaries) Like IA or IB with Ascites or +ve peritoneal washing
Stage II Tumour extend on to the uterus and fallopian tube
(Pelvic extension) Tumour extend to other pelvic organs (Bladder, rectum)
Stage III Positive retroperitoneal lymph node only
(Upper Abdominal Gross macroscopic deposits < 2 cm; extension to liver & spleen capsule
involvement) Gross macroscopic deposits > 2 cm; extension to liver & spleen capsule
Stage IV IVA Malignant Pleural effusion (with +ve cytology)
(Distant metastasis) IVB Extension to Liver / spleen parenchyma or inguinal lymph node involved
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1. Granulosa cell tumour [21]

Ans.
Granulosa cell tumours are composed of cells similar to the granulosa cells of Graafian follicle.
Clinical Presentation:
More common in women > 40 yrs of age
Often produces estrogen; presents with signs of estrogen excess
Prior to puberty – precocious puberty
Reproductive age – menorrhagia or metrorrhagia
Postmenopause - endometrial hyperplasia with postmenopausal uterine bleeding
Macroscopic appearance: oval shape & soft in consistency. The cut surface is reticular or
trabeculated with areas of interstitial haemorrhage.
Histologic picture: Call-Exner bodies (cyst-like spaces) are characteristic.
3 histological types of granulosa cell tumours have been identified:
a) Early undifferentiated form which consists of a solid mass of granulosa cell
b) Trabecular form
c) Folliculoid form – well differentiated form; has least malignant potential
Metastasis: first to the opposite ovary  and then in the lumbar region mesentery, liver and
mediastinum

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 Granulosa cell tumours  produce excess estrogen  risk for endometrial carcinoma in
postmenopausal women
Management: (refer 1st LQ – Malignant ovarian tumour)
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2. Gynaecological tumor markers. [16]
a. Tumor markers in ovarian cancers. [12]
Ans.
Tumor markers suggest the nature of tumour & also help to monitor the response during chemotherapy
Some Examples are:
– epithelial tumours, endometriosis & abdominal TB
– germ cell tumours
– granulosa cell tumour.
– endometrioid, Brenner tumour, mucinous tumour, colonic, liver, breast & lung metastasis.
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3. Aetiology of epithelial ovarian cancer. [13]
Ans.
Ovarian cancer is the 4th most common cancer in women after breast cancer, cervical cancer & gall bladder cancer.
Risk Factors for Ovarian Cancer:
 Genetic predisposition – BRCA-1 & BRCA-2 gene mutation
 Age - between 45 and 60 years
 Late menopause
 Multiple cycles of ovulation Induction ( repeated ovulation trauma to the epithelial lining)
 Nulliparous or of low parity
 Woman with previous PCOS, or on tamoxifen
 Family history of breast and gastrointestinal cancers
 Obese, High-calorie, high-fat diet
Epithelial ovarian cancers arise from the mesoepithelial cells on the ovarian surface & constitute
about 80% of all ovarian cancers
 lf the lining of tumour resembles the lining of fallopian tubes  ;
 If the lining resembles endocervical epithelium  ;
 If the lining resembles endometrium  endometrioid tumours;
 If the lining resembles bladder epithelium  clear cell carcinoma
75% of epithelial cancers are of the , about 10% are & 12%-15% are endometrioid.
Brenner tumour, clear cell carcinomas and undifferentiated cancers account for 1% or less each.

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1. Radiotherapy in Gynaecology & it’s complications [19, 04, 02]
Ans.
The effects of radiation on tissues are generally of 2 types:
1) Loss of mature functional cells by apoptosis – This usually occurs within 24 hours of radiation.
2) Loss of cellular reproductive capacity.
Techniques of Radiotherapy in Gynaecology:
– source of radiation is placed within, or close to the tumor (to avoid damage to normal
tissues)
– source of radiation is external to the patient
– source of radiation is placed directly into the tumour as an implant –
Ex: lridium-192 in the vagina & cervix
Complications of Radiotherapy:
Early complications Late complications
Nausea and vomiting – give  Persistent anaemia
anti-emetics  Chronic pelvic pain (due to fibrosis of nerve trunks)
Bladder & rectal irritation –  Post-irradiation ulcers in the bladder  dysuria,
give anti-cholinergics haematuria and vesicovaginal fistula.
Pyelitis, pyelonephritis and  Ureteric stricture and obstructive uropathy
cystitis – give Urinary  Colonic ulcer, perforation, stricture or obstruction
antiseptics and analgesics  Small bowel ulcer, perforation, stricture or obstruction
Malaise, headache and  Cervical stenosis  Pyometra
irritability  Vaginal stenosis  marital discord
Flare-up of sepsis, pyometra &  Disturbed psyche
peritonitis  Ovarian destruction  menopausal symptoms 
Skin reaction osteoporosis  fracture neck of the femur
Pulmonary embolism  Sarcoma
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