Wits Gynaecology

Department of Obstetrics and

Gynaecology

Johannesburg Hospitals and

University of the Witwatersrand
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These guidelines

This booklet is intended as a practical guide to patient care for

registrars, medical officers, interns and medical students attached to
the gynaecology units at the University of the Witwatersrand
Academic Hospitals. Anyone can use it.

This is a new draft; it may contain errors or omissions. Not all will
agree with what is here. If a senior advises you differently, take their
advice. Comments are welcome.

The original contributors were W W Edridge, F Guidozzi, E J

Buchmann, and K Frank. Since then many seniors have contributed,
some substantially.

January, 2017

Spelling: This is in a state of flux. The Americans say gynecologist, the

English gynaecologist. Some prefer dysmenorrhea some prefer
amenorrhoea. Some prefer haematologist some hematologist. Both types
of spellings are included here and accepted.

TABLE OF CONTENTS
Page

Chapter 1: Introduction 4
General comments 4
Blood tests for different conditions and surgery 4

Chapter 2: Clinical methods 5

History taking 6
Physical examination 7
Assessment, diagnosis and management 8

Chapter 3: Lower abdominal pain 9

Differential diagnosis 10
Pelvic inflammatory disease 10
Irritable bowel syndrome 13
Primary and secondary dysmenorrhea 13
Endometriosis & adenomyosis 14
Ovarian cysts 15
Urinary tract infection 16
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Table of contents(contd) Page

Acute appendicitis 17
Lumbosacral root pain 17
Pelvic congestive syndrome 17
Early pregnancy complications 18

Chapter 4: Early pregnancy problems 18

Ectopic pregnancy 18
Miscarriage 21
Gestational trophoblastic disease 24
Hyperemesis gravidarum 26
Recurrent miscarriage 27

Chapter 5: TOP and contraception 29

Termination of pregnancy 29
Contraception 32
Sterilization 35

Chapter 6: Excessive vaginal bleeding(AUB) 36

Clinical assessment 37
Management of dysfunctional uterine bleeding 38
Management for heavy bleeding 38
Vaginal bleeding in a child 39

Chapter 7: Endocrinology and infertility 40

Amenorrhoea 40
Conditions causing amenorrhoea 41
Polycystic ovarian syndrome 43
Premature menopause 44
Prolactinoma 45
Hirsutism 46
Conditions causing hirsutism 47
Premenstrual syndrome 48
Precocious puberty 48
Infertility 49

Chapter 8: Menopause 50
Hormone replacement therapy, hormone therapy 51
Osteoporosis 53
Postmenopausal bleeding 53

Chapter 9: Vulval and vaginal disorders 55

Vaginal discharge 55
Sexually transmitted and other vulval infections 56
Cervical ectropion,ectopy 58
Vulval warts 62
Vulval skin problems and dysplasia 63
Vulvodynia 64
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Table of contents(contd) Page

Chapter 10: Cancer and dysplasias 64

Cervical screening/colposcopy 64
Invasive cervical cancer 69
Endometrial cancer 72
Borderline ovarian tumours 75
Ovarian cancer 75
Vulval cancer 76

Other malignancies 78
Pain relief for cancer patients 78
Care of the terminally ill patient 78

Chapter 11: Other problems 79

HIV infection 79
Sexual assault 80

Chapter 12: Urogynaecology and prolapse 81

Urinary tract infection 81
Urinary incontinence 82
Urinary fistula 85
Uterovaginal prolapse 86

Chapter 13: Surgical procedures and others 88

Pre-operative preparation 88
Manual vacuum aspiration(MVA) 89
Evacuation of the uterus & complications 90
Marsupialization of Bartholin’s abscess & cyst 92
Laparotomy for ectopic pregnancy 93
Laparoscopy 93
Ovarian cystectomy 96
Complications of hysterectomy & laparotomy 97
Post-operative complications 97
General notes on postoperative care 98
Thromboembolism and thromboprophylaxis 99
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CHAPTER 1 INTRODUCTION

GENERAL COMMENTS
This protocol was written to help registrars, medical officers, interns and students
to cope more easily with the daily demands of working in gynaecology units.
There will be differences of opinion with the protocol, between consultants and
between units. With knowledge, experience and common sense, deviations from
this protocol are not a problem if justified.

Readers who disagree with something should offer their opinions. This way the
protocol can be improved.

STUDENTS
Students are expected to be on call with their units. This booklet may assist
students to manage patients, but help must primarily come from the doctors.

KEEPING PATIENTS INFORMED

Whatever is done in the wards, in outpatients or in theatre, the patient must be
kept fully informed at all times. Whether taking a blood test, preparing for an
operation, prescribing antibiotics, sending someone for radiotherapy….. explain
everything. Always ask if there are any questions. Appropriate words (no jargon,
no abbreviations) and language are necessary. If English is not known by the
patient the indigenous S African language must be used. Where possible, the
indigenous language should be used in preference. Where other languages are
needed, try to find someone proficient.

KEEPING MEMBERS OF STAFF INFORMED

Everyone benefits from being informed: tell colleagues what is happening; tell the
sisters. Check that information is accurate and complete. In overworked and
sometimes chaotic hospitals, good communication saves time, prevents
mishaps, and keeps everyone working together.

USE OF THIS PROTOCOL

This protocol is intended for reference. It should also be read through by doctors
at the beginning of their attachment to their gynaecology unit.

BLOOD TESTS FOR DIFFERENT CONDITIONS and Surgery

Miscarriage Hb, Compat if necessary, U&E, Rh
Septic miscarriage FBC, U&E, ABG, PI/PTT, HIV, Compat
Ectopic pregnancy Hb, U&E, hCG, Rh, if necessary,
Compat
Gestational trophoblastic disease FBC, U&E, hCG, thyroid functions,
Compat if necessary
First trimester termination Rh group
Second trimester termination Hb*, Rh group, Compat

PID Grade 1 (out-patient) None required. HIV if unknown

PID Grade 2 FBC, U & E, HIV, Compat
PID Grade 3, 4 FBC, U & E, HIV, Compat, ABG if
necessary
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Oncology presentation FBC, U&E, HIV, CD4(LFT rarely useful)

Epithelial ovarian cancer Above + CA-125, CEA, LFT
Germ cell ovarian tumor Above + AFP, hCG, LDH, LFT
Granulosa Cell tumour Inhibin(if available), LFT

Blood and Surgery

Golden Rule for X match: when a blood sample is typed and held in the blood
bank(Compat) X matched blood, if requested, can be available in 30-40 minutes.
This is adequately fast in almost all circumstances where blood is necessary in
Theatre.
Do not X match unnecessarily – it is expensive and wastes laboratory time.
Check before surgery that a taken Compat sample IS in the lab for possible X
match. If it is not, send another and check they have it.
If the Hb exceeds 10 for most operations a Compat is enough. X match for
ovarian malignancy, large fibroids, immobile masses where dissection is
expected, evacuation of molar pregnancies, abdominal pregnancies. An FBC and
U&E is expected for almost all surgery.
Where massive transfusion is expected or DIC is established ask for fresh frozen
plasma(FFP). Consider platelets. In these circumstances X match early not late.

HIV tests should be offered and performed whenever patients are seen.
Research has shown that opportunities to test are missed.

CHAPTER 2 CLINICAL METHODS

Diagnosis and treatment are based on clinical skills, i.e. history and examination.
Investigations, e.g. ultrasound and blood tests, are done to resolve a differential
diagnosis, or to confirm or refine a suspected diagnosis. Poor clinical
assessment will result in muddled and poorly directed investigations that are
expensive and lead to incorrect management.

All relevant clinical findings and management MUST be clearly written in the
patient’s file. Include the date and time of assessment.
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HISTORY TAKING
The most important thing of all is the PRESENTING COMPLAINT, but ask
The ‘big five’ questions
Always ask:
 Age
 Parity and gravidity
 Last menstrual period
 Current method of contraception, if of that age
 Marital status, occupation of patient and partner

These questions give the background, and may point towards certain diagnoses.

The main complaint

Find out the patient’s reason for coming to hospital. If referred by a clinic or a
private doctor, ask for the referral note and READ it. Do not go into detail until
you have asked the ‘big five’ questions.
History of the main complaint – very important
Pain: duration, severity, type, localization, association with the menstrual cycle,
dyspareunia, associated symptoms(urinary and bowel), aggravating
factors(lifting, bending, on rising in the morning), alleviating factors, previous
episodes and treatment used so far. Bleeding: amount, duration, clots, with pain
or not. With a discharge/ Or not/ what type? A mass? For how long? Symptoms?
Ask always if there are important symptoms the patient has that you have not
asked.
Menstrual cycle
Ask the last menstrual period, the amount, regularity/irregularity of the cycle
length, intermenstrual bleeding, post coital bleeding, menarche. Always consider
pregnancy if there is amenorrhoea.
Further gynaecological history
 Vaginal discharge and its characteristics
 Sexual history, dyspareunia, contraception(present, past)
 Previous cervical smears, and when last done
 Other previous gynaecological problems, treatment
 Previous gynaecological surgery
 Timing of menopause, and symptoms, where appropriate
 Previous mammograms in women over 50 years, and when last done
Obstetric history
Note the gestation, mode of delivery and outcome of all previous pregnancies,
and problems antenatally, at delivery, in the puerperium
Systematic history
Go through a basic systems review: cardiovascular, respiratory, gastrointestinal,
urinary, neurological, musculoskeletal, endocrine, haematological, immune. Ask
chest symptoms of all HIV affected.
Past History etc
Include past surgical history, medical, family and drug history, allergies, and
habits including smoking and alcohol. Knowledge of HIV status, CD4 count/viral
load, use of ARVs, and when tested(if negative) is essential.
Social history
As well as the type of accommodation, electricity, running water, etc. remember:
source of income, employment, dependants including children, all of which may
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cause anxiety/require arrangement if admission or review is necessary. Consider

questions on intimate partner violence if the history is suspicious. Ask where the
patient lives. Know the area. It may affect ease/difficulty of review.

PHYSICAL EXAMINATION
General assessment and vital signs
Note the general condition, e.g. well or not, comfortable or not, and the vitals –
heart rate, temperature, blood pressure, respiratory rate and colour of mucous
membranes. Remember stigmata of HIV-related illnesses, such as wasting,
rash, oral thrush, general lymphadenopathy, and chest signs of TB.
Systematic examination
Examine the head and neck including thyroid, heart, lungs, breasts, and do a
basic neurological assessment.
Abdominal examination
Use a systematic approach exactly as for a surgical patient:
 First inspection: scars, distension, hernias etc.
o Then palpation: start with touch, then gentle palpation, after which
deep palpation. Organomegaly: liver, spleen, kidneys, uterus,
ovaries
o Tenderness: location, presence/site, guarding, and rebound
o Masses: site, size, regular/irregular, solid/cystic, fixed, tender
o Ascites: shifting dullness or fluid thrill
o Inguinal and supraclavicular lymph nodes
Points about pelvic examination
 Explain the examination to the patient. Ask for consent to perform a pelvic
examination
 Ensure that the bladder is empty before proceeding
 Move slowly and gently with speculum/fingers to minimize discomfort
 Do not do a bimanual examination without passing a speculum first
(unless you know the patient and have done a speculum before)
 A considerate and careful abdominal examination often ensures an easier
and informative pelvic examination
Speculum examination
 A good light source is vitally important
 Remember to note the visual findings of the vulva first
 Avoid making loud metallic noises with the speculum
 Do not wave the speculum in front of the patient, keep it low
 Put a little bit of lubricant jelly on the outside of the blades, even when
taking a smear
 When inserting, part the labia gently with one hand, aim slightly
downwards, and insert the speculum with the blades horizontal. If it does
not pass easily, be gentle, turn and insert the speculum with the blades
vertical, then turn horizontal, but not quite to the midline vertical
 If there is resistance, wait a few seconds; do not force the speculum in
 Never push the lock/handle against the clitoris as this can be very painful
 Warn the patient just before opening the speculum that she will feel
stretching
 If the cervix cannot be found, take the speculum out and feel for the cervix
with one finger, then re-insert, aiming the speculum slowly to that spot
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 Note the appearance of the cervix – normal, ectropion, irregular,

cancerous, os open or not etc.
 If an ulcer or mass is seen on the cervix, biopsy, and omit the Pap smear
 Note bleeding (amount, clots) or discharge (appearance, smell)
 Turn the screw to fix the speculum open before taking a cervical smear
 When withdrawing the speculum, open it slightly to release the cervix and
allow the blades to collapse as you withdraw the speculum
 Note the appearance of the vaginal walls
Bimanual examination
 First ensure that the bladder is empty
 Two fingers(or one) are in the vagina, and the other hand is on the
abdomen. With gentle pressure, try to bring the two hands together to feel
what is between
 Press the abdominal hand towards the vagina, not straight down
 An examination using gentle pressure is more informative
 The following information must be sought and recorded(+/-):

o Cervical dilatation(in pregnancy), consistency,

o Products(in pregnancy) and whether offensive/not
o Irregularity of the cervix or masses
o Presence of cervical excitation tenderness
o Uterine axis, size, regularity, tenderness and mobility
o Adnexal masses and tenderness
o If a mass is present beyond the vagina does the cervix move with
it(more likely uterus, or adherent ovarian cyst)
o If endometriosis expected, is there tender uterosacral beading
Rectal Examination
 If any pelvic or vaginal mass is palpable, do a rectal examination
 Rectal examination is mandatory if any gynaecological cancer is present
or endometriosis expected. You cannot assess the parametrium, the true
mobility of a mass, recto-vaginal endometriosis, a rectal mass without it.
The anal sphincter has a distinct axis. Enter the sphincter slowly with
plenty of jelly, as you push the anal ‘sling’ slowly inwards you can feel
further, upwards and to left and right. Gentle pressure relaxes the
sphincters.

ASSESSMENT, DIAGNOSIS AND MANAGEMENT

In most patients, a diagnosis or differential diagnosis will be made on clinical
findings. If you are a junior, or more senior and in doubt, always discuss the
patient with other staff members(any).

1. Make a problem list based on the history and examination

2. Write the diagnosis or differential diagnosis clearly
3. List investigations required (if any) and make arrangements for them
4. Write up emergency or initial treatment plan - drugs, fluids, surgery
5. Discuss the findings and treatment plan with the patient
6. For admitted patients, order the nursing observations
7. Indicate when and by whom the patient will be reassessed or seen again
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Pregnancy tests
Always consider pregnancy. The history and examination may make it obvious.

Pregnancy tests are sensitive (the threshold for urine hCG is 30-50 mIU/mL) and
positive at the time of the first missed period or before. Tests remain positive for
up to two weeks after loss of a pregnancy or evacuation(long half-life of hCG). A
single drop of urine from a pregnant patient in a partly washed urine jug in the
clinic can make the next non-pregnant patient’s test positive. If a test from a
clean ‘Universal container’ is negative it is either truly negative or check from
another batch.
Ultrasound
Is an important, often vital assistance in clinical assessment. A scan should
follow and never replace history taking and examination.
ALWAYS look after the ultrasound equipment. Before removing a probe from its
cradle on the machine ALWAYS check that the cable is free and not trapped
around a wheel otherwise the probe will fall as you lift it. Never leave ultrasound
gel and used condoms on the probes. Always clean the probes before and after
use. Get consent for the scan. Document all findings in detail

CHAPTER 3 LOWER ABDOMINAL PAIN

Lower abdominal pain(LAP) is a frequent presenting symptom in gynaecology. A
full history and full examination are essential. Consider the differential diagnosis.
Many patients end up being branded as ‘PID’ or ‘chronic PID’ – doxycycline and
metronidazole must be amongst the most abused drugs in medicine.

DIFFERENTIAL DIAGNOSIS
Each condition will be covered in detail in this or other chapters.
Pelvic inflammatory disease (PID) – Overdiagnosed and underdiagnosed; from
mild to severe. A vaginal discharge is not essential for the diagnosis. Cervical
excitation/motion tenderness must be present.
Irritable bowel syndrome (IBS) – 50% of all LAP in women is caused by IBS.
The pain is chronic, severe, and intermittent. Bowel habit disorders may be mild.
Dyspareunia is usually absent. Tenderness is usually felt in the iliac fossae and
suprapubically, i.e. higher in the abdomen than in mild PID. Bimanual
examination is normal.
Primary and secondary dysmenorrhea – pain associated with menstruation.
Take a good menstrual history. In secondary consider fibroids, endometriosis,
adenomyosis, and chronic PID as causes.
Endometriosis/adenomyosis – A cause of secondary dysmenorrhea. Pain is
chronic and must worsen with menstruation. There may be associated deep
dyspareunia, sometimes infertility. Clear physical signs may be present.
Ovarian cyst accidents – Ovarian cysts twist(torsion), rupture, bleed, or
expand. Cysts may produce little pain, then present with a sudden onset of
severe pain. Feel for a mass. Ultrasound will show the cyst(remember a normal
ovarian follicle, mid-cycle, may be up to 2.5cm)
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Urinary tract infection – May be overdiagnosed (like PID), but can be easily
missed. Take a proper urinary history and test the urine with reagent strips.
Pregnancy complication – Ectopic pregnancy. Always consider. Check the last
menstrual period. Do a urine pregnancy test if ectopic pregnancy is even a slight
possibility. Remember that an ongoing pregnancy and PID do not coexist in the
first trimester unless there has been interference.
Lumbosacral root pain – This is referred to the lower abdomen; associated with
back pain; worse on movement or lifting, or getting up in the morning. There is
back tenderness and an absence of abdominal signs.
Acute appendicitis – Surgeons and gynaecologists frequently disagree and
debate PID or appendicitis. Misdiagnosis is easy. Look for abdominal signs that
exceed pelvic findings to suggest appendicitis.
Renal colic – This is not seen often, especially not in black South African
women. Look for the restless patient with severe pain of sudden onset,
sometimes radiating to the renal angle. Microscopic haematuria should be
present.

DIFFERENTIAL DIAGNOSIS OF A PELVIC MASS

Some of these may cause pain. Some do not, or may not. The presence of the
pain and the mass may coincidental.

Congenital: Para-ovarian cysts, cyst of the broad ligament

Physiological: Follicular cyst, corpus luteum cyst, corpus luteum of
pregnancy
Infective: Pyosalpinx, tubo-ovarian mass, hydrosalpinx
Ovarian: Cystadenoma, cystadenocarcinoma, sex cord stromal
tumours teratoma, etc.
Uterine: Fibroid, congenital uterine abnormality, e.g. didelphys
GIT: Appendix mass, diverticular disease, Meckel’s
diverticulum, stool, carcinoma
Miscellaneous: Ectopic pregnancy, pelvic kidney, Reidel’s lobe of liver

PELVIC INFLAMMATORY DISEASE

May be mild in an ambulant patient or severe and require intensive care

Grading of PID (Gainesville)

Grade I: Acute salpingitis without peritonitis
Grade II: Acute salpingitis with peritonitis
Grade III: Acute salpingitis with tubo-ovarian complex or tubal occlusion
Grade IV: Ruptured tubo-ovarian complex and/or generalized peritonitis

Diagnosis
Patients with pelvic inflammatory disease (PID) may have -
continuous LAP, dyspareunia, vaginal discharge(not always), dysmenorrhea,
infertility, rigors, pyrexia, abdominal guarding or rebound tenderness, cervical
excitation/motion tenderness(must be present), adnexal tenderness and there
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may be a pelvic mass. Mild cases may be apyrexial with only cervical and
adnexal tenderness.
Patients with PID probably do not have -
significant urinary or bowel symptoms, amenorrhoea, and almost never a positive
pregnancy test, unless it follows a procedure to evacuate the uterus(post abortal
sepsis).
Notes on diagnosis
 Pain may be perceived as unilateral, although PID is often
 bilateral
 Most chronic LAP is not caused by PID
 Painless intercourse during the time of symptoms suggests a diagnosis
other than PID – how can the cervix be moved in intercourse and not elicit
pain?
 There does not have to be an offensive vaginal discharge
 Cervical excitation tenderness is a ‘subjective sign’. It should not be
ignored if present
 An early ongoing pregnancy and PID(as in: infection of the upper genital
tract) cannot coexist
Treatment
Criteria for outpatient management
 Only grade I and selected patients with grade II disease
 Temperature <380 C, pulse <100
 No palpable adnexal or pelvic mass(unless patient is well - chronic mass)
 Minimal or no abdominal signs
 The patient is systemically well
Outpatient management of PID
1. Ceftriaxone 250 mg IM stat(diluted in 0.9ml lidocaine 1%), plus
Doxycycline 100 mg orally twice daily for 14 days, plus Metronidazole 400
mg orally twice daily for 14 days
2. Azithromycin 1G stat(repeated after 1 week) is an alternative to
doxycycline.
3. Analgesia, e.g. Ibuprofen 400 mg orally 3 times daily for 5 days (unless
there is renal dysfunction, history of a peptic ulcer)
4. Recommend treatment of the sexual partner
5. Advise the patient to return if she is feeling unwell or is not improving
Remember, if you are in doubt about the diagnosis, say so. Explain you are
prescribing antibiotics in case it might be. A firm statement of the diagnosis
carries a strong possibility of an infidelity. This may damage a sound relationship.
In-patient management of PID
For Grade II-III to IV disease:
1. Full clinical assessment including speculum examination. Feel for a mass
if pain allows
2. FBC, U&E and HIV, ABG if indicated - unwell, nasal flaring, tachypnoea
3. Ultrasound scan

4. Antibiotics:
Ceftriaxone 250mg im stat
Penicillin G 6 million units IV 6 hourly or Ampicillin 500mg 6hourly
Gentamicin 240 mg IV daily or Amikacin 1 g IV daily
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Metronidazole 1 g rectally twice daily or 500 mg IV 12 hourly, or

400 mg orally 6 hourly if tolerating oral medications
5. Analgesia: Ibuprofen 400 mg orally 3 times daily(unless kidney failure,
history of peptic ulcer)
6. Close monitoring of vitals and physical signs and expect improvement
7. Surgical intervention and intensive care for seriously ill patients (below)
Poor prognostic indicators in PID
 High temperature (>38.5 degrees C)
 Tachypnoea and nasal flaring
 Hypotension
 Acute renal failure – poor urine output or abnormal biochemistry
 Evidence of disseminated intravascular coagulopathy
 Generalized peritonitis
 Dusky or necrotic cervix
 Metabolic acidosis
 HIV positive with a low CD4 count
 Systemic inflammatory response syndrome
Second-line antibiotics for non-responders or allergic patients
 Ceftriaxone 1 g IV od
 Clindamycin 600 mg IV 6 hourly
 Tazocin (Piperacillin and Tazobactam) 4.5 g IV 12 hourly possibly
Patients who are severely ill or do not respond to treatment
Consider surgery (drainage and very thorough washout, deroof adnexal masses,
hysterectomy – if post abortal)
 For patients with a mass who are not responding to treatment(including
2nd line antibiotics)
 For patients with a mass who have renal failure or thrombocytopenia
 When the cervix appears dusky or necrotic
 For generalized peritonitis – that does not improve, or in association with
the unwell patient
Other considerations regarding surgery
 Decisions on surgery should be taken by a consultant
 Surgery in these patients may be difficult and consultant supervision is
required. De-roofing a pelvic abscess and breaking down all loculations of
pus is better than removing large amounts of tissue and risking bowel
perforation. The exception is severe sepsis after abortion - may require
hysterectomy
 These patients may require ICU admission, especially after surgery
Discharging in-patients with PID
1. Doxycycline 100 mg orally and Metronidazole 400 mg orally twice daily for
7 days
2. If treated with IV clindamycin, continue with 450 mg orally 8 hourly
3. Analgesia (ibuprofen 400 mg orally 3 times daily as required)
4. Recommend treatment of the sexual partner
5. Follow-up visits are not necessary as a routine
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IRRITABLE BOWEL SYNDROME

This is responsible for 50% chronic LAP or pelvic pain often mistakenly thought
to be gynaecological, often incorrectly diagnosed as PID.
Diagnosis
 A chronic rather than an acute history makes the diagnosis more likely.
There may be acute episodes
 The pain is typically colicky, intermittent
 Occasionally the pain is very severe
 The pain may go under the ribs
 Abdominal distension is reported sometimes
 Irregularity of bowel habit is often present but in some cases may be mild -
a single day’s constipation, or frequency of only two or three times a day
 Symptoms usually absent at night and do not wake the patient
 There is tenderness over the descending colon or the ascending colon
 Notable absence of pelvic signs on bimanual palpation
 No pyrexia, unless of other origin
 Presence or absence of vaginal discharge is of little relevance
 Diagnosis of exclusion – ultrasound should be normal
Management
 Explain the condition – non-pathological, bowel overactivity, pain is likely
to recur, no cancer
 Do not underplay the patient’s symptoms
 Diet: eat regular meals, green vegetables lightly cooked, wholewheat
bread
 Lifestyle: reduce or discontinue caffeine or tobacco
 Liquid paraffin or Lactulose 10 mL twice daily orally for constipation
 Antispasmodics e.g. mebeverine 135 mg orally three times daily before
meals; N.B. anticholinergics may worsen constipation

PRIMARY AND SECONDARY DYSMENORRHEA

Primary dysmenorrhoea typically begins soon after the menarche, starts a few
hours to 24 hours before menstruation, lasts 24-48 hours, then subsides after
maximal flow of the period.
Secondary dysmenorrhea commences a few hours to 24 hours prior to
menstruation, becomes worse with flow, lasts the entire period and may persist
after. It is associated with chronic PID, fibroids, endometriosis and adenomyosis.
Diagnosis
 Pain is associated with menstruation
 Take care with the history in the patient who has an irregular cycle
 Remember the uterus in normally tender during menstruation
 Fibroid uterus is common and may or may not be the cause of
dysmenorrhea
 Adenomyosis is felt as a tender, boggy, but non-pregnant uterus
 Features of endometriosis are discussed below
Management
Primary dysmenorrhea
Ibuprofen 400 mg orally three times daily, or naproxen 250-500 mg orally twice
daily, or mefenamic acid 500 mg orally three times daily(beware a history of a
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peptic ulcer, bleeding disorders, kidney problems and asthma). These drugs
should be taken with food and oral fluids. Combined oral contraceptives may also
be effective, as may Panado.
Secondary dysmenorrhea
Definitive treatment should be directed to the cause. Simple analgesics and
nonsteroidal anti-inflammatories may also be prescribed as for primary
dysmenorrhea.

ENDOMETRIOSIS and Adenomyosis

These conditions are probably underdiagnosed. Contrary to past perceptions,
endometriosis is not uncommon in black patients and a common cause of 20
dysmenorrhea.
Diagnosis
 Pain is chronic, with exacerbations associated with menstruation
 Dysmenorrhea typically lasts through the period and may persist after
 Dyspareunia may be present
 Pain on defecation(dyschezia) may be due to endometriosis in the
rectovaginal septum
 There may be infertility
 On examination - the uterosacral ligaments may be tender and nodular
(posterior and lateral to the cervix on each side)
 Adenomyosis is a tender boggy uterus outside pregnancy
 Fixed uterine retroversion if endometriosis is severe
 Endometriomata may be palpable as an adnexal mass(es) or in the POD
 Chronic PID may produce similar signs – tenderness, fixation and an
adnexal mass
Investigations
Laparoscopy with biopsy is the test for endometriosis. For adenomyosis it is
sonar or MRI. The appearance of endometriosis at laparoscopy may vary from
classical ‘powder-burns’, to vesicles, areas of fibrosis, or even normal appearing
peritoneum; biopsy is definitive with two of the three – glands, stroma,
haemosiderin. A therapeutic trial of progestogens has been recommended
without laparoscopy in poorly resourced settings or when awaiting a scope – if
effective it suggests the diagnosis. Adenomyosis is only confirmed at eventual
hysterectomy.
Management
Nonsteroidal anti-inflammatories
Ibuprofen 400 mg po tds
Hormone preparations
Medroxyprogesterone acetate (Provera) 30 mg orally daily, or dydrogesterone
(Duphaston) 5 mg orally twice daily, or gestrinone (Tridomose) 2.5 mg orally
twice weekly, all for three months. Danazol is no longer frequently used because
of unpleasant side-effects. Combined oral contraceptives given conventionally or
without a withdrawal bleed. GnRH analogue drugs(e.g goserelin) are effective
but expensive and cause menopausal symptoms and duration of use is limited by
the side effect of osteoporosis(‘Add back’ means GnRH plus HRT).
Surgery
Options: ablation of endometriosis by diathermy or laser or argon beam
coagulation, or surgical excision, adhesiolysis, and removal/ablation of
 15

endometriomas. Laparoscopic uterine nerve ablation (LUNA) is no longer in

favour. TAH and BSO is only for extreme cases. Endometriomas operated on
either laparoscopically or by laparotomy should not be pre-treated with GnRH
analogues as planes of cleavage are lost; removal may not improve fertility;
removal has a lower recurrence rate than ablation.

OVARIAN CYSTS
Ovarian cysts may twist (torsion), rupture, bleed, or expand suddenly – cyst
‘accidents’. Cyst torsion is the most frequent and is a common presentation of
benign cysts with sudden pain. Pain with a palpable mass or a cyst on sonar in
the absence of pyrexia is suggestive of a cyst accident rather than PID. If a cystic
swelling is not round but sausage shaped it may be a chronic hydrosalpinx.
Consider ectopic pregnancy if there is amenorrhoea and a positive pregnancy
test. Heteroptopic pregnancies do occur. A cyst may coexist with a threatened
miscarriage. Malignant cysts more frequently present in older patients with
vague symptoms, chronic pain weight loss often accompanied by ascites.

A benign cyst may be a serous or mucinous cystadenoma, a benign mature

cystic teratoma(a dermoid), an endometrioma or a follicular or functional cyst.
Patients have, rarely, bled over 2 litres from a simple corpus luteum rupture in a
normal menstrual cycle. On ultrasound, encysted peritoneum from adhesions or
a hydrosalpinx, both associated with previous PID, may look like ovarian cysts.
Diagnosis
 A normal pre-ovulatory follicle grows up to 2.5 cm in diameter. Do not
confuse this as pathological
 Larger cysts - torsion or rupture causes a sudden onset of severe constant
or intermittent pain (torsion-untorsion)
 Gradual expansion may cause a slower-onset dull ache
 Weakness and dizziness from hemorrhage occur unusually
 Gastrointestinal and urinary symptoms are minimal
 Amenorrhoea is usually absent in the absence of an intrauterine
pregnancy
 Pregnancy-associated cysts usually undergo torsion at 14-16 weeks or in
the puerperium when the uterus shrinks to this size(they roll on the pelvic
brim)
 There is usually no pyrexia with a cyst event
 Abdominal and pelvic signs are variable; a mass may or may not be
palpable
 A pleural effusion is rare(if associated with a benign cyst this is ‘Meig’s
Syndrome’)
Investigations
 Ultrasound - record the cyst diameter,
 appearance (simple, or solid/cystic, septate), and bilaterality, look for
ascites or haemoperitoneum,
 A collapsed cyst may appear as fluid in the pouch of Douglas
 Urinary pregnancy test if there is ANY possibility of ectopic pregnancy
 If needed, pre-operative routine blood tests – U&E, FBC, Group and Hold
 CA-125 in women >35 years old
 16

 hCG and AFP in pre-menstrual girls

 CEA is associated with mucinous cystadenocarcinoma
 Abdominal X-rays may show the teeth of a benign cystic teratoma, but are
no longer performed
Management
This depends on the presentation
If there is not an acute abdomen, and the cyst is simple and ≤6 cm in
diameter
1. Explain to the patient that the ovary normally makes cysts and that these
may resolve
2. Repeat the ultrasound scan in 2-4 weeks
3. Advise the patient to return if they are unwell or if the pain worsens
4. Give simple analgesics, e.g. Paracetamol 1 g orally 6 hourly
5. If >35 years, take blood for CA-125
6. Do not prescribe combined oral contraceptives; randomized trials have
shown they do not shrink cysts that have already formed
If there is a simple or partly solid cyst and an acute abdomen
1. Urgent laparotomy/laparoscopy is required
2. Following untwisting of a torted cyst the ovary sometimes may be saved,
but if the adnexum remains dusky adnexectomy must be done
3. If the cyst has ruptured or is expanded by bleeding, it should be removed
and the ovary properly reformed (surgical technique – Chapter 13)
4. Washout of all blood and fluid with good haemostasis is essential before
closing the abdomen. This is especially true after rupture of a dermoid or
mucinous cyst to prevent post op adhesions. Ovarian cystectomy is the
pelvic procedure most associated with adhesion formation
If the cyst has solid elements, or if it is ≥7 cm in diameter, in the absence of
an acute abdomen
1. Laparotomy/laparoscopy should be done as soon as conveniently possible
2. Take blood for tumor markers if indicated – hCG, AFP, CA-125, LDH

URINARY TRACT INFECTION

This is discussed in the urogynaecology chapter (Chapter 12)
 17

ACUTE APPENDICITIS
Diagnosis
 Central abdominal pain moving to the right iliac fossa (RIF) is typical
 Nausea and vomiting are more frequent with appendicitis than with PID
 Tenderness is usually localized to the RIF, with rebound
 Positive Rovsing’s sign – pressing on the left and asking if the pain is
more on the right; in PID the tenderness remains left-sided
 Psoas sign – pain caused by downward pressure on the patient’s flexed
right knee; it is positive in retrocaecal or pelvic appendicitis
 Fetor – although nonspecific, it is associated with appendicitis rather than
PID
 Cervical excitation is less than expected for PID
Investigations
 Ultrasound scan: the inflamed appendix is said to appear as a target if
seen in transverse section. The surgeons will ask for a CT scan
 Abdominal X-ray may be helpful (‘sentinel loop’ of bowel)
 FBC and U&E
 CRP if there is doubt about inflammation
Management
1. Call for a general surgical opinion
2. If the surgeons do not consider appendicitis to be likely and the patient
seems to require laparotomy proceed with the operation and let the
surgeons know you are doing so

LUMBOSACRAL ROOT PAIN

This is referred pain, it can be misdiagnosed as chronic PID.
Diagnosis
 There is almost never a history of known back injury. There is associated
back pain
 The pain is typically worse on movement or on rising in the morning
 The pain may be worse on stooping or lifting
 There are no abdominal or pelvic signs
 There may be marked point tenderness of the lumbosacral spine or sacro-
iliac joint

Management
1. The patient should avoid lifting heavy objects
2. Nonsteroidal anti-inflammatories (ibuprofen 400 mg orally 3 times daily)
3. Recommend sleeping on a firm supportive bed
4. Stooping to load washing machines, hang washing, when cleaning –
should be avoided
5. Relaxing in a hot bath and pulling the left knee to the chest on the right
and vice versa can relieve back spasm
6. Avoid love-making positions that exacerbate the pain (e.g. when
the man enters the woman from behind)

PELVIC CONGESTIVE SYNDROME

This condition may present with chronic lower abdominal pain and dyspareunia,
worse at the time of menstruation.
 18

It is said to be associated with laparoscopic findings of engorged veins around

the uterus, which may be seen on ultrasound.
Diagnosis is by exclusion of other causes, particularly endometriosis and
adenomyosis. Treatment is by progestagens, LHRH analogues, or analgesics.
Recurrence is likely. The diagnosis is contentious.

EARLY PREGNANCY COMPLICATIONS

Septic abortion and ectopic pregnancy are life-threatening causes of lower
abdominal pain. Threatened, inevitable, and routine incomplete miscarriages
require management but rarely lead to a crisis.
Diagnosis
 Ask a menstrual history, and for the use of contraception
 Ask the patient if she thinks she could be or have been pregnant
 Consider interference with a pregnancy(often not confessed)
 PID and a normal first-trimester pregnancy do not co-exist
 Examination & ultrasound can distinguish normal, aborted and ectopic
pregnancies and will identify sepsis
Management
 is discussed separately (Chapter 4)

Chapter 4 Early pregnancy problems

ECTOPIC PREGNANCY
Ectopic pregnancy – well patients
Some patients with ectopics walk calmly into the clinic and appear to be well. The
ectopic may be unruptured, or ruptured but not bleeding actively.
Diagnosis
 There should be at least some mild lower abdominal discomfort
 There may or may not be abnormal vaginal bleeding – it is small in volume
 Last menstrual period usually > 4 weeks
 Possible history of prolonged unprotected intercourse without conception
(subfertility – tubal factor, possible history of previous PID or STI, pelvic or
tubal surgery, or a previous ectopic pregnancy)
 There should be some lower abdominal tenderness
 Cervical tenderness and adnexal tenderness should be present
 An adnexal mass is often not felt
Investigations
 Urine pregnancy test will be positive. If not test is available the diagnosis
may be obvious
 Ultrasound will show an empty uterus, with or without an adnexal mass,
and free fluid (blood) in the Pouch of Douglas
 Culdocentesis and paracentesis are not usually done, but withdrawal of
blood is suggestive of ectopic pregnancy. Failure to obtain blood does not
exclude an ectopic
 A low Hb level may assist with the diagnosis
Management
Many are managed surgically
 19

1. Insert an IV line(14, 16 gauge)

2. FBC, U&E and Group and Hold or Cross-match(according to ward/formal
Hb
3. Ensure the blood results are received before proceeding with surgery
4. Book for laparotomy or laparoscopy. Salpingectomy/salpingostomy
5. Laparoscopy if not contraindicated is (1) to confirm the diagnosis, (2) for
surgical treatment, (3) appropriate if the surgeon is confident with the
equipment, and (4) NOT contraindicated if there is fluid ni the POD but the
patient is stable patient is stable
6. Laparoscopy the following day - if the patient is stable it is possible to
admit for observation and book for lap’scope a.m..

OR….Consider medical management with methotrexate (see below)

True conservative management(observation) is an option if there is uncertainty of

the diagnosis & the patient is well:
1. Take blood for beta-hCG level
2. Explain the problem to the patient, and the necessity for follow-up
3. Advise the patient to return to hospital without delay if she feels unwell
4. Follow up in two days (24-48 hours). Ectopic pregnancy is likely if:
o The pain has increased with marked excitation tenderness
o There is free fluid or an adnexal mass on repeat ultrasound scan
o The hCG level is >5000 U/L on transabdominal scan with an empty
uterus
o The hCG level is >1000 U/L on transvaginal scan with an empty
uterus(and no history of heavy vaginal bleeding)

Ectopic pregnancy – unwell patient, collapsed patient

The pregnancy is likely to have ruptured and be bleeding actively
Diagnosis
 Obtain as good a history as possible, from the patient, or those
accompanying her(if semi-conscious). Ask about amenorrhoea and
syncope or dizziness. Read the referral letter, if there is one, ask the
paramedics
 Specifically inquire about known medical conditions affecting anaesthesia/
surgery
 Localize the problem on examination by looking for guarding, rebound,
distension, and cervical excitation tenderness.
 An acute abdomen in a shocked patient, with a history of amenorrhoea is
an ectopic until proven otherwise
 Look for evidence of systemic infection, or septic abortion, that may
present with symptoms and signs similar to ectopic pregnancy
 A catheter specimen of urine can be used for pregnancy testing
 An ultrasound scan is useful, once the patient has been stabilized
although ultrasound will rarely add to the clinical picture. The typical
finding is an empty uterus with free fluid and a complex adnexal mass.
 Culdocentesis may occasionally be helpful to distinguish blood from
peritoneal fluid
 20

Management
1. Resuscitate as required – BAC. Give O2 if necessary and use two IV lines
if needed (large bore 14 or 16 gauge cannulas)
2. Take blood for cross-match and order red-label packed cells – up to 4
units(a ward Hb – if available, will guide the cross match)
3. Urgent U&E and FBC
4. Book theatre for urgent laparotomy and discuss with the anaesthetist

SURGERY FOR ECTOPIC PREGNANCY

The place of conservative surgery
Total salpingectomy is the standard surgical method (Chapter 13). Conservative
surgery (leaving the tube) increases the future chances of both ectopic and
intrauterine pregnancies. This involves cutting diathermy to the anti-mesenteric
border (salpingostomy/gotomy) and flushing the ectopic from the tube. Milking a
fimbrial ectopic from the tube end and observing for bleeding may be acceptable.
The contralateral tube – Fertility or Sterilization
Following surgery to the affected tube, if fertility is an issue there may be benefit
in clearing filmy peritubular adhesions on a contralateral tube, or even performing
simple cruciate diathermy salpingostomy on a hydrosalpinx. Always record
findings or surgery of the contralateral tube in the notes, this is the rate
determining step in the chance of future pregnancy.
Some patients with ectopic pregnancies will appreciate tubal ligation as their
families may be complete. Always ask about this before operating if the patient is
stable.

METHOTREXATE FOR ECTOPIC PREGNANCY

Requirements for treatment with methotrexate are:
 Well patient
 Unruptured ectopic
 Patient who is well motivated, understands the treatment, and can be
followed up, and lives relatively close to the hospital
 No fetal heartbeat on ultrasound
 Diameter of ectopic pregnancy on ultrasound < or = 3.5 cm
 hCG < 10,000 mIU/ml(IU/L)
 Consultant involved
Protocol for methotrexate
In fact there are many protocols
1. Explain the treatment, including failure rate(see below), to the patient, and
get consent
2. FBC, U&E, LFT and hCG level. FBC and U&E results must be known
before starting methotrexate
3. Methotrexate 50mg/m2 or 75mg IM or orally as a single dose
4. Folic acid is optional: give 10 mg orally three times daily after 24 hours, for
3 days(it is not required on single dose Methotrexate)
5. The patient must return immediately if she has any increase in pain or
feels unwell – record this advice in the file
6. Follow up in 4 days: ask about symptoms, do a physical examination and
ultrasound scan, and take blood for hCG level. The level should have
gone down by at least 15%
 21

7. If the hCG level is falling, repeat again 3 days later. If the hCG level is not
falling, but the patient is stable and agreeable, the methotrexate dose may
be repeated once(there are longer protocols but don’t take chances)
Notes on methotrexate
About 20% of patients on this protocol will fail (require surgery). Alopecia does
not occur with this dose of methotrexate. Marrow suppression and mucositis are
not usually significant

MISCARRIAGE
This includes threatened, inevitable, incomplete, complete and missed
miscarriages.
The term ‘abortion’ should be replaced by ‘miscarriage’ especially when used in
front of patients.
Miscarriage may cause extreme distress to some patients while others seem
genuinely untroubled and accepting. Patients’ feelings, especially self-blame and
grief, must be considered. Reassurance is important. Patients need to know that
spontaneous miscarriages are not their fault, and that miscarriage is mostly a
natural process that removes faulty pregnancies. Subsequent pregnancies can
usually be expected to be successful.

Diagnosis
 The patient presents with bleeding and usually a history of missed periods
 Products of conception (fetus, placenta, ‘fleshy’ fragments) may have
been passed suggesting a complete miscarriage (cervix closed) or
incomplete miscarriage (cervix open)
 The presence of pain and/or bleeding without passage of products and a
closed cervix suggests threatened miscarriage. Bleeding, however
slight, with a closed cervix and a dead embryo or fetus on scan is
technically not a ‘missed’ miscarriage. ‘Missed’ miscarriage does mean
discovered without symptoms.
 Inevitable miscarriage presents with pain, an open cervix, and no
passage of products (as yet). Remember the external os may be open in
the parous patient(who has had a previous birth) when the internal os is
closed. Always check for fetal heart beat on ultrasound.
 Incomplete miscarriage – if there are products emerging from an open
os the sonar is merely to confirm that the fetus has passed
 Complete miscarriage should be diagnosed if the patient has passed
products, the pregnancy test is positive, the uterus is empty, and an
ectopic pregnancy has been excluded. The bleeding on history should
have been more than expected for menstruation, usually with clots. Lower
abdominal tenderness is mild, unless there is uterine sepsis
 Consider other causes of bleeding and pain, including ectopic pregnancy
Ultrasound scan for miscarriage
 Ultrasound is not necessary if products of conception are found in the
cervical os and uterine size is clear, as this indicates incomplete
miscarriage
 Ultrasound may show:
o A viable intrauterine pregnancy
o A nonviable intrauterine pregnancy
 22

o An empty uterus
o Other pathology – hydatidiform mole, adnexal mass, free fluid etc.
 Ectopic pregnancy and complete miscarriage can be distinguished on
history (amount of bleeding: Ectopic – little, Complete miscarriage – a lot)
and not necessarily on sonar. If in doubt, follow-up if necessary
Management
Threatened miscarriage
1. No specific treatment
2. Reassure the patient: if the fetal heart is active there is a 90+% chance
that the pregnancy will continue
3. Discharge the patient home, to attend the antenatal clinic, to return if the
pain/bleeding increase
Complete miscarriage
1. Ensure that this is truly a complete miscarriage, as stated above
2. Explain what has happened
3. Discharge the patient home if she is clinically stable
Inevitable and incomplete miscarriage
1. If there are few products in the cavity, the fetus has passed and the os is
open in the first trimester, the modern management is conservative.
Advise the patient that bleeding will settle over 2-10 days. No manual
vacuum aspiration(MVA)is required.
2. If there is(or has been) significant bleeding, insert an IV drip(14 or 16
gauge), with oxytocin 20 units in 1L Ringer-lactate. Resuscitate with IV
fluids if there is hypovolaemic shock
3. If at all unstable, take blood for FBC, U&E and X-match, ABG
4. Do a ‘ward’ haemoglobin level to guide X match/resusc
5. If the patient is clinically stable, less than 14-16 weeks pregnant, the fetus
has been expelled, with a normal ward Hb (>9-10 g/dL), and with no
evidence of sepsis or suspicion of unsafe abortion, an MVA can be offered
to all incomplete miscarriages(see below). At </= 10 weeks management
may be conservative if there is NO possibility of sepsis
6. Other patients should be admitted for uterine evacuation
7. Antibiotics should be given if there is any suggestion of infection, or a
history of interference: use the same regimens as for PID (Chapter 3)
8. Ensure that patients who are severely anaemic are on blood transfusion at
the time they need to go for evacuation
9. The evacuation list should be compiled on the morning post-intake round
10. Septic or severely bleeding patients may need emergency evacuation
11. Many second trimester miscarriages may be pregnancy terminations from
private or other practitioners, and that this history may not be given
12. Some patients may be more unwell than they at first appear
13. ALWAYS inform the anaesthetist, other staff of an unwell patient
Blood transfusion
A pre-operative Hb level of 8 g/dL may be adequate for evacuation in theatre if
the patient is stable, not bleeding, has passed a fetus and is not septic. Other
patients should have an Hb level of 10 g/dL before evacuation can be safely
done, and should be transfused to that level. Discuss with the anesthetist.
Septic incomplete miscarriage
1. Severe cases may rapidly go into septic shock and multiple organ failure
2. Signs are hypotension, offensive products, tachycardia, pyrexia, and
tachypnoea(with nasal flaring)
 23

3. Assess thoroughly for organ dysfunction – FBC, U&E, clotting, chest x-ray,
ABG if necessary. Occasionally ventilation may be required. Check the
chest for pathology too..
4. Hourly nursing observations to identify septic shock
5. Urinary catheter and monitor urine output hourly. If good - vigorous fluid
resusc should be used
6. Speculum to inspect the cervix for trauma and necrosis(dusky blue or
black areas –ask someone if you are not sure)
7. Triple intravenous antibiotics, as for severe acute PID (Chapter 3)
8. Emergency evacuation may be necessary
9. Uterine evacuation must be done by at least a senior MO or registrar
10. Hysterectomy if there is a dusky or gangrenous cervix, generalized
peritonitis, septic shock, failure of two or more organ systems or
uncontrollable bleeding. Look for disseminated intravascular
coagulopathy, renal failure, and acidosis (tachypnoea, arterial blood gas).
11. If hysterectomy is required there is no need to remove ovaries, unless
they are involved in adnexal abscesses. This surgery MUST be performed
by a consultant
 24

GESTATIONAL TROPHOBLASTIC DISEASE (GTD)

Hydatidiform mole(complete and partial) is much more common than
Choriocarcinoma. The rare Placental Site Trophoblastic tumour and Epithelioid
Trophoblastic Tumour are not usually seen. Choriocarcinoma is the rare
malignant form. Benign forms metastasize – they spread, parting and breaking
tissues without true invasion except in the uterus.
Most patients with GTD present as an inevitable miscarriage, but it may occur
after a normal pregnancy, a complete miscarriage or ectopic gestation. Rarely,
there may be no clear history of current or past pregnancy.

HYDATIDIFORM MOLE
Diagnosis
 There may be passage of grape-like products from the vagina may be
brought in by the patient, noticed on examination, or an ultrasound scan
may show multiple intrauterine cysts of different sizes(the typical
‘snowstorm’ appearance was from scanners no longer in use) or first
noticed at uterine evacuation.
 Histology is diagnostic
Investigations
 FBC, hCG level and thyroid function
 Chest X-ray(for metastases)
 Consider abdominal ultrasound or CT scan for liver, spleen and kidney
metastases if hCG level >100 000 U/L.
 Sonar may show huge multi-septate theca lutein ovarian cysts – these are
managed conservatively(unless torted, which is rare)
Pre-operative preparation
For cases recognized pre-evacuation, presenting as incomplete/threatened
miscarriages

1. If Hb <9 g/dL, give 2 units packed cells pre-operatively

2. Order 2 units packed cells on standby in a blood box for theatre
3. Softening the cervix is not usually required pre-op. Avoid misoprostol or
E2 preparations to ripen the cervix as they may cause excessive
preoperative bleeding
Uterine evacuation
1. Should be done by a registrar or consultant
2. Use a suction curette
3. Place the curette just inside the uterus with the tip in the lower pole. As
suction begins the uterus will contract down towards the suction catheter.
Gentle scraping with a large curette confirms an empty cavity
4. Oxytocin infusion 10-20 units in 1 L to encourage uterine contraction
5. If bleeding persists give ergometrine 0.5 mg IM or Syntometrine 1 amp IM
at the end of the procedure
6. There is a debate that if the uterine size at presentation is >20weeks
hysterectomy rather than evac might be indicated. Seek local advice
Partial mole
In partial mole, there is an abnormal fetus. Compared with complete hydatidiform
moles, partial moles tend to occur in older patients and are less likely to
complicate with malignancy, hyperthyroidism or theca lutein cysts. Management
 25

is however the same. Absence of a fetus on ultrasound does not exclude partial
mole as the fetus may have been passed unnoticed.
Theca lutein cysts
Large bilateral multicystic ovaries may be found in association with hydatidiform
mole. Bleeding and torsion have been reported but are rare. In general, allow the
cysts to regress even if they are very large.
Metastases
Metastases are rare with hydatidiform mole but do occur. Do not biopsy
suspected vaginal metastases in the vagina as they bleed profusely. Lung
metastases seen on chest X-ray do not require biopsy. As above, CT evaluation
for metastases may be indicated. This may include head CT.
Discharging a patient after evacuation
1. Encourage, encourage, encourage the patient to attend regularly for
follow-up
2. Stress that the diagnosis must still be confirmed by histology
3. Ensure effective contraception is provided or sought (combined pill or
injectable)
Follow-up visits
First obtain histology and hCG results. International studies show that if you ask
someone with little finance to come excessively often they will default.
 See the patient every 2 weeks until hCG levels are below 25 Units/L
 Then see the patient monthly for one year after evacuation. Pregnancy
must be avoided at this time as hCG is the marker and of course
associated with normal pregnancy. A rise may make termination
necessary, and a pregnancy may worsen persisting molar disease. A
terminated pregnancy may be normal
 At each visit:
o A consultant should be informed and supervise management
o Ask about general well-being and irregular vaginal bleeding
o Confirm that the patient is taking contraception
o If hCG levels are persistently raised but stable for several weeks
there may be a subsequent drop to normal. This is the ‘plateau’
effect. With static levels and a closed cervix and no persistent
bleeding, observe for 3-4 weeks before investigation or referral for
chemotherapy
o Re-evacuate for persistent bleeding with an open cervix and
retained products on ultrasound
o Invasive mole on ultrasound, persistent high hCG levels and a
completed family is a potential indication for hysterectomy rather
than referral for chemotherapy. HCG follow up is still essential.
Indications for referral for chemotherapy
 Multiple high risk factors at the time of diagnosis (consult oncology
protocols).
 HCG levels not falling (consider re-evacuation if ultrasound shows
retained products).
 Metastases discovered at any time during work up. FIGO staging(v
simple) should be given
 Choriocarcinoma on histology
FIGO Staging: 1 – uterus, 2 – pelvis, 3 – lungs, 4 – other organs. Scoring(with a
rating of 0-3): age, preceding pregnancy, time since pregnancy, hCG level,
 26

tumour size, site and number of mets. 6 or less single agent chemo, 7 or more
multiple.

HYPEREMESIS GRAVIDARUM
This is excessive vomiting in pregnancy. It usually occurs in the first few months,
and rarely continues into the second or third trimesters. Though some vomiting
does.
Well patients can be managed as outpatients. Unwell, dehydrated patients
require admission. Indication for admission is ketonuria.
Diagnosis
 It may be associated with twin pregnancy and hydatidiform mole
 Other causes of vomiting should be excluded
 There are no physical signs except of pregnancy and dehydration
 Differential diagnoses include:
o Pyelonephritis/urinary tract infection
o Gastrointestinal complaint, e.g. gastritis, appendicitis, cholecystitis
o Thyroid disorders
o Medicines and alcohol
Investigations
 Urine dipstick – for ketones, and for evidence of UTI
 U&E – to detect hypokalaemia and dehydration
 Urine for MC&S if there is any suspicion of UTI
 Thyroid function
 Ultrasound to assess pregnancy, and encourage the patient with evidence
of viability and to exclude hydatidiform mole
Management
Mild hyperemesis (no ketonuria):
 Admission to hospital is not necessary
 Explain to the patient the condition does not harm the fetus
Advise that the patient does not need to eat while she is feeling ill, only
liquid is essential. Advise small frequent meals
 Advise avoidance of anything that causes nausea, e.g. coffee, tea,
toothpaste, fatty foods
 Advise the problem is self-limiting, and rarely goes beyond 16 weeks
 Advise the patient to return if the vomiting worsens
 Prescribe metoclopramide(Maxalon) 10 mg orally three times daily when
necessary, or cyclizine(Valoid) 50 mg orally three times daily when
necessary
Moderate to severe hyperemesis (ketonuria)
 Admit the patient
 Withhold meals for a day or two if vomiting is severe
 IVI with normal saline or Ringer-Lactate. Avoid glucose-containing
solutions. Add potassium 20-40 mmol/L if necessary
 Antiemetics: prochlorperazine(Stemetil) 12.5 mg IM 8 hourly(10mg orally),
or Metoclopramide10 mg IM or orally 8 hourly or cyclizine 50 mg IM or
orally 8 hourly when necessary
 Be alert for hypotension, dehydration or liver dysfunction
 27

RECURRENT MISCARRIAGE
This is defined as 3 consecutive miscarriages. Good history taking is essential, to
direct further investigations. Even without any specific intervention, successful
pregnancy rates are as high as 80%. The patient may present in pregnancy or
non-pregnant
Causes of recurrent miscarriage
 Many cases have no recognizable cause – idiopathic
 Cervical incompetence - second trimester
 Uterine anomalies and uterine fibroids – second trimester
 Antiphospholipid syndrome(APLS) –3 consecutive miscarriages <10
weeks with normal fetus; premature birth <34 weeks due to eclampsia or
preeclampsia; 1 or more intra-uterine fetal deaths < 10 weeks confirmed
by sonar; at least 1 of 3 serological tests
 Infections – syphilis, possibly bacterial vaginosis (rare)
 Luteal phase defect – of uncertain significance, first trimester
 Balanced translocations in the parents – first trimester (rare)
 Chronic medication – e.g. warfarin
 Diabetes mellitus and thyroid disorders – probably not causes unless
poorly controlled
 Important questions on history taking
 Outcomes of all previous pregnancies
 Paternity of all pregnancies
 Gestation at each pregnancy loss
 Duration and presence of uterine pain and bleeding
 Where and how the miscarriages were managed
 If the fetuses were seen, their size and whether they were alive
 Any medical disorders: thrombosis, endocrine conditions etc.
 Previous gynaecological surgery including myomectomy, curettage and
cervical cone biopsy
 History of sexually transmitted conditions
 What the patient thinks might be the cause of the miscarriages
Examination
 General examination is essential and must include blood pressure
 Fibroids or an obvious uterine abnormality may be found on examination
or sonar
 An incompetent cervix is almost always closed in the non-pregnant patient
 Usually, nothing abnormal is found on examination
Investigations
 RPR and HIV serology in all patients
 Anticardiolipin antibodies IgG, IgM, IgA; Lupus anticoagulant; anti beta 2
glycoprotein 1
 Sonar for fibroids, uterine anomaly
 Hysterosalpingogram, laparoscopy and hysteroscopy can show suspected
uterine abnormalities
 There are no reliable tests for cervical incompetence in non-pregnant
patients. Although easy passage of a size 9 Hegar dilator is strongly
suggestive, this is not a valid test. History will suggest the diagnosis. In
pregnancy a scan finding at >12-15 weeks of ‘funelling’ or length <1.5cm
 28

suggests cervical incompetence. Consider cerclage. A cervical length of

1.5-2.5cm is included if the history is strong
 Blood glucose, thyroid function and vaginal swabs are of limited value
Management
1. Manage any treatable cause e.g. penicillin for syphilis, myomectomy,
correction of uterine anomaly if appropriate
2. Reassure and encourage women to try a pregnancy when ready
3. Ensure early antenatal clinic attendance and ultrasound scan when
pregnant, and attendance at a high risk clinic
4. Cervical incompetence should be managed during the pregnancy with
cervical cerclage at aprox 14 weeks. Cerclage is of MacDonald. Always
consider reflecting the bladder to get an adequate cervical length as a
modified Mcdonald. If the cervix is too short, then Shirodkhar. If the cervix
has no length abdominal cerclage is indicated.
5. Progesterone – with recurrent late 2nd trimester miscarriage/premature
labour progesterone has benefit. If available(perhaps with motivation) it
should be given
6. Patients with APLS require clexane or others and aspirin from diagnosis of
pregnancy up to at least 35 weeks. One clinical criteria and at least one
serological is required for APLS diagnosis. This should be managed by a
high risk obstetric clinic if possible
 29

Chapter 5 TOP and contraception

TERMINATION OF PREGNANCY (TOP)
CHOICE ON TERMINATION OF PREGNANCY ACT, 1996(now modified)
The Act replaced the Abortion and Sterilization Act of 1976
 A pregnancy may be terminated upon request of a woman (no age
restriction) during the first 12 weeks of gestation, or:
 From the 13th week up to and including the 20th week of gestation if a
medical practitioner, on consultation with the pregnant woman, believes
that the pregnancy:
o Would pose a risk to the women’s physical or mental health
o Would pose a risk to the fetus of physical or mental abnormality
o Resulted from rape or incest
o Would significantly affect the socio-economic circumstances of the
woman
 After the 20th week two medical practitioners or a medical practitioner and
a registered midwife agree that the continued pregnancy would:
o Endanger the woman’s life
o Result in a severe malformation of the fetus
o Pose a ‘risk of injury’ to the fetus
Consent
- TOP may only take place with informed consent from the woman
- Only the informed consent of the woman is required for TOP
- When patients sign consent, they do so not only for the TOP itself, but for any
procedure that may arise as a result of complications, e.g. hysterectomy, bowel
resection, tracheostomy etc.
Consent for a Minor
The medical practitioner or midwife ‘shall advise [such minor] to consult with
parents, guardian, family members or friends before the pregnancy is
terminated,’ but this remains at the discretion of the minor, and termination
cannot be denied if this is not done. Consent given, as above is for any
procedure. The issue of discussion with a parent/guardian should be discussed
by medical staff and documented.
Consent for someone who cannot give consent
This is either a ‘severely mentally disabled person…incapable of understanding
and appreciating the nature or concept of termination of pregnancy’ or a person
‘in a state of continuous unconsciousness’ with ‘no reasonable prospect of
regaining consciousness in time to request consent to the termination of her
pregnancy’. Such a person may undergo termination according to the Act within
the first 20 weeks ‘upon the request of her natural guardian, spouse or legal
guardian’ or ‘of her curator personae.’
Who can perform a termination?
A pregnancy may be terminated by a medical practitioner or, up to and including
12 weeks, by a registered nursing sister ‘who has completed the prescribed
training course.’
Where can a termination take place?
The surgical termination of pregnancy may take place only in a facility designated
by the Minister of Health.
 30

Counseling should accompany termination

The State shall promote the provision of ‘non-mandatory’ counseling before and
after termination.

First trimester terminations

First trimester terminations should be performed in a Primary care facility or
designated clinic (within a hospital). A medically complicated patient will require
first trimester TOP in 1 of the 3 central hospitals.
Management of first trimester TOP (<13 weeks)
The patient must be counseled fully about the procedure and possible
complications as well as future contraceptive options. The gestational age
MUST be confirmed by ultrasound first.
Misoprostol 800mcg (4 tablets) pv 4-6hrly up to 3 doses
If Mifepristone available:
<9 weeks: Mifepristone 200mg PO then 24-48hrs later Misoprostol 800mcg PV
9-13 weeks: Mifepristone 200mg PO then 36-48hrs later Misoprostol 800mcg PV
then 400mcg 3hrly PV (to a max of 4 doses)
NOTES
1. The tablets will cause pain and bleeding. The fetus should be disposed of
in the toilet. The most common side effects are shivering and diarrhea
2. Analgesics should be prescribed
3. The patient can be given tablets to be taken at home, the patient should
then be advised to return with bleeding or at a prearranged time.
4. When the patient is reviewed sonar may confirm
 The uterus is empty and no further treatment is necessary
 The fetus has been passed but products remain which requires
MVA
 A viable pregnancy persists and tablets may need to be re-
prescribed and repeated. Alternatively a single Misoprostol tablet
(200mcg) can be placed sublingually and MVA performed after 1-
2hrs if the cervix is open.
5. Tablets can be inserted PV or taken orally. GIT side effects are more
common when taken PO.
6. If, on examination there is an obvious vaginal discharge, Doxycycline
100mg bd po and Metronidazole 400mg bd po can be prescribed for 5
days. Otherwise this is optional

Second trimester Termination

Second trimester TOP should take place as an inpatient in a hospital or medical
facility under the care of a medical practitioner.

Management of second trimester TOP (13-20weeks)

Day 1
1. Admission
2. U&E, Hb, Rh group and sample held in lab
3. Antibiotics as for first trimester TOPs if indicated, otherwise not
4. Misoprostol 600mcg PV to be inserted by the patients as a “vaginal
loading dose”
 31

5. Misoprostil 400mcg 3hrly either PV or Sublingual (to a MAX 5 doses)

6. Consider stopping Misoprostol if severe pain/strong regular contractions
Day 2
1. If abortion has occurred, book the patient on the next evacuation list or for
MVA by the experienced, at <16 weeks
2. If abortion has not occurred, insert Misoprostol as for Day 1 (provided
more than 12hrs since last dose Misoprostol)
3. If pain or bleeding occur, start oxytocin 20 units in 1L normal saline at 125
mL/hour 6 hours after the last Misoprostol insertion
Day 3
1. If abortion has occurred, book on the next evacuation list, or MVA as
described
2. If abortion has not occurred, give prostaglandin E2 (Prepidil) gel 0.5 mg
intracervically, or repeat Misoprostol and Oxytocin as for Day 1 and Day 2
Day 4
1. If abortion has occurred, book on the next evacuation list
2. If abortion has not occurred, book for hysterotomy or D&C on the
evacuation list.
3. Advise patients who have fundal hysterotomy that elective caesarean
section will be mandatory in future successful pregnancies
If Mifepristone available: (13-20weeks)
Mifepristone 200mg PO followed 36-48hrs after with Misoprostol 800mcg PV the
Misoprostol 400ug PV 3hrly up to 5 doses.

Important points about TOP

 Doctors are not compelled to participate in the TOP service however it is
an offence according to the CTOP Act to prevent or obstruct access to
TOP.
 Conscientious objectors therefore are compelled to refer women who
request TOP to doctors who do participate in the TOP service.
 All doctors are expected to participate in the management of emergencies,
whether associated with TOP or not
 Use agents with caution in patients with uterine scar in 2nd trimester.
 Do not deviate from the protocol without first discussing with a consultant
 Unless hysterotomy is required, patients are managed under each
successive gynaecology unit on intake (CHBAH)
 Use IV triple antibiotics (as for severe PID) if there is any suspicion of
sepsis (pyrexia, offensive products) or if prolonged termination or many
vaginal examinations
 Give anti-D to Rh negative patients within 72 hours of TOP
1st Trimester: 250 IU 2nd Trimester: 625 IU
 Patients should be referred to social worker in suspected cases of
rape/domestic abuse
 Productions of conception maybe required to be kept as evidence in rape
cases
 Contraceptive counseling is important in prevention of future unwanted
pregnancies
 If TOP is unsuccessful, confirm again on ultrasound that the pregnancy is
intrauterine
 32

CONTRACEPTION
Contraception services may be limited in Johannesburg public hospitals.
Intrauterine contraceptive devices (IUCDs) may not be freely available at most
public hospitals, but many are inserted privately or at primary care clinics. How to
insert them should be known. Condoms use provides STI protection for all who is
not in a permanent relationship. Careful counseling and information is
mandatory; many patients have no idea how and why the combined pill may fail.
Parental consent is not required for minors, however they should be advised to
talk with parents, guardian or family.
Effectiveness of contraception is measured with the PEARL INDEX, the number
of pregnancies per hundred women years(e.g. pregnancies in 25 women studied
for 4 years or in 1000 women for 10 years divided by 100).
The choice of contraceptive is based on a patient’s medical history and
preference. Risks and benefits of individual contraceptive methods should be
assessed using WHO Medical Eligibility Criteria.

EMERGENCY CONTRACEPTION
If a woman presents within 72 hours of unprotected intercourse:
1. Prescribe Ovral 2 tablets, followed by a further 2 tablets after 12 hours
2. OR levonorgestrel 75 mg (e.g. Norlevo) repeated after 12 hours or
1500mcg stat are more effective but may not be available in public
hospitals
3. Prescribe metoclopramide 10 mg orally three times daily for 2 days for
nausea and vomiting if using Ovral or levonorgestrel
4. If a woman presents from 3 to 7 days after unprotected intercourse,
consider inserting a copper-containing intrauterine contraceptive device, if
available. Consider antibiotic cover.

COMBINED ORAL CONTRACEPTIVES

General notes and contraindications
 Available preparations are Triphasil, Nordette and Ovral(avoid Ovral , if
possible, as estrogen dose is high [except where an enzyme inducer is
being taken]).There are many others to use instead
 There may be irregular spotting early on during use. This usually settles
 There may be nausea early on during use. This almost always settles
 There may be a small amount of weight gain, but this is not progressive
 Emphasize the need to take the pills on each day as instructed
 Advice on missed pills:
o One missed pill: If there is more than 12 hours delay after the usual
time, take the missed pill as soon as it is remembered, and the next
one at the usual time; use additional precautions, e.g. condoms or
abstinence, for the next 7 days
o If the missed pill is within 7 days of the end of active pills in the
pack, go straight into the next packet, without a pill free/dummy
pill(different colour) interval, and use additional precautions for the
next 7 days
o If more than one pill is missed, continue the packet, using additional
precautions until a new packet is started after a withdrawal bleed
 33

o If the missed pill or pills are in the first 7 days of active pills in the
pack and coitus has occurred, use emergency contraception and
restart the pills 24 hours later. Use additional precautions for the
next 7 days
 Advise on vomiting after pill ingestion, and diarrhea, and use of antibiotics
– continue pills and use additional precautions, e.g. condoms or
abstinence for a week after
Contraindications:
 Caution is advised in patients who smoke or have hypertension, diabetes,
obesity or dyslipidaemias, history of depression
 Absolute contraindications: Current or previous history of VTE,
Ischaemic heart disease, stroke, Migraine, APLS and certain antiepileptic
agents.

INJECTABLE CONTRACEPTIVES and IMPLANTS

General notes and contraindications
 Available preparations are medroxyprogesterone acetate 150 mg (Depo-
Provera) and norethisterone enanthate 200 mg (Nuristerate), and
Implanon(Etonorgesterel – see below) effective for 3 years, and
Norplant(Levonorgestrel) effective for 5 years
 There may be weight gain, but this is not progressive – many users
discontinue for this side-effect
 There may be irregular spotting in the first few weeks. This will almost
always settle
 Warn the user that amenorrhoea is to be expected after prolonged use
and is not a reason for alarm
 Advise regular attendance for further injections for injectables, 2 monthly
– Nuristerate, 3 monthly – Depo-Provera. Duration of effect for Implanon is
3 years, Norplant is 5 years(Norplant 2 consists of two implants)
 Injectables, Implants are relatively contraindicated in young teenagers
because of a risk of hypoestrogenic osteoporosis
 Implanon(Etonorgestrel) is currently popular. Concurrent ARV use has
been associated with a 12% pregnancy rate in one study. Levels of
Norethisterone(Nuristerate) and Medroxy progesterone(Depo-provera) are
seemingly less affected with ARVs/FDC
Contraindications
 Use with caution in patients with multiple risk factors for arterial
cardiovascular disease

INTRAUTERINE CONTRACEPTIVE DEVICE (IUCD CuT380A)

General notes and contraindications
 Explain how the IUCD works. Copper IUCDs are primarily spermicidal but
cause an inflammatory endometrial reaction also(effective 10-12 years).
This occurs with the Mirena (contains levonorgestrel) which also causes
persistent decidualisation (effective 5 years)
 Irregular spotting is common in the beginning, but usually settles
 Pain with or without vaginal discharge may suggest infection or a
complication of insertion
 Some users are surprised at how small an IUCD is. Explain this
 Explain the need to check the threads
 34

 Advise that the IUCD can be easily removed at the clinic if the user wants
to discontinue the method, for whatever reason
Contraindications
 Current pelvic TB/PID, Puerperal sepsis, Fibroid uterus with distortion of
the cavity, Gestational trophoblastic disease
 Caution: Nulliparity, Advanced HIV, unexplained PV bleeding should first
be investigated
Insertion of an IUCD
Ensure by history and discussion that the IUCD is appropriate and understood.
An ultrasound should preferably be performed to assess uterine size & axis, and
to exclude any coexistent pathology. The LMP must be known (post menstrual is
a good time for insertion). A cervical smear must be normal, there must be no
irregular bleeding, and no history of PID in the previous 5 years.
 Place patient in lithotomy
 Cleanse area with antiseptic solution
 Perform bimanual examination assessing uterine size and axis, and to
exclude pathology
 Pass a speculum, assessing vagina and cervix
 Grasp the cervix with single-toothed vulsellum
 Sound uterus with sound provided in packet and place the moveable ring
on the IUCD introducer at the appropriate point
 Gently pass IUCD in its applicator to the fundus, remove applicator, and
cut threads to 2-3 cm
Give Doxycycline 100 mg orally twice daily and Metronidazole 400 mg orally
twice daily for 5 days. Offer analgesia before insertion (Indomethacin 100 mg
suppository). Advise the patient to return for a check-up in 2 weeks and to
periodically check the threads to exclude expulsion.
The ‘Levonorgestrol-intrauterine system’ or ‘Mirena’ is much broader in the shaft
and may require greater skill, force or analgesia for insertion.
 35

FEMALE STERILIZATION
STERILIZATION ACT, 1998
This recognizes the rights of individuals ‘to be informed of and to have access to
safe, effective, affordable, and acceptable methods of fertility regulation… the
inability to give consent should not automatically entail the loss of constitutional
rights and … it is necessary to ensure that mentally disabled persons are able to
exercise these rights as far as is possible.’
Persons capable of consenting
 No person is prohibited from having a sterilization who is ‘capable of
consenting’ and 18 years of age or more.
 ‘A person capable of consenting may not be sterilized without his or her
consent.’
 ‘Sterilization may not be performed on a person who is under the age of
18 years except where failure to do so would jeopardize the person’s life
or seriously impair his or her physical health.’
Persons incapable of consenting
Sterilization may be performed upon request to ‘the person in charge of a
hospital’ by a parent, spouse, guardian, or curator, and after consideration by a
panel consisting of “a psychiatrist or a medical practitioner if no psychiatrist is
available; and a psychologist or a social worker; and a nurse”, that:
 The person is ‘incapable of making his or her own decision about
contraception or sterilization’
 Incapable of ‘developing mentally …to make an informed decision’
 Incapable of ‘fulfilling the parental responsibility associated with giving
birth’
 The person must be ‘18 years of age, unless the physical health of the
person is threatened’
 There is ‘no other safe and effective method of contraception except
sterilization”
General notes
 Laparoscopic and mini-laparotomy tubal ligations may be offered
 It is wise to ask any multiparous woman over the age of 30 if she would
consider tubal ligation
 Always ensure that the patient undergoing sterilization is not pregnant –
check the last menstrual period, and do a pregnancy test if necessary,
ideally, performing in the early follicular phase prevents a luteal phase
established pregnancy
 A recent normal Pap smear is essential
 The consent must emphasize permanence and the small chance of failure
 At mini-laparotomy tubal ligation, send the resected tubal segments for
histology (both tubes in one container to save costs)
 The ‘Essure’ or hysteroscopically inserted tubal occlusion is available as
an out-patient in some centres
 36

Chapter 6 Excessive vaginal bleeding - AUB

Excessive vaginal bleeding is a common complaint, frequently caused by a multi-
fibroid uterus. Not all such women have significant bleeding. At times, this
complaint may represent a plea for investigation of another problem, such as
infertility. It is important to take a complete history.
DEFINITIONS – there have been some changes
(the first two terms on the left are to be abandoned for the terms on the
right)
Menorrhagia - heavy regular menstruation
Metro-menorrhagia - heavy irregular bleeding
Inter-menstrual bleeding - bleeding between regular periods
Post-coital bleeding - self explanatory
Normal menstruation - duration: 2-7 days, cycle: 21-
35days(WHO definition)

All unusual bleeding patterns are referred to as ‘Abnormal Uterine bleeding’ -

AUB
Causes of excessive vaginal bleeding
 Gynaecological
o Fibroid uterus
o Cervical or endometrial malignancy and hyperplasia
o Adenomyosis
o Endometrial, cervical polyp
o Endometritis – PID
o Vaginal injury
 General
o Clotting disorder, e.g. von Willebrand’s disease – very rare
o Hypothyroidism – rare
 Pregnancy
o Miscarriage
o Secondary postpartum haemorrhage
 Iatrogenic
o Anticoagulants
o Contraception, e.g. injectable progestin or intrauterine device
 ‘Dysfunctional uterine bleeding’ – i.e. heavy bleeding with no easily
identified cause and obviously normal anatomy in the reproductive age
group….is now called AUB-N (‘Not yet specified’)

The PALM COEIN system for classifying abnormal uterine bleeding was
introduced by FIGO(the international gynaecological body) in 2010. It is an
acronym.
PALM COEIN: ‘Structural causes’(Polyps, Adenomyosis, Leiomyomas,
Malignancy and hyperplasia), and ‘Non-structural causes’(Coagulopathy,
Ovulation disorders, Endometrial local disorders of haemostasis, Iatrogenic, Not
yet specified. The system is open to further readjustment and includes
causes(e.g. Endometrial) not fully understood, as well as the acknowledged
uncertainty of ‘Not yet specified’. This classification may, in time, be changed.
 37

CLINICAL ASSESSMENT
Important points on history
 Duration of bleeding
 Last menstruation(LMP), including the possibility of pregnancy
 Regularity of menstrual cycle
 Number of days of bleeding
 Amount of bleeding – presence of clots, or increase in number of pads or
tampons needed
 Progressive increase in amount of bleeding for that patient or not
 Post-coital bleeding, intermenstrual bleeding
 Associated vaginal discharge – offensive or not
 Presence and nature of pain or discomfort
 Full gynaecological history – parity, contraception, sexually active etc.
 History of a bleeding disorder
 Use of medicines or contraceptives
Examination
 Check general condition, i.e. wasted, ill-looking etc.
 Look for bruising or petechiae
 Look for pallor
 Assess haemodynamic status, i.e. heart rate and blood pressure
 Palpate for any abdominal mass or uterine enlargement
 Palpate for abdominal tenderness
 A speculum and bimanual examination are mandatory
Investigations
 No blood tests required if the patient is well, has no pallor
 Hb - if there is pallor, or an FBC and Group and Hold or Crossmatch - if
there is pallor and haemodynamic compromise.
 Blood microscopy, differential, and B12 are essential before transfusion If
the Hb <6 or if there is bicytopenia or pancytopenia
 If miscarriage, ectopic pregnancy or molar pregnancy is suspected do a
pregnancy test
 Ultrasound scan to assess size and position of fibroids and to assess
masses that may not be fibroids
 Cervical smear must be done, but can be deferred for 2 weeks if bleeding
is heavy.
 Biopsy rather than Pap smear any cervical lesion that appears malignant
 Endometrial biopsy, e.g. Z-sample, for:
o Women over 40 years, especially with irregular bleeding and risk
factors for endometrial cancer - hypertension, obesity and diabetes
o Failed conservative management
 Transvaginal scan for endometrial thickness is only of value in
postmenopausal women
Treatment
1. Explain the problem to the patient
2. If an organic cause is found, e.g. fibroids, carcinoma, PID, pregnancy, etc.
this must be dealt with specifically
3. Give iron if there is anaemia e.g. ferrous sulphate 200 mg po tds with
meals. Advise it may nauseate, faeces will be black
4. Transfuse patients who have bled heavily only where clinically indicated
 38

5. Tranexamic acid may be given for acute bleeding (dosage below)

6. Many drugs are useful for dysfunctional uterine bleeding (discussed
below) but may also be effective in the presence of organic disease e.g.
fibroids, adenomyosis, or in women on contraception
7. Discovered medical conditions should be managed appropriately

MANAGEMENT OPTIONS FOR HEAVY BLEEDING

Management options depend on the presumed diagnosis, and on the patient’s
wishes regarding pregnancy
Medication
Drug treatment may be given for at least 3 months, and the patient may be
reviewed after that, to continue or to stop treatment.
 Tranexamic acid (Cyclokapron) 0.5 to 1 g orally 3 times daily for the first 3
days of bleeding. Can reduce regular heavy bleeding by 50%. Useful for
acute bleeding and long term. Does not make irregular bleeding regular.
Do not prescribe in patients with a history of thromboembolism.
Injectable Medroxyprogesterone acetate (Depo-Provera) 150 mg IM every
3 months, Norethisterone ethanoate(Nur-isterate) 200mg; useful for acute
bleeding and long-term. At first, bleeding may be irregular, if this happens
add 4 weeks of Norethisterone (Primolut) 10 mg orally twice daily. Reduce
bleeding by 95-100%. Progestogens may cause slight weight gain, feeling
of heaviness, oily skin, mood changes and rarely headache
 Medroxyprogesterone acetate (Provera) 5 mg orally twice daily for 21-28
days per month (never only 5-14 days: has no effect)
 Norethisterone (Primolut) 10 mg orally twice daily or 5 mg orally 3 times
daily for 21-28 days per month (not 5-14 days, as the package insert
suggests – this is ineffective); useful when bleeding is irregular
 Combined oral contraceptives. They also reduce dysmenorrhea and
provide contraception. Beware of contraindications. Decrease bleeding up
to 50%.
 Nonsteroidal anti-inflammatory drugs such as Ibuprofen 400 mg orally 3
times daily, mefenamic acid 500 mg orally 3 times daily, or naproxen 500
mg orally 3 times daily for the duration of bleeding. Useful for
dysmenorrhea, but decrease bleeding variably 10-45%. Beware of
contraindications – peptic ulceration, asthma, renal dysfunction
 Levonorgestrel-containing intrauterine system (Mirena) is effective, not
available at some public hospitals, irregular spotting may occur at first.
Reduce bleeding 95-100%.
 For prolonged bleeding following use of Depo Provera, or oral
contraceptives, one can give conjugated oestrogen (Premarin) 0.625 mg
daily for three weeks, after demonstrating a thin endometrium on
ultrasound

SURGICAL AND OTHER TREATMENT OPTIONS

Surgery depends on the cause, e.g. myomectomy or hysterectomy for fibroids
(below), or hysterectomy for persistent excessive bleeding not responding to
drug treatment. N.B. a small submucous fibroid may lead to heavy bleeding and
may be resected by hysteroscope. Endometrial ablation can be considered in
some units for bleeding from a normal uterus – i.e. when the uterus is of normal
size and no specific cause is found. If there is marked dysmenorrhoea there is
 39

less satisfaction with ablation. Many different types of ablation exist. Pregnancy
after ablation is contra-indicated, and specified as such in consent. Uterine artery
embolisation may be offered in some units. Pregnancy after is cautiously
allowed. Catheterisation and occlusion of both uterines is achieved via the
femoral artery. A watery blood stained discharge follows, which is very rarely
associated with overwhelming sepsis.

MANAGEMENT OF MULTIFIBROID UTERUS

Drug treatment (as for excessive vaginal bleeding) may control haemorrhage
sufficiently to avert hysterectomy, at least in the short term.

1. Do not force a hysterectomy an unwilling patient

2. Consider myomectomy. Consent for a myomectomy must include specific
mention of proceeding to hysterectomy if there are intraoperative
problems
3. Consider alternatives: Uterine artery embolization(UAE) or High Intensity
Focused Ultrasound(HIFU) for suitable patients who want to preserve their
fertility. UAE may shrink the uterus by 50%. Pregnancy Following UAE
may have complications(IUGR, prem labour, placenta accreta). This
should enter consent. HIFU has not to date been used much on the larger
uterus(the current limit is 18 weeks size). Always discuss with a
consultant.
4. Where fertility is an issue, consider other causes.
N.B. if, for a person with bleeding, there is a delay while awaiting an operation or
a procedure and that person is not maintained on progestagens and haematinics,
when the procedure is due there will be anaemia and it will be cancelled.

VAGINAL BLEEDING IN A CHILD

 History taking with the parent or guardian is essential
 Record duration, amount and associated discharge
 Is the bleeding definitely vaginal, or rectal, or urethral?
 Look for development of secondary sexual characteristics
 Ask about associated problems and past medical history
 Enquire carefully about any possibility of assault or interference
 Examination may be difficult. Examination under anaesthesia should
almost always be undertaken. General examination and abdominal
examination may occasionally be possible in an out-patient setting
 Pelvic ultrasound must be performed

Causes and Management

Urethral caruncle - Diathermy by experienced person, leave
catheter 12-24 hours
Foreign body - Remove under general anaesthesia (GA)
Precocious puberty - Identify by examination/blood tests; refer to
specialist clinic
Tumour - Biopsy under GA; refer to oncologist/clinic
Sexual Assault - Handle with extreme care.
 40

Take samples properly. Write good notes.

Involve senior staff, police and counselors (see
below)
Infection - Severe thrush can rarely cause bleeding, rarely

Chapter 7 Endocrinology and infertility

AMENORRHOEA
Primary amenorrhoea is no menstruation by the age of 14 years in the absence
of secondary sexual characteristics, or by the age of 16 years if they are present.
Constitutionally delayed puberty is frequent in South Africa. If a specialist
Endocrine clinic is available, refer cases (except outflow abnormalities) after
basic investigations have been ordered. Take care to approach these patients
with care and consideration, as they and their families may be extremely
concerned.
Secondary amenorrhoea is cessation of menstruation for 6 months after it has
been present. Beyond excluding pregnancy, do not investigate a woman with
amenorrhoea of < 6 months.

Amenorrhoea is best considered in terms of anatomy. Some details here apply

more to 10, some to 20, some to both. Always exclude pregnancy first.
 Outlow tract: imperforate hymen, transverse vaginal septum, absent
uterus, Asherman’s syndrome
 Ovaries: anovulation, Turner’s syndrome, menopause
 Adrenals: congenital adrenal hyperplasia(v rare), Cushing’s(rare)
 Thyroid: amenorrhoea usually occurs with hyperthyroidism
 Pituitary: hyperprolactinaemia, contraceptive agents, psychotropic drugs,
Sheehan’s syndrome, Cushing’s(rare)
 Hypothalamus: anorexia nervosa, athletes, severe stress, Kallman’s
syndrome, injury, prior infection

Important points on history taking

 Duration of amenorrhoea
 Pattern of menstruation before onset of secondary amenorrhoea
 Sexual activity and contraception
 Headache, visual disturbance, galactorrhoea (hyperprolactinaemia)
 Weight gain or loss
 Lifestyle: stress, exercise and diet
 Hot flushes
 Evidence of hirsutism or virilism
 History of pregnancies and lactation, massive haemorrhage in pregnancy
 Uterine surgery or curettage
 Use of psychotropic drugs
 Medical history – head injury, meningitis, previous radiotherapy, TB
Physical examination
 Complete general examination
 Height and weight(height <150cm makes a syndrome more likely)
 41

 Secondary sexual characteristics (breasts, hair distribution etc)

 Stigmata of chromosomal abnormalities (e.g. Turner’s syndrome)
 Abdominal/pelvic masses (pregnancy, hormone-producing tumors or
hematocolpos associated with imperforate hymen/transverse septum)
 Vaginal examination: imperforate hymen or a septum, and presence of a
cervix and uterus
Investigations
 Pregnancy test
 Pelvic ultrasound – haematocolpos, haematometra, polycystic ovaries,
presence or absence of uterus
 Progestogen challenge test (below)
 Blood tests which may be done, depending on findings, include:
o Prolactin; if raised or if symptoms of hyperthyroidism - TSH
o Estradiol
o FSH/LH
o Testosterone, SHBG, DHEAS, 17-hydroxyprogesterone
o Karyotype
Progestogen challenge test
Give medroxyprogesterone acetate (MPA, Provera) 10 mg orally twice daily for
10 days. A positive test (bleeding after completion of Provera) suggests
anovulation as the cause of amenorrhoea, and demonstrates a patent
oestrogenized outflow tract. A negative test necessitates blood tests for ovarian
and hypothalamic amenorrhoea. Do not use norethisterone (Primolut) instead of
MPA, as it is more androgenic, resulting in unfavourable side-effects in women
with polycystic ovarian syndrome.
Treatment of Amenorrhoea
1. All patients with primary amenorrhoea must be discussed with a
consultant
2. Some patients with secondary amenorrhoea may be managed quite
routinely(with a consultant) others e.g. with thyroid disorders, or Cushing’s
syndrome, require specialist physicians

CONDITIONS CAUSING AMENORRHOEA in some detail

IMPERFORATE HYMEN
Diagnosis
 Primary amenorrhoea with cyclic abdominal pain, then continuous
 Pelvic mass (haematocolpos), +/- abdominal mass(haematometra)
 Hymen appears as a bulging bluish membrane at the introitus
 Sonar findings are immediately diagnostic. Longitudinal view
Management
1. Incision and drainage on the next emergency list
2. The hymen is easily incised (under anaesthesia)
3. A large amount of viscous dark fluid (old menstrual blood) will be released
4. Warn the patient and her caregiver that the old blood will continue to drain
for several days, and to wear protection

TRANSVERSE VAGINAL SEPTUM

Diagnosis
 Primary amenorrhoea, with cyclical abdominal pain, then continuous
 42

 Pelvic mass (haematocolpos), +/- abdominal mass (haematometra)

 The septum is paler, more pink and more solid than an imperforate hymen
 The septum may be hidden in the vagina, or present at the introitus
 Look for associated urinary tract abnormalities(IVP and sonar)
Management
1. Incision is not as simple as with imperforate hymen, and may need to be
repeated
2. Do the operation on a routine elective list, supervised by a consultant
3. Though awkward in a teenager, the patient, once immediate healing has
occurred, MUST use a vaginal dilator(syringe barrel without tip) for 5 mins
daily until intercourse is started. IF NOT a ring of fibrosis will form, and
prevent later intercourse completely. This is difficult to explain but very
important

MULLERIAN AGENESIS(‘Mayer-Rokitansky-Kuster-Hauser Syndrome’)

Diagnosis
 In this condition, there is no uterus or cervix(1 in 4000)
 The patient appears as a normal XX female
 The vagina ends as a blind pouch, with no uterus seen on ultrasound scan
 There is normal pubic/axillary hair
 Differential diagnosis includes Androgen Insensitivity(pubic/axillary hair
absent), 5-alpha reductase deficiency and other androgen synthesis or
receptor errors
 Hormone profiles and karyotype are entirely normal
 Urinary tract abnormalities may co-exist
Management – should be strictly consultant driven
1. Do MRI to confirm diagnosis
2. There is no need for hormone replacement therapy
3. Counselling on infertility, sexual function and coping is essential(refer to
Psychologist and communicate with that person)
4. Investigate for associated urinary tract abnormalities(MRI, IVP, sonar[at
presentation])
5. Vaginal lengthening can be by pressure(intercourse, dilator[Frank
technique]) or by a highly complex neo-vagina operation often
using sigmoid.

ASHERMAN’S SYNDROME (INTRAUTERINE ADHESIONS or ‘synechiae’)

Diagnosis
 There is a history of previous curettage, almost always after a pregnancy
 Physical examination is normal
 The progestogen challenge test is negative
 Hormone profiles are normal
 Hysteroscopy and/or hysterosalpingogram confirm the diagnosis
Management
1. Open or hysteroscopic resection of adhesions
2. Insertion of an IUCD after resection
3. High-oestrogen oral contraceptive pill (e.g. Ovral)
4. The possibility of pregnancy depends on the extent of the Asherman’s
graded 1-3
 43

5. After treatment: there is persistent risk of infertility, miscarriage, APH,

IUGR,
premature labour, and hysterectomy placenta accrete occurs

POLYCYSTIC OVARIAN SYNDROME (PCOS) – one of the commonest

causes of 20 amenorrhoea
Diagnosis
 The Rotterdam Criteria: 2 out of 3 – oligo/anovulation, PCOS on sonar,
clinical/serological hyperandrogenism
 Obesity and hirsutism may be present but not always
 LH to FSH ratio may be high (3:1)
 Testosterone may be raised (2-5 nmol/L, but not >6 nmol/L, that suggests
a specific pathological secreting tumour)
 DHEAS may be slightly raised (not specific to PCOS). Don’t order it
 Transvaginal scan may show typical peripheral ovarian cysts, 12 or more,
2-10mm in diameter in a ‘pearl necklace’ peripheral distribution, the
stroma is denser(whiter), the ovary large, the capsule may be prominent
Management
1. Reassurance is not sufficient if menstrual abnormalities, infertility and
hirsutism are troublesome
2. If obese, it is essential for the patient to lose weight. This may be
CAUSING the problem. Not always
3. Patients not desiring fertility can be given a combined oral contraceptive
(avoid androgenic preparations e.g. those containing levonorgestrel or
norethisterone). If hirsutism is present those containing ciproterone
acetate or drosperinone can be used. N.B. these are expensive
4. Those desiring fertility will require Clomiphene(50-150mg po od on days 2-
6 of a cycle following a withdrawal bleed after progesterone 5-10mg for 5-
10 days. Ovulation occurs in 90%, pregnancy in < 50%.
5. Metformin may be of value in cases of insulin resistance* or Clomiphene
failure(*fasting insulin levels to define insulin resistance are contested)
6. Low-dose oral dexamethasone may be of value
7. If hirsutism is troublesome, antiandrogens such as Cyproterone acetate or
spironolactone should be used. Again weight loss if obese
8. Patients with PCOS must be managed by a consultant and referred to a
specialist gynae clinic if available. ALWAYS other infertility causes should
be excluded.

CHROMOSOME ABNORMALITIES in amenorrhoea usually affect the

ovary/gonad, occasionally the hypothalamus (Primary)
Diagnosis
 Learn to recognize the cardinal features of each condition. Syndromic
ovarian dysgenesis individuals often <155cm tall – Turner’s syndrome(XO,
webbed neck, short stature, multiple naevi, radio-femoral delay,
diminished secondary sexual characteristics(beware Turner mosaic…)),
Androgen Insensitivity(formerly testicular feminization) (XY, normal height,
normal breasts, no body hair, normal vulva, introitus, blind ending vagina,
gonads(testes) in pelvis or inguinal canal must be removed to prevent
 44

cancer then HRT) Ovarian dysgenesis(XX or rarely XY, varying degrees of

secondary sexual characteristics) etc.
 Physical examination and hormone profile may suggest the condition
 Karyotyping is essential for correct diagnosis
Management
1. All such cases must be discussed with a consultant
2. Avoid injudicious remarks about genitalia or chromosomes. An adolescent
or adult patient who appears female IS female
3. An androgen insensitivity individual is NOT male but female
4. A female patient with XY is at risk of gonadal malignancy and must have
gonadectomy by laparoscopy, laparotomy(but not if gonads are in the
inguinal canal – check first)

PREMATURE MENOPAUSE
Diagnosis
 This is menopause before the age of 40 years
 NB ask for symptoms: hot flushes & night sweats
 The FSH level is >30 IU/L on two occasions 4 weeks apart
 If FSH < LH, and FSH >15 IU/L this may be a ‘surge’ value before
ovulation, therefore repeat after at least a week. If FSH >15 and FSH > LH
this suggests menopause. Inhibin levels and AMH(anti-mullerian hormone
levels) may also fall – the latter may be used in IVF programmes to predict
stimulation success
Management
1. Reassure the patient that there is a range of ages at which menopause
occurs, and that this does not mean she is ‘old’
2. Consider the need for hormone replacement. Osteoporosis risk (Chapter
8). Fertility issues(prospects are v poor) and other gland involvement
should be considered

PROLACTINOMA
Diagnosis
 Patients may present with menstrual disorder and/or galactorrhoea
 The prolactin level will be >29 ng/mL (in the non-pregnant)
 Increased prolactin levels may occur with pregnancy, hypothyroidism and
with use of certain drugs(HCTZ, Aldomet), hypothyroidism - take blood for
TSH level, and after chest trauma
 In female patients, only 10% of prolactinomas are macroadenomas (>1 cm
diameter and cause headache, tunnel vision), in males it is 50%
 Ask about pressure symptoms – headache and visual problems(less
common in females)
 Arrange a CT scan of the brain, or consider an MRI scan
 Arrange for visual field testing (ophthalmology consult if macroadenoma;
you can test also). Bitemporal hemianopia is almost always not noticed by
the patient
Management
1. Explain the condition to the patient
2. Refer to the Endocrine clinic or discuss with an experienced consultant
3. Management may depend on the patient’s needs – fertility, menstrual
cycle control, or control of galactorrhoea
 45

4. Surgery or radiotherapy are very rarely used

5. Oral bromocriptine (Parlodel) is an effective first-line drug:
a. Start with 1.25 mg at night(to avoid postural hypotension) for 3
days, then 2.5 mg nocte for 3 days, then 2.5 mg twice daily, with
meals.
b. Follow up monthly; the prolactin level should reduce
c. The dosage may be slowly increased (rarely up to 30 mg daily)
d. Side-effects include nausea, postural hypotension and dizziness
6. Oral cabergoline (Dostinex) is a second-line agent:
a. Start with 0.5 mg weekly, increase if necessary up to 1 mg twice
weekly, rarely to 4 mg per week
b. Side-effects and follow-up are as for bromocriptine
Pregnancy and prolactinoma
1. Patients not desiring fertility should use contraception (combined pill,
injectable)
2. If patients on treatment for prolactinoma report amenorrhoea, consider
pregnancy as a cause
3. Pregnancy is not a reason to stop bromocriptine or cabergoline

OTHER CAUSES OF AMENORRHOEA

These include delayed puberty, anorexia nervosa, cachexia, psychological
stress, athletic training, Sheehan’s syndrome, previous meningitis, head trauma,
intracranial space occupying lesions, Cushing’s syndrome and hypothyroidism.
Diagnosis
 Take a careful history and do a full clinical examination
 If the cause is not obvious, refer to a consultant or the Endocrine clinic
 Physiological delay may be confirmed by delayed ossification in wrist X
ray
Management
 Anorexia nervosa should be referred to a psychiatrist
 Unexplained weight loss, Cushing’s syndrome and thyroid disorders
require referral to specialist physicians
 Sheehan’s syndrome requires referral to the Endocrine clinic
 Neurological disorders affecting pituitary function should be referred to
physicians and neurologists
 46

HIRSUTISM
Many cases of hirsutism (90%) are idiopathic and require no more than
symptomatic treatment or reassurance. Many such ‘idiopathic’ cases may have
subtle hormonal synthetic errors (as in mild polycystic ovarian syndrome) or
slighty altered sensitivity to androgens.
Pathological causes include polycystic ovarian syndrome, Cushing’s syndrome,
congenital adrenal hyperplasia, 5-alpha reductase deficiency and testosterone-
secreting tumors. Tumors should not be missed in these patients(Testosterone >
or = 7nmol/L).
Clinical assessment
 A full general history and examination
 Onset of hirsutism - recent and/or sudden(suggests tumour)
 Menstrual regularity, irregularity
 Use of any medications
 Obesity suggests polycystic ovarian syndrome (PCOS)
 Hypertension, striae, and/or muscle wasting suggest Cushing’s
syndrome(v rare)
 Pelvic mass suggests an androgen-secreting tumor but they are more
likely too small to be palpable
 Extent of hirsutism (Ferriman-Galwey score(11 or 13 areas of the body –
used in research)
 Virilism – voice changes, clitoromegaly, frontal balding, muscle bulk, and
hirsutism
Investigations
 LH and FSH: a ratio of 3:1 suggests PCOS
 Testosterone:
o level of 2-5 nmol/L suggests PCOS
o level >6 nmol/L suggests an androgen-secreting tumor
 DHEAS:
o Slightly raised suggests PCOS
o Markedly raised suggests Cushing’s syndrome
o Does not usually affect management
 17-hydroxyprogesterone levels if congenital adrenal hyperplasia is
suspected
 Pelvic ultrasound scan to look for ovarian cysts or masses, or polycystic
ovaries
 47

CONDITIONS CAUSING HIRSUTISM

TESTOSTERONE-SECRETING OVARIAN TUMORS
Diagnosis
 These are rare but serious: androblastomas, arrhenoblastomas, lipid cell
tumors, thecomas and luteomas
 Onset of hirsutism is sudden and marked; virilism is frequent
 Serum testosterone level >7 nmol/L is virtually diagnostic
 Ultrasound scan might not identify the tumor
 CT or even MRI scan may be required, or ovarian vein catheterisation
Management
 Surgical removal

CUSHING’S SYNDROME/DISEASE
Diagnosis
 Cushing’s syndrome - an adrenal adenoma or other cortisol-producing
tumor
 Cushing’s disease - a pituitary ACTH-producing adenoma
 Cushingoid features, hirsutism and hypertension are frequent
 Early morning cortisol (>620 nmol/L), short and long dexamethasone
suppression tests are diagnostic
Management
Refer to specialist physicians

CONGENITAL ADRENAL HYPERPLASIA (CAH) - rare

Diagnosis
 Atypical maturity onset variant presents with hirsutism(salt losing death at
childbirth is another)
 Frequently primary or secondary amenorrhoea
 Mild virilism or ambiguous genitalia may be found
 17-hydroxyprogesterone level >20 nmol/L may be found
 17-hydroxyprogesterone may rise only in response to ACTH stimulation
Management
1. Refer to physicians
2. Low-dose oral dexamethasone is the mainstay of medical treatment
3. These individuals often consider themselves male and may be deeply
traumatized by the diagnosis

5-ALPHA REDUCTASE DEFICIENCY

Diagnosis
 Very rare condition
 Primary amenorrhoea, and hirsutism or virilism particularly at puberty
 Mullerian agenesis (no uterus or cervix)
 Testosterone level is >6 nmol/L, with an XY karyotype
Management
1. Management by consultant and specialist clinic if available
2. Gonadectomy is recommended
3.
POLYCYSTIC OVARIAN SYNDROME
 48

This is a common cause of hirsutism and is discussed above as a cause of

amenorrhoea.

SYMPTOMATIC MANAGEMENT FOR ‘IDIOPATHIC’ HIRSUTISM

1. Treatment with anti-androgens takes 6 months to produce an effect
2. Spironolactone 50-100 mg daily is effective
3. Spironolactone must be taken with a non-androgenic combined pill to
prevent pregnancy and possible feminization of a female embryo
4. Cyproterone acetate (CA) can given as Diane-35 (CA 2 mg + EE 35 µg) or
as Androcur (CA 10 mg on days 5-14 and estradiol 30 µg on days 5-15)
5. Use of Androcur is cheaper than Diane-35. Diane is expensive
6. Cosmetic measures, such as bleaching, plucking, shaving, electrolysis
and laser may be considered, but the hospital does not provide these.

PREMENSTRUAL SYNDROME(PMS)
This is the association of psychological and physical symptoms with the days
preceding menstruation. In its severest form, the premenstrual dysphoric disorder
consists of a cluster of 7 categories of psychological symptoms. Irritability,
anxiety and mood lability are sometimes described as being ‘quicker to anger
and quicker to tears’ and cause considerable distress. Physical symptoms
include a feeling of heaviness or bloating and breast engorgement and
tenderness.
Diagnosis
The pattern must be cyclical, by definition it is confirmed over 3 cycles(rarely
insisted upon) and should not be a misdiagnosed depression which is
continuous.
Management
Explanation, the relationship to the hormonal cycle, is essential. Many treatments
have been attempted with mixed success. SSRIs remain the cornerstone of the
treatment of psychological symptoms. Diuretics may assist with bloating and
breast tenderness. NSAIDs may give symptomatic relief. Many vitamin
preparations have been used. Avoidance of caffeine and alcohol may be of
benefit.

PRECOCIOUS PUBERTY
Menstruation before the age of 10 years or the development of secondary sexual
characteristics before the age of 8 years.
Many cases are idiopathic (constitutional). Other causes: hormone secreting
tumors, cerebral tumors(craniopharyngioma or any other), McClune-Albright
syndrome, previous head injury or meningitis, encephalitis, and accidental
ingestion of hormone preparations. Damage to inhibitory brain pathways causes
precocity, damage to stimulatory pathways, amenorrhoea and, in a child, delayed
puberty.
Diagnosis
1. History includes details of the pubertal development and
neurodevelopmental milestones, and past medical history
2. Examination should look for causes as above and any abdominal masses
3. Basic blood hormone profile
4. Abdominal ultrasound scan
5. Skull x-ray(Craniopharyngioma in skull base may calcify)
 49

Management
 All patients must be referred to a specialist gynae endocrine clinic
 Treatment is directed at the cause, if one is found
 GnRH analogues may be required
 Careful counseling is very important including parents
 Contraception should be discussed/issues of sexual abuse too

INFERTILITY
Infertility is defined as failure by a couple to conceive after a year of regular
sexual intercourse. This is a common problem at all levels of care. 50% those
presenting at 1 year will conceive without assistance. Some patients present with
infertility, others indirectly, with complaints of lower abdominal pain, abnormal
vaginal bleeding etc. All nulliparas in their thirties should be asked specifically if
they have an infertility problem, otherwise the true reason for presenting
symptoms may be missed.
Many government hospitals are not equipped to investigate and manage infertility
properly, and are unable to treat most couples.
Common causes of Infertility
 Tubal factor (most frequent) – mostly chronic PID, also endometriosis
 Male factor (also very common)
 Uterine factor – fibroids, Asherman’s syndrome, tuberculosis(rare in SA)
 Ovarian factor – anovulation, PCOS, premature menopause
 Hypothalamic / pituitary factor – underweight, severe stress
 Couple factor – infrequent intercourse or poor coital technique
 Other causes – congenital abnormalities, chromosomal abnormalities etc.
 Unexplained – some couples fail to achieve pregnancy, for unknown
reasons(= or > 20% in most series)
History and Examination
 Establish whether the couple is truly infertile
 Duration and circumstances of the infertility
 Routine gynaecological history
 General and gynaecological examination to establish whether the
woman’s genital tract is entirely normal
 Cause of infertility may not be obvious from clinical assessment
Investigations
 HIV test – a positive test does not prevent infertility treatment
 Semen analysis(write a request to Ampath/Lancet) – many men will
decline to do. Normal values(WHO): Vol - 1.5ml or more; pH > or equal to
7.2; sperm concentration 15 million/ml or more; total motility 40% or more;
progressive motility 32% or more; morphology 4% or more normal(strict
criteria – Tygerburg); vitality 58% or more; WBC < 1 million/ml
 Pelvic sonar
 Hysterosalpingogram
 Laparoscopy and dye test (with adhesiolysis if appropriate)
 Day 21 Progesterone level(though a regularly menstrual individual IS
ovulatory)
 Endocrine tests as for PCOS if indicated(above)
 50

Management
1. Refer patients with anovulation to a consultant or specialist clinic if
available; weight loss is effective if appropriate. Clomiphene can be
prescribed, with counseling, with an outside script, or metformin, or
ovarian drilling if resistant. Some units may offer gonadotrophin
stimulation(or not)
2. Well-chosen patients with fibroids may benefit from myomectomy or
embolization(UAE), or High Intensity Focused Ultrasound (HIFU)
3. Advise on lifestyle – avoidance of smoking and alcohol, moderate exercise
4. Advise on coital technique and timing around ovulation – fertility maximal
either side of Day 14 in a regular cycle
5. Patients with tubal factor gain some advantage by laparoscopic surgery/
salpingostomy/ adhesiolysis
6. Patients with tubal factor / male factor / unexplained infertility cannot at the
moment be offered assisted reproduction, IVF/ICSI(intracytoplasmic
sperm injection), in Johannesburg public hospitals. This may change. For
male factor ICSI is the only significant treatment though intra-uterine
insemination and donor sperm may be considered
7. Counsel carefully about cause and ideal management
8. Discuss whether the couple can afford private infertility care
9. Be honest and sympathetic. Mention alternatives, e.g. adoption
10. Do not exclude all hope: some couples will achieve pregnancy
spontaneously
11. Do not bring patients back repeatedly if nothing further can be done

Chapter 8 Menopause
Menopause may be spontaneous, or surgically induced after bilateral
oophorectomy, pelvic radiation or chemotherapy.
Menopausal symptoms - hot flushes, night sweats, mood swings, dry vagina,
dyspareunia, urinary frequency and incontinence, loss of energy, insomnia,
depression.
The perimenopause or climacteric – an ill-defined period prior to true
menopause(12 months without periods) when symptoms may occur, bleeding
may be irregular.
Indications for Hormone Replacement Therapy (HRT) also called Hormone
Therapy (HT)
 Treatment of vasomotor symptoms
 Prevention of bone loss in women with premature menopause(<40 years)
or osteoporosis in 50-60 year old women
 Symptomatic urogenital atrophy
The indications are being reviewed continuously and have been the cause of
much controversy with two randomized trials in the 2000s showing low incidence
risks exceeding low incidence benefits. HRT may be requested by the patient.
Contraindications to HRT/ HT
 Active of history of thromboembolism
 Thrombophilia
 History of CHD, stroke or TIA
 51

 Current, past, suspected breast, endometrial, or other estrogen dependant

ca(women with one first degree relative may want to consider non-
hormonal therapy)
 Undiagnosed genital tract bleeding
 Untreated hypertension
 Liver disease
 Porphyria
Assessment, precautions, and advice
1. Counsel about menopause, options, to stop smoking, balanced diet,
exercise
2. Full medical and gynaecological history to exclude contraindications.
3. Physical examination, including breast and gynaecological
4. Blood pressure and at least annual rechecking. Pap smear if not in last 3
years
5. Mammogram and annual repeats. Fasting lipogram, HbA1c, TFT
6. Breast cancer risk is +/- 10% for all women without HRT, increased to
about 11% if HRT is used. Risk with estrogen alone may be less than
opposed
7. Monthly withdrawal bleeds will occur with opposed HRT (oestrogen plus
progestogen), which should diminish over time
8. Nausea and breast discomfort may be troublesome early on
9. Unopposed HRT (oestrogen alone) must never be given when a uterus is
present (risk of endometrial hyperplasia then cancer)
10. When starting HRT, review the patient after 6 months, then annually
11. On review, ask about problems (irregular bleeding, breast discomfort etc.)
12. Blood pressure check at least annually
13. Mammogram and breast examination annually
14. Record ALL important discussions at initiation and follow up visits
General principles for prescribing HRT/HT
HRT is best started within 2-3 years of the menopause. With previous
hysterectomy, unopposed oestrogen-only therapy is sufficient(breast ca risk may
be smaller). With an intact uterus, sequentially opposed oestrogen therapy will
result in cyclical bleeding. The lowest dose that reduces symptoms should be
used. Continuously opposed oestrogen(best started 1 year after the menopause
to avoid irregular spotting) often results in amenorrhoea.

HRT/HT REGIMENS
Oral opposed oestrogen (with progestogens)(EPT)
Sequentially opposed
 Estradiol valerate 2 mg with cyproterone acetate 1 mg and placebo in a
28-day pack (Climen)
 Conjugated oestrogen 0.625 mg or 1.25 mg with medrogestone 5 mg and
placebo in a 28-day pack (Prempak-N)
 Estradiol 1 mg and 2 mg with norethisterone acetate 1 mg in a 28-day
pack (Trisequens)
Continuously opposed
 Estradiol 2 mg with norethisterone acetate 1 mg (Kliogest) – taken
continuously, no withdrawal bleeds, not to be used in the first 2 years after
menopause
 Estradiol 1mg with drosperinone 2mg (Angeliq)
 52

Conjugated oestrogen 0.625mg with medroxyprogesterone acetate 2.5mg – 5mg

(Premelle 2.5 or 5)
Oral unopposed oestrogen (ONLY if no uterus present)
 Conjugated oestrogen (Premarin) 0.3, 0.625 or 1.25mg daily
 Estradiol (Estrofem)1-2 mg daily
 Start with lower doses and increase if necessary according to symptoms
 Newer lower dose preparations are emerging
Parenteral unopposed oestrogen
 Oestradiol Implants 20 mg have been withdrawn. Patches(applied to dry
clean area and transdermal gels(both applied away from the breast) may
not available in the state. They are good options if patient obese,
hypertensive or DM
 Transdermal systems - estradiol 3.9mg or 7.8mg, change weekly, can use
continuously or for 3w then interrupt for 1w (Climara)
 Transdermal patch – estradiol 25mcg, 37,5mcg, 50mcg, 75mcg or
100mcg/day, change every 3-4days (Estradot)
Vaginal oestrogen – only after a clear diagnosis of atrophy
 Conjugated oestrogen(Premarin) vaginal cream, apply 1-4 g daily – only
used after full assessment of any vaginal bleeding
 Vaginal cream - Conjugated oestrogen, apply 1-2g daily, max 4g, on a
cyclical basis (Premarin)
 Vaginal ring - Estradiol 2mg - max 2 years (Estring)
 Vaginal tablets – Estradiol 25mcg, 1 tab/d for 2w, then 1 twice weekly –
safety not established >1 year (Vagifem)
For vasomotor symptoms: Herbal remedies, phyto-estrogens(e.g. black cohosh)
have so far not been found effective, also acupuncture. Tibolone and clonidine
do have some benefit as have SSRIs. Newer agents and existing selective
estrogen receptor modulators(SERMS) remain under consideration.
The South African Menopause Society(SAMS) website contains many details.
The MenoPro app by the north American society(NAMS) is free from the app
store.
 53

OSTEOPOROSIS
Osteoporosis is defined as a bone mineral density(BMD) of more than 2.5
multiples of the median(MoM) less than the average in a young healthy person(T
score) as opposed to in an aged matched person(Z score). Osteopenia is
between -1MoM to -2.5. This is calculated on a DEXA scan(dual energy X ray
absorptiometry); these machines are expensive and may not be available. X rays
are old fashioned but may suggest the condition. Ultrasound of the heel is an
alternative. The commonest fractures are vertebral.
Diagnosis
Certain women are at risk. Risk factors include: family history, premature
menopause, Caucasian, smokers, alcohol abusers, those with reduced BMIs,
thyroid disorders, epileptics, steroid use, immobility. A fracture risk assessment
tool(FRAX index) may be used.
Treatment
Avoidance is better than cure. Healthy active living, Vit D 1,000-2,000 IU daily
and 500mg calcium daily are recommended. HRT/HT has returned as a
preventative measure and adjunct to treatment. Bisphosphonates, e.g.
alendronate(Fosamax) 5-10mg po daily must be taken standing up with water
only. SERMS may prevent fracture. Many agents(fluoride, strontium) come into
and go out of use.

POSTMENOPAUSAL BLEEDING (PMB)

This is vaginal bleeding occurring > or 6 months after cessation of menstruation.
About 10-15% of cases of postmenopausal bleeding (PMB) are caused by
cancer. Inappropriately prescribed unopposed oestrogen is sometimes
implicated.
Causes of PMB
 Malignancy – cervical, endometrial, vaginal, and fallopian tube carcinomas
and uterine sarcomas
 Endometrial and cervical polyps
 Endometrial hyperplasia
 Atrophic vaginitis/endometrium
 Haemorrhagic cystitis
 Bladder papillomas
 Haemorrhoids, anal fissures, low GIT malignancy
 Infections
 Urethral prolapse

Clinical assessment
 History of the main complaint, including the amount(clots makes atrophy
less likely)
 Drug history including HRT/HT
 Systematic history & PMH
 General examination, and look for anaemia and lymphadenopathy
 Vaginal examination including speculum examination.
 Pap smear, and/or endometrial or cervical biopsy(if a lesion is seen)
 Bimanual examination
 54

Further investigations
 Transvaginal ultrasound: if the endometrial thickness seen longitudinally is
<5mm there is a 97% chance there is NOT any significant endometrial
pathology. The opposite applies. Saline hysterography using saline
through a pediatric feeding tube instilled in the endometrial cavity may
highlight endometrial polyps at sonar. Endometrial thickness
measurement is NOT always possible or easy and v difficult when fibroids
are present
 Review the patient after 3 weeks
 Consider hysteroscopy with curettage/polypectomy
 If rectal/bladder pathology is suspected on history – investigate
How to do a ‘Z’ sample/endometrial sample
 Ultrasound to identify anatomy, particularly cavity and endometrial
thickness
 Pelvic examination to confirm uterine size, axis, position of cervix and to
exclude other causes of PMB
 Sampler inserted through the cervix under direct vision using a vaginal
speculum. If this will not pass either a) gently dilate with plastic ‘os finder’
or b) grasp the cervix with single tooth vulsellum
 Push the sampler slowly to the fundus. Pull back the central piston to
create a vacuum. Twist and turn the sampler while withdrawing
 Push the specimen into the formalin container by pushing the piston back
into its original position
 Repeat if a better specimen is desired, after wiping the sampler with
cotton wool
 The quoted sensitivity of the endometrial sampler is very different in
different studies(!) – 40 to 90%
Hysteroscopy and curettage if
 If there is heavy vaginal bleeding or bleeding with clots, it is prob not
atrophy
 Thick endometrium on transvaginal ultrasound scan (≥5 mm) without a
diagnostic ‘Z’ sample
 Failure to insert a ‘Z’ sampler (use an os finder or plastic dilator before
giving up or a single toothed vulsellum)
 If the ‘Z’ sampler shows cancer proceed to hysterectomy not hysteroscopy
Treatment of PMB
1. Discuss the finding of hyperplasia, premalignant conditions and malignant
conditions with a consultant
2. Malignancies must be managed according to oncology protocols (Chapter
10)
3. Hyperplasia (except simple non-atypical hyperplasia – a form of atrophy)
is treated by hysterectomy
4. Infection(rare) is treated with appropriate antimicrobials
5. Atrophy is treated with conjugated estrogen (Premarin) cream nocte
vaginally until the tube is empty. ‘No specimen’ or ‘inadequate specimen’
on ‘Z’ sample histology is suggestive of atrophy IF there is no obvious
abnormality or risk factor for malignancy and the bleeding is slight and the
endometrial thickness is <5mm
 55

Chapter 9 Vulval and vaginal disorders

VAGINAL DISCHARGE
General remarks
Vaginal discharge does not automatically mean there is PID or bacterial
vaginosis
 History and examination must be appropriate and complete
 History: duration of discharge, exact description of discharge and
associated symptoms
 Inspect the cervix and vagina with a speculum and a good light
 Do a Pap smear if not recently done
 Cancer is an uncommon but very important cause of vaginal discharge
 Consider ultrasound and endometrial biopsy in older patients (>45 years)
 Search for a cause of vaginal discharge, one may not be found, resulting
in syndromic or empirical treatment, or no treatment at all
Important causes of vaginal discharge
 Vaginal candidiasis
 Trichomoniasis
 Bacterial vaginosis
 Mucopurulent cervicitis
 Pelvic inflammatory disease
 Cervical or endometrial malignancy
 Cervical ectropion
 Foreign body
 Physiological discharge

VULVOVAGINAL CANDIDIASIS (VVC, THRUSH)

This is caused by infection with the fungus Candida albicans/ glabrata/
cerviciensis
Diagnosis
 Irritation or soreness, with or without discharge. Episodes may be
intermittent and recurrent or continuous or after each menstruation
 Usually the discharge appears like curdled milk or may be scanty with only
a little redness of the vulva and vagina
 Exclude diabetes or HIV infection poorly controlled in patients with severe
or recurrent thrush
 Consider association with antibiotics
 Wet prep: pseudo hyphae(albicans) or spores may be seen or on Pap
smears
Management
1. Clotrimazole long-acting pessary (Canesten ‘1’) given as a single dose
2. Alternatives include clotrimazole, econazole (Pevaryl) or miconazole
(Daktarin) vaginal creams, applied daily before bedtime for 7 days
3. Some recommend that the partner apply some of the cream to his penis at
the same time as the patient treats herself. The evidence is unclear
4. Advise thrush is not a sexually transmitted infection
 56

5. Suggest simple measures – pelvic hygiene without douches, and wearing

loose fitting underwear, and allowing the body to dry for some minutes,
walking in a dressing gown or towel after showering or bathing, before
putting clothes on. Other fungal infections: wash feet after genitalia
6. Candida glabrata and cerviciensis are not sensitive to the conventional
anti fungals mentioned

FOREIGN BODY
Diagnosis
 This usually presents with a foul-smelling or blood-stained vaginal
discharge
 More common in small children
 Adult women may forget tampons in the vagina
 A tampon or swab may be left behind following a surgical procedure, e.g.
episiotomy, cone biopsy etc.
 Speculum examination will identify the offending object
 Examination under anaesthesia is required for a suspected vaginal foreign
body in a child
Management
1. Carefully remove the foreign body completely
2. Use general anaesthesia if necessary (always in a small child)
3. Broad spectrum antibiotics if necessary, e.g. amoxicillin 500 mg orally 3
times daily, with metronidazole 400 mg orally 3 times daily
4. Vaginal oestrogen cream for a child less than 8 years old

VULVOVAGINAL TRICHOMONIASIS
Diagnosis
 This typically presents as a profuse offensive discharge, there can be
dysuria, or vaginal itching, irritation, dyspareunia
 Sometimes there are no symptoms (e.g. if found on a Pap smear)
 The classical ‘strawberry cervix’ on speculum is rarely seen
 Frothy grayish discharge may/may not be seen with speculum
 On wet prep or Pap smears biflagellate protozoa may be seen
Management
1. Metronidazole 2 g orally as a single dose, or 400 mg orally twice daily for
7 days. In the first trimester of pregnancy the WHO recommends
clotrimazole as for candidiasis
2. Recommend treatment of the partner
3. although the CDC permits metronidazole

BACTERIAL VAGINOSIS
This is not an infection. Rather, it represents overgrowth of the vagina with
bacteria, other than the normally predominant lactobacillus, mainly anaerobic
bacteria, many of them commensal in sexually active women.
Diagnosis
The complaint may be of a fishy smelling vagina, especially after intercourse
Diagnostic criteria (not always used) are the 4 Amsel criteria:
o The discharge - profuse or scanty, grey or off white
o Positive whiff test – fishy smell after adding potassium hydroxide
 57

o ‘Clue cells’(epithelial vaginal cells covered with bacteria) under the

microscope on wet prep
o Vaginal pH greater than 4.5(litmus or other test)
Management
1. Metronidazole as for trichomoniasis or clindamycin 300mg bd po for 7
days. Alternative: clindamycin ovules 100mg intravaginal for 3 nights - not
usually available in the state
2. Recurrence is a problem. Monthly single dose metronidazole 1g and
fluconazole 150mg has been successful
3. Advise that bacterial vaginosis is not a sexually transmitted infection
4. Place of probiotics remains uncertain
5. There is no need to treat the partner
6. Asymptomatic BV detected on a Pap(clue cells) does not need treatment
out of pregnancy

MUCOPURULENT CERVICITIS AND GONOCOCCAL CERVICITIS

Gonorrhoea or Chlamydia cause cervicitis in adults. In prepubertal girls,
gonococcal vaginitis may occur, associated with sexual abuse. If a gonococcal
discharge is found in a child, discuss with a consultant for specific treatment and
intervention i.e. social worker referral.
Diagnosis
 This may or may not coexist with acute PID
 The discharge is yellowish and non-offensive
 On speculum examination, a mucopurulent discharge from the external
cervical os
 In a child, there is vaginitis rather than cervicitis
 Pus swabbing using routine materials is unlikely to grow these organisms
 Gonococcal infection is classically associated with purulent discharge from
paraurethral (Skene’s) glands when milking the urethra from the anterior
vaginal wall
Management
1. Prescribe Ceftriaxone 750mg im as a single dose for gonorrhea plus either
azithromycin 1G as a stat dose or doxycycline 100 mg orally twice daily for
10 days(which will also cover chlamydia)
2. Metronidazole 400 mg orally twice daily for 10 days may be added
3. Advise treatment of the partner

PELVIC INFLAMMATORY DISEASE

An offensive vaginal discharge may be associated with acute PID, but if there is
NO cervical motion tenderness and no adnexal tenderness, PID is unlikely. PID
and treatment regimens for PID are discussed in Chapter 2.

CERVICAL OR ENDOMETRIAL MALIGNANCY

A blood stained and foul-smelling discharge may be caused by malignancy.
Speculum examination is always mandatory. Consider cervical biopsy,
endometrial biopsy and/or transvaginal ultrasound for women over the age of 45
years. There is even a possibility of fallopian tube or even ovarian cancer(v rare
causes). Malignant conditions are discussed in chapter 10.
 58

CERVICAL ECTROPION or ‘ectopy’

This has been called a ‘cervical erosion’ because of its appearance
Diagnosis
 The complaint is of a profuse inoffensive clear or cloudy discharge
 The cervix looks reddened at the centre since the mucus-producing
epithelium of the endocervix is exposed at the external os
 There is no inflammation and no infection
Management
1. When doing a Pap smear, sample the true squamo-columnar junction and
transformation zone (further out from the os than usual)
2. Colposcopy and biopsy essential to confirm normality; do not confuse with
cancer
3. Diathermy or cryotherapy restores the normal position of the squamo-
columnar junction. The discharge ceases
4. Discuss cases with a consultant to avoid missing a malignancy

PHYSIOLOGICAL VAGINAL DISCHARGE

Diagnosis
 The amount of normal discharge varies between individuals, within
individuals, with the menstrual cycle, with pregnancy and with sexual
arousal
 The discharge is whitish
 The discharge is not fishy or foul-smelling
Management
1. Reassure the patient that the discharge is normal. This may not be
adequate
2. Advise use of panty-liners
3. Do not disregard symptoms if the patient insists the discharge is abnormal
– consider follow-up of such patients
4. If in doubt about infection, prescribe doxycycline 100 mg orally twice daily
and metronidazole 400 mg orally three times daily for 10 days. This may
not be effective

OTHER VULVAL INFECTIONS and STIs

STREPTOCOCCAL INFECTION
Diagnosis
 This appears as a reddened vulva and may occur in young girls
 Treatment for candidiasis is unsuccessful
 There is no thickening of the skin to suggest dermatosis or dysplasia
Management
1. Amoxycillin 500 mg orally three times daily (lower doses for children)
2. Advise that this is not a sexually transmitted infection
3. In a child, reassure that this is not evidence of child abuse

WORM INFECTION
Diagnosis
 59

 Pruritus ani or pruritis vulvae is the presenting symptom

 Other members of the family may be infected
 Worms may be identified in the anus or in the stools. Sticky tape applied
to the perianal area may pick up the eggs or worms, for microscopic
identification
Management
1. Prescribe mebendazole (Vermox) 100 mg orally twice daily for 3 days
2. For pregnant women, prescribe pyrantel (Combantrin) 600 mg orally as a
single dose
3. Consider treating other family members and advise on general hygiene

SCABIES
Diagnosis
 Generalized itchy rash is typical, which may involve the vulva
 The head and neck are typically not involved
 Distinctive burrows are most easily seen webs of finger and toes
Management
1. Benzyl benzoate emulsion (Ascabiol) is applied in a thin layer over the
whole body except for the head and neck, and wash off after 12-24 hours.
This can be repeated in 7 days if necessary
2. Gamma-benzenehexachloride shampoo (Gambex) is used in the same
way as benzyl benzoate, but is contraindicated in pregnancy and lactation
3. Consider treatment of the whole family, clothes and bedding

PUBIC LICE (‘CRABS’)

Diagnosis
 This presents as itching in hairy parts of the external genitalia
 Careful inspection will reveal the lice or their nits
Management
1. Prescribe gamma-benzenehexachloride (Gambex) 30 mL, to be
massaged and lathered into the affected area with a little water, avoiding
contact with the vestibule, vagina and urethra. Rinse off thoroughly after 4
minutes. Nits can be removed by fine combing.
2. In pregnant and lactating women, use benzyl benzoate emulsion
(Ascabiol), applied to the affected area and washed off after 24 hours
3. Suggest treatment of the partner

HERPES SIMPLEX
Genital herpes is almost always HSV 2(cold sores HSV 1)
Diagnosis
 This appears as small blisters which erode and crust in the immune
competent patient
 In HIV positive women, there may be large clearly defined ulcers, with a
beefy red flat base(these resemble chancroid)
 Lymphadenopathy commonly coexists in primary or severe infections
Management
1. Give acyclovir (Zovirax) 400 mg tds po daily for 5-10 days in a primary
infection, and 5 days in a recurrence.
 60

2. Use topical acyclovir 3% ointment twice daily for mild cases

3. For HIV positive patients with chronic ulcers, give aciclovir 400 mg orally 5
times daily for 10 days
4. Recurrent herpes simplex can be suppressed with long-term aciclovir 400
mg orally twice daily; discuss with a consultant
5. Valaciclovir(1G bd), Famciclovir(400mg bd) are not available at most
public hospitals

CHANCROID
Diagnosis
The causative organism is Haemophilus ducreyi. Rare in SA.
 Ulcers may single or multiple, and are typically dirty, soft-based,
undermined and painful. Regional lymphadenopathy is common
 Syphilis serology and microscopy should be negative
Management
1. Specific treatment is erythromycin 500 mg orally 3 times daily for 7 days,
or azithromicin 1G po x1, or ceftriaxone 250mg im x1, or ciprofloxacin
500mg bd po for 3days
2. Syndromic management of genital ulcer disease includes erythromycin
3. Advise treatment of the partner
4. Consider HIV testing

GRANULOMA INGUINALE (DONOVANOSIS)

Diagnosis
The causative organism is Klebsiella granulomatis (formerly Calymmatobacter
granulomatis). Rare in SA.
 The condition is rare in Johannesburg – more common in the tropics
 Ulcers are painless, large, beefy, raised, single or multiple, with rolled
edges. Chronic herpes simplex ulcers may look similar
 There may be ‘pseudolymphadenopathy’, and associated lymphatic
stenosis or elephantiasis
 Diagnosis is difficult by culture. Donovan bodies on micro
 scopy
Management
1. Give doxycycline 100 mg orally twice daily for 3 weeks or erythromycin in
pregnant women) 500 mg orally 4 times daily for 3 weeks, or azithromycin
1g weekly for 3 weeks, or ciprofloxacin 750mg bd for 3 weeks
2. Advise treatment of the partner
3. Consider HIV testing

LYMPHOGRANULOMA VENEREUM
Diagnosis
The causative organism is Chamydia trachomatis. Rare in SA.
 The most common presentation is lymphadenopathy, tender, often
unilateral(at first). Glands may suppurate or become matted in a large
mass with sinuses. Elephantiasis may follow in untreated patients
 Ulcers, often not seen, are small, single and painless
 Rectal involvement: pain, tenesmus, constipation, mucoid discharge which
can lead to stricture, fistulae
 Swabs for immunofluorescence, serum testing not usually in our setting
 61

Management
1. Prescribe doxycycline 100 mg bd po for 3 weeks or Erythromycin 500mg
qds po 3 weeks
2. Advise treatment of the partner
3. Consider HIV testing

SYPHILIS
Diagnosis
The causative organism is Treponema pallidum
 A single firm painless ulcer (chancre) is typical in primary syphilis
 Secondary syphilis may present with condylomata lata – grey, flat, velvety
painless lesions (unless secondarily infected), with associated rash, fever
and adenopathy
 The RPR test is strongly positive in secondary syphilis, but may be
negative in the early stages of primary syphilis. TPHA tests, though more
specific for syphilis, remain positive for life(even if an infection was
successfully treated for example 20 years ago)

Management
1. Both primary and secondary syphilis respond to benzathine penicillin 2.4
million units IM as a single dose
2. Secondary latent – 3 such injections(weekly)
3. Penicillin-sensitive patients may be offered penicillin desensitization or
given doxycycline 100 mg orally twice daily or erythromycin 500 mg orally
4 times daily, for 15 days
4. Recommend treatment of the partner
5. Suggest HIV testing
 62

VULVAL WARTS
Diagnosis
 The causative organism is the human papillomavirus(HPV 6 and 11)
 The cauliflower appearance is typical
 Warts may be small but distressing to patient
 Large warts may be obstructive, painful, infected and foul-smelling
 Large warts are more frequent in teenagers, pregnant women and
immunocompromised patients
Management of small warts
1. Prescribe podophyllin paint (25%) for the patient to bring to the clinic. Do
NOT use unless you are sure pregnancy has been excluded. Aldara
cream is an alternative(a Category C drug in pregnancy; safety unknown)
2. A doctor must apply the paint carefully to the warts
3. Use a cotton bud or bacteriology swab to apply the paint
4. Do not allow any contact with normal skin – it burns
5. Advise that the paint will burn even on the warts
6. The paint should be washed off thoroughly after 3-6 hours
7. Repeat the treatment weekly as necessary
8. Trichloroacetic acid 85% can be used as an alternative in the same way
9. Moderate warts, or not responding, treat with diathermy, cryotherapy

Management of large warts

1. Consider HIV testing(positivity is likely and probably known)
2. Give amoxicillin 500 mg orally 3 times daily and metronidazole 400 mg
orally 3 times daily for 7 days if the warts are infected or foul smelling
3. In pregnancy, defer treatment until after delivery. Warts resolve
significantly postpartum
4. Large warts may be burnt with diathermy or surgically removed, under
general or regional anaesthesia. Burn the wart, not the surrounding skin
5. Radiotherapy has been recommended in HIV seropositive non-pregnant
patients with very advanced warts. Discuss with a consultant. Such cases
should be referred to the oncology group
 63

VULVAL SKIN PROBLEMS AND DYSPLASIAS

Besides allergic vulvitis, there are a number of conditions that present as white or
coloured raised lesions of the vulva, with a number of causes. Some are
premalignant.
ALLERGIC VULVITIS
Diagnosis
 The rash appears as a typical allergic rash
 The patient may be using a new type of underwear, soap or skin care
product in the region of the external genitals
 Shaving may produce an eczema-like response
Management
 Remove the allergen

VULVAL DERMATOSES
Dermatoses affecting the vulva include psoriasis, eczema and lichen planus
Diagnosis
 Ask for a history of rash anywhere on the body
 Look for evidence of dermatosis elsewhere:
o Psoriasis on extensor surfaces
o Eczema on flexor surfaces
o Lichen planus in the mouth
 Ask for an experienced colleague’s opinion
Management
1. Refer to dermatology
2. Steroids are frequently used for these conditions

VULVAL DYSPLASIAS
These conditions include lichen sclerosus, vulval intraepithelial neoplasia,
Paget’s disease of the vulva. These lesions have variable malignant potential or
may be associated with carcinoma, which must therefore be excluded.
Diagnosis
 These lesions may present with itching or soreness
 Non-troublesome lesions may be noticed by the patient, or incidentally by
a clinician
 Before making a diagnosis, arrange for vulvoscopy(looking closely with a
colposcope) and biopsy. Call an experienced consultant for guidance with
vulvoscopy
 Biopsy: raise a bleb of local with a dental/diabetic/orange needle. Biopsy
with Keye’s/Stieffel punch biopsy. Remove tissue with pointed scalpel
e.g. blade no 11. Stop bleeding with silver nitrate stick
 Do a Pap smear, to be interpreted in conjunction with the vulval biopsy
Appearance on vulvoscopy
 Lichen sclerosus – pale, onion-skin, hour glass pattern around the labia
and anus. Uniform in colour
 Vulval intraepithelial neoplasia (VIN) – discrete lesions of any colour, may
or may not be raised
 Vulval Paget’s disease – pearly appearance, any colour
 Carcinoma – ulceration, raised areas, rough areas, etc.
 64

Management
1. Lichen sclerosus – high dose topical steroid clobetasol propionate 0.05%
(Dermovate) cream twice daily for 2 weeks followed by low dose
betamethasone valerate 0.05% (Betnovate Half-Strength) or
Hydrocortisone 0.5% or 1% cream for one month, repeating if necessary
2. VIN - excision or ablation of VIN 2 & 3, observation of VIN 1, with long
term follow-up. Ensure cervical follow up also – both dysplasias may be
HPV16 and 18 dependent; instruct smokers with VIN to terminate their
habit – recurrence & progression is increased
3. Paget’s disease – excision and follow up. The association with underlying
adenocarcinoma is more rare than with breast Paget’s
4. Malignant lesions – treat according to oncology protocols (chapter 10)

Vulvodynia
This is a chronic condition of unknown aetiology that may occur at any age of
adulthood that has no known cause. Sharp pain, burning, stinging, or irritation is
experienced on the vulva. In a severe form vulval pain is experienced by touch
with a cotton bud or swab at the introitus and is called ‘Vulvar vestibulitis’.
Diagnosis
This is a diagnosis of exclusion. The differential diagnosis includes infections
(candidiasis, herpes, HPV); inflammation(lichen planus, other dermatoses);
neoplasm or dysplasia(Paget’s disease, VIN, vulval cancer); neurological
disorder(neuralgia secondary to herpes virus, spinal nerve injury).
Management
This is difficult. Supportive counseling may have some but sometimes limited
benefit. SSRIs have been used. Ultimately vestibulectomy may be performed but
should only be the choice of a clinician experienced in the condition.

Chapter 10 Cervical Screening/Colposcopy

CERVICAL SCREENING
Cervical screening by means of cervical smears (Pap smears) provides a safe,
simple and effective method of preventing cervical cancer. This allows early
detection of its precursor, cervical intraepithelial neoplasia (CIN).
The Aylesbury spatula is superior to the Ayre’s particularly in the parous patient.
Cervical brushes may be better still, but are expensive. Endocervical brushes
have special applications (see below). Shaking the spatula or brush into fluid
(‘liquid based’ preparation) rather than wiping on a slide may give a higher yield
of cells, but is more expensive.
HPV testing may be of value, although only in women over the age of 35 years
when nuclear inclusion makes infection more persistent. Prior to this many
infections are transient. Its application is not yet fully agreed upon. If CIN 1 is
discovered on biopsy, a finding of HPV 16 or 18 may necessitate an excisional or
ablative procedure.
Patients who should have cervical smears
 All sexually active women should have regular Pap smears but not <20
years
 Suggested guidelines for South African public health facilities is for 3 Pap
smears in a woman’s lifetime – at 30, at 40 and at 50 years
 65

 Avoid doing smears on teenagers, unless there are risk factors, e.g.
sexually transmitted infections.
 All patients who have been treated for CIN 1,2, or 3 should have annual
smears for life, and ideally 4 smears in the first 2 years
 All patients going for operations must have recent Pap smear results
 Pap smears should always be done for patients presenting without a Pap
in the previous 3 years, e.g. infertility workup, fibroid uterus, abnormal
vaginal bleeding, any patient for hysterectomy or tubal ligation etc.
How to take a cervical smear
1. Write the patient’s details clearly on both the slide and the form
2. Use a small amount of lubricant jelly on the outside of the vaginal
speculum
3. Good visualization of the cervix is essential
4. If the cervix cannot be seen clearly, reposition the speculum or ask a
colleague to try
5. Turn the spatula or brush around several times with the extended tip in the
cervical os.
6. The endocervical brush may be of benefit in patients with a previous
glandular abnormality, if the squamocolumnar junction is not clearly seen,
or if there has been a previous excisional procedure with a positive
endocervical margin. Twist the brush inside the canal and wipe it onto the
slide at a different point or onto a separate slide
7. Wipe the spatula or brush several times onto the slide
8. Spray the slide immediately with fixative from about 10-20 cm
9. Make clear arrangements for follow-up

The Bethesda Classification 2001

This is the third classification. The first, in 1989, was previously revised in 1991.
Squamous abnormalities
HSIL: High grade squamous intra-epithelial lesion (suggesting CIN 2 or 3)
LSIL: Low grade squamous intra-epithelial lesion (suggesting CIN1)
ASC-H: Atypical squamous cells – high grade abnormality cannot be
excluded
ASCUS: Atypical squamous cells of uncertain significance
Glandular abnormalities
AIS: Adenocarcinoma-in-situ
AGC: Atypical glandular cells
AGNOS: Atypical glandular cells not otherwise specified

Adequate cervical smears

An adequate smear is one with at least 10 endocervical cells and/or squamous
metaplastic cells. There are 8 000 to 12 000 cells per slide, and no more than
75% of the slide should be obscured by blood or inflammatory cells
ABNORMAL SMEARS and how to act
1. Many patients with an abnormal smears should be referred for colposcopy
(HSIL, recurrent LSIL, ASC-H, AIS, AGC)
2. In certain cases it is permissible to defer colposcopy and repeat the smear
(ASCUS, AGNOS, or first LSIL).
3. Before referral, explain to the patient that:
a. The abnormality is not cancer
 66

b. The possible treatment involves removal of a coin-sized piece of

cervix which grows back
c. Colposcopy and follow-up will help to prevent cervical cancer

COLPOSCOPY AND ASSOCIATED ABLATIVE PROCEDURES

A single high grade cervical smear result is an indication for colposcopy and
probably ‘See and Treat’ (see below). A recurrent low grade smear (at least two)
should be colposcoped. Colposcopically proven low grade (CIN 1) may be
treated by LLETZ (large loop excision of the transformation zone) OR observed,
with good follow up. In patients older than 35 years, colposcopically and biopsy
proven CIN 1 can be tested for HPV. Such women with HPV subtypes 16 and 18,
may be offered LLETZ, laser conization, or cold knife conization, with HPV
negative women observed with annual cytology and/or colposcopy.
HIV makes the risk of progression from low grade to high grade dysplasia
greater, and recurrence after treatment. Improving CD4 counts on antiretroviral
drugs may lessen this trend. Conservative management of colposcopically
proven low grade disease avoids endless treatment, but follow up is essential.
COLPOSCOPY
 History: referral cervical smear, previous abnormal smears and treatment,
LMP, parity and past medical history
 Exclude pregnancy if there is any possibility
 Explain colposcopy
 Place the patient in lithotomy
 Bimanual examination to assess uterine size and axis
 Speculum: examine the cervix with the naked eye, then by colposcope at
low power, then high power. Coarse focus is by moving the colposcope
nearer and further from the patient on its arm. Fine focus is attained by
turning a wheel on the side of the scope
 Wipe excessive mucus if present off the cervix with cotton wool mounted
on a sponge holder
 Soak the cervix with 2% Acetic acid on a drenched cotton wool ball on a
sponge holder
 Aceto-white epithelium(a brilliant white patch with a sharp border)
suggests dysplasia, as opposed to the grey-white with indistinct border of
squamous metaplasia (non-pathological). The aceto-white areas may
have a pavement like pattern (‘mosaic’), or fine evenly spaced red dots
(‘punctation’). With experience, low grade abnormalities can be
distinguished from high grade which tends to have larger mosaic squares
for example. The presence of ‘corkscrew’ vessels or abruptly branching
vessels suggests frank invasion. These are best seen with a green filter.
 ‘Adequate‘ colposcopy is defined as complete visualization of the squamo-
columnar junction and the upper limit of aceto-white areas. Inadequate
colposcopy was before an indication for cone biopsy, but LLETZ is now
considered appropriate. If colposcopy is inadequate, excision (LLETZ,
laser Cone, knife Cone) is preferable to ablative procedures (cryotherapy
or laser vaporization) – for the latter there is no histology
 If the referral smear is low grade, perform punch biopsies (at least 2 & up
to 4). If the referral smear is high grade, perform a LLETZ. Even if the
colposcopy does not clearly show high grade, a difference between
colposcopy and cytology results is an indication for LLETZ
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 To assess the cervix by colposcopy and immediately perfom a LLETZ is

called ‘See and Treat.’
LLETZ (Large Loop Excision of the transformation Zone) - how to do it
 A diathermy plate is needed – LLETZ uses monopolar diathermy
 A special speculum is used with an exhaust pipe inside the upper blade.
 A condom over the speculum or the thumb of a rubber glove, cut the end
off with scissors, may hold back floppy vaginal walls
 Stain the cervix with 2% acetic acid to see the lesion
 Inject, with a dental syringe, 1% lignocaine at the junction of the cervix
with the vaginal fornices at 12, 3, 6, and 9 o’clock
 After a minute, with the diathermy machine set to blended cut (with
coagulation), pass the loop from left to right, or from above down to a
depth deepest at the cervical canal of 1 cm.
 If the pass is too fast there is excessive bleeding, too slow and the loop
may halt and it may be difficult to push further
 Ball diathermy is used across the entire crater, starting at the top. Specific
bleeding points can be stemmed with a cotton bud. Roll the bud away and
use ball diathermy
 Antiseptic creams and antibiotics are optional
 Follow up plans must be properly explained

Cancer
General Notes
 All cancer patients must have a thorough examination at diagnosis and
follow up
 The diagnosis of cancer comes as a great shock to most. Handle the
matter with sensitivity and sympathy. Avoid terms like “huge”, “biggest
I’ve seen” in front of the patient
 Await biopsy results before making definitive statements
 Some patients have a surprisingly good prognosis. Knowing survival
figures can help to encourage patients
 Remember that HIV positive patients have two diagnoses to contend with
 Social organization is vital to all people. Engage relatives, with patient
consent, wherever possible. Be sensitive to requests to arrange domestic
affairs but encourage patients to return
 Terminally ill patients must have good analgesia. Ask about pain. Involve
the palliative care team, social workers, relatives, and hospices
ASSESSMENT OF THE NEW PATIENT
All new patients must be thoroughly assessed.
 A patient may come referred as a known cancer patient or may be newly
suspected by yourself, in either case….
 ‘Top and Tail’ ALL patients – i.e.
A thorough history detailing
1. Symptoms
2. Past Gynae/Medical/Surgical History
3. HIV status
4. Any/All investigations – if taken
5. Social including financial support/relatives
 68

Full examination
1. General well-being, vital signs, anaemia, jaundice
2. All regional lymph nodes
3. Breast examination
4. Chest and Abdomen(full examination)

 What you notice, somebody else may have missed

PAIN RELIEF FOR CANCER PATIENTS
Cancer patients vary from well patients to those in extreme pain or terminally ill. It
is important to ask patients regularly about pain. Consult the Palliative Care
Team if there are difficulties with pain relief. Beware that not all pain relates
directly to the cancer. Patients awaiting treatment, undergoing treatment, and
under review imagine that all pain is cancer related. If it is not, after investigation,
say so.

Also a pain may relate to a specific pattern of spread of the cancer as below:-
Common causes of pain
Abdominal pain
Urinary tract infection – history and urine examination: antibiotics
Constipation – history, tenderness and loaded bowel in left iliac fossa: laxatives
Bowel obstruction – examination, abdominal X-ray: drip and suction
Referred root pain (metastases) – examination, X-ray, bone scan: radiotherapy
Back pain
Nonspecific backache – history, examination, exclude metastasis: simple
analgesia, advice
Pyelonephritis – history, examination, urine examination: antibiotics
Lumbosacral metastases – examination, lumbar x-ray, bone scan: radiotherapy
Refer patients with bone metastases for urgent radiotherapy
Management of cancer related pain
Use the WHO stepwise approach(below, Steps 1 to 4). Gradually increase
doses, then change the type of analgesia according to the effectiveness.
Communicate regularly with the patient
Use laxatives with opiates of any strength(i.e. Liquid Paraffin or Lactulose 10ml
bd, or another).
Also exclude non-malignancy causes as mentioned above, and involve the
Palliative Care Team if help is needed.
Step 1:
Simple analgesics
 Paracetamol, Aspirin, Ibuprofen, Naproxen etc.
Step 2:
Mild opiate containing agents
 Add dihydrocodeine (DF118) 30 mg orally 4 times daily, increasing to 60
mg (rarely 120 mg) orally 4 times daily if necessary
 Prescribe laxatives with all opiate preparations – e.g. liquid paraffin 10mL
orally twice daily with sennosides (Senokot) 7.5 mg orally at bedtime
 Continue with anti-inflammatories as above
Step 3:
Strong opiates
 Morphine sulphate tablets 30 mg orally twice daily, increasing to 60 mg
orally twice daily or more if necessary
 69

 Supplement with morphine oral solution 10-20 mL 4 times daily when

necessary, for breakthrough pain
 Continue with anti-inflammatories and prescribe laxatives as above

Step 4:
Alternative methods
 These include radiotherapy to bony metastases, epidural analgesia, and
nerve ablation

CERVICAL CANCER
The most common gynaecological cancer in South Africa. Most patients present
with locally advanced disease and require radiotherapy with chemotherapy. Early
stage is treated with hysterectomy(micro-invasive) or radical hysterectomy.
Diagnosis and assessment at presentation
 Describe the nature and extent of the lesion
 Punch biopsy(histology marked ‘Urgent’)
 Assess for metastases on history and examination
 FBC, U&E, and HIV(CD4 if positive) – not RPR or LFT
 Chest x-ray
 Ultrasound kidneys(for hydronephrosis) – if present, automatically Stage
3b
 Palpable lymph nodes must be FNA’d or biopsied
 If there is suspicion of bony metastasis (lumbosacral pain, sciatic nerve
root symptoms) – X ray, bone scan
 Cystoscopy and biopsy if lower 1/3 vagina involved
 Inform the unit consultant
 Arrange a follow-up appointment in 10-14 days, for possible admission
and for presentation to the weekly oncology meeting
 The differential diagnosis(other possibilities): cervical TB, schistosomiasis
(may coexist with ca)
Follow up visit
 The histological report will confirm the diagnosis. Explain the diagnosis to
the patient
 The patient must be properly staged: speculum, PV, PR, sonar – by an
experienced person
 Stage 1B lesions need to be assessed for possible Wertheim’s
hysterectomy. Other cases, for radiotherapy(DXT) +/- chemotherapy, can
be presented at the Joint Oncology meeting at Charlotte Maxeke on
Thursdays, as an out-patient or in-patient. Explain all this to the patient
 The Hb result needs to be 12 g/dL or more for radiotherapy – but there is
a delay so give haematinics unless severely anaemic
Stages and types of cervical cancer (FIGO 2009)
Stage Ia1: Minimal stromal invasion (<3mm deep, <7mm diameter).
Stage Ia2: 3-5mm depth invasion, <7mm diameter

Stage Ib: Any tumour confined to the cervix larger than stage 1a2
Ib1: 4cm diameter or less
Ib2: >4cm diameter

Stage 2a: Involvement of vagina, confined to upper 2/3

 70

Stage 2b: Involvement of either or both parametria, not to sidewall

Stage 3a: Involvement of vagina lower 2/3, not to sidewall

Stage 3b: Spread to either pelvic sidewall or both, or hydronephrosis

Stage 4a: Involvement of mucosa of bladder or rectum

Stage 4b: Distant spread - outside the pelvis
The majority, 85%, are squamous, 15% are adenocarcinomas - the incidence of
which has not been reduced by cervical screening. Other rare variants exist.
Squamous carcinomas and adenocarcinomas are treated the same.
Presentation at the Joint Oncology Meeting
CMAH every Thursday at 09:30. Generally, the patients do not need to attend.
The patients’ files and oncology forms are taken early in the morning to CMAH.
The following must be included:
 Summary of the case in the file(for the presenter to read out) and DXT
form completed
 Results of FBC, U&E, HIV (CD4 count if positive).
 ‘Hard’ copy of histology report or laboratory number
 Chest X-ray report
 Kidney ultrasound report
 Staging examination, including:
o Size of lesion
o Vaginal involvement
o Parametrial involvement
 Drawing of the lesion
 Any metastases: histology or cytology reports (glands, bladder biopsy etc.)
Patients requiring DXT(+/- chemotherapy)
 Stage Ib2 and all stage II-IV
 DXT is for 4- 6 weeks at Johannesburg Hospital
 Chemotherapy may also be used(platinum based)
 Most patients are transported daily in a hospital vehicle
 Inform patients about the treatment, in particular:
o What takes place with radiotherapy
o How long radiotherapy takes
o Side-effects and complications of radiotherapy
o Need to use vaginal dilators(if necessary)
 After completion of treatment, follow-up is at CMAH and then respective
hospitals
Patients requiring Wertheim hysterectomy(radical with lymph node
dissection)
 Some stage Ia2, Ib1(occasionally Ib2) and IIa(occasionally) qualify
 Cross-match 2 units of packed cells on standby for theatre
 Consent for ‘Wertheim hysterectomy’
 Explain that further treatment, e.g. radiotherapy +/- chemo, may be
necessary after the operation (histology determines: +ve margins/nodes)
 NB after catheter removal(2 days) ask for voluntary voiding plus every 4-6
hours. When 4-6 hours produces nothing voluntary voiding only
Follow up
 If excision is complete with negative nodes:
o Review at 3 months, 6-monthly twice, then annually
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o At each visit, ask about general health, pain and vaginal bleeding
o Full examination, looking for evidence of metastases
o Vaginal examination at 6 months, then annually
o Pap smear at 6 months, then annually
Management of associated problems of Ca cervix
Excessive vaginal bleeding
 Catheterize the bladder
 Prepare a vaginal pack with acetone to stop the bleeding
o Soak the tip of the gauze pack with acetone
o Insert the pack through a Cusco speculum using a packing forceps
or sponge holder(avoid touching normal vagina with acetone, it
burns)
o Ensure that the pack is closely applied to the cervix
o Alternative: soak the pack tip with 3 vials of Cyclokapron for
injection instead
 Tranexamic acid (Cyclokapron) 500 mg orally 3 times daily may be helpful
 In premenopausal patients consider incidental menorrhagia as a cause
 In desperate cases, emergency DXT, internal iliac artery ligation(at
surgery) or embolisation are all options
Vesico-vaginal fistula
 This can be confirmed on cystoscopy but usually is easy to define on
examination
 Take a biopsy from the edge of the fistula if possible
 If the fistula is associated with previous radiation, take a biopsy and inform
the radiotherapy department, even if the biopsy is tumor-free
 Urinary diversion(ileal conduit – big operation) will be considered if there is
no cancer. Consult a urologist
 Fistula is discussed in more detail in Chapter 12
Pain relief
 Ask regularly about pain
 Exclude specific causes and treat appropriately, e.g. urinary tract infection
or constipation
 Consider lumbosacral metastases as a cause of pain(urgent DXT)
 Know the WHO stepwise approach to increase pain relief(as above)
 72

ENDOMETRIAL CANCER
Diagnosis
 Usually presents with postmenopausal bleeding (Chapter 8), can occur
before
 Endometrial biopsy is obtained by z-sampling, curettage or hysteroscopic
biopsy
 Rarely endometrial cancers present with distant metastases. All patients
should be evaluated for metastases as for cervical cancer
Treatment
1. Total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH
& BSO) unless spread beyond the uterus
2. Additional radiotherapy is for Grade 3(poorly differentiated), some Grade
2, 1B and above, and for +ve nodes if taken. The place of chemo remains
uncertain at present
3. Hormone therapy(Provera 30mg e.g) may shrink lung mets or be used for
infirm old ladies but is not part of routine treatment
4. Vault radiation prevents local recurrence but not distal
Pre-operative preparation
 Prepare the patient as for any hysterectomy
 Pay attention to associated diabetes or hypertension;
anaesthetic consult if necessary
Postoperative review
 This is done two weeks after the operation
 Histology results should be available
 The oncology forms are prepared for presentation at the oncology meeting
Presentation at the oncology meeting
 Staging is done at surgery, so most cases are presented after operation
 Patients who are unfit for, or refuse, surgery, are presented on diagnosis
Follow up
 Patients treated with radiotherapy are followed up by the radiotherapy
department
 Patients requiring only surgery are followed up as for cervical cancer
Stages, grades, and types of endometrial cancer (FIGO 2009)
Stage Ia: Limited to the endometrium or inner ½ myometrium
Stage Ib: Outer ½ of the myometrium
Stage 2: Involves the uterus and cervix stroma but not beyond. Cervical
glandular involvement now considered Stage 1
Stage 3a: Uterine serosa breached and/or adnexal involvement
Stage 3b: Vaginal spread
Stage 3C(i): Involvement of pelvic nodes
Stage 3C(i): Involves para-aortic nodes
Positive peritoneal cytology is reported separately but does not affect the stage
Stage 4a: Bladder or bowel mucosa involved
Stage 4b: Distant metastases including intra-abdominal and/or inguinal lymph
nodes
Histological grading
This reflects the degree of differentiation, with grade 3 being the most poorly
differentiated and having the worst prognosis for patient survival. It is used in all
cancers, but is particularly influential in endometrial.
Grade 1: 5% of less of a ‘non-morular’(normal) growth pattern
 73

Grade 2: 6-50% of a non-morular solid growth pattern

Grade 3: More than 50% of a non-morular growth pattern

Tumour type
 The majority, also with the best prognosis, are endometrioid
adenocarcinomas.
 Adenoacanthomas(endometrioid adenocarcinomas with benign
squamous metaplasia) have a relatively good prognosis.
 Adenosquamous and clear cell have a poorer prognosis. Papillary
serous adenocarcinoma is by definition poorly differentiated and has a
poorer prognosis.

OVARIAN CANCER
Diagnosis
 Many cancers present with an abdominal mass and/or ascites. Always
assess distension and vague abdominal pain in a patient over 50years.
 Most patients, but not all, are postmenopausal and present with advanced
disease(60% StageIII). Epithelial ca can occur in a younger patient. A cyst
in a child(pre-menstrual) is a germ cell malignancy until proven otherwise
 Suggestive ovarian cyst ultrasound findings include:
o Solid elements
o Papillary projections
o Bilateral cysts
o Septated cysts
o Ascites
 Risk of Malignancy Index(RMI) from the RCOG(there are others) is U x
M x CA125. U= ultrasound score, M= menopause status. With a cut off of
250, sensitivity is 70%, specificity 90%. Its use – to guide referral to an
oncology surgeon. If the tumour is confined to the ovary the CA125 may
not be raised
 Look for metastases – pleural effusion(tap), peripheral nodes(FNA), Sister
Joseph’s nodule at umbilicus(remove for histology, or biopsy)
 Not all is at it seems: Dermoid ovarian cysts have solid elements and are
benign and the pleural effusion of Meig’s syndrome is from an atypical
benign ovarian mass
Assessment and Investigations
 Full history and examination
 Look for primary tumors (breast, stomach, bowel etc.) that may
metastasize and appear as ovarian cancers (Krukenberg tumors)
 Omental cake, liver enlargement and pleural effusion may be found on
examination
 Ultrasound may show enlarged liver or omental cake. Obviously a pelvic
mass must be scanned
 Chest X-ray may show metastases or a pleural effusion
 Pleural effusion, tap the fluid for cytology
 Lumps or nodules, e.g. Sister Joseph’s nodule, biopsy
 An abdominal CT scan may show extent of disease
 Tumor markers:
 74

o For possible epithelial tumors take serum CA-125 – values >30u/ml

suggest malignancy. Also raised in endometriosis, PID, fibroids,
pregnancy, menstruation
o For possible germ cell tumors (age<30), take hCG, AFP and LDH
Pre-operative preparation
1. Prepare as for TAH & BSO, with special additions below
2. Cross-match 2-3 units packed cells on standby for theatre
3. Bowel prep: Go-lytely or fleet enema
4. Colostomy(usually not performed) may need to be discussed; consult the
stomatherapy staff if necessary
5. ICU bed may be needed, consult with the anaesthetists
Treatment
 TAH & BSO and omentectomy with removal of all tumor deposits >1 cm is
the standard for all epithelial cancers – ‘bulk reduction’
 If optimal debulking is NOT achieved at the first operation, multi-centre
studies have shown interval repeat surgery(post chemotherapy, or part of
it) offers the same prognosis/benefit with less complications
 Platinum-based chemotherapy plus Taxol(Paclitaxel) is given to all tumors
except stage 1a
 Chemotherapy is started 2-3 weeks postoperatively, ideally
 Six courses are given at 2-3 week intervals, as an out-patient in most
cases
 Alopecia is the rule. Carboplatin is less nephrotoxic but myelosuppressive.
Cisplatin is more nephrotoxic and causes high tone deafness at toxic
levels and peripheral neuropathy
 Arrange chemotherapy at Johannesburg Hospital area 495 (0114883495).
All details plus histology must be faxed
 Germ cell and stromal tumors may be treated with relative conservatism,
depending on tumor type, stage, and age of the patient – MUST be
presented
 The chemotherapy unit will follow up
Stages and types of ovarian cancer (FIGO 2009)
Stage Ia: Limited to one ovary, capsule intact, no malignant ascites
Stage Ib: Limited to both ovaries, capsule intact, no ascites
Stage Ic: Capsule not intact, with ascites, or positive peritoneal cytology
Stage 2a: Extension to uterus or fallopian tubes
Stage 2b: Extension to pelvic organs other than uterus or fallopian tubes
Stage 2c: Any pelvic organs involved with capsule not intact, malignant
ascites or positive peritoneal cytology
Stage 3a: Limited to pelvis, with negative nodes but microscopic evidence of
abdominal spread
Stage 3b: Abdominal implants ≤2 cm
Stage 3c: Abdominal implants >2cm or positive retro-peritoneal or inguinal
nodes
Stage 4: Distant metastases, including cytology-proven pleural effusion, or
hepatic parenchymal deposits

The majority of cancers(85%) are epithelial - serous and mucinous cystadeno-

carcinomas. 85% secrete CA125. Sadly, only 50% stage 1 cancers secrete
CA125 making it a poor screening test. Endometrioid cancer coexists with
 75

endometrial cancer in 30% of cases. Germ cell tumors are rare and include
dysgerminomas, endodermal sinus tumours, embryonal carcinomas,
choriocarcinomas, immature teratomas, and mixed tumours. Germ cell tumors
occur mainly in younger patients. Sex cord stromal tumours are usually not
malignant, but some granulosa cell tumors may recur. Granulosa or theca
tumours may secrete oestrogen and result in precocious puberty, irregular
vaginal bleeding associated with endometrial hyperplasia, and post-menopausal
bleeding.

BORDERLINE OVARIAN TUMORS– ‘Tumours of low malignant potential’

These tumors are recognized by histology - pleomorphic/atypical/ dysplastic cells
with mitoses, with ‘stratification’ of the epithelial lining of cysts or papillae but no
ovarian stromal invasion.
Though they are not invasive, these tumours may metastasize(a borderline
tumour can be stage III). At surgery and pre-op they may be thought benign or
malignant.
Diagnosis and management
 Borderline tumors occur predominantly in young and middle aged patients
 Staging is as for ovarian cancer
 About 10% of borderline tumors recur
 Management is controversial and often based on age or fertility wishes
 76

VULVAL CANCER
Cancer of the vulva, in the past, was most common at two age groups, around 40
and around 70 years. In HIV +ve patients vulval ca is occurring in women in their
20s.
VIN and lichen sclerosus are premalignant conditions that may lead to vulval ca.
CIN like VIN may be associated with HPV. Always check the cervix, and do a
Pap if not done recently.
Surgery is the mainstay of treatment. There is a move towards wide local
excision(2cm margin) where possible. Radiotherapy accompanies surgery where
indicated post op, and may be used with chemo to shrink large lesions pre-op.
Diagnosis and work up
 A raised lesion on the vulva, or one that bleeds, is ulcerated, or associated
with a past history of dysplasia is suggestive of possible malignancy
 Large lesions require simple biopsy.
 Small or uncertain lesions require vulvoscopy and biopsy
 Full history and complete physical examination
 Describe the full extent of the lesion
 Search for metastases:
o Inspect for vaginal and anal spread and biopsy if necessary
o Look for inguinal nodes and arrange fine needle aspiration if the
diagnosis remains uncertain, otherwise await lymphadenectomy
 Pap smear(if not recently done) and inspect the cervix
 Chest x-ray
 FBC, U&E, RPR, and HIV(+/- CD4)
 Involve an experienced consultant
Management of proven vulval cancer
1. The decision to perform wide local excision with a 2 cm margin for a
laterally placed lesion should be taken by an experienced surgeon. A
larger lesion requires lymphadenectomy as there is more likely invasion
>1mm(the limit of micro-invasion)
2. Midline lesions and large lesions will require radical vulvectomy including
lymph node dissection for which the patient should be prepared
3. If the tumor invades the anus, organize for colostomy to be done as a
separate procedure – counsel well, call a stoma sister, consult a surgeon
4. If the tumor is very large or inoperable, radiotherapy or chemotherapy may
be given before vulvectomy – such patients should be seen at the weekly
oncology meeting for initial assessment and for discussion of possible
surgery after initial radiotherapy
5. Large lesions may require a skin flap
Preparation for radical vulvectomy
 Explain the operation to the patient. In most cases, the clitoris will be
removed(in sexual terms this leaves the G spot - 3cm from the introitus,
anterior vaginal wall, and the deep vaginal orgasm). A ‘triple incision’ will
be used. Flaps may be required, and may require plastic surgery
assistance
 Cross-match 2 units of blood on standby for theatre
 An ICU bed will not normally be needed
Postoperative wound breakdown
 Wound breakdown is relatively common after radical vulvectomy
 77

 Take a wound swab for MC&S

 Give oral cloxacillin or intravenous amoxicillin/ampicillin and or treat
according to swab results
 Dress with saline, absorbent polymers, honey etc. (acetic acid for
Pseudomonas)
Postoperative review and follow-up
 Patients who have positive nodes on histology and have not received
radiotherapy will need to be presented at the weekly oncology meeting
 Patients with surgery alone are followed up at their own hospitals, as for
cervical cancer
 Look for recurrence at each visit, as early treatment of a central
recurrence frequently results in cure
 Patients who smoke must be urged to stop; smoking is associated with a
higher risk of recurrence
Staging and types of vulval cancer (FIGO 2009) – node features are a bit
confusing
Stage Ia: Tumor confined to vulva or perineum, <2 cm, <1mm invasion no
nodal spread
Stage Ib: Tumour >2cm, or >1mm invasion, no nodes
Stage 2: Tumor, any size, confined to vulva or perineum involving lower 1/3
urethra, lower 1/3 anus, no nodal spread
Stage 3a(i): 1 lymph node met >/=5mm
Stage 3a(ii): 1-2 lymph node mets < 5mm
Stage 3b(i): 2 or more lymph nodes >/= 5mm
Stage 3b(ii): 3 or more nodes <5mm
Stage 3c: Positive nodes with extracapsular spread
Stage 4a(i): Invasion of upper 2/3 vagina or urethra, mucosa of bladder or
rectum or fixed to bone
Stage 4a(ii): Fixed or ulcerated inguino-femoral nodes
Stage 4b: Distant metastases, including spread to pelvic nodes
The TNM classification is also used, and N refers to nodal metastases and M to
other metastases where appropriate.
The majority of vulval cancers (85%) are squamous (epidermoid). Melanoma
(pigmented or not) accounts for 5%. Melanoma is staged using Clark’s or
Breslow’s classifications. Sarcomas and adenocarcinomas (including
Bartholin’s gland carcinoma) also occur.
 78

OTHER MALIGNANCIES
Choriocarcinoma
This tumor is related to gestational trophoblastic disease (Chapter 4).
Chemotherapy is used. The tumor very rarely occurs as a primary ovarian
malignancy and may be found incidentally on histology.
Uterine sarcoma
Whether leiomyosarcoma or Mixed Mesordermal Müllerian tumors(Triple MT/
MMMT)), these are managed as for endometrial carcinoma if diagnosed
preoperatively.
Occasionally, detection is only on histology after surgery for multifibroid uterus or
ovarian mass.
When does a fibroid become a leiomyosarcoma? When there are 10 or more
mitoses per 10 high power fields. Malignant transformation in fibroids is very rare.
All patients should be presented at the weekly oncology meeting for
consideration of radiotherapy. Prognosis is generally poor, except for early stage.
Staging is v simple, not unlike the old endometrial ca staging –
Leiomyosarcoma(and Endometrial Stromal Sarcoma) staging
Stage Ia: confined to uterus <5cm diameter
Stage 1b: confined to uterus >5cm
Stage 2a: pelvic spread – adnexa
Stage 2b: pelvic spread – other structures
Stage 3a: Abdominal spread 1 site
Stage 3b: Abdominal spread >1 site
Stage 4: Mucosal involvement rectum or bladder
MMMT Staging is the same except Stage 1a – confined to endometrium or
endocervix, Stage 1b – inner ½ myometrium, Stage 1c – outer ½ myometrium

Tumors in children
Children with germ cell tumors, sarcoma botryoides or other malignancies
must be presented at the weekly oncology meeting, but will receive
chemotherapy if indicated in the paediatric oncology unit. Appropriate referral
must be arranged. If surgery is required, consult with paediatric surgeons and
anaesthetists.

CARE OF THE TERMINALLY ILL PATIENT

Patients may appear terminally ill when they are not. Extreme pain can subdue a
patient and can make her appear very unwell. Severe dehydration and severe
constipation, both correctable, may also give an impression of terminal illness.
Rights of the terminally ill patient
 The right to know the prognosis
 The opportunity for loved ones to know the prognosis (it is relatively
obligatory to request patient permission)
 The right to decline treatment
 The right to discharge herself from hospital or to request discharge
 The right to receive adequate analgesia
Advice for clinicians
 Determine if the patient wishes to return to her original home to die
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 Involve social workers / the Palliative Care Team / hospices where

appropriate
 Ensure that the patient is adequately hydrated (this improves comfort)
 Give subcutaneous opiates by butterfly needle if oral medication cannot
be taken
 Beware of what is said within earshot of apparently comatose patients
 Mark in the notes and tell on-call teams if a patient has a very poor
prognosis

Chapter 11 Other important problems

HIV INFECTION
Infection with HIV may be associated with increased severity and poorer
prognosis in conditions such as pelvic inflammatory disease and cervical
intraepithelial neoplasia.
Wasting syndrome or AIDS-defining infections may complicate the management
of various gynaecological conditions, and increase the risks associated with
general anaesthesia.
However, in the era of Anti-Retoviral Treatment(ARVs) the situation is much
improved. Life expectancy on ARVs exceeds 30 years providing the patient does
not react to the ARVs or the virus develop resistance.
Indications for HIV testing in gynaecology
In truth……every single patient who has been sexually active should be asked if
they have tested, and if not it should be explained why it might be advisable.
General remarks
 Testing for HIV, and CD4 count/viral load, cannot be done without first
obtaining informed consent from the patient
 A second ELISA test is done on the same blood specimen to confirm a
positive result. Patients can only be told of positivity after the second
ELISA
 Post-test counseling for positivity must be done in private and with the
help of an interpreter, if necessary
 CD4 count testing +/- viral load is required in all HIV positive patients. A
low CD4 count is not, on its own, a reason to withdraw treatment for any
condition though it may be modified
 Any patient with a CD4 count less than 200 should receive
sulphamethoxazole/trimethoprim (Bactrim) 2 tablets orally daily, and TB
prophylaxis(Isoniazid 300mg qid with Pyridoxine 50mg qid) according to
protocols and be referred to the local clinic
 Consider associated conditions including TB in any immune-compromised
patient. It should be considered in all pregnancy visits
Treatment
 Indications to treat may change. Currently all HIV positive patients are
offered treatment
 The standard Fixed Dose Combination(FDC) regimen may consist of
Tenofovir(TDF) 300mg, Lamividine(3TC) 300mg and Efavirens(EFV)
600mg each day; Nevirapine(NVP) may replace TDF if contraindicated,
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Zidovudine(AZT) if TDF is contraindicated and Abacavir(ABC) if TDF and

EFV are contraindicated. Many first and second line regimens exist
 If treatment is to be offered please refer to the local clinics for prescription,
assessment, follow up
 Occupational exposure to HIV (needlesticks, cuts or splashes) must be
managed in accordance with the hospital protocol. There should be no
delay in washing exposed sites with antiseptics, and starting ARVs. Risk is
small

SEXUAL ASSAULT
Hospitals may have medicolegal sexual assault clinics, staffed by police officers,
nurses, and/or doctors. Where there is no such clinic or if the clinic is closed,
hospital clinicians will need to attend to the legal as well as clinical matters.
Patients presenting to gynaecology with a complaint of sexual assault
 Patients who have not already attended a sexual assault clinic should be
encouraged to do so first, if available. Full examination, treatment, follow-
up, and legal requirements will be dealt with by that clinic. If a patient
declines to go, attend to the clinical needs, then offer telephone numbers
and encourage the patient to call for counseling and advice. The
suggestion of police involvement is mandatory but may not be accepted
 If there is no sexual assault clinic, take a relevant history, examine the
patient carefully, and make clear notes. Use the ‘rape kit’ – provided by
the police - to complete a full medicolegal examination. Some instructions
are provided with the kit. Complete the J88 assault form. A police officer
should assist with submission of the ‘rape kit’.
 Handle all patients with extreme care. Patients frequently remember the
events in hospitals/clinics with bitterness and a feeling of being let down
by those who are expected to care.
 The patient may wish to be examined by a female doctor, and this should
be arranged if possible.
 Children with vaginal bleeding must undergo an examination under
anaesthetic to determine the extent of injury and complications. Discuss
first with a consultant. Consent from a parent/guardian is required. Call a
consultant or paediatric surgeon if there is anything more than superficial
damage to the vagina, vulva or perineum. Beware – absence of the
hymen is NOT necessarily an indication of penetration. Take specimens
for the ‘Rape kit’
 EUA, suturing may also be required for a teenager/adult. Take specimens
for the ‘Rape kit’
 Prophylactic antibiotics should be prescribed. For adults, use azithromycin
1G or ceftriaxone 250mg im as a single dose, doxycycline 100 mg orally
twice daily and metronidazole 400 mg orally twice daily for 10 days.
 Regarding post-exposure antiretroviral prophylaxis, Nthabiseng Clinic at
CH Baragwanath, for example, can assist rape survivors who are HIV
negative. If the HIV result is unknown, do a rapid test for HIV and give
ARVs to those who are negative, or positives not on ARVs
 Emergency contraception must be provided to women at risk of
pregnancy. Give Ovral two tablets orally for 2 doses 12 hours apart with
metoclopramide 10mg orally three times daily, with follow-up to exclude
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pregnancy or levonorgestrel. See the chapter on contraception for

alternatives
 Counseling is available from social workers and must be offered/organized

Chapter 12 Urogynaecology and Prolapse

URINARY TRACT INFECTION
Diagnosis
 There may be frequency, dysuria and lower abdominal pain
 Flank or loin pain will be present if there is pyelonephritis
 Central suprapubic tenderness is frequent (tenderness from PID extends
away from the midline)
 Renal angle tenderness is usually found only with pyelonephritis
Investigations
 Urine dipsticks usually reveal leukocytes, nitrites, blood, and/or protein.
 Indications for urine MC&S include: 1. where the diagnosis is in doubt,
2. where the patient is unwell, 3. where previous treatment has been
unsuccessful – and symptoms persist
 Record that urine MC&S has been requested and arrange follow-up
Management
The well patient may be treated with oral antimicrobials:
Cephalexin (Keflex) 500 –1000 mg four times daily for 5-7 days, or
sulphamethoxazole-trimethoprim (Bactrim) two tablets twice daily for 5-7 days, or
nitrofurantoin 50-100 mg four times daily for 5-7 days. Resistance of E.coli to
amoxicillin is widespread.
The unwell patient requires admission to hospital:
1. Take urine for MC&S before starting treatment
2. Take blood for U&E and FBC
3. Prescribe intravenous antibiotics, followed by oral antibiotics after
improvement and discharge from hospital
4. Ensure good hydration throughout, treat vomiting with antinausea drugs,
e.g. prochlorperazine (Stemetil 12.5 mg IM)
5. After clinical improvement, follow-up is unnecessary unless there has
been renal impairment or recurrent infection
Intravenous antibiotics for unwell patients with urinary tract infection
First-line drugs (from first choice)
Kefzol(Cefazolin) 500mg – 1G 8 hourly
Cephradine (Cefril) 500 – 1 000 mg 6 hourly
Cefoxitin (Mefoxin) 1 g 8 hourly
Cefuroxime (Zinacef) 750 mg 8 hourly
Co-amoxiclav (Augmentin) 1.2 g 8 hourly
Ceftriaxone (Rocephin) 500 – 1 000 mg mg 12 hourly
For penicillin-sensitive patients consider trimethoprim/sulphamethoxazole 10 mL
(160/800 mg) twice daily, or erythromycin 500 mg 6 hourly
Oral follow-up treatment is usually cephalexin 500 mg four times daily,
cefuroxime 500 mg twice daily or sulphamethoxazole 2 tablets twice daily, all for
5-7 days.
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URINARY INCONTINENCE
Urinary tract infection must always be excluded in the incontinent patient – some
require Stix testing, others formal MC&S.
Types
 Genuine stress incontinence (GSI) – weakness of the bladder neck
 Overactive bladder, formerly Detrusor instability (DI) – overactivity of the
bladder muscle
 ‘Mixed’ incontinence – a combination of GSI and DI
 Overflow incontinence – following over-distension of the bladder
 Continuous incontinence – resulting from fistula
Important questions
 Duration of the problem
 Severity of the problem – how incapacitating it is
 Frequency of micturition (>7 times per day. Ask if the patient passes once
an hour or so)
 Nocturia (>2 times per night)
 Dysuria – pain on passing urine
 Stress incontinence - with coughing, laughing, sneezing or movement/
always, sometimes or occasionally
 Urgency – a feeling of an urgent need to pass urine, Urge incontinence –
patient doesn’t quite make it in time
 Smoking and chronic cough
 Previous medical problems, including diabetes mellitus, and
medication(including diuretics)
 Previous cervical or genital tract cancer, or radiotherapy(incontinence)
 Previous gynaecological or urological surgery
 Outcome and mode of delivery of pregnancies
If the only significant symptom on history is stress incontinence, it is very likely
(90%) that the cause of incontinence is GSI.
Physical examination
 General examination, and chest and neurological examination
o Chronic chest problems and obesity are associated with GSI
o Neurological problems may be associated with overflow or DI – the
anal wink, and bulbocavernosus reflex(stroke side of labia majora –
equivalent to cremasteric reflex
 Abdominal and pelvic examination
o Look for evidence of fistula if the history is suggestive
o Pelvic mass or prolapse may be associated with GSI and DI
o Trigonitis (tenderness in the upper anterior vaginal wall) may mimic DI
o Loss of urine with coughing or straining is suggestive of GSI
Investigations
 Urine MC&S – essential as urinary tract infection mimics GSI and DI
 Urinary calendar – ask the patient to record on a piece of paper: leaking,
frequency, urgency, nocturia for 7 days
 Urodynamic studies – when GSI or DI or overflow are considered….BUT:
Urodynamics has become more controversial, prone to false negatives
 Intravenous pyelogram – when fistula is considered particularly post-
operative, to assess possible ureteric damage/effect
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Organizing urodynamic studies (UDS)

1. Contact Johannesburg Hospital Urology at 011-4883383/6
2. An appointment date and time will be given
3. Arrange a follow-up visit at which patient will present her UDS report
Interpretation of UDS reports
 Read the summary provided with the print-out
 Check if the investigation is described as ‘adequate’ or not
 Bladder capacity should be at least 400 mL
 Ensure the emptying flow rate is adequate (no obstruction)
 Look for the true detrusor pressure(PDet) line (intravesical pressure with
rectal pressure subtracted)
 Spikes on the detrusor pressure line (>2 mL water) are suggestive of DI
 GSI is indicated by leakage on provocation, without spikes
 Leakage with and without spikes suggests mixed GSI and DI
Management of genuine stress incontinuence (GSI)
1. Weight reduction, and treatment of chronic cough and stopping smoking
2. Teach pelvic floor (Kegel’s) exercises particularly in the younger patient,
especially post-partum (see below)
3. There is limited experience with alpha-agonists (phenylpropanolamine)
4. Estrogen replacement is of no value in post-menopausal patients
5. Surgery is definitive, and necessary in many cases, and for almost all
older patients
Kegel’s exercises in treatment of GSI
 These are tightening contractions of the perineal muscles, as in trying to
hold urine or faeces, or squeezing the vagina
 Squeeze for 3 seconds and release for 10; repeat 10 times. This is done
10 times per day
 Compliance is essential, ask patients about this at follow-up
 These exercises are most beneficial in younger patients with mild GSI
Operations for GSI
Surgery is the standard management for many patients
 All patients must be fully assessed by a consultant
 Patients must understand that surgery may:
o Not be successful
o Need to be repeated
o Result in voiding difficulties occasionally necessitating intermittent
catheterization
o Worsen DI in cases of mixed GSI and DI
o Cause damage to the lower urinary tract
o Tape erosion may result
 Obturator tape(Out-In, or In-Out) is now the gold standard. The Tension-
free vaginal Tape (TVT), first published in 1995 is an alternative. They are
both described as mid urethral tapes. Burch colposuspension, once the
‘gold standard’, is now almost of historical interest only
 In the presence of prolapse, consider vaginal hysterectomy with Kennedy-
Kelly plication, or preferably combined with a tape procedure if available
Management of Detrusor Instability (DI) – Overactive bladder
Bladder drill is the mainstay of treatment, with drugs in the majority. Surgery (e.g.
Clam cystoplasty, phenol injection in the trigone) is almost never indicated.
 84

Bladder drill
 The patient should sit by the toilet when she gets an urge to urinate, and
wait
 Each time she records how long she can wait before urinating
 She also records the frequency of micturition
 If possible, urine volumes should also be measured
 All these events are noted on a piece of paper, with dates and times
 Explain this thoroughly and ask the patient to explain it back
 Urinary volumes should increase, and frequency should decrease
 Usually, the condition improves a little, then worsens, then improves
significantly
 Compliance is essential for best results
Medication
The intention is to inhibit muscarinic receptors preferably M2 receptors, but anti-
cholinergic side-effects include blurred vision, constipation, confusion
 Oxybutinin(Ditropan) is the standard: give 2.5 mg orally twice daily, up to 5
mg 4 times daily. Warn about anticholinergic side-effects, e.g. dry mouth,
blurred vision, constipation. Alternatives are listed below
 Propantheline(Probanthine): give 15 mg orally 3 times daily. Warn about
anticholinergic side-effects
 Tolteridone(Detrusitol): give 1-2 mg orally twice daily
 Imipramine(Tofranil): give 25 mg orally at night, mainly for nocturnal
enuresis, urgency or frequency
Management of mixed incontinence (GSI AND DI)
1. Treat the DI first and assess the response. If limited response, surgery for
GSI, and continue drug treatment if overactive bladder symptoms persist
2. Kegel’s exercises may be attempted in younger patients
3. The bladder neck should not be hitched too high at surgery, as this may
worsen DI. This is the advantage of tension free(OT & TVT) procedures as
this is far less common
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URINARY FISTULA
The most common is vesicovaginal fistula(VVF). Fistulae present with continuous
incontinence of urine. The common causes are:
 Obstetric (obstructed labour)
 Post-surgical (caesarean section, hysterectomy)
 Malignancy (cervical cancer)
 Radiation (treatment for cervical cancer)
FISTULA FOLLOWING CHILDBIRTH OR SURGERY
Clinical assessment
 Establish the events that preceded and caused the fistula
 General, abdominal and vaginal examination
 Speculum examination, and look for leakage of urine by asking the patient
to cough while withdrawing the speculum
 Fistulae are not always easily palpable or visible on examination
 Exclude other causes of ‘continuous incontinence’:
o Stress incontinence – urine leaks from the urethra with pressure
o Watery discharge – infection or granulations after hysterectomy
Investigations
 Urine MC&S – infection is unusual with a fistula
 Three-swab test with methylene blue
 Intravenous pyelogram (IVP) – to show site of fistula and state of ureters
 Voiding cysto-urethrogram (VCU) – to show site of fistulae
 Cystoscopy
Three-swab test
Inject 2ml methylene blue into 1L N/saline. Insert a Foley catheter into the
patient’s bladder and empty the bladder if necessary. Insert 3 swabs into her
vagina. Run the methylene blue solution into the bladder. The patient will tolerate
about 200ml. Ask the patient to stand up and walk around for 2 minutes, then
remove the three swabs. Always count the swabs after removal.

 If the upper swab only is stained with yellow urine, the fistula is uretero-
vaginal
 If the middle or upper swab is stained blue, the fistula is vesicovaginal
 If the lower swab only is stained blue, there may be stress incontinence or
no fistula, but leakage around the catheter
Surgery
 Cystoscopy may precede surgery. The approach may be abdominal or
vaginal or combined
 The method of fistula repair will depend on the nature of the fistula as
defined clinically and on investigation. In summary the fistula is excised
and the layers of the defect closed separately –Latzko technique. A graft
may be used for larger fistulae – omentum, or labia majora swung
graft(Martius graft)
 Consult a gynaecologist or urologist experienced with management of
fistulae
 Obstetric fistula repair should be delayed for 2-3 months after delivery
 Post-surgical fistulae may be repaired as soon as they are recognized
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FISTULA CAUSED BY CERVICAL MALIGNANCY

Patients have advanced stage malignancy, and may not be fit for surgery.
Assessment
 History and full clinical examination
 Search for metastases and other manifestations of malignancy
 Work up fully for cervical cancer, including biopsy, if not already done
(Chapter 10).
 Consider pain relief, nutrition, and quality of life issues
Management
1. The definitive treatment is urinary diversion, e.g. ileal conduit
2. Discuss with an experienced consultant
3. Consult urologists for diversion if the patient agrees and prognosis allows
4. Continue usual care (radiotherapy, pain relief etc.)
FISTULA CAUSED BY RADIOTHERAPY
It is important to determine if the fistula is caused by radiation or by a cancer
recurrence

Assessment
 Take a complete history and do a full clinical examination
 Search for metastases and other manifestations of malignancy
 Vaginal and speculum examination may be painful and difficult
 Biopsy from the edge of the fistula if possible
 FBC, U&E, HIV and CD4 count, chest x-ray; consider IVP and cystoscopy
with biopsy.
Management
1. Discuss with an experienced consultant
2. Report the fistula to the radiotherapy department (Johannesburg Hospital)
3. Consult urologists for urinary diversion surgery
4. If tumour is found in the fistula diversion may not be considered

UTEROVAGINAL PROLAPSE
Prolapse is descent of the uterus (uterine prolapse) and/or vaginal walls
(cystocoele, rectocoele, enterocoele, vault prolapse) through a deficient pelvic
floor.
Symptoms: never operate without knowing if there are urinary or bowel
symptoms and without knowing if the patient is sexually active.
Points on history taking
 Patients present with a feeling of something coming down or out of the
vagina, and backache
 Severity of the symptoms and how much this upsets the patient’s lifestyle
 With cystocoele or rectocoele there may be a feeling of incomplete
emptying – a desire to micturate or defecate shortly after doing so.
 Digitation – with rectocoele downward pressure with fingers on the vaginal
floor assists defecation
 General gynaecological and medical history, including promoting factors
such as cough or constipation
Physical examination
 General examination
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 Chest - check for evidence of chronic lung disease. Coughing worsens

prolapse
 Abdomen - note obesity or abdominal mass, which may promote prolapse
 Pelvic examination:
o Look for procidentia and a ‘decubitus ulcer’ on the prolapsed
cervix(it is the cervix roughened by underwear and looks like
cancer – biopsy if necessary
o Ask the patient to bear down
o Use a Cusco speculum to assess laxity and atrophy of tissues
o Inspect the cervix and take a Pap smear if indicated
o With the patient in a left lateral position use a Sims’ speculum.
Ask an assistant to hold the right leg up a little. Use the Sims’
speculum to hold back the anterior vaginal wall. Ask the patient to
bear down and see if the posterior wall descends. Hold back the
posterior vaginal wall and see if the anterior wall descends
Assessment of prolapse
 Anterior vaginal wall descent suggests cytocoele
 Posterior vaginal wall descent is suggestive of rectocoele or enterocoele
 A finger in the rectum will fill a rectocoele, but not an enterocoele
 Prolapse long after a hysterectomy may be vault prolapse
 With uterine prolapse, there is some degree of cytocoele or rectocoele
 Cystocoele and rectocoele may exist separately or together, with or
without uterine prolapse
Grading of uterovaginal prolapse
 Ideally, the POP-Q (pelvic organ prolapse quantification) system should
be applied to express the degree and location of prolapse. It is complex. In
simple terms the reference point is the hymen
 Cystocoele and rectocoele are often graded mild, moderate or severe
 Uterine prolapse may be graded in degrees
o 1st degree: Cervix descends but higher than 1cm above the hymen
o 2nd degree: between 1cm above and 1cm below the hymen
o 3rd degree: beyond 1cm below the hymen but total vaginal
length(TVL) -2cm
o 4 degree: total eversion, ‘procidentia’
th

Management
Where possible, start with conservative before operative
Conservative management
1. Remove promoting factors – obesity, chronic cough, constipation
2. Try pelvic floor (Kegel’s) exercises in younger, mildly affected patients,
and in postpartum patients
3. Use pessaries in patients who decline surgery or are not fit for surgery
4. Pessaries with oestrogen (Premarin) cream may restore normal anatomy
and allow the vagina to heal and strengthen before surgery
Insertion of ring pessaries
1. Show and explain the pessary to the patient
2. Estimate the pessary diameter by opening the index and middle fingers in
the lateral fornices and removing them while still open
3. Cover the pessary with KY jelly or oestrogen cream
4. Insert at 45% to the horizontal axis of the vagina – the posterior rim goes
higher up. Avoid pressure on the urethra with insertion
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5. Leave the pessary to rest between the posterior fornix and retropubis
6. Change the pessary every 3 to 6 months:
7. Ask about bleeding, pain, discharge, urinary or bowel symptoms
8. After removing a pessary, inspect the vagina for erosions
9. Replace or reinsert the pessary
10. Other pessary designs – Hodge, cube are perfectly acceptable
Surgery
Operations for prolapse: include anterior colporrhaphy for cystocoele and
posterior colpoperineorrhaphy for rectocoele, each alone, together or
combined with vaginal hysterectomy. Abdominal or laparoscopic
sacrocolpopexy and vaginal sacrospinous fixation are used to for vault
prolapse. Urinary stress incontinence procedures, e.g tape(preferable), sling, or
Kelly-Kennedy plication may be added. The choice of operation depends on each
patient’s unique needs and symptoms, and all have their complications.
Modern tapes may correct mild prolapse as well as stress incontinence.
However, such tapes may contribute to other forms of prolapse, e.g. enterocoele.
A complication of tapes and meshes is erosion into the vagina and bladder.
Larger meshes erode in up to 10% cases and more and are currently under
discussion.

Chapter 13 Surgical procedures and others

PRE-OPERATIVE PREPARATION
Important pre-operative considerations
 Blood tests and blood transfusion needs are listed above
 Pap smears must be checked on all cases.
 Specific consent forms exist for myomectomies and sterilization
 Anaesthetic consults can be arranged with the anaesthetic department
 Consider surgery or urology consults, and consults with the stomatherapy
staff if extensive and difficult abdominal surgery is expected.
 WHO Safe surgical check list must be reviewed

Consent and note keeping

Advise the patient of well-known operative complications, e.g. all laparoscopy
patients should be advised of the risk of possible visceral damage and of
possible laparotomy. Record discussions in detail in the notes.
Blood to be taken before surgery – see section at the beginning of this
protocol
The recommendations above relate to the operation itself and are given for the
healthy, fit patient. Remember that the elderly and those with co-morbidity need
extra blood tests, e.g. women with endometrial cancer may have specific
associations e.g. diabetes, requiring a sugar series.
Bowel preparation
This remains controversial, as current surgical wisdom is that prepared bowel
may contain liquid faeces that might complicate more than untreated bowel.
 89

URGENT CASES
Problem cases, e.g. septic abortions, molar pregnancies, laparotomies etc. must
be marked to be done by an appropriately experienced registrar or consultant.
The anaesthetist must be informed about problem cases. In general, septic
cases should be done at the end of a list, unless very urgent. No doctor should
feel out of their depth if help/experience is at hand.

MANUAL VACUUM ASPIRATION (MVA) is done in an out-patient setting

Indications
Any uterus with retained products and without a fetus in situ up to 14-16 weeks
size(operator dependant) can (should) be emptied by MVA. If the fetus is present
the skill required is greater and incomplete evacuation is more likely. When a
fetus is present at 9-10 weeks MVA is relatively easily achieved.
The os must be open, naturally or with the aid of misoprostol(single tablet
200mcg pre procedure), since dilatation at MVA is not easy nor is it well
tolerated.
Analgesia
A gentle but adequate and well directed technique will reduce patient discomfort.
Nonsteroidal anti-inflammatory agents such as diclophenac 75mg IM or
Indomethacin 100 mg suppository may be given but are inadequate alone.
Additives or alternatives include midazolam 2 mg IV or Pethidine 50 mg im or
Morphine 5mg. Sedating drugs should be used and the patient must be observed
during and after the procedure and should be discharged accompanied if
possible.
Pre-procedure assessment
 Check the details of the patient – parity, LMP, history of current
pregnancy, medications so far given, medical history, clinical and scan
findings
 Ultrasound scan unless it has recently been done; if the products are less,
less needs to be removed(does the procedure need to be performed?) if
more, more is expected
 Advise the patient of the procedure
 Ask her to empty the bladder in the toilet if she has not done so

Procedure
 Ensure all instruments are correct and present. Learn how to assemble
the MVA set and to create a vacuum
 Place the patient in lithotomy position. In certain situations, e.g. an unwell
patient in a medical ward(too unwell for formal curettage), this is not
completely essential
 Inspect the vulva, vagina, and cervix, and perform a gentle bimanual
examination (size, axis, adnexa), and check that the os is open
 If the cervical os is closed, give further misoprostol sublingually(see
above) or insert a Lamicel, or do evacuation under GA or spinal
anaesthesia
 The diameter of the MVA catheter chosen should be a little less in mm
than the gestation in weeks. The largest easily passing catheter is better
 Insertion without a vulsellum is ideal. If required, apply one(single toothed)
to the anterior of the cervix. You can use a ml of local first
 90

 Push the catheter to the fundus gently, release the vacuum and withdraw
the instrument in a spiralling motion. Repeat at least once.
 Antibiotics are optional. Give if indicated
 If there are doubts about the emptiness of the cavity, do an ultrasound
 If the patient cannot tolerate MVA, be understanding. Scan the cavity
again. If significant products are present, book for evacuation in theatre

EVACUATION OF THE UTERUS

For all uteri less than 14-16 weeks(operator dependant), rather perform an MVA
see below. For all larger uteri formal curettage may be necessary.
Procedure
1. Read the patient’s notes – this is required for any operation.
Note the gestation, history of the miscarriage, previous estimations of
uterine size. Look for any evidence of sepsis or complications
2. Decide if the evacuation needs to be done by a senior person, e.g.
registrar/experienced MO
3. Bimanual examination is essential, and note the size and axis of the
uterus
4. Catheterization is only necessary if the uterus cannot be easily palpated.
Clean technique essential(the post cath UTI rate of up to 20% is avoided)
5. Grasp the anterior lip of the cervix with a vulsellum (first trimester) or
sponge holding forceps (second trimester); 2 vulsellums or sponge
holders side by side lessen the chance of tearing the cervix. Dilatation
may not usually necessary. If it is pass the largest dilator that will safely
pass from smaller to larger.
6. If possible, remove placenta or pieces with your fingers
7. Use ovum or swab-holding forceps next and remove large pieces, staying
in the lower pole of the uterus
8. Use a curette, and take the largest that can be easily inserted
9. Insert the curette, holding it loosely between finger and thumb until the
fundus is reached allowing your finger and thumb to slip back along the
shaft as you bump against the fundus This may prevent perforation
10. Be firm. Only ever curette towards the cervix, pulling towards yourself
only. In a floppy uterus ask for oxytocin 2 units as it may firm the uterine
wall. Curette around the four quadrants until the cavity feels empty
11. Ask for oxytocin 10 units or Syntometrine 0.5 mg IV if the uterus is not well
contracted. Rub up the uterus to assist contraction and apply bimanual
compression if there is vigorous bleeding
12. Bleeding should settle down once the uterus is empty and well contracted
13. Make clear and complete notes including estimation of blood loss.
14. Always right a ‘Plan’ – either “discharge if well”, “admit for transfusion”,
“antibiotics”, “on call unit to check post op Hb”
15. Do not take long over an Evac. Learn to do it safely in 5 minutes
Management of complications of evacuation
Excessive bleeding
1. Ensure that all products have been removed. Palpate digitally for products
and repeat the curettage with the largest curette that will easily pass
2. Empty the bladder if it feels full
3. Apply bimanual compression by rubbing the uterus between an abdominal
hand and the fingers in the vagina, until the uterus contracts
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4. Give oxytocin 10 units IV stat and 20 units in Ringer-Lactate 1 L

5. Give ergometrine – by itself or as Syntometrine 0.5 mg IV or IM stat. Be
cautious or avoid the drug with hypertensive patients
6. Try prostaglandins – misoprostol 1 mg (5 tablets) rectally(of uncertain
benefit) or other prostaglandins e.g. prostaglandin F2-alpha 5 mg into the
uterine muscle.
7. Inspect the cervix for bleeding tears, and ligate or sew over the tears. This
is an unusual cause of bleeding
8. Call help
Bleeding that continues despite uterine contraction suggests a cervical tear or
uterine perforation
Uterine perforation
Perforation recognized at evacuation is an emergency requiring senior
assistance.
Recognizing a perforation
 Usually, the instrument – sound, dilator, forceps or curette – goes in too
far
 Bimanual examination may assist to remind the operator of the uterine
size
 Bowel appearing in the cervical os is uncommon but is alarming, and
confirms that the uterus has been perforated
Management
Some gynaecologists recommend simple observation if perforation is with blunt
instruments including early recognized perforation with a curette, and
laparoscopy for perforation with sharp instruments. It may however be difficult to
know which instrument caused the perforation. If in doubt, a laparotomy should
be done.
Laparotomy following uterine perforation
1. Do a midline incision
2. Inspect the uterus
3. Inspect the entire length of the small and large bowel
4. Through the perforated uterus complete the evacuation and check that the
uterus is empty
5. Repair the uterus and avoid hysterectomy if possible
6. If there is bowel perforation (bowel mucosal defect) call a general surgeon
Postoperative collapse
Call for help, from an anaesthetist if still in theatre. Attend to the ABC of
resuscitation and try to establish a cause. Call for gynaecological assistance and
manage according to the cause that is suspected.
Causes of collapse after uterine evacuation
 Pre-existing hypovolaemia or anaemia worsened at evacuation
 Pre-existing septic shock worsened at evacuation
 Severe haemorrhage during and after evacuation
 Uterine perforation with internal haemorrhage
 Rupture of an undiagnosed ectopic pregnancy
 Non-gynaecological causes, e.g. embolism, arrhythmia etc.
Incomplete evacuation
This presents as continued vaginal bleeding and lower abdominal discomfort.
There may be evidence of infection. Products may be felt on clinical examination
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or seen on ultrasound. An experienced doctor should perform a uterine re-

evacuation in theatre, with antibiotic cover
Sepsis
This presents with fever, tachycardia, lower abdominal pain, offensive vaginal
discharge, continuing bleeding, and lower abdominal tenderness. Consider other
sources of infection, e.g. chest, urinary tract, HIV-related. Treat as for septic
incomplete abortion (Chapter 4) with re-evacuation by a senior medical officer or
registrar if there are retained products suspected clinically or by ultrasound.
Hysterectomy may be necessary.

MARSUPIALISATION OF BARTHOLIN’S ABSCESS

 Lithotomy position, prepare and drape as for an evacuation
 Incise vertically the medial aspect of the abscess where the vulval and
vaginal skin meets for approximately 4 cm, releasing the pus
 Digitally explore, breaking down loculations
 If necessary, remove a thin slice of redundant tissue from one skin edge
with scissors
 Pass stitches from the cavity through to the vaginal skin and tie
separately, at 10, 2, 4, 8 o’clock stitching the cavity open (4 vicryl sutures)
 A pack serves no purpose, does not prevent recurrence, and is painful to
remove
At discharge, advise that the defect will heal, and the stitches will fall out on their
own(they can be removed but it is v painful).

Bartholin’s cysts, though very different, can be managed in the same way –
marsupialisation. If excision is attempted, the supplying artery may retract
causing a 700ml ischio-rectal haematoma.
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LAPAROTOMY FOR ECTOPIC PREGNANCY

1. Read the bed
2. letter thoroughly, as for all operations
3. Have a plan for the operation – salpingectomy, or tubal conservation
4. Find out if the patient has considered tubal ligation(i.e. if a fully conscious
33 year old, Para 3, with an unwanted pregnancy consented for
sterilization)
5. Do a Pfannenstiel incision only if the diagnosis is certain and no problems
are expected. Otherwise, midline
6. Clear the operating field after opening the abdomen – scoop out blood, lift
structures aside and gently pack if necessary. Enlarge the incision if
necessary
7. If there is vigorous bleeding, clamp the offending bleeder as soon as it can
be easily isolated(often the bleeding is slow)
8. Peritubular adhesions can be put on the stretch and then divided, if
present, to free up the tube. Consider this for the other tube if fertility is an
issue
9. A single Maingot clamp, diagonally placed across the tube and along the
mesosalpinx, is usually adequate. If the ovary cannot be separated, the
infundibulopelvic ligament must be separately divided and the ovary
removed
10. If adhesions are troublesome, ligate and cut the round ligament and open
the broad ligament, to approach the ectopic from outside in. This shows
the position of the ureter beneath the infundibopelvic ligament.
Oophorectomy may occasionally become necessary
11. For tubal conservation, incise the anti-mesenteric edge of the tube for 3
cm with cutting diathermy, empty the tube digitally, diathermise bleeders
and leave the defect open
12. If the contralateral tube is a hydrosalpinx and fertility is hoped for, cut a
cruciate terminal salpingotomy with a diathermy, and divide simple
peritubular adhesions only
13. If the patient has requested sterilization do a modified Pomeroy tubal
ligation on the contralateral tube
14. Minimise trauma to the tissues to ensure less complications and quicker
recovery
15. Ensure good haemostasis and leave the abdomen free of blood
Ectopics should be performed laparoscopically if possible. The operation remains
the same. 3 ports should suffice. Suck the blood out to improve vision.
Salpingectomy or salpingotomy are acceptable. Tissue retrieval can be into a
10mm 20 port with a ‘toilet seat’ to pass a grasper or with an artery clamp passed
directly through the skin at the 20 port site or with a bag.

LAPAROSCOPY
Patient choice, preparation and consent
Patient selection includes attention to obesity, past history of midline laparotomy
with a risk of anterior abdominal wall adhesions (and certain Pfannenstiel
procedures are a risk, e.g. myomectomy, operations for sepsis, ovarian
cystectomy), and previous known abdominal sepsis. All patients should be
thoroughly examined before the operation and have an ultrasound scan.
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All should be advised of the risk of visceral injury, and the possibility of
proceeding to laparotomy, and this should be clearly recorded in the notes.
Injury
At laparoscopy, 50% injuries are caused by trocar and cannula and Verres
needle insertion and 50% by diathermy/dissection accidents. Avoid this by
learning anatomy, patient selection, and entry technique. Learn open entry
technique (Hasson’s technique) and Palmer point entry (left costal margin, 3cm
down, not discussed here) in patients with previous midline incisions. Avoid
diathermy injury by checking for distance from bowel/ureter/bladder and lack of
contact to viscera when using diathermy. Diathermize with good vision only.
Always make good records in the notes. Saved images are increasingly used.
Check all equipment before operation
Unlike open surgery, the equipment – laparoscope tower and settings, gas bottle
and insufflator (gas machine), camera, scope, Verres needle, trocars and
cannulas, instruments – should all be checked by the surgeon.
Position the patient, catheterize, attach uterine manipulator
Make sure the table is horizontal, and that patient’s buttocks are off the bottom of
the table, with the lower section dropped/removed. Position the legs in lithotomy,
but thighs horizontal, at the level of the patient’s abdomen. If lithotomy pole slings
are used, ensure the slings and poles are padded to prevent compression.
Operate with the table as low as possible.
Pass an indwelling catheter if there is any prospect of the procedure taking time,
otherwise in-out catheterization will do. Always perform a bimanual examination
before proceeding. Place a vulsellum on the anterior lip of the cervix and insert
and attach a uterine manipulator. If there might be an ectopic or an early intra-
uterine pregnancy insert the manipulator only after the ectopic pregnancy is
confirmed by direct vision with the scope..
The Procedure
 Incise the umbilicus vertically with a ‘No 15’ bladed scalpel(small blade).
Insert the blade just through the skin at the deepest point of the umbilicus
flick upwards and outwards. 12mm defect(to fit 10mm trocar and cannula)
 Insert the Verres needle at 700, aim midline. Some surgeons prefer to
elevate the anterior abdominal wall at entry. A sensation and a click or two
clicks may be felt and heard as the Verres needle pierces the sheath and
peritoneum
 Laparoscopy without the Verres is widely practiced. As is entry with main
trocars and cannulas that allow vision
 Checking that the Verres needle is in the abdominal cavity and not in the
bowel can be done with the hanging drop technique, or elevation of the
abdominal wall to hear a ‘hiss’ from the top of the needle, or by saline
injection through the needle (no resistance to flow), and finally resistance
to the pulling back of the syringe barrel (there is a vacuum in the
abdominal cavity) when the syringe is inserted onto the Verres and
insufflated water has also not returned brown
 Next, attach the CO2 pipe to the Verres needle, and switch on the gas.
The pressure on the monitor should remain in single figures (< or =
7mmHg). If the figure rises a) elevate the abdominal wall, or b) remove
and re-insert the Verres needle. The pressure will rise as the abdomen fills
to capacity. Fill to 20-25 mmHg for ALL port insertions. If a port comes out
half way through the operation
 95

 Only the primary (umbilical) trocar is inserted blind. Learn how to palm the
trocar and cannula. Different trocars and cannulas perform differently.
Learn how to ‘arm’ them if needed. Then place the index finger along the
shaft to prevent too deep insertion. Aim in the midline at 45-700 to the
horizontal
 Secondary trocars are usually inserted lateral to the inferior epigastric
artery on each side after the artery is identified with the scope, after
cutting a 7 mm horizontal incision in the skin. Midline suprapubic is a good
alternative – the favoured position for the Filshie clip applicator
 Once the trocars and cannulas are in and operating commences drop the
pressure to 15mmHg to prevent a) difficulty ventilating b) hypercapnia c)
decreased and unpredictable venous return
Good vision
 If the image is blurred, check the focus, then wipe the telescope tip on
bowel or remove and wipe with a swab or alcohol
 Withdraw the scope for a wider view, and at times, push in the scope and
zoom in close. Try both.
 Keep the viewed object(s) in the middle of the screen at all times
 The top of the camera always faces the ceiling of the room
 Try to keep the camera still once the view is good
 Uterine elevation and pushing bowel into the upper abdomen with the
patient in Trendelenburg will help to reveal anatomy. Elevate the uterus
Operating technique – adhesiolysis, sterilization, ectopics
 Adhesiolysis is done as with open surgery – place adhesions on stretch
by manipulating with care. Transilluminate adhesions to look for vessels
and the boundaries of viscera. Know your anatomy. Inspect thoroughly
before cutting or using diathermy
 Diathermize once all adjacent structures are free. Do not make contact
with other instruments when using diathermy. Diathermy can sometimes
be set lower(20-30 Watts) than in open surgery
 For sterilization, ensure that the fallopian tube is correctly identified (by
the fimbrial end), and that the Filshie clip will occlude the tube completely.
Keep the long jaw of the applicator underneath to avoid dropping the clip.
Keep the jaws half closed for insertion through the port and manipulation.
If in doubt, apply a second clip or recall the patient later for a
hysterosalpingogram
 For ectopic pregnancies, do a linear salpingotomy with unipolar diathermy
on the anti-mesenteric border, and remove the conceptus with graspers
or irrigation and retrieve it into a 10 mm secondary port with a ‘toilet seat’
(to take the 5mm grasper) or an artery forceps through the skin or a bag.
Alternatively, do a salpingectomy with bipolar
diathermy/ligasure/harmonic scalpel to blanch the tube mesentery and
then the tube before cutting, with retrieval in the same way. An ‘Endobag’
to remove the tube may be available(others use a sterile rubber glove). If
there is blood inside the abdomen, suck it out first as it absorbs light
 96

OVARIAN CYSTECTOMY – open or laparoscopic

1. Score a line on the outer layer of the serosa over the cyst with a gentle
stroke of the scalpel, or if operating laparoscopically with a diathermy
needle, then with scissors
2. Separate the serosa from the cyst wall and extend the incision carefully
with McIndoe or laparoscope scissors through the hole but with scissor
blades laid flat
3. Insert the back end of the scalpel at open surgery into the gap between
the outer ovarian serosa and cyst, and strip the serosa off the cyst
completely, or pull apart with laparoscopic graspers
4. Ligate or diathermize the vascular base of the cyst and remove it. If
operating laparoscopically, removal in a bag is ideal. The cyst can be
punctured in the bag, all fluid aspirated and the cyst wall retrieved. If there
is no bag, and there is almost no chance of malignancy, the cyst can be
punctured during or after separation from the ovary and retrieved. Wash
out the abdomen thoroughly with Ringer’s Lactate (less adhesion
formation)
5. Evert the ovary and apply diathermy to the bleeders
6. Use deep interrupted 2/0 polyglycolic sutures in the ovarian stroma to
close the deep space of the defect and to ensure haemostasis
7. Serosa: secure a 2/0 or 3/0 monofilament suture inside the ovary at one
end and then go ‘out to in’ – the ‘baseball stitch’ – on both sides with good
bites along the defect with a continuous suture, leaving only external
ovarian tissue exposed. Laparoscopically, the ovarian interior can be
diathermized, which causes the edges to roll inwards lessening
adhesions. Suturing is an alternative for the more experienced
laparoscopist
8. If the cyst has ruptured, the cyst walls can still be stripped and steps 3 to 7
above followed
9. Whenever operating on an ovarian cyst, take peritoneal washings for
cytology
10. Always wash out well before closing and ensure good haemostasis

This is said to be the pelvic operation most associated with postoperative

adhesions. If the cyst is intact, it should be removed intact or in an ‘Endobag’ and
the ovary put back together with sutures, or diathermied and left open but with
edges inverted. Always wash out very thoroughly particularly with mucinous
cysts(syrupy contents) or dermoid cysts.
 97

COMPLICATIONS OF HYSTERECTOMY AND LAPAROTOMY

Intra-operative complications
Bleeding
 Minimize blood loss by good technique, by use of bloodless planes and by
cautery
 Look for bleeders at regular intervals, keep track of blood loss
 For sudden severe bleeding apply firm pressure and call for help
o The consultant may employ packing or ligation of major arteries
 Consider blood transfusion, with platelets and/or FFP if there are clotting
problems
 Arrange close postoperative care – recovery area, ICU
 Always keep the anaesthetist well informed of bleeding
Bladder injury
 It is better to recognize the bladder injury at operation
 Routinely check for bladder injury at hysterectomy. If in doubt pass dye(or
milk) through the urinary catherter
 Simple bladder defects may be closed in 2 layers with polyglycolic
suture(Vicryl)
 Bladder base defects require attention to the position of the ureters, at
times with stenting. Call for help from a consultant or urologist. Bladder
suturing at or near the trigone may accidentally close the ureter
Ureteric injury
 Always check both ureters for damage or dilatation at the end of a
hysterectomy
 If a ureter is dilated, follow its course distally. If ureteric ligation or injury is
suspected, call a consultant or urologist. Re-implantation may be required
Bowel injury
 Very small defects can be closed with a simple Vicryl sutures
 Diathermy burns are often more severe than they first appear
 If in doubt, or with significant injury, call a consultant or general surgeon

Post-operative complications
Haemorrhage
1. Assess for shock – pallor, hypotension, tachycardia
2. If still in theatre/recovery, get help from an anaesthetist
3. Order emergency blood
4. If there is no rapid improvement, take the patient back to theatre
5. Call for a consultant
6. Vaginal bleeding from the vault can sometimes be tackled from below
7. Suspected intra-abdominal bleeding would require relook laparotomy
Postoperative collapse
Causes are:
 Anaemia worsened by intraoperative bleeding
 Internal haemorrhage
 Pulmonary embolism
 Sepsis (not immediately after clean surgery)
 Myocardial infarction or a medical condition e.g. cardiac failure.
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Management of postoperative collapse

1. Call for assistance
2. Attend to the ABC of resuscitation
3. Ensure venous access
4. Take FBC, U&E and ABG
5. Look for a cause – read the notes for underlying problems
6. Treat the cause, and manage in a high care / intensive care area
Postoperative infection
Sources may be:
 Chest – cough, lung crackles, chest X-ray
 Urine – symptoms, urinalysis, urine culture
 Wound – Painful oozing red hot wound
 Vault – Offensive discharge, bogginess and heat in vagina
Management of postoperative infection
1. Treat with appropriate antibiotics
2. Check HIV status and CD4 count if HIV positive
3. Observe for signs of severe sepsis
4. Do blood cultures, FBC, U&E, ABG if necessary
5. Vault infection or haematoma:
a. Try to push a finger through to drain pus or blood
b. If necessary, drain under general or spinal anaesthetic(cut the vault
suture)
6. Wound sepsis:
a. Remove as many sutures as is necessary to expose all infected
surfaces
b. Clean the wound with saline
c. Explore the length and depth of the wound
d. Debride necrotic tissue under general or spinal anaesthetic if
necessary
e. Dress with saline at first, then special wound dressing

GENERAL NOTES ON POST OPERATIVE CARE

Checking post operative patients should be done systematically and thoroughly,
and care must be taken to explain the operation to the patient and if at all to
reassure them.
Examine the patient carefully noting obvious features of concern such as
tachypnoea, tachycardia, hypotension, chest abnormalities, and marked
abdominal distension or rigidity. Note colour and amount of urine passed.
Always check the observation charts in the notes, and any clinical findings
entered by doctors who may have been called to see the patient.
 Urinary catheters may be removed on the day after operation, except with
vaginal hysterectomies, anterior repairs or operations for stress
incontinence (day 2).
 For most pelvic surgery, patients may be fed and mobilized on the day
after operation
 Postoperative antibiotics should only be given for a specific indication –
established infection or suspected infection
 With postoperative pyrexia beyond 24 hours after operation, consider
chest, urinary tract, wound and vaginal vaults sepsis, and
thromboembolism
 99

THROMBOEMBOLISM AND THROMBOPROPHYLAXIS

Deep vein thrombosis (DVT)
This is usually recognized by a painful swollen hot calf or lower limb a few days
after surgery.
Immediate management of DVT
1. Do FBC +/- INR, APTT depending on the post-op condition of the patient
2. Give Clexane 80mg bd sc
3. Arrange Doppler and ultrasound scan of the ilio-femoral or popliteal veins
4. Start Warfarin if the diagnosis is confirmed
Pulmonary embolism
This may present as chest pain, shortness of breath, haemoptysis or acute
collapse with cyanosis and cardiac arrest. Treatment is as for acute collapse,
with Clexane/iv Heparin(1,000 units per hour) as for DVT. Treatment should not
be delayed while waiting for V/Q scan or CT PA scan. Call for physician help if
the patient is unstable.
Risk factors for thromboembolism
 Previous history of deep venous thrombosis
 Prolonged pre-operative bed-rest
 Dehydration
 Obesity
 Smoking
 Hypertension
 Malignancy
 Sepsis
 Age >35years
 Known thrombophilia
Discuss with consultant and/or anaesthetist when considering
thromboprophylaxis
Giving thromboprophylaxis
All gynaecological surgical patients are potentially at risk.
1. Keep patients well hydrated postoperatively, and avoid taking down
intravenous lines unless the patient is drinking adequately
2. Mobilise patients early postoperatively, within reason
3. Pneumatic compression stockings may be used
4. Give Clexane 40 mg daily, starting 4-6 hours after surgery
5. Continue thromboprophylaxis until the patient is fully mobile, although in
certain high risk patient (previous thromboembolism with other factors) 6
weeks anticoagulation is required
6. Current oncology guidelines recommend prophylaxis in indicated patients
for 4-6 weeks post-op. This may not be chosen. Discuss