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Part 2 book “Jeffcoate’s principles of gynaecology” has contents: Tumours of the corpus uteri, tumours of the fallopian tubes, chemotherapy in gynaecological malignancies, radiotherapy in gynaecological malignancies, vaginal discharge, instruments in gynaecological procedures, endoscopic surgery in gynaecology,… and other contents.
Tumours of the Corpus Uteri • Benign Neoplasms • Malignant Neoplasms ENLARGEMENT OF UTERUS BENIGN NEOPLASMS Adenoma Pathology A true adenoma occurs with or without associated endometrial hyperplasia and is invariably polypoidal (mucous polyp) (Figs 30.1 and 30.2) Polyps can be single or multiple; when the latter, the term multiple polyposis is sometimes used The tumour rarely exceeds a grape in size and is usually no larger than a pea On section, it shows endometrial glands and stroma, and these may or may not react to ovarian hormones by exhibiting the menstrual phases The causes of enlargement of the body of the uterus are as follows: • Pregnancy or recent pregnancy: This is the most common and the first possible cause to be considered in the repro ductive age group • Retained products of conception: Incomplete abortion and placental polyp Delayed and incomplete involution • Distension by fluid: Haematometra; pyometra; hydrome tra • Hypertrophy (myohyperplasia): Developmental or idio pathic; active or passive congestion; excessive oestrogen, or oestrogen/progestogen stimulus • Adenomyosis • Cysts: These, it is believed, arise from Müllerian diverticula and are exceptionally rare • Endometrial polyp • Benign neoplasms – Leiomyoma – Rarities such as the haemangioma, glioma, chon droma and osteoma • Malignant neoplasms – Carcinoma – Sarcoma – Choriocarcinoma – Mixed mesodermal tumours – Metastatic growths from any site, including melanoma – Rarities such as the lymphoma and pericytoma – Placental (or foetal) • Malignant – Carcinoma – Sarcoma; mixed Müllerian tumours – Choriocarcinoma • Enlargement of Uterus • Polyps CHAPTER 30 POLYPS Many tumours of the uterus present as polyps within its cavity For all practical purposes a uterine polyp comes under one of the following headings • Benign – Adenoma (mucous) – Leiomyoma (fibroid) vip.persianss.ir Fig 30.1: An endometrial polyp 453 Tumours of the Corpus Uteri Fig 30.3B: Saline infusion sonography in the same patient The endometrium is normal, the cystic spaces are now seen to be tamoxifen-induced subendometrial spaces A polyp is seen projecting into the endometrial cavity This was confirmed and resected at hysteroscopy Fig 30.2: Multiple endometrial polyps associated with endometrial hyperplasia and follicular cysts in the ovaries The endometrial lesion could only be distinguished from carcinoma by histological examination Multiple polyps show a strong tendency to recur after removal This is because they are generally a manifestation of endometrial hyperplasia with a persisting background of hyperoestrogenism The cause of single mucous polyps is unknown Clinical Features Single endometrial polyps are common, especially in the postmenopausal uterus when they are mostly symptomless; they are often surprise findings on opening the excised organ Symptoms are more likely when the tip of the polyp becomes necrotic and ulcerated; these include menorrhagia, intermenstrual (or postmenopausal) discharge, bleeding after coitus and, occasionally, uterine colic The presence of a polyp may be suspected from the history and by finding the cervix patulous Transvaginal ultrasound reveals a thickened endometrial shadow (Fig 30.3A) The endometrial polyp may be outlined at saline infusion sonography (Fig 30.3B) or hysterography The diagnosis is made for certain by hysteroscopy or if the polyp is removed by curettage (See Fig 30.4) Fig 30.4: A single subserous pedunculated leiomyoma diffusely calcified Treatment - Curettage can be done but this is not always satisfactory because one or more polyps may elude the polyp forceps Hysteroscopy guided polypectomy is the gold standard Only very rarely will hysterectomy be required and then only if there is associated significant endometrial pathology Leiomyoma (Myoma, Fibromyoma) Pathology Excluding pregnancy, the leiomyoma is the most common of all pelvic tumours, being present in 20% of women in the reproductive age group, and increasing with age It is com posed essentially of muscle tissue although there is a variable amount of fibrous connective tissue as well, especially in the older and larger tumours (Fig 30.5) It is also termed myoma or fibromyoma and is popularly called a fibroid Various types of fibroid are shown in the Figures 30.6 to 30.39 Fig 30.3A: Transvaginal sonogram shows an appearance of a thickened endometrium with irregular cystic spaces The patient was receiving tamoxifen for breast cancer for the last years vip.persianss.ir 454 Jeffcoate’s Principles of Gynaecology Fig 30.5: Microphotograph of a leiomyoma of the uterus showing the interlacing bonds of smooth muscle and fibrous tissue Fig 30.8: Calcified fibroid an attempt to cut Fig 30.6: Calcified fibroid Fig 30.9: Calcified fibroid at vaginai hysterectomy Fig 30.7: Calcified fibroid after removal Fig 30.10: Calcified fibroid at X-ray vip.persianss.ir 455 Tumours of the Corpus Uteri Fig 30.11: Fibroid uterus identified at hysterosalpingography Fig 30.14: Fibroids–red degeneration Fig 30.12: Fibroid Fig 30.15A: Fibroids Fig 30.13: Fibroid Fig 30.15B: Fibroids vip.persianss.ir 456 Jeffcoate’s Principles of Gynaecology Fig 30.16: Fibroids cut specimen Fig 30.19: Fibroids Fig 30.17: Fibroids uncut Fig 30.20: Fibroids Fig 30.18: Fibroids Fig 30.21: Fibroids fibroid polyp vip.persianss.ir 457 Tumours of the Corpus Uteri Fig 30.22A: Fibroids Fig 30.23B: Fibroids with pregnancy cut specimen Fig 30.22B: Fibroids—fibroids cut and confirmed Fig 30.24: Fibroids intracavitory Fig 30.23A: Fibroids with pregnancy uncut Fig 30.25: Fibroids intracavitory vip.persianss.ir 458 Jeffcoate’s Principles of Gynaecology Fig 30.26: Fibroids bicornute looks as fibroid Fig 30.29: Cut section of multiple intramural fibroids Fig 30.27: Fibroids bicornuate looks as fibroid cut Fig 30.30: Hystrectomy specimen of fibroid with fetus Fig 30.28: Multiple fibroids Fig 30.31: Hystrectomy specimen (fibroid with fetus) vip.persianss.ir Tumours of the Corpus Uteri Fig 30.32: Hystrectomy of fibroid uterus with fetus Fig 30.35: Multiple fibroids at operation Fig 30.33: Multiple fibroids in one uterus Fig 30.36: Multiple fibroids at operation Fig 30.34: Multiple fibroids after operation Fig 30.37: Pregnancy with multiple fibroids cut specimen vip.persianss.ir 459 Jeffcoate’s Principles of Gynaecology Each individual uterine leiomyoma is monoclonal It arises from a somatic mutation in a progenitor myocyte Multiple chromosomal abnormalities are detected in approximately 50% of leiomyomas by cytogenetic analysis; the most common being translocation between the long arms of chromosomes 12 to 14 followed by deletion on the long arm of chromosome Y Leiomyomas are frequently multiple and as many as 200 maybe found in one uterus (Fig 30.40) More often the number is between and 30 The tumours tend to be spherical in shape although their surface can be lobulated (Figs 30.4 and 30.40 to 30.42) They are surrounded by a pseudocapsule which consists of compressed normal uterine 460 Fig 30.38: Pregnancy with multiple fibroids foetus seen Fig 30.41: Symmetrical enlargement of the uterus caused by a single intramural leiomyoma By becoming retroverted and impacted in the pelvis this uterus caused acute retention of urine in a woman aged 44 years Fig 30.39: Pregnancy with multiple fibroids Fig 30.40: Innumerable small leiomyomas scattered throughout the uterus of a nulliparous woman only 25 years of age Such a distribution of tumours creates one of the few circumstances in which myomectomy is generally impracticable Fig 30.42: A single submucous leiomyoma in the uterus of a woman aged 56 years who complained of heavy but regular periods vip.persianss.ir 461 Tumours of the Corpus Uteri Parity: Leiomyomas are more common in nulliparous or relatively infertile women, but it is not known whether infertility causes leiomyomas or vice versa, or whether both conditions have a common cause The general view is that the uterus which is deprived of pregnancies consoles itself with myomas or, as the old adage put it, “fibroids are the reward of virtue, babies the fruit of sin” Racial and genetic factors: The women of certain races, notably African, are especially prone to develop uterine leiomyomas Also, irrespective of race, these can have a familial incidence Ovarian function: It is often suggested that excessive oestrogen stimulation causes leiomyomas but the evidence is unconvincing These tumours not significantly atrophy at the climacteric, as was suggested at one time Moreover, they sometimes arise after the menopause—even after bilateral oophorectomy at an early age However, oestrogen and progesterone may cause them to increase in size The original experiments, so frequently quoted in support of the idea that leiomyomas can be caused by oestrogens, are misleading in that the tumours which appeared in guinea Diseases commonly and possibly significantly associated with leiomyomas are follicular cysts of the ovary, endometrial hyperplasia, endometrial carcinoma and endometriosis It is sometimes stated that salpingitis is a frequent finding but this is not true The only possible link between the two is infertility It may be added that when two conditions such as follicular cysts and leiomyomas have each a high incidence, their coexistence maybe fortuitous Sites Leiomyomas are described as being subserous, interstitial or submucous, according to their relationship to the peritoneal coat and to the endometrium (Fig 30.43) Their site is determined by the position of their origin and by the direction in which they grow; an interstitial leiomyoma can, by development, become submucous or subperitoneal Subserous and submucous leiomyomas often become pedunculated Most leiomyomas are situated in the body of the uterus but in 1–2% of cases they are confined to the cervix and usually to its supravaginal portion A cervical leiomyoma is commonly single and is either interstitial or subserous (Fig 30.44) Rarely does it become submucous and polypoidal (Figs 30.45 and 30.46) The subserous tumour usually grows out into one or other broad ligament The cervical leiomyoma presents special clinical features because, being extraperitoneal, it remains fixed in the pelvis and displaces the bladder and ureters; its removal is hazardous for the same reasons (Fig 30.44) A myoma developing in the cervical stump after subtotal hysterectomy is a rare but interesting possibility and can create a surgical problem (Fig 30.47) Extrauterine leiomyomas may develop in the broad ligament or at other sites where smooth muscle exists Symptoms The majority of small leiomyomas and some large ones are symptomless The nearer the leiomyoma to the endometrial cavity, the more likely it is to cause symptoms, especially menstrual symptoms A leiomyoma does not cause pain unless it is complicated by: extrusion from the uterus as a polyp—in this case the pain is caused by uterine colic which “aborts” the myoma; torsion of its pedicle or of the uterus; degeneration; sarcomatous change; or adhesions to other organs vip.persianss.ir Age: Uterine leiomyomas are rare before the age of 20 years but are to be found, if only as single tiny tumours, in approximately 20% of women over 20 years of age and in 40% of women over the age of 40 years They most commonly cause symptoms between the ages of 35 and 45 years but probably exist in microscopic form before the age of 30 years Associated Conditions Aetiology pigs after oestrogen therapy were neither true myomas nor situated in the uterus! To induce a “fibroid” in an animal requires an incessant supply of hormone applied directly to the uterine wall - - - - wall Except when modified by degeneration, they are hard in consistency and their cut surface presents a white and whorled appearance They can grow to immense size filling the whole abdomen There are accounts of a block and tackle having to be fitted to the theatre ceiling in order to lift the tumour from the abdomen at the time of operation The modern development of ultrasound together with increased availability and safety of surgery have made mammoth tumours rare, but they are still to be found Leiomyomas are slow to grow and it is often said to take years for one to reach the size of an orange This, however, is only a generalisation; the rate of growth varies from patient to patient and from time to time in the same patient There may be waves of growth interspersed with phases of quiescence, and a degenerative change can cause a rapid and gross enlargement of any tumour An arrest or slowing of activity is most likely after the menopause but at least 10% of leiomyomas continue to grow after this time The tumours themselves are relatively avascular, the main blood vessels being distributed in their capsules Occasionally, a tumour has numerous blood or lymph vessels, with large cavernous spaces throughout its substance; it is then called a telangiectatic or a lymphangiectatic leiomyoma 913 Index Interleukin 12 (IL-12), 540 Internal genitalia, autonomic innervation of, 48 Internal iliac artery, 43 Internal pudendal artery, 44 International Menopause Society, 811 Intersex, 203–204 after birth, 225 classification, 203–204 treatment, 223–224 Interstitial brachytherapy, 444–445 Intertrigo, 303 Intra-abdominal laser surgery, 889 Intracavitary radiotherapy (ICRT), 444 Intracervical and intrauterine aspiration techniques, 402 Intracytoplasmic sperm injection (ICSI), 368, 678 in PCOS, 389 Intraligamentary pregnancy, 146 Intrauterine insemination, 676 Intrauterine contraceptive devices advantages, 755–756 advantages, 758 adverse effects and complications, 754–755 combined hormonal contraception, 756–757 contraindications, 753, 758 copper releasing IUCDS, 733–734 efficacy, 753, 759–760 formulations, 757 history, 742 hormone-releasing, 743 insertion technique, 747–748 lippes loop, 743 mechanism of action, 747 postpartum, 774 side effects, 758–759 supervision and management, 748–749 technique, 757–758 types, 745f use of, 131 Intrauterine pathological variables, 536 Intravaginal tampons, 81 Intravastion of contrast bilateral Rogid pipeline tubes with, 335f into tubal musculature, 335f Invasive cancer of cervix, management of, 442t Invasive cancer of vulva, 413–417 Invasive carcinoma of endometrium, 474–475, 474f, 475f Invasive hydatidiform mole, 715 In vitro fertilisation (IVF), 93 in PCOS, 389 Iodine deficiency disorders, 873–874 Irritable bowel syndrome, 838 causes, 838 diagnosis of, 838–839 results, 839 treatment, 839 Isthmic obstruction, of fallopian tube, 332f–333f Isthmus, 27 IVF See In vitro fertilisation; In vitro fertilisation (IVF) K Kegel’sperineomate Keyhole surgery technique, 716 Klinefelter’s syndrome, 212–213 Kobelt’s tubules, 487 L Labia majora, 18 structure of, 18 Labia minora (spaniel ear nymphae), 19, 199 asymmetry of, 199 hypertrophy of, 199 pathology, 199 symptoms, 199 treatment, 199 LAC See Lupus anticoagulant Laceration of cervix, 237–239 clinical features, 238–239 complications and after effects, 238 cervical ectropion, 238 distortion and scarring of cervix, 238 treatment, 239 types and causes, 237–238 obstetrical injuries, 237–238 surgical injuries, 238 Lactation, 162–163 and amenorrhoea, 543 breast diseases in, 163 and drugs, 163–164 failure, 163 suppression of, 163 Lactational amenorrhoea method, advantages, 736 Lactogenesis, 162 Laparoscope, 717 Laparoscopic chromotubation, 11 Laparoscopic myomectomy, for uterine leiomyoma, 468–469, 725f Laparoscopic ovarian diathermy, 672 Laparoscopic ovarian drilling, 367, 367f in PCOS, 367, 376f Laparoscopy-assisted vaginal hysterectomy (LAVH), 832 advantages, 832 disadvantages, 832 Laparoscopy technique, 14, 14f, 690, 716 approach, 717t vip.persianss.ir complications of, 15–16 anaesthetic, 725 bladder injury, 726 bowel injury, 726 patient positioning, 725 pneumoperitoneum, 725–726 ureteral injury, 726 vascular injury, 726 contraindications to, 16, 717 diagnostic, 721–723 disadvantages, 716 equipment for, 717 for ovarian tumours, 519, 520 for primary dysmenorrhoea, 582 graspers, 719f incidence of, 726–727 indications for, 716–717 instruments for, 15, 15f operating room layout, 15f operative procedures, 14–15, 717, 723 role of, 142 techniques of, 719–720 Laparotomy, steps of staging, 517–518 Large loop excision of the transformation zone (LLETZ) See Loop electrosurgical excision procedure (LEEP) Laser assisted hatching, 678–679 Laser surgery for cervix, 888 hysteroscopic, 889 intra-abdominal, 889 vagina, 889 vulva, 888–889 Late-onset adrenal hyperplasia, 371–372, 374 treatment of, 374 Lateral displacement of uterus, 269 causes, 269 treatment, 269 LDL See Low-density lipoprotein Leiomyoma of cervix, 434 Leiomyoma of uterus, 454–460f aetiology of, 461 complications of, 469 degeneration of, 470–471, 470f differential diagnosis of, 465 general effects of, 462–463 malignant changes in, 469–470, 470f menstrual disturbances, 463 pathology of, 453, 460–461 physical signs of, 464–465 and pregnancy, 464, 464f, 465f pressure symptoms of, 463–464 symptoms of, 461–462 treatment of, 465 abdominal myomectomy, 467–468 curettage or endometrial aspiration, 467 914 Jeffcoate’s Principles of Gynaecology Luteinising hormone/follicle-stimulating hormone (LH/FSH) levels, 363 Luteinising hormone-release hormone See Gonadotrophin-releasing hormone Luteoma of pregnancy, 492–493 Lymphatic and vascular embolism, 348 Lymphatic permeation and embolism, 438 Lymphatics, 22, 46 of internal pelvic organs, 42f of ovaries, 32 permeation of, 476 of rectum and anus, 38 of sigmoid (pelvic) colon, 37 of ureter, 37 of urethra and bladder, 36 of uterus, 30 of vagina, 26 of vulva, 22 LymphogranulomaVenereum (LGV), 292–293, 305 Lymphokine-activated killer cell (LAK), 541 Lymphomas, 483 Lynch II syndrome, 510, 525 embolotherapy, 469 general, 466 hysterectomy, 469 laparoscopic myomectomy, 468–469 myoma coagulation, 469 palliative, 466 polypectomy and vaginal myomectomy, 467 Leiomyomas, 473, 488 Leiomyosarcoma, 481–482 Leptotene, 56 Leucoplakia, 375 Leucorrhoea, 614 pruritus associated with, 619–621 Leukaemia and lymphoma, 525–526 Leukaemic and lymphadenomatous growths, 483 LGV See Lymphogranuloma venereum (LGV) LH See Luteinising hormone LH-mediated terminal differentiation of granulosa cells, 364 Libido, 226 Lichen sclerosus, 376–377 corticosteroids for, 378 testosterone for, 378 Linear accelerator, 535 Lipoid cell tumours dysgerminoma, 507 germ cell tumours, 504 mixed germ cell tumours, 508 ovarian choriocarcinoma, 506–507 teratomas, 504–506, 505f, 506f yolk sac tumours, 507 LNG rod, 768 Local analgesia, 378 Local injury, 561–562 Local vulvar anaesthesia, 47, 47f Loop electrosurgical excision procedure (LEEP), 393, 393f Low backache differential diagnosis of, 631t extragenital causes of bone and joint lesions, 632 diseases of rectum, 632 muscular and ligamentary lesions, 631–632 psychological factors, 632 general considerations of, 630 gynaecological conditions causing, 630–631 management and treatment of, 632 Low-density lipoprotein, 84 Low-grade stromal sarcoma, 481 “Lunchtime” abortions, 787 Lupus anticoagulant, 123 Luteal phase, ovarian cycle, 52, 53, 58–60 Lutein cyst, 708 M Mackenrodt’s ligaments, 40 Magnetic resonance imaging (MRI), 17, 171, 857 for abnormal uterine bleeding, 569 Male fertility assessment of, 656–659 clinical, 656–657 hormonal assessment, 658 semen analysis, 657–658 sperm antibodies, 658 sperm function tests, 658 sperm penetration assay, 658 testicular biopsy, 658 varicocele assessment, 659 in vitro sperm penetration tests, 658 Male frigidity and impotence, 644–645 Male infertility, prevention of, 667–668 Male sterilisation adverse effects of, 780 contraindications, 780 techniques, 779–780 Malignant disease, 841, 856 Malignant neoplasms, 409 adenocarcinoma in situ of endometrium, 473, 474f adenocarcinomas, 474–475, 474f, 475f basal cell carcinoma, 417 endometrial carcinoma, 472–473, 472f, 472t vip.persianss.ir primary vaginal cancers, 426 vaginal intraepithelial neoplasia (VAIN), 426–428, 428f vulvar cancer aetiology of, 413 clinical features of, 415 diagnosis of, 415 melanoma, 417 pathology of, 413, 414f sarcoma, 417 spread, 414 staging of, 414, 415t treatment of, 415–417 types of, 413, 414t Mammary glands, 159 Mammogenesis, 162 Marriage annulment of, 637–638 companionship as basis of, 635 consummation of, 636–637 faithfulness in, 648 Masculinisation, and virilisation, 369 Mastitis, 168 Masturbation, 638 Maternal complications, 674 Maternal factors, euploid abortion, 122–124 Maternal infections, 121 Maturation index, 79 Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome, 183 Medroxy-progesterone acetate, 480 in endometriosis, 355–356 for hirsuitism, 373 Medulla, 51, 176 Meigs’ syndrome, 508–509, 509f Meiosis, 56 phases division anaphase, 56 metaphase, 56 prophase, 56 telophase, 56 Melanocyte-stimulating hormone, 66, 81, 101 Melanoma of uterus, 483 of vagina, 430 Melanoma, 417, 417f Membranous dysmenorrhoea, 585 Menarche, 101 and standard menstrual habit, Menometrorrhagia, 560–561 Menopausal atrophy, 25 Menopausal transition, 577 postmenopause, 812 stages of, 812 Menopause amenorrhoea, 543 915 Index androgens in, 828–829 cancer screening in, 823–824 causes, 811 collagen, 817 defined, 811 factors of, 813 hormonal changes, 814–815 history, 811 induced menopause, 811–812 kyphosis, 820f management of, 824–825 physiology of, 813 problems associated with, 815, 822–823 recommendations for screening, 824 stages of, 812–813 staging, 811–812 recommendation, 818 treatment, 818 urinary symptoms, 818 vision-threatening conditions, 817 Menopause and climacteric, 82–89 age, 82–83 climacteric (menopausal) symptoms, 83–85 cardiovascular, 84 gastrointestinal, 84 genital and sexual, 84 neurotic and psychotic, 84 osteoporosis, 84 urinary, 84 definition, 82 management of, 85–89 alternative therapy for menopause, 88–89 general, 85 hormone replacement therapy, 85–88 medical, 85 nonhormone replacement therapy regimens, 88 physical changes, 83 psychological changes, 83 Menorrhagia, 188, 560 causes of, 565 treatment for, 570, 571f Menses, 80 Menstrual cycle, 50 definition, 72 misinterpretation of, 4, 4f Menstrual dysfunction, in PCOS, 362 Menstrual endometrium, 72 Menstrual epilepsy, 594–595, 595f Menstrual irregularities, 577 in PCOS, 365 with PCOS, 365–366 Menstrual migraine, 590–591 Menstrual period, knowledge of last, 4–5 Menstruation, 2, 80–82 artificial deferment, 82 description, 80 general disturbances with, 80–81 management of, 81–82 disadvantages, 81 and pain, 4, Mesenchymal stroma cells, 51 Mesenchyme, 176 Mesenteries, 180 Mesoderm, 117 Mesonephros, 177 Mesotheliomas, 489 Metaphase, 56 Metastases, 515 Metastatic (secondary) ovarian tumours, 523–524 Metastatic tumours, 713–714 Metformin, mechanism of action of, 367 Methanol extraction residue (MER), 540 Methotrexate, 406, 531 Methyl tetrahydrofolate reductase (MTHFR) gene, 129 Metritis, 318 Metronidazole for bacterial vaginosis, 314 for Trichomonas vaginitis, 311–312 Metrorrhagia, 560 Microwave endometrial ablation, 573–574 Micturition, 34–35, 35f Mifepristone (RU-486), 356 Migraine headaches, 762–763 Migraines, 817 Minimally invasive surgery, See also Laparoscopy technique Miscarriage See Spontaneous abortions Missed abortion, 126, 135 clinical picture, 126 complications, 126 investigations, 126 signs, 126 treatment, 126 Mitoses, 72 Mixed germ cell tumours, 508 Mixed Müllerian tumours, 482–483 Mondor disease See Superficial thrombophlebitis Monoclonal antibodies disadvantages of, 542 as therapeutic agents, 541–542 Mons veneris, structure of, 18 Morphine, 852 for cancer pain, 404–405 Morula, 113 MRI See Magnetic resonance imaging MSH See Melanocyte-stimulating hormones MUC-1, 539 Müllerian duct anomalies, 182–193 vip.persianss.ir cause, 188 classification, 182 clinical features, 192 coital, 188 bleeding, 188 dyspareunia, 188 congenital gynatresia, 191 diagnostic signs, 189 differential diagnosis, 192 duplication and diverticula, 190–191 imperfect fusion, 185–187 arcuate uterus (class VI), 187 bicornuate uterus (class IV), 185 deformities in combination, 187 des-related anomalies (class VII), 188 pathology, 185 septate and subseptate uterus (class V), 185 septate and subseptate vagina, 187 uterus didelphys (class III), 185 incomplete development, 182–184 class I, 182–184 class II, 184 menstrual, 188 failure to contain flow, 188 menorrhagia, 188 spasmodic dysmenorrhoea, 188 obstetrical, 188 abortion and premature labour, 188 cornual pregnancy, 188 inefficient uterine action, 189 infertility, 188 malpresentation, 189 obstructed labour, 189 sacculation of uterus, 188 site of the conceptus, 188 pathology, 191–192 sites, 191 congenital atresia, 191 vaginal atresia, 191 symptoms, 188 treatment, 189–190, 192–193 Müllerian (paramesonephric) ducts, 180 Müllerian ducts (Class I), 182–184 incomplete development, 182–184 clinical aspects, 184 pathology, 182–184 Müllerian ducts (Class II), 184 incomplete development, 184 diagnostic signs, 184 pathology, 184 symptoms, 184 treatment, 184–185 Müllerian tubercle, 180 Muscular incoordination, in primary dysmenorrhoea, 580 Mutinous cystadenoma, pathology of, 497–498, 497f, 498f 916 Jeffcoate’s Principles of Gynaecology Mycobacterium tuberculosis, 330, 331 Myoma See Leiomyoma Myoma coagulation, for uterine leiomyoma, 469 Myoma screw, 685, 686f Myomectomy, 723, 725f patient benefits, 898 surgeon benefits, 897–898 Myometrial cycle, 78 Myometrium, 62 Myxoid-soft tissue tumours, 425, 426 carbohydrates, 866 elder, 878–880 fats, 864 iodine, 878 iron, 877–878 macronutrients, 876 pregnancy, 875–877 proteins, 864 zinc, 878 Nymphomania, 643–644 N Obesity aetiology of, 869–870 environmental influences on, 870 and insulin resistance, 361f other factors, 870 and PCOS, 362 prevention of, 870 stunting, 874–875 undernutrition, 874–875 calcium requirements in, 875 Obstetrics, Occupation, environment, and fertility, 655 Oedema of legs, 405, 515 of vulva, 409, 410f, 515 Oestradiol, 61 Oestradiol pellets, 86 Oestradiol valerate, 825 Oestrogen production, 813 Oestrogen-progestogen contraceptive preparations, 82 Oestrogens, 61–64, 101, 120, 160, 436, 473 action, 62–63 breasts, 62–63 endocrine system, 63 Fallopian tubes, 62 oestrus, 62 secondary sex characters, 62 secondary sex organ, 62 uterus, 62 vulva and vagina, 62 bleeding threshold level, 76 hyperplasia of endometrium, 473 production, 61 receptors, 61–62 skeletal system, 63–64 blood, 64 general, 64 urinary tract, 63 withdrawal bleeding, 76 Oestrogen deficiency effect of, 815–817 hot flushes, 815–816 physiology of, 816 cardiovascular effects, 822 Nabothian follicles, 316, 432–433, 433f Natural defence mechanisms, 618–619 Nausea and vomiting, 531 Neisseria gonorrhoeae, 620–621 Neoadjuvant chemotherapy, for cervical carcinoma, 528–529 Neoplasms of Bartholin’s gland, 419 Nephrogenic cord, 176 Neuroendocrinology, 50 Neuropathic pain, 405 Neuroscience, 50 Neurosecretion, 50 Newer delivery systems, 86 NIDDM See Noninsulin dependent diabetes mellitus (NIDDM) Nipple, 159 Noma vulvae, 306 Nonhormone replacement therapy regimens, 88 Noninfective vaginitis, 315 Noninsulin dependent diabetes mellitus (NIDDM), 368 Nonmenstrual bleeding, 575 Nonmetastatic disease, 154 Nonproliferative, 168 Nonself antigens, 539 Non-steroidal anti-inflammatory drugs (NSAIDs) for cancer pain, 404 Noonan syndrome, 212 Norethisterone, 82 Normal menstrual cycle, 72 ovarian cycle follicular phase, 72 luteal phase, 72 uterine cycle menstrual endometrium, 72 phase of endometrial breakdown, 72 preparation for implantation, 72 proliferative phase, 72 secretory phase, 72 Nutrition basics, 863 calcium, 878 O vip.persianss.ir Oestrogen receptors, 815 age-related, 813 natural, 825 semisynthetic, 825 synthetic, 825 Oestrogen therapy, 378 Oestrogen withdrawal bleeding, 76 Oestrogens, 856 OHSS See Ovarian hyperstimulation syndrome Omentectomy, 522 OMI See Oocyte maturation inhibitor Oocyte donation, 675 Oocyte maturation inhibitor, 56 Oocytes, 51 Oogenesis, 51 Oogonia, 51, 56 Oophorectomy, 833–834 Oophoritis, 323 Operative hysteroscopy, instruments for, 16f Operative treatment, 669–671 Opiates, 852 Opioids, for cancer pain, 404–405 Oral contraceptive preparations (OCPs), 373 Oral contraceptives for hirsuitism, 366 for PCOS, 365 Oral epithelial abnormalities, 379 Orgasm, 636, 655 failure to achieve, 643 Osteoblasts, 63 Osteoporosis prevention and management of, 821 recommendations for pharmacological treatment, 821f spinal complications of, 820–821 Outpatient (office) curettage, 10–11 Ovarian adenocarcinoma, pathology of, 499 Ovarian amenorrhoea, 547–550 oestrogen and progesterone continuous production of, 548 underproduction of, 547–548 overproduction of androgens, 548 and PCOS, 548–550, 548f, 549f, 550f Ovarian choriocarcinoma, 506–507 Ovarian compartment, in PCOS, 361 Ovarian cycle, phases of follicular, 50 luteal, 50 Ovarian cystectomy, 723 Ovarian dysfunction, classification of, 92 Ovarian enlargements causes of, 490 with haemorrhage, 490 Ovarian granulosa cells, 813 917 Index Ovarian hormones, 61–66 activin, 66 follistatin, 66 inhibin, 66 oestrogens, 61–64 progesterone, 64–65 relaxin, 65–66 Ovarian hyperstimulation syndrome, 45, 680, 708 Ovarian ligament, 39 Ovarian neoplasms, 706–707 Ovarian pregnancy, 143–144 clinical features, 144 differential diagnosis, 144 pathology, 144 treatment, 144 Ovarian remnant syndrome, 709 Ovarian sonography benign cystic lesion of ovarian and paraovarian structures, 706 endometriosis, 710 evaluation of ovarian mass, 714 functional cysts, 707 germ cell tumours, 713 lutein cyst, 708 metastatic tumours, 713–714 ovarian hyperstimulation syndrome, 708 ovarian neoplasms, 706–707 ovarian remnant syndrome, 709 ovarian vascular lesions, 706, 711–712 paratubal, paraovarian cysts, 710 pelvic inflammatory disease, 710–711 peritoneal inclusion cysts, 711 polycystic ovarian syndrome, 708–709 rete cysts, 707–708 sex cord—stromal tumours, 713 surface epithelial inclusion cysts, 707 surface epithelial stromal tumours, 712 Ovarian tumours and age, link between, 515 ascites, 515 associated with carcinoma of body of uterus, 526, 526f borderline epithelial, 493 borderline tumours criteria for diagnosis of, 516 definition of, 515 chemotherapy for, 522–523 classification of, 493, 494t, 495t clinical features of age incidence, 509 genetic factors, 509–510 complications of, 516 connective tissue tumours adenofibroma, 508, 508f fibroma, 508, 508f Meigs’ syndrome, 508–509, 509f primary sarcoma, 509 consistency of, 515 degeneration of, 517 diagnosis of, 510–511, 513–515, 513f, 514f epithelial, 493 exploration of, 521 fixation of, 515 follow-up, 523 germ cell tumours, 496 gonadoblastomas, 496 granulosa cell tumours, 495 haemorrhage into or from, 516 infection, 517 intestinal obstruction, 517 leukaemia and lymphoma, 525–526 lipoid cell tumours dysgerminoma, 507 germ cell tumours, 504 mixed germ cell tumours, 508 ovarian choriocarcinoma, 506–507 teratomas, 504–506, 505f, 506f yolk sac tumours, 507 malignancy, 517, 517f metastases, 515 metastatic (secondary), 523–524 number of, 515 oedema of feet and vulva, 515 pain and tenderness with, 515 pathology of brenner tumour, 499 clear cell (mesonephroid) tumours, 499 endometrioid tumours, 498–499 epithelial ovarian tumours, 496–497 mutinous cystadenoma, 497–498, 497f, 498f ovarian adenocarcinoma, 499 tumours of borderline malignancy, 499–500 undifferentiated carcinoma, 499 physical signs of, 510 positions of, 511f during pregnancy differential diagnosis of, 527 treatment of, 527 types of, 526 primary carcinoma BRCA1 and BRCA2 mutation, 525 Lynch II Syndrome, 525 origin of, 524 pathology of, 524, 525 screening of, 525 radiotherapy for, 522 rupture of cyst, 516–517 sex cord stromal tumours, 493, 495 androblastomas, 502–503 granulosa and theca cell tumours, 500–502, 501f, 502f gynandroblastoma, 503 vip.persianss.ir sex cord mesenchymal tumour with annular tubules, 503–504 staging of, 517–518 surgery for conservative, 520 indications for, 518–519 omentectomy, 522 pelvic tumour resection, 521–522 results of, 523 surgical procedures, 519–520, 519f symptoms of, 510 treatment of, 518, 525 hysterectomy, 513f oopherectomy, 512f, 513f varicosities, 515 Ovarian vascular lesions, 706, 711–712 Ovaries, 42f, 49, 193–194, 693–694 absence or underdevelopment, 193 accessory, 193–194 blood supply to, 43f changes with age and parity, 32 failure of descent, 194 function production of hormones, 51 production of ova, 51 lymphatics of, 46 normal and polycystic, 360f ovotestis, 194 relations of, 32 structure of, 32 supernumerary, 193–194 vascular connections, 32 Ovariotomy and salpingo-oophorectomy, for ovarian tumours, 519 Ovotestis, 209–210 Ovulation, 52, 58, 90–98 analysis of symptoms, 91 assessment of, 654 changes in cervical mucus, 91 diagnosis of, 90 direct observation, 92 endometrial changes, 91 estimation of time and frequency of, 659 hormone assays, 92 and menopause, 90 ovarian dysfunction, 92 suppression of, 98 androgen, 98 danazol, 98 disease, 98 drugs and other therapeutic agents, 98 hypothalamic-releasing factors analogues, 98 irradiation, 98 oestrogens, 98 progestogens, 98 surgical procedures, 97–98 918 Jeffcoate’s Principles of Gynaecology temperature changes, 91 treatment, 92–97 of cause, 93 GnRH agonists and GnRH antagonists, 96–97 hypothalamic-releasing factors (GnRH), 96 induction of ovulation, 93 ultrasound, 92 vaginal smears, 91–92 Ovulation induction, by clomiphene citrate, 366–367 Ovulatory bleeding, 575 polymenorrhoea and polymenorrhagia, 565–567 Ovum early development, 113 early development of, 113 fertilisation, 111–113 fertilisation of, 111–113 maturation of, 56–58 into uterus, 113–116 Oxytocin, 66 P Pachytene, 56 PAF See Platelet-activating factor Paget’s disease, 380–381, 381f Pain on defaecation, in endometriosis, 349–350 intensity, onset and duration, relationships, site and radiation, Palliative, for uterine leiomyoma, 466 Papilloma, 424 PAPP See Placental associated plasma proteins Paracentesis, 518 Paracrine mechanism, 51 Paralytic ileus causes, 853 clinical features, 853 treatment, 853 Parasympathetic nerves, 47–49 Paratubal, paraovarian cysts, 710 Parovarian tumours during pregnancy differential diagnosis of, 527 treatment of, 527 types of, 526 Partial hydatidiform mole (PHM), 149, 715 Passive immunotherapy, 541 Pathological amenorrhoea, 543 Pathological discharges, 614 Pathology of, 394 Patient examination and handling clinical methods for, 2, 2f history taking, menstrual function, 4–5 symptoms, 3–4 physical examination abdomen, 5–6, 6f breasts, pelvic examination See Pelvic examination PCOS See Polycystic ovarian syndrome (PCOS) Pearl index, 734 Pediculosis pubis, 306–307 Pelvic muscles, electrical stimulation of, 883–884 Pelivs, calcific density on left side of, 332f Pelvic allergy, 593 Pelvic cancer early diagnosis and treatment of, 399–400 cervical cytology, 402 cervical scrape, 401–402, 401f cervicography, 403 colposcopy, 402 cytodiagnosis, 400–401 intracervical and intrauterine aspiration, 402 peritoneal cytology, 402 public education, 400 routine medical examination, 400 tumour markers, 403 ultrasound, 403 vaginal cytology, 401, 401f prevention of, 399 Pelvic cellulitis, 324–325 acute and subacute, 324–325 clinical features of, 325 diagnosis of, 325 pathology of, 325 treatment of, 325 Pelvic colon See Sigmoid colon Pelvic congestion, 631 Pelvic disease, emotional and environmental factors in, Pelvic examination under anaesthesia, 443 bimanual examination, 9–10, 10f case study, combined rectal and vaginal palpation, patient positioning for, 8–9, 8f, 9f prerequisites, rectal examination, size of uterus, vaginal examination, 7–8 Pelvic fascia and cellular tissue, 40 vip.persianss.ir Pelvic inflammatory disease (PID), 131, 326–329, 710, 711 aetiology of, 326 criteria for hospitalisation in, 326t recommended regimens for oral therapy, 327t for parenteral therapy, 328t sequelae of, 326 treatment of, 326–329 Pelvic kidney, 202, 715 Pelvic ligaments, neoplasms of, 488–489 Pelvic musculature iliococcygeus, 40 ischiococcygeus, 40 levator ani, 39 pelvic peritoneum, 38 piriformis muscle, 40 pubococcygeus, 39 Pelvic organ pedunculated leiomyoma, 280 aetiology, 280–281 differential diagnosis, 281 ovary, 280 treatment, 281 tube, 280 torsion of normal organs tube and ovary, 279 uterus, 279 torsion of abnormal organs, 280 uterus, 279–280 Pelvic organs, innervation of autonomic nerves, 47 parasympathetic nerves, 47 somatic nerves, 46–47 sympathetic nerves, 47, 48 Pelvic pathology displacements, 562 endometriosis, 562 errors in uterine development infections, 561 infection, 561 local injury, 561–562 pregnancy states, 561 Pelvic peritonitis, 323–324 aetiology of, 323–324 clinical features of, 324 pathology of, 324 treatment of, 324 Pelvic plexuses and veins, 45, 46 Pelvic tumour resection, 521–522 Pelvic varicocele, 631 Pelvic vasculature, volume and flow characteristics of, 41 Pelvis, veins of, 44, 45 Perimenopausal bleeding, 576 Perimenopause, 811 Perineal muscles, and triangular ligament, 40 919 Index Perineum syndrome, 18, 19, 837 blood vessels and nerves of, 44f coitus effect on, 21 lymphatics of, 46 skin and subcutaneous tissue, 19 treatment, 837 Periovarian adhesions, 723 Peripheral compartment, role in PCOS, 362 Peritonitis causes, 854 treatment, 854 types, 853 Peritoneal carcinomas, 489 Peritoneal cysts, 321 Peritoneal cytology, 402 Peritoneal inclusion cysts, 711 Peritoneal malignant mesotheliomas, 489 Peritoneal pouches, 38 Peritoneum of anterior abdominal wall, 38 neoplasms of, 489 Peritonitis, pelvic, 323–324 aetiology of, 323–324 clinical features of, 324 pathology of, 324 treatment of, 324 Peritubal adhesions, 723 Persistent gestational trophoblastic tumour, 154–158 metastatic disease, 154–156 clinical features, 155 diagnosis, 156 incidence, 154 pathology, 155 staging, 155–156 nonmetastatic disease, 154 placental site trophoblastic tumour, 154 treatment, 156–158 chemotherapy, 156–157 radiotherapy, 158 results, 158 subsequent pregnancies, 158 summary of management of GTN, 158 surgery, 157–158 Pessary and management, 884–885 hodge, 884 impaction of, 885–886 indications, 884–885 insertion, 884–885 ring, 883–884, 885f PET See Positron emission tomography P53 gene mutation, 399, 539 Phagedaena, 306 Phyllodes tumour, 168 Physical sex See Coitus Physiological discharges, 613–614 Phytoestrogens, 88–89 PID See Pelvic inflammatory disease (PID) Pituitary adenomas, 546 Pituitary amenorrhoea, 546–547, 546f Pituitary hormones, 66–67 anterior lobe hormones, 66 catecholoestrogens, 67 follicle-stimulating hormone, 66 posterior lobe hormones, 66 Pituitary-hypothalamic relations, 67–69 gonadotrophin-releasing hormone, 69 Pituitary-ovarian relations, 69–70 Placenta associated plasma proteins, 119 hydatidiform mole, 149 partial hydatidiform mole, 149 trophoblastic tumour, 154 trophoblastic tumour of, 715 Plant products, 407 Platelet-activating factor, 78 Platinum compounds, 531 Pneumoperitoneum, 721 Podophyllin, 412–413 Polycystic ovarian disease, 724f Polycystic ovarian syndrome (PCOS), 56, 90, 92, 360–368, 708–709 and alopecia, 366 anovulation in, 363–364 anovulation in, mechanism of, 363–364 antiandrogens in, 365–366 clinical, biochemical, and metabolic features of, 362–364, 364f enzymatic dysregulation, 363 FSH levels, 363 GnRH secretion, 363 insulin level, 363–364 P450c 17 alpha, role of, 364f criteria for metabolic syndrome in, 365 cyproterone acetate in, 366 definition of, 360 finasteride in, 366 flutamide in, 366 gonadotrophin therapy for, 368 hirsuitism, 366–367 alopecia, 366 clomiphene citrate in, 366–367 infertility and, 366 weight loss, 366 hirsuitism in, 366 hyperinsulinaemia in See Hyperinsulinaemia, in PCOS hyperstimulated, 364f hypothalamic-pituitary compartment in, 360f, 362 vip.persianss.ir infertility in, 366 insulin resistance in, 362, 363 intracytoplasmic sperm injection in, 368 laparoscopic ovarian drilling in, 367, 376f long-term monitoring of, 368 management of, 365 menstrual irregularities with, 365–366 metformin treatment of, 367 obesity in patients with, 362 onset during puberty, 365, 365f and ovarian amenorrhoea, 548–550, 548f, 549f, 550f overview, 360 pathology of, 362, 362f pathophysiology of, 360–362, 361f, 362f adrenal compartment role, 361 androgen excess, 361f CYP17 dysregulation, 361 hypothalamus-pituitary compartment, 360f, 362 leutinising hormone levels, 362, 363, 364, 364f oligogenic origin, 362 peripheral compartment and, 362 peripheral compartment role, 362 testosterone levels, 361 prevalence of, 360 during puberty, 365 skin manifestations of, 365–366 spironolactone and aldosterone antagonist in, 366 treatment of gonadotrophin therapy, 368 laparoscopic ovarian drilling, 367, 367f metformin, 367 ultrasonographic examination of, 364, 364f uterine artery Doppler in, 364f in vitro fertilisation in, 368 weight loss in, 366 Polycystic ovary, 360f Polymenorrhoea, 560 Polypectomy and vaginal myomectomy, for uterine leiomyoma, 467 Polyunsaturated fats, 865 Positron emission tomography, 171 Postcoital test, 665 Posterior lobe hormones, 66 Postmenopausal bleeding, 576–577 Postoperative management complications, 849–850 general, 845–846 postoperative examination, 848–849 Postoperative vaginal vault irradiation, for endometrial carcinoma, 480 920 Jeffcoate’s Principles of Gynaecology Pouch of Douglas, 38, 694 Preantral follicle, 52 Precocious puberty, 103–109, 162, 575 adrenal cortical tumours, 105 androgenic tumours of ovary, 105 causes, 103 classification, 103, 104 constitutional, 103–104 definition, 103 disease in midbrain, hypothalamus and pituitary, 104 ectopic gonadotrophin production, 105 oestrogenic tumours of ovary, 105 Pregnancy and amenorrhoea, 543 ovarian and parovarian tumours during differential diagnosis of, 527 treatment of, 527 types of, 526 states, 561 Premarital chastity, 648 Premature ejaculation, 646 Premature orgasm, 643 Premenopause, 812 Premenstrual mastalgia, 591 Preoperative management bowel preparation of, 844–845 counselling, 843 preparation of abdomen, 845 prophylactic antibiotics, 844 routine investigation, 843 surgery and menstruation, 844–845 universal precautions, 845 vagina preparation of, 845 Prepubertal bleeding, 575 Premenstrual syndrome (PMS), 631 aetiology of, 587, 588 clinical features of, 587 differential diagnosis of, 588 treatment of, 588 evening primrose oil, 589 fluid elimination, 589 hormone therapy, 589–590 pyridoxine, 589 serotonin reuptake inhibitors, 589 surgery, 590 Presacral neurectomy, 49 for primary dysmenorrhoea, 582 Primary carcinoma BRCA1 and BRCA2 mutation, 525 Lynch II syndrome, 525 origin of, 524 pathology of, 524, 525 screening of, 525 Primary dysmenorrhoea behavioural and psychological factors, 579 clinical features of, 580 definition of, 579 frequency, 579 hormone imbalance and, 580 muscular incoordination and, 580 prevention of, 581, 582 prostaglandins and, 580 treatment of, 580, 581f calcium-channel blockers, 582 hormone therapy, 582 prostaglandin synthetase inhibitors, 581–582 surgical, 582–583 uterine hyperactivity and, 580 Primary malignant neoplasms, 484–486 Primary oocytes, 56 Primary sarcoma, 509 Primordial follicles, 52, 176 Primordial germ cells, 51 oogonia, 176 spermatogonia, 176 Proctitis, radiation, 841 Production of OVA, 51–60 follicular atresia, 60–61 follicular phase, 53–56 maturation of ovum, 56–58 preantral follicle, 52 primordial follicles, 52 two-cell two-gonadotrophin theory, 53 ovulation, 58 Progesterone, 64–65, 70–71, 160, 856 actions, 64–65 breasts, 64 endocrine system, 64 general, 64–65 genital tract, 64 pregnancy, maternal instinct, 64 secondary sex organs, 64 for endometrial carcinoma, 480 production, 64 withdrawal bleeding, 76 Progestogen intrauterine system (Mirena) adverse effects, 769 delayed follicular atresia, 770 efficacy, 769 indications, 769 insertion and removal, 770 return to, 770 risk of, 770 structure, 769 time of insertion, 769 Prolactin, 66, 107, 164 Prolapse of ovaries, 268 Proliferative phase, 72–73 Prophase, 56 stages diakinesis, 56 diplotene, 56 vip.persianss.ir leptotene, 56 pachytene, 56 zygotene, 56 Prophylactic antibiotics, 844 Prostaglandins, and primary dysmenorrhoea, 580 Prostaglandin synthetase inhibitors, for primary dysmenorrhoea, 581–582 Proteins, 864 background, 864 biological values of, 864 sources of, 864 Pruritus ani causes, 839 treatment, 839 Pruritus associated with leucorrhoea, 619–621 Pruritus vulvae, 618 Pruritus without vaginal discharge, 621–624 allergy and drug sensitivity, 622 animal and fungal parasitic infections, 621 chronic vascular changes, 623–624 conditions of urinary tract, 622 deficiency states, 623 diseases of anus and rectum, 621–622 epithelial disorders of vulva, 623–624 generalised pruritus, 621 psychological factors, 623 skin diseases, 621 Pseudocyesis, 544 Pseudocysts, 321 Psoriasis, of vulva, 307f Psychological factors, 623 Psychological sex, 221 trans-sexuality, 221 transvestism, 221 Psychoses, 544 Psychosomatic gynaecology, 1–2 Psychosomatic medicine, Pubarche, 101 Pubertal bleeding, 575–576 Puberty, 99–110 abnormalities, 102–103 delayed puberty, 103 menstrual disorders, 103 obesity, 102–103 definition and description, 99 hyperprolactinaemia, 107–109 management, 105–107 PCOS onset during, 365, 365f precocious, 103–105 prolactin, 107 Puberty menorrhagia, 109–110 aetiopathology, 109–110 causes, 109 921 Index management, 109 diet, 109 hormones, 109 Public education, 400 Pubocervical fascia, 40 Pudendal block and local vulvar anaesthesia, 47, 47f Puerperal and postabortal infection, 321 Pulmonary embolism aetiology, 860 anticoagulants, 861 clinical features, 860 complications, 861 diagnostic aids, 860 embolectomy, 861 general, 860 thrombolysins, 861 treatment, 860 vena cava interruption, 861 Purine antagonists, 406 Pyelonephritis causes, 851 clinical features, 851–852 mechanism, 851 results, 852 treatment, 852 Pyogenic infections, 303–304 abrasions and wounds, infection of, 303 furunculosis, 303 intertrigo, 303 of pelvic peritoneum, 318 sebaceous and apocrine glands, infection of, 304 Pyometra, 317, 473 Pyosalpinx, 319f, 320f bilateral tuberculous, 331f Pyrexia, 851 Pyrimidine antagonists, 406 R Race and family, endometriosis and, 344 Race and invasive cancer of cervix, link between, 434–435 Radical hysterectomy, for endometrial carcinoma, 479 Radical surgery, for advanced pelvic cancer, 408 Radio-immuno conjugates, 541 Radioisotopes, 857 Radiotherapy biological basis of, 534 brachytherapy, 535 in carcinoma cervix, 443–446, 536 complications, 445–446 external beam radiotherapy, 444 interstitial brachytherapy, 444–445 intracavitary radiotherapy, 444 combined treatment with surgery and, 537 definition of, 534 for dysfunctional uterine bleeding, 574–575 in endometrial cancer, 480 as adjuvant therapy, 535 aggressive histological variants of, 536 confined to uterus body, 535 intrauterine pathological variables of, 536 for ovarian tumours, 522 radiation dosage, 534 for squamous cell carcinoma of vagina, 429 therapeutic ratio, 535 Radiotherapy machines, 535 Rape, 638 Rarities, 616 Reactive squamous cell hyperplasia, 385, 385f Reassurance, 666 Reconstruction operations on tubes, 669 Rectal prolapse, 835, 835f causes, 835 treatment, 836 palliative, 836 surgical, 836 Rectal and anal pain, 839 pathology, 839–840 signs, 840 symptoms, 840 treatment, 840 Rectal and vaginal palpation, combined, Rectum and anus carcinoma of, 838 importance of, 37 relations of, 38 structure of, 37, 38f vascular connections, 38 Recurrent buccal ulceration (aphthous ulcers), 591–593, 591f “Recurrent cystitis,” in women, 310 Recurrent early pregnancy loss, 127–129 aetiology, 127–129 coagulation investigations, 127–128 endocrinologic investigations, 128–129 immunologic investigations, 129 parental cytogenetic investigation, 129 Recurrent miscarriage, 127 Recurrent pregnancy loss, immunotherapy in, 542 Reimplantation of tube, 671 Relations of tissues, 21, 21f Relaxin, 65–66 vip.persianss.ir Renal toxicity, 532 Resectoscope loop, 729f, 730 Residual urine, 848 Rete cysts, 707–708 Retention cysts, 409, 490 in cervix, 316f epidermoid cysts, 410, 411 hymeneal and clitoridal cysts, 411 sebaceous cysts, 410, 411f Retroverted gravid uterus, 274–275 impaction of uterus, 274–275 diagnosis, 274–275 pathology, 274 treatment, 275 management, 275 outcome and effects, 274 sacculation of the uterus, 275 Rhabdomyosarcomas, 483 Ring pessaries, 883–884 RM See Recurrent miscarriage Robotic surgery advantages of, 892–894 features of, 890 innovations used, 894 risks of, 894 system, 891f endometriotic resection, 896–897 criticism and controversies, 898–899 myomectomy, 899f Rod lens system, 717 Round ligament, 39 Routine medical examination, 400 RTI diagnosis, approaches to, 625 Rubin’s insufflation cannula, 685, 686f S Salmonella paratyphi, 315 typhi, 315 Salpingitis isthmica nodosa, 335f severe, 335f Salpingitis isthmica nodosa, 131 Salpingolysis and fimbriolysis, 669–671 Salpingo-oophoritis, 318–323 acute, 321–322 aetiology of, 318 chronic, 322 clinical features of, 321–322 pathology of, 318–321 abscess formation, 319 healing by fibrosis, 319 hydrosalpinx, 319–321 peritoneal cysts and pseudocysts, 321 puerperal and postabortal infection, 321 resolution, 319 tubo-ovarian mass, 321 922 Jeffcoate’s Principles of Gynaecology subacute, 322 treatment of, 322–323 Salpingostomy, 671 Sanitary pad (diaper), 81 Sarcoma, 417 of uterus, 481 of vagina, 430–431 Sarcoidosis, 301–302 Saturated fatty acids, 865 Scissors, 682–683, 683f Sebaceous and apocrine glands, infection of, 304 Secondary dysmenorrhoea aetiology of, 583–584, 584f clinical features of, 584–585 diagnosis of, 585 treatment of, 585 Secondary malignant neoplasms, 484 Secondary sex organs breasts, 62 Fallopian tubes, 62 uterus, 62 vagina, 62 vulva, 62 Second-look laparotomy (SLL), 523 Secretory phase, endometrium, 73–74 layers, 74 Selective oestrogen receptor modulators, 62, 88 Self antigens, 538–539 Semen abnormal, 653t cryopreservation of, 675 preparation of, 676–677 Senile atrophy, 375–376 Senile endometritis and pyometra, 473 Senile vaginitis See Atrophic vaginitis Septate and subseptate uterus (class V), 185 Septic abortion, 126–127 clinical picture, 127 complications, 127 treatment, 127 Septic shock, immunotherapy in, 542 SERM See Selective oestrogen receptor modulators Serosal cell metaplasia, 348 Serum CA-125, 478 Sex as emotional and physical experience, 635 and marriage, problems of, 645 Sex chromosomal intersex, 210–213 genetic influences, 213 Klinefelter’s syndrome (47XXY), 212–213 triple X syndrome (47XXX), 212 Turner’s syndrome, 210–212 characteristics, 210–211 karyotypes associated with streak gonads, 211–212 Noonan syndrome, 212 YY syndrome, 213 Sex cord mesenchymal tumour, with annular tubules, 503–504 Sex cord-stromal tumours, 493, 495, 713 androblastomas, 502–503 granulosa and theca cell tumours, 500–502, 501f, 502f gynandroblastoma, 503 sex cord mesenchymal tumour with annular tubules, 503–504 Sex determination, 203 factors, 203 in foetus and its anomalies, 204 introduction, 203 physiological considerations, 203 Sex determining factor Y, 203 Sex education, adolescence management, 102 Sex hormone-binding globulin (SHBG) and hair growth, 371 in hirsutism, 371 Sex of rearing, 221 Sexual desire, 635–636 absence of, 641–642 Sexual feelings, 635–636 Sexually transmitted infection (STI) classified by syndrome, 626 diagnosis, approaches to, 625 risk assessment for women, 625–626 SHBG See Sex hormone–binding globulin (SHBG) Shock, 849–850 adrenal insufficiency, 849 causes, 849 drug sensitivity, 849 extracardiac, 849–850 mixed aetiology, 850 treatment, 850 Short-wave therapy indications, 886–887 results, 887 techniques, 887 Sialyl–Tn, 539 Sigmoid colon, 37 lymphatics of, 46 Sildenafil, 646 Simple hyperplasia (cystic glandular hyperplasia), 394, 394f clinical features of, 395–396 treatment of, 396 Sims speculum, 684, 684f Site-specific familial ovarian cancer, 509 Skene’s tubules, 25 Skin diseases, 621 Smoking, 131 Social medicine, vip.persianss.ir Sociological gynaecology, SOL See Space-occupying lesion Sonohysterography, 705 Sonosalpingogram, for abnormal uterine bleeding, 569 Sonosalpingography, 11 Space-occupying lesion, 92 Spasmodic dysmenorrhoea, 5, 188 Specialised treatment schedules, 224–225 male hermaphroditism, 224 testicular feminisation syndrome, 224 true hermaphroditism, 225 Turner’s syndrome, 225 Speculum examination, 688 Suction/irrigation sets, 720f Spermatogonia, 56 Spermatozoa, 111 failure to produce, 651–652 in vagina, failure to deposit, 652 Spermicides, 741 Sphincter mechanism, 34–35 Sphincter vaginae, 26 Spirochaeta, 306 Spironolactone, 230, 366 for hirsutism, 373 for PCOS, 366 Spontaneous abortions clinical varieties, 124–127 cervical abortion, 125 complete abortion, 126 incomplete abortion, 125–126 inevitable abortion, 125 missed abortion, 126 septic abortion, 126–127 threatened abortion, 124–125 pathology of ageing sperm or ovum, 122 blighted ovum, 121 chromosomal abnormalities, 121 drugs and environmental causes, 122 endocrine causes, 121 euploid abortion, 122 idiopathic, 122 immunological causes, 122 maternal anoxia and malnutrition, 122 maternal infections, 121 mechanism of abortion, 124 nervous, psychological conditions and over fatigue, 122 overdistension of uterus, 122 trauma, 121 uterine defects, 122 Squamous cell carcinoma of cervix, 437, 437f of uterus, 475 clinical features of, 476–477 clinical staging of, 478 923 Index diagnosis of, 477–478 prognosis of, 478 spread of, 476 treatment of chemotherapy and hormone therapy, 480 radiotherapy, 480 surgery, 478–480 surgery and radiotherapy, 480 of vagina, 428–429, 428f Squamous cell hyperplasia, 385f, 386 Squamous cell metaplasia, 385–386, 385f, 386f of endometrium, 396–397, 397f SRY See Sex determining factor Y Staphylococcus aureus, 168 Stem cell theory, 529 Stratum compactum, 72 Stratum spongiosum, 72 Sterilisation dangers and complications, 786–787 definition, 776 indications, 776 legal position, 776 termination of, 780–785 Streptococcus, 168 Stroma, 72 Stump carcinoma, 450 Suction curettage, evacuation method, 152 steps of, 152 Superficial and deep external pudendal arteries, 44–46 Superficial thrombophlebitis, 168 Suppurative thrombophlebitis, of pelvic veins, 329 Surface epithelial inclusion cysts, 707 Surface epithelial stromal tumours, 712 Surgery for carcinoma of cervix, 446–447 endometrium, 478–480 for primary dysmenorrhoea, 582–583 and radiotherapy for genital cancer, 398 Surrogacy, 676 Suture materials, 687 Swellings of vulva, causes of, 409 Sympathetic nerves, 47 Syncytiotrophoblast, 113, 149 Syndactyly, 149 Syndromic approach to, 617 Syphilis, and herpes simplex genitalis, 305 T Tamoxifen, 94, 473 Tanner’s staging (breast development), 160 Taxanes, 531 TDF See Testes determining factor Telescope, types, 718f Telophase, 56 Teratomas, 504–506, 505f, 506f Testes determining factor, 203 Testicular feminsing syndrome, 214 characterstics, 214 Testosterone, 180 and hair growth, 370 for lichen sclerosus, 378 in PCOS, 361 Theca cells, 54, 61 Theca cell tumours, 500–502, 501f, 502f Theca interna, 55 Thelarche, 101 Threatened abortion, 124–125 clinical picture, 124 prognosis, 124 treatment, 124–125 Thromboembolism, 601 Thrombophlebitis, 855 Thyroid gland, 81 Thyroid-stimulating hormone, 66, 83, 101, 151 Thyrotrophin-releasing hormone, 612 Tinea cruris, 306 Tissue clamps, 683, 684f TNF See Tumour necrosis factor TNF-a, 51 TNF-b, 51 TORCH See Toxoplasmosis, rubella, cytomegalovirus, herpes Total abdominal hysterectomy (TAH), 478 Total hysterectomy with bilateral salpingo-oophorectomy for ovarian tumours, 520 Toxic shock syndrome, 81 Toxoplasmosis, rubella, cytomegalovirus, herpes, 129 Transcutaneous electric nerve stimulation (TENS), 887 indications, 887 results, 887 technique, 887 Transdermal oestradiol gels, 86 Transdermal oestradiol patch, 86 Trans fatty acids, 865 Transrectal sonography, 13 Trans-sexuality, 221 Transvaginal colour Doppler blood flow studies, 13 Transvaginal sonography (TVS), 13, 13f, 87, 691, 693f endometrial carcinoma, 477 female pelvis, 693f ovarian sonography See Ovarian sonography vip.persianss.ir procedure, 692f ultrasound of uterus See ultrasound of uterus Transverse cervical ligaments, 40 Transvestism, 221 and trans-sexuality, 647 Trastuzumab, 541 Trauma, 121 Treatment regimens, 407–408 Triangular ligament, and perineal muscles, 40 Trichloroacetic acid (TCA), 413 Trichomonas endocervicitis, 310 Trichomonas infection, 619 Trichomonas vaginalis, 309, 310f, 311, 312f Trichomonial vaginitis, 309–312, 615 aetiology of, 309–310 clinical features of, 310 diagnosis of, 311 pathology of, 310 treatment of, 311–312 Triple X syndrome (47XXX), 212 Trocar and cannula, 718, 718f Trophoblast, 113 Trophoblastic hyperplasia, 150 Trophoblastic tumours, 147 geographical distribution, 148 Tropical ulcer, 306 True amenorrhoea, 543 True caruncle, 420, 420f TSH See Thyroid-stimulating hormone TSS, 81 Tubal patency tests, 11, 660 Tubal sterilization, 723, 724f Tubercular salpingitis, 331f Tubo-ovarian mass, 321 Tumour sanctuaries, protected, 532 Tumour-associated antigens (TAA), 538–539 Tumour-infiltrating leucocytes (TIL), 541 Tumour markers, 403 Tumour necrosis factor, 63 Tumours of Bartholin’s gland Bartholin’s cyst, 418–419, 418f neoplasms of Bartholin’s gland, 419 types of, 147–148 aetiology, 147–148 Tumours of uterus uterine polyp See Uterine polyp Tunica albuginea, 176 in female, 176 Turner’s syndrome, 210–212 TVS See Transvaginal sonography Twins and higher-order multiple gestation, 679–680 Two-cell two-gonadotrophin theory, 53, 56 924 Jeffcoate’s Principles of Gynaecology Ulcers of chancroid, appearance of, 304f Ultraradical surgery and palliation, for carcinoma of cervix, 448–449 Ultrasonography, 12, 12f, 691 of polycystic ovary syndrome (PCOS), 364, 364f Ultrasound, 92, 403, 887 for abnormal uterine bleeding, 568 and puerperium, 705 Ultrasound-guided cyst aspiration, 518 Ultrasound of uterus See also Ovarian sonography for adenomyosis, 700–701 for arteriovenous malformation, 704 for diseases of cervix, 705–706 for diseases of endometrium, 699 for diseases of myometrium, 696, 699f for diseases of uterine cavity, 699–700 for endometrial carcinoma, 705 for endometrial fluid, 705 for endometrial hyperplasia, 704 for endometrial polyp, 704, 705 for endometritis, 704 for leiomyoma, 703–704 for myometrial calcifications, 703 for myometritis, 701–703 for sarcomatous change within leiomyoma, 704 for synechiea, 705 for uterine shape, 696, 696f for uterine size, 694–695, 695f Umbilical cord, 117 Undifferentiated carcinoma, pathology of, 499 Undifferentiated germ cell tumours, 507, 507f Unicornuat uterus, 338f Unmarried mother, 649 Upward displacement of uterus, 269 causes, 269 treatment, 269 Ureter, 36–37 Urethra, 22f, 32, 63 anatomy of, 33–34, 33f development of, 180–181 involuntary intrinsic muscle in, 34, 34f lymphatics of, 46 relations of, 35 vascular connections, 35–36 wall of, 34 Urethral caruncle, 420 Urethral prolapse, acute and chronic, 419 Urethral resistance, 35 Urethral tumours carcinoma of urethra, 421–422, 421f cysts of Skene’s (paraurethral) tubules, 420, 420f diverticulum of urethra, 419–420, 419f granulomatous caruncle or diffuse caruncle, 420–421, 421f true caruncle, 420, 420f urethral caruncle, 420 urethral prolapse, acute and chronic, 419 Urethritis, 309–312 causes, 851 clinical features, 851–852 mechanism, 851 results, 852 treatment, 852 Urinary and faeculent discharges, 616 Urinary fistula, 405 Urinary injury, 242–247 causes, 243 accidents, 243 congenital malformations, 243 extension of disease processes, 243 obstetrical injury, 243 operative injury, 243 radiotherapy, 243 clinical features and diagnosis, 243–244 menouria, 244 pregnancy after cure of vaginal fistulas, 246 treatment, 244–246 conservative treatment, 244–245 prevention of fistulas, 246 surgery for complicated fistulas, 246 surgery for ureteric fistulas, 245 surgery for urethrovaginal fistulas, 245–246 surgery for uterovesical fistulas, 245 surgery for vesicovaginal fistulas, 245 types, 242–243 Urethral Sphincter incontinence, 795–804 investigation of, 792–795 treatment of, 795 urethral length, 792 Urinary systems, development, 176–181 gonad, 176 ligaments, 180 mesenteries, 180 Müllerian (paramesonephric) ducts, 180 wolffian system, 176–179 Urinary tract conditions of, 622 malformations of, 200–202 absence of one kidney and ureter, 201 accessory and aberrant ureter (and kidney), 200–201 ectopia vesicae, 200 epispadias, 200 vip.persianss.ir fusion of the kidneys, 201 urethral diveticula, 200 Urinary tract infections aetiopathogenesis, 808–809 bacterial factors, 809 definitions, 808 host risk factors, 809 incidence, 808 special conditions, 810 Urine anuria, 851 incontinence of, 851 Urogenital atrophy, 817–818 Urogenital diaphragm, 20, 20f, 39 Urogenital ridge, 176 Urogenital sinus, 181 Uterine amenorrhoea, 550 Uterine and adnexal (pelvic) arterio venous malformation, 13f Uterine manipulators, 720f Uterine and vaginal prolapse, 251–268 activating factors, 259 aetiology, 258 backache, 260 cervix or vagina, carcinoma of, 258 differential diagnosis, 260–261 difficulty in emptying rectum, 260 dragging discomfort in lower abdomen and pelvis, 260 genital prolapse and pregnancy, 258 hypertrophy of cervix, 257 congestion and oedema, 257 elongation of supravaginal cervix, 257 glandular hypertrophy, 257 obstructive lesions of urinary tract, 257 operation types, 262–266 operative treatment, 262 physical signs, 260 predisposing factors, 258–259 pregnancy after repair operations, 267–268 prevention, 261 prolapse incarceration, 258 renal failure, 257–258 results of operations, 266–267 sensation of swelling or fullness in vagina, 259 symptoms, 259 treatment, 261–262 types, 251–254 Baden-Walker halfway system, 253–254 uterine (uterovaginal) prolapse, 251–253 urinary symptoms, 260 difficulty in emptying bladder, 260 frequency, 260 stress incontinence, 260 U 925 Index uterus supports, 251 lower tier, 251 middle tier, 251 upper tier, 251 vaginal prolapse, 254–267 anterior compartment defects, 254–255 complications, 257 middle compartment defects, 255–256 posterior compartment defects, 256–257 Uterine arteries, 42f, 43–44 blood flow through, 41 Uterine bleeding, 76–78 anovular menstruation, 77–78 menstruation, 77 Uterine contractions, 631 Uterine corpus endometrial hyperplasia aetiology of, 395 atypical hyperplasia, 395 clinical features of, 395–396 complex hyperplasia (adenomatous hyperplasia), 394f, 395 pathology of, 394 simple hyperplasia (cystic glandular hyperplasia), 394, 394f treatment of, 396 Uterine hyperactivity and primary dysmenorrhoea, 580 Uterine leiomyoma See Leiomyoma of uterus Uterine masculature, 48 Uterine polyp benign neoplasms adenoma, 452–453, 452f, 453f leiomyoma See Leiomyoma Uterine position and malformations, correction of, 671–672 Uterine (uterovaginal) prolapse, 251–253 Uterine sound, 684, 684f Uterine tumours endometrial carcinoma See Endometrial carcinoma haemangiopericytoma, 483 high-grade stromal sarcoma, 481 leiomyosarcoma, 481–482 low-grade stromal sarcoma, 481 lymphomas, 483 melanoma of uterus, 483 mixed Müllerian tumours, 482–483 rhabdomyosarcomas, 483 sarcoma of uterus, 481 Uterine veins, 45 Uterosacral ligament, 39, 40 Uterovesical pouch, 38 Uterus, 26f, 42f, 62–63, 194–195, 691, 693 absence, 194 cavity of, 26 cervix, 27–28, 28f changes in, with age and parity, 28, 29f cochleate uterus, 195 clinical features, 195 pathology, 195 treatment, 195 congenital hypertrophy of cervix, 195 conical cervix and pinhole os, 195 corpus, 27 deformed, 340f dimensions of, 26 enlargement of, 452 fundus, 27 hypoplasia, 194 causes, 194 clinical features, 194 diagnosis, 194 treatment, 194 types, 194 isthmus, 27 ligaments of, 39f Müllerian ducts, 180 partial hydatidiform mole, 149 perforation of, 240 position of, 28–29 relations of, 29 rupture of, 239–340 structure of, 26f, 27 supports of, 40–41 unicornuat, 338f vascular connections, 29–30 Uterus didelphys (class III), 185 Uterus inversion, 275–276 acute inversion, 275–276 V Vaccines antigen-directed vaccines, 539 in cancer cervix, 542 whole cell lysate, 540 whole cell vaccine, 539 Vagina, 62–63, 180–181, 195–197 absence, 195–197 clinical features, 195–196 pathology, 195 treatment, 196–197 changes in, with age and parity, 24–25, 24f, 25f congenital atresia and stricture, 197 development of, 180–181 duplication, 197 fascia and muscle, 24, 24f hollow elastic fibromuscular canal, 22 hypoplasia, 197 lymphatics of, 46 pH level of, 23 relations of, 25–26 vip.persianss.ir septate and subseptate, 197 stratified squamous epithelium, 23, 23f supports of, 41 swellings of, 423 vascular connections, 26 vault of, 22 veins of, 45 width and length of, 23 Vaginal adenocarcinoma, 430 Vaginal adenosis, 383 Vaginal artery, 26, 44 Vaginal atrophy, 817f Vaginal burns, 234 causes, 234 effects, 234 treatment, 234 Vaginal cells, mature, 314f Vaginal creams, 86 Vaginal cycle, 79 Vaginal cysts cysts of vestigial structures, 423–424, 423f endometriotic cysts, 424 epidermoid cyst, 424 Vaginal cytology, 401, 401f Vaginal dilators, 686, 686f Vaginal discharge bacterial vaginosis, 614–615 cellulitis, 861–862 cervical discharge, 862 cervical polyps, 616 chronic cervicitis, 615–616 granulation tissue, 861 inflammatory discharge, 614 inflammatory vaginitis, 615 investigation of clinical history, 616–617 examination, 617 pathological discharges, 614 physiological discharges, 613–614 pruritus associated with, 619 rarities, 616 retained foreign body, 862 symptomatology of, 621 syndromic approach to, 617 treatment of, 617 syndromic, 626–629 trichomonial vaginitis, 615 urinary and faeculent discharges, 616 vaginitis, 862 vulvovaginal candidiasis (moniliasis), 615 Vaginal discharge algorithm risk assessment in, 626 Vaginal discharge syndromes, 626 Vaginal examination, 7–8, 688–689 treatment of, 480 Vaginal faecal fistula, 405 Vaginal hypoplasia, 197 926 Jeffcoate’s Principles of Gynaecology Vaginal intraepithelial neoplasia (VAIN), 382–383, 426–428, 428f Vaginal metastases, 476 Vaginal myalgia, 841 Vaginal neuralgia, 841 Vaginal orgasm, 636 Vaginal packing indications, 886 method, 886 Vaginal prolapse, 631 Vaginal “secretion,” composition of, 23 Vaginal ultrasonography, 578 Vaginal wall carcinoma of, 885 muscle of, 24 Vaginal wall cysts, anterior, 424f, 425f, 426f, 427f Vaginal yeast infection, 619 Vaginitis, 308–315 Candida, 312–314 aetiology of, 312 clinical features of, 312–313 diagnosis of, 313 pathology of, 312–313 transfer of infection, 313 treatment of, 313–314 “granular,” 310 in infancy, 308–309 aetiology and pathology of, 308 clinical features of, 309 diagnosis of, 309 treatment of, 309 noninfective, 315 senile or atrophic, 309 Trichomonas, 309–312 aetiology of, 309–310 clinical features of, 310 diagnosis of, 311 pathology of, 310 treatment of, 311–312 Vaginitis emphysematosa, 315 Vaporisation conisation, 888 Varicose veins, 409, 410f Varicosities, 515 Vascular connections, 22 Vascular endothelial growth factor, 72 Vasoactive agents, 646 Vasopressin, 66 VEGF See Vascular endothelial growth factor Veins, 22 Venography, 857 Veress needle, 718, 718f Vestibular bulb, 20 Vestibule, 19 Vestibulitis, 629 Vestigial structures, cysts of, 423–424, 423f Virilisation and masculinisation, 369 Virilism, 226–228 causes, 227–228 constitutional, 227–228 oestrogen deficiency, 228 psychological, 228 diagnosis, 229 excessive androgen stimulus, 228–229 administration of androgens, 228 adrenal, 228 diseases of base of skull, 229 diseases of hypothalamus, 229 diseases of midbrain, 229 diseases of pituitary, 229 drugs, 229 ovary, 228–229 hair, 227 hormonal, 230–231 antiandrogens, 230 corticosteroids, 230 cosmetic, 231 GnRH agonists, 230 medroxyprogesterone acetate, 230 oestrogen, 230 libido, 227 manifestations, 226 personality and outlook, 227 secondary sex characters, 226–227 sex organs, 226 treatment, 229–230 medical, 230 surgical, 229–230 Vitamins, 379 Vitamin A deficiency, 874 Vomiting causes, 852 drugs, 852 inherent tendency, 852 radiotherapy, 852 Vulsellum, 685, 685f Vulva, 62–63, 197–199 absence, 197 atresia of labia minora, 199 Bartholin’s glands, 20, 21, 21f blood vessels and nerves of, 44f change with age and parity artery, 22 lymphatics, 22 relations of tissues, 21, 21f vascular connections, 22 veins, 22 clitoris, 19 condyloma acuminata of, 306f development of, 181 duplication, 197 endometriosis of, 342f gross underdevelopment, 197 vip.persianss.ir histological appearance of, 376f hymen, 20, 20f hymen abnormalities, 199 hypertrophic tuberculosis of, 330 hypertrophy of clitoris, 199 hypoplasia, 198 bifid clitoris (diphallus), 198 labia majora, 18 labia minora, 19 lymphatics of, 46 metastatic tumours of, 418 mons veneris, 18 perineum, 18, 19 psoriasis of, 307f skin of, 375 tuberculosis of, 306 urogenital diaphragm, 20, 20f vestibular bulb, 20 vestibule, 19 Vulvar abnormalities, 379 Vulvar and vaginal candidiasis, 377 Vulvar cancer aetiology of, 413 clinical features of, 415 diagnosis of, 415 pathology of, 413, 414f spread, 414 staging of, 414, 415t treatment of, 415–417 radical excision of vulva, 416, 416f radiotherapy, 417 types of, 413, 414t Vulvar epithelial disorders, oestrogens for, 599 Vulvar intraepithelial neoplasia (VIN) clinical features, 381 diagnosis, 381–382 incidence and aetiology, 379 pathology Paget’s disease, 380–381, 381f squamous intraepithelial neoplasia, 379, 380f recurrences of, 382 treatment, 382 Vulvar warts See Condylomata acuminata Vulvectomy, for non-neoplastic epithelial disorder, 379 Vulvitis, 303–307 acute simple ulcers, 304–305 diagnosis and management of, 305 herpes genitalis, 304–305 candidiasis, 306 diabetic, 306 elephantiasis, 307 genital ulcers, recurrent, 305 infantile and senile, 304 Website: www.gynecologyblog.blogspot.com 927 Index pediculosis pubis, 306–307 pyogenic infections, 303–304 abrasions and wounds, infection of, 303 furunculosis, 303 intertrigo, 303 sebaceous and apocrine glands, infection of, 304 tinea cruris, 306 Vulvodynia, 624–629 Vulvovaginal candidiasis (moniliasis), 615 W Walthard inclusions, 491 Weight loss and hirsuitism, 366 in PCOS, 366 Whirling spray, 886 WHI See Women’s Health Initiative Whole cell lysate, 540 Whole cell vaccine, 539 Wolffian system, 176–179 Women’s Health Initiative, 85 Wound disruption causes, 854 diagnosis, 854 treatment, 855 Wuchereria bancrofti, 307 Y Yolk sac, 51, 117 Yolk sac tumours, 507 YY syndrome, 213 Z Zona pellucida, 55 Zygotene, 56 PDF Book By: Tonmoy_007 (TPL) Website: www.gynecologyblog.blogspot.com THE END vip.persianss.ir ... outcome of endometrial vip.persianss.ir 4 72 Jeffcoate’s Principles of Gynaecology metaplasia but most often they represent pieces of foetal tissue left in the uterus after instrumental termination of. .. pregnancy uncut Fig 30 .25 : Fibroids intracavitory vip.persianss.ir 458 Jeffcoate’s Principles of Gynaecology Fig 30 .26 : Fibroids bicornute looks as fibroid Fig 30 .29 : Cut section of multiple intramural... Tumours of the Corpus Uteri Fig 30 .22 A: Fibroids Fig 30 .23 B: Fibroids with pregnancy cut specimen Fig 30 .22 B: Fibroids—fibroids cut and confirmed Fig 30 .24 : Fibroids intracavitory Fig 30 .23 A: Fibroids