Dr.G.

Bhanu Prakash

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Most important characteristic symptom of menopausal syndrome is vasomotor disturbances (Hot flushes). Osianders sign is seen in fibroid uterus, Pelvic inflammatory disease and first trimester. Weinbergs sign is seen in abdominal prignancy. Carunculae myrintiformes are remnants are remnants of hymen(after parturition) 1971 Schally & Gullemin discovered a decapeptide, now called gonadotropin-releasing factor(gnRH) Allen & Doisy disovered oestrogen. Allen & Corner ...discovered progesterone. Karl Ernst first identified mammalian ovum. Mueller, Johannes described paramesonephric duct (Muellerian duct) Ogino & Knaus opined that ovulation sually occurs 14 days before the onset of the next menstrual period irrespective of the length of the menstrual cycle. Rock & Hertig have shown that the interval between ovulation and nidation varies between five & eight days and have seen segmentation may occur in vitro & vitro fertilization.. Implantation occurs at blastocyst stage. Epithet helium of bladder trigone develops from mesoderm. The clitoris, when compared to the penis, lacks the corpus spongiousm. The vulval tissues respond to hormones (especially oestrogens) during the child-bearing years. Vulval lymphatics do not cross the libicrural fold. Doderleins bacillus convert glycogen of vaginal epithelial cells into lactic acid which has a protective function against bacterial invasion. Follicular development starts in 20 primordial follicles per menstrual cycle. FSH & LH are produced in basophilic cells where as prolactin is produced in acidepholic cells. Progesterone usually does not act independent of oestrogen. Progesterone is absent or is in negligible amounts(extra ovarian sources) in anvulatory cycles. Granulose cells lack 17 o-hydroxylase necessary for oestrogen production: and ovary lacks 21-hydroxylase & 11-hydroxylase enzymes necessary for

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Dr.G.Bhanu Prakash

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glucocorticoids & mineral corticoid production. Puberty is brought about by the maturation of hypothalamus. At puberty the body of uterus enlarges under the direct influence of ovarian hormones. Urinary gonadotrophins in young females usually appear 1 to2 years before menarche. FSH act only on granulose cells whereas LH acts both on theca and granulose cells. Earliest histopathological evidence of ovulation(36-48 hrs after ovulation) is the appearance of sub-nuclear vacuoles in the endometrium. Menstruasl bleeding is mainly arterial in character. The menstrual blood does not clot for many hours. Oestrogen is growth hormone for all tissues of the Mullerian system. Hydrolysis of pregnanediol occurs in the interstine. Progesterone has an anaesthetic effect. The failure of milk production during the first 3 or 4 days of puerperium may be due to the inhibition of the alveoli in the breast by oestrogen.(when oestrogen levels fall after delivery, this inhibition is withdrawn & milk begins to be produced). The increase in breast size during pregnancy is due to hormonal stimuylation by oestrogen, progester-one and HPL. In pure form oxytocin has slight vaspressor and antidiuretic effects while in pure synthetic form vasopressin has a slight oxytocic action. When liver function is impaired. oestrogen in circulation results in excessive menstrual bleeding. Prolactin is chemically and antigenically related to GH & HPL.Q The main androgen secreted by the ovarys stromal cells is Androstenedione. HCG is most similar in its chemistry & biological action to LH. Turners syndrome substitution therapy with oestrogen. True hermaphroditismsurgical removal of contradictory organs & Reconstruction of external genitalia. Hirsutism without a specific cause Androgen antagonist. A longitudinal hymenal incision for haematocolpos should be avoided (otherwise urethra or rectum be opened accidentally). Fusion of the labia majora occurs in pseudohermaphroditism. Vaginal cysts representing vaginal adenosis due to diethylstilbestrol are precursors of adenocarcinoma. Endometriosis or adenomyosis is associated with congenital atresia of the cervix. Atresia of the oviducts may be a factor in infertility or may favour ectopic pregnancy. Removal of testes from a very young mammalian fetus will allow development of female genitalia & cause regression of Wolffian ducts. Urological anomalies are often associated with Mullerian duct dysplasia. The K lebs classification depends upon the gondal structure.

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Dr.G.Bhanu Prakash

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Hysterosalpingography is the most useful method of diagnosing the different varieties of uterine malformations. Double vagina may accompany split pelvis & absence of one kidney. Sex hormone binding globulin (SHBG) is a key factor in determining androgen activity. Well formed uterus is never associated with absence of the fallopian tubes. Vaginal abnormalities are often associated with urgenital or urorectal defects (Duplication of rectum & sigmoid colon with congenital rectovaginal fistula). the menstrual cycle is usually normal in uterus didelphys and uterus bicornis. Uterus didelphys has the best kprognosis for pregnancy to viability whereas septate & biocornuate uteri have the poorest progfnosis for pregnancy to term. The barr body first appears in trophoblast cells at about 12th day & in the tissues of the fetus itself by 18th day.(Barr body is also detectable in the nuclei of the cells of the amnion). The development of an ovary depends not so much on an XX chromosome complement but on the absence of Y. Women who display the testicular feminization syndrome are immune to virilism (no matter how large a dose of testosterone id administered to them). The number of sex chromation bodies in one less than number of X chromosomes. Disorders due to consanguinity are most likely inherite according to Autosomal recessive Mendelian principle. IVP is the most important X-ray study in patients with genital anomalies. The most effective therapy for khiusutism in a young woman with irregular menstrual cycles is by birth control pills. Peritoneal fluid in women wirth endometriosis contains higher concentrations of more active macrophages, and higher concentrations of PG s than normal. Typical peritoneal endometriotic lesion is described as a powder burn, but recently non-pigmented lesions have been described. Prolapsed is benign except when third degree uterine prolapsed may be associated with ureteric obstruction. Surgery is the most usual form of treatment for prolapsed and should be deferred until childbearing and vaginal delivery have been completed. Anterior repair is a reliable cure for a cystourethrocele but is unreliable for correction of stress incontinence. Tele theraphy is used to treat large volumes. Chemotherapy can be curative in trophoblastic disease and ovarian germ cell temors. Carboplatin, related to cisplatin but unlike it, does not have neuro or nephrotoxicity but cause thrombocytopenia. Four pitfalls in colposcopy arefalse squamocolummar junction (SCJ) caused by abrasion; SCJ in the canal; previously treated cervix; glandular.

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Most cases of vaginal intraepithetial neoplasia are seen after hysterectomy. Surgical excision and intracavity radiotherapy are most effective. Menstrual blood is rich in PGE1 PG F2-O, In carcinoma cercvix with pregnancy, wertheims operation is done with abd. Hysterotomy. In ovarian tumor(symptomatic) with pregnancy, ovariotomy is to be done in first half of pregnancy and following labour ovariotomy may be done immediately. Commonest cause of secondary amenorrhea(missing 3-cycles after normal cycle ) is psychogenic leaving aside pregnancy and premature menopause. Commonest congenital cause of primary amenorrhora is congenital adrenal hyperplasia. Cottle operation(presacral neurectomy) is done in dysmenorrheal. Metrostaxis is irregular intermenstrual bleeding before puberty and after menopause. Use of oral contraceptive preparations is relatively contraindicated in patients with amenorrhoea or oligomenorrhoea. Clomiphene is not indicated unless the complaint is infertility as well as amenorrhoea. Overtreatment of infrequent menstruation or oligomenorrhoea should be avoided, particularly in young girls in whom a spontaneous cure can be expected. Tuberculosis & malingnancy must be excluded in a case of dysfunctional uterine bleeeing. Curettage should precede hysterectomy in case of DUB. Congenital adrenal hyperplasia is best treated with cortisone. The best time to perform a curettage in a case of abnormal uterine bleeding is secretory phase. Pituitary adwrfs are deficient in growth factor but gonadotropic functions are normal. In loctational amenrrhoea, ovulation can occur in the absence of menstruation. Spasmodic variety of dysmenorrhoea is cured by kpregnancy. Anovular cycles are painless in spasmodic dysmenorrhoea. Progesterone diminishes uterine bleeding chiefly be chemical curettage. Progestogens are more successful in the treatment of primary dysmenorrhoea. Herpes genitalis of vulva is treated with Local 5% acyclovir ointment. Uncomplicated chronically infected Bartholins cyst is treated with simple marsupialization. Bowens disease of vulva is treated wwith Simple vulvectomy Pagets disease of vulva is treated with through local vulvectomy(wide local excision is the treatment of choice). The most likely cause of simple acute ulcer of the vulva is Vincents organisms.

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Dr.G.Bhanu Prakash

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Rete hyperplasia is important in the tissue diagnosis of Lymphogranloma All the pigmented lesions of the vulva should have excisional biopsies. Enlargement in the post menopausal patient should arouse a suspricion of cancer in Bartholins duct cyst. Pruriits vulvae or a mass in the presenting complaint in vulval carcinoma. The urethral caruncle is best treated by fulgration. Urethral carcinoma is usually treated by Radiation. Breast tissue may be detected in the labia because they are located in the milk line Microinvasive lesions of vulva should always be regarded as invasive cancer. Basal cell carcinomas of vulva arise almost exclusively in the skin of labia majora Congenital angimota of the vulva usually regress Improper use of vaginal tampons complication is Toxic shock syndrome. G. vaginalis vagnitis results in purerperal morbidity, infection & septicemia after abdominal hysterectomy, with gaseous crepitation in the abdominal incision. The blebs of emphysematous vaginitis contains CO2. The maximal glycogen content of vaginal epithelium is found in the vaginal fornices & is lowest in the lower thirdh. Small cell carcinoma of vagina has poor prognosis. Vaginal bleeding or blood discharge is the usual presenting complaint of vaginal sarcoma. Sarcoma botryoides is thought to arise primarily from vagina. Trichomoniasis tends to be worse just after menstruation or during pregnancy. Menharbour the Trichomonas vaginalis in the urethra & postate. Vagnitis emphysematosa is otherwise known as colpitis cystica . The adenocarcinoma of vagina are associated with diethylstilbestrol exdposure. At the pelvic brim, the ureter passes anteriorly to the sacroiliac joints and crosses the bifurcation of common iliac artery. Thus risk of injury during oopherectomy. Mullerian agenesis is the commonest cause for an absent vagina in girls. Gondal dysgenesis can occur in an XX individual. Wolffian system is dependent upon androgens for its development. Although the second X-chromosome is usually inactivated. Both Xchromosomes are required for fertility. The mucous membrance of endocervix has anterior and posterior columns from which folds radiate out the arbor vitae. The primary concern in the management of congenital anomalies in childhood is function of the bladder and3bowel. If correction of cervical atresia is unsuccessful, hysterectomy should be emjployed to avoid the potentially lethal peritonitis that may result.

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Dr.G.Bhanu Prakash

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Unilateral renal aplasia isfrequently associated wsith failure of mullerian development in the same side since both are dependent on adequate of mesonephric system. Doderleins bacillus in important in maintaining the acid pH in vagina and thus preventing vaginal infections. There are no true anatomical sphinters to the urethra. The round and ovarian ligaments together form the homologue to the gubernacutum testis in the male. The power density (PD) is the most important determinant of effects of the lase upon (GTreater Widespread pertitoneal metastasis occurs in state III ovarian cancer. Vaginal ultrasound has a sensitivity and specificity in the diagnosis of ectopic pregnancy and also plays ans important role in timing ovulation and oocyst recovery. Involuntary loss of urine is the most common symptom of cystocele. Procidentia can cause acute angulation of the urethra and result in retention. MRI accurately shows parametrial invasion of cervical cancer but does not identity LN metastases reliably. The hymen is a derivative of mullerian tubercle. CT scanning may have a role in recurrent cervical cancer but is of limited value in other gynaecological tumourts. Dysmenorrhoea occurs in both endometriosis and adenomyosis. Adenocarcinoma is the most common malignant tumour arising frm uterine body. Total abdominal hysterectomy with bilateral salpingo-oophorecttomy is the treatment of choice in patients with stage I endometrial cancer. Lymphangiography lacks precision in identifying nodal metastases. Nabothian cysts are the features of chronic cervicitis. IVp and chest X-ray are essential investigations in a patient with CA cervix. The pudenda constitutes the female genitalia excluding the gas trointestinal tract (Anus). Almost all vitamins are found in Breast milk except cyancobalamin (Vit. B12) The karyotype of a complete hydatidiform mole is 46 XX. Tuboscopy is used to study physiology and anatomy of the tuber and for selection of patients for IVT. Endometrial destruction is indicated in menorrhagia with a normal sized uterus. Steroids exert their action through intracellular receptors whereas trophic hormones act through receptors located on cell membrance then through a second messenger system within the cell. Androgen, progesterone and glucocorticooid receptors are less precise than oestrogen receptors in their binding affinity. Synthetic progestogens can bnind to both androgen and progesterone receptors reflecting the dual biological activities of progestogens.

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Dr.G.Bhanu Prakash

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Due to amplification of hormone signals by the second messenger system, only 1% of the cell receptors need to be evident. LHRH controls the secretion of both FSH and LH with oavian sex steroids playing the role in modulating it. Oestrogens decreases Pulse amptitude of gonadtrophin secretion (more so of FSH and LH) whereas progesterone reduces Pulse frequency of LH as showing during luteal phase. The role of lprostaglandian E (secreted on stimulation of NE nerve terminals) in LHRH release may be and intracellular one. There is no place of vulvectomy in the management of lichen sclerosis. Schroeders disease is metropathica haemorrhagica (painless anvulotory irregular heavy bleeding often preceded by history of amenorrhoea for 2-3 periodes). It constitutes 1/4 to 1/3 cases of DUB and there is cystic glandular hyperplasia (Swiss cheese opearance) Granulose cell tunor of ovary is important because of menorrhagia, DUB, post menopausal bleeding and precocious puberty. Due to endometrial hyperplasia. Carcinoma and endomertiosis may arise. Virilizing tumors are arrhenoblastoma. Dysgerminoma, adrenal rest tumor, hilus cell tumor and Brenners tumor, Luteoma of pregnancy whereas feminizing tumor is Granulos cell tumor, thecoma, luteoma and embryonic cell tumor. For vaginal atresia, the tumor operations used ar --- McIndoes, Williams, Baldwins, Shrodkars. Absence of fructose in semen indicates blocked ejaculatory ducts. Bonneys or Marchetts test is used instress incontinence. First menstrual period is shortest menstrual cycle minus 18 or longest menstrual cycle minus 11. Ureterovaginal fistula (UVF) is commonest after Gynae operations (total hysterectomy) whereas VVF is commonest after obstructed labour. Downregulation by internalization of hormone receptors is a unique mechanism for limiting polypeptide hormone activity. Hormone replacement therapy is not contraindicated in postmenopausal women with fibroids. Oestrogen increases target tissue responsiveness to itself by increasing FSH receptors. The final step in the release of stored LH and FSH and subsequent induction of further biosynthesis of both following LHRH stimulation involves Ca++, Protein C, and cAMP. The response of pituitary gland to LHRH depnds upon ovarian sex steroid environment prevailing and the degree of LHRH stimulation. Receptors for both oestrogen and progesterone are present in grater concentrations in fibroids than in the adjacent myometrium but the role of progesterone if any, is unclear. Aetiology is unknown but fibroid growth is thought to be oestrogen dependent.

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Dr.G.Bhanu Prakash

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Factors contributing to menorrhagia in fibroid uterus includes a mechanical obstruction to veous drainage; increased total prostaglandin synthesis and metabolism. Medical therapy with GnRH antagonists alone is unsutitable for long term management because of hypooestrogenic side effects and regrowth of fibroids following therapy discontinuation. Asymptomatic benign ovarian cysts in young women often resolve spontaneously. Ultrasound can not reliably exclude ovarian malignancy. Ovarian failure constitutes the largest single cause of delayed puberty. The effect of danazol on reducing menstrual blood flow, length of period and length of cycle is dose dependent. The developing placenta (syncytiotrophoblast) begins producing AHCG as soon as implantation occurs. Ovarian cysts are very rarely malignant in womn below 35 years and if size below 10 cm diameter. ABO incompatibility is usually manifested by hyperbilirubinaemia in the neonatal period. There is evidence of rate of PGs in menorrhagea associated with adenmyosis, uterine fibroid and presence of an IUCD. Maternal cholesterol is the primary precursor of progesterone on the pregnant lady. Supine hypotension is characteristic of third trimester of Pregnancy. Antifibrinolytic drugs and PG synthetase inhibitors are useful in menorrhocgia, in those with DUB and IUCD. The smallest distance in the midplane is the distance between the ischial spines. The distance between ischial tuberosities measures the pelvic outlet. Almost all cases of hydatidiform mole have vaginal bleeding. Eclampsia is frequently associated with renal shutdown and necrosis of the renal cortex. When the posterior parietal bone presents it is known as posterior asynclitism. Similarly if anterior parietal presents it is called anterior asynclitism. HPL stimulates lactation. Solid ovarian tumours are often malignant --- in young women these are usually germ cel or sex cord stromal tumors. Major oestrogen postmenopausally is oestrone produced by conversion of adrenal androgens in a dipose tissue. Fall in oestrogen levels lead to increase in LDL and increased chance of ischaemic heart disease. Oseoporosos that occurs postmenopausally results from loss of collagfen matrix as the bone is normally calcified. Virilization is very rarely seen without hirsutism (apart from in the neonate) and is due to excess of androgen production.

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Sarcoma butyroides(embryonic sarcoma) is common in infants and children. In nullipare, carcinoma is common in breast , uterus, tubes, vulva and also benign ovarian cyst of ovary.

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