GYNECOLOGIC

DISORDERS
Mary Lourdes Nacel G. Celeste, RN, MD
Anatomy Recall

DR CELESTE
mlngc 2
DR CELESTE
mlngc 3
DR CELESTE
mlngc 4
Common Gynecological Complaints
• Vaginal discharge
• Vaginal/ Vulvar pruritus
• Genital ulceration
• Inguinal lymphadenopathy
• Pelvic mass
• Dyspareunia
• Pelvic pain
• Vaginal bleeding
• Amenorrhea

DR CELESTE
mlngc 5
 Diagnostic Tests
• Bloodwork • Genital tract biopsy
- CBC - vulvar
- HCG - vaginal
- LH, FSH, TSH, PRL - endometrial

• Imaging • Vaginal/ endocervical

- Ultasound culture
- Hysterosalpingography • VDRL
- Sonohystography • Papanicolau Smear
• Colposcopy
• Laparoscopy

DR CELESTE
mlngc 6
 GYNECOLOGICAL INFECTIONS

ABNORMAL UTERINE BLEEDING

DYSFUNCTIONAL UTERINE BLEEDING

AMENORRHEA

ANATOMICAL DISORDERS

BENIGN LESIONS of the genital tract

MALIGNANT LESIONS of the genital tract

FEMALE SEXUAL DYSFUNCTIONS

BREAST DISORDERS
DR CELESTE
INFERTILITY mlngc 7
DR CELESTE
mlngc 8
 Gynecological Infections
Lower genital tract Sexually Transmitted
• Vulvitis Diseases/ Infections
• Vaginitis (STD/ STI)
• cervicitis • Bacterial
• Viral
Upper genital tract • Others
• Endometritis
• Pelvic inflammatory
disease (PID)

DR CELESTE
mlngc 9
 VAGINITIS

• inflammation of the vagina characterized by an

increased vaginal discharge containing numerous
WBCs

Causes:
• Douches
• Antibiotics
• Hormones
• Contraceptives (oral and topical)
• Change in sexual partners

• In contrast, vaginosis - not associated with WBC

DR CELESTE
mlngc 10
Signs and Symptoms:
• Itching
• Burning
• Pain
• Erythema
• Edema

DR CELESTE
mlngc 11
 VULVOVAGINITIS
• inflammation of the vulva and vagina
• may be caused by vaginal infection or copious
amounts of leukorrhea (increased amount of vaginal
and cervical discharge consisting of epithelial cells
and cervical mucus that can cause maceration of
tissue)

DR CELESTE
mlngc 12
 BACTERIAL VAGINOSIS
• nonspecific vaginitis, hemophilus vaginitis, gardnerella)
• most common cause of abnormal vaginal discharge
• most common vaginal infection in childbearing women
• not considered a sexually transmitted disease
• normally dominant organism lactobacillus is replaced
with a high concentration of facultative aerobic and
anaerobic bacteria

DR CELESTE
mlngc 13
Signs and Symptoms:
• Fishy odor
• Increased thin vaginal discharge
(no inflammatory response)

Diagnosis (based on Amsel criteria)

• White/gray thin adherent discharge
• Ph > 4.5
• Positive whiff test (fishy odor will be released when
KOH is added to vaginal secretion on a slide or on the
lip of the withdrawn speculum
• clue cells on wet mount (vaginal epithelial cells coated
with bacteria that obscure cell borders)

DR CELESTE
mlngc 14
Treatment:
• Oral agents: Metronidazole 500 mg or Clindamycin
300 mg BID for 7 days
• Vaginal agents: Metronidazole gel (.075%) or
Clindamycin cream (2%) BID for 7 days
• Sexual partner does not need treatment

DR CELESTE
mlngc 15
Nursing interventions
• Teach the importance of completing the course of
medication and of not consuming alcohol while
taking Metronidazole and 48 hours after
completing the treatment
• Remind client to avoid intercourse
• Instruct good hygiene

DR CELESTE
mlngc 16
 CANDIDA VAGINITIS
• vulvovaginitis candidiasis/ yeast vaginitis/ yeast or
fungus/ Moniliasis

• second most common cause of abnormal vaginal

discharge
• common cause:
Candida albicans

DR CELESTE
mlngc 17
Predisposing factors
• Repeated courses of systemic or topical antibiotics
• Diabetes especially when uncontrolled
• Pregnancy
• Obesity
• Use of corticosteroids and exogenous hormones
• Local allergic or hypersensitivity reaction

DR CELESTE
mlngc 18
Signs and Symptoms
• Thick, curd-like/ cheeselike, white discharge that
has no odor
• Vaginal erythema, edema and tenderness
• Ithchiness of the vulva
• Dryness
• Painful urination especially when urine flows in the
vulva
• Dyspareunia

DR CELESTE
mlngc 19
Diagnosis
• Vaginal pH is normal (if > 4.5 suspect trichomoniasis or
bacterial vaginosis)
• KOH wet smear- pseudohyphae

Treament
• Oral agent: Fluconazole 150 mg (single dose)
• Vaginal agents: antifungal preparation (fungicidal azole
creams: Clotrimazole, Miconazole) for 3 to 7 days
– Nystatin –vaginal suppository twice a day for 7 to 14
days or
– Clotrimazole vaginal suppository at bedtime for 7
days or
– Miconazole nitrate vaginal cream applied nightly for 7
days

DR CELESTE
mlngc 20
Nursing interventions
Client teaching:
• not wearing underwear to bed
• wearing cotton-crotched underwear
• completing full course of treatment even during
menstruation
• avoiding feminine sprays, deodorants, scented pads
(allergies and irritation)
• Vitamin C, live culture yogurt - increase vaginal acidity
• Local application of anti fungal agents (eg, Nystatin)
• Inform the patient that the disease can be transmitted to the
newborn leading to the development of ORAL THRUSH

DR CELESTE
mlngc 21
Home Remedies:
– Vaginal douche of two teaspoons ordinary
baking powder dissolved in one quart of warm
water
– Application of gentian violet to the vagina &
perineum. Use sanitary pad to prevent staining
of undergarments.

DR CELESTE
mlngc 22
 BARTHOLIN’S CYST
• occlusion of a duct with mucus retention resulting in a
nontender mass approx. 1-4cm in size

Causes
• if the duct becomes
blocked for any reason:
infection,
injury or chronic
inflammation
• Very rarely, caused by
cancer
• Unknown (many cases)
DR CELESTE
mlngc 23
Causative organisms: Staphylococcus aureus
(others: S. fecalis, E. coli, N. gonorrhea, C. thromatis)

Symptoms:
• Bartholyn’s Cyst (asymptomatic)
• Bartholin’s Abscess - pain or tenderness, dyspareunia

Diagnosis
• clinical

Management
• incision and drainage
• marsupialization – entire abscess is incised and sewn open
• Word catheter for 2 – 4 weeks
• broad spectrum antibiotic

DR CELESTE
mlngc 24
Nursing interventions
• Teach the importance of completing the course of
antibiotic
• Teach the importance of good hygiene
• Sitz bath – for both pain relief and to decrease
healing time

DR CELESTE
mlngc 25
 SEXUALLY TRANSMITTED DISEASES
• Trichomoniasis
• Chlamydia
• Gonorrhea
• Syphilis
• Herpes simplex
• Condylomata acuminatum
• Human Immunodefiency Virus (HIV)

DR CELESTE
mlngc 26
 TRICHOMONIASIS
• protozoan infection: Trichomona vaginalis

Signs and Symptoms

• Frothy yellow-green malodorous vaginal discharge
• “strawberry” cervix
• Vaginal irritation & inflammation
• Dyspareunia
• Dysuria
• Vulvar itching

Among males: usually asymptomatic

DR CELESTE
mlngc 27
Diagnosis
• microscopic exam of vaginal discharge
-positive motile flagellated protozoa in a saline wet
mount
• elevated vaginal pH 5.5+ (alkaline)

Management
• Sexual partner should receive oral treatment.
• Metronidazole (Flagyl) 500 mg BID for 7 days or a single
2 g dose (contraindicated during pregnancy)

DR CELESTE
mlngc 28
Home Remedy
• Acidic vaginal douche : 1 tablespoon vinegar with 1 liter
water to counteract the alkaline environment of the vagina
that favors the growth of Trichomonas vaginalis

Nursing interventions
• Include sexual partner in treatment.
• Advise use of condom during intercourse
• Nursing alerts:
- Concurrent alcohol ingestion with Metronidazole causes
severe GI symptoms (Antabuse-like reaction)
- Metronidazole is associated with preterm labor,
premature rupture of membranes and postcesarean
infection

DR CELESTE
mlngc 29
 CHLAMYDIA

• most common cause of mucopurulent cervicitis

• most common bacterial STD in women
• caused by gram (-) bacterium Chlamydia trachomatis
• Vertical transmission to newborns may result in
conjunctivitis and otitis media
• Tends to coincide with gonorrhea infection

IP: 2-10 days

Risk Factors
• Sexual activity < 20 years
• Multiple sexual partners
• Lower socioeconomic status
• (+) others STDs DR CELESTE
mlngc 30
Signs and symptoms
• May be asymptomatic
• Gray white/ yellowish vaginal discharge
• Burning and itchiness
• Bleeding between periods
• Mucopurulent cervicitis
• Painful and frequent urination

Diagnosis
• (+) culture/ antigen detection test on cervical smear
• Polymerase chain reaction (PCR)

DR CELESTE
mlngc 31
DR CELESTE
mlngc 32
Management
• Doxycycline 100 mg PO BID for 7 days
(causes fetal long bone deformity if used in
pregnancy)
• Azithromycin (Zithromax) 1 g PO in a single dose
• Erythromycin 500 mg QID for pregnant patient
• Patient may also be treated for gonorrhea with a
single IM shot of Ceftriaxone 250 mg
• Infant treated with Erythromycin ophthalmic ointment

Nursing interventions
Client teaching:
• Teach the importance of completing the course of
antibiotic
• Use condom during sex
• Sexual partner shouldDRreceive
CELESTE treatment
mlngc 33
Complications
• Pelvic inflammatory disease (PID)
• Ectopic pregnancy
• Fetus transmittal (vaginal birth); may cause
conjunctivitis
(also associated with premature rupture of
membranes, preterm labor and endometriosis, low
birth weight and perinatal mortality due to placental
transmission)

DR CELESTE
mlngc 34
 GONORRHEA
• Morning drop, Clap, Jack
• Sexually transmitted disease caused by gram (-)
Neisseria gonorrhea, which causes inflammation of
the mucus membrane of the genito urinary tract

IP: 3-7 days

Signs and Symptoms

• Females: may be asymptomatic; may have purulent
vaginal discharge, pelvic pain and fever;
dyspareunia
Males: Painful urination; purulent yellow penile
discharge; urethritis
(decreased sperm count)
• Newborn: yellow discharge, both eyes
DR CELESTE
mlngc 35
Diagnosis
• gram stain and culture of
cervical secretions on
Thayer Martin medium

Complications
• PID
• ectopic pregnancy
• infertility
• Chorioamnionitis
• ophthalmia neonatorum
in newborns (associated
with severe eye infection and
blindness)
• preterm delivery
• sterility & pelvic
inflammatory disease
DR CELESTE
mlngc 36
Management (single dose only)
• Ceftriaxone (Rocephin) 125 mg IM (drug of
choice for pregnant women)
• Ofloxacin (Floxin) 400 mg orally
• Treat concurrently with Doxycycline or
Azithromycin for 50% infected w/ Chlamydia
• Ophthalmic ointment is routinely given as Crede’s
prophylaxis to prevent opthalmia neonatorum
(0.5% Erythromycin or 1% Tetracycline ointment
for newborn babies)

DR CELESTE
mlngc 37
DR CELESTE
mlngc 38
Nursing interventions
Health Teachings:
• Avoid sexual intercourse until cured of the infection or
use condom to prevent transmitting the infection.
• Examination and treatment of sexual partner to
prevent reinfection is necessary.
• Return to clinic for check-up in 4 to 7 days after
completion of treatment.
• Monitor treatment

DR CELESTE
mlngc 39
 SYPHILIS
• caused by motile anaerobic spirochete Treponema pallidum
• “ beautiful” fast moving but delicate spiral thread
• can cross the placental barrier

IP: 7-14 days

• can cause 100% fetal infection if primary and secondary
infection is untreated, and 6-14% fetal infection in latent
syphilis
• 2nd trimester infections cause spontaneous abortion, preterm
labor, stillbirth and congenital anomalies
• 3rd trimester infection causes enlarged liver,spleen, skin rash
and jaundice in a newborn

DR CELESTE
mlngc 40
Signs and Symptoms

• Primary Stage - painless chancre on genitalia, anus or

mouth; most infectious stage

• Secondary Stage - about 2 months after primary

syphilis resolves; generalized maculopapular skin rash
including palms and soles
- painlesscondylomata lata on vulva
- hepato/ splenomegaly
- headache; anorexia; fever

• Latent syphilis – asymptomatic

• Tertiary Stage –most destructive stage;

neurosyphilis/permanent damage (insanity); gumma
(necrotic granulomatous lesions), aortic aneurysm

DR CELESTE
mlngc 41
Primary – painless chancre Secondary – generalized
rash

Tertiary - gumma

DR CELESTE
mlngc 42
Diagnosis
• VDRL (venereal disease research laboratory test)
or RPR (rapid plasmin reagin) – nonspecific tests
- for screening and to follow treatment course
(decrease fourfold in 3-6 months)
• Fluorescent Treponemal Antibody AbsorptionTest
(FTA-ABS) or Microhemagglutination Assay for
Antibodies to TP (MHA-TP)– specific tests for
syphilis
• Dark-field microscopic examination of lesion- 1st
and 2nd stage

DR CELESTE
mlngc 43
Management
• Primary and secondary and early latent disease -
Pen G (Benzathine Penicillin G 2.4 M U IM)
- Alternatives: Tetracycline 500 mg orally QID or
Doxycycline 100 mg orally BID
• Tertiary - IV Pen G
• Erythromycin & Cefriaxone are the drugs of choice
for pregnant women

Complications
• Congenital syphilis in newborn if untreated in late
pregnancy
• Late abortion
• Stillbirth

DR CELESTE
mlngc 44
Health Teachings :
• Educate women to recognize signs of syphilis.
• Educate women to seek immediate treatment if known
exposure occurs.
• Encourage women to wear cotton underwear.
• Use condom during intercourse.

DR CELESTE
mlngc 45
 Sexual partners must also be treated to prevent
re-infection.
• No sexual intercourse until lesions disappear
• After completion of treatment, the woman is
treated monthly & the sexual partner at 3 months,
6 mos & 12 mos.

• Fetus will not be affected if the mother is treated

before the 5th month. Emphasize the importance of
screening for syphilis during the first prenatal visit
for early detection & treatment.

• Inform patients treated with penicillin about Jarish

Herxheimer reaction, a reaction to penicillin
characterized by: fever, chills, malaise, headache,
nausea, & tachycardia. This is a normal reaction
that subsides within 24 DR
hours.
CELESTE
mlngc 46
DR CELESTE
mlngc 47
DR CELESTE
mlngc 48
 HERPES GENITALIS
• Sexually transmitted disease caused by the Herpes
Simplex Virus 2 (HSV 2)

Signs and Symptoms

• Flulike symptoms (malaise, myalgia, nausea, fever)
• Vulvar burning and pruritus
• Painful vesicles (cervix, vagina, perineum, glans penis) 2
- 20 days after exposure
• Painful genital ulcer
• Recurrent episodes 1-6x a year (during stress, fever,
menstruation)
• Dyspareunia

Diagnosis
• Viral culture
• Pap smear (shows cellular changes)
• Tzanck smear (scraping of ulcer for staining) –
multinucleated giant cells
DR CELESTE
mlngc 49
 Management
• Antiviral agents –
Acyclovir 200 mg PO q 4
hrs for 5 days
• Sitz bath
• Analgesics

DR CELESTE
mlngc 50
Complications: Health teachings
• Meningitis • NO sexual activity in the
• Neonatal infection presence of lesions and 10-
(vaginal birth) 14 days after lesions
subsided
• Trigeminal herpes zoster
• Keep vulva clean and dry in
(facial muscle paralysis) the presence of lesions
(wearing of cotton
underwear)
• Sitz bath
• use foley catheter if retention
persists
• Povidone- iodine douche
and acyclovir NOT used
during pregnancy
DR CELESTE
mlngc 51
 CONDYLOMA ACUMINATUM
• Genital warts
• Genital or venereal warts caused by Human
Papilloma Virus (HPV)
• May be a precursor to cervical cancer

• HPV types 6 & 11 – condyloma acuminatum

• HPV types 16, 18 and 31 – cervical cancer

Signs and Symptoms: Single or multiple dry soft, fleshy

painless (wartlike) growths on the vulva, vagina,
cervix, urethra, or anal area; penis
• Can evolve into larger cauliflower-like growths
• Vaginal bleeding, discharge, odor and dyspareunia

DR CELESTE
mlngc 52
 Diagnosis
• Clinical
• Pap smear-shows cellular
changes (koilocytosis)
Acetic acid swabbing (will
whiten lesion)

Management
• Small lesions – treated
topically with podophyllin or
trichloroacetic acid
• Larger lesions – ablated with
cryotherapy, laser
Complications vaporization or surgical
•Neoplasia excision.
•Neonatal laryngeal • Recurrence rate : 20%
papillomatosis
(vaginal birth)

DR CELESTE
mlngc 53
Health Teachings
• Inform the patient that infection with the virus
increases the incidence of CERVICAL CANCER
• Therefore: Annual PAP smear is indicated

DR CELESTE
mlngc 54
 HIV and AIDS
• Retrovirus (HIV1 & HIV2)

• Attacks and kills CD4+

lymphocytes (T-helper)

• Capable of replicating in
the lymphocytes
undetected by the immune
system

• Immunity declines and

opportunistic microbes set
in
• No known cure
DR CELESTE
mlngc 55
MOT:
• Sexual intercourse ( vaginal and anal)
• Exposure to contaminated blood, semen,
breast milk and other body fluids
• Blood Transfusion
• IV drug use
• Transplacental
• Needlestick injuries

DR CELESTE
mlngc 56
HIGH RISK GROUP
• Homosexual or bisexual
• Intravenous drug users
• BT recipients before 1985
• Sexual contact with HIV+
• Babies of mothers who
are HIV+
• THE INFECTED MOTHER
CAN PASS THE VIRUS
TO THE FETUS DURING
PREGNANCY &
CHILDBIRTH OR VIA THE
BREAST MILK

DR CELESTE
mlngc 57
s/sx:
1. Acute viral illness (1 mo after initial
exposure) –Sx: fever, malaise,
lymphadenopathy
2. Clinical latency – 8 yrs w/ no sx;
towards end, bacterial and skin
infections and constitutonal sx – AIDS
related complex; CD4 counts 400-200
3. AIDS – 2 yrs; CD4 T lymphocyte < 200
w/ (+) ELISA or Western Blot and
opportunistic infections
DR CELESTE
mlngc 58
Effects on the Infant:

• Microencephaly
• CNS lymphomas
• CVA’s
• Respiratory failure
• Lymphadenopathy
• Developmental anomalies

DR CELESTE
mlngc 59
 HIV CLASSIFICATION
• CATEGORY 1 – CD4+ 500 OR MORE

• CATEGORY 2 – CD4+ 200-499

• CATEGORY 3 – CD4+ LESS THAN 200

DR CELESTE
mlngc 60
 HIV TEST
• Elisa – Enzyme Link Immunosorbent
Assay ( first test conducted)
• Western Blot - confirmatory

• Rapid hiv test

– Suds hiv-1
– Results are obtained in less than 10
minutes
– Color indicator similar to pregnancy test
– Positive result needs a confirmatory test
DR CELESTE
mlngc 61
 How to Diagnose
• HIV+
2 consecutive positive ELISA and
1 positive Western Blot Test
• AIDS+
HIV+
CD4+ count below 500/ml
Exhibits one or more of the ff: (next slide)
• Full blown AIDS
CD4 is less than 200/ml

DR CELESTE
mlngc 62
 Exhibits one or more of the ff:
• Extreme fatigue
• Intermittent fever
• Night sweats
• Chills
• Lymphadenopathy
• Enlarged spleen
• Anorexia
• Weight loss
• Severe diarrhea
• Apathy and depression
• PTB
• Kaposis sarcoma
• Pneumocystis carinii
• AIDS dementia DR CELESTE
mlngc 63
DR CELESTE
mlngc 64
 Treatment
• Anti-retroviral Therapy (ART) – ziduvirine
(AZT) ( Azidothymidine)
a. Prolong life
b. Reduce risk of opportunistic infection
c. Prolong incubation period

DR CELESTE
mlngc 65
DR CELESTE
mlngc 66
 Health teachings
For infected persons:
• 1. Avoid infections
• 2. Use latex condom to protect partner
during sexual intercourse
• 3. Do not donate blood, sperm, organs or
other body tissues
• 4. Do not share items with other persons
that may be contaminated with blood &
other body fluids
• 5. Do not breastfeed infant
DR CELESTE
mlngc 67
For non-infected persons:
• 1. Stick to one partner, practice
monogamous relationship
• 2. Use condoms
• 3. Avoid anal & oral sex
• 4. Practice good personal hygiene
• 5. Practice healthful living: exercise,
adequate rest, nutritional diet, safe sex
DR CELESTE
mlngc 68
• 6. Be aware of the signs & symptoms of
infections:
– Weight loss of greater than 10% of body
weight
– Chronic diarrhea, more than one month
– Prolonged fever, lasting more than one month
– AIDS cannot be transmitted by sharing foods,
eating utensils, toilet, swimming pools, water

DR CELESTE
mlngc 69
Precautionary measures for health workers:
• Handle all sharp instruments with care, use
disposable needles & do not reuse as much as
possible
• Protect yourself, increase resistance to infection
by proper diet, exercise, rest & sleep
• Avoid body fluids – label blood & other specimens
of a person known or suspected with AIDS
properly, clean blood spills with disinfectant
• Practice strict aseptic technique –
handwashing,wear gloves, clean, disinfect &
sterilize
• Wear, protective clothing when necessary –
gloves, masks, goggles
DR CELESTE
mlngc 70
 PREVENTION
A – ABSTINENCE
B – BE FAITHFUL
C – CONDOMS
D – DON’T USE DRUGS

DR CELESTE
mlngc 74
OTHERS
• Pelvic inflammatory disease (PID)
• Toxic shock syndrome (TSS)

DR CELESTE
mlngc 75
 Pelvic Inflammatory Disease
• Caused by microorganisms colonizing
endocervix ascending to endometrium and
fallopian tubes
• Due to sexually transmitted
microorganisms ie Neisseria, Chlamydia,
Haemophilus influenza, peptostreptococci

DR CELESTE
mlngc 76
 Risk Factors
• Multiple sexual partners
• History of PID
• Early onset sexual activity
• Recent gyne procedure
• IUD

DR CELESTE
mlngc 77
 Manifestations
• pelvic pain – sharp and cramping
• Fever
• Excessive vaginal discharge
• Menorrhagia
• Metrorrhagia
• Urinary symptoms
• Cervical uterine tenderness with movement

DR CELESTE
mlngc 78
 Diagnostics
• History and PE
• CBC
• Vaginal and endocervical culture
• VDRL
• Endometrial biopsy - endometritis
• Sonography – tubo-ovarian abscess
• Laparoscopy - salpingitis

DR CELESTE
mlngc 79
 Management
• Antibiotics
• IV fluids/increase oral fluid
• Pain medications
• Remove IUD
• Evaluation of sexual partners

DR CELESTE
mlngc 80
 Toxic Shock syndrome
• Reproductive age, near menses or postpartum period
• D/t S. Aureus
• R/t use of tampons, cervical cap or diaphragm

Manifestations: fever, rash on trunk, desquammation of

skin, hypotension, dizziness, vomiting, diarrhea, myalgia,
inflamed mucous membranes

DR CELESTE
mlngc 81
Diagnostics:
Elev BUN, Crea
Elev AST, ALT, total bilirubin
Dec platelets

Management:
IV fluids
Antibiotics
renal dialysis
Client education – change tampons 3-6 hours, avoid
tampons 6-8 wks after childbirth, do not leave
diaphragms>48 hours

DR CELESTE
mlngc 82
DR CELESTE
mlngc 83
• AUB- diagnosis referring to any uterine
bleeding that is irregular in amount,
duration, or timing
• DUB- most common type of AUB and is
frequently defined as irregular uterine
bleeding unrelated to organic pathology,
medication, pregnancy related disorders,
systemic condition,

DR CELESTE
mlngc 84
• causes of AUB:
1. pregnancy-ectopic, spontaneos abortion
2.endocrine problem- cushing
syndrome,diabetes
3.medication-
amphetamines,anticoagulants,steroids,IN
H,SSRIs
4. systemic dse.- thyroid
dysfunction,leukemia,ITP
DR CELESTE
mlngc 85
• Types:
– 1.anovulatory DUB- due to lack of progesterone in
the luteal phase of anovulatory cycles leads to
unstable ,excessively vascular endometrium,often
lead to abnormal cycle interval, or abnormal amount
of bleeding
– 2. ovulatory DUB- are regular and tend to be
cyclic,although the bleeding pattern are often
abnormal,menorrhagia is commonly observed and is
commonly associated with pelvic pathology

DR CELESTE
mlngc 86
• Causes of anovulation:
– Physiologic:
• Pregnancy
• Lactation
• Perimenarche
• Perimenopause
– Pathologic causes:
• Hyperandrogenic disorder
• Hyperprolactinemia
• Extreme stress

DR CELESTE
mlngc 87
• s/sx: uterine bleeding
• Physical Examination:
– 1. pelvic examination
– 2.Speculum examination
– 3. bimanual examination

DR CELESTE
mlngc 88
• Management:Goal:1. normalize the
bleeding
2. correct any anemia
3. restore quality of life
4.prevent cancer
1. medication – oral contraceptives
2. surgery- D and C, Hysterectomy

DR CELESTE
mlngc 89
Endometriosis

Endometrial tissue outside the uterine cavity

Pelvis most common location
Bleeding results to inflammation, scarring of
peritoneum and adhesions
Cause unknown
Common in 20-45 yrs old

DR CELESTE
mlngc 90
Common Sites 0f Endometriosis Formation

DR CELESTE
mlngc 91
Risk Factors:

Physiologic disruption after gyne surgery or

cesarean birth
Hereditary
Possible immunologic effect

DR CELESTE
mlngc 92
Manifestations:
1. Pelvic pain – dull/cramping, r/t menstruation
2. Dyspareunia
3. Abnormal uterine bleeding
4. Fixed tender retroverted uterus
5. Palpable nodules in the cul de sac

Diagnostics:
laparoscopy

DR CELESTE
mlngc 93
Management:
OCP-combination contraceptives to induce
amenorrhea
Analgesics
NSAIDS
Danazol – antiprogesterone; suppresses GnRH, low
estrogen and high androgens to suppress ovulation,
promote amenorrhea and decrease endometrial
support
GnRH agonists ie leuprolide suppress the menstrual
cycle through estrogen antagonism
Progestins ie Medroxyprogesterone – antiendometrial
effect
DR CELESTE
mlngc 94
DR CELESTE
mlngc 95
DR CELESTE
mlngc 96
DR CELESTE
mlngc 97
 amenorrhea
• Absence of menstruation
• Can be primary and secondary
amenorrhea

DR CELESTE
mlngc 98
• Primary amenorrhea • Secondary
– Pregnancy amenorrhea
– Upper genital tract – Pregnancy
causes(mullerian – ashermans syndrome
agenesis, testicular – Cervical stenosis
feminization
– Hormonal
– Lower genital tract contraception
causes( imperforate
hymen) – Hypothyroidism
– Hypergonatropic- – PCOS
hypogonadism( gonad – Pituitary tumor
al dysgenesis) – menopause

DR CELESTE
mlngc 99
• Management:
– Progestational challenge- administered
progesterone 300mg OD for 5 days or
provera 10 mg OD for 5 days
– Prolactin and TSH level to rule out pituitary
and thyroid pathology

DR CELESTE
mlngc 100
DR CELESTE
mlngc 101
 Cystocele
• Downward displacement of bladder, w/c
appears as a bulge in the anterior vaginal
wall
• R/t genetics, childbearing, obesity, age
• S/s: incontinence, vaginal fullness
• Mx: Kegel’s exercises, estrogen, surgery

DR CELESTE
mlngc 102
 Rectocele
• Posterior vaginal wall is weakened
• Anterior wall of rectum sags forward into
the vagina
• S/sx:constipation
• Mx: surgery

DR CELESTE
mlngc 103
 Uterine Prolapse
• Cervix may prolapse into vagina
• S/sx: dragging sensation in groin,
backache in sacrum
• Mx: estrogen, surgery

DR CELESTE
mlngc 104
DR CELESTE
mlngc 105
 Nabothian cyst
• Common findings
• Cause is unknown
• Diagnosis is made clinically
• Treatment: no treatment

DR CELESTE
mlngc 106
 Cervical polyps
• Are a result of benign hyperplasia of the
glandular tissue arising from the mucosa

• Causes: unknown
• Treatment: removal of polyps

DR CELESTE
mlngc 107
 Uterine fibroids
• Myomas or leiomyomatas, are benign
growth that arise from the smooth muscle
of the uterus
• Types: subserosal( external surface of the
uterus
intramural (within the myometrium)
submucosal (with in the
endometrial layer)

DR CELESTE
mlngc 108
 Benign Ovarian masses
• Ovarian cysts – physiologic variations in
menstrual cycle
• Dermoid cysts - (cystic teratomas) –
cartilage, bone, teeth, skin or hair can be
observed
• Endometriomas (chocolate cysts)

DR CELESTE
mlngc 109
 Manifestations
• Sensation of fullness, cramping, dyspareunia,
irregular bleeding

Diagnostics:
USG

Management:
OCP to suppress ovarian function
surgery

DR CELESTE
mlngc 110
 Leiomyoma
• Fibroid tumors
• 40 yrs old
• Potential for cancer is minimal
• Smooth muscle cells present in whorls and
arise from uterine muscle

DR CELESTE
mlngc 111
 Manifestations
• Frequently asymptomatic
• Lower abdominal pain
• Fullness or pressure
• Menorrhagia
• Metrorhaggia
• dysmenorrhea

DR CELESTE
mlngc 112
Diagnostics: USG

Management:
Routine pelvic exam every 3-6 months
surgery

DR CELESTE
mlngc 113
DR CELESTE
mlngc 114
Vaginal Cancer
• Upper 1/3 most common site
• S/S: painless vaginal bleeding and discharge,
urinary retention, bladder spasm, hematuria,
frequency of urination, tenesmus, constipation,
blood in the stool
• Dx: pap smear, biopsy
• Mx: radiation, surgery

DR CELESTE
mlngc 115
 Cervical Ca
• Preventable

Risk Factors:
coitus at an early age
Multiple sexual partners
Sex partner w/ a hx of numerous sexual partners
Exposure to STD
HPV infections
Chemotherapy
Contraceptive use>5 yrs
Smoking
Antenatal exposure to DES
History of dysplasia
DR CELESTE
mlngc 116
Diagnostics:
Pap smear
Colposcopy
Endocervical curettage

Management:
surgery

DR CELESTE
mlngc 117
 Endometrial Ca
• Postmenopausal

Risk Factors:
Obesity
Multiparity
DM
HPN
Use of unopposed estrogen
High fat diet
Early menarche and late menopause
Use of tamoxifen

DR CELESTE
mlngc 118
Manifestations:
• Bleeding in postmenopausal women not treated
with HRT

Diagnosis:
Pap smear
Endometrial biopsy
USG

Management:
TAHBSO
counseling

DR CELESTE
mlngc 119
 Ovarian Ca
Risk Factors:
Increased age (mean age 59 yrs old)
Fertility drugs
Early menarche or late menopause
Asbestos and talc exposure

S/sx: abdominal swelling or inc abdominal girth,

bloating, pelvic pressure, mild constipation

Management: surgery

DR CELESTE
mlngc 120
DR CELESTE
mlngc 121
 Fibrocystic breast disease
• Most common benign condition of the breast
• 20-50 yo
• D/t imbalance between hormones
• Rare in postmenopausal women not taking HRT
• Not risk for Ca except if px has (+) family hx and w/
atypical cellular changes on biopsy
S/sx: bilateral cyclic pain, tenderness, nipple discharge

Dx: mammography, sonography, FNA

Mgmt: restrict Na, mild diuretic, Danazol (hormone inhibitor),

Bromocriptine and Tamoxifen to decrease symptoms

DR CELESTE
mlngc 122
 Fibroadenoma
• 2nd most common
• Teens, early 30’s
• Not associated w/ breast Ca

S/sx: freely movable, solid, well defined, sharply delineated,

rounded w/ a rubbery texture

Dx: USG, FNA

Mgmt: surgery of enlarged

DR CELESTE
mlngc 123
 Intraductal Papilloma
• Tumors growing in terminal portionof duct
• Potentially malignant

S/sx: unilateral mass/solitary nodule, bloody discharge

Dx: ductogram followed by mammogram

biopsy

Mgmt: excision w/ follow up care

DR CELESTE
mlngc 124
 Breast Ca
Risk Factors:
Age, female, family hx, HRT > 5 yrs, overweight
after menopause, alcohol, bo hx of pregnancy or
1st pregnancy after age 30, never breastfeeding,
early menarche, late menopause, radiation, upper
socioeconomic areas, geographic location

DR CELESTE
mlngc 125
Manifestations: painless mass or lumpnipple inversion, change in
breast size or shape, erosio, ulceration, axillary lump

Dx: mammography, FNA, USG, MRI

Mgmt: surgery
Simple/Total Mastectomy
Modified Radical Mastectomy – breast + LN
Lumpectomy
chemotherapy, radiation
Tamoxifen (anti-estrogen)
Emotional responses

DR CELESTE
mlngc 126
DR CELESTE
mlngc 127
 Infertility

• Inability to conceive a child or sustain a pregnancy to

childbirth
• Pregnancy has not occurred after at least 1 year of
engaging in unprotected sexual intercourse
• Affects 14% of couples desiring children

DR CELESTE
mlngc 128
.
Types of infertility:
• Primary infertility - refers to a couple who has never
established a pregnancy
• Secondary infertility - refers to couple who has
conceived previously but are currently unable to
establish a subsequent pregnancy

DR CELESTE
mlngc 129
 Male Infertility Factors

• Inadequate sperm count

• Obstruction or impaired sperm motility
• Ejaculation problems

DR CELESTE
mlngc 130
• Male factor:
• Obstruction in seminiferous tubules , duct, or
vessels preventing movement of spermatozoa
• Qualitative or quantitative changes in the seminal
fluid preventing sperm mobility
(movement of sperm).
• Problem in ejaculation or deposition preventing
spermatozoa from being placed close enough to
the woman’s cervix to allow ready penetration and
fertilization.

DR CELESTE
mlngc 131
– Causes of inadequate sperm:
• Chronic infection
• Congenital anomalies
• Varicocele
• Increase in body temperature
• Trauma to the testes
• Endocrine imbalances
• Drug or excessive alcohol use
• Environmental factor

DR CELESTE
mlngc 132
–Obstruction or impaired sperm motility:
– Mumps or orchitis
– Anomalies of the penis
– Extreme obesity

DR CELESTE
mlngc 133
 Female Infertility Factors

• Cervical problems
• Vaginal problems
• Unexplained infertility

DR CELESTE
mlngc 134
• Ovarian factor:
• Anovulation- most common cause of infertility in
women
1. genetic abnormality
2.hormonal imbalance
3. ovarian tumor
4. stress
5.decreased body weight

DR CELESTE
mlngc 135
• Tubal factor:
– Pelvic inflammatory disease
• Uterine factor:
– Tumor ( fibroma)
– Congenitally deformed uterine cavity
– Endometriosis
– Inadequate endometrium formation

DR CELESTE
mlngc 136
• Cervical factor:
– Characteristic of cervical mucus
– Infection/inflammation of cervix

• Coital factor :
– pH of the vagina: alkaline pH is optimum (8)
– Presence of sperm-immobilizing/sperm
agglutinating antibodies

DR CELESTE
mlngc 137
 Fertility Assessment

• Fertility testing
 Semen analysis
 Ovulation monitoring
 Tubal patency assessment

DR CELESTE
mlngc 138
 Semen Analysis

• Number of sperm
• Appearance of sperm
• Motility of sperm
• Sperm penetration

DR CELESTE
mlngc 139
 semen analysis

– count: 20 million / ml or
50 million /ejaculation
– volume: 2.5ml - 6 ml
– Motility: >75%
– Quality of motion: graded 1-4 (poor to excellent)
– Morphology: more than 70% normal

DR CELESTE
mlngc 140
 Ovulation Monitoring

• Record basal body temperature

• Ovulation by test strip
 Assesses upsurge of LH that occurs before ovulation

DR CELESTE
mlngc 141
 Tubal Patency

• Sonohysterography
 Ultrasound to inspect uterus
• Hysterosalpingography
 Radiologic exam of fallopian tubes

DR CELESTE
mlngc 142
 Advanced Surgical Procedures

• Uterine endometrial biopsy

• Hysteroscopy
• Laparoscopy

.
DR CELESTE
mlngc 143
 Infertility evaluation:
• Male factor:
• Semen analysis
• Post-coital test-mucus is examined microscopically
between 2- 12hrs after coitus
– Satisfactory test- many motile spermatozoa
seen per high power field
– Unsatisfactory result:
» No spermatozoa are seen
» Majority of spermatozoa are immotile
» Very few spermatozoa are present

.
DR CELESTE
mlngc 144
 • Motility is characterized as shaking movement
rather than forward movement
• Hostile cervical mucus is present
– Sperm antibodies: maybe measured in
– Seminal plasma
– Male serum
– Female reproductive tract fluids
– Female serum

DR CELESTE
mlngc 145
 – Test of fertilizing capacity of spermatozoa:
• Measurement of sperm acrosin-enzyme in sperm head
that responsible for preliminary changes in the sperm
• zona-free hamster ovum penetration test
• Human ovum fertilization test
• Coital factor:
• Taking history of coital frequency, pattern and technique
• Anatomic evaluation of the position of the cervix with
relationship to the vagina
• Post coital testing

.
DR CELESTE
mlngc 146
• Cervical factor:
– Cervix is the first major barrier encountered by sperm after
arrival in the female reproductive tract
1.Abnormalities in the cervix or the cervical mucus
– Abnormal position of the cervix( prolapse or uterine
retroversion
– Chronic infection
– Previous cervical surgery
– Presence of sperm antibody in the cervical mucus

DR CELESTE
mlngc 147
2.mucus quality:
- pH
-bacteriologic culture for microorganism

• Uterine factor:
* role of uterus in reproduction:
- retention of the zygote after arrival from the fallopian tube
- provision of suitable environment for implantation
- protection of embryo /fetus from the external
environment

DR CELESTE
mlngc 148
– Hysterography- visualize contour of the
uterine cavity
– Hysteroscopy –visualize uterine cavity
to detect anomalous development,
polyps or tumors

DR CELESTE
mlngc 149
• Tubal factor:
- functions:
1.mechanical function- act to :
-conveys recently ovulated ova into fallopian tube
-permits spermatozoa to enter the oviduct
-effects transfer of the blastocyst into the
uterine cavity

DR CELESTE
mlngc 150
• Ovarian factor:
-function: serve as repository for oocytes, they release
mature oocytes at regular interval throughout
reproductive life
- secrete steroid hormones that influence the structure
and function of tissue in reproductive tract, promoting
fertility

DR CELESTE
mlngc 151
*documentation of ovulation:
a. basal body temperature records
demonstrate a 14 day elevation of basal
temp.( progesterone-thermogenic effect)
b. Blood progesterone level
c. endometrial biopsy- secretory
endometrial pattern

DR CELESTE
mlngc 152
• Treatment :
– Correction of male factor:
a. Medical - correction of underlying deficiencies
- artificial donor insemination
b. surgical - reversal of sterilization
- varicocele surgery

DR CELESTE
mlngc 153
c. assisted reproductive technologies
1. in vitro fertilization and embryo transfer IVF)
2. gamete intrafallopian tube transfer(GIFT)
3. assisted fertilization

DR CELESTE
mlngc 154
– Correction of ovarian factor:
1. induction of ovulation:
- correction of underlying endocrine
disorder
- clomiphene citrate to correct
hypothalamic function
- human menopausal gonadotropin
- bromocryptine for anovulation due to
prolactin excess
- glucocorticoids for androgen excess

DR CELESTE
mlngc 155
 Assisted Reproductive Techniques

• Artificial insemination
• In vitro fertilization
• Gamete intrafallopian transfer
• Zygote intrafallopian transfer
• Surrogate embryo transfer

DR CELESTE
mlngc 156
• Artificial insemination – instillation of sperm into the
female reproductive tract to aid conception
- technique of micromanipulation that thins the
zona pellucida and inject sperm into the ovum in an
effort to enhance fertilization

• In vitro fertilization (IVF)– removing 1 or more

mature oocytes from a woman’s ovary by
laparoscopy and then fertilizing them by exposing
them to sperm under laboratory conditions outside
the woman’s body (placed on a dish together with
the sperm)

• Embryo Transfer (ET)– ova transfer; insertion of

laboratory grown fertilized ovum into the woman’s
uterus approx. 40 hours after fertilization where 1
or more of them will implant and grow

.
DR CELESTE
mlngc 157
ARTIFICIAL INSEMINATION

DR CELESTE
mlngc 158
IN VITRO FERTILIZATION

DR CELESTE
mlngc 159
.
• Gamete intrafallopian transfer (GIFT) –ova and sperm
are instilled in the patent fallopian tube within a matter
of hours without waiting for the fertilization to occur in
the laboratory

• Zygote intrafallopian transfer (ZIFT) – retrieval of

oocytes, culture and insemination of oocytes in the
laboratory; fertilized eggs are transferred in the patent
fallopian tube within 24 hours

DR CELESTE
mlngc 160
• Surrogate embryo transfer –oocyte from a donor is
fertilized by the recipient woman’s male partner’s sperm
and placed in the recipient’s uterus by ET or GIFT

• Intravaginal culture
• Blastomere analysis

DR CELESTE
mlngc 161
DR CELESTE
mlngc 162