Clinical anatomy and physiology of the female sexual organs. Methods of gynecological patients’ investigation. Abnormal positions of the female sexual organs
By Korda I.
The internal reproductive organs
Figure 2.5 shows a sagittal section of the human female pelvis.
The labia minora are two thin folds of skin that lie between the labia majora. Anteriorly they divide into two to form the prepuce and frenulum of the clitoris. Posteriorly they fuse to form a fold of skin called the fourchette. They contain sebaceous glands but have no adipose tissue. They are not well developed before puberty, and atrophy after the menopause. Their vascularity allows them to become turgid during sexual excitement. The clitoris is a small erectile structure. The body of the clitoris contains two crura, the corpora cavernosa, which are attached to the inferior border of the pubic rami. The clitoris is covered by the ischiocavernosus muscle; b ulbospongiosus muscle inserts into its root. The clitoris is about 1 cm long but has a highly developed nerve supply and is very sensitive during sexual aro usal. The vestibule is the cleft between the labia minora. The urethra, the ducts of the Bartholin's glands and the vagina open in the vestibule. The vestibular bulbs are two oblong masses of erectile tissue that lie on either side of the vaginal entrance. They contain a rich plexus of veins within the bulbospongiosus muscle. Bartholin's glands, each about the size of a small pea, lie at the base of each bulb and open via a 2 cm duct into the vestibule between the hymen and the labia minora. These are mucus-secreting, producing copious amounts during intercourse to act as a lubricant. The hymen is a thin fold of mucous membrane across the entrance to the vagina. There are usually openings in it to allow menses to escape. The hymen is partially ruptured during first coitus and is further disrupted during childbirth. Any tags remaining after rupture are known as carunculae myrtiformes. Age changes In infancy the vulva is devoid of hair and there is considerable adipose tissue in the labia majora and pubis that is lost during childhood but reappears during puberty, at which time hair grows. After menopause the skin atrophies and becomes thinner. The labia minora shrink, subcutaneous fat is lost and the vaginal orifice becomes smaller.
The vagina is a fib romuscular canal lined with st ratified squamous epithelium that leads from the uterus to the vulva. It is longer in the posterior wall (around 9 cm) than anteriorly (approximately 7 cm). The vaginal walls are normally in apposition, except at th vault, where they are separated by the cervix. The vault of the vagina is divided into four fo rnices: posterio r, anterior and two lateral (Fig. 2.6). The midvagina is a transverse slit and the lower portion is an H shape in transverse section. The vaginal walls are rugose, with transverse folds. The vagina is kept moist by secretions from th uter ine and cervical glands and by some transudation from its epithelial lining. It has no glands. The epithelium is thick and rich in glycogen, which increases in the postovulatory phase of the cycle. However, before puberty and after the menopause, the vagina is devoid of glycogen because of oestrogen deficiency. Doderlein's bacillus is a normal commensal of the vagina that breaks down the glycogen to form lactic acid, producing a pH of around 4.5. This has a protective role for the vagina in decreasing the growth of pathogenic organisms. The upper posterior vaginal wall forms the anterior peritoneal reflection of the pouch of Douglas. The middle third is separated from the rectum by pelvic fascia and the lower third abuts the perineal body. Anteriorly, the lip of the vagina is in direct contact with the base of the bladder; the urethra runs down the lower half in the midline to open to the vestibule. Its muscles fuse with the anterior vaginal wall. Laterally, at the fornices, the vagina is related to the attachment at the cardinal ligaments. Below this are the levator ani muscles and the ischiorect.?l fossae. The cardinal ligaments and the uterosacral ligaments, which form posteriorly from the parametrium, support the upper part of the vagina. ,- Age changes At birth, the vagina is under the influence of maternal oestrogens, so the epithelium is well developed. After a couple of weeks, the effects of the oestrogens disappear and the pH rises to 7 and the epithelium atrophies. At puberty the reverse occurs, and finally, at the menopause, the vagina tends to shrink and the epithelium atrophies.
The uterus The uterus is shaped like an inverted pear, tapering inferiorly to the cervix, and in the non-pregnant state is situated entirely within the pelvis. It is hollow and has thick muscular walls. Its maximum external dimensions are approximately 7.5 em long,S em wide and 3 em thick (Fig. 2.7). An adult uterus weighs about 70 g. The upper part is termed the body or corpus. The area of insertion of each Fallopian tube is termed the cornu and the part of the body above the cornu, the fundus. The uterus tapers to a small central constricted area, the isthmus, and below this is the cervix, which projects obliquely into the vagina and can be div'ded into vaginal and supravaginal portions (Fig. 2.8). The cavity of the uterus is the shape of an inverted triangle and, when sectioned coronaliy, the Fallopian tubes open at the lateral angles. The constriction at the isthmus where the corpus joins the ervix is the anatomical internal os. Seen microscopically, the site of the histological internal os is where the mucous membrane of the isthmus becomes that of the cervix. The uterus consists ofthree layers: the outer serous layer (peritoneum), the middle muscular layer (myometrium) and the inner mucous layer (endomet rium). The peritoneum covers the body of the uterus and, posteriorly, the supravaginal portion of the cervix. The serous coat is intimately attached to a subserous fibrous layer except laterally, where it spreads out to form the leaves of the broad ligament. The muscular myometrium forms the main bulk of the uterus and comprises interlacing smooth muscle fibres intermingling with areolar tissue, blood vessels, nerves and lymphatics. Externally these are mostly longitudinal, but the larger intermediate layer has interlacing longitudinal, oblique and transverse fib res. Internally they are mainly longitudinal and circular.
The inner endometrial layer has tubular glands that dip into the myometrium. The endometrial layer is covered by a single layer of columnar epithelium. Ciliated prior to puberty, this epithelium is mostly lost due to the effects of pregnancy and menstruation. The endometrium undergoes cyclical changes during menstruation and varies in thickness between 1 and 5 mm. The cervix The cervix is narrower than the body of the uterus and is approximately 2.5 cm in length. Due to antiflexion or retroflexion, the long axis of the cervix is rarely the same as the long axis of the body of the uterus. Anterior and lateral to the supravaginal portion is cellular connective tissue, the parametrium. The posterior aspect is covered by peritoneum of the pouch of Douglas. The ureter runs about 1 cm laterally to the supravaginal cervix. The vaginal portion projects into the vagina to form the fornices. The upper part of the cervL'C mostly consists of involuntary muscle, whereas the lower part is mainly fibrous connective tissue. The mucous membrane of the endocervix has anterior and posterior columns from which folds radiate out, known as the arbor vitae. It has numerous deep glandular follicles that secrete a clear alkaline mucus, the main component of physiological vaginal discharge. The epithelium of the endocervix is cylindrical and is also ciliated in its upper two-thirds and changes to stratified squamous epithelium around the region of the external os. This squamocolumnar junction is also known as the transformation zone and is an area of rapid cell division; approximately 90 per cent of cervical carcinoma arises in this area. Position of the uterus The longitudinal axis of the uterus is, approximately, at right-angles to the vagina and normally tilts forwards. This is termed anteversion. The uterus is usually also flexed forwards on itself at the isthmus - anteflexion. In around 20 per cent of women, this tilt is not forwards but backwards - retroversion and retroflexion. This does not have a pathological significance. Age changes The disappearance of maternal oestrogens after birth causes the uterus to decrease in length by around one-third and in weight by about one-half. The cervix is then twice the length of the uterus. At puberty, however, the corpus grows much faster and the size ratio reverses. After the menopause, the uterus atrophies, the mucosa becomes very thin, the glands almost disappear and the wall becomes relatively less muscular. These changes affect the cervix more than th corpus; cervical loops disappear and the external os becomes more or less fl ush with the vault.
The Fallopian tubes Each Fallopian tube extends outwards from the uterine cornu to end near the ovary. At the abdominal ostium, the tube opens into the peritoneal cavity, which is therefore in communication with the exterior of the body via the uterus and the vagina. The tubes (oviducts) convey the ovum from the ovary towards the uterus, which provides oxygenation and nutrition for sperm, ovum and zygote should fertilization occur. The Fallopian tube (Fig. 2.9) runs in the upper margin of the broad ligament, part of which, known as the mesosalpinx, encloses it so that the tube is completely covered with peritoneum except for a narrow strip along this inferior aspect. Each tube is about 10 cm long and is described in fo ur parts: 1. the interstitial portion 2. the isthmus 3. the ampulla 4. the infundibulum, or fimbrial portion. The interstitial portion lies within the wall of the uterus; the isthmus is the narrow portion adjoining the uterus. This passes into the widest and longest portion, the ampulla. This in turn terminates in the extremity known as the infundibulum, where the funnel-shaped opening of the tube into the peritoneal cavity is surrounded by finger-like processes, called fimbriae, into which the muscle coat does not ext~n d. The inner surfaces of the fimbriae are covered by ciliated epithelium, which is similar to the lining .o.f the Fallopian tube itself. One of these fimbriae is longer than the others and extends to, and partly embraces, the ovary. The muscle fibres of the wall of the tube are arranged in an inner circular and an outer longitudinal layer. The tubal epithelium forms a number of branched folds, or plicae, which run longitudinally; the lumen of the ampulla is almost filled with these folds. The folds have a cellular stroma, but at their bases the epithelium is only separated from the muscle by a very scanty amount of stroma. There is no submucosa and there are no glands. The epithelium of the Fallopian tubes contains two functioning cell types: the ciliated cells, which act to produce a constant current fluid in the direction of the uterus; and the secretory cells, which contribute to the volume of tubal fluid. Changes occur under the influence of the menstrual cycle, but there is no cell shedding during menstruation.
The ovaries The size and appearance of the ovaries depend on both age and the stage of the menstrual cycle. In the young adult they are almond shaped, solid, a greyishpink and approximately 3 cm long, 1.5 cm wide and 1 cm thick. In the child, the ovaries are small structures, approximately l.5 cm long. They have a smooth surface and at birth contain between 1 and 2 million primordial follicles, some of which will ripen into mature follicles in the reproductive years. The ovaries increase to adult size in the months preceding puberty. This considerable increase is brought about by proliferation of the stromal cells and by the commencing maturation of the ovarian follicles. After the menopause, no active follicles are present and the ovary becomes a small, shrunken structure with a wrinkled surface. The ovary is the only intra-abdominal structure not to be covered by peritoneum. Each ovary is attached to the cornu of the uterus by the ovarian ligament, and at the hilum to the broad ligament by the mesovarium, which contains its supply of vessels and nerves. Laterally, each ovary is attached to the suspensory ligament of the ovary with folds of peritoneum' which become continuous with that overlying the psoas major. Anterior to the ovary lie the Fallopian tubes, the superior portion of the bladder and the uterovesical pouch. The ovary is bound behind by _!he ureter where it runs downwards and forwards in front of the internal iliac artery. Structure The ovary (Fig. 2.10) has a central vascular medulla consisting of loose connective tissue containing many elastin fibres and non-striated muscle cells. It has an outer thicker cortex, denser than the medulla, consisting of networks of reticular fibres and fusiform cells, although there is no clear-cut demarcation between
the two. The surface of the ovaries is covered by a single layer of cuboidal cells, the germinal epithelium. Beneath this is an ill-defined layer of condensed connective tissue, the tunica albuginea, which increases in density with age. At birth, numerous primordial follicles are found, mostly in the cortex, but some are found in the medulla. With puberty, some form each month into Graafian follicles, which, at later stages of their development, form corpora lutea and ultimately atretic follicles, the corpora albicans. Vestigial structures Vestigial remains of the mesonephric duct and tubules are always present in young children, but are variable structures in adults. The epoophoron, a series of parallel blind tubules, lies in the broad ligament between the mesovarium and the Fallopian tube. The tubules run to the rudimentary duct of the epoophoron, which runs parallel to the lateral Fallopian tube. Situated in the broad ligament, between the epoophoron and the uterus, are occasionally seen a few rudimentary tubules, the paroophoron. In a few individuals, the caudal part of the mesonephric duct is well developed, running alongside the uterus to the internal os. This is the duct of Gartner.
The bladder, urethra and ureter
The bladder The average capacity of the bladder is 400 mL. The bladder is lined with transitional epithelium. The involuntary muscle of its wall is arranged in an inner longitudinal layer, a middle circular layer and an outer longitudinal layer. The ureters open into the base of the bladder after running medially for about 1 em through the vesical wall. The urethra leaves the bladder in front of the ureteric orifices; the triangular area lying between the ureteric orifices and the internal meatus is known as the trigone. At the internal meatus, the middle layer of vesical muscle forms anterior and posterior loops round the neck of the bladder, some fibres of the loops being continuous with the circular muscle of the urethra. The base of the bladder is related to the cervix, with only a thin layer of connective tissue intervening. It is separated from the anterior vaginal wall below by the pubocervical fascia, which stretches from the pubis to the cervix.
The urethra The female urethra is about 3.5 em long, and has a slight posterior angulation at the junction of its lower and middle thirds. It is lined with transitional epithelium. The smooth muscle of its wall is arranged in outer longitudinal and inner circular layers. As the urethra passes through the two layers of the urogenital diaphragm (triangular ligament), it is embraced by the striated fibres of the deep transverse perineal muscle (compressor urethrae), and some of the striated fibres of this muscle form a loop on the urethra. Between the muscular coat and the epithelium is a plexus of veins. There are a number of tubular mucous glands and, in the lower part, a nurr,:.ber of crypts, which occasionally become infected. In its upper twothirds the urethra is separated from the symphysis by loose connective tissue, but in its lower third it is attached to the pubic ramus on each side by strong bands of fibrous tissue called the pubourethralligaments. Posteriorly it is related to the anterior vaginal wall, to which it is firmly attached in its lower twothirds. The upper part of the urethra is mobile, but the lower part is relatively fixed. Figure 2.11 depicts the bladder and urethra. Medial fibres of the pubococcygeus of the levator ani muscles are inserted into the urethra and vaginal wall. When they contract, they pull the anterior vaginal wall and the upper part of the urethra forwards, forming an angle of about 1000 between the posterior wall of the urethra and the bladder base. On voluntary voiding of urine, the base of the bladder and the upper part of the urethra descend and this posterior angle disappears, so that the base of the bladder and the posterior wall of the urethra come to lie in a straight line. It was formerly claimed that absence of this posterior angle was the cause of stress incontinence, but this is probably only one of a number of mechanisms responsible.
The ureter As the ureter crosses the brim of the pelvis it lies in front of the bifurcation of the common iliac artery. It runs downwards and forwards on the lateral wall of the pelvis to reach the pelvic floor, and then passes inwards and forwards, attached to the peritoneum of the back of the broad ligament, to pass beneath the uterine artery. It next passes forwards through a fibrous tunnel, the ureteric canal, in the upper part of the cardinal ligament. Finally it runs close to the lateral vaginal fornix to enter the trigone of the bladder. The ureter's blood supply is derived from small branches of the ovarian artery, from a small vessel arising near the iliac bifurcation, from a branch of the uterine artery where it crosses beneath it, and from small branches of the vesical arteries. Because of its close relationship to the cervix, the vault of the vagina and the uterine artery, the ureter may be damaged during hysterectomy (Fig. 2.12). Apart from being cut or tied, in radical procedures the ureter may undergo necrosis because of interference with its blood supply. It may be displaced upwards by fibromyomata or cysts that are growing between the layers of the broad ligament, and may suffer injury if its position is not noticed at operation.
The rectum The rectum extends from the level of the third sacral vertebra to a point about 2.5 cm in front of the coccyx, where it passes through the pelvic floor to become continuous with the anal canal. Its direction follows the curve of the sacrum and it is about 11 cm in length. The front and sides of the upper third are covered by the peritoneum of the rectovaginal pouch; in the middle third only the front is covered by the peritoneum. In the lower third there is no peritoneal covering and the rectum is separated from the posterior wall of the vagina by the rectovaginal fascial septum. Lateral to the rectum are the two uterosacral ligaments, beside which run some of the lymphatics draining the cervix and vagina.
The pelvic muscles, ligaments and fasciae
The pelviC diaphragm The pelvic diaphragm is formed by the levator ani muscles (Fig. 2.13). Levator ani muscles Each is a broad, flat muscle, the fibres of which pass downwards and inwards. The two muscle;;, one on either side, constitute the pelvic diaphragm. The muscle arises by a linear origin from: • the lower part of the body of the os pubis, • the internal surface of the parietal pelvic fascia along the white line, • the pelvic surface of the ischial spine. The levator ani muscles are inserted into: • the pre-anal raphe and the central point of the perineum where one muscle meets the other on the opposite side,
• the wall of the anal canal, where the fibres blend with the deep external sphincter muscle, • the postanal or anococcygeal raphe, where again one muscle meets the other on the opposite side, • the lower part of the coccyx. The muscle is described in two parts: the pubococcygeus, which arises from the pubic bone and the anterior part of the tendinous arch of the pelvic fascia (white line), and the iliococcygeus, which arises from the posterior part of the tendinous arch and the ischial spine. The medial borders of the pubococcygeus muscles pass on either side from the pubic bone to the preanal raphe. They thus embrace the vagina, and on contraction have some sphincteric action. The nerve supply is from the third and fourth sacral nerves. The pubococcygeus muscles support the pelvic and abdominal viscera, including the bladder. The medial edge passes beneath the bladder and runs laterally to the urethra, into which some of its fibres are inserted. Together with fibres from the opposite muscle, they form a loop, which maintains the angle between the posterior aspect of the urethra and the bladder base. During micturition this loop relaxes to allow the bladder neck and upper urethra to open and descend. Urogenital diaphragm The urogenital diaphragm (triangular ligament) lies below the levator ani muscles and consists of two layers of pelvic fascia, which fill the gap between the descending pubic rami. The deep transverse perineal muscle (compressor urethrae) lies between the two layers, and the diaphragm is pierced by the urethra and the vagina.
The perineal body This is the perineal mass of muscular tissue that lies between the anal canal and th lower third of the vagina. Its apex is at the lower end of the rectovaginal septum, at the point where the rectum and posterior vaginal walls come into contact. Its base is covered with skin and extends from the fourchette to the anus. It is the point of insertion of the superficial perineal muscles and is bounded above by the levator ani muscles where they come into contact in the midline between the posterior vaginal wall and the rectum.
The pelvic peritoneum The peritoneum is reflected from the lateral borders of the uterus to form, on either side, a double fold of peritoneum - the broad ligament. This is not a ligament but a peritoneal fold, and it does not support the uterus. The Fallopian tube runs in the upper free edge of the broad ligament as far as the point at which the tube opens into the peritoneal cavity. The part of the broad ligament that is lateral to the opening is called the infundibulopelvic fold, and in it the ovarian vessels and nerves pass from the side wall of the pelvis to lie between the two layers of the broad ligament. The mesosalpinx, the portion of the broad ligament which lies above the ovary, is layered; between its layers are to be seen any Wolffian remnants that may be present. Below the ovary, the base of the broad ligament widens out and contains a considerable amount of loose connective tissue, called the parametrium. The ureter is attached to the posterior leaf of the broad ligament at this point. The ovary is attached to the post~rior layer of the broad ligament by a short mesente~y (the mesovarium), through which the ovarian vessels and nerves enter the hilum. The rectovaginal pouch has already been described. It will be noted that while the vagina does not have any peritoneal covering in front, behind it is in contact with the recto vaginal pouch for about 2 cm where the vagina is separated from the abdominal cavity only by the peritoneum and thin fascia. The peritoneal cavity can be opened by posterior colpotomy at this point.
The ovarian ligament and round ligament The ovarian ligament lies beneath the posterior layer of the broad ligament and passes from the medial pole of the ovary to the uterus just below the point of entry of the Fallopian tube. The round ligament is the continuation of the same structure and runs forwards under the anterior leaf of peritoneum to enter the inguinal canal, ending in the subcutaneous tissue of the labium majus. Together, the ovarian and round ligaments are analogous to the gubernaculum in the male.
The pelvic fascia and pelvic ce llu lar tissue Connective tissue fills the irregular spaces between the various pelvic organs. Much of it is loose cellular tissue, but in some places it is condensed to form strong ligaments, which contain some smooth muscle fibres and which form the fascial sheaths enclosing the various viscera. The pelvic arteries, veins, lymphatics, nerves and ureters run through it. The cellular tissue is continuous above with the extraperitoneal tissue of the abdominal wall, but below it is cut off from the ischiorectal fossa by the pelvic fascia and the levator ani muscles. There is a considerable collection of cellular tissue in the wide base of the broad ligament and at the side of the cervix and vagina, called the parametrium. The pelvic fascia may be regarded as a specialized part of this connective tissue. Anatomists describe parietal and visceral components. The parietal pelvic fascia lines the wall of the pelvic cavity, covering the obturator intern us and pyramidalis muscles. There is a thickened tendinous arch (or white line) on the side wall of the pelvis. It is here that the levator ani muscle arises and the cardinal ligament gains its lateral attachment. Where the parietal pelvic fascia encounters bone, as in the pubic region, it blends with the periosteum. It also forms the upper layer of the urogenital diaphragm (triangular ligament). Each viscus has a fascial sheath, which is dense in the case of the vagina and cervix and at the base of the bladder, but is tenuous or absent over the body of the uterus and the dome of the bladder. Various processes of the visceral pelvic fascia pass inwards from the peripheral layer of the parietal pelvic fascia. From the point of view of the gynaecologist, certain parts of the visceral fascia are of particular importance, as follows. The cardinal ligaments (transverse cervical ligaments) provide the essential support of the uterus and vaginal vault. These are two strong, fan-shaped, fibromuscular expansions that pass from the cervix and vaginal vault to the side wall ofthe p Ivis on either side. The uterosacral ligaments run from the cervix and vaginal vault to the sacrum. In the erect position they are almost vertical in di rection and support the cervix. The bladder is supported laterally by cond nsations of the vesical pelvic fascia one each side; there is also a sheet of pubocervical fascia which lies beneath it anteriorly.
Arteries supplying the pelvic organs
The ovarian artery Because the ovary develops on the posterior abdominal wall and later migrates down into the pelvis, it derives its blood supply directly from the abdominal aorta. The ovarian artery arises from the aorta just below the renal artery and runs downwards on the anterior surface of the psoas muscle to the pelvic brim, where it crosses in front of the ureter and then passes into the infundibulopelvic fold of the broad ligament. The artery divides into branches that supply the ovary and tube and then run on to reach the uterus, where they anastomose with the terminal branches of the uterine artery.
The internal iliac (hypogastric) artery This vessel is about 4 cm in length and begins at the bifurcation of the common iliac artery in front of the sacroiliac joint. It soon divides into anteriq! and posterior divisions; the branches that supply the pelvic viscera are all from the anterior division. The uterine artery provides the main blood supply to the uterus. The artery first runs downwards on the lateral wall of the pelvis, in the same direction as the ureter. It then turns inwards and forwards, lying in the base of the broad ligament. By this change of direction the artery crosses above the ureter, at a distance of about 2 cm from the uterus, at the level of the internal os. On reaching the wall of the uterus, the artery turns upwards to run tortuously to the upper part of the uterus, where it anastomoses with the ovarian artery. In this part of its course it sends many branches into the substance of the uterus. The artery supplies a branch to the ureter as it crosses it, and shortly afterwards another branch is given off to supply the cervix and upper vagina. The vaginal artery is another branch of the internal iliac artery that runs at a lower level to supply the vagina. The vesical arteries are variable in number. They supply the bladder and terminal ureter. One usually runs in the roof of the ureteric canal. The middle rectal artery often arises in common with the lowest vesical artery. The pudendal artery is another branch of the internal iliac artery. It leaves the pelvic cavity through the sciatic foramen and, after winding round the ischial spine, enters the ischiorectal fossa, where it gives off the inferior rectal artery. It terminates in branches that supply the perineal and vulval structures, including the erectile tissue of the vestibular bulbs and clitoris.
The superior rectal artery This artery is the continuation of the inferior mesenteric artery and descends in the base of the pelvic mesocolon. It divides into two branches, which run on either side of the rectum and supply numerous branches to it.
The pelvic veins The veins around the bladder, uterus, vagina and rectum form plexuses which intercommunicate freely. Venous drainage from the uterine, vaginal and vesical plexuses is chiefly into the internal iliac veins. Venous drainage from the rectal plexus is via the superior rectal veins to the inferior mesenteric veins, and the middle and inferior rectal veins to the internal pudendal veins and so to the iliac veins. The ovarian veins on each side begin in the pampiniform plexus that lies between the layers of the broad ligament. At first there are two veins on each side accompanying the corresponding ovarian artery. Higher up, the vein becomes single; that on the right ends in the inferior vena cava and that on the left in the left renal vein.
The pelvic lymphatics Lymph draining from the lower extremities and the vulval and perineal regions is all filtered through the inguinal and superficial femoral nodes before continuing along the deep pathways on the side wall of the pelvis. One deep chain passes upwards lateral to the major blood vessels, forming in turn the external iliac, common iliac and para-aortic groups of nodes. Medially, another chain of vessels passes from the deep femoral nodes through the femoral canal to the obturator and internal iliac groups of nodes. These last nodes are interspersed among the origins of the branches of the internal iliac artery, receiving lymph directly from the organs supplied by this ar tery, including the upper vagina, cervix and body of the uterus. From the internal iliac and common iliac nodes, afferent vessels pass up the para-aortic chains, and finally all the lymphatic drainage from the legs and pelvis flows into the lumbar lymphatic trunks and the cisterna chyli at the level of the second lumbar vertebra. From here, all the lymph is carried by the thoracic duct through the thorax, with no intervening nodes, to empty into the junction of the left subclavian and internal jugular veins. Tumour cells that penetrate or bypass the pelvic and para-aortic nodes are rapidly disseminated via the great veins at the root of the neck.
Lymphatic drainage from the genital tract The lymphatic vessels from individual parts of the genital tract drain into this system of pelvic lymph nodes in the following manner (Fig. 2.14). The vulva and the perineum medial to the labiocrural skin folds contain superfidallymphatics that pass upwards towards the mons pubis and then curve laterally to the superficial inguiIJ,al and femoral nodes. Drainage from these is through the fossa ovalis into the deep femoral nodes. The largest of these, lying in the upper part of the femoral canal, is known as the node of Cloquet. The vagina: the lymphatics of the lower third follow the vulval drainage to the superficial inguinal nodes, whereas those from the upper two-thirds pass upwards to join the lymphatic vessels of the cervix. The cervix: the lymphatics pass either laterally in the base of the broad ligament or posteriorly along the uterosacral ligaments to reach the side wall of the pelvis. Most of the vessels drain to the internal iliac, obturator and external iliac nodes, but vessels also pass directly to the common iliac and lower para-aortic nodes, so that radical surgery for carcinoma of the cervix should include removal of all these node groups on both sides of the pelvis. The corpus uteri: nearly all the lymphatic vessels join those leaving the cervix and therefore reach similar groups of nodes. A few vessels at the fundus follow the ovarian channels, and there is an inconsistent pathway along the round ligament to the inguinal nodes. The ovary and Fallopian tube have a plexus of vessels that drain along the infundibulopelvic fold to the para-aortic nodes on both sides of the midline. On the left, these are found around the left renal pedicle, whereas on the right there may be only one node intervening before the lymph flows into the thoracic duct, thus accounting for the rapid early spread of metastatic carcinoma to distant sites such as the lungs. The bladder and urethra: the drainage is to the iliac nodes, whilst the lymphatics of the lower part of the urethra follow those of the vulva. The rectum: the lymphatics from the lower anal canal drain to the superficial inguinal nodes, and the remainder of the rectal drainage follows pararectal channels accompanying the blood vessels to both the internal iliac nodes (middle rectal artery) and the para-aortic nodes at the origin of the inferior mesenteric artery.
Nerves of the pelvis Nerve supply of the vulva and perineum The pudendal nerve arises from the second, third and fourth sacral nerves. As it passes along the outer wall of the ischiorectal fossa, it gives off an inferior rectal branch and divides into the perineal nerve and the dorsal nerve of the clitoris. The perineal n~rve gives the sensory supply to the vulva; it also innervates the anterior part of the external anal sphincter and levator ani, and the superficial perineal muscles. The dorsal nerve of the clitoris is sensory. Sensory fibres from the mons and labia also pass, in the ilioinguinal and genitofemoral nerves, to the first lumbar root. The posterior femoral cutaneous nerve carries sensation from the perineum to the small sciatic nerve, and thus to the first, second and third sacral nerves. The main nerve supply of the levator ani muscles comes from the third and fourth sacral nerves.
Nerve supply of the pelvic viscera To describe what can be seen on dissection of the extensive autonomic nerve supply of the pelvic organs is one thing - to determine the physiological functions of the various parts of the system is another. Nerve fibres of the pre-aortic plexus of the sympathetic nervous system are continuous with those of the superior hypogastric plexus, which lies in front of the last lumbar vertebra and is wrongly called the presacral nerve. Below, the superior hypogastric plexus divides, and on each side its fibres are continuous with fibres passing beside the rectum to join the uterovaginal plexus (inferior hypogastric plexus, or plexus ofFrankenhauser). This plexus lies in the loose cellular tissue posterolateral to the cervix below the uterosacral folds of peritoneum. Parasympathetic fibres from the second, third and fo urth sacral nerves join the uterovaginal plexus. Fibres from (or to) the bladder, uterus, vagina and rectum join the plexus. The uterovaginal plexus contains a few ganglion cells, so it is likely that a few motor nerves have their relay stations there and then pass onwards with the blood vessels to the viscera. The ovary is not innervated by the nerves already described but from the ovarian plexus, which surrounds the ovarian vessels and joins the pre-aortic plexus high up. This description has avoided any conjecture as to the particular function of the sympathetic and parasympathetic nerves, and no opinion has been expressed as to whether the various nerves carry sensory or motor impulses. Clinical facts are few. It is evident that afferent sensory impulses are often carried in the superior hypogastric plexus. If this is divided during presacral neurectomy, pain from the bladder and uterus can often be blocked. Apart from a transient pelvic hyperaemia, there is no change in the motor function of either bladder or uterus. At an ordinary hysterectomy, the uterovaginal plexus is not disturbed, but after a more extensive Wertheim operation, there may be painless atony and distension of the bladder, which is attributed to loss of bladder sensation because the sacral connections of the uterovaginal plexus have been divided. The motor effects are even less certain than the sensory. Stimulation of the cut lower end of the hypogastric plexus seems to have no effect on the bladder or the uterus. Although it has been stated that the parasympathetic nerves are excitatory to the musculature of the body of the uterus and inhibitory to that of the cervix, and that the sympathetic nerves have the opposite effect, there is not general agreement about this. The myometrium contains both a and (3 adrenergic receptors and also cholinergic receptors. In the non-pregnant uterus, the balance of their action is uncertain, but during pregnancy, strong stimulation of (3-receptors with (3 -mimetic drugs such as isoxsuprine will inhibit myometrial activity.
The most obvious manifestation of the normal menstrual cycle is the presence of regular menstrual periods. These occur as the endometrium is shed following failure of implantation or fertilization of the oocyte. Menstruation is initiated in response to changes in steroids produced by the ovaries, which themselves are controlled by the pituitary and hypothalamus.
The ovary Within the ovary, the menstrual cycle can be divided into three phases: 1. the follicular phase 2. ovulation 3. the luteal phase.
The development of the oocyte is the key event in the follicular phase of the menstrual cycle. The ovary contains thousands of primordial follicles that are in a continuous state of development from birth, through periods of anovulation, such as pregnancy, to the menopause. These initial stages of follicular development are independent of hormonat stimulation. In the absence of the correct hormonal stimulus, however, follicular development fails at the pre-antral stage, with ensuing follicular atresia. Development beyond the pre-antral stage is stimulated by the pituitary hormones (luteinizing hormone [LHJ and folliclestimulating hormone [FSH]), which can be considered as key regulators of oocyte development. At the start of the menstrual cycle, FSH levels begin to rise as the pituitary is released from the negativefeedback effects of progesterone, oestrogen and inhibin.
Rising FSH levels rescue a cohort of follicles from atresia, and initiate steroidogenesis. Figure 4.1 shows the hormonal changes throughout the ovarian and menstrual cycles. Steroidogenesis The basis of hormonal activity in pre-antral to pre-ovulatory follicles is described as the 'two cell, two gonadotrophin' hypothesis. Steroidogenesis is compartmentalized in the two cell types within the follicle: the theca and granulosa cells. The two cell, two gonadotrophin hypothesis states that these cells are responsive to the gonadotrophins LH and FSH respectively. Within the theca cells, LH stimulates the production of androgens from cholesterol. Within the granulosa cells, FSH stimulates the conversion of thecally derived androgens to oestrogens (aromatization) (Fig. 4.2). In addition to its effects on aromatization, FSH is also responsible for the proliferation of granulosa cells. Although other mediators are now known to be important in follicular development, this hypothesis is still the cornerstone to understanding events in the ovarian follicle. The respective roles of FSH and LH in follicular development are evidenced by studies on women undergoing ovulation induction in whom endogenous gonadotrophin production has been suppressed. If pure FSH alone is used for ovulation induction, an ovulatory follicle can be produced, but oestrogen production is markedly reduced. Both FSH and LH are required to generate a normal cycle with adequate amounts of oestrogen. Androgen production within the follicle may also regulate the development of the pre-ant~~l follicle. Low levels of androgens enhance aromatization and therefore increase oestrogen production. In contrast, high androgen levels inhibit aromatization and produce follicular atresia. A delicate balance of FSH and LH is required for early follicular development. The ideal situation for the initial stages offollicular development is low LH levels and high FSH levels, as seen in the early menstrual cycle. If LH levels are too high, theca cells produce large amounts of androgens, causing follicular atresia. Selection of the dominant follicle The developing follicle grows and produces steroid hormones under the influence of the gonadotrophins LH and FSH. These gonadotrophins rescue a cohort of pre-antral follicles from atresia. However, normally only one of these follicles is destined to grow to a preovulatory follicle and be released at ovulation - the dominant follicle. The selection of the dominant follicle is the result of complex signalling between the ovary and the pituitary. In simplistic terms, the dominant follicle is the largest and most developed follicle in .the ovary at the mid-follicular phase. Such a follicle ha; the most efficient aromatase activity and the highest concentration of FSH-induced LH receptors. The dominant follicle therefore produces the greatest amount of oestradiol and inhibin. Inhibin further amplifies LH-induced androgen synthesis, which is used as a substrate for oestradiol synthesis. These features mean that the largest follicle therefore requires the lowest levels of FSH (and LH) for continued development. At the time of follicular selection, FSH levels are declining in response to the negative-feedback effects of oestrogen. The dominant follicle is therefore the only follicle that is capable of continued development in the face of falling FSH levels. Ovarian-pituitary interaction is crucial to the selection of the dominant follicle, and the forced atresia of the remaining follicles. Figure 4.3 depicts the positivefeedback and negative-feedback mechanisms of the hypothalamo-pituitary-ovarian axis. When this interaction is bypassed, as in ovulation induction with the administration of exogenous gonadotrophins, many follicles continue to develop and are released at ovulation, with an ensuing multiple gestation rate of around 30 per cent. During in-vitro fertilization (IVF), the production of many ovulatory follicles is desired, as once the oocytes have been harvested, and fertilized in vitro, the number of embryos replaced can be carefully controlled. However, if such multiple follicular development occurred unchecked in the normal response to the negative-feedback effects of oestrogen. The dominant follicle is therefore the only follicle that is capable of continued development in the face of falling FSH levels. Ovarian-pituitary interaction is crucial to the selection of the dominant follicle, and the forced atresia of the remaining follicles. Figure 4.3 depicts the positivefeedback and negative-feedback mechanisms of the hypothalamo-pituitary-ovarian axis. When this interaction is bypassed, as in ovulation induction with the administration of exogenous gonadotrophins, many follicles continue to develop and are released at ovulation, with an ensuing multiple gestation rate of around 30 per cent. During in-vitro fertilization (IVF), the production of many ovulatory follicles is desired, as once the oocytes have been harvested, and fertilized in vitro, the number of embryos replaced can be carefully controlled. However, if such multiple follicular development occurred unchecked in the normal
cycle, it would lead to the product ion of multi ple gestations of high-order numbers, with their asso c·ated problems. Inhibin and activin Although folliculogenesis, ovulation and the production of progesterone from the corpus luteum can be explained largely in terms of the interacti n betwe n pituitary gonadotrophins and sex steroids, it is becoming clear that other autocrine or paracrine mediat rs also playa role. One of the most important of these is inhibin. Inhibin was originally described as a testicular product that inhibited pituitary FSH production - hence its name. However, inhibin is also produced by a variety of other cell types, including granulosa cells within the ovary. Granulosa cell inhibin production is stimulated by FSH, but in women, as in men, inhibin attenuates FSH production. vVithin the ovary, inhibin enhances LH -induced androgen synthesis. The production of inhibin is a further mechanism by which FSH levels are reduced below a threshold at vlhich only the dominant follicle can respond, ensuring atresia of the remaining follicles. Activin is a peptide that is structurally related to inhibin. It is produced both by the granulosa cells of antral follicles and by the pituitary gland. The action of activin is almost directly opposite to that of inhibin in that it augments pituitary FSH secretion and increases FSH binding to granulosa cells. Granulosa cell activin production therefore appears to amplify the effects of FSH within the ovarian follicle. Insulin-like growth factors Insulin-like growth factors (IGF-I and IGF-ll) act as paracrine regulators. Circulating levels do not change during the menstrual cycle, but follicular fluid levels increase towards ovulation, with the highest level found in the dominant follicle. The actions of IGF-I and IGF-II are modified by their bindi~_9 proteins: insulin-like growth factor binding proteins (IGFBPs). In the follicular phase, IGF-I is produced by theca cells under the action of LH. IGF-I receptors are present on both theca and granulosa cells. Within the theca, IGF-I augments LH -induced steroidogenesis. In granulosa cells, IGF-I augments the stimulatory effects of FSH on mitosis, aromatase activity and inhibin production. In the pre-ovulatory follicle, IGF-I enhances LH-induced progesterone production from granulosa cells. Following ovulation, IGF-II is produced from luteinized granulosa cells, and acts in an autocrine manner to augment LH-induced proliferation of granulosa cells.
Late in the follicular phase, FSH induces LH receptors on granulosa cells. Oestrogen is an obligatory co- factor in this effect. As the dominant follicle develops further, follicular oestrogen production increases. Eventually the production of oestrogen is sufficient for it to reach the threshold required to exert a positive-feedback effect on pituitary LH secretion. Once this occurs, LH levels increase, at first quite slowly (day 8 to day 12 of the menstrual cycle) and then more rapidly (day 12 onwards). During this time, LH induces luteinization of granulosa cells in the dominant follicle, so that progesterone is produced. Progesterone further amphfies the positive-feedback effect of oestrogen on pituitary LH secretion, leading to a surge of LH. Ovulation occurs 36 hours after the onset of the LH surge. The LH surge is one of the best methods by which the time of ovulation can be determined, and is the event detected by most over-the-counter 'ovulation predictor' kits. The peri-ovulatory FSH surge is probably induced by the positive-feedback effects of progesterone. In addition to the rise in LH, FSH and oestrogen that occurs around ovulation, a rise in serum androgen levels also occurs. These androgens are derived from the stimulatory effect ofLH on theca cells, particularly those of the non-dominant follicle. This rise in androgens may have an important physiological effect in the stimulation of libido, ensuring that sexual activity is likely to occur at the time of ovulation, when the woman is at her most fertile. Prior to the release of the oocyte at the time of ovu- 1ation, the LH surge stimulates the resumption of meiosis, a process which is completed after the sperm enters the egg. Additionally, the LH surge stimulates increased follicular expression of macrophage chemotactic protein-1 (MCP-I) and interleukin 8 (IL-8), which in turn causes an influx of macro phages and neutrophils into the pre-ovulatory follicle. Once activated, these leukocytes secrete mediators such as matrix metalloproteinases (MMPs) and prostaglandins, which cause the follicle wall to break down, releasing the oocyte at ovulation. The crucial importance of prostaglandins and other eicosanoids in the process of ovulation is demonstrated by studies showing that inhibition of prostaglandin production may result in fa ilure of release of the oocyte from the ovary, despite apparently normal steroidogenesis (the luteinized unruptured foll icle syndrome [LUF]). Althouah LUF appears to be an uncommon cause of infertility, women wishing to bec me pregnant should be advised to avoid taking prostaglandin synthetase in hibitors such as aspirin and i uprofen, which may inhibit oocyte release.
The luteal phase is characterized by the production of progesterone from the corpus luteum within the ovary. The corpus luteum is derived both from the granulosa cells that remain after ovulation and from some of the theca cells that differentiate to become theca lutein cells. The granulosa cells of the corpus luteum have a vacuolated appearance associated with the accumulation of a yellow pigment, lutein, from where the corpus luteum derives its name. Extensive vascularization within the corpus luteum ensures that the granulosa cells have a rich blood supply providing the precursors for steroidogenesis. The production of progesterone from the corpus luteum is dependent on continued pituitary LH secretion. However, serum levels of progesterone are such that LH and FSH production is relatively suppressed. This effect is amplified by moderate levels of oestradiol and inhibin A, which are also produced by the corpus luteum. The low levels of gonadotrophins mean that the initiation of new follicular growth is inhibited for the duration of the luteal phase. Luteolysis The duration of the luteal phase is fairly constant, being around 14 days in most women. In the absence of pregnancy and the production of human chorionic gonadotrophin (hCG) from the implanting embryo, the corpus luteum regresses at the e~d of the luteal phase, a process known as luteolysis. The mechanism of control of luteolysis in women remains obscure. As the corpus luteum dies, oestrogen, progesterone and inhibin A levels decline. The pituitary is released from the negative-feedback effects of these hormones, and gonadotrophins, particularly FSH, start to rise. A cohort of follicles that happen to be at the pre-antral phase is rescued from atresia and a further menstrual cycle is initiated.
The pituitary gland The process of follicular development, ovulation and the maintenance of the corpus luteum has been described in terms of ovarian physiology. In reality, however, the ovary, pituitary and hypothalamus act in concert (the hypothalamo-pituitary-ovarian axis) to ensure the growth and development of (ideally) one ovarian follicle, and to maintain hormonal support of the endometrium to allow implantation. The pituitary hormones LH and FSH are, as we have seen, key regulators of folliculogenesis. The output ofLH and FSH from the pituitary gland is stimulated by pulses of gonadotrophin-releasing hormone (GnRH) produced by the hypothalamus and transported to the pituitary in the portal circulation. The response of the pituitary is not constant, but is modulated by ovarian hormones, particularly oestrogen and progesterone. Thus low levels of oestrogen have an inhibitory effect on LH (negative feedback), whereas high levels of oestrogen actually stimulate pituitary LH production (positive feedback). In the late follicular phase, serum levels of oestrogen are sufficiently high that a positive-feedback effect is triggered, thus generating the peri-ovulatory LH surge. In contrast, the combined contraceptive pill produces serum levels of oestrogen in the negative-feedback range, so that measured levels of gonadotrophins are low. The mechanism of action of the positive-feedback effect of oestrogen involves an increase in GnRH receptor concentrations and an increase in GnRH production. The mechanism of the negative-feedback effect of oestrogen is uncertain. In contrast to the effects of oestrogen, low levels of progesterone have a positive-feedback effect on pituitary LH and FSH secretion. Such levels are generated immediately prior to ovulation, and contribute to the FSH surge. High levels of progesterone, such as those seen in the luteal phase, inhibit pituitary gonadotrophin production. Negative-feedback effects of progesterone are generated both via decreased GnRH production and via decreased sensitivity to GnRH at the pituitary level. Positive-feedback effects of progesterone operate at the pituitary level only and involve increased sensitivity to GnRH. Importantly, progesterone can only have these effects if there has been prior priming by oestrogen. As we have seen, oestrogen and progesterone are not the only hormones to have an effect on pituitary gonadotrophin secretion. The peptide h ormones inhibin and activin have opposing effects on gonadotrophin production: inhibin attenuates pituitary FSH secretion, whereas activin stimulates it.
The hypothalamus The hypothalamus, via the pulsatile secretion of GnRH, stimulates pituitary LH and FSH secretion. Production of GnRH not only has a permissive effect on gonadotrophin production, but altera tions in the amplitude and frequency ofGnRH pulsation throughout the cycle are also responsible for some fi ne tun ing of gonadotrophin production (see the section on the pituitary gland above). The importance of GnRH secretion is seen in disorders such as anorexia nervosa and in the amenorrhoea associated with excessive exercise. In these disorders, GnRH production is suppressed, leading to anovulation and amenorrhoea. Ovulation can be restored in these women by the administration of GnRH in a pulsatile manner (although this should be approached carefully, since pregnancy is relatively contraindicated in women whose body weight is significantly below average). It is important to remember that GnRH is produced in a pulsatile manner to exert its'physiological effect. Drugs that are GnRH agonists (e.g. buserelin and goserelin) are widely used in gynaecology for the treatment of endometriosis and other disorders. Although these drugs act as GnRH agonists, they cause a decrease in pituitary LH and FSH secretion. The reason for this is that these agonists are long acting, and the continued exposure of the pituitary to moderately high levels of GnRH causes down-regulation and desensitization of the pituitary. LH and FSH production is therefore markedly decreased. Ovarian steroidogenesis is suppressed, so that serum oestrogen and progesterone fall to postmenopausal levels. Most women become amenorrhoeic whilst taking GnRH agonists. A potential disadvantage of the currently available GnRB agonists is that such down-regulation and desensitization of the pituitary take up to 3 weeks to exert their effects. The initial effect of GnRH administration is to stimulate pituitary LH and FSH production, leading to increased ovarian steroidogenesis. \!\Then a patient commences GnRH therapy, this temporary increase in ovarian steroidogenesis leads to a vaginal bleed within the first month of administration, and it is important to warn the patient of this.
The endometrium The changes in the hypothalamo-pituitary-ovarian axis during the menstrual cycle have already been described. These changes occur whether or not the uterus is still present. Menstruation, which occurs in the presence of the uterus, is the most obvious external manifestation that regular menstrual cycles are occurring. The changes in the endometrium that occur during the menstrual cycle are described below.
Menstruati on As the corpus luteum dies at the end of the luteal phase, circulating levels of oestrogen and progesterone fall precipitously (see Fig. 4.1).In an ovulatory cycle, where the endometrium is exposed to oestrogen and then progesterone in an orderly manner, the endometrium becomes 'decidualized' during the second half of the cycle to allow implantation of the embryo. Decidualization is an irreversible process, and if implantation does not occur, programmed cell death (apoptosis) ensues. MenstruatioI is the shedding of the 'dead' endometrium and ceases as th endometrium regenerates. Menstruation is initiated by the withdrawal of oestrogen and progesterone. Such an effect can be produced experimentally, and women recei 'ng oestrogens and progestogens in the form of the combined contraceptive pill or hormone replacement therapy will experience a 'withdrawal bleed' on completion of a pack. Withdrawal of progesterone has several main effects. First, intense spiral artery vasoconstriction is generated. Since most reports suggest that the spiral arteries do not express the progesterone receptor, it appears that the constricting effects of progesterone on the endometrial spiral arteries are indirect, and generated by locally produced prostaglandins, endothelins and angiotensin II. The other major effect of the withdrawal of progesterone, which proceeds in parallel with spiral artery vasoconstriction, is the production of pro-inflammatory cytokines such as MCP-J, IL-8 and cyclo-oxygenase-2 (which produces prostaglandins). These agents, particularly MCP-1 and IL-8, attract and activate macrophages and neutrophils, respectively, into the endometrium. Both invading leukocytes and endometrial stromal cells then release and activate MMPs, which break down extracellular matrix. The final main effect is that tissue hypoxia induced by vasoconstriction leads to the production of vascular endothelial growth factor (VEGF), which stimulates angiogenesis (important in postmenstrual tissue repair) and MMP production. The above events lead to ischaemia (particularly of the upper endometrium) and tissue damage, shedding of the functional endometrium (the stratum compactum and stratum spongiosumJ and bleeding from fragments of arterioles remaining in the basal endometrium. Menstruation ceases as the damaged spiral arteries vasoconstrict and the endometrium regenerates. Rising oestrogen and progesterone levels inhibit MMP production. Thus, haemostasis in the endometrial vessels differs from haemostasis elsewhere in a number of important aspects. Normally, bleeding from a damaged vessel is stemmed by platelet accumulation, fibrin deposition and platelet degranulation. Such events may, however, lead to scarring. In the endometrium, scarring would significantly inhibit function (as seen in Asherman's syndrome), and an alternative system ofhaemostasis is therefore required. Vasoconstriction is the mechanism by which haemostasis is initially secured in the endometrium. Scarring is minimized by enhanced fibrinolysis, which breaks down blood clots. Later, repair of the endometrium and new blood vessel formation (angiogenesis) lead to the complete cessation of bleeding within 5-7 days from the start of the menstrual cycle. Endometrial repair involves both glandular and stromal regeneration and angiogenesis. Both VEGF and fibroblast growth factor (FGF) are found within the endometrium, and both are powerful angiogenic agents. Increasing evidence suggests that oestrogeninduced glandular and stromal regeneration is mediated by epidermal growth factor (EG F). Other growth factors, such as transforming growth factors (TGFs) and IGFs, and the interleukins, particularly IL-I, may also be important. Increased understanding of the agents involved in menstruation may improve attempts to control pathologically excessive menstruation. Prostaglandin synthetase inhibitors such as mefenamic acid (Ponstan) are widely used in the UK as a first-line treatment for menorrhagia. They are thought to increase the ratio of the vasoconstrictor prostaglandin (PG) F2O' to the vasodilator prostaglandin PGE2. Although mefenamic acid does reduce menstrual loss, the mean reduction is only in the order of 20-25 per cent in women with true menorrhagia, and the search for more effective agents has therefore continued.
The proliferative/follicular phase
Once endometrial repair is completed, usually at around day 5-6 of the cycle, menstruation ceases. Within the endometrium, the remainder of the follicular phase is characterized by glandular and stromal growth - hence the name the proliferative phase. During this time, the epithelium lining the endometrial glands changes from a single layer of low columnar cells to pseudostratified epithelium with frequent mitoses. The stromal component of the endometrium re-expands, and is infiltrated by bone marrow-derived cells. The massive development taking place in the endometrium is reflected in the increase in endometrial thickness, from 0.5 mm at menstruation to 3.5-5 mm at the end of the proliferative phase.
The secretory/luteal phase
The postovulatory or luteal phase of the menstrual cycle is characterized by endometrial glandular secretory activity - hence the name the secre ory phase. Under the action of progesterone, oestrogen-induced cellular proliferation is inhibited, and the depth of the endometrium remains fixed. Despite this, som elements continue to grow, leading to increased tortuosity of both the glands and spiral arteries in order to fit into the endometrial layer. Shortly after ovulation, vacuoles containing subnuclear intracytoplasmic granules appear il1 glandular cells. These vacuoles progress to the apex of the glandular cells and their contents are released into the endometrial cavity. Peak secretory activity occurs at the time of implantation, 7 days after the gonadotrophin surge. Progesterone is essential for the induction of endometrial secretory changes and these changes are only seen after ovulation in the absence of exogenous steroid therapy. Histological examination of luteal phase endometrium used to be performed commonly to confirm that ovulation had occurred (Fig. 4.4). However, access to inexpensive, accurate steroid hormonal assays has rendered this invasive test obsolete, so that ovulation is now confirmed by serum progesterone measurements in the luteal phase. Within the stroma, oedema is induced in the secretory phase under the influence of oestrogen and progesterone. The predominant bone marrow-derived cell within the endometrium is the large granulated lymphocyte, which has properties similar to those of the natural killer cell and is thought to be important in regulating trophoblast invasion during implantation. In the late secretory phase, progesterone induces irreversible decidualization of the stroma. Histologically, decidualization is initiated around blood vessels. The
Summary of endometrial events
Menstruation • Menstruation is initiated largely by arteriolar vasoconstrictio n. • The functional layer (upper 75 per cent) is shed. • Menstruation ceases due to vasoconstriction and endometrial repair. • Fibrinolysis inhibits scar tissue formation.
Proliferative phase • This phase is characterized by oestrogen-induced growth of glands and stroma.
Luteal phase • This phase is clharacterized by progesterone-induced glandular secretory activity. • Decidualization is induced in the late secretory phase. • Decidualization is an irreversible process and leads to endometrial apoptosis and menstruation unless pregnancy occurs. surrounding stromal cells display increased mitotic activity and nuclear enlargement and a basement membrane is generated (Fig. 4.5 ). Immediately prior to menstruation, three distinct zones of the endometrium can be seen. The basalis is the basal 25 per cent of the endometrium, which is retained during menstruation and shows few changes during the menstrual cycle. The mid-portion is the stratum spongiosum, with oedematous stroma and exhausted glands. The superficial portion (the uppermost 25 per cent) is the stratum compactum, wi h prominent decidualized stromal cells. The withdrawal of oestrogen and progesterone leads to collapse of the decidualized endometrium, repeated vasoconstriction and relaxation of the spiral arterioles, and consequent shedding of the endometrium. The onset of menstruation heralds the end of one menstrual cycle and the beginning of the next.
The normal menstrual cycle Clinical features Medical students are taught that the normal menstrual cycle is 28 days long (from the start of one cycle to the start of the next) and that the usual duration of menstrual flow is 3-7 days. In fact, only 15 per cent of women have a perfect 28-day cycle, and any cycle of between 21 and 35 days long can be regarded as normal. Menstrual cycles are longest immediately after puberty and in the 5 years leading up to the menopause, corresponding to the peak incidence of anovulatory cycles. The length of the menstrual cycle is determined by the length of the follicular phase. Once ovulation occurs, luteal phase length is fairly fixed at 14 days in almost all women. The duration of menstrual flow also varies among women from 2 to 8 days. The amount of menstrual flow peaks on the first or second day of menstruation. The normal volume of menstrual loss is 35 mL per month. A menstrual loss of greater than 80 mL is considered to be excessive - this level is rather arbitrary and corresponds to the threshold at which iron deficiency anaemia may ensue unless treated.
New developments Oocyte growth in vitro During IVF, exogenous gonadotrophins are administered to stimulate follicular growth within the ovary. The administered dose of gonadotrophins has to be controlled carefully to achieve adequate follicular growth with minimal side effects. Ideally, many ovulatory follicles should be generated and harvested prior to ovulation. However, such a process requires intensive monitoring, which is time consuming for both the patient and physician. At present, follicular grovvth can only be achieved in vivo, although in future it may be possible to culture primordial follicles in vitro from frozen ovarian biopsies. If ovulatory follicles could be generated, this would be a major advance - the adverse effects of gonadotrophin therapy could be avoided, and there would be no need for frequent hospital attendances for scans and hormone assays during ovulation induction. Moreover, ovarian biopsies could be taken (before pelvic radiotherapy, for example) and stored until required.
GnRH antagonists We have seen that the use of GnRH agonists is associated INith an initial increase in ovarian steroidogenesis until down-regulation of the pituitary is achieved. GnRH antagonists have now been developed. GnRH antagonists inrlibit the action of GnRH at the pituitary and therefore reduce LH and FSH secretion. The use of GnRH antagonists avoids the initial stimulatory effect of GnRH agonists at the pituitary gland; hence a therapeutic effect is achieved more rapidly, and some of the side effects of the GnRH ago nists can be prevented.
METHODS OF EXAMINATION IN GYNECOLOGY
Examination of gynecological patient consists of:
· history taking,
· objective (general and special)
· additional methods of examination.
The examination begins with obtaining the history in accordance with a certain plan.
First of all, the passport data is required: surname, name, patronymic, and also birth date (woman’s age).
History taking. History has extraordinary value in gynecology. Sometimes it deals with the intimate life problems, that’s why it is necessary to ask a patient delicately and accurately for obtaining sufficiently full and exact information. Carefully taken history sometimes is sufficient for making the previous diagnosis. At first patient should be asked about complaints, development of the disease (anamnesis mîrb³), life conditions and the previous diseases (anamnesis vitae). Gynecological history should be taken in such a way.
Patient Complaints. Most often patients complain of pain, pathological secretions from vagina, bleeding and also of the adjacent organs’ dysfunction.
The character of pain may point out the disease: the dull pain arises due to abnormal uterine position and chronic inflammatory processes of ovaries. Colicky pain appears in case of uterine or tube contraction (tube or uterine abortion, protruding myoma). Pain has stabbing and stinging character in case of inflammation. Its intensity becomes more severe that is followed by peritoneal irritation. Such pain appears at blood presence in abdominal cavity. Pain has an acute, cutting character at uterine tube and pyosalpinx rupture. Permanent pain is typical for chronic inflammatory diseases and malignant tumors.
Pain appeares in sacrum and dorsal lumbar region in dorsal uterine dislocations (retropositio uteri), parametritis and perimetritis. in adnexal diseases pain is present in lateral regions of the lower parts of abdomen.
Leucorrhea is a discharge from vagina, that is common at inflammatory processes, uterine disposition and tumors. It is important to pay attention to amount, colour and smell of the discharge. For instance, at trichomoniasis it has “foamy” character, in case of candidiasis it is cheese-like, at cervix erosions it has mucous character, and in case of malignant tumors it looks like “meat slops”.
Bleeding can be the manifestation of irregular menstrual cycle, malignant processes and pregnancy.
The physician should inquire about disorders of adjacent organs such as the character and frequency of urination (pain, urine incompetence, extremely frequent urination), defecation (constipation presence, pain at defecation act ) and also about the general disorders (hot flushes, palpitation, dizziness, loss of weight or, to the contrary the obesity).
Gynecologic History (anamnesis morbi). The following questions are typical for gynecologic history:
l Is the onset of the disease acute or gradual?
l Have you had any previous examinations or treatment? Notes from the previous physicians may be helpful.
l What were the circumstances at the time when the problem has began (i. e. supercooling, physical overload, previous abortions and traumas)?
Life history (ànàmnåsis vitae) should define, in which conditions woman has grown up and was formed and also in which conditions she lives at present. Conditions, in which girl lived from early age can have effect on the development of the whole organism. Material-domestic and job conditions have also a great effect on woman’s health state.
Professional and work conditions. There are many professional factors, that have negative effect on woman’s health. first of all this is weight lifting, that can contribute to genital organs prolapse, long standing on feet can cause blood stagnation in lower extremities and in pelvic organs causing hypersecretion of mucous membranes. Salts of heavy metals, aniline paints, varnishes and some other chemical substances and radiation have harmful effect on woman’s health. most frequently their action causes menstrual and regenerative dysfunction. Mental overloads can also cause various disorders.
Previous diseases. It is important to find out whether the patient was ill with tuberculosis and sexually transmitted diseases. It is important to know whether the operative interventions on abdominal cavity organs took place. Appendectomy in the past can provoke ovarian inflammation and lately performed appendectomy should be a cause of adhesion process.
Special importance has allergic history, for instance, presence of allergic reactions on some medicines. The physician should inquire patient about harmful habits (smoking, alcoholism and drug abuse).
Gynecological history includes data about menstrual, sexual, generative and woman’s secretory functions.
Menstrual history reflects the state of sexual system and organism in a whole. It is important to establish^
· the patient’s age at first menstruation (menarche),
· the interval from the first day of one menstrual period to the first day of the next menstrual period (cycle length),
· the duration of the menstrual flow,
· the estimated amount of flow (number of pads)
· pain presence.
Sexual history. It is important to know whether the woman is married or not, about the presence of sexual partners, whether there appeared any signs of disease beginning of sexual life or with partner change. Patient’s contraceptive history should include the contraceptive method currently used, when it was firstly used, any problems or complications connected with the method and her partner’s satisfaction with the method.
Generative (childbearing) function. Child birth is the women’s basic function. In this part one ought to find out, in what time after the beginning of sexual life the first pregnancy had happened without contraception, how many pregnancies were in the past, what was the duration of each one and how they have finished (with delivery or abortion), whether there were premature births or, stillborn children.
Secretory history. Much discharge from genital organs is an indication of the gynecological diseases presence. It is necessary to know about amount, smell, appearance, discharge periodicity, because at different gynecological diseases their character differs (due to trichomonal vaginitis they have “foamy” character, in candidiasis — cheese-like character, in malignant tumors — the appearance of “meat slops”).
It starts from general examination. It is important to pay attention to the color of skin: pallor can indicate anemia, ground color characterizes malignant neoplasm presence.
Excessive hairiness, the lipids dysmetabolism can indicate presence of endocrine diseases.
Dry, coated tongue can indicate to the inflammatory process, “raspberry” one points to candidiasis.
attention should be paid to the form of the abdomen (tumors of abdominal cavity, ascitis). Special attention in examination of gynecological patient belongs to breasts palpation.
Gynecological examination. All the methods of gynecological examination are divided into basic which are obligatory, and additional those are performed according to certain indications.
To basic methods belong:
l external genital organs examination
l speculum examination
l bimanual (vaginal-abdominal and rectal-abdominal) examination
Following methods belong to additional ones:
l cytological examination
l bacterioscopic examination
l bacteriological examination
l examination with tenaculum
l uterine sounding
l dilatation and curettage with the following cervical canal and uterine histological examination
l biopsy, especially aspirative one
l pelviography, especially bicontrast one
l endoscopic methods: colposcopy, cervicoscopy, hysteroscopy, laparoscopy, culdoscopy
l functional tests (investigation of ovarian function)
l medical-genetic examination
Basic methods of examination
Gynecological examination is performed on the examination table. Woman lays on back, with half-flexed legs in femoral and knee joints. it is obligatory to empty the urinary bladder before examination. Examination is made in sterile gloves.
Pelvic examination begins with the inspection of external genital organs. Attention should be paid to pubic hair type (masculinizing, feminizing or mixed type), presence or absence of hair on the internal thigh surfaces. Skin irritation in the same places can occur at excessive discharge. Doctor should examine the labia major and labia minor, their size, pigmentation, presence or absence of edema, ulcers, condylomatous nodes and varicose veins.
After finishing of external genitals inspection vaginal speculum examination is performed. For this purpose single-blade Sims’ speculum with vaginal retractor or bivalve Cuskoe’s speculum are used (fig. 20, 21). Recently single-use bivalve specula were used.
Bivalve speculum is introduced into vagina with closed values. With thumb and index fingers of the left hand labia are drawn and speculum is inserted into vagina, placing blades parallel to pudendal cleft. After insertion speculum is turned on 90°. The speculum is inserted as far as it goes which in most women means insertion of the entire speculum length. The speculum is then opened in a smooth delicate way with slight tilting of the speculum, the cervix slides into space between the blades of the speculum. The speculum is then locked into the opened position using the thumb screw.
Sims speculum is inserted into vagina in such a way: with left hand labia major and minor are drawn laterally and with right one the speculum turned, slantwise to pudendal cleft is inserted into vagina, slightly pressing on perineum. Flat anterior speculum (lateral) should be inserted parallely, lifting up anterior wall of vagina (fig. 23). Flat speculum should be inserted additionally in case if vagina is wide and its lateral walls are hanging.
Uterine cervix, its size, shape (cylindrical, conic), shape of external os (round in nonparous women, fissured in parous ones) must be inspected.
Character of the cervical mucous membrane (cyanosis, hyperemia), erosions, ruptures, inversions, condylomas presence, hyperemia around external cervical orifice, secretions character may be marked.
After cervical examination speculum is gradually withdrawn, inspecting vaginal walls. Attention should be paid to the state of mucous membrane (hyperemia, edema), discharge character.
During inspection by Sims speculum at first the elevator, and then the speculum are withdrawn.
After finishing speculum examination, bimanual vaginal-abdominal (fig. 25) and rectal-abdominal examination should be performed.
The bimanual (vaginal-abdominal) examination. With thumb and index fingers of the left hand labia minor are spread. The middle and index fingers of the right hand are inserted into vagina, nameless and little fingers are pressed to palm, and thumb finger is facing the pubis. An examination is made by one finger if vagina is narrow. Fingers during insertion into vagina should be gently pushed downwards to avoid unpleasant feelings of irritation of the most sensible areas such as anterior wall, clitoris, region of urethra. During introducing fingers into vagina following signs are estimated: presence or absence of pain, outer width (in women, which live sexual life, two fingers enter easily). Determination of the muscles tone and perineum state is performed with pressing on the muscles of the pelvic floor. During gradual moving of fingers into vagina its length, width, ability to tension, rugosity, humidity degree, septums presence, tumors, scars, constrictions are determined.
Uterus is situated in pelvis in such a way that its body and cervix form an angle, opened frontally (anteflexio), and the whole uterus is flexed forward (anteversio). It is sufficiently mobile at displacement attempt. Overmobility of the uterus is observed at its descent and prolapses due to incompetence of ligament system. Limited movability is common at adhesions and infiltrates presence in true pelvis.
During uterus examination its size (in nonparous women it is smaller than in parous ones) is determined. Diminish of the uterus size is observed at genital infantilism and menopause. Enlarged uterus can be found at pregnancy and tumors presence. Uterine shape normally is pear-like, flattened in front-back direction, at pregnancy it can be asymmetric due to protrusion of implantation place, at subserous fibromyoma it is tuberous. Uterine consistency is tightly-elastic and painless.
Bimanual examination of the adnexa begins with placing the vaginal fingers to the side of the cervix deep in the lateral fornix. It is important to note that the fallopian tubes are not palpable. Ovaries can be palpated as elastic painless structures. They are mobile and rather sensitive. Normal uterine and ovarian ligaments could not determined. normally there is no pain and infiltration in paramethrium.
Additional methods of examination
They are: bacterioscopy examination (smear for purity degree), cytologic investigation of vaginal smears, bacteriological checkup, methods of functional diagnostics, colposcopy, biopsy, uterine sounding, fractional diagnostic curettage of cervical canal and uterine cavity with the following histological research, culdocentesis, pertubation and hydrotubation. X-ray examination methods such as hysterosalpingography, pelviography and bicontrast pelviography are also used. Colposcopy, hysteroscopy, laparoscopy and culdoscopy are endoscopic methods in gynecology. Ultrasonic examination is wide-spreaded nowadays. These methods are used for verification of the diagnosis. Cytologic investigation is obligatory for women who undergo monitoring.
Nurse or midwife prepares the woman and necessary instruments (specula, sets for abrasion, spoons or brushes for smear taking) for carrying out additional examinations. Nurse must prepare a bottle with 10 % formalin solution for tissual fixation of the biopsy tissue after curettage. Proper assignment registration on research is of great importance.
Smears from vagina are taken for purity degree, gonorrhea, oncocytologic investigation, “hormonal mirror”.
Following instruments are necessary for material taking:
l vaginal specula
l Folkman’s spoon or gynecological spatula or brush
l glass slide
l cotton swab
l antiseptic solution
l registration form for laboratory
l to place the patient on examining table
l to make desinfection of external genitalia
l to insert gynecological speculum into vagina, dispose cervix in speculums
Bacterioscopic investigation of vaginal discharge gives possibility to determine vaginal purity degree, bacterial flora, presence of contraindications to different diagnostic manipulations. This method gives possibility to diagnose inflammatory process.
Technique of smear taking for examination on vaginal purity degree:
l to insert a gynecological speculum into vagina
l to take some discharge from the posterior vaginal fornix with gynecologic forceps, spatula, gutter sound, or Folkman’s spoon and by stroking motions to drift it on a glass slide
l withdraw a speculum from vagina
l write out an order to laboratory
Laboratory assistant quantifies epithelium cells, leukocyte number, microflora character (Doderlein’s bacillus, pathogenic flora — gram-negative bacillus, cocci, fungi, trichomonades, gonococci) and also reaction of vaginal discharge.
There are 4 stages of vaginal discharge purity.
Smear on gonorrhea presence. Material for research is taken just from the cervical canal, urethra (before urination after light massage of the posterior urethra wall) and rectum drift on a glass slide as separate strokes.
Bacteriological research is taken to find the pathogene and its sensitiveness to antibiotics. Material for research is a content of cervical canal, vagina, urethra and puncture material. This material should be sent into bacteriological laboratory. It is necessary to indicate the date and time when the material was taken.
Oncocytologic research (Pap smear) is made for the early diagnostics of oncologic diseases.
Smear taking technique for oncocytologic research:
l speculum insertion
l carefully taking the discharge from the cervix by cotton swab which is clutched in forceps
l material for investigation is taken by gynecological disposable wooden spatula from the anterior and lateral vaults of vagina, external cervical os, vaginal part of cervix and from pathologically altered parts which are revealed during colposcopy. Material is taken by brush or gutter probe (fig. 26 a, b)
l drift it on the glass slide (fig. 27)
l withdraw a speculum
l write an order to the laboratory
Cytological investigation gives a possibility to reveal women who need more detailed examination (biopsy, diagnostic curretage, etc).
There are 5 Pap smear types:
l I type — unaltered epithelium
l ²²-à type — inflammatory process
l ²²-b type — proliferation, metaplasia, hyperkeratosis (at corresponding clinical picture they are interpreted as polyp, simple leukoplakia, endocervicosis
l ²²²-à type — light, moderate, dysplasia on the background of benign processes on unaltered epithelium
l ²²²-b type — severe dysplasia of squamous epithelium on the background of benign processes and on unaltered epithelium
l IV type — suspicion on malignisation, intraepithelial cancer should be possible
l V type — cancer
l VI type — smear is non-informative (material has been taken in a wrong way)
Smear on “hormonal mirror”. Material is taken by light touch of instrument from the upper one-third of lateral vaults not earlier than in 2 days after cessation of any manipulations in vagina. The taken material is thinly smeared on a glass slide. Woman’s age, pregnancy term or day of menstrual cycle is indicated.
This method can be used for diagnostics of pregnancy loss, menstrual cycle disordes and also as a control for hormone therapy results.
Methods of functional diagnostics
Properties of cervical mucus. Properties of cervical mucus are changing due to estrogen and progesterone action during menstrual cycle. Maximum quantity is secreted during ovulation, the minimum is secreted before menses.
1. The mucus tension symptom. In case, when you place some mucus from cervical canal between forceps legs and carefully move them apart, then you’ll get a mucus string, the length of which depends on the mucus viscosity. Maximum length of the string will be in ovulation period when mucus viscosity is maximal. String’s length is measured in centimeters (the greater estrogen production the longer is the string) and is estimated for 3-point system: 1 point (+) at string length up to 6 cm (early follicular phase), 2 point (++) — 8-10 cm (medium follicular phase, moderate estrogen saturation), and 3 point (+++) when string length is
15 cm and more (maximum estrogen saturation). tension symptom diminishes and then disappears in luteal phase of menstrual cycle.
2. The “pupil symptom”. cervical tone and its external os diameter are changing during menstrual cycle under the influence of estrogen hormones. Dilatation of external cervical os and mucus appearance in it starts from the 8-9th cycle day and up to the 14th day it is maximally dilated (up to 3-6 mm in diameter). Mucus drop, that comes forward from external os seems to be dark and looks like a pupil at illumination on the background of pink cervix. this is a positive “pupil” symptom. Amount of mucus begins to decrease during the next days and up to 18th-20th day of the cycle this symptom disappears and cervix becomes “dry”. Such changes are typical for normal menstrual cycle. In case of follicle persistence, the “pupil” symptom does not disappear up to the time when bleeding occurs. This indicates on hyperestrogenemia and absence of luteal phase in ovaries. The “pupil” symptom is slightly positive or absent at amenorrhea. This symptom is also absent during pregnancy. The “pupil” symptom is estimated on the 3-point system: presence of small dark dot means 1 point (+), early follicular phase; 2,0-2,5 mm — 2 points (++), medium follicle phase; and 3,5 mm — 3 points (+++), ovulation. If cervix is strained by postnatal ruptures, erosion or endocervicitis test is unreliable.
3. The “fern symptom”. The “fern test” is used to distinguish the ovaries functional state. It is named from the pattern of absorbtion that occurs when discharge is placed on a slide and is allowed to be dried in the room air. Arborisation intensity depends on the menstrual cycle phase i.e. on the ovarian estrogenic effect. Mucus is taken by forceps, which are inserted into cervical canal to depth of 5 mm. Then it is drifted on a glass slide, dried up and examined under the microscope. such varieties of “ferm symptom” are distinguished (fig. 28 a-d) as:
a) separated leaves of the fern plant (when the quantity of estrogen secretion is the minimal) — 1 point (+), early follicular phase;
b) expressed leaves of the fern plant — 2 points (++), medium follicle phase with moderate estrogen secretion;
c) thick stems and leaves deviate at angle of 90° (in the period of ovulation, when more estrogens are present) — 3 points (+++);
d) negative symptom.
thick stems and leaves deviate at angle of 90° (in the period of ovulation, when more estrogens are present) — 3 points (+++);
This test like the previous one is used for ovulation determination. Presence of “fern symptom” during the whole menstrual cycle indicates on high estrogen saturation (persistation of the follicle) and absence of the luteal phase; absence of this symptom can testify about estrogen insufficiency. Diagnostic value of all the described above tests is considerably increased in their complex using.
Cervix index or cervical number (maximum value of each point is — 3, minimum — 0 (table 1) should be determined after the summarizing of the amount of all the points received from each test.
Cervical index up to 3 numbers indicates on the expressed estrogen insufficiency, 4-6 — moderate estrogen insufficiency, 7-9 — sufficient estrogen saturation, 10-12 — high saturation. Cervical index estimates presence or absence of ovulation and cyclic changes of the organism’s estrogen stimulation.
Basal temperature. Basal temperature (BT) changing is based on the hyperthermic influence of progesterone on hypothalamus. BT is measured in rectum in the morning regularly by the same thermometer with the empty stomach, without getting up. In first phase of menstrual cycle temperature is below 37 °Ñ (0,2-0,3° lower), after ovulation it rises and holds on between 37,1-37,4 °Ñ. Basal temperature change indicates on presence or absence of ovulation, follicle persistence, threatened abortion and some other states. This test is simple, easily available and sufficiently objective, however one should remember, that any causes of non-hormonal character (diseases, that are accompanied with temperature reaction) can affect it. It is necessary to carry out measuring during 2-3 cycles. Only in this case this method has the diagnostic value.
Cytological examination of vaginal smears
during examining degree of estrogen saturation determines the morphology of vaginal epithelium, which is changing during menstrual cycle. Basal, parabasal, intermediate, superficial layers are distinguished in the stratified squamous epithelium of vagina. Vaginal epithelium is exposed to rhythmic changes during menstrual cycle, that is characterized by different stages of mucous membrane proliferation. According to degree of organism saturation by estrogens, superficial, intermediate and basal cells in different ratio are differed. Method of colpocytodiagnostics is based on the determination of quantity and morphological peculiarities of epithelial cells.
Such indexes are determined:
l maturity index is a correlation of superficial, intermediate, parabasal and basal cells ratio, expressed in percents; index is written in such a way: parabasal/intermediate/superficial (parabasal and basal cells are counted up together)
l cariopicnotic index (CPI) is a correlation of superficial cells with picnotic nuclear and general amount of cells ratio expressed in percents. CPI is directly proportional to the degree of organism’s estrogen saturation
l eosinophile index — superficial cells with eosinophile cytoplasm and cells with basophilic cytoplasm ratio expressed in percents
Cells’ disposition (layers presence) and amount of the “rolled up” cells should be determined for revealing of progesterone effect on vaginal epithelium. Progesterone stimulation degree is estimated for 3-point system too: the plenty of the “rolled up cells” makes 3 points (+++), moderate amount makes 2 points (++), low quantity makes 1 point (+), undetermined cells makes 0 (-).
Due to functional diagnostics tests and cytological research data normal menogram may be represented (table 2).
Endoscopic methods of examination
Colposcopy, cervicoscopy, hysteroscopy, laparoscopy and culdoscopy are used in gynecology. Endoscopes are necessary for all these methods. Some of them have manipulators, with the help of which some medical operations in abdominal cavity could be performed.
Colposcopy is the first endoscopic method that is wide spread in gynecology.
Colposcopy. A colposcope is a fixed stereomicroscope with a source of internal light and magnification in 10-30 times used to facilitate the detailed examination of the cervical surface, vagina and vulva when malignacy is suspected. It is used to make direct biopsies of suspecious area and to control the process of healing during the treatment. Diagnostic value of this method is extraordinarily great.
There are simple and broadened colposcopies. During simple colposcopy cervix is visualized without the previous processing with chemical substances. During broadened colposcopy cervix is examined after application of 3% solution of acetic acid with 3% Lugol solution.
Some models of colposcope allow to make research by method of fluorescent analysis thanks to revealing of secondary gleaming in ultra-violet rays.
Simple colposcopy has preliminary character and gives possibility to define the cervix and its external os, colour, relief of mucous membrane and squamo-columnar junction.
After the simple colposcopy cervix is processed by 3% solution of acetic acid, which causes temporary (up to 3 min) epithelium edema, constriction of the subepithelial vessels and decreasing of blood supply. This method is called broadened colposcopy. It gives a possibility to distinguish distinctly flat epithelium from the columnar one, to find the epithelium transformation, state of glands ducts etc. After this cervix is processed with 3% Lugol solution (Shiller’s test). Iodine has ability to paint the cells, rich with glycogen into brown color. Pathologically altered cells (at dysplasias), and also atrophic cells are poor with glycogen, that’s why they are not painted with iodine and look like white blots. In such a way the areas that undergo biopsy are revealed.
One of the modifications of broadened colposcopy is cervical chromocolposcopy. It is performed after application of some paints: hematoxylin, toluidin blue or methylviolet. The last one paints tissues into the violet colour (only the squamous epithelium). Usage of these dye-stuffs allows to find borders of lesion and to choose the area for biopsy.
Colpomicroscopy is a histological examination of vaginal part of cervix without making a biopsy. This research is made with contrasting luminescent colpomicroscope, the tubes of which are directly enclosed to cervix. Before examination cervix is processed with 0,1% hematoxylin solution. then nuclei acquire violet colour, cytoplasm is sky-blue; cells of the squamous epithelium have polygonal form and distinct borders. Subepithelial vessels have proper, not expanded bifurcations. This method has high accuracy. its results in 97-98 % of cases correlate with histological research data.
Hysteroscopy is the method by which uterine mucous state, presence of polyps, cancer, synechias and submucous fibromyoma of uterus may be diagnosed, polypectomy should be controlled, and place of sighting biopsy is chosen. Modern hysteroscopes make magnification in 5 times (fig. 31).
After dilation of cervical canal hysteroscope is inserted into the uterine cavity. Hysteroscopy is performed introducing into its cavity carbonic gas (gaseous hysteroscopy) or liquid (liquid hysteroscopy). Preference is given to liquid hysteroscopy (inserting of the isotonic Sodium chloride solution, Polyglucin etc.), because it gives a possibility to make control after diagnostic curettage. it is also performed at uterine bleeding. Liquid washing the walls improves examination possibility.
Indications for making hysteroscopy: cyclic and acyclic uterine bleedings, suspicion on intrauterine pathology, and especially continuation of bleeding after fractional diagnostic curettage. This method is also of a great value to control treatment of hyperplastic processes.
Contra-indications for hysteroscopy: acute inflammatory diseases of genital organs, III-IV stages of vaginal cleaning, and also extragenital pathology such as thrombophlebitis, acute pyelonephritis, serious cardiac-vascular pathology. Special hysteroscopes with manipulators are introduced recently. They are able to perform polypectomy, submucous myomatous nodes enucleation, intrauterine contraceptives insertion.
Laparoscopy gives a possibility to visualize internal organs of the abdominal cavity, including the organs of true pelvis (fig. 32-34). Ovarian and uterine tumors, extragenital tumors, ectopic pregnancy, polycystic ovaries and ovarian inflammatory processes may be diagnosed with laparoscopy. Except that, this method can specify the cause of the “acute abdomen”.
recently laparoscopy is used not only as a diagnostic method. Laparoscopy becomes a necessary method for taking of ovum with aim of the extracorporal insemination.
New models of laparoscopes are created. They are used for ovarian biopsy, cystectomy, dissection of adhesions and other operations.
Indications for laparoscopy in planned order:
l determining of uterine tubes permeability simultaneously with chromoperturbation
l diagnostics of ovarian cystic disease
l diagnosing of uterine abnormalities
l performing of small operative interventions
In urgent cases laparoscopy is performed for diagnostics of:
l pyosalpinx rupture or microperforation
l ruptured ectopic pregnancy
l ovarian apoplexy
Contra-indications to laparoscopy: decompensed heart failure, essential hypertension, kidneys’ and liver insufficiency and other severe diseases.
Culdoscopy is made for ovaries examination in case of obesity. This method is rarely used. it is almost displaced by laparoscopy. Intervention is made under the local anesthesia with 0,25% Novocain solution. Examination is made in knee-elbow position of the woman. under specula control a needle is introduced into posterior fornix, air penetrates through it into abdominal cavity independently. Bowels then move to diaphragm. Cut of 3-5 mm length at posterior fornix is made to introduce the laparoscope optical system. Accessible for examination area done with this method is considerably less than at laparoscopy — one can see posterior uterine surface, ovaries, tubes.
Contra-indications to culdoscopy: presence of adhesions in small pelvis, tumors of small pelvis, and also extragenital pathology, that is contraindication to laparoscopy.
This method is based on tissual ability to absorb or to reflect ultrasonic waves in different ways. It is used for diagnostics of tumors, differential diagnostics between tumor and pregnancy. The examination is made while urinary bladder is filled that makes some discomfort for women. The day before it is necessary to make the evacuant enema.
vaginal sonography and dopplerometry are widely used for recent years (fig. 35). Last models are so perfect that they are used for follicle growth control, ovulation observing (fig. 36, 37), endometrial thickness, hyperplasia and polyps determination. Vaginal sonography allows to diagnose a pathology without filling urinary bladder. Obesity and adhesion process do not affect on this examination. This method gives a possibility to diagnose retrocervical endometriosis and ovarian inflammation that is impossible to diagnose by the abdominal sonography.
Instrumental methods of examination
Examination by tenaculum gives a possibility to specify uterine and ovarian tumors origin.
Necessary instruments: Sims speculum with retractor, pincers and tenaculum.
Cervix is opened by specula, then it is processed with disinfective solution and gripped by the anterior lip with tenaculum. Specula are taken out after that. The tumor is displaced upwards during the bimanual examination. If tumor is connected with uterus, then another method should be used. The doctor displaces tumor upwards, and assistant pushes the tenaculum downwards. During this tumor’s pedicle stretches and becomes accessible for examination.
Uterine sounding. This method allows to determine cervical canal permeability, length and configuration of uterine cavity, neoplasm presence in uterus. Sounding is used not only as a single diagnostic method, but it is a stage of some operations (dilation and curettage).
necessary instruments: specula, pincers, tenaculum and uterine sound. Manipulation is made in extraordinarily sterile conditions. Sound is an incurved metallic instrument 20-30 cm long, with transversal centimeter points. there is a bulbous nodule on the probe end.
Operation technique. After speculum examination and disinfection the cervix is gripped for the anterior lip with tenaculum. Retractor is taken out dragging the cervix introitus of vagina, a little posteriorly (at anteflexio uterine position), straightening the cervical canal. Sound is carefully pulled through the external os into the canal and beyond the borders of internal os, which is felt as nonsignificant resistance, then into uterine cavity. At anteflexio uterine position, sound is directed forward, in retroflexio — backwards. Sound insertion allows to measure uterine length, then to determine the form of its cavity by sliding on anterior, posterior and lateral uterine walls, presence of tumors, membranes and polyps in it. Sounding is made exceptionally in stabile patients condition, because sometimes such complications as bleeding and uterine perforation may develop.
Contra-indications to this operation: ²²²-²V stages of vagina purity,vaginitis, endometritis, cervical neoplasia, suspicion on pregnancy.
Biopsy is a tissue taking for histological research (fig. 38). Most frequently biopsy is taken from the cervix at erosions, dysplasias, papillomas presence. It is performed under control of colposcopy. Sometimes tissue for research is taken from female external genitalia such as vulva, vaginal walls, and from the other places depending on the lesion localization.
Sims speculum with retractor, forceps, tenaculum, scalpel or conchotom are necessary for biopsy (fig. 128). Cervix is examined with specula, then it is disinfected and gripped with two tenaculums on both sides of biopsy place. A slice of tissue should be cut out in such a way, that there must be not only altered, but also non-altered tissue. Material can be taken also by conchotom. The tissue is poured over with 10 % formalin solution and then sent to histological laboratory.
Diagnostic fractional dilatation and curettage. This method is one of the biopsy modifications. It is made if polyps, dysfunctional uterine bleeding, suspicion on polyposis of mucous membrane, malignant tumors are present. before the operation pubic hair should be shaved and urinary bladder emptied. The following instruments are necessary: Sims speculum with retractor, pincers, tenaculum, uterine sound, Hegars dilators and curettes.
The operation is performed under the general (intravenous) or local (paracervical) anesthesia. Novocain anesthesia must be done in sterile conditions. Cervix is disclosed by specula and desinfected. The anterior lip is gripped with tenaculum, then it is pulled a little posteriorly (at anteflexio uterine position) or to symphisis (at retroflexio uterine position). Uterine sound for its length determination is used. Hegars dilators are inserted into the cervical canal. each one is 0,5 mm wider, than previous one. Dilation is made up to 9-10 number of dilator. After dilation the curette is inserted. One should watch whether its curve coincides with the uterine curve. Then insert the curette into the cervical canal and scrape off its walls. the material is collected into the separate bottle with 10% formalin solution. Curette end reaches the uterine fundus and then gradually scrape off mucous from all the uterine walls by motions from fundus to cervix. The obtained material is inundated with 10 % formalin solution and send to histological research.
Contra-indications to operation: III-IV stages of vaginal purity, acute inflammation of uterus and its adnexa, infectious diseases, rising temperature (except of the cases when abrasion is made for cure purpose and according to vital indications).
Culdocentesis. Puncture of abdominal cavity is made through the posterior fornix (fig. 39). This method gives a possibility to diagnose (or to exclude) ectopic pregnancy or pelvioperitonitis by receiving blood or exudation of inflammatory character (serous, purulent) from abdominal cavity. Puncture of abdominal cavity is made through the anterior vaginal wall at ascitis presence.
Sims speculum with retractor, tenaculum, syringe with long needle and forceps are necessary for culdocentesis. Preparing is the same as for uterine dilation and curretage.
The technique for culdocentesis involves needle puncture of the posterior vaginal cuff to identify free fluid in the posterior fornix
Cervix is disclosed by specula and disinfected. The posterior lip is gripped with globular forceps, cervix is pulled forward making posterior fornix visible. Puncture is made by needle in the middle of sacro-uterine ligaments on the depth of 1-2 cm. After that the syringe piston is weight down at simultaneous slow moving out the needle. If pus is present during the punction, it is send into laboratory for bacteriological investigation. Antibiotics are injected into abdominal cavity.
Determination of uterine tubes’ permeability. For examination of uterine tubes’ permeability insertion of air (pertubation) or liquid (hydrotubation) is performed. For this method speculum with retractor, tenaculum, special apparatus which consists of tubes system with balloon for pumping air or with device for insertion of liquid are required. This system is connected with pressure-gauge showing the pressure, under which air or liquid is pumped. Manipulation is made in sterile condition.
Contraindications: III-IV stages of vaginal purity degree, vaginitis, cervicitis, acute and subacute inflammatory processes in uterus and its adnexa. Non-keeping of these demands can cause complications up to peritonitis.
Operation technique. Woman lays on the table. Cervix is disclosed in speculums and disinfected. The anterior lip is gripped with globular forceps, and a device’s tip is inserted into the cervical canal. Air or liquid pumped by balloon pass through the uterus into the tubes. Kymograph record of tubes’ contractions should be used during pertubation. It is necessary to perform hydrotubation and pertubation during the first week after menses. Air or liquid is pumped up to
100 mm.Hg pressure, then a short pause should be made and then pressure is raised up to 150 mm.Hg. Maximal pressure to which air or liquid can be pumped is 180 mm.Hg.
At uterine tubes occlusion the following signs are present:
l pressure-gauge indicator does not fall
l there is no sound during auscultation typical for air or liquid passage through tubes
l pressure grows on kymography data
Permeability of the uterine tubes can also be defined in a retrograde way. During laparotomy a special cannula is inserted into tube’s ampula, then it is snuggled with fingers and by syringe the liquid is injected into the tube. At tubes’ occlusion they are stretched by liquid in the obstructed place.
Methods of X-ray examination
Hysterosalpingography (metrosalpingography) gives a possibility to re-search tubes’ permeability, defects of internal genitalia,uterine abnormalities, endometriosis, presence of submucous fibrous nodes, synechias (fig. 40-42).
Contraindications for this method: inflammatory processes of woman’s genitalia, suspicion on pregnancy, III-IV stages of vaginal purity degree. Instruments, necessary for hysterosalpingography: Sims speculum with retractor, tenaculum, Brown’s syringe and contrasting substance.
The technique: The cervix is opened by specula and disinfected. The anterior lip is gripped with tenaculum, contrasting substance is inserted into uterus by Brown’s syringe and then X-ray examination is made. The internal contours of uterus are clearly visible on the film, its cavity has triangle form. Contrasting substance outpours into abdominal cavity through the permeable tubes.
Rhoentgenopelviography. Through a special device carbon gas is inserted into the abdominal cavity (through puncture of frontal abdominal wall, or posterior fornix). Roentgenogram should be made after this. The configuration of uterus, ligaments and ovaries are perfectly visible. This method is used at suspicion on uterine abnormality, polycystosis.
Bicontrast pelviography is a combination of metrosalpingography and pelviography. This method gives a possibility to perform detailed examination of the internal genitalia condition.
Rhoentgenological examination of the adrenal glands on the background of pneumoperitoneum and rhoentgenogram of turkish saddle in some cases is required.
For diagnostics in gynecology axial computered tomography is rarely used in everyday practice. It is expensive method.
This method includes medical-genetic counseling and cytological research.
Cytogenetic analysis is performed by genetics specialists. One of the basic methods of cytogenetic investigation is the sexual chromatin determination. This method plays an important role in diagnostics of congenital defects of genital glands. Determination of sexual chromatin is made in nucleus of superficial epithelial cells, which are received by abrasion from mucous membrane of internal cheek surface by spatula.
One of X-chromosomes makes sexual chromatin. Normally its quantity is 16-28% (quantity of nuclei that possess a corpuscle of sexual chromatin per 100 counted nuclei). Changing of quantity and structure of sexual chromosomes leads to changing of percent of sexual chromatin containing.
Determination of sexual chromatin can be used as a screening-test. Analysis of caryotype in connection with its complicity is made only for some indications, namely: deviation in sexual chromatin amount, presence of short height in patients, plural, frequently effaced anomalies of somatic development, dysplasias, and also in plural mutations or spontaneous abortions in early terms of pregnancy.
Determination of caryotype is obligatory in patients with gonad dysgenesia, because presence of Y-chromosome indicates on the high risk of malignant growth possibility.
Pelvic pain is a common complaint. It may originate in pelvic or extrapelvic organs, or it may be secondary to a systemic disease. Sometimes no cause is found.
Pelvic pain may be due to a surgical emergency (eg, ovarian cyst torsion, ectopic pregnancy, ruptured tubo-ovarian abscess, appendicitis, bowel perforation). Chronic pelvic pain (lasting >= 6 mo) may require surgical intervention and can be debilitating.
Categorizing pain as cyclic or noncyclic may help determine the cause. However, disorders causing cyclic pain occasionally cause noncyclic pain, and vice versa.
History: A thorough history--including the type, location, radiation, status (stable or increasing or decreasing in severity), and onset (circumstances and suddenness) of the pain--can help identify the cause (see Table 237-1). The patient should be asked if any factors exacerbate or alleviate the pain and if the pain is related to menses, movement, micturition, defecation, sexual activity, sleep, or eating.
The history should include past surgical procedures and episodes of pelvic inflammatory disease. The patient should be asked about past treatment of the pain and its effectiveness. A detailed menstrual history (including time of menarche, cycle regularity and length, duration of menses, and amount of blood loss) should be obtained. Whether the pain began with menarche or is relatively new should be determined.
Physical examination: General observation may be diagnostically helpful; eg, poor posture and ambulation difficulties suggest a musculoskeletal cause.
The abdomen is examined for tenderness or masses. If a painful area is found, the patient should be asked whether this pain is the same as the primary complaint.
Pelvic examination: Examination of the introitus includes culture of a specimen obtained with a cotton swab to identify agents (eg, Candida sp) responsible for vulvar pain syndromes, including vulvar vestibulitis, a cause of dyspareunia. A sequential one-finger vaginal examination of the bladder, urethra, cervix, fornices, rectum, and levator muscles can help differentiate pelvic pain from lower abdominal muscular pain. Bladder and urethral pain, associated with such disorders as interstitial cystitis, can be elicited when the anterior vaginal wall is palpated. Levator spasm is present if pain is felt when the levator muscles behind the posterior vaginal wall are palpated. Assessment of cervical motion tenderness, vaginal fornix pain, and adnexal tenderness can help differentiate pelvic inflammatory disease or endometriosis from adhesions.
During bimanual examination, uterine size, tenderness, and mobility are evaluated. A markedly enlarged, bulky uterus suggests fibroids; a mildly enlarged, boggy, symmetric uterus suggests adenomyosis. Fixation of the uterus may indicate adhesions or endometriosis. Uterosacral nodularity (confirmed by a rectal examination) suggests endometriosis. A rectal examination should always be performed, and the stool should be tested for occult blood.
Special procedures: Laboratory tests are of limited use in evaluating patients with pelvic pain. A serum or urine pregnancy test should be performed. For patients with bleeding, measuring Hb or Hct identifies anemia. Measuring ESR or C-reactive protein may help identify an inflammatory or infectious process.
Ultrasonography may help if a physical examination is difficult (eg, if the patient has pain) or if an adnexal mass is suspected. However, inconclusive ultrasound results may further confuse the diagnosis, resulting in additional tests and/or unnecessary surgery.
Diagnostic laparoscopy is appropriate if a patient has severe pain and the diagnosis is unclear, if pathology is suspected on the basis of the history and physical examination, or if a patient does not respond or responds poorly to medical therapy (eg, oral contraceptives, NSAIDs). Laparoscopy can confirm the diagnosis and provide histologic documentation. It can also confirm that there is no anatomic abnormality of the pelvic or abdominal organs.
Treatment should be directed at the specific cause of the pain, if possible. However, symptomatic treatment with NSAIDs is often the only option. Patients who have a poor or partial response to one NSAID may respond well to another one. Hypnosis helps relieve pelvic pain due to functional causes unamenable to surgery.
Uterosacral nerve ablation is reserved for patients with central pelvic pain or dysmenorrhea unresponsive to medical therapy. Long-term complications are unknown. Presacral neurectomy is reserved for patients with central pelvic pain, dysmenorrhea, deep-thrust dyspareunia, or sacral backache unresponsive to conservative therapy.
Hysterectomy is reserved for patients with chronic pelvic pain unresponsive to medical or conservative surgical therapy. Patients without known organic pelvic disease must be informed that their pain may remain or even worsen after hysterectomy.
Nerve block or transection may be helpful when malignancies are inoperable but is of little use if they have metastasized. Nerve blocks can also be performed in some women with severe chronic pain syndromes of unknown etiology after workup.
Cyclic Pelvic Pain
Cyclic pelvic pain occurs in 30 to 50% of reproductive-aged women; it is severe enough to interfere with normal activity in 10 to 15%. Cyclic pain may suggest a pelvic cause, but not all pain that occurs during the menstrual cycle has a pelvic cause. It may be due to disorders affecting other abdominal organs or psychosomatic or musculoskeletal disorders.
The premenstrual syndrome (PMS) may produce pelvic heaviness or pressure and backache, occurring 7 to 10 days before and disappearing after menses begins (see Ch. 235).
Mittelschmerz (severe midcycle pain due to ovulation) frequently occurs. Rupture of the follicle and subsequent irritation of the peritoneum (by the fluid and/or blood from the ruptured follicle) may produce the pain. The pain, although sometimes severe, resolves spontaneously. Patients should be monitored and given NSAIDs.
Dysmenorrhea (pain related to the menstrual cycle) can be primary or secondary (see Ch. 235). Most women experience primary dysmenorrhea at some time during their life. The pain is cramping or sharp and lasts the first few days of the menstrual period. It may radiate to the back, thighs, or deep pelvis. Occasionally, nausea or vomiting occurs. Secondary dysmenorrhea may be due to endometriosis or cervical stenosis or, if associated with heavy menstrual flow, to fibroids (see Ch. 240), adenomyosis, or large endometrial polyps. Using gonadotropin-releasing hormone agonists to suppress secondary dysmenorrhea associated with PMS may help in diagnosis, but long-term use (> 6 mo) requires caution and coadministration of exogenous estrogen. Adjunctive use of antidepressants relieves pain through peripheral neuroblockade and central stimulation.
Endometriosis can cause mild to severe pain, probably from irritation of pain fibers on the peritoneal surface (see Ch. 239). In its early stages, endometriosis causes cyclic pain, which starts several days before menses and continues through the first few days. However, as the disorder becomes chronic, pain commonly occurs at variable times unrelated to menses.
Noncyclic Pelvic Pain
Of pelvic origin: Sudden, severe pelvic pain associated with a pelvic mass indicates a serious underlying disorder. An incarcerated uterus can cause acute pelvic pain early in pregnancy and is usually associated with retroversion and pelvic adhesions. Acute growth or degeneration of a uterine myoma can also cause acute pain.
Ectopic pregnancy manifests as acute pelvic pain, menstrual irregularity, and an adnexal mass
Ovarian cysts and masses are frequently asymptomatic but may cause pressure, aching, or heaviness. Sudden sharp pain may indicate rupture, adnexal torsion, or hemorrhage. Hemorrhage into a cyst or leakage into the pelvis is very common and produces severe pain. A ruptured dermoid cyst can cause severe chemical peritonitis. For ovarian cyst torsion, the pedicle can be untwisted if it appears viable. A thrombosed ovarian vein with prolonged torsion requires removal of the affected ovary to prevent subsequent thromboembolism.
Acute pelvic inflammatory disease (salpingitis, endometritis) is usually bilateral and is associated with severe lower abdominal pain and cervical motion tenderness (see Ch. 238). Fever, leukocytosis, and a mucopurulent cervical discharge usually accompany the pain. Nausea and vomiting are uncommon. Tubo-ovarian abscess is a late complication, and rupture may temporarily reduce the pain but is followed by sudden severe, unrelenting pain and deterioration requiring surgical intervention.
Pelvic congestion syndrome is pain that occurs 7 to 10 days before menses. It is more severe when the woman sits or stands and is relieved by lying down. It is thought to be caused by vascular congestion or varicosities of the pelvic veins. It is often accompanied by low back pain, leg ache, and dyspareunia and, less often, by fatigue, mood lability, headache, and abdominal bloating similar to symptoms of PMS. On examination, the uterus is usually tender, and the pain during the examination is the same as that during sexual intercourse. The pain usually responds to NSAIDs.
Retroversion of the uterus is an uncommon cause of pelvic pain. Symptoms include pelvic pressure and low back pain. A successful trial with a pessary predicts a good response to surgery. Vaginal hysterectomy or uterine suspension may be performed depending on the patient's desire to have children.
Adhesions resulting from previous surgery or pelvic infection may cause pain. Patients should be warned that the removal of adhesions (adhesiolysis) may make the pain worse and that even if surgery is beneficial, the adhesions may recur and cause further pain.
Deep-thrust dyspareunia (see Ch. 243) with no intrinsic abnormality is common. Instructing the partner to lessen the depth of thrust during intercourse can provide relief.
Pelvic malignancy is an uncommon cause of pelvic pain (see Ch. 241).
Vulvodynia (vulvar pain) is pain with no apparent cause. Scarring from an episiotomy may cause it. Vestibulitis must be ruled out, and psychogenic causes must be considered.
Of extrapelvic origin: Pain may be referred from extrapelvic organs to the pelvis.
In up to 60% of cases, pelvic pain can be attributed to GI problems. Because the bowel and pelvic organs share visceral innervation, lower abdominal pain of GI origin is often confused with that of pelvic origin. Peritonitis due to a pelvic infection is difficult to differentiate from that due to appendicitis.
Correlation of pain with eating or defecation suggests GI disease. Alternating constipation and diarrhea, lessening of pain after a bowel movement, prompt urge to evacuate after eating, or worsening of pain with stress suggests irritable bowel syndrome or spastic colon. Dyspareunia may be linked with irritable bowel syndrome. Hard, infrequent stools with pain during or after bowel movements, rectal fullness, or a sensation of incomplete evacuation suggests chronic constipation. Recurrent left lower quadrant pain with fever, especially in a woman > 40 yr, suggests diverticulitis. Inflammatory bowel disease, suggested by tenderness of the rectum, and cancer are uncommon but should be ruled out. Surgical emergencies, such as appendicitis, usually manifest more acutely but should be considered.
If the pain does not progress, further search for the cause is indicated before initiating treatment. Ultrasound examinations during the episode may reveal gallbladder or ureteral stones. In selected patients, sigmoidoscopy, colonoscopy, or barium enema is appropriate.
Typical symptoms of urinary tract problems include frequency, dysuria, burning, fever, chills, hematuria, and colicky ureteral pain. Occasionally, the only finding is tenderness over the suprapubic or trigone area. Urinalysis, cystourethroscopy, and urodynamic studies help in diagnosis. Postcoital voiding difficulties suggest the urethral syndrome (dysuria and frequency without bacteriuria), with or without chronic urethritis. This syndrome may require urethral dilation. Once symptoms are alleviated, the woman should regularly void after coitus to reduce the risk of recurrence.
Pain that radiates down the legs or is worsened by motion suggests a musculoskeletal problem. Poor posture, abnormal gait, scoliosis, unilateral standing, marked lumbar lordosis, discrepancy in leg length, previous surgery with a diagnosis of a normal pelvis, or a history of low back trauma suggests a musculoskeletal cause.
Symptomatic pelvic relaxation (cystocele, rectocele, or uterine prolapse) or pelvic tumors can cause symptoms of pressure, pelvic heaviness, or a sensation of the "organs falling out of the vagina."
Backache, a common complaint, is more often caused by poor posture, lack of exercise, trauma, or a skeletal disease (eg, osteoporosis, ruptured disk of the spine, osteoarthritis, bone tumor) than by a gynecologic disorder.
Separation of the pubic symphysis is a rare cause of pelvic pain, most commonly secondary to pregnancy. A history of pubic pain during ambulation and pain on pressure of the pubic bone during the abdominal or pelvic examination establish the diagnosis. The patient is treated with pelvic rest and, if not breastfeeding, NSAIDs. The disorder may take up to 6 mo to resolve.
Abdominal wall trigger points can cause pelvic pain and may be identified by an abdominal examination of the lateral borders of the rectus muscle. Trigger points can be injected with a local anesthetic (<= 10 mL bupivacaine 0.25%), resulting in complete pain resolution. If trigger points are not directly injected, the injection may be less effective but still lessens tenderness, relaxes the muscle spasm, and lessens pain when the rectus muscle is palpated. Physical therapy, NSAIDs, muscle relaxants, and application of heat are useful adjuncts.
Laboratory studies are needed to rule out organic causes of pain. Somatization disorder is a common psychogenic disorder in patients with chronic pelvic pain (see Ch. 186). Emotional problems may manifest as physical complaints. Often the patient has multiple complaints for which no organic cause can be identified. Psychiatric consultation is recommended.
Victims of physical or sexual abuse in childhood or in adulthood may present with chronic pelvic pain. These patients are at high risk of other psychologic or psychiatric disorders. Inquiries must be compassionate, but the patient must be asked if she has ever been touched by anyone against her will as a child or as an adult. Referral for counseling and to a support group may help.
History and Physical
The first step for many couples seeking medical treatment for infertility is to discuss their inability to conceive with an OB/GYN. The OB/GYN will review the couple's medical history and conduct a complete physical on the female. The evaluation of the male's medical history includes a discussion of previous pregnancies, developmental problems, surgeries, testicular trauma or infections and environmental exposure. The female medical history includes review of previous pregnancies, painful periods or pelvic pain, infections and previous surgeries. The age of the patient must be taken into consideration when developing a cost-effective, medically appropriate evaluation and treatment plan. While there is little necessity to initiate aggressive therapy for a 20-year old with unexplained infertility, those over 35 deserve a more aggressive approach.
Based on the results of the medical history evaluation and physical, the OB/GYN will often recommend that the couple see a reproductive endocrinologist for a routine infertility work-up to determine the cause of infertility. After the cause is determined, your physician will work with you to develop a personalized treatment plan that will help you build the family of your dreams.
If you are under the age of 35 and you and your partner have been trying to conceive for one year without success; or if you are over the age of 35 and have been unsuccessful after trying to conceive for six months, it is time to seek medical treatment for infertility.
The first step in overcoming infertility is to perform what is called the infertility evaluation. We realize that most patients have limited resources to dedicate to building a family and our philosophy is to treat patients as quickly, effectively and inexpensively as possible…making the best use of all available resources. The main concern during the evaluation is to only conduct the tests that will give the physician clues to the cause of infertility and ultimately lead to the development of an effective treatment plan. There are a number of tests that have traditionally been run as part of the initial work up but may be unnecessary in many cases, such as the diagnostic laparoscopy, post coital test and endometrial biopsy.
The results of the evaluation lead the physician to determine the cause of infertility which is most often related to age, ovulatory disorder, tubal factor or male factor.
Testing for Male Factor Infertility
When male factor infertility is suspected, the initial test performed is a semen analysis. A semen analysis allows the doctor to examine the count, motility and morphology of the sperm. At Georgia Reproductive Specialists, we prefer a formal semen analysis over the post-coital test and consider the semen analysis to be more useful in the fertility evaluation.
Sperm count - The normal range for sperm is between 40 and 300 million sperm per milliliter of ejaculate. A low sperm count is fewer than 20 million per milliliter of ejaculate.
Motility - Low sperm motility (movement) may reduce the chances of conception, especially when paired with low sperm count. In a normal semen sample, at least half of the sperm have typical movement.
Morphology - Sperm that do not have normal morphology (shape) are often unable to swim effectively or penetrate an egg. A normal sperm has an oval head, slender midsection and tail that moves in a wave-like motion.
In order for a physician to evaluate the count, motility and morphology of sperm, a semen sample must be provided. The sample is most often collected by masturbation in a private, comfortable room in the fertility center. In some cases, the sample may be collected at home by masturbation or during intercourse with the use of a special condom provided by the physician. In some cases, the test results are not normal due to problems during sample collection and the test must be repeated.
Depending on the results of the semen analysis, more tests can be ordered to diagnose specific causes of infertility. If the semen analysis shows clumping or signs of infection, a semen culture, prostate fluid culture and urinalysis may be ordered. An antisperm antibody test may also be ordered to evaluate potential immune system disorders. A fructose test can be used to evaluate structural problem or a blockage of the seminal vesicles.
Sperm Chromatin Structural Assay (SCSA) - New studies suggest that sperm with certain levels of DNA fragmentation serve as a strong predictor of reduced male fertility. Georgia Reproductive Specialists is now offering SCSA, a test to measure the level of DNA fragmentation in the sperm, to enhance the diagnosis of and treatment for male infertility. A review of data on hundreds of semen samples show that patients with a DNA fragmentation level of greater than 30% are likely to have significantly-reduced fertility potential as well as a greater risk of miscarriage.
Treatment Options…Overcoming Infertility
Nearly 90% of all infertility cases, both male and female factor, are overcome through treatment, including surgical and medical techniques. The physicians at Georgia Reproductive Specialists are committed to developing a treatment plan specific to each patient's needs that will lead to the desired result of conceiving a child. We treat the patient as a partner in treatment and work with them to determine the treatment option that will be most fitting for their situation based on financial, social, religious, ethical and medical factors. Treatment options include assisted reproductive techniques such as IVF and ICSI, ovulation induction to enhance the production of eggs, surgery to repair reproductive organs and intrauterine insemination to increase the chances for egg fertilization by the sperm.