Gynecology

Welcome to the Gynecology & Obstetrics clinic in JINEPLAST. I appreciated to introduce me and my clinic.We are trying to take care of our patients in a correct way and planning all treatments with a real indications.

Benign Gynecologic Diseases

*Benign Ovarian Masses

*Uterine Fibroids & Adenomyosis

*Cervical Polyps

*Bartholin Gland Cysts

*Vaginal & Vulvar Inclusion Cysts

ginoBenign Ovarian Masses ;

Functional cysts are mostly seen in reproductive age and benign in nature. They are smaller than 5 cm usually resolve spontaneously and should be followed up for three months.

Corpus luteum cysts are also benign and resolve spontenously.

Benign Ovarian Tumors may be solid or contain cystic components . They rarely become malignant so must be followed up carefully.

*Cystadenoma

*Benign cystic teratomas ( dermoid cysts )

Most benign ovarian masses may not give symptoms. Sometimes menstrual abnormalities or abdominal pain can be seen due to adnexial torsion of a cyst or mass.

Treatment;

*Cysts follow up

*Removal of a cyst or oophorectomy may be performed.

Uterin Fibroids (Leiomyomas )

Uterin fibroids are the most common benign uterine tumors occurring about  % 60-70 of women by age 40-45.

They originate from smooth muscle and rarely cause symptoms.However most uterine myomas are small and asymptomatic about % 40 women could suffer from severe symptoms such as uterine bleeding, urinary and intestinal symptoms, pregnancy complication,infertility,abdominal pain and pressure.

Even uterine fibroids are benign tumors of uterine smooth muscle, there may be some sarcomatous changes  about % 1.

Treatment

Treatment depends on age, symptoms and patient’s desire to keep her uterus.

Medical treatment and follow up every 6 months is offered for small fibroids.Oral progestins and GnRH analogs may be offered to resolve the bleeding symptoms and shrink fibroids before surgery.

Levonorgestrel-releasing intrauterine device could be used to reduce uterine bleeding and increase blood counts.

Surgery should be planned in case of;

*Large pelvic masses causing intestinal,urinary symptoms

*Severe and recurrent uterine bleeding

*Infertility

Every patient should be evaluated individually about surgery.If the fibroid is asymptomatic  or postmenopausal small fibroids, the patient should be followed regularly 6 months intervals.

Myomectomy is a choice of restoring infertility and keeping the uterus in reproductive age. But fibroids may recur after surgery.

Hysterectomy is a definitive treatment performed in the presence of new fibroids after surgery,multiple myomas. Hysterectomy also done to reduce the risk of CIN, ovarian ca and endometrium ca in women at high risk.

Cervical Polyps

The cervix is a part of uterus plays a role in menstrual blood passage and baby during normal vaginal delivery.

Cervical polyps are commonly seen red, finger-like growth benign tumors of cervical canal and may cause irregular bleeding or completely asymptomatic .The cause of cervical polyps may be infection or elevated levels of estrogen.

They are usually diagnosed during gynecologic examination and pathologic examination. They are attached to the cervix by a peduncle or may prolapse from uterine endometrium but these may be endometrial polyps. Treatment is the the removing of the polyp. Follow up is done after pathologic examination.

Bartholin Gland Cyst

Bartholin gland cysts are mucus-filled and may occur bilaterally in the vaginal orifice. Bartholin duct obstruction results in a cyst and sometimes may form abscesses. Most cysts are asymptomatic but may cause severe vulvar pain, irritation and dyspareunia.

If the symptoms are mild treatment is not necessary. Symptomatic cysts and abscesses require surgical treatment. The aim is to produce an opening from the cyst to the exterior to keep the gland and vaginal lubrication.

*Simple drainage

*Marsupialization

*Cyst exision

Gynecologic Infections

Pelvic Inflammatory Disease (PID)

PID is an infection of the cervix, uterus,fallopian tubes and ovaries namely cervisitis, endometritis, salpengitis, oophoritis and rarely peritonitis.

Sometimes infection may be very severe even causes abscesses formation.Sexually transmitted microorganism like N.Gonorrhoeae and Chlamydia Trachomatis are the most common causes of PID.

Patient mostly suffers from lower abdominal pain, irregular bleeding, pain during sexual intercourse, bloody or purulent vaginal discharge, fever and difficulty becoming pregnant.

If suspected, vaginal cultures and blood chemistry should be checked according the results differential diagnosis should be done. The symptoms are similar to endometriozis,adnexial masses, appendicitis and ectopic pregnancy.

As a treatment convenient antibiotics are given covering the N. Gonorrhoeae and C. Trachomatis. Partners should  be treated.

Mild to moderate PID can respond to antibiotics. In severe cases patients are hospitalized and parenteral treatment are started as soon as possible.

Cervisitis

Infection of a cervix by microbial agents or chronic irritation. The symptoms are vaginal discharge bleeding after intercourse,dysuria and dyspareunia.

Gynecologic examination reveals purulent discharge, erythema and tenderness.

Antibiotics should cover C.Trachomatis, N.Gonorrhoea, bacterial vaginosis and trichomoniasis.

LabiaplastyVaginitis    

Fungal vaginitis can be seen in different situations ; hormonal changes, irritation, chronic systemic disease (diabetes), pregnancy and after using broad spectrum antibiotics. Vulvar and vaginal pruritus, burning, dyspareunia are very common. Examination reveals cheese like vaginal discharge and erythema, edema of the vaginal orifice and mucosa.

As a treatment , oral or topical antifungal preparats  should be preferred , also wearing cotton cloths to keep vaginal and vulvar dryness.

Bacterial vaginosis is the most common infectious vaginitis mostly effected by vaginal Ph changes. Normally vaginal flora consist of Lactobacilli that keeps vaginal Ph (3.8-4.2) at normal levels and protect the vagina by preventing overgrow of the pathogen microorganisms (anaerobic microorganisms).

This can be seen in all ages  especially girls age of 2-8 the main cause of vaginitis is p a poor hygiene soaps and wet tissues. Women of reproductive age microorganisms, tampons, cosmetic products cause vaginitis. During postmenopausal period estrogen levels decreases dramatically and result in vaginal mucosa thinning, Ph changes that increasing the infection.if untreated PID, endometritis, pregnancy complications would develop.

Vaginal discharge is gray smelly and thiny accompanied by burning pain and erythema.

Topical and oral antibiotics are prescribed.

Stress Urinary Incontinence (SUI)

SUI is the uncontrolled leakage of the urine happens when coughing, sneezingand heavy lifting.

It’s a really big problem that makes patient embarrassed,isolate herself and hesitate to be in social activities.

Normally when the bladder fills with urine, the urethra stay closed and prevent urine leakage till to a need to void. Any pressure (increased  intra abdominal pressure )to urinary bladder can make someone more vulnerable urine loss especially when the bladder is full. The reason for that is the weakening of the muscles, supporting tissue around the urethra and bulging of a bladder into the vagina because of multiple vaginal deliveries also chronic coughing and  constipitation which forces intra abdominal and pelvic muscles causing the high pressure on the bladder.

The symptoms and unhappiness may vary from patient to patient some have extreme urgency but some may reveal little awareness of need to void.

 

Stressed Incontinence; is an uncontrolled urine leakage when the intra abdominal pressure is increased.It is commonly seen in women mainly delivered babies vaginally,in anthropic urethritis.

There is outlet insufficiency due to the weakness of pelvic floor muscles .The vesicovaginal junction, bladder neck and the urethra become weak and located beneath the bladder, cannot do its function properly. There is mostly anatomical deformities (vaginal relaxation, systocele )need to be corrected.

Urge Incontinence; is involuntary loss of urine occurs immediately after a need to void not neccesarily requires increased inta abdominal pressure.Mainly seen in elderly who suffer from atrophic vaginitiseffecting the urethra.The detrusor muscle contracts in an uncontrolled manner even the bladder is partially full and cause urgency mimicking the stress incontinence.

Treatment;

Kegel exercises are usually effective if done correctly and regularly.The goal is to contract the pelvic muscles for 10 seconds and relaxation for 10 seconds for 15 minutes.

Bladder training means to create regular voiding intervals and gradually lengthen the intervals.Patients are taught to void every 2 to 3 hours. Then the intervals gradually may be increased up to every  4 hours.

Drugs: Anticholinergics and antimuscarinics are used to prevent uncontrolled contraction of the detrusor muscle especially in urge incontinence.

Treatment is focused to improve the outlet incompetence.If there is urge incontinence the treatment should cover detrusor muscle overactivity.

Gynecologic Endocrinology

Amenorrhea

Amenorrhea means the absence of mensturation can be seen at any age.In normal menstrual cycle GnRH ( Gonadotropin releasing hormone) is secreted from the hypothalamus and stimulates the pituitary gland to produce gonadotropins (Follicular stimulant hormone,luteinizan hormone). These hormones stimulate the ovaries to promote the secretion of estrogen,progesterone and androgens.Onthe other hand these ovarian hormones make some cellular changes in the endometrium to get ready for menstrual bleeding.If there is any malfunction in this mechanism all hormone levels are altered especillay central secretion of GnRH , amenorrhea may result.Other causes of amenorrhea are congenital anomalies of genital tract,outlet obstruction, intrauterine adhesions, hyperprolactinemia,postpartum hemorrhage,strict exercises  and some antidepressant drugs.

Amenorrhea can be primary or secondary due to age or hormonal status.

Primary amenorrhea; the patient had no mensturation about age 14 and not gone to puberty or even the patient gone through the puberty ( secondary sex charactheristics are well developed ) but not had mensturation at age of 16.

Secondary amenorrhea; absence of mensturation for 3 or more cycles in normally menstruated women.

Amenorrhea may also occur anovulatory and ovulatory.

Anovulatory amenorrhea  may be due to drugs,pituitary disorders,hypothalamic infiltration,ovarian dysfunction, autoimmune dysfunction,metabolic disorders,DM,viral infections, throid gland diseases,PCOS,obesity,hyperprolactinemia, genetic abnormalities.

Ovulatory amenorrhea may be due to congenital anomalies of genital tract, obstruction and endometrial adhesions.

Treatment depends on the underlying pathology may require also treatmen of accompanying problems; osteoporosis, hirsutism and infertility.

Dysfunctional Uterine Bleeding

DUB is irregular uterine bleeding due to hormonal imbalance and disruption of ovulatory hormonal stimulation to the endometrium.

The bleeding may be cyclic or unpredictable  heavy or light.

Underlying pathologies are thyroid gland disorders,hyperprolactinemia,disorders of blood coagulation syste, ovarian cysts,uterine polyps, cervical erosions,uterine fibroids,intrauterine devices,carcinomas,endometrial hyperplasia and polycystic over sendrome.

Clinically seen as ; hypermenorrhea,polymenorrhea,menomethrorhagia and methroragia.

DUB is mostly seen premenopausal period and mostly anovulatory.This means normal cyclic secretion of progesterone does not occur and estrogen stimulated endometrium becomes unopposed. Then endometrium bleeds in an uncontrolled manner. If this condition is untreated, endometrial hyperplasia and endometrial ca may develop eventually.

Patient should be evaluated carefully and diagnosed correctly.Treatment must be done according to the underlying pathology.

First of all B-hCG is ordered to make sure that there is no pregnancy.

Endometrial sampling (curetage) is very important to identify endometrial pathologies; hyperplasia,endometrium ca in all patients especially who are at high risk (obesity, family history,increased  endometrial thickness )

Endometrial curatage can be done as a treatment.

Pharmacological treatment includes;

*Oral contraceptives, re-establish endometrial lining and bleeding is controlled.

*Estrogens are indicated in certain and emergency cases especially in prolonged uterine bleeding.

*Progestin are prescribed (MPA 10mg) cyclic or continuously.

*Levonorgestrel – releasing Intra uterine device (IUD) should be offered as an other option.

*Endometrial ablation may be done in excessive bleeding unresponsive to treatment to keep the fertililty and the uterus.

*Hysterectomy  is a radical treatment and chosen in certain cases;

*Atypical adenomatous hyperplasia

*Endometrium Ca

 

Endometriosis

Endometriozis means the transportation of the cells from the uterine cavity to the ovaries,peritoneum,vagina, vulva and rarely other organs through the fallopian tubes and circulatory system.

The tissue are also sensitive to estrogen and progesterone during the menstrual cycle so bleeding from these ectopic implants result in typical cyclic pelvic pain,dyspareaine, dysmenorrhea.Symptoms may be dysuria, hematuria and rectal bleeding.

Diagnosis is confirmed by pelvic or transvaginal ultrasound, laparoscopy.Typical appearance of implants are red,blue in colour and focal or multiple locations.Serum CA 125 levels are elevated but not so diagnostic.

 

Stages of Endometriozis:

Stage I                  Minimal

Stage II                Mild

Stage III              Moderate

Stage IV               Severe

Non steroidal anti-inflammatory drugs may be used for relief of pain especially if taken a few days before mensturation. Additionally conservative overian surgery;  just removal of the endometrioma and cauterization of the implants could be done to protect fertility and keep the uterus.

Encourage the patient to become pregnant  because there won’t  be any bleeding during pregnancy this may improve the symptoms  and decrease the size of implants or even may cure the disease.

In severe cases; large  endometrioma with multiple adhesions refractory to treatment, oophorectomy could be done,  even total abdominal hysterectomy and bilateral salphingoophorectomy may be performed.

Premenstural Sendrome

Premenstural syndrome is a condition that starts from 7-12 days before the next menses and ends with the onset of menses.Usually she suffers from the breast pain,depression, uncontrolled feelings,anger, weighty gain,dysmenorrhea,mood disorders,withdrawal of daily activities and insomnia. All these may be very difficult to deal with.

Treatment is symptomatic. Dietary supplements,analgesics,oral contraceptives and long-acting progestins may be prscribed as a medical treatment.

 Hyperprolactinemia

The hormone prolactin is secreted from the pituitary gland and plays a role in reproductive functions and production of breast milk after childbirth.Hyperprolactinemia is an exess prolactin secretion from the pituitary gland may be due to prolactin producing tumors micro and macroadenomas,hypothyroidism,pregnancy,drud usage,large tumors compressing the pituitary gland.

Hyperprolacctinemia clinically seen as galactorrhea,oligomenorrhea, amenorrhea,infertility,vaginal dryness,decreased in libido and osteoporosis.

Increased blood prolactin levels with unexplained milk secretion or irregular menses indicate hyperprolactinemia.MRI is the most sensitive diagnostic tool for detecting micradenomas (less than 1 cm )and macroadenomas.

Treatment depends on the underlying pathology and usually corrected by medication with dopamine agonists. Routine follow up should be done.

Polycystic Ovarian Syndrome

Polycystis ovarian syndrome(PCOS) is characterized by oligomenorrhea,hirsutizm, obesity, insulin resistance and glucose intolerance.It is an unknown ethiology and involving about % 5-10 women of reproductive age.Generally the symptoms begin in adolescence.

PCOS may be a genetic disorder. Pelvic ultrasound is very important in diagnosing as well as blood hormone profile and clinical symptoms.

Ovaries contain many immature follicules, not succeeding to become a dominant follicle, in size of 5-7 mm and located at the periphery of the ovaries.These cysts are actually immature follicules resulting anovulatory cycles.That’s why normal menstrual cycle doesn’t occur. Ovaries are stimulated by increased insulin, insulin like substance and LH secrete excessive amounts of androgens resulting in hirsutizm and acne.

Treatment includes restoration of ovarian function and menstuaration,lower the insulin resistance,lower the body weight and fertility by the help of oral contraceptives,antidiabetics and diet.

Menopause

Menopause is a special and naturally developing phase in women’s life.The spirit of this period should be felt and the experiences are recorded in a positive way.If you are energic and conscious about menopause it would be easier to manage the symptoms that may be difficult to deal with.

The average age is about 45-50.Clinically cessasion of menses for 12 months either physiologically (naturel) or iatrogenic (surgery or radiotherapy).

Ovarian response to follicle-stimulating hormone (FSH) and luteinizing hormone (LH) decreases this leads to low estrogen and progesterone production.Eventually circulating FSH and LH increase.Menstural irregularities;because of the short follicular phase ,frequent menses occurin early menopause then the cycle legth prolong in the late perimenopause.

Symptoms are hot flushing,especially of the face,head and neck lasting from 1-3 minutes is seen in many women because of the changes in the thermoregulatory center.

Night sweats also seen very often and anxiety depressive mood,insomnia, vaginal dryness,atrophy may be associated with it. As you guess all these may decrease the quality of life that’s why life style should be modified by cooling the environment and thiny clothes should be choosen.

If a women suffer from the symptoms seriously Hormone Replacement Therapy should be offered for a limited time. Of course after all routine check up are done.As every women should undergo gynecologic examination and get PAP smear test every year. Mammography, ultrasound blood chemistry should be done routinely.

As the time passed the symptoms will regress.

Gynecologic Operations

Abdominal Hysterectomy

Total Abdominal Hysterectomy & Bilateral Salpengoophorectomy

Vaginal Hysterectomy

Ovarian cyst exisicion

Colphoraphy anterior & posterior

Tubal ligation

Genital aesthetic operation ;

vaginoplasty, labioplasty, perineoplasti, clitoral hoodoplasty

Bartholin gland cystectomy

Vaginal cyst exisicion

Obstetrics

Pregnancy

The initiation of pregnancy is the fertilization which means fusion of the female and male gamete form zygote. The zygote moves toward the uterus  while the cell division continues very rapidly form the blastocyst. This cell mass implants the uterine wall and growth very rapidly and the cells differentiate into circulatory,nervous,gastro intestinal systems . This period is called embryogenesis. The placenta  is a miracle connection between mother and baby allow nutritient uptake  eliminate the toxic materials from the baby.

When the fetal stage comes all the organs and body systems begin to mature for birth.

During pregnancy there would be some physiological changes and surely you want to know these are normal and does everybody feels what I feel ? That’s why you require prenatal care for yourself and your baby.

The initial routine prenatal visit should be planned at about 6-8 weeks gestation then the follow up should be scheduled on 4 weeks intervals till 36 weeks and weekly thereafter till 40 wk or delivery.

In the first prenatal visit physical examination including blood pressure,blood counts ( blood typing,Rh antibody levels,HBsag, TORCH,urine analysis,throid hormones, iron levels,Vit B12, Glucose), body weight pelvic ultrasound and fetal heart is recorded.Maternal well being is assessed.

During subsequent visits fetal well being; placental location,amniotic index, biparietal diameter, abdominal circumference, femur lenght , Doppler ultrasound (20-24 weeks ), NST ( Non Stress Test; indicates 1 week well being ) measuraments must be done.

All done from the beginning to the delivery should be recorded very carefully to make correct decision in case of unexpected situations and emergencies; preterm labour, vaginal bleeding , placental pathologies leads to delivery,preeclampsia and so on.

 

Prenatal Screening Tests

All these tests should be offerred to find out any risk of carrying a baby who has certain chromosomal anomalies and neural tube defects. These tests are optional and not diagnostic.

First Trimester Screening Test

Cell free fetal DNA (cffDNA)is an earliest prenatal screening non invasive test done at 8- 10 weeks gestation.Cell- free fetal DNA circulating maternal blood and can be detectedabout 6-7 weeks of gestation.This give a great advantage to detect fetal DNA fragments as early as 7 weeks gestation  so some chromosomal anomalies ( Trisomy 21, Trisomy 18, Trisomy 13 ) can be detected early.

Double test is done 11-14 weeks gestation combined with a special ultrasound (nuchal thickness measuraments,nasal bone ) and maternal blood Hcg(human chorionic gonadotropin), PAPP-A (pregnancy associated plasma protein).

Second Trimester Screening Test

Triple test is based on blood tests which can be done 16-18 weeks gestation.

Maternal blood AFP,Estriol,B-Hcg levels are measured and the risk is calculated by adding the age factor.If there is a risk then you should be referred to invasive procedures; amniocentesis

 Quadruple test most often done between 15-22 weeks gestation.

Maternal blood levels of AFP,Estriol,B-Hcg and Inhibin A levels are measured and the probable risk is calculated for carrying a baby with chromosomal anomalies, spina bifida and anencephaly.