Management of Common Gynecological Problems A Guide for Practitioners

Management of Common Gynecological Problems A Guide for Practitioners Consulting Editor Kanwal Gujral DGO MS (Obs & Gyne) FICOG FIMSA FICMCH

Co-Chairperson and Senior Consultant Institute of Obstetrics and Gynecology Sir Ganga Ram Hospital New Delhi, India

Series Editors Atul Kakar

Samiran Nundy

FRCP

MA MChir FRCP FRCS

Senior Consultant Physician and Rheumatologist Vice Chairman Department of Internal Medicine Sir Ganga Ram Hospital New Delhi, India

Emeritus Consultant Department of Surgical Gastroenterology and Liver Transplantation Sir Ganga Ram Hospital New Delhi, India

Foreword Atul Kakar Samiran Nundy

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Contributors Abha Majumdar

Mala Srivastava

Anurag Vashista

Mamta Dagar

Chandra Mansukhani

Neeti Tiwari

Debasis Dutta

Pallavi Sharma

Divya

Pramod Yerne

Geeta Mediratta

Punita Bhardwaj

Harsha Khullar

Rakesh Kumar Koul

Indrani Ganguli

Rashmi Nigam

Kanika Chopra

Ruma Satwik

Kanika Jain

Sharmistha Garg

Kanwal Gujral

Shweta Mittal Gupta

Foreword Medicine is an ever-changing field. It is constantly advancing and the guidelines for practice keep altering so that busy practitioners find themselves lost and confused. This practitioners’ series at the Ganga Ram Institute for Postgraduate Medical Education and Research is an attempt to inform the General and Family Physician what he or she needs to know. These books provide guidance on how to manage commonly encountered clinic situations in a simple and easy-to-understand language. We are sure that after going through this book readers will become more confident to tackle problems they meet every day. Puberty and adolescence are important topic rarely discussed. The changes during this period are so intense that they require especially mention. The transition into adulthood has physiological, emotional and hormonal effects and they may impact social adjustment and a person’s self-esteem. Vaginal discharge is a common complaint in gynecological outpatient departments. Physicians need to differentiate between a normal and abnormal discharge and treat both appropriately. The other interesting, yet less discussed, topics are urinary problems in women. One chapter lists the common conditions responsible and their management. Pain in the pelvic region can very annoying and many chapters are dedicated to symptoms, i.e. chronic pelvic pain, pelvic inflammatory pain and dysmenorrhea. These books we hope will serve as ready reckoners for practicing gynecologists and deal with all the changes between puberty and menopause. Their contents are written in simple english, so that comprehension is easy with many figures and illustrations to supplement the text. Breast, ovarian, cervical and endometrial cancers have been discussed with up-todate information as is the vaccine for human papilloma and other preventive measures in gynecological practice. We hope that our readers will find the publication a useful guide in their day-to-day work and would be pleased to receive feedback on how it might be improved.

Series Editors Atul Kakar Samiran Nundy

Preface This book brings together contributions from experts on commonly encountered gynecological conditions, presenting pathophysiology, symptomatology and management in an easy-to-comprehend manner. All chapters liberally employ tables, original pictures/diagrams to enlist and explain important concepts. The inaugural chapter deals with the physiology behind puberty and lists points to identify, investigate and manage girls presenting with abnormal puberty. The subsequent chapters deal with common conditions of menopause and vaginal discharge and help differentiate between normal symptoms from the abnormal. Dysmenorrhea and chronic pelvic pain can often be debilitating symptoms leading to loss of productive hours. Its management is detailed in the next two chapters. Urologists have often managed urinary problems in women. This book has a chapter presenting information on what a gynecologist ought to know and what do when she sees a patient with such a complaint. All fibroids or ovarian cysts do not need medical or surgical intervention. Chapters 8 and 9 provide a closer insight into what needs attention and what can be left. Pelvic inflammatory disease has implications on a woman’s well-being and reproduction. Chapter 10 details the symptomatology, investigations and management of pelvic inflammatory disease (PID). The following chapter, explains how polycystic ovary syndrome (PCOS), the commonest endocrinological disorder in women, can manifest across all age groups in different ways and how best to manage it. The prevalence of infertility seems to be growing in women across the globe, largely due to delayed child-bearing but also due to fast-changing lifestyles, environmental pollutants and increasing work-related stress. Its work-up and management is dealt with in the next chapter. The other end of the spectrum is contraception. In a country such as India, slated to be the world’s most populous by 2030, safe, effective, cheap and readily acceptable contraceptive methods are the need of the hour. The chapter on contraception talks about what is on offer and for whom. Increasingly, the medical fraternity is moving from surgical abortion to the medical means. The do’s and don’ts of medical abortion are dealt with next. Two chapters in the book deal with abnormal postmenopausal bleeding and the burning question of whether hormone replacement therapy is safe and effective in postmenopausal women.

x Management of Common Gynecological Problems: A Guide for Practitioners Prevention strategies employing early detection of that dreadful disease, cancer, can limit the morbidity and mortality associated with it. This is addressed in Chapters 15 and 16 followed by chapters on comprehensive surgical and medical-oncological management once the diagnosis is made. It is hoped, that through this effort, general practitioners will find a readily usable and easy to understand reference book for common gynecological problems. Kanwal Gujral

Acknowledgment No book gets completed without help from its authors and I would especially like to thank ours for the efforts they made and the quality of their contributions to this volume. I am also grateful for the encouragement and support given to us by Professor Dr DS Rana, Chairman, Board of Management and Professor Dr Kusum Verma, Dean, GRIPMER (The Ganga Ram Institute for Postgraduate Medical Education and Research) who are always there behind us during all educational activities. I also thank Professors Atul Kakar and Samiran Nundy whose idea it was to start the GRIPMER Medical Series and push us towards completing this book in time. Dr Lipika Khurana, Research Officer, from the obstetrics and gynecology office and Mr Parmanand Tiwari, Junior Executive in our hospital have helped us right from the beginning up to the completion of this important publication. I greatly appreciate the staff of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for their assistance, thoroughness, patience and professional work. I am thankful to Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Managing Director), Ms Chetna Malhotra Vohra (Associate Director— Content Strategy), and Ms Payal Bharti (Senior Manager—Professional Publishing) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for giving a go-ahead at the very beginning and helping us in every way possible to bring out this book. Kanwal Gujral

Contents 1.

Normal and Abnormal Puberty ........................................................... 1 Chandra Mansukhani, Rashmi Nigam, Divya, Pallavi Sharma Puberty 1 • Mechanism 1 • Factors Determining Onset of Puberty 1 • Endocrinology in Puberty 2 • Thelarche and Adrenarche 4 • Changes in Genital Organs 4 • Delayed Puberty or Interrupted Puberty 6 • Precocious Puberty 9

2.

Menopause: Physiology and Symptomatology ............................... 15 Mala Srivastava, Mamta Dagar • Premature Ovarian Failure 15 • Physiology 15 • Lipids and Lipoproteins 17 • Central Nervous System 17 • Prediction of Menopause 18 • Evaluation of the Women 18 • Sequelae of Ovarian Failure 20

3.

Vaginal Discharge: Normal and Abnormal ....................................... 24 Mala Srivastava • Normal Vaginal Discharge 24 • Natural Defense Mechanism of Vagina 25 • Flora Normally Present in Vagina 25 • Organisms Normally Present in the Vagina 25 • Causes of Vaginal Discharge 26 • Abnormal Vaginal Discharge 26 • Bacterial Vaginosis 28 • Fungal Infection 30 • Trichomoniasis 31 • Neisseria Gonorrhoeae 32 • Chlamydiasis 33 • Summary of Characteristics of Common Vaginal Infections 33

4.

Abnormal Uterine Bleeding .............................................................. 35 Chandra Mansukhani, Anurag Vashista, Rashmi Nigam • Incidence 35

xiv Management of Common Gynecological Problems: A Guide for Practitioners • Etiology 35 • Approach to Abnormal Uterine Bleeding 36 5.

Dysmenorrhea .................................................................................... 49 Punita Bhardwaj • Prevalence 49 • Types 49 • Etiology 50 • Symptoms 54 • Diagnosis 55 • Treatment 56

6.

Chronic Pelvic Pain ............................................................................. 58 Shweta Mittal Gupta • History 58 • Causes of Chronic Pelvic Pain 59 • Physical Examination 60 • Diagnostic Test 62 • Management 63

7.

Urinary Problems in Women: Hush No More.................................... 67 Geeta Mediratta • Urinary Incontinence 67 • Types of Disorders 67 • Risk Factors for Urinary Incontinence 69 • Approach to Patient with Incontinence 69 • Nonsurgical Treatment 72 • Surgical Treatment for Stress Incontinence 74 • Surgical Treatment for Detrusor Overactivity 75 • Surgical Treatment of Fistula 75 • Voiding Dysfunction 76 • Bladder Pain Syndromes 77

8.

Fibroids: A Close Insight .................................................................... 80 Kanwal Gujral, Pramod Yerne, Anurag Vashista • Risk Factors 80 • Signs and Symptoms 80 • Classification 81 • Diagnosis 81 • Management of Fibroids 82

9. When to Intervene in a Case of Ovarian Cyst?.................................. 90 Kanika Jain, Kanika Chopra • Functional Ovarian Cysts 90 • Benign Ovarian Neoplasm 91

Contents

• Malignant Ovarian Neoplasm 93 • Approach to the Patient with Ovarian Cyst 94 10.

Pelvic Inflammatory Disease ............................................................. 99 Kanwal Gujral • Risk Factors for Pelvic Inflammatory Disease 99 • Acute Pelvic Inflammatory Disease 99

11.

The Enigma of Polycystic Ovarian Syndrome ................................ 107 Ruma Satwik • Definition and Diagnosis 107 • Criteria in Adolescence 108 • Management 114

12.

Management of an Infertile Couple ................................................ 124 Abha Majumdar, Neeti Tiwari • Evaluation of Female Partner 124 • Evaluation of Male Partner 130 • Treatment of Specific Disorders 133 • Unexplained Infertility 139

13.

Contraception: Making the Right Choices...................................... 141 Mamta Dagar • Contraceptive Choices and Efficacy 141

14.

Medical Abortion: What a General Practitioner Should Know?.... 156 Sharmistha Garg • Clinical Care of the Women Undergoing Abortions 161 • Medical Methods of Abortion—Adapted from World Health Organization Safe Abortion Guidelines 2012 162 • Complications of Abortions 163

15.

Breast Cancer Surveillance .............................................................. 165 Debasis Dutta, Kanika Chopra • Breast Anatomy 165 • Patients History and Physical Examination 165 • Types of Lesions in Breast 167 • Breast Cancer 167

16.

Screening of Gynecological Cancers ............................................... 174 Indrani Ganguli • Cervical Cancer 175 • Breast Cancer 177 • Ovarian Cancer 180 • Endometrial Cancer 183

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