METHODICAL INSTRUCTIONS
for practical lesson
« Endometriosis. Gynaecological diseases of children and teenagers. Abnormalities of
location and development of female genital organs. »
MODULE 3: Diseases of the Female Reproductive system. Family planning.
CONTEXT MODULE 4: Endocrine disorders the female reproductive system.
I. Scientific and methodical grounds of the theme
Recently the problem of endometriosis has become especially actual due to the increase of
frequency of this pathology, implementation of modern diagnostic and therapeutic methods in
to practice that’s why the aim of the practical lecture is the study of etiopathogenesis of
endometriosis, methods of its diagnostic and treatment
II. Aim:
A student must know:
1. Classification of endometriosis of female genitalia .
2. Main clinic symptoms for endometriosis of female genitalia.
3. Methods of diagnosis of endometriosis of female genitalia.
4. Main principles of therapy of endometriosis of female genitalia.
5. Indications for surgery of endometriosis of female genitalia.
6. Possible developmental anomalies of uterine tubes, ovaries.
7. Clinic, diagnosis and treatment infantilism.
A student should be able to:
1. Collect general and specific gynecologic anamnesis.
2. Make up a plan of examination and treatment
of endometriosis.
III. Recommendations to the student
ENDOMETRIOSIS
Endometriosis involves deposits of endometrium outside the uterine cavity. Its
manifestations are very variable and often bear no relation to the extent of the disease.
Pathology
The gross appearance shows ectopic deposits which can very in number from a few in one
locality to large numbers distributed over the pelvic organs and peritoneum.
The commonest sites of these deposits are:
The commonest appearance of a typical lesion is that of a round protruding vesicle which
shows a succession of colours from blue to black to brown. The variation in colour is due to
haemorrhage with subsequent breakdown of the haemoglobin. Ultimately the area of
haemorrhage heals by the formation of scar tissue. The result is a puckered area on the
peritoneum. Commonly however the haemorrhage results in adhesion to surrounding
structures. These adhesions are more apt to form between fixed structures such as the broad
ligament, ovary, sigmoid colon or the posterior surfaces of the vagina and cervix.
The ectopic deposits of endometrial tissue vary in size from pin-point to 5 mm or more.
It is these larger deposits which tend to rupture leading to adhesions. These adhesions over the
ovary can lead to the formation of quite large haemorrhagic cysts due to continued bleeding
from deposits, the blood being unable to escape. Investigation has shown that many lesions do
not have a 'typical' appearance. The following is a list of other appearances which have been
described. White, slightly raised opacities due to retro-peritoneal deposits. Red flame-like or
vascular swellings, more common in the broad ligament or utero-sacral ligament. Small
excrescences like the surface of normal endometrium.
Adhesions under the ovary or between the ovary and the ovarian fossa peritoneum.
Cafe-au-lait patches often in the Pouch of Douglas, broad ligament or peritoneal surface of the
bladder. Peritoneal defects on utero-sacral ligament or broad ligament. Areas of petechiae or
hypervascularisation usually on the bladder and the broad ligament.
Secondary pathology
This is due to the adhesions between the endometriotic deposits and adjacent organs. In longstanding cases the pelvic cavity is obliterated by these adhesions. Retroversion of the uterus
can be produced.
Clinical findings
The incidence of endometriosis has been estimated at 3 to 7% of women but the true
incidence is unknown. Quite often deposits are found incidentally in women who have no
symptoms of endometriosis and are undergoing laparoscopy or laparotomy for some other
condition. In addition, as indicated in the section on pathology, many peritoneal changes now
known to be due to endometriosis were undiagnosed in the past.
The prevalence of endometriosis peaks between the ages of 30 and 45 years. Since ectopic
endometrium is stimulated by the same ovarian steroid hormones as the endometrium lining
the uterine cavity, endometriosis is almost never found outside the reproductive years.
Symptomatology
A. Pain affects more than 80% of women with endometriotic deposits. The pain tends to
begin premenstrually reaching a peak during menstruation and subsiding slowly.
The character of pain may vary as does its apparent origin. It may be generalised
throughout the abdomen and pelvis like the pain of severe dysmenorrhoea. Alternatively, pain
may be localised to a particular site within the pelvis. Deep dyspareunia affects around 40%
of women with endometriosis.
B. Menstrual disturbance. Menstrual disturbance affects around 20% of women with
endometriosis. It may take the form of premenstrual 'spotting', menorrhagia or infrequent
periods. Lesions in the wall of the bladder may result in 'menstrual haematuria'.
C. Infertility. Endometriosis is found more commonly in women undergoing
investigation for infertility than in the 'normal' population. It is not clear which condition
arises first. Approximately 30% of patients with endometriosis complain of infertility. When
endometriosis is extensive, and both fallopian tubes are occluded, the mechanism by which
endometriosis prevents conception is obvious. However, milder forms of endometriosis are
also associated with subfertility, and here the pathophysiology is less clear. The most likely
mechanism appears to be that immunological factors within the peritoneal cavity inhibit
normal gamete function, thus reducing fertilisation rates.
Physical examination
Endometriosis cannot be diagnosed by physical examination alone. However, enlargement of
the ovaries, fixed retroversion of the uterus and tender nodules within the pelvis may each
raise the suspicion of the disease. Endometriosis should always be considered when patients
have symptoms referable to the pelvic cavity.
Laparoscopy
Laparoscopic examination is the only way of making a positive diagnosis. The lesions can be
seen and their number and location estimated. Endometriosis of long standing may be very
difficult to diagnose due to obliteration of the pelvic cavity by adhesions. Histological
confirmation must be obtained if feasible.
Imaging techniques
Ultrasound, computerised tomography and magnetic resonance imaging may suggest the
presence of endometriosis (e.g. by the demonstration of a particular type of ovarian cyst) but
are by themselves insufficiently reliable to make the diagnosis.
Differential diagnosis
Due to the mixture of symptoms and the variation in appearance of the pelvic structures,
conditions such as pelvic inflammatory disease and tumours of the ovary and bowel must be
considered and eliminated.
Histogenesis. There are three theories.
Retrograde spill of menstrual debris through the tubes. Retrograde menstruation takes
place in most women, but it is unclear why some women should develop endometriosis while
others are unaffected.
Metaplasia of embryonic cells. These are derived from the primitive coelom and may
remain in and around the pelvis and differentiate into Mullerian duct tissue.
Emboli of endometrial tissue may travel by lymphatics or blood vessels and become
established in various sites.
The first of these theories is most favoured.
TREATMENT. Medical treatment. Any treatment must be aimed at treating
symptoms. Since ovarian hormones are responsible for growth and activity in endometrium
many medical therapies are designed to reduce ovarian steroid production or oppose their
action.
1. Progestogens
Progestogens in a relatively high dose (e.g. medroxyprogesterone acetate 10 mg tid)
induce decidualisation, and sometimes resorption of ectopic endometrium. Side effects
include weight gain, bloating and irregular vaginal bleeding.
2. Combined contraceptive pill
The combined oral contraceptive pill also induces decidualisation of ectopic
endometrium. It may be given continuously for up to 3 months.
3. Danazol
Danazol is a steroid hormone closely related to testosterone, which inhibits pituitary
gonadotrophins, is anti-oestrogenic, anti-progestational, slightly androgenic and anabolic. The
dose of danazol given can be titrated to the patient's symptoms up to a maximum of 800 mg
daily. If danazol can be tolerated, symptoms and objective signs of disease can be alleviated
in the majority of patients. However, androgenic side effects including amenorrhoea, weight
gain, acne, hirsutism and deepening of the voice may limit acceptability of the drug.
4. Gestrinone
Gestrinone is a derivative of 19-nortestosterone. It has slight androgenic activity and is
markedly anti-oestrogenic and anti-progestogenic. It interacts with the pituitary steroid
receptors and decreases gonadotrophic secretion resulting in diminished follicular growth and
anovulation. A bi-weekly oral dose of 2.5 to 5.0mg for 6 months induces amenorrhoea,
disappearance of pain and regression of the endometrial deposits. Side effects include weight
gain, acne, seborrhoea and mild hirsutism.
Gonadotrophic releasing hormone analogues (GnRH analogue)
GnRH analogues are administered by depot injection or nasal spray. Their mode of action is
shown above. Although these drugs are generally effective in treating symptoms, menopausal
side effects, in particular bone loss, may preclude long term use. In the future, use of 'add
back' regimens which include small supplementary doses of oestrogen may prove to be
effective in treating the symptoms of endometriosis without the complications of total
oestrogen deprivation.
Conclusion
As with medical therapies for other conditions, the optimum treatment is dictated by the
side effect profile which is most acceptable to the patient. None of the drug treatments
described will prevent recurrence of endometriosis once therapy has been stopped, although
there may be a period of some months between stopping treatment and the re-emergence of
symptoms. No medical treatment has been shown to improve subsequent fertility.
Notwithstanding, none of the above, with the exception of the combined pill, is a proper
contraceptive agent and patients should be advised to use barrier contraception to avoid the
potential teratogenic effects of drugs such as danazol if they are at risk" of becoming
pregnant.
Surgical treatment
Where infertility is not a problem radical surgery to remove both ovaries is said to be a
lasting cure for endometriosis, since it removes the oestrogenic stimulus to endometrial
growth. In many cases the patient wishes relief from pain but also desires to retain the
possibility of future pregnancy. In these circumstances only conservative surgery can be
employed.
The intentions in conservative surgery are:

To ablate as many endometrial deposits in the pelvic cavity as possible.

To restructure the pelvic anatomy by destroying adhesions which interfere with
ovarian and tubal function.

To destroy endometrial deposits in the ovaries.

To deal with sensory nerve pathways.
In view of the many vital structures such as the bladder, rectum, colon and ureters in close
proximity to each other, conventional open surgery is not always feasible. Laser surgery under
laparoscopy, with its almost microscopic accuracy, may be employed. Endometrial deposits
and adhesions can be vaporised easily without damaging tissue outside a radius of a fraction
of a millimetre from the target. Similarly the laser destruction of ovarian lesions can be
carried out without destroying any of the functional tissue.
The question of dealing with sensory nerve pathways is difficult to answer. Severe pain
is a feature of a number of gynaecological conditions, especially those related to malignancy.
Elsewhere in this book operative techniques are described which involve interfering with
sensory conductivity centrally, i.e. at the spinal cord level. Recently, a local operative
procedure, paracervical uterine denervation, has been recommended. This consists of
vaporising the utero-sacral ligaments by laser at their attachment to the posterior aspect of the
cervix where the sensory fibres emerge from the uterus. Two difficulties are associated with
this procedure. First, the ureters must be avoided and, secondly, veins lying lateral to the
ligaments must not be injured. Unfortunately severe pain is often associated with severe
endometriosis and adhesions may make the operation very difficult.
Reports in the literature record complete relief from pain in 50% of patients followed
for more than a year and another 41% obtained moderate relief.
IV. Control questions and tasks
1. Frequency of endometriosis pathology.
2. Classification of endometriosis.
3. Laboratory methods of endometriosis diagnosis.
4. Conservative methods of treatment.
5. Surgical methods of treatment.
V. List of recommended literature
1. Danforth’s Obstetric and gynaecology.-Seventh edition.-1994.-P.845-853
2. Gynecology.-Stephan Khmil, Zina Kuchma, Lesya Romanchuk.-2003.-P.263-267
3. Gynaecology illustrated. David McKay Hart, Jane Norman.-Fifth Edition.-2000.-P.122128
DEVELOPMENT OF FEMALE GENITALIA IN PRENATAL PERIOD
On the 3-4th weeks of embryo development on internal surface of primary kidney a
gonad germ is generated. Primary gonad has an indifferent structure (identical for both
genders) and consists of celomic epithelium cells (external layer), mesenchyme (internal
medullar layer) and gamete cells — gonocytes. Sexual differentiation of indifferent glands is
induced by sexual chromosomes. Y-chromosome presence determines testicle development,
and X-chromosome presence determines ovarian development.
External genitals of fetus also goes through the different stages of development. They
are germinated on the 6-7th weeks of the development in the form of genital prominence and
urethral fissure, bordered by urethral and labioscrotal folds.
Forming of masculine sexual glands begins from the 7th week, and masculine genitals
— from the 8th week of fetal development.
Differentiation of female reproductive system takes place in later terms. Forming of
female-type gonads begins from 8-10th week of pregnancy. Presence of 2 X-chromosomes in
a zygote is necessary for ovarian development. A gene inducing ovarian development is
localized in long shoulder of X-chromosome. Under its influence gonocytes are transformed
into ovogonies, then — into ovocytes, around which the primary granulous cells are generated
from mesenchymal cells. They are situated in the cortex of sexual gland and intensively
reproduce themselves by means of mitotic division. On the 5th month of embryonal
development a number of primary follicles reaches 4 mln., till the birth time of a girl their
amount is reduced to 1 mln. The ovary is morphologically formed.
Internal genitalia — uterine tubes, body, uterine cervix, upper 1/3 of vagina are formed
from paramesonephral ducts. Process starts on the 5-6th and finishes to 18th week of
pregnancy. From upper one-third of paramesonephral ducts uterine tubes are formed. Lower
and middle parts uniting together form a body and uterine cervix. Lower department of
paramesonephral ducts forms the upper one-third of vagina, lower 2/3 are formed from urinogenital sinus
Common organ cavity is formed to 21-22 week of gestation. The rest of mesonephral
channels are preserved as paraovophorone, epiovophorone and Gartner's passages on the
lateral walls of vagina. External female genitals are formed since the 17th week of gestation.
At first major labia are formed from labioscrotal folds, from urethral folds minor labia are
generated. Clitoris is formed from genital prominence
DEVELOPMENT ANOMALIES OF EXTERNAL GENITALIA
Most frequently defects of external genitalia development are common at androgeny
and adrenogenital syndrome. These defects of external genitalia development are
manifestations of genital glands development violations and they will be discussed in the
corresponding chapter
UTERINE AND VAGINAI DEVELOPMENT ANOMALIES
Genitalia formation in female fetus takes place during the first months of gestation from
the middle embryonic layer (mesenchyme). From the same layer the organs of urinary system
are generated, that's why the uterine and vaginal anomalies can be combined with urinary
organs anomalies.
The ovaries are formed on the first weeks of gestation from indifferent (identical for
both genders) genital gland. On the third month of gestation their differentiation starts. The
ovaries dislocate down and draw into the small pelvis.
Uterus, uterine tubes and vagina are developed from mesodermal germs (Muller's
ducts). One uterine tube, a half of uterus and vagina are generated from each of them. The
middle and lower third of these ducts are united on the second month of gestation, forming the
external organ contour, but on all the length uterus and vagina are parted by membrane.
During the 3rd month of fetal development this membrane is dissolved, uterine cavity and
vagina are generated. Uterine tubes are formed from the upper parts of Muller's ducts that
didn't join.
External genitalia are generated from urino-genital sinus.
If during the act of sexual organs forming harmful factors, specifically medicinal ones
(uncontrolled medicines reception), would affect a pregnant woman, a differentiation process
of the genitals can be broken. Agenesy is the absence of the organ and even of its rudiment.
Aplasia is the absence of the organ's part. Atresia is underdevelopment in the result of the
prenatal cause.
Proceeding from mechanism of genitalia forming, such variants of uterine and vaginal
development defects are possible:
Both mesonephral ducts are formed properly, but they are not joined together along the
whole length. A full uterus and vagina doubling (uterus didelfus) is generated: the patient has
two vaginas divided by a thin membrane. Uterine cervix opens into each vagina. There are
two uteruses (unicornous), in each uterus there is one tube and one ovary. Both uteruses can
function. In the patients with such pathology pregnancy loss is more frequent. In most cases
one half of sexual apparatus is developed better than the other one.
Both mesonephral ducts are formed properly, but their uniting takes place only at any
interval. Other parts of uterus and vagina are divided by a membrane. There can be following
variants: membrane in vagina (vagina septa); presence of one vagina, into which two uterine
cervices open (uterus bicornus bicollis); membrane in uterine cavity (uterus septa), twohorned uterus (uterus bicornus); saddle-like uterus (uterus arcuatus). At such anomalies
genitals can function normally, pregnancy can occur, but frequently pregnancy loss takes
place. When there is a saddle-like uterus the irregular fetus positions are usually diagnosed.
One of Muller's ducts develops properly, and the other one does not develop at all.
Vagina, single-horn uterus with one ovary and one tube is formed (uterus unicornus). In such
patient one should inspect urinary system, because such defect correlates with the absence of
kidney on the affected side. Unicornous uterus can function, menstrual function is usually for
the type of hypomenstrual syndrome.
The woman can become pregnant, however there exists high frequency of pregnancy
loss on the early terms.
One of the mesodermal ducts develops properly, the other—insufficiently. The uterus with
rudimentary horn is formed. These cavities can be joined, that's why pregnancy in
rudimentary horn is possible. It develops as ectopic pregnancy. During its interruption a
considerable bleeding takes place (horn rupture) that's why the surgical intervention is
necessary. At presence of closed cavity of rudimentary horn during menstruation blood can
deposit inside, that needs the removal of the horn.
If uterine development anomalies are combined with underdevelopment of genitals it is
followed by violation of menstrual cycle, infertility.
Diagnosis is made after examination of external genitals, uterine cervix examination in
specula, bimanual examination. Ultrasound examination, sounding, hysterosal-pingography or
contrasting sonography (contrasting substance "Echovist" is used) are necessary for
specification of diagnosis.
Treatment of the development anomalies is surgical. Doubling of uterus and vagina,
which does not disturb woman's sexual and reproductive functions, doesn't need intervention.
Operative treatment is necessary at presence of ectopic pregnancy or agglomeration of
menstrual blood in rudimentary horn. Membranes in vagina are usually diagnosed during
pregnancy or delivery; if they prevent child's birth, they are lanced.
Absence of vagina (aplasia vagina) is a serious defect, which makes impossible the
realization of menstrual, sexual and reproductive functions. It develops primarily (in fetus) or
secondly in the result of healing after the carried difficult inflammatory processes in
babyhood (smallpox, diphtheria, scarlet fever). It can rarely appear in women after serious
labour traumas.
Treatment is only surgical. It is a plastic operation with vagina formation from allotment
of sigmoid bowel, recently allopl'asty is common.
Gynatresy — violation of genital channel permeability in some of its departments. Most
frequently atresia of hymen, vagina and uterine cervix are present.
Primary gynatresy develops in fetus in the result of embryonic development defects.
Secondary gynatresy (acquired) develops in the result of inflammatory processes, carried in
childhood. In mature age vaginal atresia can occur in the result of labour traumas, uterine
cervix atresia after diathermocoagulation, atresia of uterine cavity or adhesion in it after
surplus uterine curretage because of abortion.
Primary atresia of hymen ought to be diagnosed by medical personnel or by girl's
mother still in newborn period. Then all the further complications can be avoided. If
gynatresy is not found in time, then with the beginning of the first menses blood begins to
accumulate in vagina, straining it (haematocolpos). Girls complain of pain. After finishing of
such "latent menses blood gemolizes, liquid part of it is absorbed, volume is decreased, pain
stops until the following menses begin. If the patient does not apply for medical help, then
blood, accumulating more and more, gathers in the uterine cavity (haematometra), and in the
uterine tubes (haematosalpinx).
Diagnosis consists of examination of external genitals, during which one can see
obstructed hymen and blood, that has accumulated behind it. During the rectal examination
one can palpate tumorous formation in allotment of vagina, uterus and uterine tubes.
Treatment. Surgical incision of hymen is necessary. Hymen is crosswise incised. Thick,
brown-colored blood is removed from vagina. In order to prevent secondary atresia they put
several stitches in dissection edges.
Prognosis depends on the interna diagnostics of disease. At long illness duration and
development of haematometra and haematosalpinx later a woman can have problems with
pregnancy. Destructive process in uterine tubes leads to their occlusion. Endometriosis of
internal genitals develops frequently.
ABNORMALITES OF OVARIAN DEVELOPMENT
Hermaphroditism is a presence of signs of both sexes in one person. True
hermaphroditism is presence of genital glands of both sexes in one person on condition of
their simultaneous functioning. Such defects are almost not found in practice, because
children, sexual glands of which contain simultaneously the tissue of ovary and testicle, are
born with other different defects, and die during the first days of their life.
False hermaphroditism (pseudoandrogeny) is a defect, at which the structure of
external genitalia does not correspond to the character of sexual gland. Human sex is
determined by chromosome set, according to which genital glands are developed. At false
female hermaphroditism internal genitals and sexual glands are female (ovaries), and external
sexual organs are developed like the male ones — clitoris is enlarged and looks like penis,
major labia are hypertrophied and look like scrotum. Sometimes after the birth such children's
sex is mistakenly determined and parents begin to bring a girl up as a boy. That's why in case
of child birth with anomaly of genitals development it is necessary to carry out careful
examination, including the genetic one.
At false male hermaphroditism genital glands are male (testicles), and structure of
sexual organs looks like the female ones.
The congenital adrenogenital syndrome is the disease that develops by reason of
adrenal glands cortical layer hyperfunction. It is followed by increasing in fetal organism of
female sex sexual hormones (androgens) and causes the formation of female genitals
according to the masculine type. It is very important to determine correctly the child's sex at
birth.
Clinic. In such girl the period of puberty begins at the age of 6-7 and it is followed by
virilization signs (appearance of masculine secondary sexual signs) — hair growth, forming
of skeleton and body building according to masculine type. Children are of a low height,
lower extremities are short because of the early epiphisar cartilage closing. At postpubertal
form, when the disease starts after the period of the puberty beginning, amenorrhea or
oligomenorrhea are found in girls. Breasts, uterus and ovaries do not develop. Later the
woman suffers from the primary infertility.
Treatment is prescribed by an obstetrician-gynecologist together with endocrinologist.
Medicines of glucocorticoid hormones (Prednizolone, Cortisone, Dexametasone) are
prescribed to decrease androgens production by adrenal glands. Owing to this the
gonadotropic pituitary function increases, ovarian stimulation and production of own
estrogens begins.
Ovarian absence — two or one — happens rarely, predominantly in fetuses having
other severe development defects.
Ovarian hypoplasy is the insufficient development of ovaries frequently combined
with uterine underdevelopment. Clinically it is manifested as hypomenstrual syndrome.
The gonads' dysgenesia (the Shereshevsky-Terner syndrome) is the disease, associated
with chromosome abnormalities (one X-chromosome is absent) that causes ovarian tissue
underdevelopment. The ovaries are represented by connective tissue, their function is absent.
Diagnosis. These patients are of low hight (not higher 130-145 cm). Body weight after
birth is low even at interm pregnancy. During examination a short neck with wing-like folds
from ears to shoulders, wide shoulders and tubby thorax are typical. The external eyes'
corners are drawn down, palate is high, that's why these patients have special timbre of voice.
Psychic development is normal, sexual orientation is female, but in the puberty period
secondary sexual signs develop not enough.
During gynecological examination highly expressed signs of genital infantilism are
found. External genitalia are underdeveloped, there is a severe vagina, uterine and ovarian
hypoplasia. Genetic examination, that confirm the chromosome anomaly has a great
importance for specification of diagnosis. Tests of functional diagnostics give a picture of the
expressed lowering or practical absence of hormones, the basal temperature is permanently
low, "fern" and "pupils" symptoms are absent. There is 50% of parabasal cells during
colpocytological investigation.
Treatment at prepuberty age is directed on the growth stimulation. After 15-17 years of
age replacement therapy with hormones is prescribed: they are estrogens for 6-9 months, after
this the cyclic therapy with Estrogens and Progesterone is indicated. Such treatment leads to
development of secondary sexual signs, uterine cyclic bleedins initate.
Polycystic ovarian disease (the Stein-Leventhal's syndrome). This is a genetically
predisposed disease, pathogenesis of which is a violation of sexual hormones synthesis in
ovaries in the result of insufficiency of enzyme systems. Excess amount of androgens is
produced.
Clinically this disease is characterized by excessive hairiness (hirsutism), by
hypomenstrual syndrome or by amenorrhea and infertility. Well-developed secondary sexual
signs and enlarged two-sided ovaries are found during the examination. During US-onografy
the presence of a great deal of follicular cysts, that is a cause of ovarian enlargement is
revealed. Excess androgen stimulation causes thickening of albuminous ovarian envelope,
that's why ovulation does not come, and follicles, do not burst, transform into cysts.
Treatment of disease can be conservative (hormonal therapy) or operative (wedgeshaped ovarian resection).
You can get more detailed information about the Shereshevsky-Turner syndrome and
the Stein-Leventhal's syndrome from the chapter "Menstrual function disorders".
DELAYED PUBERTY
Underdevelopment or absence of the secondary sexual signs at the age of 13-14 and
lack of menses at the age of 15-16 should be considered as delay of sexual development
(DSD).
There are central and ovarian form of delayed puberty. It depends on the primary link of
disease pathogenesis. At central genesis the ovarian insufficiency comes secondary in the
result of insufficient gonadotropine stimulation. At primary lesion of gonads a secretion of
gonadotropic hormones is raised. It is caused by the lack of inhibiting influence of sexual
hormones on pituitary.
Central form of delayed puberty is most frequently caused by such factors, as
infectious-toxic diseases (rheumatism, viral influenza, chronic tonsillitis, tuberculosis), stress
situations, excessive physical loading. These factors, acting in the child age, give rise to
functional immaturity of hypothalamic structures that are responsible for sexual development,
functional regulation of reproductive system is disturbed. The lesion level at central form can
be different. To genetically predisposed forms delayed puberty at Lorenz-Munne-BardeBidle's syndrome is refered. Delay of sexual maturity develops in patients with
hypopituitarism of organic origin.
Delay of sexual development of ovarian genesis most frequently appears in patients
with genetic defects. Hereditary factor is present in 2/3 of patients. Damage of ovaries
happens still in pre-natal period, damage degree of fetal ovaries depends on the duration of
pathogenic factor action such as taking of medicines especially hormonal ones by mother,
infectious mother's diseases, etc. In childhood epidemic parotitis and measles most frequently
cause ovarian insufficiency.
Clinically a delay of sexual development is expressed by that or other degree of sexual
(genital) infantilism.
Genital infantilism is a such state, when in reproductive age women anatomic and
associated with them functional peculiarities of genitalia, typical for child organism, are
preserved.
Diagnosis. External examination of women reveals low hight, frail body building, small
breasts. Hairiness on pubis is weakly developed, major labia don't cover the minor ones.
Vagina is narrow, vaults are not expressed. Uterus is small, 2/3 of it is the cervix, 1/3 is the
body. Taking into consideration such anatomic peculiarity, the expressed uterine bend to front
— sharp-angle anteflexion frequently occurs. Uterine cavity length is always shorter than the
norm (6 cm and less). There are three degrees of uterine underdevelopment for cavity lenght.
They are:

I degree — 7- cm

II degree — 5-3,5 cm

III degree — less then 3,5 cm
Uterine tubes are long and sinuous, ovaries are considerably smaller as compared with
the
Functional changes are closely connected with the structural ones. Menses in such
women start lately at the age of 15-16. Primary amenorrhea can appear in the result of
considerable underdevelopment. Amount of discharge is insignificant, menses duration is 1-2
days (hypomenstrualsyndrome). Sometimes menses comes not monthly, and is more rarely.
Menses are followed by strong pain (algo-dysmenorrhea), that is connected with uterine
structure. At expressed ovarian underdevelopment and considerable lowering of their
function, sexual desire is absent in women. If hormonal background is moderately altered,
sexual function is preserved.
Women with hypoplastic uterus can't become pregnant (primary infertility) for a long
time after marriage. If pregnancy comes, it can be ectopic (because of uterine tubes'
structure), or it interrupts in early terms, because insufficient amount of hormones does not
provide normal pregnancy development. Such interruptions of pregnancy in patients with
genital infantilism can occur several times (regular abortions), but pregnancy and associated
with it intensive hormones secretion always has positive influence on the patient's organism,
for it contributes to uterine development.
Treatment of such patients should be complex and includes restorative therapy,
physiotherapy, prescribing small doses of hormones for ovarian function stimulation. Going
in for sports, sanatorium-health-resort cure, gynecological massage are also recommended.
The earlier the cure begins, the greater are the chances for success.
At central genesis of disease Prephisone (25-50 AU i/m) is indicated during the first
phase of menstrual cycle (at amenorrhea the first cycle day is considered the first day of cure)
daily, 8-10 days. Then Choriogonine (2500-3000 AU i/m) is prescribed during the 12, 14, 15,
16, 18th cycle day. Clostylbept (Clomiphen) — 50 mg per day from 5th till 9th cycle day,
then Microfolline — 0,05 nig 2 times per day till 12-14th cycle day are also indicated.
Treatment with Clomiphen and estrogens takes 2-3 months, then synthetic Progestines in
cyclic mode during 2 courses with 7-days intervals are taken. For better hormones' reception
folic acid (0,06g per day) in first phase, in ovulation period and second phase — Thymidine
— 25-50 mg per day and vitamin E 50-100 mg per day are prescribed.
INCORRECT UTERINE POSITIONS
Physiological uterine position is considered to its situation in the center of small pelvis
on identical distance from symphysis, sacrum and lateral walls of pelvis. Uterine fundus is
situated beneath the plane of inlet, external cervical os is on the level of ishial spines (linea
interspinalis).
This situation is provided by sustaining fixative and suspentive apparatus of uterus.
Uterine and vaginal own tone, the tone of frontal abdominal wall, diaphragm and muscles of
pelvic floor have a great importance.
Uterine position is uterine relation to the leading pelvis axis. Uterus is able to displace
as for its normal position. This displacement can be physiological (uterus goes back to its
previous position) or pathological and fixed. For such conditions uterus is immovably fixed to
pelvis walls or adjacent organs by adhesions or tumor.
Anteposition — uterine displacement considering to leading axis to front.
Retroposition — uterine displacement backwards.
Lateroposition — (dextro- et sinistropositio) displacement of uterus to correspond side.
Physiological retroposition of uterus happens at repletion of urinary bladder
Anteposition appears at full rectum
Pathological uterine displacement happens at tumors presence or pus accumulation
Then uterus replaces to the healthy side. After operative interventions or after the
carried inflammatory process with formation of adhesions, a connective cicatrix tissue drags
uterus into this side. Uterine movability is limited or absent
Inclination of uterus (versio uteri) is a relation of vertical uterine axis to horizontal
plane. Inclination of uterus to front (anteversio), aside (lateroversio), and also backwards
(retroversio) are distinguished.
Causes of pathological uterine inclinations may be the tumors of genital organs (only
uterine body is displaced, and cervix remains in its place) and insufficiency of uterine
ligaments.
Uterine flexion (flexio uteri) is the relation of uterine body to its cervix. Normally
between uterine body and cervix there exists an obtuse angle (for about 120°), opened
forward (anteflexio). If the angle is less than 120°, such anteflexion refers to the sharp one (it
is found at genital infantilism).
Uterine flexion to back (retroflexio), to the right (lateroversio dextra), or to the left
(lateroversio sinistra) is pathological. Retroflexion is mobile and fixed. Fixation happens at
accretion of uterus with parietal peritoneum.
Combination of retroversion and retroflexion is called uterine retrodeviation.
Retroflexion and uterine retrodeviation are followed by aching dull pain in lower abdomen,
painful menses (algodysmenorrhea) and infertility. Uterine cervix erosions and endocervicites
can develop in the result of blood supply violation and blood stagnation. Sometimes patients
complain of frequent and painful urination. There can be a delay of evacuation and pain
during it. These phenomena sometimes can be eliminated owing to uterine reposition. Aged
women with retrodeviation can have uterine and vaginal prolapse often.
UTERINE DESCENSE AND PROLAPSE
Prolapse is a single pathological process based on a tight anatomic tie between uterus,
vagina, ovaries, urinary bladder and rectum. Depending on the stage of this process, uterine
descense and prolapse are distinquished.
The vaginal walls descense—vaginal wall has lost its tone, they are descent and do not
leave the borders of vagina's introitus.
The vaginal walls prolapse — vaginal walls are beneath the introitus of vagina.
Degrees of uterine displacement:

I degree — vaginal part of uterine cervix is found lower, then sciatic spines
(linea interspinalis), however it stays inside of pudendal cleft borders even
during the exerting (uterine descense)

II degree — external cervical os goes beyond the borders of pudendal cleft, it is
found beneath vaginal introitus, and uterine body is above it (incomplete uterine
prolapse)

III degree — all the uterine and vaginal walls are found outside of pudendal cleft
(complete prolapse)
Etiology and pathogenesis. Multiple deliveries, vaginal and perineum ruptures during
the previous delivery, constipations, weight lifting, hard work can cause weakening or
violation of the supportive, fixative and suspentive apparatus of the uterine structure and
uterine displacement. More frequently descense and prolapse of uterus develops in women
after 50 years in connection with the beginning of age atrophy of sexual organs and ligament
apparatus.
Clinic. Uterine descense and prolapse is a long process. Woman complain of dragging
pain in lower abdomen and in sacrum region, frequent urination, urine incontinence, that
appears during the smallest physical loads — cough, quick motions. Later a tumorous
formation — uterine cervix with external cervical os appears from vagina. Menorrhage is
possible if woman menstruates. Sexual life is possible after uterine reposition. Woman can
become pregnant. During the first months of pregnancy cases of its spontaneous interrupting
are common. After the 12th week of gestation uterus stops to prolapse because of its
largeness, after delivery the prolapse appears again.
Together with the anterior vaginal wall urinary bladder wall discences and prolapses.
Cystocele is formed. Descense and prolapse of posterior vaginal wall causes formation of
rectum hernia (rectocele).
At complete uterine prolapse, its body together with cervix is found beneath the
introitus of vagina. Vagina is turned out by the mucous membrane. Elongation of the cervix
develops frequently.
Mucous membrane of vagina thins or thickens and dries out. Secondary trophic changes
can develop — trophic (decubital) ulcers on cervix and vaginal walls, polyps near the external
os are common. Histologically microcirculation impairment, hyper- and parakeratosis,
inflammatory infiltration, sclerotic changes are found.
Changes in urinary system can also appear. Patients complain of frequent urination and
urine incontinence. At urine analysis bacteriuria is found. During chromocystoscopy
trabecularity and cavities in mucous of urinary bladder, ureters dyslocation, cystitis, lowering
of sphincters' tone are revealed. During excretory urography atony and dilation of ureters are
present. At US examination nephroptosis, dilation of kidney are observed. Changes in this
system are caused by violation of the blood circulation and position of urinary bladder, ureters
and associated with this urine outflow.
Diagnosis is not of a special difficulty because prolapse is found during inspection of
external genitalia. It is important to determine whether it is a complete or incomplete
prolapse. Doctor takes the prolapsed organs with index and forefingers on the level of vaginal
introitus. If uterine body is palpated between them, then the prolapse is incomplete. If fingers
close behind the uterine fundus — this is the complete uterine prolapse. Perineum inspection
is necessary to find scars and to estimate the functional state of pelvic muscles.
Treatment. Method of treatment for each patient is individually selected. It depends on
the age, general patient's state, presence of menstrual and sexual functions.
Conservative treatment is indicated for women at small descense of uterus, in
reproductive age or for emaciated patients, the age or general state of which does not allow to
use a surgical intervention. Medic ally-protective regimen with exclusion of physical loads is
of great importance. Medical physical training, directed to the strengthening of abdominal
press and pelvic floor muscles, rational feeding for constipation prevention should be
recommended.
Orthopedic method is in introduction of special devices into vagina for support of uterus
in its place (rubber rings). Great attention is paid to hygiene of genitals during pessaries
usage, taking them out regularly and sterilizing by boiling.
Conservative treatment consist also of the treatment of trophic ulcers and vaginitis, that
develop in such patients rather frequently. Doctor prescribes cure. Midwife or medical sister
can fulfil it. Vaginal walls, that have prolapsed and uterine cervix are processed with
antiseptic
solutions
(Potassium
permanganate,
Furacillin,
Hydrogenium
peroxide,
Chlorhexidin bigluconate). After processing of the prolapsed tissues, they are dried up by a
sterile gauze serviette. On decubital ulcer's surface ointment or liniment with antiseptics are
applied, a surface is covered by sterile serviette, and the uterine is replaced into vagina. Then
a tampon with aseptic remedy is inserted, tampon size depends on the vaginal size. After
elimination of inflammatory process and vaginitis for acceleration of tissue regeneration on
the region of decubital ulcer there can be applied an ointment with Solcoseril, Apilac,
Methyluracil, Propoceum. Such procedures are hold daily during 1-2 weeks to complete ulcer
epithelization. If ulcer is not healed up to that time, then biopsy for differential diagnostics
with cervix cancer is made.
Aged women which have used vaginal pessaries undergo careful supervision by a
doctor of female dyspansery, a midwife, and a medical assistant. Their long usage can cause
bedsores on the uterine cervix and vagina.
Acute urine delay appears if tissues that have prolapsed squeeze. Urine should be let out
by catheter, and patient should be hospitalized. During catheterization a catheter is directed
not upwards to symphysis but on the contrary downwards, because urethra which is connected
with anterior wall of vagina changes its usual location.
Surgical treatment is the most radical method. The main aim of cure is restoring of
pelvic floor muscles integrity, creation of uterine support, and also renewing of normal
structure and function of uterine ligaments.
Basic methods of surgical interventions are:

the plastyc of frontal vaginal wall (anterior colporrhaphy), the plastyc of
posterior vaginal wall and perineum (posterior colporrhaphy, colpoperineorrhaphy) — the plastyc of pelvic floor and perineum is made

shortening of round uterine ligaments (is used in women of reproductive age);

ventrofixation — uterus is fixed to the anterior abdominal wall (is combined
with frontal and posterior plastics of vagina)

amputation of the cervix by Shturmdorf is made at uterine cervix pathology
In senile age at complete uterine prolapse in combination with concomitant pathology
(uterine tumors etc), vaginal hysterectomy through vagina is made. This operation is
combined with the plastic of posterior vaginal wall and levatoro-plastics.
Obligatory condition for surgical intervention is the complete healing of decubital
ulcers, absence of inflammatory process in vagina.
Prevention of uterine and vaginal walls descense and prolapse is necessary in medical
and social aspects. It is important for woman to do physical exercises, to go in for sport, to
train abdominal press and pelvic floor muscles. During delivery it is necessary to diagnose
interm and to restore perineal muscles in their rupture. Doctor and midwife of postnatal
department have to take careful tendance for seams, to watch closely for the regimen and
women's conduct in postnatal period, not to allow woman with perineum ruptures to get up
and to sit down prematurely.
Uterine inversion
Uterine inversion is a state, in some causes of which uterine fundus is pressed inside. So
serous membrane is inside, and mucous one is outside. In this case the ovaries get inside this
formation, their blood supply violates. The stagnant phenomena and uterine edema develop.
There are two forms of uterine inversion: puerperal (postnatal) and oncogenetic (caused
by a tumor). The mechanism of puerperal inversion was described in obstetrics course.
The oncogenetic uterine inversion is caused by the case of protruding myoma placed on
a short pedicle.
Clinically the oncogenetic uterine inversion is followed by extending strong pain low in
the abdomen like delivery. A fibromatous node, that is situated in uterine cavity, more
frequently near its fundus, descends into lower segment, is perceived by it as a foreign body,
and uterus begins to push it out. Uterine cervix is dilated, node appears outside, but a pedicle
stem does not allow it to be born. Node's and uterine blood supply is disturbed, node necrosis
is developed.
Hysterectomy is the treatment of oncogenetic uterine inversions. An attempt to remove
the node through the uterine cervix is dangerous because of uterine perforation possibility, if
nodes pedicle is short and wide.
The uterine torsion
The uterine torsion (torsio uteri) is turning of uterine body around vertical axis. It
happens extraordinarily rarely. Uterine and ovarian tumors, adhesions process in small pelvis
are the main causes of uterine torsion.
TRAUMAS OF FEMALE GENITALS
Damages of external genitals can be as contusion, haematoma, hypodermic effusions of
blood, that ordinary are accompained by damage of skin. More often these damages appear as
a result of trauma such as falls and blows. In the village hornblows of domestic animals are
observed. These traumas can be followed by lacerated wounds which ordinary penetrating
deeply into tissues, sometimes vagina and even rectum can be damaged. In case of heavy
traumas of urethra, urinary bladder, and also pelvis bone can be damaged. In case of damage
of vagina trauma can penetrate into abdominal cavity. Ruptures of lateral walls of vagina are
very dangerous because vaginal branches of uterine arteries pass in this area.
Clinically trauma is characterised by pain and haematoma of blue to purple colour in
damaged place. In case of severe internal bleeding a picture of hemorrhagic shock develops.
Bleeding can be followed by anaemia. In case of clitoris rupture bleeding can be especially
massive. Sometimes inserting of foreign objects into genital organs can happen. Especially
frequently it happens in girls before 10 years. Adult women can introduce catheters, sounds
and other objects into uterus with aim of pregnancy interruption. In such cases frequently
uterus perforation, bleeding can appear, that's why the woman applies for medical care. If
there is no damage of genital organs, presence of foreign body causes inflammatory process.
Purulent excretions from vagina, sometimes with blood admixtures appear. Foreign body in
adults can be found due to speculum examination. For children one should use cautious rectal
research and vaginoscopy.
Diagnosis is based on examination. If there is suspicion on trauma of adjacent organs
catheterization of urinary bladder, cystoscopy is made. US can be useful for diagnostics of
foreign bodies in vagina.
Treatment. Traumatized tissues are sutured. In case of haematoma it is incised, bleeding
vessels are knitted and drained. If it is necessary hemotransfusion is performed. Uterine
cervix, vaginal, uterine ruptures, associated with labor act, are described in obstetrics course.
IV. Control questions and tasks
1. What is suspensive apparatus of the uterus?
2. What is fixative apparatus of the uterus?
3. What is supportive apparatus of the uterus?
4. Classification positional anomalies of female genitalia in woman.
5. Main causes of irregular positions of internal genitalia in woman.
6. What clinical symptoms occur at positional anomalies of female genitalia in
woman?
7. Prevention of irregular positions of female genitalia.
8. Etiology, clinic, diagnosis, treatment of vulva and vagina injuries.
9. Etiology, clinic, diagnosis, treatment of uterine cervix and uterus injuries.
V. List of recommended literature
1. Danforth’s Obstetric and gynaecology.-Seventh edition.-1994.-P.887-905
2. Gynecology.- Stephan Khmil, Zina Kuchma, Lesya Romanchuk.-2003.-P.81-101
3. Gynaecology illustrated. David McKay Hart, Jane Norman.-Fifth Edition.-2000.-P.233252