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Gynecology Cases - Clinical Features, Treatment & Viva Questions

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CASE 1 & 34: THREATENED ABORTION

Clinical Features

• Vaginal bleeding before 20 weeks of gestation (usually light spotting)
• Mild lower abdominal cramps or backache
• Cervical os is CLOSED (key distinguishing feature)
• Uterine size corresponds to period of amenorrhoea
• Fetal heart sounds present on ultrasound (viable IUP confirmed)
• No passage of products of conception

Treatment

• Bed rest (though evidence is limited)
• Avoid intercourse
• Serial beta-hCG and progesterone levels
• Repeat ultrasound in 1-2 weeks to confirm viability
• Progesterone supplementation (controversial - evidence of limited benefit, but commonly used in practice)
• Rh-negative mothers: Anti-D immunoglobulin 300 mcg within 72 hours
• Monitor for progression to inevitable/missed abortion

Viva Questions

1. What is the definition of threatened abortion?
2. How do you differentiate threatened from inevitable abortion on examination?
3. What ultrasound findings confirm viability in threatened abortion?
4. Is bed rest evidence-based in threatened abortion? Explain.
5. When do you give Anti-D in threatened abortion?
6. What are the complications of threatened abortion?

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CASE 2: INEVITABLE ABORTION

Clinical Features

• Vaginal bleeding (often heavier than threatened abortion)
• Severe, rhythmic cramping lower abdominal pain
• Cervical os is OPEN (key finding)
• Tissue/membrane may be felt at os but not yet passed
• Uterus size corresponds to dates

Treatment

• First trimester: Suction evacuation (Manual Vacuum Aspiration - MVA) or misoprostol 800 mcg vaginally
• Second trimester: Oxytocin infusion or prostaglandins to complete expulsion, then curettage if needed
• Anti-D immunoglobulin for Rh-negative mothers
• Analgesia
• IV fluids / blood transfusion if hemodynamically unstable

Viva Questions

1. What is the difference between inevitable and incomplete abortion?
2. Why is the cervical os open in inevitable abortion?
3. What is MVA and when is it preferred over sharp curettage?
4. What is the role of misoprostol in inevitable abortion?
5. How do you manage inevitable abortion in the second trimester?

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CASE 3: MISSED ABORTION

Clinical Features

• History of amenorrhoea followed by regression of pregnancy symptoms (breast tenderness, nausea subside)
• Brown/dark scanty vaginal discharge
• Cervical os is CLOSED
• Uterine size SMALLER than expected for gestational age
• Fetal heart sounds absent
• Ultrasound: Anembryonic gestation (gestational sac >25 mm with no embryo) OR embryo with CRL >7 mm and no cardiac activity
• May be asymptomatic - discovered incidentally

Treatment

• Expectant management: Wait for spontaneous expulsion (may take weeks)
• Medical: Misoprostol 800 mcg vaginally (repeat after 3 hours if needed)
• Surgical: Suction curettage (MVA preferred in first trimester)
• Histopathology of products of conception (to exclude GTD)
• Anti-D for Rh-negative mothers
• Emotional support and counselling

Viva Questions

1. Define missed abortion. What are the diagnostic ultrasound criteria?
2. What is anembryonic gestation (blighted ovum)?
3. Distinguish missed abortion from a normal early pregnancy with uncertain dates.
4. What is the risk of DIC in missed abortion? After how many weeks does it occur?
5. Compare expectant, medical, and surgical management of missed abortion.

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CASE 4: INCOMPLETE ABORTION (also Case 35 - with Rh incompatibility)

Clinical Features

• Heavy vaginal bleeding (may be profuse)
• Crampy lower abdominal pain
• Cervical os is OPEN
• Partial passage of products of conception - some tissue passed, some retained
• Uterus smaller than expected (some tissue expelled)
• On speculum: tissue may be seen at os or in vaginal canal

Treatment

• Suction evacuation / MVA to remove retained products
• Oxytocin 10 IU IV to contract uterus
• Broad-spectrum antibiotics if signs of infection
• Blood transfusion if anemia is severe
• Anti-D immunoglobulin (Rh-negative mothers) - Case 35: this is the Rh incompatibility component - see Case 35 below

Viva Questions

1. Differentiate incomplete from complete abortion clinically.
2. What is the most dangerous complication of incomplete abortion?
3. Why is uterine curettage required in incomplete abortion?
4. How do you manage hemorrhagic shock in incomplete abortion?

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CASE 35: RH INCOMPATIBILITY WITH INCOMPLETE ABORTION

Clinical Features (additional to incomplete abortion)

• Rh-negative mother with Rh-positive fetus
• Previous history of abortion, blood transfusion, or sensitizing event
• In sensitized mothers: rising anti-D titers
• Fetal complications (in subsequent pregnancies): hydrops fetalis, jaundice, stillbirth

Treatment

• Unsensitized mother: Anti-D immunoglobulin 300 mcg IM within 72 hours of any abortion/bleeding event
• Sensitized mother (anti-D titers already raised): Monitoring of fetal well-being; intrauterine blood transfusion for severe fetal anemia
• Complete evacuation of retained products
• Kleihauer-Betke test to determine degree of fetomaternal hemorrhage

Viva Questions

1. What is Rh incompatibility and how does it cause fetal harm?
2. When and how do you give Anti-D prophylaxis?
3. What is Kleihauer-Betke test?
4. What is hydrops fetalis?
5. Why does Rh disease not typically affect the first pregnancy?

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CASE 5: SEPTIC ABORTION

Clinical Features

• History of abortion (spontaneous, induced, or unsafe)
• High fever (>38°C), rigors, chills
• Foul-smelling vaginal discharge or bleeding
• Lower abdominal pain and tenderness (peritonism in severe cases)
• Cervical motion tenderness on PV examination
• Tachycardia, hypotension (septic shock in severe cases)
• Lab: Leukocytosis, elevated CRP, positive blood cultures

Treatment

• Admit immediately
• IV fluid resuscitation; treat septic shock if present
• Broad-spectrum IV antibiotics:
  • Ampicillin/sulbactam 3g IV, OR
  • Clindamycin 600mg IV + Gentamicin 1-2 mg/kg IV (covers both vaginal flora and STI organisms)
• Early uterine evacuation (suction curettage) after initial antibiotic cover
• Serial abdominal examination for peritonitis / Fothergill's sign
• ICU care if septic shock; vasopressors if needed

Viva Questions

1. What organisms cause septic abortion?
2. What are the signs of septic shock in abortion?
3. Why must uterine evacuation be performed even in septic abortion?
4. What are the complications of septic abortion?
5. What is the Clindamycin + Gentamicin regimen and why is it used?

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CASE 6 & 19: CANDIDA VAGINITIS (MONILIASIS / CANDIDIASIS)

Clinical Features

• Intense vulvovaginal itching (pruritus) - hallmark symptom
• Thick, white, curdy/cottage cheese-like discharge
• Discharge is odourless
• Vulval and vaginal erythema, edema
• Dysuria (superficial)
• Dyspareunia
• Whitish plaques on vaginal walls; removal causes bleeding
• Risk factors: pregnancy, diabetes, antibiotic use, immunosuppression, OCP use

Treatment

• Single dose: Fluconazole 150 mg oral (preferred in non-pregnant)
• Topical (first-line in pregnancy): Clotrimazole 1% cream or 100mg vaginal pessary for 7 days
• Miconazole or Nystatin vaginal tablets
• For recurrent Candidiasis (≥4 episodes/year): Fluconazole 150mg weekly for 6 months
• Treat predisposing factors (control diabetes, stop unnecessary antibiotics)
• Partner treatment usually not required unless symptomatic

Viva Questions

1. What is the most common organism causing vaginal candidiasis?
2. How do you distinguish candida discharge from BV discharge?
3. Why is oral fluconazole avoided in pregnancy?
4. What is the definition of recurrent vulvovaginal candidiasis?
5. What pH is expected in candida vaginitis vs. BV?

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CASE 7: TRICHOMONAS VAGINALIS

Clinical Features

• Yellow-green, frothy vaginal discharge - classic finding
• Foul/musty odour
• Vulvovaginal itching and burning
• Dysuria, dyspareunia
• Strawberry cervix (punctate hemorrhages/colpitis macularis) on speculum - pathognomonic
• Vaginal pH >4.5
• Wet mount microscopy: motile pear-shaped flagellate organisms (definitive diagnosis)
• Asymptomatic in 50% of women

Treatment

• Metronidazole 2g single oral dose (both patient and partner)
• Alternative: Metronidazole 500mg twice daily x 7 days
• Tinidazole 2g single dose (if metronidazole resistance)
• Avoid alcohol during and 24h after metronidazole (Antabuse effect)
• Partner must be treated simultaneously (sexually transmitted)

Viva Questions

1. What is the causative organism of Trichomonas vaginitis? Is it a protozoan, bacterium, or fungus?
2. What is the classic discharge appearance in Trichomonas?
3. What is "strawberry cervix"?
4. How is Trichomonas diagnosed on wet mount?
5. Why must the partner be treated?
6. What is the Antabuse effect with metronidazole?

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CASE 8: BACTERIAL VAGINOSIS (BV)

Clinical Features

• Thin, homogeneous, greyish-white discharge
• Fishy/amine odour (worse after intercourse or during menstruation)
• Mild vulvovaginal irritation (less severe than Candida)
• Vaginal pH >4.5 (usually 5.0-6.0)
• Clue cells on wet mount (squamous epithelial cells studded with bacteria) - pathognomonic
• Whiff test positive (addition of 10% KOH releases amine odour)
• Amsel criteria (3 of 4): homogeneous discharge, pH >4.5, clue cells, positive whiff test

Treatment

• Metronidazole 500mg PO twice daily x 7 days (first-line)
• Alternatively: Metronidazole 0.75% gel vaginally x 5 days
• Clindamycin 300mg PO twice daily x 7 days (alternative)
• Clindamycin 2% vaginal cream x 7 days
• In pregnancy: Metronidazole 500mg BD x 7 days or Clindamycin
• Partner treatment NOT recommended routinely

Viva Questions

1. What are Amsel's criteria for BV?
2. What is Gardnerella vaginalis and its role in BV?
3. What are clue cells?
4. How do you differentiate BV from Trichomoniasis clinically?
5. Why is BV important in pregnancy?

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CASES 9, 12, 31: CERVICAL CANCER (Ca. Cervix)

Clinical Features

• Post-coital bleeding - classical symptom
• Intermenstrual bleeding
• Post-menopausal bleeding
• Foul-smelling, blood-stained vaginal discharge
• Pelvic/low back pain (advanced disease - parametrial involvement)
• Bladder/bowel symptoms (vesico-vaginal fistula, rectal involvement in advanced)
• On examination: cervical mass, ulcer, or friable/bleeding cervix
• Most common type: Squamous cell carcinoma (70-80%), then Adenocarcinoma

Staging (FIGO):

• Stage I: Confined to cervix
• Stage II: Beyond cervix but not pelvic wall or lower 1/3 vagina
• Stage III: Pelvic wall / lower vagina / hydronephrosis
• Stage IV: Bladder/rectum or distant metastasis

Treatment

• Stage IA1: Cold knife conization or simple hysterectomy
• Stage IA2 - IIA: Radical hysterectomy (Wertheim's) + pelvic lymph node dissection OR Chemoradiation
• Stage IIB and above: Concurrent chemoradiation (cisplatin + radiotherapy)
• HPV vaccination (prevention): Gardasil (4-valent), Cervarix (2-valent), Gardasil-9
• Pap smear screening (early detection)

Viva Questions

1. What HPV types are most commonly associated with cervical cancer?
2. What is the difference between CIN I, II, and III?
3. What is the FIGO staging of cervical cancer?
4. What is Wertheim's hysterectomy?
5. Why is post-coital bleeding the classic presentation?
6. When do you do a Pap smear and how often?
7. What is the role of colposcopy in cervical cancer?

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CASE 10: ENDOMETRIOSIS

Clinical Features (Classic triad)

• Dysmenorrhoea (secondary, progressive, begins 1-2 days before menstruation)
• Dyspareunia (deep dyspareunia - pain with deep penetration)
• Infertility
• Chronic pelvic pain (cyclical, worsening with menses)
• Dyschezia (painful defecation, cyclical)
• Haematuria (cyclical) if bladder involved
• On examination: tender, fixed, retroflexed uterus; nodularity in the POD; adnexal mass (endometrioma/"chocolate cyst")
• Diagnosis: Laparoscopy (gold standard) - blue/black "powder burn" lesions

Treatment

• Medical (hormonal suppression):
  • Combined OCP (first-line for mild-moderate)
  • Progestogens: Medroxyprogesterone acetate, Norethisterone
  • Levonorgestrel-IUS (Mirena)
  • GnRH agonists: Leuprolide (with add-back therapy) - 6 month course
  • Danazol (androgenic side effects limit use)
• Surgical:
  • Conservative: Laparoscopic ablation/excision of endometriotic deposits
  • Definitive: TAH + BSO (for completed family, severe disease)
• Fertility: Ovarian stimulation + IUI or IVF

Viva Questions

1. What is the most common site of endometriosis?
2. What are the theories of pathogenesis of endometriosis?
3. What is a "chocolate cyst"?
4. Why does endometriosis cause infertility?
5. What is the r-AFS/ASRM staging of endometriosis?
6. What are the "powder burn" lesions seen at laparoscopy?
7. What is the role of GnRH agonists in endometriosis?

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CASE 11: ADENOMYOSIS

Clinical Features

• Dysmenorrhoea (secondary, progressive, severe)
• Menorrhagia (heavy menstrual bleeding - often presenting complaint)
• Symmetrically enlarged, uniformly tender "boggy" uterus (2-3x normal size)
• Uterus soft and tender, especially premenstrually
• Affects multiparous women, 35-50 years
• May coexist with fibroids, endometriosis

Investigations

• Transvaginal ultrasound: asymmetric myometrial thickening, heterogeneous myometrium, myometrial cysts
• MRI (gold standard for diagnosis): junctional zone thickness >12mm
• Definitive diagnosis: Histopathology of hysterectomy specimen (endometrial glands and stroma within myometrium, >2.5mm from basal endometrium)

Treatment

• Medical (for women desiring fertility/avoiding surgery):
  • Combined OCP
  • Progestogens
  • Levonorgestrel-IUS (Mirena) - excellent for symptom control
  • GnRH agonists (temporary)
  • Tranexamic acid, NSAIDs for menorrhagia/dysmenorrhoea
• Surgical (definitive): Total abdominal hysterectomy (curative)

Viva Questions

1. What is the pathological definition of adenomyosis?
2. How does adenomyosis differ from endometriosis?
3. What is the classic uterine finding on examination in adenomyosis?
4. What is the role of Mirena IUS in adenomyosis?
5. What is the gold standard for definitive diagnosis?

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CASE 13: SUBMUCOUS FIBROID

Clinical Features

• Menorrhagia (most common and severe with submucous type)
• Intermenstrual bleeding
• Dysmenorrhoea
• Infertility and recurrent miscarriage
• Uterus enlarged, irregular (though submucous fibroids may be small)
• Anemia secondary to blood loss
• May prolapse through cervix ("fibroid polyp")

Treatment

• Medical (temporary): GnRH agonists to shrink fibroid preoperatively, Tranexamic acid, NSAIDs, combined OCP, Mirena IUS
• Surgical (definitive for submucous):
  • Hysteroscopic myomectomy - treatment of choice for submucous fibroids
  • Open myomectomy (if fertility desired, large fibroids)
  • Hysterectomy (if family complete)
• Uterine artery embolization (UAE) for symptomatic fibroids

Viva Questions

1. What are the types of uterine fibroids? Which causes the most bleeding?
2. What is the classification of submucous fibroids (FIGO)?
3. What is the treatment of choice for submucous fibroid?
4. Why do fibroids cause menorrhagia?
5. What are the complications of uterine fibroid?

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CASE 14: MENORRHAGIA

Clinical Features

• Menstrual blood loss >80 mL per cycle, lasting >7 days
• Cyclical (regular intervals), with heavy flow
• Flooding, passage of clots
• Anemia (fatigue, pallor, breathlessness)
• Causes: fibroids, adenomyosis, endometrial polyp, coagulation disorders, hypothyroidism, PCOS, endometrial hyperplasia

Treatment

• Non-hormonal:
  • Tranexamic acid 1g TDS during menstruation (reduces blood loss by ~50%)
  • Mefenamic acid (NSAID) - reduces blood loss and dysmenorrhoea
• Hormonal:
  • Levonorgestrel-IUS (Mirena) - most effective medical treatment (reduces loss by 86-97%)
  • Combined OCP
  • Progestogens (norethisterone 5mg TDS days 5-26)
  • GnRH agonists (short-term)
• Surgical:
  • Endometrial ablation (e.g., NovaSure) - for family complete, uterus <12 weeks
  • Hysterectomy (definitive)

Viva Questions

1. Define menorrhagia. What is the objective definition?
2. What is the pictorial blood loss assessment chart (PBAC)?
3. How does Mirena work in menorrhagia?
4. What investigations would you do for menorrhagia?
5. What is endometrial ablation? Name the types.

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CASES 15 & 16: UTERINE PROLAPSE / UTEROVESICAL PROLAPSE

Clinical Features

• "Something coming down" per vaginum - classic complaint
• Dragging sensation/heaviness in the pelvis
• Low backache
• Urinary symptoms: frequency, urgency, stress incontinence, incomplete voiding, or urinary retention
• Dyspareunia
• Bowel symptoms: constipation, incomplete evacuation
• On examination: descent of uterus/cervix/vaginal walls on Valsalva
• Prolapse graded: 1st degree (within vagina), 2nd degree (at introitus), 3rd degree (outside introitus), procidentia (complete)
• Cystocele (anterior wall prolapse), Rectocele (posterior wall), Uterovesical prolapse (anterior + uterine)

Treatment

• Conservative:
  • Pelvic floor exercises (Kegel's)
  • Pessary (ring pessary) - for elderly/unfit for surgery or awaiting surgery
  • Oestrogen cream (post-menopausal atrophy)
• Surgical:
  • Anterior colporrhaphy (cystocele repair)
  • Posterior colpoperineorrhaphy (rectocele repair)
  • Manchester (Fothergill's) operation: Amputation of cervix + anterior colporrhaphy + PF repair (for cervical elongation/descent with cervix, preserves fertility)
  • Vaginal hysterectomy + pelvic floor repair (commonest procedure)
  • Sacrocolpopexy (for vault prolapse)

Viva Questions

1. Define uterine prolapse and classify it.
2. What are the predisposing factors for prolapse?
3. What is a cystocele and how does it present?
4. What is the Manchester operation and when is it indicated?
5. What are the complications of untreated prolapse?

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CASE 17: CERVICAL ELONGATION WITH DESCENT

Clinical Features

• Elongated cervix with descent of the uterus, but the body of the uterus may be at normal position
• Dragging sensation/pressure in vagina
• History of prolonged labour, multiparity
• On examination: cervix elongated, protrudes at or beyond introitus
• Uterine body at normal level (differentiates from complete procidentia)

Treatment

• Manchester (Fothergill's) operation - specifically indicated for this condition (amputation of cervix + pelvic floor repair)
• Fothergill stitch involves amputation of cervix, shortening of Mackenrodt's ligaments, anterior colporrhaphy, and posterior repair

Viva Questions

1. What is cervical elongation? How does it differ from true prolapse?
2. Why is the Manchester operation preferred in cervical elongation?
3. What ligaments are plicated in the Manchester operation?

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CASE 18: STRESS URINARY INCONTINENCE (SUI)

Clinical Features

• Involuntary leakage of urine with increased intra-abdominal pressure (coughing, sneezing, laughing, lifting, exercise)
• No urgency or detrusor overactivity
• Multiparity, post-menopausal status, obesity as risk factors
• Positive cough test (leakage on coughing with full bladder)
• Urethral hypermobility or intrinsic sphincter deficiency (ISD)
• Q-tip test: >30° rotation confirms urethral hypermobility

Treatment

• Conservative (first-line):
  • Pelvic floor muscle training (PFMT/Kegel's exercises) - for at least 3 months
  • Weight loss
  • Lifestyle modifications (reduce caffeine, fluid management)
  • Continence pessary
• Pharmacological: Duloxetine (SNRI) - moderate efficacy
• Surgical (gold standard):
  • Mid-urethral sling (TVT - Tension-free Vaginal Tape or TOT - Trans-Obturator Tape) - most effective
  • Burch colposuspension (open or laparoscopic)
  • Periurethral bulking agents (for ISD, elderly patients)

Viva Questions

1. Differentiate SUI from urge incontinence (overactive bladder).
2. What is the Q-tip test?
3. What is TVT procedure? Describe it briefly.
4. What is urodynamic study and when is it indicated?
5. What is intrinsic sphincter deficiency?

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CASE 20: GENITAL WARTS (Condylomata Acuminata)

Clinical Features

• Soft, fleshy, cauliflower-like or papular lesions on vulva, vagina, cervix, perianal area, perineum
• Usually painless but can cause pruritus, bleeding, discharge
• Caused by HPV types 6 and 11 (low risk - do NOT cause cancer)
• Multiple, pedunculated or sessile lesions
• May be extensive and coalesce
• Apply 3-5% acetic acid: lesions turn white (acetowhitening)
• Associated with HPV 16, 18 in concurrent high-risk infection (may be present on cervix)

Treatment

• Patient-applied:
  • Podophyllotoxin 0.5% solution or 0.15% cream BD x 3 days/week for up to 4 weeks
  • Imiquimod 5% cream (3x weekly for up to 16 weeks) - immune modulator
  • Sinecatechins 15% ointment (green tea extract)
• Provider-applied:
  • Trichloroacetic acid (TCA) 80-90% - chemical destruction
  • Cryotherapy with liquid nitrogen
  • Surgical excision, electrocautery, laser ablation
• Prevention: HPV vaccination (Gardasil - protects against HPV 6, 11, 16, 18)

Viva Questions

1. What is the causative agent of genital warts?
2. Which HPV types cause genital warts vs. cervical cancer?
3. What is acetowhitening and what does it indicate?
4. How does imiquimod work?
5. What is the role of HPV vaccine in prevention?

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CASE 21: HERPES GENITALIS

Clinical Features

• Primary episode:
  • Prodrome: tingling, burning, itching at site
  • Painful vesicles and ulcers on vulva, vagina, cervix, perianal area
  • Bilateral tender inguinal lymphadenopathy
  • Fever, malaise, myalgia (systemic symptoms in primary)
  • Dysuria (may be severe, urinary retention)
  • Lasts 2-3 weeks
• Recurrent episodes: Milder, shorter (5-7 days), no systemic symptoms; prodrome precedes lesions
• Caused by HSV-2 (most genital cases) or HSV-1
• Diagnosis: viral culture, PCR, or clinical appearance

Treatment

• Primary episode:
  • Acyclovir 400mg TDS x 7-10 days, OR
  • Valacyclovir 1g BD x 7-10 days
  • Famciclovir 250mg TDS x 7-10 days
• Recurrent episodes: Same agents x 5 days (start at onset of prodrome)
• Suppressive therapy (≥6 recurrences/year): Acyclovir 400mg BD or Valacyclovir 500mg OD daily
• Pain management: topical lignocaine, analgesics
• In pregnancy: Acyclovir is safe; caesarean section if active lesions at term (to prevent neonatal herpes)

Viva Questions

1. What virus causes genital herpes?
2. Why does herpes recur after the primary episode?
3. What is the difference between primary and recurrent herpes?
4. What is the risk of herpes in pregnancy?
5. When is suppressive antiviral therapy indicated?

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CASE 22: POLYCYSTIC OVARY SYNDROME (PCOS)

Clinical Features

• Rotterdam criteria (2 of 3 required):
  1. Oligo/anovulation (irregular periods, oligomenorrhoea/amenorrhoea)
  2. Clinical/biochemical hyperandrogenism (hirsutism, acne, androgenic alopecia; raised testosterone/DHEAS)
  3. Polycystic ovaries on ultrasound (≥20 follicles per ovary, each 2-9mm, or ovarian volume >10mL)
• Obesity (central, apple-shaped body)
• Infertility (anovulatory)
• Acanthosis nigricans (insulin resistance)
• LH:FSH ratio >2:1 (though not in diagnostic criteria)

Treatment

• Lifestyle modification (first-line): Weight loss, exercise (improves insulin sensitivity, restores ovulation)
• Menstrual regulation: Combined OCP or progestogen withdrawal bleed
• Hirsutism: OCP + spironolactone; Metformin; Eflornithine cream (facial hirsutism)
• Infertility:
  • Clomiphene citrate (first-line ovulation induction)
  • Letrozole (aromatase inhibitor - increasingly preferred)
  • Metformin (insulin sensitizer; may restore ovulation)
  • Gonadotropin injections
  • Laparoscopic ovarian drilling (if resistant to medical treatment)
  • IVF (if above fail)
• Long-term: Screen for DM2, dyslipidaemia, hypertension, endometrial hyperplasia

Viva Questions

1. What are the Rotterdam criteria for PCOS?
2. What is the LH:FSH ratio in PCOS?
3. How does insulin resistance contribute to PCOS?
4. What is laparoscopic ovarian drilling?
5. What are the long-term metabolic risks of PCOS?
6. Which is better - clomiphene or letrozole for ovulation induction in PCOS?

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CASE 23: INFERTILITY DUE TO GALACTORRHOEA WITH HYPERPROLACTINAEMIA

Clinical Features

• Galactorrhoea: Spontaneous milky discharge from breasts (unrelated to pregnancy)
• Oligo/amenorrhoea or secondary amenorrhoea (prolactin suppresses GnRH)
• Infertility (anovulation due to high prolactin)
• Headache, visual field defects (bitemporal hemianopia) if pituitary macroadenoma
• Hypoestrogenism: vaginal dryness, decreased libido
• Prolactin >25 ng/mL (elevated)
• Causes: Prolactinoma (most common), hypothyroidism, drug-induced (metoclopramide, antipsychotics, antidepressants), stress

Treatment

• Dopamine agonists (first-line):
  • Cabergoline 0.25-0.5mg twice weekly (preferred - fewer side effects)
  • Bromocriptine 1.25-2.5mg BD/TDS (older agent)
  • These reduce prolactin levels, restore menses, and shrink tumor
• Surgery: Transsphenoidal surgery (if macroadenoma with visual symptoms, or resistant to drugs)
• Treat underlying cause (thyroid replacement if hypothyroid, stop offending drugs)
• Once prolactin normalized, ovulation returns and fertility is restored

Viva Questions

1. What is the most common cause of hyperprolactinaemia?
2. How does hyperprolactinaemia cause infertility?
3. What is a prolactinoma? Macro vs. microprolactinoma?
4. How does cabergoline work?
5. When is surgery indicated for prolactinoma?
6. What drug causes hyperprolactinaemia as a side effect?

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CASE 24: SECONDARY INFERTILITY WITH SEPTIC ABORTION CAUSING TUBAL OCCLUSION

Clinical Features

• Previous history of pregnancies (secondary infertility = no conception after previously being pregnant)
• History of septic abortion / PID causing tubal damage
• Tubal factor infertility (most common cause of secondary infertility post-infection)
• Investigations: HSG (hysterosalpingography) showing blocked tubes; laparoscopy confirms
• May have hydrosalpinx on USS

Treatment

• Diagnostic: HSG + laparoscopy + chromopertubation (dye test) to confirm blockage
• Tubal surgery: Laparoscopic salpingostomy (for distal blockage), tubal cannulation (proximal blockage)
• IVF-ET (if tubal surgery fails or not possible; treatment of choice for severe tubal disease / bilateral hydrosalpinx)
• Treat any active infection before fertility treatment
• Hydrosalpingectomy before IVF (hydrosalpinx reduces IVF success rate by ~50%)

Viva Questions

1. What is the difference between primary and secondary infertility?
2. What is the mechanism by which septic abortion causes infertility?
3. What is HSG and what does it show in tubal blockage?
4. What is chromopertubation?
5. Why should hydrosalpinx be removed before IVF?

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CASE 25: ENDOMETRIAL / CHOCOLATE CYST (Ovarian Endometrioma)

Clinical Features

• Ovarian cyst containing old, brown blood ("chocolate-coloured" fluid)
• Symptoms of endometriosis: dysmenorrhoea, dyspareunia, pelvic pain, infertility
• Palpable adnexal mass
• Ultrasound: thick-walled, homogeneous, low-level echo ("ground glass") cyst - classic appearance
• CA-125 may be mildly elevated (not specific)
• Complication: Risk of rupture (acute abdomen), malignant transformation (<1%)

Treatment

• Symptomatic / small (<4cm): Expectant or medical management (OCP, GnRH agonists)
• Surgical (>4cm or symptomatic): Laparoscopic cystectomy (preferred over drainage)
• If fertility desired: Conservative cystectomy, followed by IVF if needed
• If family complete + severe disease: BSO

Viva Questions

1. What is a chocolate cyst and how does it form?
2. What is the classic ultrasound appearance of an endometrioma?
3. Why is cystectomy preferred over aspiration for endometrioma?
4. What is the risk of malignant transformation in endometrioma?
5. How does an endometrioma affect ovarian reserve?

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CASE 26 & 33: BARTHOLIN'S ABSCESS

Clinical Features

• Tender, fluctuant unilateral swelling at the posterior lateral aspect of the vulva (4 or 8 o'clock position) - typical location
• Pain (often severe, aggravated by walking/sitting)
• Erythema and edema of overlying skin
• Dyspareunia
• May have fever if extensive infection
• Caused by mixed flora: polymicrobial (Polymicrobial, E. coli, anaerobes); also N. gonorrhoeae, C. trachomatis

Treatment

• Incision and Drainage (I&D) alone - high recurrence rate
• Word catheter insertion (after I&D; left in place 4-6 weeks to allow epithelialization) - preferred
• Marsupialization - surgical procedure of choice (creation of new opening); permanent solution, lower recurrence
• Sitz baths + analgesia
• Antibiotics only if cellulitis present (amoxicillin-clavulanate or cephalexin + metronidazole)
• Bartholin's cyst (without infection): Asymptomatic - observe; symptomatic - marsupialization
• In women >40 years: excision biopsy (to exclude Bartholin's gland carcinoma)

Viva Questions

1. Where is Bartholin's gland located and what is its function?
2. What is the difference between a Bartholin's cyst and abscess?
3. What is marsupialization?
4. What organisms commonly cause Bartholin's abscess?
5. Why is biopsy important in older women with Bartholin's cyst/abscess?

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CASE 27: OVARIAN TUMOR

Clinical Features

• Pelvic mass (often found incidentally)
• Abdominal distension, bloating
• Pelvic pressure, heaviness
• Urinary frequency (if large)
• Menstrual irregularities
• Symptoms depend on type:
  • Dermoid/teratoma: Young women, pain if torsion
  • Serous/mucinous cystadenoma: Middle age
  • Malignant (epithelial ovarian cancer): Postmenopausal, "silent killer" - presents late
• Complications: Torsion, rupture, infection, malignancy
• Investigations: USS, CA-125, AFP, beta-hCG (germ cell), LDH

RMI (Risk of Malignancy Index) = U x M x CA-125

• Surgery indicated for high RMI

Treatment

• Benign: Cystectomy (conservative) or oophorectomy
• Malignant (Epithelial ovarian cancer):
  • Primary debulking surgery (TAH + BSO + omentectomy + pelvic lymph node dissection)
  • Adjuvant chemotherapy: Carboplatin + Paclitaxel (standard)
• Dermoid: Laparoscopic cystectomy
• Laparoscopy (preferred) vs. laparotomy depending on size/suspicion

Viva Questions

1. What is the most common benign ovarian cyst in reproductive age?
2. What tumor markers are used for ovarian cancer?
3. What is the most common type of epithelial ovarian cancer?
4. What is "silent killer" in reference to ovarian cancer?
5. What is Meigs' syndrome?
6. What chemotherapy is used in ovarian cancer?

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CASE 28: GENITAL TB (Tuberculosis)

Clinical Features

• Infertility (most common presentation) - usually primary infertility in endemic areas
• Menstrual irregularities: amenorrhoea, oligomenorrhoea, irregular bleeding
• Chronic pelvic pain
• General symptoms: low-grade fever, weight loss, night sweats, malaise
• Primary organ: Fallopian tubes (in 90-100% of cases)
• Endometrium (in 50-80%), ovaries, cervix
• Asherman's syndrome (intrauterine adhesions) - from endometrial TB
• Investigations: HSG (show "tobacco pouch" appearance of tubes, beaded tubes), laparoscopy, endometrial curettage + culture/AFB stain/PCR for TB

Treatment

• Anti-TB therapy (ATT):
  • HRZE regimen: Isoniazid + Rifampicin + Pyrazinamide + Ethambutol x 2 months (intensive phase)
  • Then Isoniazid + Rifampicin x 4 months (continuation phase) = Total 6 months
• Adjunctive surgery for complications (pyosalpinx, abscess)
• Fertility after ATT is poor (particularly if tubes are destroyed); IVF-ET with surrogate uterus if uterus normal
• Corticosteroids may reduce adhesion formation

Viva Questions

1. What is the most common manifestation of genital TB?
2. Which pelvic organ is most commonly affected first in genital TB?
3. What is the HSG appearance in genital TB?
4. What is the ATT regimen for genital TB?
5. What is Asherman's syndrome?
6. How does genital TB cause infertility?

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CASE 29: PELVIC INFLAMMATORY DISEASE (PID)

Clinical Features

• Bilateral lower abdominal pain (acute onset)
• Abnormal vaginal discharge (purulent)
• Dyspareunia
• Fever (>38°C)
• CDC minimum criteria (at least ONE of):
  • Cervical motion tenderness
  • Uterine tenderness
  • Adnexal tenderness
• Additional criteria: Fever >38.3°C, elevated ESR/CRP, endocervical discharge, positive NAAT for gonorrhoea/chlamydia
• Complications: Tubo-ovarian abscess (TOA), Fitz-Hugh-Curtis syndrome (perihepatitis), infertility, ectopic pregnancy, chronic pelvic pain

Treatment (per Harrison's/CDC guidelines)

• Outpatient (mild-moderate):
  • Ceftriaxone 500mg IM single dose PLUS
  • Doxycycline 100mg PO BD x 14 days PLUS
  • Metronidazole 400-500mg BD x 14 days
• Inpatient (severe/TOA):
  • Regimen A: Cefotetan 2g IV q12h OR Cefoxitin 2g IV q6h PLUS Doxycycline 100mg q12h
  • Regimen B: Clindamycin 900mg IV q8h PLUS Gentamicin (IV/IM loading then maintenance)
  • Switch to oral after 24-48h clinical improvement; complete 14 days total

Viva Questions

1. What is the minimum CDC criteria for diagnosing PID?
2. What organisms cause PID?
3. What is Fitz-Hugh-Curtis syndrome?
4. What is a tubo-ovarian abscess (TOA) and how is it managed?
5. What are the long-term complications of PID?
6. When do you hospitalize a patient with PID?

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CASE 30: CERVICAL POLYP

Clinical Features

• Intermenstrual bleeding (most common presenting complaint)
• Post-coital bleeding
• Post-menopausal bleeding (in older women)
• Excessive mucoid discharge
• Usually asymptomatic (incidental finding)
• On speculum: smooth, red/pink, pedunculated mass protruding from cervical os
• Most are benign (malignant transformation rare)

Treatment

• Polypectomy (avulsion/twisting off the polyp) - simple, OPD procedure
• Histopathology of excised polyp (mandatory - to exclude malignancy)
• If base is broad, hysteroscopic resection
• Dilatation and curettage (D&C) if recurrent or multiple polyps
• No specific medical treatment

Viva Questions

1. What is a cervical polyp and from where does it arise?
2. What is the most common presenting symptom of a cervical polyp?
3. How do you perform polypectomy?
4. Why is histopathology mandatory after polypectomy?
5. How do you differentiate a cervical polyp from an endocervical carcinoma?

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CASE 32: SYPHILIS

Clinical Features

• Painless chancre (solitary, indurated, clean base) at site of inoculation (vulva, vagina, cervix)
• Non-tender inguinal lymphadenopathy
• Heals spontaneously in 3-6 weeks

• Generalised maculopapular rash (palms and soles involvement - classic)
• Condylomata lata (flat, moist grey plaques on genitalia)
• Mucous patches, snail-track ulcers (in mouth)
• Fever, malaise, lymphadenopathy, alopecia
• Highly infectious

• Gummas (granulomatous lesions)
• Cardiovascular syphilis (aortitis, aortic regurgitation)
• Neurosyphilis (tabes dorsalis, general paresis, Argyll Robertson pupil)

Investigations

• Screening: VDRL / RPR (non-treponemal)
• Confirmatory: TPHA / FTA-ABS (treponemal)
• Dark-field microscopy of chancre exudate (T. pallidum spirochetes)

Treatment

• Benzathine Penicillin G 2.4 million units IM single dose (primary, secondary, early latent)
• Tertiary/late latent: Benzathine Penicillin G 2.4 MU IM weekly x 3 doses
• Neurosyphilis: Aqueous Crystalline Penicillin G 18-24 MU/day IV x 10-14 days
• Penicillin allergy: Doxycycline 100mg BD x 14 days
• In pregnancy: Penicillin only (no doxycycline)
• Jarisch-Herxheimer reaction (fever, malaise, headache 2-8h after first dose) - treat with antipyretics

Viva Questions

1. What organism causes syphilis?
2. What is a chancre and how does it differ from a herpetic ulcer?
3. What are the stages of syphilis?
4. What is the difference between VDRL and TPHA?
5. What is Jarisch-Herxheimer reaction?
6. What is Hutchinson's triad in congenital syphilis?
7. How do condylomata lata differ from condylomata acuminata?

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SUMMARY TABLE

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