Female Reproductive Diseases

We are discussing here common gynecological conditions which we come across in general practice.

Dysmenorrhoea –

Cramping pain accompanying menstruation

Two types of dysmenorrhea –

1.Primary – Idiopathic or True –

Pain of uterine origin directly linked to menstruation, but no visible pelvic pathology is involved. Usually first day pain is spasmodic type. (Usually related to muscle contraction so colicky in nature).

2. Secondary – Uterine or pelvic pathology involved may continue throughout the flow or congestive type i.e. < premenstrual & > during menses

Can be because of endometriosis, PID

Causes – just before and during menstruation most of the women are less efficient physically or unstable emotionally. These factors may lower the pain threshold. The local and systemic symptoms are apparently resulting of increased levels of prostaglandin in menstrual fluid.

Along with uterine cramping, nausea, vomiting, backache, diarrhea, giddiness, syncope, fainting may occur in some patients. Ovulation pain occur at midcycle (10-15^th day) in hypogastrium or iliac fossa last for 12-24 hrs in few females. It is because of contraction of fallopian tubes or uterus or increased tension in graafian follicle.

Menorrhagia and Dysfunctional Uterine Bleeding (DUB) –

Menorrhagia – cyclical bleeding at normal intervals which is excessive in amount or duration (5/28-8/28).

Polymenorrhea – cyclical bleeding which is normal in amount but occurs too frequently of less than 21 days (4-5/20).

Polymenorrhagia– excessive and too frequently bleeding (8-10/20).

Metrorrhagia – bleeding of any amount which is acyclical and which occurs irregularly or continuously in between normal cycle.

Causes –

1. General Diseases –

• Blood dyscrasia like anemia, coagulopathy, leukemia, thrombocytopenic purpura, etc.
• Thyroid dysfunction – hyperthyroidism and even hypothyroidism.
• Occ. T.B. can cause menorrhagia.

2. Local Pelvic causes –

• Uterine – tumors, fibroids, polyps, adenomyosis
• Chocolate cyst, PCOS, endometriosis
• PID
• Immediate Puerperal and post abortal period

3. Iatrogenic – and progesterone administration especially OC pills.

4. Intra uterine device – IUCD

DUB – no structural cause or abnormality is found.

Classified into anovulatory 80%, ovulatory 20%

Anovulatory –

Puberty

Premenopausal bleeding

Metropathia Haemorrhagica – endometrian is thick and polypoidal and one or the other ovary contains a cystic follicle.

Ovulatory –

Irregular ripening of follicle

Irregular shedding

IUCD insertion

Ovarian cyst –

It can occur at any age. Functional and inflammatory enlargement of ovary can develop during childbearing age group. They may be asymptomatic or produce local discomfort, menstrual disturbances infertility or rarely cause acute hemorrhage or rupture.

Such an ovarian enlargement may be the result of ovarian congestion due to adnexal inflammatory state, ovarian endometriosis causing chocolate cyst or persistence and enlargement of physiological structures in the ovary like graafian follicle or corpus luteum.

Types

• Follicular cyst
• Follicular hematomas (hemorrhagic cyst)
• Lutein cysts

Most of these cysts disappear spontaneously within few weeks or months.

Polycystic Ovarian Syndrome (PCOS)

It is a complex hormonal disturbance that affects entire body. Incidences are increasing recently. Exact cause of PCOS is not known but it has been determined that PCOS may be caused by a combination of environmental and genetic influences.

This syndrome can affect adolescent and women of childbearing age group. 

In adolescent it presents with menstrual irregularities such as oligomenorrhoea, polymenorrhoea, acne and hirsutism and obesity etc. Married women of reproductive age group complain of infertility. In later stages (40-60 years) that may present with long term complications of diabetes, cardiovascular diseases etc.

Diagnosis is confirmed by ultrasonography.

Weight reduction plays important role in management of PCOS.

Leucorrhoea

Leucorrhoea is nothing but excessive amount of normal vaginal discharge.

It is very common condition that female come across at any stage of her life.

It is physiological during following conditions:

• During ovulation
• Premenstrual phase (due to congestion)
• During and after sexual intercourse (secretion from Bartholin’s glands)
• During pregnancy
• After childbirth

It is usually white or cream coloured when fresh it dries to leave brownish yellow stain on clothing.

It is usually white or cream coloured when fresh it dries to leave brownish yellow stain on clothing.

Causes –

1. at birth – mucoid vaginal discharge for 1-10 days. It is due to stimulation of uterus and vagina by placental oestrogen.

2. at puberty – temporary phase

3. Active or passive congestion of cervix – increased secretary activity by glands which may be prolonged due to ill health, anxiety, sedentary occupation, standing for long time, working in hot atmosphere.

4. OC. Pills – caused by development of an ectopy on the cervix.

5. Regular douching – it predisposes to infection by washing away naturally protective lactobacilli and by altering pH. Washing away natural secretion encourages cervix to secrete more.

Inflammatory discharge-

Causes –

Infections like – Gonococcal, Chlamydial / Monilial / Trichomonas vaginitis, Candida albicans etc.

 It is mucopurulent or frankly purulent cream yellow to green discharge often offensive and with irritation of the parts. Patient may complaint of abdominal pain, low backache, dyspareunia (difficulty or pain in coitus)

Leucorrhoea is managed well with Homoeopathic medicines.

Endometriosis

Endometriosis is defined as presence of functioning uterine gland and stroma (endometrial tissues) at any site outside the cavity of uterus.

Pathology-

Ordinarily islets of endometriosis show the cyclical changes characteristic of menstruation. However, there is no outlet for its menstrual discharge, so blood and debris get collected within the tissues to form a cyst. With each menstrual episode the collection increases in size but continual absorption of some of the fluid elements causes the blood to become inspissated and dark coloured to produce a tarry or chocolate cyst.

Many patients may remain asymptomatic. Most common symptom is dysmenorrhea. Pain begins before the onset of menstruation, builds up until the flow begins and thereafter it gradually declines. Dyspareunia is another symptom.

 Endometriosis interferes with tubal motility and function. It may inhibit ovulation leads to infertility. A change in cycle indicates ovarian involvement.

Abdominal pain – chronic – aching and discomfort

                             – Acute – when cyst ruptured.

Diagnosis- USG, Laparoscopy are useful tools for diagnosis.

Adenomyosis

It is also called as uterine endometriosis. The myometrium is invaded by endometrial glands from within. Islets of endometrium are found in the wall of the uterus.

This often coexists with uterine fibromyomas and endometrial carcinoma.

Women around 40 years of age present with menorrhagia and progressively increasing dysmenorrhoea. Pelvic discomfort, backache and dyspareunia are other symptoms.

Diagnosis – Hysteroscopy is necessary for diagnosis.

Pelvic Inflammatory Disease (PID)

PID implies infection of uterus, fallopian tubes, ovaries and overlying pelvic peritoneum or it is also called as upper genital tract infection as opposed to lower genital tract infection which include cervix, vulva and vagina.

Acidity of vaginal secretion inhibits the growth of bacteria. Cervical canal has a relatively small lumen and is normally filled with plugs of alkaline mucus. The ciliary movement of endometrial lining in the uterus and cervical canal is directed downwards and discourages the upward spread of infection in the cavity of uterus. This natural protective mechanism is hampered during menstruation, after abortion and delivery.

Predisposing factors-

• IUCD like copper T
• Multiple sexual partners
• Untreated male sexual contacts
• Destruction of tissues by curettage, trauma or surgery
• Anemia, malnutrition
• Diabetes Mellitus
• Unhygienic conditions.

Organisms- Aerobes and anaerobes are involved in 70% of cases.

S/S – pelvic pain, dysmenorrhoea, low grade fever, malaise, nausea, vomiting, vaginal discharge, menstrual irregularities.

O/E – lower abdominal tenderness

Chronic PID –

Symptoms – may be asymptomatic

                     Infertility

                     Chronic abdominal pain

                     Menstrual irregularities, dysmenorrhoea

Previous history of one or more attacks of acute pelvic inflammatory disease.

Ultrasonography, Complete blood count and ESR are helpful for the diagnosis.

Smear test – culture and sensitivity is useful to find out organism.

Infertility

Infertility- it is the inability of couple to achieve conception after 1 year of unprotected coitus.

Common Causes

Male infertility should be tested first by doing semen analysis

In females, ovarian factors such as PCOS, hyperprolactinemia and hypothyroidism should be ruled out.

Tubal obstruction is one of the major causes. Impenetrable cervical mucus is also responsible for infertility. Along with these factors anxiety and apprehension is believed to be important cause for infertility.

To find out cause of infertility necessary investigations are required. At this stage it is wise to refer patient to gynecologist for further work up.