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Myoma of the Uterus

 General Considerations:

1. Incidence: around 30% of all reproductive females

2. Synonym: fibroid tumor, leimyoma.

3. Origin: smooth muscle of uterus.

4. Estrogen dependent.

5. Incidence of malignant transformation: 0.4%.

 Clinical Features:

1. Abnormal uterine bleeding, excessive or prolonged menses

2. Pain: when there are degeneration change, myoma delivery, compression, torsion of pedunculated myoma.

3. Palpable mass

4. Asympomatic

5. Infertility, repeated abortion 

Types of myoma:

1. Submucosal myoma

2. Pedunculated myoma (subsersal & submucosal)

3. Intramural myoma

4. Cervical myoma

5. Broad ligament myoma 

Diagnosis:

1. Pelvic examination: size was described as gestation week

2. Gyn. sonography: transabdominal or transvaginal sonography

3. Computed tomography (CT scan)

4. MRI

5. Hysteroscopy: for submucosal myoma 

Secondary Changes:

1. Hyaline degeneration

2. Cystic degeneration

3. Red degeneration

4. Fatty degeneration

5. Calcification degeneration

6. Necrotic degeneration

7. Septic degeneration

8. Malignant change: leiomyosarcoma 

Pathology:

1. Leiomyoma

2. Degeneration changes

 Treatments:

1. Expectant Tx:

a. Myoma < 6 cm often regress after menopause

2. Medical Tx:

a. Progestine and Antiprostaglandin : controll MC amount

b. GnRH-a, LHRH-a: reduce myoma size

c. Danazol: uncertain effect

3. Surgical Tx:

a. Myomectomy: recurrent rate of myoma is high (40%). used in p¡¦t  not completing family or who don¡¦t want to receive hysterctomy.

b. Hysterectomy: ATH, LAVH.

  4. Alternate Tx:

a.  Uterine artery embolization (UAE) , after UAE uterine fibroidshrink at least 50% in volume on average and symptoms of refractory vaginal bleeding and chronic pelvic pain are controlled in approximately 85% of patients. (Reference)

b. Uterine artery ligation (electrocautization or clip ligation)

 Indication of surgery:

1. Severe menorrhagia

2. Obvious symptom and sign of pain, compression

3. Rapid growing tumor

4. Possibility of malignant change 

Pre-OP evaluation:

1. Pathology of Fr D&C + Cx Bx is required

2. Other evaluations are same as general Gyn. Pre-OP  

Post-OP care:

1. Post-OP evaluation in the night of operation

2. C.D., Flatus passage stimulation, CBC/DC et, al. are same as general Gyn  laparotomy

3. Pathology report on the third day postoperatively 

Special Conditions of Uterine Myoma:

1. Leiomyomatosis: polypoid extension of benign smooth muscle tumor into the pelvic vein

2. Leiomyomatosis peritonealis disseminata: multiple myoma in the subperitoneal surface

3. Benign metastasizing fibromyomas: a variant of low-grade leiomyosarcoma

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* ­Yuterine myoma¦P®É¦X¨Övaginal bleeding¥²¶·survey¬Ý¦³¨S¦³¾®¦å¾÷¯à²§±`¡C

* ¥»°|¶}ATH«e¤@©w­n¦³¥b¦~¤ºªºFr D&C + Cx Bx³ø§i¡C

* Myomectomy«á¤l®cÁ_¦X¶Ë¤f³Ì¦n¥ÎInterceedÂл\¥H¨¾¸zÖßÂH¡C

* Uterine artery embolization²{©MX-¥ú¬ìÄDZҩúÂå®v¦X§@¡C

* Reference:

Wong GC, et al. Uterine artery embolization: a minimelly invasive technique for the treatment of uterine fibroids. Journal of Womens Health & Gender-Based Medicine. 9(4): 357-62, 2000.

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Endometriosis 

Endometriosis

1. Endometriosis is the presence and growth of the glands and stroma of the lining

  of the uterus in an aberrant or heterotopic location.

2. Endometriosis is a benign, but a progressive disease. It has the characteristics of

  malignancy--locally infiltrative, invasive, and widely disseminating.    

3. Conservative estimates find that endometriosis is present in 5% to 15 % of 

  laparotomies performed on reproductive-age females. If the women are infertile, 

  the incidence of endometriosis is 30% to 45%.  

4. The typical patient with endometriosis is in her mid-30s, is nulliparous and 

  involuntarily infertile, and has symptoms of secondary dysmenorrhea and pelvic

  pain. However, in clinical practice the majority of cases are not" classic." Women

  with extensive endometriosis may be asymptomatic, whereas other patients with

  minimal implants may have incapacitating pelvic pain.

  Etiology

 1. Retrograde menstruation: the most popular theory

 2. Metaplasia

 3. Lymphatic and vascular metaplasia: can helps to explain rare and remote sites of endometriosis ( as well as multiple lesions in the lung). 

 4. Iatrogenic dissemination:

 5. Immunologic defects: it is not yet established whether endometriosis is a related to

   immunologic problem.

 6.Genetic predisposition: the risk of endometriosis is seven times greater if a first-degree relative has been affected by endometriosis.

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Pathology

1.  The majority of endometrial implants are located in the dependent portions of the female pelvic.
common sites: ovaries, pelvic peritoneum, ligaments of the uterus, sigmoid colon,               pelvic lymph nodes, appendix, cervix, vaginal fallopian tubes. 

2.  Gross pathologic changes of endometriosis exhibit wide variability in color, shape, size, and associated inflammatory and fibrotic changes. The color of the lesion varies widely and may be red, brown, black, white, or yellow or a pink, clear, or red vesicle. New lesions are small, sometimes blood filled cysts that are less than 1 cm in diameter. The older lesions have more intense scarring and are usually puckered or retracted from the surrounding tissue.

3.  The three cardinal histologic features of endometriosis are ectopic endometrial glands,

Ectopic endometrial stroma, and hemorrhagic into the adjacent tissue.   

Clinical diagnosis

Symptoms

1.  The classic symptoms of endometriosis are cyclic pelvic pain and infertility. The 

chronic pelvic pain usually presents as secondary dysmenorrhea and/or dyspareunia.

Approximately one third of patients with endometriosis are symptomatic.

2.  No correlation between the anatomic stage of the disease and the patient's perception of severity of pelvic pain.

3. Increased incidence of first trimester abortion.

4. Approximately 15% of women with endometriosis have coincidental anovulation.

5. Less common symptoms: cyclic abdominal pain, intermittent constipation, diarrhea,

dyschezia, catamenial hemothrax, bloody pleural fluid.

 Signs

1.  The most prominent pelvic finding of endometriosis is a fixed retroverted uterus with

scarring and tenderness posterior to the uterus.

2.  Ultrasound examination shows no specific pattern for pelvic endometriosis. Therefore

pelvic ultrasound may give additional and confirmatory information, but cannot be used for primary screening.

  Sonagraphy findings of endometrioma:

  echogenic homogenous cystic mass: most common

    Multiple lobular cystic mass

    Heterogenic cystic mass

    Cystic with local echogenic mass 

Natural History

1.  The rate of progression of the disease varies widely from one patient to another.

Serial pelvic examinations are a poor indicator of progression of the disease. The natural history of the disease is largely speculation.

2.  CA-125 levels are elevated in most patients with endometriosis and increase

  incrementally with advanced stages. However, assays for serum levels of CA-125

  have a low specificity, physicians may only be able to follow the course of persistent 

  or recurrent disease or predict the success of therapy by measuring serial CA-125 

  levels.

3.  Approximately 10% of teenagers who develop endometriosis have associated

  congenital outflow obstruction. 

Management

The appropriate treatment for endometriosis varies widely because of the spectrum of clinical symptoms and vast differences in extent of the disease from one patient to another. Therefore the treatment plan must be individualized. Choice of therapy depends on multiple variables, including the patient's age, her future reproductive plans, the location and extent of her disease, her symptoms, and associated pelvic pathology.

Medical Therapy

The primary goal of the hormone treatment of endometriosis is induction of amenorrhea.

To date no hormonal therapy has been able to produce long-lasting cures with ablation of all foci of endometriosis after discontinuation of hormonal management. 

Danazol

1. Danazol is a synthetic steroid derivative of ethisterone (17-à-ethinyltestosterone). The 

  half-life of this oral drug is between 4 and 5 hours. It is metabolized in the liver with

  cleavage of the isoxazol ring, women who take danazol for longer than 6 months should 

  have serum liver enzyme determinations.

2.The drug is mildly androgenic and anabolic. Many of danazol's side effects are directly

  related to these two properties. Danazol binds to androgen and progesterone receptors 

  and also binds to sex hormone- binding globulin. The latter effect results in a three-fold

  increase in endogenous free testosterone levels.

3.It can significantly decreases FSH and LH levels by a dose of 800 mg a day.

  Dosages of 800 mg daily produce amenorrhea and inhibition of ovulation within 4

  to 6 weeks after onset of therapy. The drug is started on the fifth day after the onset of 

  menses. The lower dosages of danazol are not as effective at producing amenorrhea  

  and anovulation.

4.  Side effects related to danazol therapy include menopausal hot flushes, atrophic

  vaginitis, emotional lability, weight gain averaging 8 to 10 pounds, fluid retention,

  migraine headaches, dizziness, fatigue, depression, oily skin, facial hair, and deepening 

  of voice, decreases HDL levels and elevates LDL levels.

5.  The uncorrected fertility rate following danazol therapy is approximately 40%, 5% to 

  30% of patients will have recurrence of symptoms within 2 years following therapy.    

  No significant differences between the efficacies of danazol and GnRHa.

GnRH Agonists

1.  GnRH agonists are 10 to 200 times more potent and have much longer half-lives than

  the natural hormone, induce protracted periods of downward regulation. These  

  agonists may be administered by intravenous, intramuscular, subcutaneous, intravaginal,

  or intranasal routes.

2.  GnRH agonists have no effect on sex hormone-binding globulin. Thus the androgenic

  side effects from danazol caused by the increase in free serum testosterone are not 

  observed, and no significant changes occur in total serum cholesterol, HDLs, or LDLs

  during therapeutic periods as long as 6 months. The side effects are primarily those 

  associated with estrogen deprivation, similar to menopause. The three most common

  symptoms are hot flushes, vaginal dryness, and insomnia. The decrease in bone density 

  is partly or completely reversible after discontinuing therapy.

3.  After 6 months of GnRH agonists therapy, ovarian function will return to normal in 6 to 12 weeks. Endometriomas and severe adhesive disease have not responded to hormonal therapy. The primary advantage of GnRH agonists over danazol is better patient compliance. 

Oral Contraceptives

1.  The present low-estrogen combination pills, specifically the ones with a relatively high progestin potency, are equally effective. The regimen is aimed to maintain their amenorrhea on a comparatively low dosage of steroids. It is important to emphasize to the patient the goal of continuous rather than intermittent oral contraceptive therapy.

2.  The many side effects of inducing amenorrhea with oral contraceptives include weight gain, breast tenderness, nausea, chloasma, an increase in appetite, irritability, depression, edema, hypertension, and vaginal discharge.

3.  The results of continuous oral contraceptive therapy include a decrease in symptomatology in approximately 80% of patients during therapy and an uncorrected pregnancy rate of about 30 % after therapy.

 Surgical Therapy

The choice between medical treatment to suppress endometriosis and surgical therapy to

remove it depends on the patient's age, symptoms, and reproductive desires.

1.  Laparoscopy is employed frequently for diagnostic reasons and can also be used therapeutically. Conservative surgery has as its goal the removal of all macroscopic,

  visible areas of endometriosis with preservation of ovarian function, adhesionlysis to 

  restore normal anatomy. Definitive surgical treatment is reserved for patients with far-

  advanced disease and for whom future fertility is not a consideration. Definitive surgery

  involves total hysterectomy, BSO, and the remove of all visible endometriosis.

2.  Classification system of endometriosis:

  AFS(American fertility society )system:

  This system reflects the extent of endometrial disease, but it is not based on the  

  correlation of pain or infertility .

 AFS classification of endometriosis               Additional  Endometriosis

Stage I (Minimal) 1-5      _________________________        ______________________________

Stage II (Mild)    6-15    _________________________        ______________________________

Stage III (Moderate) 40   _________________________        ______________________________

Stage IV (Severe)    >40 _________________________        ______________________________

Total:  _________________________

* If the fimbriate end of the fallopian tube is completely enclosed, change the point assignment to 16.

3.  The pregnancy rate after laparosopy treatment :

  Treatment of moderate disease has an approximate 60% pregnancy success rate,

  severe disease has pregnancy success rate of 35%. Surgical management of infertile 

  women with minimal to mild endometriosis is controversial .

Recurrence rate after treatment:

1.Operation: recurrence rate is about 5-20% per year a cumulative rate of 40% after 5 

   years

2.GnRHa: minimal disease: 37% (five years after therapy)

          Severe disease: 74% (five years after therapy)

3.Danazol: similar to GnRHa.
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Adenomyosis

1.  Adenomysis is the growth of endometrial glands and stroma in the uterine myometrium at a  

  depth of at least 2.5mm from the basalis layer of the endometrium. These glands do not   

  usually undergo the traditional cyclic proliferative and secretory changes that are associated

  with differing levels of ovarian hormone production. The uterine posterior wall is usually 

  involved more than the anterior wall. In the more common, diffuse type of adenomyosis the

  uterus is uniformly enlarged, usually 2 to 3 times normal size.

2.  The incidental may exceed 60% in women 40 to 50 years of age.

3.  Some studies have demonstrated a lack of progesterone receptors in tissue from adenomyosis and fewer estrogen receptors than normal endometrium.       

Clinical Diagnosis

Symptoms and signs:

1. The majority of women with adenomyosis are asymptomatic or minor symptoms.

2. Symptomatic adenomyosis usually presents in women between the ages of 35 and 50, and             

  the majority women are parous and frequently have several children.

3.  The clinical symptoms of adenomyosis are secondary dysmenorrhea and menorrhagia, dyaparareunia.

 Diagnosis:

1. Adenomysis is a clinical diagnosis and imaging studies, although helpful are not definitive .

2. In women with diffuse uterine enlargement and negative pregnancy test. Secondary    

  dysmenorrhea may be attributed to adenomyosis.

3.  Suspected adenomyosis can be confirmed pathologically only at the time of hysterectomy. The clinical diagnosis was confirmed in only 48% of cases. 

Management:

1.There is no satisfactory medical treatment for adenomyosis,

2.Patients can be treated with cyclic hormones or prostaglandin synthetase inhibitors for their 

  abnormal bleeding and pain.

3.Hysterectomy is the definitive treatment if this therapy is appropriate for women¡¦s age, parity, and plans for future reproduction. 

Ectopic Pregnancy 

Definition: Pregnancy outside of endometrial cavity.

Location:

1. Fallopian tube (including interstitial pregnancy)

2. Ovary

3. Broad ligament

4. Abdominal cavity

5. Cervix 

Incidence:1.4% of pregnancy, increased with parity and age, highest in 35-44y/o. 

Part I: Tubal Pregnancy

I. General considerations:

A 95% of ectopic pregnancy, 80% in ampulla. 

B. Risk factors:

1. Laparoscopically proved PID:

2. Previous tubal pregnancy:

a. Subsequent ectopic pregnancy: 10-25%(7-13X).

b. Subsequent IUP: 50-80%.

3. Current use of IUD: 6-10X risk for tubal pregnancy.

4. Previous tubal surgery for infertility:

a. Sterilization: 5-16% for tubal pregnancy, the greatest risk is in the first 2 years.

b. Tubal repair or reconstruction:4-5X.

5. Abdominal surgery:Removal for ruptured appendix: increased.

6. Others:

a. Abortion

b. Infertility

c. Salpingitis Isthmica Nodosa(SIN)

d. Endometriosis and Leiomyomata: not consistently associated.

e. DES

f. Smoking: >2X

 II. Diagnosis:

A. History:

1. Past history:

a. Systemic disease.

b. Operation, esp. for infertility or ruptured appendicitis.

2. Gyn history:

a. Two recent menstrual periods, interval/duration, amount of menses.

b. Infertility, ectopic pregnancy, abortion.

c. PID, laparoscopically-proved.

d. Contraceptives use, IUD(copper or progesterone-containing).

 B. Symptom/sign:

1. Missed period: pregnancy test should be performed.

2. Abdominal or pelvic pain: >95%, The pain may be localized unilaterally.

3. Abnormal vaginal bleeding: 60-80%, due to tubal myometrial invasion by trophoblasts.

4. Others: nausea/vomiting, shoulder soreness, faintness, shock.

5. Pelvic exam:

a. Cervix: lifting pain.

b. Uterus: soft, slightly enlarged but tender.

c. Adnexae: palpable, tender mass or not(may be due to guarding).

d. CDS: may be bulging.

 C. hCG: serial hCG

1. Discriminatory zone:

2. Doubling time:

a. In the first 6 weeks of amenorrhea: 48hr, regardless of the initial level..

b. 85% of normal IUP, hCG will rise >66%, only 15% of the ectopics > 66%.

c. 85% of the ectopics, hCG rises < 66%. 

d. After 6th week, rise of hCG is not consistent.

e. If hCG become plateau or half ³ 7days: ectopics are most likely.

 3. Half life:

a. < 1.4 days: rarely ectopic pregnancy.

b. ³ 7days or plateau: mostly ectopic pregnancy.

c. drop of hCG < 50% over 48hr: ectopic pregnancy is most likely.

d. drop of hCG > 50% over 48 hr: complete abortion is likely.

4. "20-day window":

a. hCG can be detected on the 8th day after fertilization, and gestational sac is visible on the 28th day after fertilization. During this period, if no IUP is detected by vaginal sonography, recheck GS on the day when hCG is expected to be > 2,000mIUI/mL.

5. Other markers:

Progesterone: 1.5% of ectopic pregnancies with progesterone > 25ng/ml, whereas only <1/1500 of viable IUP with progesterone < 5ng/ml.  Useful in "20-day window" or hCG not available.

 D. Ultrasound:

1. Diagnostic triad: (1).empty uterus, (2).adnexal mass clearly separated from ovary, (3)hCG>2,000mIU/mL.

2. CDS fluid: suggestive of hemoperitoneum if adnexal mass is also seen.

3. GS may be seen at 4.5-5 weeks gestation by vaginal sonar and 6-7weeks by abdominal sonography.

4. Doppler: high-velocity, low-resistance peritrophoblast flow.

 E. Culdocentesis: 18-20 gauge needle with syringe.

1. Positive: unclotting blood(liquefied old blood clot), source uncertain.

2. Negative: clear fluid.

3. Nondiagnostic: nothing is withdrawn.

F. D&C: for villi. If no villi can be found, check hCG.

 G. Laparoscopy: old standard for diagnosis of ectopic pregnancy.

 III.Treatment:

A. Principles: on vaginal sonography:

1. If no IUP and hCG > 2,000mIU/mL: treat without further testing.

2. Adnexal fetal cardiac activity: treat without further testing.

3. A tubal mass as small as 1 cm can be identified and characterized.  Masses > 3.5-4.0 cm should not be treated medically.

4. Suction D&C is used to differentiate nonviable IUP from ectopic pregnancies: < 50% rise in hCG/48hr, hCG < 2,000mIU/mL and an indeterminate sonography.

 B. Surgery:

1. Indications:

a. Indeterminate pregnancy: suction D&C first.

b. Adnexal mass > 3.5cm.

c. Ruptured ectopic pregnancy.

d. Unstable hemodynamics: laparotomy.

e. Ectopics in other sites of abdominal cavity or pelvis than fallopian tubes.

f. Complications or failure of medical treatrment.

2. Linear salpingosotomy v.s salpingectomy:

Salpingostomy: unruptured ecotopics, desiring future fertility.

Salpingectomy: history of infertility.

3. Outcome:

a. Pregnancy rate is similar between L copy and laparotomy.

b. L copy salpingostomy: 60% of subsequent pregnancy is IUP.  L copy salpingectomy: 54%

 C. Medical treatment:

1. Agnets: Methotrexate(MTX), KCl, hyperosmolar glucose, prostaglandin, RU486.

2. Systemic therapy--MTX:

a. Inhibiting dehydrofolate reductase and then inhibiting DNA synthesis.

b. Candidates for MTX:

(1) An hCG is present after salpingostomy or salpingectomy.

(2) A rising or plateaued hCG is present at least 12-24 hours after suction D&C.

(3) No intrauterine gestational sac or fluid collection is detected by TVUS, hCG level is < 2,000mIU/mL and an ectopic pregnancy mass < 3.5cm.

c. Initiating MTX:

(1) Obtain hCG level.

(2) Perform TVUS within 48hr.

(3) Suction D&C if hCG < 2,000mIU/mL.

(4) CBC, D/C (WBC > 2,000/mL, Platelet > 100,000), GOT, BUN, Cr.

(5) Adminster Rhgam if Rh(-).

(6) Identify unruptured ectopic pregnancy < 3.5cm.

(7) Prescribe FeSO4 if Hct < 30%.

(8) F/U hCG on Days 4, 6, 7.

(9) Well explain to the patient and avoid alcohol, multiple vitamins containing folic acid and intercourse untill hCG is negative.

(10) Call doctor if prolonged or severe vaginal bleeding or abdominal pain.  * Lower abdominal or pelvic pain is normal during the first 10-14 days of treatment.

(11) Use oral contraceptives or barrier methods for contracption.

d. Regimens:

(1) Multiple MTX with citrovorum factor:

(a) Multiple MTX(1mg/kg/day), im injection on days 1, 3 , 5, 7, and citrovorum factor(0.1mg/kg/day) im on days 2, 4, 6, 8, until at least >15% decline between 2 consecutive daily hCG levels (maybe 2 or more courses are required) , then DC MTX and follow hCG level weekly until negative.

(b) Success rate: 96%. In case of FHB(+), success rate is 80%(4/5).

(2) Single dose of MTX(50mg/m2) without citroverum factor:

(a) Day 0 D&C, hCG

1 CBC, GOT, BUN, Cr, blood type and Rh

4 MTX 50mg/m2 i.m.

7 hCG

(b) If < 15% decline in hCG level between days 4 & 7, give 2nd dose of MTX If > 15% decline in hCG level between days 4 & 7, F/U hCG weekly untill hCG < 10 mIU/mL.

(c) Combine days 0 and1 in patients not requiring D&C.( hCG>2,000 and no IUP)

(d) Success rate: 96.7%.

(e) Surgical intervention if rupture of ectopics, precipitous drop of Hct or unstable hemodynamics occur.

(f) Avoid pregnancy within 2 months after completeness of therapy.

(g) Outcome: similar to outcome L‘scopically-treated.

3. Local injection of agents into the amniotic sac with transvaginal ultrasound, tubal cannel or L‘scopy, including MTX, PGF2a, KCl or hyperosmolar glucose.

4. Side-effects of MTX: < 1%.

a. Bone marrow inhibition: leukopenia, thrombocytopenia, bone marrow aplasia.

b. Mucosa damage: ulcerative stomatitis, diarrhea, hemorrhagic enteritis, and less commonly, alopecia, dermatitis, elevated liver enzyme and pneumonitis

.Part II: Nontubal ectopic pregnancy:

I. Cervical pregnancy: 1/2,400-50,000 of pregnancies.

A. Risk factors:

1. Previous therapeutic abortion.

2. Asherman‘s syndrome.

3. Previous C/S.

4. Leiomyoma.

5. IVF.

 B. Diagnosis:

1. Clinical criteria:

a. The uterus surrounding the distended cervix is smaller.

b. The internal os is closed.

c. Curettage of the endometrial cavity is nonproductive of placental tissue.

d. The external os opens earlier than in spontaneous abortion.

2. Ultrasound criteria:

a. Echo-free uterine cavity or the presence of a false gestational sac only.

b. Decidual transformation of the endometrium with dense echo structure.

c. Diffuse uterine wall structure.

d. Hourglass uterine shape.

e. Ballooned cervical canal.

f. Gestational sac in the endocervix.

g. Placental tissue in the cervical canal (or peritrophoblast flow on Doppler).

h. Closed internal os.

 C. Treatment:

1. Nonsurgical: intra-amniotic or systemic injection of MTX.

2. If bleeding due to suction D&C, hemostasis may be tried by one of the following:

a. uterine packing,

b. lateral cervical suture to ligate lateral cervical vessels,

c. placement of cerclage,

d. insetion of 30-ml Foley for tamponade,

e. angiographic embolization.

3. Hysterectomy if massive bleeding or the above methods fail to stop bleeding. 

II. Ovarian pregnancy: 0.5-1.0% of ectopic pregnancies.

A. Risk factor: IUD.

 B. Diagnosis criteria(for primary ovarian pregnancy):

1. The fallopian tube on the affected side is intact.

2. The fetal sac must occupy the position of the ovary.

3. The ovary must be connected to the uterus by the ovarian ligment.

4. Ovarian tissue must be located in the sac wall.

 C. Treatment:

1. Ovarian cystectomy via laparotomy or L‘scopy.

2. MTX or PG injection. 

III. Abdominal pregngncy: 1/372-9714 live births.

A. Primary or secondary:

1. Studdiford‘s criteria for diagnosis of primary abdominal pregnancy:

a. Presence of normal tubes and ovaries with no evidence of recent or past pregnancy.

b. No evidence of uteroplacental fistula.

c. The presence of a pregnancy related exclusively to the peritoneal surface and early enough to eliminate the possibility of secondary implantation after tubal nidation.

2. Secondary: subsequent implantation due to tubal rupture or abortion, or less commonly, uterine rupture. 

B. Diagnosis:

1. Clinical manifestation:

a. Symptoms: painful fetal movement, fetal movement high in abdomen, sudden n cessation of fetal movement.

b. P.E: persisitent fetal lie, abdominal tenderness, displaced cervix, easy palpation of fetal parts, palpation of uterus separating from the gestation.

c. Diagnosis:

(1) No uterine contraction after oxytocin infusion.

(2) Image: MRI, X-ray, ultrasound, angiography for feeding vessels. 

C. Treatment: surgery only

1. If feeding vessels of the placenta can be identified and ligated, remove the placenta and leave packing in the abdomen for 24-48 hours.

2. If feeding vessels of the placenta can not be identified and ligated, ligate the cord near the placenta and leave the placenta in the abdominal cavity, with serial follow-up of the hCG and, sonography. Watch for complications.

3. Complications: bowel obstruction, fistula formation, sepsis.

4. MTX is contraindication because of high rate of complications. 

D. Pregnancy outcome:

1. Term pregnancy is possible but with high rate of complications and congenital anomalies.

2. Congenital anomaly: pulmonary hypoplasia, pressure deformity, facial and limb asymmetry. 

IV. Others:

A. Ligmentous pregnancy: 1/3,000 of ectopic pregnancies.

Secondary implantation of the gestation through tubal serosa or uterine fistula.

B. Interstitial pregnancy: 1% of ectopic pregnancies.

C. Heterotropic:1/30,000 of pregnancies.

Intraamniotic injection of KCl through TVUS or L‘scopy or remove the ectopic, and the normal intrauterine gestation can continue. 

D. Pregnancy after hysterectomy: secondary to

1. supracervical hysterectomy: perioperative period.

2. total hysterectomy: defect of vaginal cuff. 

E. Spontaneous resolution:

1. by resoption or tubal abortion. 

2. hCG is falling but watch for the tubal rupture.

F. Persistent ectopic pregnancy:

1. After a conservative surgery(salpingostomy, fimbrial expression), trophoblastic tissue remains.

2. Trophoblast tissue may be confined to the muscularis medial to the incision, or implanted in the peritoneum.

3. If postoperative hCG or progesterone levels on days 0, 3, 6, remain plateaued, the the diagnosis of persistent ectopic pregnancy should be made.

4. Risk factors: based on

a. types of surgical procedure: L copy salpingostomy: 3-20%.  laparotomy salpingtomy: 2%.  * the incidence is increased with the use of conservative surgery.

b. the initial hCG level:

(1) preoperative: <3,000--23%,  >3,000--1/67.

(2) postoperative D2 >1,000--36%,  D7 > 1,000--64%.

c. the duration of amenorrhea: < 7 weeks, increased risk.

d. the size of the ectopic: < 2cm, increased risk.

5. Treatment:

a. Salpingectomy or repeat salpingostomy.

b. MTX: preferable because the trophoblast tissue may be elsewhere out of tubes.

G. Chronic ectopic pregnancy:

1. Pregnancy did not resolve during the expectant management

2. Duration of amenorrhea: 90% ranging from 5-16 weeks.

3. S/S: pain--86%,  vaginal bleeding--68%,  both--58%, pelvic mass: most are asymptomatic.

4. Diagnosis:

a. Ultrasound: helpful if there are pelvic masses.

b. hCG: low or absent, may be mistaken as resolution.

5. Treatment: surgical removal of gestational tissue.

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Benign Ovarian Tumors 

Clinical features:

1. Almost happen during the years between menarche and menopouse

2. No symptom or symptoms such as local discomfortable, menstral dysfuction, infertility, dysmenorrhea

3. Low abdominal pain, palpable abdominal mass, flank soreness 

Classifications of benign ovarian tumors

Functional cysts:

lFollicular cysts

lcorpus luteum cysts

lpolycystic ovarian dis.

Neoplastic lesions:

lserous adenomas

lmucinous adenomas

lmature teratomas

lEndometrioid adenofibroma

lBrenner tumors (fibroma ; transitional tumors) 

Diagnosis:

1. Pelvic exam. , rectal exam.

2. Sona ( transabdominal, transvaginal ) , Color Dopple sonography

3. Tumor markers: CA-125, CEA, AFP, £]-HCG

4. KUB

5. CT-scan,  IVP, Low-GI, etc.

A. Follicle cysts:

¬ Dominant follicle failing to rupture or an immature follicle failing to atresia.

­ translucent, thin-walled, filled with a watery, clear to strawcolored fluid. Normal size about 3 to 8 cm.

® Most follicles disappeared spontaneously within 60 days without treatment.

B. Corpus luteum cysts:

¬ Spontaneous and limited bleeding filled the corpus luteum cavity, we say hemorrhagic cystic corpus luteum

­ Spontaneous absorption without treament

® If rupture, intraperitoneal bleeding and peritoneal sign were found and surgical intervention is nessary

C. Polycystic ovarian dis.:

¬ Enlarged bilat. Ovaries, smooth, pearl-white surface and many small follicles beneath thicken fibrous cortex.

­ Symptom: secondary amenorrhea, oligomenorrhea, infertility, and obesity or hersutium in 50% pts.

® Diagnosis by 17-ketosteroid, FSH, LH, basal body tempture.

¡Â Treatment: clomiphene citrate 50-100 mg/day for 5-7 days cyclically or surgical intervention

D. Serous/ mucinous adenomas:

¬ Serous adenomas: unilobular, smooth lining surface, papillary projection on the inner surface cause cauliflower pattern

­ Mucinous adenomas: huge, discrete septa or lobules containing clear, viscid fluid

® Surgical intervention:

l    solid mass at any age

l    cystic mass > 8 cm or size about 5 to 8 cm longer than 8wks.

l    Frozen pathology is necessary R/O malignancy

E. Mature teratomas:

¬ Synonym: Dermoids, cystic teratomas

­ unilateral, 10-15 % are bilateral

® cystic content including bone, teeth, hair, and dermal tissues

¡Â Surigcal intervention in any age for enucleation or oophrectomy

F. Meigs syndrome is a rare dis:

¬ Three-combined signs : Fibroma, Ascites, Hydrothorax

­ If size larger than 6 cm , ascites found in 50% pts.

® Both ascites and hydrothorax were resolved after fibroma was removed 

Pre-op evaluation:

1. sonography :

¬ Transabdominal: large adnexal mass, size > 6 cm solid mass, irregular margin, combined ascites.

­ Transvaginal: bladder distension is not needed, cystic mass size < 6 cm, cul-de-sac mass.

® Color doppler: R/O malignancy, large mass, solid mass, irregular margin, combined ascites, bilateral adnexal mass.  If the resistance index < 0.4, malignancy is highly suspected.

2. Tumor marker:

¬ CA-125: Normal < 35, if > 65 R/O endometrioma, malignant ovarian cancer

­ CEA: Normal 0-2.5 ng/ml, if elevated R/O adenocarcinoma

® AFP: Normal value < 15 ng/ml, ¡ôR/O germ cell tumors

¡Â £]-HCG: Normal value: O, ¡ôR/O malignant tumor or GTD dis except pregnancy

¢X LDH: Non-specific markers, elevated in dysgerminoma

3. KUB for calcification of teratoma (bone, tooth)

4. CT scan: Large adnexal mass, bilateral, adnexal tumors, combined ascites to R/O liver, lymph node metastasis and displacement of ureter.

5. Low-GI : larger ovarian tumor compression cause GI symptoms

6. IVP : larger ovarian tumors compression cause urinary symptoms

7. Others evaluation are same as general Gyn. Pre-op

8. Pre-Op susvey¶·Àˬdpelvic mass¬O§_¬°presacral tumor:

¬ PV PR®Éµo²{tumor¦brectum¤U¤è¡C

­ CT Scanµo²{rectum³Qtumor©¹«e±À¡C

® ­Y¬°presacral tumor«h¶··Ó·|ª½¨z¬ì¡A¨Ã¤j¶q³Æ¦å¡C

¡@

Op indication:

1. ¦ó®É¥Îlaparotomy? ¦ó®É¥Îlaparoscope?

¬ ·ímass³Q»{¬°¬Obenign(¥]¬Apre-op evaluation)¡A¥B«Dsevere pelvic adhesion±¡ªp¤U¡A¬Ò¥i¥Îlaparoscope op¡C

­ ¦ýdemoid cyst³Ì¦n¥Hlaparotomy¹ý©³²M°£demoid cyst content¡A¦]demoid cyst content­Y¯}µõ¡A®e©ö³y¦¨chemical irrigation¡C

2. Functional cyst, size < 6 cm«h¥i¥Hfollow up 3 minth­Y«ùÄò¦s¦b«h¥i¥H¦Ò¼{¥Îlaparoscope op¡C

3. ©ópre-op evaluation R/O malignancy®É¡Aeg large solid mass, low resistance color doppler flow, bilateral mass, combined ascites«hÀ³¥Hlongiludinal incision larparotomy¡A¥B»Ý­n°efrozen pathology¥HR/O malignancy¡C

4. Acute abdomen¤Uªºadnexal mass (rebounding pain, mass¤¶©ó8-10cm¥ª¥k)»ÝR/O ovarian tumor torsion¡÷immediate operation¡C

Post-op care:

1. Post-op evaluation in the night of operation

2. Check CBC , D/C , CD and flatus passage in coming morning

3. If frozen pathology was malignancy , refer to oncology for further tretment

4. Follow final pathological report in third or fourth day
¡@

Pelvic Inflammation Disease (PID)¡]°©¬ÖµÄª¢¯g¡^ 

General Consideration:

1.   °©¬ÖµÄª¢¯gªº²£¥Í¡A¥D­n¬O¥Ñ©ó¸s»E¦bendocervixªº·L¥Íª«¥Ñ¤U©¹¤W¶Ç¬V¡]endometritis-salpingitis-peritonitis¡^©Ò­P¡C

2.   °©¬ÖµÄª¢¯g¥]¬A¦UºØªº¤W¥Í´Þ¹Dµoª¢·P¬V¡A¦p¡Gendometritis, salpingitis, peritonitis, tubo-ovarian abscess (TOA)µ¥¡C

3.   ¸gÁ{§É¯gª¬¦Ó¶EÂ_¡]Clinical diagnosis¡^¡C

4.   ¯f¦]¡]Pathogens¡^¡G

1)  sexually transmitted microorganisms: ¤j³¡¤Àªº¯f­ì¡A¦p¡G²O¯fÂù²yµß¡]Neisseria gonorrhoeae¡^¦û50%¡A¬â²´©Ü¦çµß¡]Chlamydia trachomatis¡^¦û20%¡C

2) respiratory pathogens: ¤Ö³¡¤Àªº¯f­ì¡A¦p¡GHaemophilus influenzae, Group A streptococci, pneumococci¡C

3) endogenous microorganisms: Prevotella, Gardnerella vaginalis¡C

 Risk Factor:

1.   ©Ê¦ñ«Q¦h¡C

2.   §CªÀ·|ª¾ÃѤô·Ç¡C

3.   ¨Ï¥ÎIUD¡C

4.   ±µ¨ü¹L³±¹D¤â³N¡]¦p¡GD & C¡^

 Symptoms/Signs and Diagnosis:

PID¤j¦h¼Æµo¥Í©ó¸g´Á¤¤©Î¸g´Á­èµ²§ô®É¡A³Ì±`¨£ªº¯gª¬¬O¤U¸¡¯kµh¡]Äݶwµh¡^¡A¦³®É¦ñÀHµÛµo§Nµo¼ö¡A³±¹D¤Àªcª«¼W¥[¡AIJ¶E®É¦³¤U¸¡À£µh¡A¤º¶E®É¦³cx lifting pain¡C

 Triad of symptoms and signs: ¶Ç²Î¤W±`¨£ªº¯gª¬¦³pelvic pain, cervical motion tenderness (§Ycx lifting pain), adnexal tenderness and fever¡C

 Genitourinary tract symptoms indicating PID: ¦plower abdominal pain, excessive vaginal discharge, menorrhagia, metrorrhagia, fever, chills, and urinary symptoms

¡]µù¡G¦³¨Ç¯f¤HÁöµMµo¥ÍPID¡A¦ý½T¨S¦³¥ô¦ó¯gª¬¡^

 Differential diagnosis:

Acute appendicitis, Ectopic pregnancy, Septic abortion, Endometriosis, Internal GI bleeding, GI infection, Corpus luteal bleeding, Pelvic adhesion, Renic colic, Lower lobe pneumonia, Torsion of adnexal structure, Acute pyelonephritis

¡]µù¡G¶EÂ_§xÃø®É¡A¥i¦Ò¼{±Ä¦æDiagnostic laparoscope¡^ 

Basic Lab Work-up:

CBC, D/C, CRP, ESR, beta-hCG, U/A, Blood culture, Cx culture, Grain stain and ultrasonography 

Hospitalization:

¤@¯ëPID­Y¯à¥¿½T¶EÂ_»PªvÀø¡A¦bµ¹ÃÄ«á24-48¤p®É¡A¯gª¬«K·|§ïµ½¡A¬ù70%ªº¯f¤H¦bªù¶E°lÂܪvÀø§Y¥i¡A¦ý¦³¥H¤U±¡ªp®É¡A«K¶·¦Ò¼{¦í°|ªvÀø¡G

Indication: (¦í°|)

1.   ¶EÂ_¦³ºÃ°Ý¡]diagnosis is uncertain¡^¡C

2.   ºÃ¦³Pelvic abscess¡C

3.   ºÃ¦³appendicitis, ectopic pregnancy¡C

4.   Ãh¥¥¡C

5.   ¯f±¡ÄY­«¡]clinical disease is severe¡^¡Aªù¶EªvÀø¥¢±Ñ¡C

6.   ¯f¤H°t¦X«×®t¡]compliance with an outpatient regimen is in question¡^¡C

7.   µLªk°lÂܦÜ48-72¤p®É¡C

Discharge: (¥X°|)

1.   °h¿N24¤p®É¥H¤W¡]fever totally lysed (< 37.5¢J) for more than 24hr¡^¡C

2.   ·P¬V«ü¼ÐÁͩ󥿱`¡]WBC count, ESR, CRP are normal¡^¡C

3.   ¤Ï¼uÀ£µh®ø¥¢¡]rebound tenderness is absent¡^¡C

4.   ­«ÂЪº²z¾ÇÀˬdÅã¥Ü°©¬ÖµÄÀ£µh²{¶H¦³©úÅã§ïµ½¡]repeat examination shows marked amelioration of pelvic organ tenderness¡^¡C

5.   TOA (tubo-ovarian abscess)ªº¯f¤H°£¤F¥H¤W©Ò­z¡A¥t¥~¥i¦õ¥H¶W­µªi³ø§iTOA¦³©úÅãÅܤp¡C 

Treatment:

1.  Medical Tx:

1)   ªvÀøPID¥H§Ü¥Í¯ÀªvÀø¬°¥D¡AªvÀø«eÀ³¥ý°µblood culture¤Îendocervical culture¡Aµ¹ÃÄ«h¥ý¥H¤©¸gÅçÀøªk¡]¸Ô¨£¤Uªí¡^¡A«Ýcultureµ²ªG¥X¨Ó¦A¨M©w¬O§_­n§ïÃÄ¡C

2)   Therapy regimens for PID must provide empiric, broad-spectrum coverage of likely pathogens including Neisseria gonorrhoeae, Chlamydia trachomatis, gramnegative facultative bacteria, anaerobes, and streptococci.

 ¥H¤Uªºªí®æ¬OªvÀøPIDªº¥ÎÃĤèªk¡]¿ï¦ÛNovak¡¦s 12ed¡^

 # Cefoxitin, Ceftriaxone¤ÎCefotetan¬Ò¬°Cephalosporins, Ofloxacin¬°Quinoloone, Doxycycline¬°Tetracycline, Gentamicin«hÄÝ©óAminoglycoside¡C

 # ¬ì¤º±`¥Îªºthree-combined antibiotics¦p¤U¡G

  Cefamezine 1 Vial (500mg) iv Q6hr

  Gentamicin 80mg im/ivf st & 60 mg im/ivf Q8hr

  SABS 1 bottle (500mg) ivf Q8h

  (µù¡GCefamezine¬°²Ä¤@¥NCephalosporin, SABS¬°Metronidazole)

 PID¯f¤Hªº©Ê¦ñ®È­YÃhºÃ¦³chlamydia or gonorheaªºurethral infection¡A¥i¨Ì¤Uªíµ¹¤©ªvÀø (Sexual partners of women with PID should be evaluated and treated for urethral infection with chlamydia or gonorhea)¡C

¡@

2.  Surgcal Tx:

=§Ü¥Í¯ÀªvÀø¥¢±Ñ¡A¦³®É·|²£¥ÍTOA (an end-stage process of acute PID)¡A¦¹®É¤´¥H§Ü¥Í¯ÀªvÀø¡]75% respond to antimicrobial therapy alone¡^¡F¦ý­YªvÀø72¤p®É«á¡Afever¥¼°h©Îabscess¥¼®ø¡A«KÀ³¦Ò¼{±Ä¥Îsurgical exploration (laparotomy©Îlaparoscopy) °µ¤â³N¤Þ¬y¡]drainage of abscess¡^¡C

=¥»¬ì±`¥Î¤§¤Þ¬y¤è¦¡¡G©ñ¸msump drain irrigation¡A¥ÎL/R·í¨R¬~²G¡A¥Hlow pressure¡A³t«×±q150ml/hr®120®100®80®60ml/hr®dry drain³v¤é»¼´î¡AÁ`­p¬ù5¤Ñ¡A·íµM¹ê»Ú¤W¤´µøÁ{§É±¡ªp¦Ó©w¡C

=·íTOA rupture²£¥Íperitoneal sign«h¥²¶·¥ß¨è¤â³NªvÀø¡F­Y¥¼¯à©ó24¤p®É¤º¤â³N¡A¦º¤`²v¥i¹F100%¡C¤â³N¥]¬A¤Á°£¦³TOA¤§adnexa¨Ã°µabscess¤Þ¬y¡C¡]¦]USO¦³17% reoperation rate¡A©Ò¥H­Yµû¦ô¥i¦æ¡A¥i±Ä¦æATH + BSO¡^¡C

 Sequele:

1.  infertility

2.  recurrent inflammation

3.  ectopic pregnancy

Pelvic Relaxation

Pelvic relaxation is the loss of the stuctures that support the contents of the female pelvis. The result is a group of clinical symptoms ,manifested by complaints of pelvic heaviness , discomfort and genital protrusion.

 Supportive anatomic structures:

a. bony pelvis.

b. pelvic diaphragm (levator ani muscle complex and its superior and  inferior fascia ).

c. urogenital diaphragm.

d. cardinal and uterosacral ligments.

e. bulbocavernous muscle and external sphincter ani muscle.

f. perineal body.

 Pelvic organs involved in pelvic relaxation and associated clinical manifestations

a. bladder: cyctocele, pelvic pressure, genital protrusion

b. urethra: urethrocele (urethral detachment), stress urinary incontinence.

c. rectum: rectocele, defecatory dysfunction, genital protrusion.

d. uterus and cervix : uterine descensus (uterovaginal prolapse ), pelvvc pressure, genital protrusion.

e. vagina: anterior wall prolapse (cyctocele, urethrocele, cystourethrocele); posterior wall prolapse (rectocele, enterocele); vault prolapse.

f. omentum and bowel : enterocele, vault prolapse.

 Etilogy of plvic support disorders:

1. congenital weakness of tissues

2. aging. collagen is lost from the connective tissues of postmenopausal women ,causing loss of strength

3. vagal delivery . passage of an infant through the birth canal stretches and weaken the levators and connective tissues of the pelvis

4. exercise .  frequent strenuous exercise

 diagnosis

symptoms

A. prolapse: uterus prolapse completely prolapse beyond the introitus termed "procedentia"

Grading¡G¥Í´Þªc§¿¾¹©x²æ««µ{«×ªº¤À¯Å(grading)¡A¤@ª½¤£¬O«Ü²M·¡¥B¨S¦³¯S©w¼Ð·Ç¡C¦]¬°³oºØ¤À¯Å¤è¦¡(¤ñ¦p¥u¤Àminimal¡Bmoderate¡Bsevere)¹ï©ó¾¹©x²æ««­ì¦]ªº±´°Q»PªvÀø®ÄªGªºµû¦ô·|³y¦¨¤£½T¹êªº«áªG¡C

I. Vaginal profile¡G³o¬O¥ÑBaden»PWalker¦b1972¦~­º¥ý´£¥X¡A«á¨Ó¤S¸gShull§@¤F­×¥¿¡C¥L­Ì¥Hhymen»P³±¹Dªº¤¤ÂI¨Ó°µ¤À¯Åªº¼Ðªº(land mark)¡C¥H¤l®cÀV§¿¹D©Î»H¯Ö¦Ó¨¥¡AÅý¯f¤Hªº¸¡³¡¥R¤À¥Î¤Oªº±¡ªp¤U¡A¤l®cÀV(portio)¦b³±¹D¤¤ÂI¥H¤W¡A§Y¥¼¶W¹L¤¤ÂI®É¬°zero degree¡A·íportio cervix¶W¹L¤¤ÂI®É¡A¬°first degree¡A¦Óportio cervix¨ì¹Fhymenªºlevel¬°second degree¡A·íportio cervix¶W¹Lhymen¬°third degree¡A°²¦p¾ã­Ó¤l®c­Ë½¥X¨Ó¡A«h¬°fourth degree¡C¦ý¬O¡Aenteroceleªº¤À¯Å«h¥t¦³¤@®M¡F¥H³±¹D¥Ñculdesac¨ìhymenªºªø«×¨Ó¤À¡C·ículdesac¹F1/4 to hymen¬°first degree¡A¹F1/2 to hymen¬°second degree¡A¹F3/4 to hymen¬°third degree¡Aculdesac±¼¨ìhymen level«h¬°fouth degree¡C

II. ICS(International Continence Society)System¡G³o¬OICS¦b1994¦~©Ò´£¥X¤@ºØ·sªº¤À¯Åªk(¦p¹Ï)¡C

Point Aaªº©w¸q¬O¦b«e³±¹D¾Àªº¤¤¶¡½u¡AÂ÷§¿¹D¤f3¤½¤À³B¡C¦]¦¹°²¦p¨S¦³²æ««ªº¸Ü¡AAa»PhymenªºÃö«Y¬°-3cm¡A°²¦pcomplete vault eversion«h¬°+3cm¡C³o­Ó¤À¯Å¨t²Î¸û¬°±M·~¥B½ÆÂø¡A¤S¸g²Î­p¤ÀªRÃÒ¹ê¡A¤W­z¨â­Ó¤À¯Å¨t²Î¦U¦³¨ä¦s¦bªº¥²­n©Ê¥B¨ã¬ÛÃö¥¿½T©Ê¡C¹ï¤@¯ëÁ{§ÉÂå®v¦Ó¨¥¡Avaginal profile¨¬¨o¡I

¥H¤W¨â­Ó¨t²ÎªºÀˬdªk¦p¤U¡G¯f¤H¥ý±N»H¯Ö±ÆªÅ¡A¥Hsupine position¨üÀË¡CÀˬdªÌ¥ýÆ[¨äexternal genitalia»Pintroitus¡C¦A¥ÎSims speculum©ñ¤J³±¹D¼fµø¦³§_urethrocele¡Bcystocele¡Butero-vaginal prolapse¡Benterocele©Îrectocele¡AµM«áÅý¯f¤H¸¡³¡¥Î¤O¦Ü¤W­z¾¹©x±¼¨ì³Ì§CÂI¬°¤î¡C

 B. pelvic discomfort: dull lower back or pelvic pain, introital irritation, dyspareunia

C. urinary symptoms:

a. stress urinary incontinence

b. recurrent urinary infection

c. urinary obstruction

D. rectal symptoms:

a. difficult defecation

b. incontinence 

Treatment of pelvic support disorders 

Choice of Treatment

Expectent management:

No symptoms or relatively mild, patient should be taught the technique of perineal muscle exercise and encouraged to do them. 

Estrogen replacement , Kegel's exercise

 Pessaries: too ill to undergo operation or p't refuses operation 

Surgical management indication:

Sugery should be undertaken only in the patient who is either still symptomatic after nonsurgical approaches have been attempted or desires  sugical intervention in lieu of nonsurgical therapy. 

1. Surgery for uterine prolapse

vaginal hysterectomy with colporrhaphy , McCall Culdoplasty and to reattaching the endopelvic fascia and the uterosacral ligment to vaginal cuff to provide additional support or sacrospinous ligment fixaton or abdominal approach retroperitonel uterosacropexy 

2. Surgery for cystocele: Corrected by anterior colporrhaphy

 3. Surgery for rectocele: Correctd by posterior colporrhphy  

4. Uteropexy: abdominal uterine suspension eg. Gilliam suspension ,and colporrhaphy without hysterectomy with prolapse who desire future fertility .

Operation for Complete eversion of the vagina:

1. Colpectomy and colpocleisis eldly women,not sexally active can be managed by surgically removing the vagina and closing the space

2. Colpopexy younger women retain sexal function

a. transvaginal sacrospious colpopexy

b. transabdominal sacral colpopexy Both opertions are highly successful in resuspending the vaginal apex.
¡@

Dysfunctional Uterine Bleeding

 Definition:

Excessive uterine bleeding with no demonstrable organic cause ( genital or extragenital ), most frequently due to abnormalities of endocrine origin, particularly anovulation.

 Pattern of abnormal bleeding:

1. Menorrhagia¡Xprolonged uterine bleeding occurring at irregular intervals.

2. Hypomenorrhea¡Xscant menstrual flow at regular cyclic intervals.

3. Metrorrhagia¡Xuterine bleeding at irregular intervals.

4. Menometrorrhagia¡Xprolonged uterine bleeding occurring at irregular intervals.

5. Polymenorrhagia¡Xregular intervals of less than 21 days.

6. Oligomenorrhagia¡Xintervals between bleeding episodes vary from 36 days to 6 months.

 Etiology:

A. Ovulatory

1. Midcycle spotting

2. Frequent menses

3. Luteal phase deficiency

4. Prolonged corpus luteum activity

B. Anovulatory

About 90 % DUB is anovulatory

C. Others

1. Uterine lesions: eg myoma, adenomyosis

2. Vaginal infection

3. Foreign body

4. Problems of reproduction

5. Organic pelvic disease

6. Endocrine dysfunction

7. Systemic disorders

D. Early pregnancy threaten abcortion 

Diagnosis:

A. a careful history:

1. Frequency, duration, the amount of bleeding and menstrual pattern

2. Other systemic symptoms

3. Unusual bleeding from other organs

4. Sustained aspirin use

5. Hormonal use

B. Pelvic examination: to detect pelvic mass, myoma, adenomyosisendometriosis

C. Laboratory investigation:

1. Hb/Hct , serum ferritin to evaluate anemia or not.

2. Platelet count and tests of platelet function , PT/APTT

3. £]-HCG, pregnancy test

4. TSH,TRH stimulation test

5. Luteal phase progestreone

6. Serum prolactin, androgen

D. Diagnostic procedures

1. D&C

2. Hysteroscopy

3. Premenstrual endometrium sampling

4. Charting basal body tempreature

5. Sonography to rule out organic lesion

6. Hormonal survery: FSH, LH, E2, Prolactin, TSH, T3, T4

7. Immunologic survery: ANA 

Management:

A. medical therapy

1. Estrogens: In acute stage, iv form estrogen for 24 hours, then E + P for 7 days

2. Progestins

3. NSAID

4.Antifibrinolytic agents

5. Ergot

6. Androgenic steroids ( danazol )

7. GnRH agnoists: works 3 wks after iniation of therapy

B. surgical therapy

1. D&C

2. Endometrial ablation¡Xfor ovulatory DUB unrespond to medical managemant, or excessive side effects with medical therapy

3. Hysterectomy¡Xfor ovulatory DUB only after medical therapy has failed and excessive uterine bleeding has been documented by objective measurement

¹ê¥Î±Ð¾Ô¤â«h¡G

1.  age < 50 ® ¥ýÅçIcon

2.  ·Ó¶W­µªi¡Gorganic lesion

             MUC, adenexal mass

             Em

3.  ¦pªGEm > 1.6 cm«hD & C¤ñ¸û¦n

      Em < 1.6 cm

      ¥ýPremarin 25mg 1 vial iv stat 

      Then 25 mg  q4h-6h

      MBD Rx:

      Premarin

      Provera

      Ponstan

      Transamice

      Gasgel     aa 1#  qid

      ¦A¬ùOPD F/U

Vaginal Agenesis 

General considerations:

1. usually associated with congenital abscence of the uterus, commonly referred to as the Rokitansky-Kuster-Hauser syndrome.

2. 25-40% GU anomaly 12% skeletal anomaly.

3. Embryology: agenesis of Mullerian duct.

4. 25% of patients have a short vaginal pouch (derived from urogenital sinus).

 Diagnosis:

1. Primary amenorrhea

2. No vaginal introitus or only short vaginal pouch during pelvic examination

3. No uterus found by sonar or rectal examination

4. Normal female karyotype (46, XX)

5. Normal functional ovaries

6. Normal female phenotypic appearance

7. Usually diagnosed after puberty

Differential diagnosis:

1. Imperforated hymen: uterus & vagina (+)

2. Transverse vaginal septum: uterus & vagina (+)

3. Testicular feminization: chromosome study 46, XY

 Treatment: Centered around having a functional vagina:

1. Vaginal dilatation: in patients who are highly motivated.

Patients apply pressure for about 10 mins twice daily.

When sufficient depth is achieved, wider forms of dilators are used until the patient eventually be able to have intercourse.

2. Neovaginoplasty

¡Etiming of operation: the surgery should not be done until the patient is desirous of becoming sexually active and responsible enough to be able to use the vaginal forms on a regular basis for several months after surgery.

¡EWithout proper motivation and compliance, the vagina may contract due to scarring, making subsequent surgery more difficult.

¡EMcIndoe operation: the traditional procedures using split thickness skin graft.

3. Laparoscopically assisted neovaginoplasty¡Ðdeveloped by Dr. Soong, has the advantages of:

(1) minimal likelihood of "poor intake" or later contraction.

(2) minimal short and long term care.

(3) the technique is simple in experienced hands.

(4) pelvic peritoneum used for construction of a vagina, replacing a laparotomy by a minimally invasive laparoscopic approach.

(5) cosmetic benefits.

(6) the neovagina facilitates comfortable sexual intercourse.

 Post op care:

1. The vaginal stent is removed four to seven days after operation and a neovagina is created.

2. The patient is taught to apply a dilator to mainatin the length and width of the neovagina.

3. Dilatation is carried out for an hour four times a day and during the sleep period for a minimum of 3 months.

4. Then weekly dilation is applied and is discontinued after 3-6 months.

5. Estrogens may be given for the induction of epithelialization for a short interval.

¡@

Imperforate Hymen

 General Consideration:

1. The hymen is composed of endoderm from the urogenital sinus epithelium.

2. It is perforated during embryonic life to established a connection between the lumen of the vaginal canal and the vestibule.

3.The hymen may be cribriform in appearance. If  there are no perforations throughthis membrane, the hymen is imperforate. An opening the size of a pinhead was sufficient.

 Symptoms:

1.Hematocolpos : accumulation of  menstrual blood in the vagina.

2.Hematometra : accumulation of  menstrual blood in the uterine cavity.

3.When the intrauterine pressure reaches a certain point, there is retrograde passage of blood into the tubes, forming hematosalpinx. Sometimes  blood passes freely into theperitoneal cavity, forming hematoperitoneum.

4. Most patients are brought to the gynecologists because of amenorrhea.The most coomon symptoms caused by vaginal distension are lower abdominal pain, discomfort in the pelvis, and pain in the lower back.

5.Pain often is aggravated  on defecation. Urination also can be difficult because pressure of the distended vagina on the urethra may compress the urethra and prevent emptying of the bladder.

6.Cramplike pains recur in the suprapubic region, along with the common urologic symptoms of dysuria, frequency, and urgency. Overflow incontinence may eventually develop.

7. Protrusion of the hymen is massive and dark in color because the occult blood shows through the stretched mucous membrane.   

Diagnosis  & Operation Time:

It is rare  to make the diagnosis of  imperforate hymen before puberty, at which point primary amenorrhea is the major symptom. Detailed history taking, physical examination esp. inspection. The presence of a budging membrane at the introitus is an important sign. Gynecological sonography should be done to evaluate the condition of the uterus and fallpian tube. As soon as the diagnosis is made, operation may be arranged.

 Treatment:

1. The hymen membrane is simply incised, preferably at the 2, 4, 8, and 10 o'clock positions. The quadrants of the hymen are then excised and the mucosal margins are approximated with fine delayed absorbable suture.

2. To prevent scarring and stenosis, which could result in dyspareunia, the hymenal tissue should not be excised too close to the vaginal mucosa.  

Post-OP care:

1. Patient may be discharged immediately after the operation and OPD follow-up.

2. Duracef  1# B.I.D   for prevention of infection

Scanol  1# B.I.D 
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Bartholine Cyst 

General considerations:

1. Bartholine cyst is a embryonic derivative of the urogenital sinus.

2. Location: posterior lateral aspect of vestibule.

3. Acini are lined with mucus-secreting epithelial cells and drain into bartholine duct.

 Clinical Features:

1. Infection: gonorrheal infection.

2. Obstetric or accidental trauma.

3. Congenital atresia.

4. Ductal epithelial hyperplasia. 

Diagnosis:

1. Made by its appearance: like any cystic swelling, painful tender.

2. Differential diagnosis: lipomas, fibromas, hydrocele, hernias.

 Management:

1. No therapy is required for the asymptomatic bartholines cyst.

2. Painful edematous cyst that required prompt treatment:

a. Sitz baths.

b. Incision and drainage

  3. Definite surgical therapy:

a. Marsupialization.

b. Glandular excision.

  ¡P Technique of marsupialization:

a. Under local, regional, or general anesthesia.

b. A wedged-shaped, vertical incision is made in the vaginal mucosa over the center of cyst, outside the hymen ring.

c. The incision should be wide as possible to enhance postoperative patency of the stoma.

d. After the cyst wall is opened and drained of its contents, the lining of the cyst is everted and approximated to the vaginal mucosa with interrupted sutures of No.2-0 delayed absorbable material.

e. Drained and packs are not necessary.

    f. Recurrent rate after marsupialization: 10-15%.

    g. Postoperative Care:

¬ Use oral antibiotics for prophylactic infection.

­ Iodoform gauze packed to open wound.

® Remove iodoform gauze 3 days later.

¡Â Daily sitz baths beginning on the third or fourth postoperative day.

  ¡P Technique of excision:

a.  Indications:

¬ Basal induration.

­ Patient older than 40 years of age.

® Recurrence.

b. An incision is made in the mucosa over the cyst.

c.  Dissection is begun, using the handle of the scalpel.

d. Dissection has been continued by sharp and blunt dissection.

e.  Complete removal of cyst.

f.   Ensure permanent hemostasis.

g.  The entire cavity must be obliterated by approximating the walls with fine delayed-absorbable suture material.

4. More than 80% cultures from the cysts are sterile.

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Uterine Anomaly 

General considerations:

1.    The most common encountered congenital uterine defects.

2.    Incidence :0.1-0.4% of the female population . 2%-3% during delivery finding.

3.    Many are asymptomatic .

4.    The symptoms are principally related to reproductive failure or obstetric complications.

5.    May associated with abnormalities of the urinary tract.

 Clinical features:

1.    Recurrent abortion.

2.    Premature labor.

3.    Placental abruption.

4.    Malpresentation.

5.    Postpartum retained placenta.

6.    Dysmenorrhea.

7.    Menorrahgia.

8.    Amenorrhea.

9.    Failure of IUD

 Types of anatomic picture.

1.    Didelphic uterus :

2.    Septate uterus :complete , partial .

3.    Bicornuate uterus : complete , partial .

         Above three with complete , partial , no longitudinal vagina septum.

4.    T-Shaped uterine cavity :No operative procedure indicated.

5.    Unicornuate uterus :

       Y commmunicating .

       Y noncommunicating 90%.

       Y No cavity .

       Y No horn .

6.    Acurate uterus : rarely  productive failure .

7.    Hypoplasis or Agensis :Rokitansky -Kuster Hauser syndrome.

Diagnosis:

1.    History :

        (1) second trimster abortion .

        (2) premature labor .

        (3) Persistent malpresentation .

2.    PV + PE:

        (1) a longitudinal septum in the vagina .

        (2) two cervices

        (3) asymmetric corpus .

        (4) single myoma or a normal corpus with an adnexa mass.

3.    IVP : incidence of urinary tract anomalies.

4.    Sona : (a) Didelphic uterus: a common centeral wall between the two uteri.

            (b)Septate uterus: depending on the size of the septum.

        (c) Bicornuate uterus: typical pear shape of the uterus on multiple sagittal

              scans; binodular structure on  transverse scans.

         (d) T-shaped uterus: greater-than-usual transverse dimension, as well as

              decreased thickness of the fundus.

         (e) Other:

             Y may incidental finding and confused with adnexa mass.

             Y obstruciton of a uterine horn, cervix or vaginal tract: hydrometrocolpos,  

                 hematometrocolpos with either anechoic or eclogenic internal content,

                 usually mobile when the patient is scanned in various positions .

5.    Classification :

       (1) Hysterosalpingography.

a.    Didelphic uterus:

      two completely separate cervical canals opening into fusiform endometrial cavities, each ending with a solitary fallopian tube, in some one limb of the vagina may be atretic or occluded.

b.    Septate uterine:

      acute angle of separation between the uterine horns helps to differentiate this anomaly from biocornuate uterus.

c.    Bicornuate uterus:

      a single cervical os., two wide angle separate horn of the uterine cavity.

d.    Arcuate uterus:

      completely symmetric uterine horns. The transverse diameter of the uterine cavity may be slightly increased.

e.    Unicornuate uterus:

      the endometrial cavity has a fusiform shape and tapers at its apex, where it joins with a single fallopian tube; nonfilling of a second uterine horn does not exclude its present.

    (2) Hysteroscopy: can not distinguish a bicornuate from a septate uterus.

    (3) Laparoscopy: viewing of the external contour of uterus.

Surgical timing:

1.    Patient experiences pregnancy wastage .

2.    Hesitate to do solely for menstrual difficulties.

OP methods:

1.    TCR concomitant laparoscopy: for  septate uterus . After resec tion the septus the abortion rate decline from 88%to 15%.

2.    The modified Jones Metroplsty : particularly broad septum

3.    The strassman metroplasty : bicornuate , didelphic .

4.    Pregnancy after metroplasty requires cesaream rection. Those after TCR can accommodate NSD.

Pre-OP prepare with evaluation:

1.    The same as general Gyn. Pre-OP.

2.    Addition to TCR: vagina douch , laminaria Cx dilatation the night before operation. 

                      Danazol , GnRH agonist 2 months. Antibiotic prophylactic.

Post-OP care:

1.    Post-OP evaluation in the night of operation,

2.    CD ,flatus passage stimulation, CBC/DC. Remove foley et . al. are same as general Gyn laparotomy.

3.    For TCR :

             Y antibiotic 5 days limit the risk of infection.

            Y foley catheter tamponade in uterine cavity 4-6 hours for excessive bleeding.

       Y may premarin 1.25mg/day, 30 days.

4.    How long to conceive a child: any time. 

¡@

Sexually Transmitted Disease

 I. Gonorrhea:

1. Incubation preiod:2-8 days

2. Transmission almost always by sexual contract

A. history:

1. sysmptom  include vaginal discharge , urinary  frequency and ydsuria  & Bilateral lower abdominal pain

2. infection seen in other mucosal site , such as oropharynx & anoretal reta .

3. hemotogenous  spread may occur also .

B. PE: diagnosis is dependent on bacteriologic  investigation .

C. investigation procedure

1. Gram stain -60-70 % false negative in  female.

2. Gonorrhea culture -Thayer -Martin median

D. management :

1. Uncomplicated gonococcal infection

a. ceftriaxone 125mg  m st + oral tetracycline x 7days

b. spectinomycin  2.0 g m st + oral  tetracycline  x 7days

2. Treatment  failure -usually due to reinfection indicating a need for inproved contact tracing and patient education .

 II. syphilis:

1. incubation period is 2-6 weeks

2. spread is by sexual intercouse or  intrauterine transmission

A. Early (primary , secondary , latent less than 1 year )

1. History  :

(1) primary chancre usually appear on the genitalia , mouth , or anus and is painless .

(2) secondary stage may present with uluration of mucosal membrane or skin eruption .

2. PE:

(1) chancre :a nontender clear cut ulcer with an indurated base and an associated regional adenopathy

(2) Secondary stage skin lesion :tent to be maculopapular ,  lymphadenopathy  is very aommon finding .

3. investigation procedure :

(1) Dark-fied  microscopy

(2) Serologic test -RPR  screening

TPHA are specific  but are not quantitative .

4. Management

(1) Benzathine  penicillin G 2.4 million m st

(2) Quantitive  nontreponemal test  VDRl. RPR should be repeated at 3, 6 and 12 month after treatment .

B. late (neurosyphilis latent more than 1 year )

1. History antecendent treatment & previous serologic test are important  in  establishing the diagnosis.

2. PE :

(1) Gumma  :nodular  ulcerative lesion

(2) cardiovascular syphilis :aortitis , aneurysm  or aoetic regugitation

(3) Neumroysphilis- asymptomatic or as tabes dorsalis , meningovas anlar syphilis or gemenal paralysis of the on same

3. Investigative procedure :CSF VDRL should be done for clinical sign & symptom consistent with a CNS lesion .

4. Management

(1) cardiovascular , late benign syphilis and syphilis  more than 1 year duration - Benzahtine penicilline  G 2.4 million unit im weekly for 3 weeks.

(2) Neurosyphilis :aqueous crystalline penicillin G 2-4 million unit q 4 hr iv for 10-14 days

III. Chlamydia trachomatis:

15 serotypes , and those associated with genital infection are D-K

A. History :chlamydial cercicitis is frequently asymptomtic.

B. PE: macopurulent cercicitis is  seen in 50% of cases .

C. investigative precedure : culture is the only reliable way to establish the diagnosis.

D. Management :Tetracycline , erythromycin and azithromycin are highly effective with cure rate of 95%.

IV. Gentital herpes simplex virus infection:

With type I or type II the most common cause of ceesiculoulcreration lesion  of female genital tract .75-80% of genital lesion are type III.

A. History :

1. Incubation  period range from 1-3 days & generally the presenting complaint is of Blister or ulcer on the vulva or severe vulvar pain .

2. Some patient may have no symptom & recurrent infection are less severe.

B. PE: exquisitely sensitive ueside and errosion of th elabia , vaginal canal , perineum and oropharynx may be formed .

C. Investigative procedure :

1. The vesicle and ulcer characteristic of the disease are easily reconized , especially of there is a positive history .

2. Definitive diagnosis can beconfirmed by viral culture .

D. Management :

1. General measure :

(1) Keep vulva & perineum dry .

(2) Wear cotton underwear .

(3) Expose the vulva to heat lamp .

2. Specific measure :

(1) First clinical  episode of genital herps:acyclovir 200 mg  P0 5 times a day for 7-10 days .

(2) Recurrent episode:

A cyclovir 200mg P0 5 times a days for 5 days and treatment may be of limited Benefit when during prodrome or with 2 days of lession onset .

V. Condyloma accuminata:

1. History

Vulvar lesion frequently present with the complain of new bumps and vaginal condyloma may cause vaginal discharge and pruritis.

2. Physical examination

Condyloma accuminata usually found in the genital region.

3. Investigative procedure

(1) biopsy of the specimen of the vulvar lesion

(2) cervical lesion usually detected by Pap smear

(3) HPV DNA testing should become an important tool

4. Management

(1) vulvar lesion-Podophyllin in 25-40% solution in alcohol, mineral oil should be applied to the lesion weekly

Bi-or trichloroacetic acid in 30-50% solution should be applied to the lesion twice monthly.

Fluorouracil (5-FU) applied topically has been used also.

Excision or electrodesiccation should be reserved for recurrent and very large lesion.

(2) vaginal lesion:

a. asymptomatic lesion should not be treated

b. symptomatic lesion-cryotherapy weekly for approximately 3 weeks is very effective and 5-FU is usually reserved for refractory lesion

(3) cervical lesion:

  Cryotherapy and loop electrosurgical excision can be used

¡@

Cervical Intraepithelial Neoplasia

General consideration:

1. CIN is most like to begin either during menarche or following pregnancy, when metaplasia is most active.

2. A woman who has reached menopause without developing CIN has little metaplasia and is at a low risk.

3. HPV (human papillomavirus) plays an important role in the development of CIN.

 Clinical features:

1. Asymptomatic

2. Presents only as an abnormal pap smear

3. Postcoital bleeding or spotting but his may be related to cervicitis found in association with the CIN. 

Diagnosis:

1. The pap test

a. not to douche for 48hr

b. not to vaginal creams for 1 wk

c. abstain form coitus for 24hr

2. Colposcopy and biopsy

3. Human papilloma virus - a means of secondary assessment of abnormal cytology

4. Cervicography - a secondary means of assessment of patient with pap test result, and use to identify lesions

Cytology classification system

Cervix intraepithelial neoplasm

Treatment:

1. Before treatment:

(1) The histologic diagnosis must be accurate.

(2) The extent of the lesion must be determined.

2. Ablative techniques:

(1) Cryotherapy:

Indications

a. CIN I - II

b. Small lesion

c. Ectocervical location only

d. Negative endocervical curettage

e. No endocervical gland involvement on biopsy

(2) Laser vaporization therapy:

Indications

a. Large lesions that the cryoprobe cannot adequately cover.

b. Irregular cervix with a "fish month" appearance an deep clefts

c. Extension of disease to the vagina or satellite lesions on the vagina

d. Lesions with extensive glandular involvement in which the treatment must beyond the deepest gland cleft.

(3) Loop electrosurgical excision:

Contraindications

a. patient anxiety

b. contraindication to local anesthesia or vasoconstrictor

c. extremely large lesions

d. vaginal extension

e. obvious clinical carcinoma

(4) Conization:

Indications

a. Limits of the lesion cannot be visualized with colposcopy.

b. The squamocolumnar junction (SCJ) is not seen at colposcopy.

c. Endocervical curettage histologic findings are positive for CIN 2 or CIN 3.

d. There is a lack of correlation between cytology, biopsy, and colposcopy results.

e. Microinvasion is suspected based on biopsy, colposcopy, or cytology results.

f. The colposcopist is unable to rule out invasive cancer.

(5) Hysterectomy:

Indications

a. microinvasion

b. cervical intraepithelial neoplasia at limits of conization specimen

c. poor compliance with follow-up

d. other gynecologic problems requiring hysterectomy, such as fibroids, prolapse, endometriosis and pelvic inflammatory disease

e. cancer phobia

f. CIN I, II are not indications of hysterectomy.

3.After treatment - complications:

(1) Cryotherapy:

a. Cervical stenosis

b. Post-treatment bleeding

c. Infection

(2) Laser vaporization therapy

a. clear vaginal discharge:  3-5 days

b. spotting

(3) Loop electrosurgical excision

a. Intraoperative hemorrhage

b. Post-operative hemorrhage

c. Cervical stenosis

(4) Hysterectomy

a. bleeding

b. infection

c. death 

Follow-up: by pap smeas

1. an inherent recurrence rate:  up to 10%

2. at approximately 3-month intervals for 1 year

 Prognosis

1. each of the recommended therapies, if properly applied, provides care in at least 90% of patient after one treatment (some patients require as many as four appllications)

2. With proper follow-up and treatment, over 99% of women with CIN are ultimately cured with preservation of reproductive function. 

 *Pap smearÀ³¨ú¨ìendocervical cell¤~ºâ¦X®æªº±Ä¼Ë¡A±Ä¼Ë®É©y¥Î¤ì´Î(spatula)¤£©y¥Î´ÖªK(cotton swah)¡C±Ä¼Ë¿ù»~±`µo¥Í¦b¥u¨ú¨ì«áªÆ¶©¤ºªº¤l®cÀV²æ¸¨²Ó­M¡C

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Pelvic Adhesion

 Definition

Pelvic adhesion are defined as pathologic bonds between surfaces of the peritoneal cavities formed during the scarring of peritoneal scar defects. 

Clinical Significance

  Four main problems produced by pelvic adhesion

1.      small bowel obstruction

2.      difficulties on reoperation

3.      female subfertility / infertility

4.      pelvic pain 

Etiology

Post-surgical procedure

Endometriosis

PID (Pelvic inflammatory disease)

Severe form of PID : TOC (Tuboovarian complex) TOA (tuboovarian abscess)

Benign ovarian neoplasm

Malignant disease

Pathogenesis

Crucial events leading to adhesion formation

1.      Peritoneal inflammatory response with fibrin formation

2.      Loss of fibrinolytic activities in mesothelial cells

Clinical Manifestation

Symptom:  noncyclic abdominal pain  (esp. increased with intercourse or activity)

Sign :  bowel obstruction, infertility

Diagnosis

Previous history of abdomino-pelvic surgery & inflammatory disease of pelvic cavity

Clinical signs suggestive of pelvic adhesion

1.  Vaginal exam. : limitation of motion of pelvic organs (uterus & adnexas ) ; fibrosis / nodularity of cul-de-sac

2.  Ultrasound : abnormal spatial relationship among pelvic organs

3.  Signs related to bowel obstruction : postprandial distension, abdominal distension, constipation, decreased bowel sound, and low quadrant tenderness

Confirmation of diagnosis : Laparotomy/ Laparoscopy

Management

Prevention of Pelvic Adhesion

 Improvement in surgical technique

 l       Using principles of microsurgery:

1.      Using magnification

2.      Gentle tissue handling

3.      Meticulous hemostasis

4.      Using fine instruments & non-reactive suture material

l       Avoiding tissue dessication

l       Talc-free gloves

l       Avoiding tissue ischemia

l       Liberal use of peritoneal lavage with saline or Ringer¡¦s lactate solution

l       Allowing peritoneal defect to heal spontaneously (efficacious in animal study)

Intraperitoneal instillates 

a.      Ringer¡¦s Lactate ---

Ø          around 300-500cc soln could be left in peritoneal cavity;

Ø          it decreased adhesion formation in a rat moel; but results in human is   unconvinced

Ø          there is cocern about the dilutional effect of crystalloid with impaired immune response and subsequent infection or sepsis

b.      High molecular weight dextran (dextran-70)   ---

Ø          efficacy ??

Ø          there is anxiety over pelvic infection after large volume of instillation

c.       Carboxymethylcellulose  --- similar to dextran

d.      Hyaluronic acid  ---

Ø          a high molecular weight polymer;

Ø          it protects and lubricate cell;

Ø          it should be used before tissue injury;

Ø          combined use with low molecular weight heparin (LMWH) improved the efficacy

e.       Chondroitin sulfate --- higher concentration(25%) is superior to carboxymethylcellulose

f.       Fibrinolytic agents ---results were promising in animal studies

1        Streptokinase

2        Urokinase

3        tPA 

Barrier agents

a.      Oxidized cellulose (Interceed^®)---absorbable; excellent hemostasis is needed at sites of application; adhesion formation is reduced in human studies; cocerns: it is degraded by inflammatory reaction & may be a procoagulant

b.      Polytetrafluoroethylene (Preclude^®)---nonabsorbable; it mechanically seperates the traumatic tissues and prevents adhesion formation ; it has to be anchored to the tissue; it has shown fewer postsurgical adhesion than Interceed^® in 2 studies.

c.       Seprafilm^®(hyaluronate + carboxymethylcellulose) ---bioresorbable membrane; adherence to peritoneal surfaces without procoagulant effects; resorption within 7 days and excretion within 28 days; effective in reducing post-myomectomy adhesion

d.      Polyethylene gycol hydrogel --- results were comparable to Interceed & Seprafilm

Antiinflammatory agents

(Systemically administered antiinflammatory agents seems to be ineffective in prevention of pelvic adhesion as access of drug to the ischemic/traumatic tissue is poor.)

a.       NSAIDs

b.      Corticosteroids

c.       Histamine antagonists

d.      Antioxidants eg.VitE

Second-Look Laparoscopy for Lysis of Adhesion

a.       The optimal time to perform second-look lalaproscopy is within 6 weeks after initial surgery.

b.      Early second-look laparoscopy and lysis of adhesions are associated with increased pregnancy rate

c.       Possible superiority of laparoscopy

1.  Peritoneal surface is less exposed to dehydration during laparoscopy than with laparotomy.

2.  The lack of need to use bowel packs to expose the operative site, which can traumatize peritoneal surface

3.  Magnification of image makes precise incision and coagulation possible.

4.  Reduction in tissue handling

Hydatidiform Mole

Hydatidiform moles categorised as either complete or partial moles.

Features of Complete and Partial Hydatidiform moles. 

                                                    Complete Mole     Partial Mole

Fetal or embryonic tissue                           Absent           Present

Hydatidiform swelling of chorionic villi          Diffuse           Focal

Trophoblastic hyperplasia                         Diffuse           Focal

Scalloping of chorionic villi                      Absent           Present

Trophoblastic stromal Inclusions                      Absent           Present

Karyotype                                           46XX; 46XY        69XXY; 69XYY

Reproduced from Berkowitz RS, Goldstein DP. The management of molar pregnancy and gestational trophoblastic tumors. In: Knapp RC, Berkowitz RS, eds. Gynecologic oncology. New York: MacMillan, 1993:425, with permission.

Presenting Symptoms and Signs in Patients with Complete and Partial Molar Pregnancy.

                                            Complete Mole^a           Partial Mole^b

                                            N = 307 (%)                 N = 81 (%)

Vaginal bleeding                                97                          73

Excessive uterine size                        51                          4

Prominent ovarian theca lutein cysts          50                          0

Toxemia                                      27                          3

Hyperemesis                                       26                          0

Hyperthyroidism                                 7                            0

Trophoblastic emboli                         2                            0

Adapted from ^aBerkowitz RS, Goldstein DP. Pathogenesis of gestational trophoblastic neoplasms. Pathobiol Anna 1981;11:391, and ^bBerkowitz RS, Goldstein DP, Bernstein MR. Natural history of partial molar pregnancy. Obstet Gynecol 1985;66:677-681.

Diagnosis

1.  Made on the basis of D & C.

2.  Ultrasound: complete moles¡Ða characteristic vesicular sonographic pattern, "snowstorm" pattern; partial moles¡Ðfocal cystic spaces in the placental tissues and an increase in the transverse diameter of the gestational sac.

Treatment and follow-up

1.  Before evacuation, obtain the following laboratory studies: CBC, D/C, PT, APTT, blood chemistries, including lirer function tests, blood type and screen, and b¡VhCG; and CXR.

2.  Evaluation of associated medical complications, including preeclampsia, hypothyroidism, anemia, infection, electrolyte imbalance and coagulopathy.

3.  Suction curettage with oxytocin infusion.

4.  Weekly serum b-hCG follow-up.

5.  3 consecutive weeks of undetectable serum b-hCG then monthly determinations for at least half a year.

References

1.  Berkowitz RS, Goldstein DP,Gestational trophoblastic neoplasia, in Hacker NF, Berek-JS (eds): Practical Gynecologic Oncology 3^rd ed Lippincott Willians and Wilkins, 2000,pp615-623.

2.  Lyons C: Gestational Trophoblastic Disease, in: The Johns Hopkins Manual of Gynecology and Obstetrics. Lippincott Williams and Wilkins, pp389-397.

¡@

Abdominal Tubal Sterilization 

Indication:

1. Voluntary ( complete family )

2. Other ( poor obestetric history, pychiatric, mental retardation )

*¬°°ü¤k¬I¦æµ²²Ï¤@©w­n±o¨ì¤Ò©dÂù¤èªº®Ñ­±¦P·N®Ñ¡C

Type of operation:

1. Pomeroy ¡÷ Simplest, resonably

(1) Puerperal:

This procedure should be performed prior to significant uterine involution.  A small (2-cm), infraumbilical, slightly curved incision is made.  The fasciae and peritoneum are individually identified and entered.  Small retractors pull forcibly toward the side that is to be ligated.  The uterus can often be moved by external transabdominal pressure.  Babcock's forceps are used to grasp the tube as soon as it is visualized.  The fimbriae should be positively identified by "walking" the Babcock forceps toward the distal end of the tube.

The most common method of postpartum sterilization is the Pomeroy technique.  The Babcock forceps grasp the ampullar portion of the tube.  A loop of tissue is ligated with plain suture and held with a hemostat. It is prudent to remove as little of the tubal ampulla as possible to facilitate possible future re-anastomosis techniques.  A second suture ligature is applied just proximal to the first.  The tip of a small scissors can be used to perforate the mesosalpinx.  The loop of tubal tissue is then excised.

Most failures following the Pomeroy method are the result of fistula formation.  The use of plain catgut apparently reduces this risk, as compared with chromic suture.

(2) Nonpuerperal:

A small suprapubic incision, approximately 3 cm in size, is made transversely several centimeters above the symphysis pubis.  A manipulating device, such as a Cohen cannula, has been previously inserted in the uterus.  The peritoneum is entered, and the uterus is pushed into an anteverted position. Clips, rings, coagulation, or the Pomeroy technique can be used to occlude the tubes.  Other techniques such as the Irving and the Kroener procedures are infrquently used in the United States today.  The Kroener technique may be appropriate in patients with extensive adhesive disease in whom the mid-portion of the tube is not accessible. The suture ligatures must be placed proximal to all the fimbrial tissue to avoid sterilization failure.  Chromic catgut suture, which may predispose the patient to tuboperitoneal fistulas, should be avoided.

2. Parkland

3. Irving

4. Madlener

5. Kroener fimbriectomy

6. Ucheda 

Timing:

1.Puerperal ¡÷ after delivery

2.Nonpuerperal

Side of ligation:

1.Isthmus: because isthmus have the most reastomosis rate

2.fimbriectomy

Complication:

1.Sterilization failure:

(1).Surgical failure

(2).Reanastomosis, Recannulization

(3).hydrosalpix

2.Increased ectopic pregnancy rate

3.Anesthetic: most important

* Vaginal tubal sterization:

Indication: nonpuerperal time

Operation method and procedures:

1. Colpotomy from the posterior fornix.

2. Head down position to make the bowel mone upward.

3. grasping the fimbrial ent to do fimbriectomy.

4. Close the culdotomy wound.
¡@

Cervical Incompetence

1.  Incidence:

about 0.1 to 1 % of all pregnancies,

responsible for up to 20% of mid-trimester abortions.

2.  Clinical presentation:

Three clinical settings in which the diagnosis of cervical incompetence should be considered.

a.  history of mid-trimester pregnancy loss, often recurrent,

b.  the acute presentation during pregnancy of advanced cervical effacement and dilation in a woman with no history of pregnancy loss,

c.  by cervical ultrasonography ¡V the observation of cervical effacement or funneling, made either in the course of evaluating a patient whose gynecologic or obstetric history has suggested the possibility of cervical incompetence or in whom ultrasound findings suggestive of incompetence were observed incidentally.

** Ultrasonographic observations of cervix have demonstrated that cervical effacement actually begins at the internal cervical os and proceeds caudad, as shown in Figure 29-1 (Reference 2).

¡@

3. Etiology:

Except for previous trauma of the cervix, such as in the course of dilatation and curettage, conization, cauterization, or amputation, other causes may be obscur

4.     Diagnosis:

The diagnosis is mainly based upon carefully observed and recorded events which include painless cervical dilatation and spontaneously ruptured membranes.

** Cerclage is most likely to be efficacious in preventing preterm delivery and fetal loss in women who met three or more of five criteria:

a.  previous premature delivery of mid-trimester abortion without cause,

b.  visual evidence of surgical or obstetric trauma to the cervix,

c.  history of painless premature labor or rapid delivery,

d.  progressive dilation or dilation greater than 2 cm on initial examination during the mid trimester,

e.  previous diagnosis of cervical incompetence with previous cerclage.

5.     Treatment:

Surgical reinforcement of the weak cervix by some type of purse string suture, including: Shirodkar¡¦s cerclage, McDonald¡¦s cerclage, and emergency cerclage.

6.     Timing of operation and preoperative evaluation:

a.  Cerclage is generally delayed until after 14 weeks so that early abortions due to other factors will be completed.

b.  Sonography to confirm a living fetus and to exclude major fetal anomalies is done prior to cerclage.

c.  Obvious cervical infections should be treated, and cultures for gonorrhea, chlamydia, and group B streptococci are recommended.

d.  For at least a week before and after surgery, there should be no sexual intercourse.

7.     Complications of cervical cerclage:

a.  increased risk of infection,

b.  preterm rupture of membranes (PROM),

c.  preterm labor,

d.  suture displacement,

e.  cervical stenosis,

f.   cervical laceration during labor.

8.     Pre-op preparation:

1. bed rest,

2. prophylactic tocolytic agent (Ritodrine) started with initial dose (3 ampules- 150 mg in total- in D5W 500 c.c. run 20 mgtt/min) on the morning of operation day,

3. NPO since midnight and keep main IVF run 100 c.c. / hr,

4. No need for skin preparation, fleet enema, or prophylactic antibiotics.

9.     Post-Op care:

a.  complete bed rest for at least 1 day,

b. on feto-toco monitoring for 1 hr, then perform it b.i.d.,

c.  tocolytic agent (Ritodrine) continued for 1 day then tapered if there is no uterine contraction detectable,

d. watch for surgical complications (described above),

e.  routine post-op antibiotics with ampicillin 500 mg i.v. q6h for 3 doses.

10.  Removal of the cervical suture when there is:

a.  spontaneous PROM,

b. inevitable abortion,

c.  evidence of infection,

d. term pregnancy in labor.

Reference:

1.  Williams Obstetrics, 20^th Edition, 1997, edited by Cunningham et al. pp. 588-591.

2.  Maternal-Fetal Medicine, 4^th Edition, 1999, edited by Creasy and Resnick, Chapter 29, pp. 445-464.

3.  Vaginal Operations, 2^nd Edition, 1996, edited by Reiffenstuhl et al, pp. 72-75.

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Procedures:

Shirodkar¡¦s cerclage:

The Mersilene band with needles attached at both ends (right lower Figure) is ready to use without threading a Mersilene band through the Deschamps needle.

McDonald cerclage:

Emergency cerclage:

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® Continuous sequential estrogen-progestogen therapy: ¨C¤ÑªA¥Î»Û¿E¯À©ó²Ä10¤Ñ¨ì²Ä12¤Ñ¦A¥[¤W¶ÀÅé¯À¡AÁ`¦@¥Î12-14¤Ñ¡C

¡Â Continuous estrogen-progestogen therapy: »Û¿E¯À¥[¤W¶ÀÅé¯À«ùÄòªA¥Î¡A¤è«K©Ê¬O¨äÀuÂI¡A¦ýªì´Áªº¤£³W«h¥X¦å¬O¨ä¯ÊÂI¡C

¢XTransdermal estrogens: ¤è«K¡A¦ý©ö©ó³y¦¨local skin reaction¡C¦Óprogestogen¤´¶·¦P®É¨Ö¥Î¡C³q±`¥Î©ó¨xŦ¾÷¯à¤£¦n¤§¯f¤H¡C

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® Progestogens: ¹ï©ó¤£¾A©ó¥ÎestrogenªvÀøªº¯f¤H¡A¨Ï¥ÎMedroxyprogesterone Acetate¥ç¥i´î§C¼ö¼é¬õ¤Î°©½è²¨ÃP¯gªºµo¥Í²v¡C

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¢X Vit. D.: required for calcium absorption, especially for those confined to nursing homes.

 ¤­¡BContraindications to estrogen replacement therapy:

Absolute contraindications         Relative contraindications

History of breast cancer              Preexisting H/T

Active endometrial cancer          Fibrocystic disease of the breast

Leimyoma

Unexplained vaginal bleeding     Familial hyperlipidemia

Active thrombophlebitic             Migraine

or thromboembolic disease         Chronic thrombophlebitis

Active liver disease                    Endometriosis

Gallbladder disease

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