• Onset:
• Occurs before the age of 8 years.
• Characterized by early pubic hair development.
• Minimal growth of axillary hair (normal puberty timing).
• Bone Growth and Maturation:
• Slightly advanced compared to typical development.
• Secondary Sex Characteristics:
• Absent during this stage.
• Signs of Virilization:
• May include the development of secondary male characteristics or the absence/regression of secondary female sexual characteristics, such as clitoral hypertrophy.
• Typical Progression:
• Often evolves toward normal puberty.
• Etiology:
• Primarily associated with premature adrenarche, unrelated to gonadal stimulation.
• May also be associated with underlying hypothalamic disorders.

• Slight Increases in Breast Development During Childhood:
• Characterized by minor breast development without concurrent nipple and areola development and pigmentation.
• Absence of Other Secondary Sex Characteristics:
• Secondary sexual characteristics beyond slight breast development are not present.
• Progression and Regression:
• This condition may either spontaneously regress or progress towards normal puberty.
• Etiology:
• Typically attributed to an unexplained increase in estrogen levels.

Tx: If etiological: suppress estrogen release

⇒ Tx = Etiological

• Tx of hot flashes
• Ø for long-term prevention ⇒ Risk > benefits for osteoporosis / CAD
• Estrogens and/or progestins
• Estrogens: ↓ menopausal symptoms
• Progestin if intact uterus:
• Prevents endometrial hyperplasia (↓cancer risk) & bleeding
• Not required if post-hysterectomy

**preperation details

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💬

⇒ 📷

• center of vagina (equal anterior and posterior distance to walls)
• at 8-10cm depth (compared to introit of vagina)
• Abnormal location: tumor? (uterine, adjacent organs)

⇒ 📷

• Nulli: Conical + punctiform ext. orrifice
• Multi: Cylindrical/Bivalve + transverse ext. orrifice

• Dimensions:
• An important marker is the comparison between the length of the cervix and that of the uterine body.
• In adult women, a normal ratio is 1:2.
• This ratio is reversed in girls.
• Mobility:
• The cervix is mobile in all directions.
• It allows for a 2-3 cm displacement.

Anterversion flexion 📷 vs Retroversion flexion 📷! → Anteversion-flexion: easily palpated; Retroversion-flexion: difficult to palpate

• Anteversion-Flexion:
• Typically, the uterus can be easily palpated between the two exploratory hands in most cases.
• Retroversion-Flexion:
• In situations involving retroversion-flexion, the uterus may pose challenges in palpation between the two exploratory hands or even become inaccessible.
• Efforts can be made to retrieve the uterine body, although success may be limited, particularly when evident adherences are present.

• Measurement Difficulty:
• The size of the uterus can be easily measured through bimanual examination in an anteverted uterus.
• In contrast, it is more challenging to measure the size of a retroverted uterus, which often feels larger during vaginal touch.
• Expressing Uterine Size:
• To convey the size of the uterus accurately, one can compare it to that of a pregnant uterus of a specific gestational age.
• Uterine Volume:
• The volume of the uterus may vary:
• Small: Occurs before puberty or during menopause.
• Large: Notably during pregnancy, in cases of tumors in the uterine body or cervix, or due to metritis.

• Position:
• Located in the medio-sagittal plane, below the superior strait.
• It can be laterally deviated to the right or left.
• Shape:
• Typically piriform in shape.
• May be deformed in the presence of uterine fibroids.
• Consistency (similar to the cervix)
• In a non-pregnant uterus, it is firm and elastic, .
• In the case of uterine fibroids, it may feel rough.
• Mobility:
• A normal uterus is mobile in both the medio-sagittal and lateral planes.
• Limitation of mobility can occur due to various factors including uterine tumors, adnexal tumors, pregnancy, PID, peritonitis, or scarring.
• Sensitivity:
• The normal uterus is typically painless.
• Pain in the uterus can be associated with inflammatory processes, endometritis, uterine abscess, while non-complicated uterine fibroids may not cause pain.

• Palpating the Adnexa:
• Adnexa examination involves bimanual palpation in the lateral recto-uterine pouches, directed towards the walls of the excavation.
• Normal Findings:
• In a normal examination, the ovaries are the only structures palpated.
• Ovaries typically have a size similar to that of almonds.
• The normal fallopian tube is not typically palpable.

• Detecting Tumor Formation:
• When a tumor formation is detected laterally to the uterus, it's important to differentiate whether it originates from the adnexa or is part of the uterine body.
• Differentiation Indicators:
• A separation ditch is typically present between an adnexal mass and the uterine body.
• In the case of a uterine formation, this ditch is not present, and the formation moves along with the mobilization of the cervix.

• Shape:
• Cystic or solid ovarian tumors typically exhibit a round or oval shape.
• Inflammatory formations tend to be elongated and sensitive.
• Consistency:
• The consistency can provide insights:
• Cystic tumors may feel renitent.
• Solid tumors may have a rough texture.
• Tubo-ovarian abscesses may feel fluctuant.
• Mobility:
• Mobility can vary:
• Present in benign tumors.
• Reduced in malignant tumors, pelvic inflammatory processes, or intraligamentary tumors.
• Sensitivity:
• Sensitivity is an important factor:
• Ovarian tumors are typically painless.
• Adnexal inflammatory masses often cause pain.
• Torsion of ovarian masses can be painful.
• Size:
• The size of the adnexal formation should also be assessed.

• PROGESTIN only contraceptives
• COMBINATION oral contraceptives (P+Estrogen)

The mechanism of combined oral contraceptives is due to A. Inhibition of ovulation B. Modification of cervical mucus (hostile mucus which does not allow the passage of sperm) C. Hyperplasia of the endometrium D. Hypermotility of the tubes E. Luteolysis

Contraindications for the use of combined oral contraceptives: A. Women under 35 years B. Thrombophlebitis C. Hepatic tumors D. Unexplained abdominal vaginal bleeding E. History of vascular cerebral thrombosis

The contraindications for the use of combined oral contraceptive pills are: A. History of thrombophlebitis B. Estrogen-dependent neoplasms C. History of cerebrovascular accidents D. Hypermenorrhea (Metrorrhagia) E. Within 3-4 weeks prior to surgery

📷

• Goal: disruption of Fallopian tubes → Low failure rate • Often done postpartum • Also performed outside pregnancy ("interval") • Reversible in some cases based on technique

1. Medical Conditions Posing Risks in Pregnancy:
• These are medical conditions that elevate risks during potential pregnancies.
2. Obstetrical Indications - Repeated Caesarean Sections:
• Permanent contraception may be recommended for individuals with a history of multiple caesarean sections.
3. Genetic Indications - Family History of Transmissible Diseases:
• When there is a family history of genetic diseases with high transmission risk, permanent contraception can be considered.
4. Contraceptive Indications - Intolerance to Other Methods:
• Permanent contraception becomes an option for individuals who cannot tolerate or use other contraceptive methods effectively.

⤴️ ectopic pregnancy

other:

• Complications due to the surgical procedure.
• Hormonal disorders, which can be debatable and may result from ovarian vascularity being affected.
• Menstrual changes.
• Possibility of tubal repermeabilisation.

• Ligation of bilateral vas deferens 📷
• Usually outpatient under local anesthesia

⇒ Use alternate method of contraception until semen analysis

F → USUALLY permanent • Rare cases of recanalization (~ 0.2% of patients) • Reversal possible in some cases

• To save the life, health, or body integrity of the pregnant woman that cannot be saved otherwise.
• When interrupting the course of pregnancy is required for therapeutic reasons
• If pregnant woman is unable to express her will, and interruption of the pregnancy course is required for therapeutic reasons

• Morphologically, the uterus exhibits small dimensions and often assumes a hyper-anteverted or hyper-retroverted position.
• This condition is frequently linked to symptoms such as amenorrhea (absence of menstruation), dysmenorrhea (painful menstruation), infertility, or miscarriage.
• Uterine hypoplasia may also co-occur with other forms of pelvic-genital hypoplasia.

• Endometriosis
• Adenomyosis
• Uterine polyps
• Uterine anomalies (e.g., non-communicating uterine horn)
• Leiomyoma
• Intrauterine synechia
• Ovarian cysts
• Cervical stenosis
• Imperforate hymen
• Transverse vaginal septum
• Pelvic inflammatory disease
• IUD (copper)
• Foreign body

Ultrasound - ovarian endometrioma 📷

Common locations • Ovaries • Fallopian tubes • Uterus • Cul-de-sac (behind vagina) • Broad / uterosacral ligaments • Round ligaments • Sigmoid colon or appendix

• White, young, skinny, academic woman without kids 📷
• White woman
• Aged 30-40 (mainly > 25 years old)
• Possesses an increased educational level
• Thin
• Experiences regular ovulatory menstrual cycles
• Nulliparous (has not given birth)
• Congenital anomalies of the genital tract (obstructive)
• Abundant menstruation
• Family history (7-10 times increased risk if there is a affected 1st-degree relative)

• Dysmenorrhea
• Cyclic menstrual pelvic pain
• Classically 1 to 2 weeks before menses
• Out of proportion to bleeding
• Dyspareuria
• Painful intercourse
• Ectopic tissue near vagina
• Infertility
• Inflammatory changes impair fertility
• Dyschezia
• Painful defecation
• Ectopic tissue near rectum
• Dysuria
• Painful urination
• Ectopic tissue near bladder
• Improves at menopause and in pregnancy
• Increased risk of ovarian epithelial cancer

👉🏼

Physical exam: - normal exam or location-specific tendness/mass - normal uterus size (DDx adenomyosis) but might be displaced

‣

💬

displaced*:

🦇

US findings: ⇒ nodule/cyst: ovaries = 🍫Chocolate cysts

‣

💬

⇒ Negative sliding sign

‣

💬

BIOPSY =definite dgx (often only empirix Tx without definite Dgx)

‣

💬

Physical Exam

• May be normal
• Location-specific changes
• Vaginal tenderness
• Cervical motion tenderness (dull)
• Nodules along uterosacral ligaments 📷
• Ovarian /adnexal mass
• Normal uterus size (Enlarged uterus: adenomyosis)
• Anatomic distortions of uterus
• Lateral displacement
• Retroverted uterus
• May be caused by adhesions

• #1 Combination oral contraceptive pills (COCs) • Cause atrophy of endometrial tissue • Progestin-only • additive: Nonsteroidal anti-inflammatory drugs (NSAIDs)
• GnRH antagonists • ↓ LH/FSH production → ↓Estrogen → Improves endometriosis-related pain • Immediately effective (contrast with GnRH agonists) • SE: hot flashes, night sweats
• #2 GnRH Agonists • Binds to GnRH receptors in pituitary → Down-regulation →Pituitary desensitization → LH/FSH • Leads to amenorrhea and endometrial atrophy • May be given with estrogen/progestins • Minimizes hot flashes and menopausal symptoms
• Surgical removal (laparoscopically) • for refractory cases • definitive diagnosis & excludes other pathology • Remove endometrial tissue

**SERM = Selective Estrogen Receptor Modulator (or SPRM → Progesteron)

• Multiparity
• Age (late reproductive period, 40-50 years)
• Hyperestrogenism
• Coexistence of leiomyomas, endometrial hyperplasia, endometrial cancer
• Uterine trauma at birth
• Prior surgical interventions involving the uterine cavity

• Previous acute PID
• Age < 30 years
• Risk factors for STI (chlamydia and gonorrhea)
• “Introduction”
• Vaginal douching
• IUD (within the first 10 days after insertion)
• Invasive gynecologic procedures (D&C, endometrial biopsy)

1. Pelvic PAIN (Ønecessarily during menstruation)
2. SYSTEMIC signs → fever, chills, ↑leukos

→ RUQ pain → Fitz-Hugh-Curtis (Perihepatitis) 📷

‣

💬

Spread of infection ⇒ Inflammation of liver capsule

Tx = same as PID

Definite Dgx: laparoscopy: "Violin string" adhesions

Gyn exam:

1. TENDERNESS:
• Cervical motion (🛋️ ”Chandelier” signs) tenderness
‣
💬

1. Uterine / Adnexal tenderness
2. purulent DISCHARGE 📷 + CERVICAL BLEEDING (”spotting”)

If severe (↑fever, n/v, ↑pain, hospitaliz):

DDx pelvic pain

• Ectopic pregnancy
• Adnexal complications (torsion, bleeding)
• Appendicitis or other types of acute abdomen involving lower abdominal pain
• Endometriosis
• Enteritis
• Septic incomplete abortion
• Diverticular abscess

HIV, Gonorrhea, Chlamydia

cover G+ (chlamydia), G- (gonorrhea), & anaerobes

#1

Regimen A: cefoxitin 2g IV q6h + doxycycline 100mg IV/PO q12h

Regimen B: clindamycin 900mg IV q8h + gentamicin loading dose 2 mg/kg IV/IM followed by 1.5 mg/kg IV/IM q8h

↓

#2 (Ø response to ABs)

Laparoscopic drainage

↓

#3

Surgery (options: salpingectomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy)

📷 Scarring / Adhesions in uterus / fallopian tubes ⇒ blockage

⇒ INFERTILITY

⇒ ECTOPIC PREGNANCY

other complications (Ølong term): abscess, systemic spread(peritonitis, sepsis, septic arthritis)

“I FACE PID”📷

• Before puberty
• During pregnancy and lactation
• During menopause

‣

PRIMARY syphilis: Clinical presentation?

💡

onset after 2-3 weeks → resolves within weeks (4-6w)

1. Chancre (ØPAIN!) 📷 📷
2. Regional painless ↑LN

mouth: 📷

finger: 📷

perianal: 📷

‣

SECONDARY syphilis: Clinical presentation?

💡

after weeks-month (6-8w)

Condylomata LATA 📷 (DDx = HPV-assoc. Condylomata accuminata)

Other:

1. Flu-like symptoms
2. GENERALIZED ↑LN
3. Rash (PAPULOSQAMOUS / MACULOPAPULAR) 📷
4. Lues maligna 📷
5. Pigmentary changes (hyper-/hypo)
6. Allopecia
7. Mucous patches 📷 (tongue, oral mucosa, lip corner)

‣

TERTIARY syphilis: Clinical presentation?

💡

YEARS after onset (1-10y)

Gumma 📷

Other:

1. Tuberous syphilids (Tubero-serpinginous 📷 and tubero-ulcero-serpinginous 📷)
‣

💬

tubero-serpiginous: -red, brows -flat-topped red papules -progress periph. -heal centrally with atopy + pigm. changes

tubero-ulcero-serpinginous

- same as tubero-serpiginous +ULCER

2. Cardiac
3. Aortitis

‣

NEUROSYPHILIS syphilis: Clinical Presentation? (6)

1. Focal Gumma
2. Meningo-vasc. Syphilis
3. General paresis
4. Argyll-Robertson pupil
5. Deafness
6. Tabes dorsalis

‣

CONGENITAL SYPHILIS - EARLY vs. LATE: Clinical presentations?

➡️

1st - 3rd T

early: <2 yo

late: >2 yo

• Congenital syphilis

descent of pelvic organs (herniation) to or beyond the vaginal walls

• Vaginal wall prolapse
• Anterior vaginal wall prolapse: herniated anterior vaginal wall, which is often associated with
• cystocele (descent of the bladder)
• urethrocele (descent of the urethra);

→ can be due to weakness of the pubocervical fascia 📷

• Posterior vaginal wall prolapse: herniated posterior vaginal wall, which is associated with
• enterocele (herniated section of the intestines);
• rectocele (descent of the rectum)

→ can be due to weakness of the rectovaginal fascia 📷

• Uterine prolapse: descent of the uterus
• Vaginal vault prolapse: descent of the apex of the vagina (often after hysterectomy)

1. 🕳️ Pelvic floor WEAKNESS
• Gestational characteristics: ligaments + pelvic floor extension&relaxation during birth
• Conjunctive tissue abnormalities
• conjunctive tissue DEFICIENCIES
• Endocrine: E-DEFICIENCY→ ATROPHY of conj. tissue
2. 💥 Pelvic floor TRAUMA
• during Birth
• Iatrogenic (surgery, brutal maneuvers, incorrect forceps use)

• STRESS incontinency ⇒ ↓strenght of pelvic floor muscles ⇒ cant hold during stress (i.e. cough)
• URGE incontinency ⇒ sudden urge
• other types
• mixed
• transient (drugs, infections, stool impaction, restricted mobility)
• functional (↓mobility, cant reach)
‣
💬
Functional incontinence can result from various factors, including:
• Confusion
• Dementia
• Impaired eyesight
• Limited mobility
• Poor dexterity
• bedwetting (young children)
• structural (malformation)

• Most will clear infection within 12 months
• Some will have infection persist ⇒ Cervical cancer:
• HPV 16: 50% of cases
• HPV 18: 20% of cases
• Others: HPV 31, 33, 45, 52, and 58

1. Related to Sexual behaviour
• HPV infection or history of other STD
• sex at young age
• multiple partners
2. Smoking
3. Immunodeficiency
4. Hormonal factors

Q. It isn't a risk factor for cervical intra-epithelial neoplasia (CIN) A. HPV infection B. Smoking C. Immunosuppression D. Hormonal factors E. High socioeconomic level

→ E) Low socioeconomic level (only listed for carcinoma; Ø CIN)

💡

TRANSFORMATIONAL ZONE of SQUAMO-COLUMNAR JUNCTION (SCJ) 📷 📷

• Squamocolumnar junction
• Junction between squamous and columnar epithelium
• Endocervix: columnar epithelium
• Ectocervix: squamous epithelium
• Transformation zone
• SCJ moves from exposure to hormones
• TZ: area between original SCJ and new SCJ
• Most (95%) cancers arise here

Q. Which part of the cervix do cancerous lesions begin: a. Exocervix b. Endocervix c. Squamo -columnar junction d. External cervical ostium e. Internal cervical ostium

HPV testing (PCR) ⇒ identifies HPV-INFECTION (Øcellular changes)

PAP smear ⇒ epithelial CELL changes (Koilocytes) due to HPV 📷

• CIN1 (corresponds to mild dysplasia)

→ the anomalies described are present in 1 / 3 basal epithelium, maintaining a mature aspect in superficial layers

• CIN2 (moderate dysplasia) - anomalies are present in the 2 / 3 basal epithelium.
• CIN3 (severe dysplasia and intraepithelial cancer) - anomalies are present in all epithelial structure.

⇒ 📷