ously monitor pulse, BP, ECG. Continue with boluses until the signs of shock ease. \200 Then give the daily requirement + \202 uid de \201 cit as above, making good continu- ing loss with 0.45% or 0.9% saline depending on type of dehydration. Measure plasma and urine creatinine and osmolality (p176), and plasma bi- carbonate. Metabolic acidosis usually corrects itself. Guidelines for success: Above all be simple. Complex regimens cause errors. 1 Stay at the b edside; use clinical state + lab results to adapt IVI. 2 Beware sudden changes in Na+ ( \200\200 or \200\201); may cause seizures or central pon- tine demyelinolysis. 3 Beware hidden loss (oedema, ascites, GI pools), and shifts of \202 uid from the intravascular space to the interstitial space ( \200\230third-spacing \200\231). 4 Measure U&E and urine electrolytes often. 5 Give potassium once you know that urine is \202 owing. The ready-prepared \202 uid \200\2300.45% Saline With 5% glucose With Potass ium Chloride 20mmol/L \200\231 is usually a good choice. Be guided by serum K+.795 Hypernatraemic dehydration: (greater water loss than salt, eg from wrongly made feeds, or r arely, if breastfed.) It causes intracellular dehydration ( \201 ts, CNS thrombosis/hem orrhages on MRI).796 Treatment: rehydrate slowly with 0.45% or 0.9% saline (which is hypoto nic for a hypernatraemic patient): re- place de \201 cit over 48h, lowering Na+ by <12mmol /L/24h, and giving only 60% of maintenance volume, to avoid CNS oedema (p200). A big danger is too rapid rehydration. Hyperglycaemia is common, but self-correcting.797,798 Water bala nce in the preterm infant Water comprises 50 \200\22370% of weight gain (eg of 15g/day) in preterm babies. Insensible water loss (IWL) falls with increasing body weight, gestational age, and postnatal age; it increases with \200\200T (ambient & body) and low humidity. I n a single-walled, thermoneutral incu- bator with a humidity of 50 \200\22380% IWL \211 \210 30 \200\22360mL/kg/day (may double in infants on phototherapy under a radiant heater). Fecal water loss \211\210 5 \200\22310mL/kg/day (except during diarrhea). Urine loss: If 90mL/kg/day, there is no excessive renal stress. \200 APLS procedures \200\224intraosseus transfusion 236 \200 \200 (APLS=advanced pediatric life support.) Immediate vascular access is required in pediatric and neonatal practice in the following circumstances: cardiopulmonary arrest, severe burns, prolonged status epilepticus, hypovolaemic and septic shock. In many cases rapid intra- ve nous access is not easily obtained. Intraosseous (IO) infusion is a rapid, safe, easy, and eff ective means of obtaining vascular access, and is recommended for life-threatening pedi atric emergencies in which IV access cannot be ob- tained.799 In such an emergency attempt an IV line but if unsuccessful within 60 \200\22390s, attempt an IO line. It is safe to adm inister all intravenous medicines via the IO. Bloods can be taken and sent to the lab for c ross match, FBC, U&E.800 Inform the hematology lab they will see blasts. A blood gas can be sent (if no \202 uids given already) \200\224but it shouldn \200\231t be used on an auto analyser as it may clog the machine. Send it to the lab and inform them that it is a marrow sam- ple \200\224they may be able to test it in a cartridge analyzer.800 Contraindications Osteoporosis, osteogenesis imperfecta, and infection or fracture at the site of insertion. Technical aspects Learn from an expert. The major choice is between a manual needle or a s emi-automatic device such as an intraosseous gun or drill. The two major devices available are the Bone Injection Gun (B.I.G. ) \200\224a spring loaded device available for childr en and adults, and the EZ-IO device a reusable drill with a 15mm needle for children <39 kg, and a 25mm needle for patients >40kg. A new 45mm needle is available for those with sig ni \201 cant tis- sue/oedema overlying the site of injection. The EZ-IO may be faster than both manual needles and the B.I.G. and easier to place 1st time.801 Preparation Set trolle y: Dressing pack, povidone iodine, needles, 10mL sy- ringe, lidocaine (=lignocaine) 1% (5mL ), scalpel, intraosseous needle, paediat- ric infusion set, 10mL 0.9% saline, adhesive tape . Choosing the site of insertion The proximal tibia is the best site. Other sites are the p roximal humerus, distal femur or distal tibia. Choose a point on the \202 at anteromedial surface of the tibia, 1 \200\2232 cm medial to and 1 \200\2232cm below the tibial tuberosi ty. The child \200\231s leg should be restrained, with a small support placed behind the kn ee. Procedure \200 Sterilize the skin with antiseptic, in \201 ltrate with lidocaine as necessary. s c i r t a d e a P i (Puncturing the skin with the scalpel is not usually necessary.) Insert the intraosseous needle at an angle of 90 to the skin; advance with a boring or sc rewing motion into the marrow cavity. Correct location of the needle is signi \201 ed by a decrease in resistance on entering the marrow cavity. \200 Stabilize the needle and veri fy the position by aspirating marrow, or by the easy \202 ushing of 5 \200\22310mL of 0.9 % saline, without any in \201 ltration of surround- ing tissue. The needle should stand up right without support, but should be secured with tape. Take samples for culture, U&E, FBC, group & save! \200 Connect to IV infusion via an exte nsion: better \202 ow rates are often got by syringing in \202 uid boluses (standard bo lus is 20mL/kg of crystalloid or colloid). Complications (Infrequent) There may be extravas ation of \202 uid, or cellulitis, fractures, osteomyelitis, pain, and fat or bone microem boli. These are more common with prolonged use \200\224so intraosseous infusion should be d iscontin- ued as soon as conventional IV access is attained (should be within 24h). NB: Int raosseous delivery may also be used in adults.802 The position on the tibia in adults is 2c m medial to tibial tuberosity and 1cm above it (as opposed to below it in children). \200 Anaphylaxis (Adrenaline=epinephrine) resus.org.uk Never blame yourself for forgetting anything, except your humanity (and the dose of adrenaline). \200 Call the resuscitation/ cardiac arrest team (paramedics if in the community). \200 Ideally place patient on back w ith legs raised. If they have signi \201 cant respir- atory distress allow the patient to put themselves in a position of comfort. Do not let them stand or sit up rapidly. If comato se, use left-lateral position (to prevent caval compression). 237 \200 \200 ABCDE: Airway (any swelling, hoarseness, stridor?); breathing (rate \200\200, wheeze , fatigue, cyanosis, SpO2 <92%?); circulation (pale, clammy, BP \200\201, faints?); disabil - ity (conscious level, eg drowsy/coma?); exposure of skin (erythema/urticaria?). \200 The chief drug priority is adrenaline. Give intra-muscularly (IM). Use a suita- ble syringe fo r measuring small volumes; absolute accuracy isn \200\231t essential.803 Note strength! (1 : 1000 not 1 : 10,000.) IM dose of 3 drugs: If aged <6 months If aged 6 months \200\2236yrs 0.15mL (150 g) 0.3mL (300 g) Dose if aged 6 \200\22312yrs Adolescent/adult dose 0.5mL (5 00 g) s c i r t a i d e a P Adrenaline 1 : 1000 Chlorphenamine Hydrocortisone 0.15mL (150 g)[13] 25 g/kg 2.5mg 5mg 10 mg 25mg 50mg 100mg 200mg \200 Repeat adrenaline dose after 5min if no improvement. Also: high- \202 ow O2 ( IPPV ) & crystalloid (20mL/kg IVI). NB: weight (kg) \211\210 2 (age in yrs + 4). OK if 1 \200 \22310yrs old. \200 Remove the trigger, eg bee sting; turn off any drug or colloid IVI. \200 IV route: This can be used for hydrocortisone and chlorphenamine, although there is little evidence t hese help much. Steroids are unlikely to be harmful, but antihistamines may worsen hypotens ion and cause somnolence which can cloud the picture with regards to the CNS eff ects of an aphylaxis so wait until initial resuscitation is complete prior to giving these. Don \200 \231t use the IV route for adrenaline (unless on ITU with experienced user; special doses a pply). \200 If bronchospasm is a feature: give salbutamol 2. 5mg nebulized too. \200 Co ntinuously monitor: pulse, BP, SpO2, and ECG. If cardiac arrest, start CPR. \200 Differen tial diagnosis: asthma; septic shock; breath-holding or panic attack. \200 After the emer gency: if reaction is due to a drug, idiopathic or due to an envenomation, take blood as so on as possible after symptoms start; ideally 1 \200\2232h, but de \201 nitely within 4h fo r mast cell tryptase (>0.5mL in LFT bottle, ask lab to freeze); admit as an in-patient; ref er to an allergist. Self-use of pre-loaded pen injectors may be needed (after training).804 EpiPen has 0.3mg of adrenaline (1 : 1000). This is suitable if weight >30kg. If 15 \200 \22330kg, use Anapen Junior or EpiPen Junior , which both contain 0.15mg of adrenaline. Epipen Junior (1 : 2000) delivers 0.15mg of adrenaline (1.7mL remains after using the aut oinjector). It is suitable for a 15kg child ( 4yrs). \200 European pediatric basic life-support 805 This algorithm assumes no equipment and tha t only 1 professional rescuer is present. Remove yourself and the child from danger. Phone for help at once. How to give the rescue breaths to a child: Ensure head tilt and chin lift . Pinch the soft part of his nose. Open his mouth a little, but maintain chin up. Take a br eath, and place your lips around his mouth (good seal). Blow steadily into his mouth over 1 \200\2231.5sec. Does his chest rise? Take your mouth away, and watch for the chest to fall . Take another breath, and repeat this sequence up to 5 times. To an infant: Do as above, b ut cover the nasal apertures and the mouth with your lips. The head should be in the neutra l position. If the chest does not move, respiratory ob- struction may exist \200 move on t o \200\230Remov- ing foreign body \200\231 sequence for obstructed airway \200\224ie: \200 If coughing, encourage to cough. Once un- 238 \200 \200 Pediatric Basic Life Support (Healthcare professionals with a duty to respond) UNRESPONSIVE? Shout for help Open airway conscious or an ineff ective cough: s c i r t a d e a P Remove any obvious obstructions. Re- check that there is adequate head tilt and chin lift, but do not overextend the neck. \200 Do up to 5 back blows between the scapu- lae to disl odge hidden obstructions (hold on your lap whilst seated, positioning the head lower than c hest). NOT BREATHING NORMALLY? i 5 rescue breaths NO SIGNS OF LIFE? If this fails, do 5 chest thrusts: turn to supine; over 12sec, give 5 sternal thrusts (same position as for compressions, but be sharper and more vigorous). Remove any foreign bodies which have become visible. 15 chest compressions 2 rescue breaths 15 compressions Tilt head upwards; lift chin to reopen the airway, and assess breathing. If not breathing; do 5 more rescue breaths: Call the resuscitation team does the chest move now? Fig 1. Pediatric basic life-support, applicable only to healthcare pro- fessionals with a d uty to respond. Resuscitation Council UK www.resus.org.uk If not, for a child >1 year, give 5 abdomi- nal thrusts (directed towards diaphragm); use t he upright position if the child is con- scious; supine if not. Repeat these sequences until breathing is OK, alternating chest and abdominal thrusts. Do n ot give abdominal thrusts to infants (risk of internal injury). When breathing place in the recovery position \200\224as near to the true lateral position as possible, with mouth dep endent to aid draining of secretions. The position must be stable (eg use pillows placed be hind back). The degree of movement is determined by risk of spinal injury. How to give ches t compressions: Compress lower half of sternum to \205\223 of the chest \200\231s depth; u se the heel of one hand (or, in babies, with both your thumbs, with your hands encircling t he thorax) If >8yrs, the adult 2-handed method is OK. For an infant, 2 \201 ngers are suf fi cient, in the middle of a line joining the nip- ples. Perform resuscitation for 1min be fore going for help. Remove the cause, if possible. Causes are: drowning; pulmonary embolis m; trauma; electrocution; shock; hypoxia; hypercapnia; hypothermia; U&E imbalance; drugs/to xins, eg adrenaline (= epinephrine), digoxin, and blue-ringed octopi.806 239 Cardiac arrest: pediatric advanced life-support1 \200 Neonates: see p107 Pediatric Advanced Life Support UNRESPONSIVE? not breathing or only occasional gasps Call resuscitation team (1 min CPR \201rst, if alone) CPR (5 initial breaths then 15:2) Attach de \201brillator/monitor Minimize interruptions s c i r t a i d e a P Assess rhythm Non-Shockable (PEA/asystole) Shockable (VF/pulseless VT) Return of spontaneous circulation 1 Shock 4J/kg Immediately resume CPR for 2 min Minimize interruptions Immediately resume CPR for 2 min Minimize interruptions Immediate post cardiac arrest treatment \200 Use ABCDE approach \200 Controlled oxygena tion and ventilation \200 Investigations \200 Treat precipitating cause \200 Temperat ure control \200 Therapeutic hypothermia? During CPR \200 Ensure high-quality CPR: rate, depth, recoil \200 Plan actions before i nterrupting CPR \200 Give oxygen \200 Vascular access (intravenous, intraosseous) \200 Give adrenaline every 3 \200\2235 min \200 Consider advanced airway and capnography \200 Continuous chest compressions when advanced airway in place \200 Correct reversible causes Reversible Causes \200 Hypoxia \200 Hypovolaemia \200 Hypo-/hyperkalaemia/metabolic \200 Hypothermia \200 Tension pneumothorax \200 Toxins \200 Tamponade \200\223 card iac \200 Thromboembolism Fig 1. Pediatric advanced life-support. Resuscitation Council UK, 2010. Order of assessment and intervention for any seriously ill or injured child follows the ABC DE principles: Airway (AC for airway and cervical spine stabilization for the injured child ); Breathing; Circulation (with hemorrhage control in injured child); Disability (level of consciousness and neurological status); Exposure to ensure full examination (while respecti ng dignity and temperature conserva- tion). Note: 15 : 2 means 15 compressions (rate=100 \200\223120/min) to 2 ventilations. In shockable VF/VT: \200 Give adrenaline (epinephrine) 10 g/kg IV/IO + amiodar- one 5mg/kg IV over 3min after the 3rd shock, once compressions r esumed. \200 Repeat adrenaline on alternate cycles until spontaneous circulation returns. \200 After 5th shock, give a last dose of amiodarone if still in a shockable rhythm. \200 Continue shocks every 2min, and continue compressions during de \201 brillator chargings. Non-shockable rhythm: \200 Give adrenaline as soon as you have IV/IO access. 1 AED = Automated external de \201 brilator. IO = intraosseous (p236). PEA = Pulseless ele ctrical activity. 240 3 Gynecology History and examination 242 Sexual health 243 Gynecological anatomy 244 Genital abnormaliti es 246 Uterine retroversion 246 Female genital cutting/mutilation 247 Normal menstruation 2 48 De \201 ning menstrual abnormalities 250 Amenorrhoea 251 Polycystic ovaries 252 Menorrh agia 253 Premenstrual syndrome 254 The menopause and hormone replacement therapy (HRT) 256 Termination of pregnancy 258 Miscarriage (spontaneous abortion) 260 Recurrent miscarriage 2 61 Ectopic pregnancy 262 Gestational trophoblastic disease 264 The vulva 266 Vulval lumps a nd ulcers 268 The cervix 270 Cervical carcinoma 272 The uterus 274 Vaginal carcinoma 275 Fi broids 276 y g o o c e a n y G l Fig 1. Caleb Parry (see OPPOSITE) is seen here unwisely mixing work and leisure: note the p edunculated \201 broid within his balloon which, like his bedside manner, was made of var nished silk.1 in pregnancy 277 Endometrial carcinoma 278 Endometrial sampling 279 Ovarian tumors 280 in pregnancy 282 Postmenopausal ovarian tumors 282 Ovarian carcinoma 283 Vaginal discharge 284 Pelvic infect ion 286 Endometriosis 288 Prolapse 290 Subfertility: causes, tests, treatment 292 \200\2234 Male subfertility 295 Contraception 296 The ideal contraceptive 297 Intrauterine contracep tive device 298 Emergency contraception 299 Hormonal contraception (the Pill) 300 further details 302 Depot, implant, patch, and ring contraception 304 Sterilization 305 Urinary malfunction 306 Voiding diffi culty 307 Gynecological surgery 308 Pelvic pain 310 Dyspareunia 310 Ovarian hyperstimulation 311 We thank Ms Alison Peattie, our Specialist Reader, and Pooja Sakar, ou r Junior Reader, for their contribution to this chapter. 241 A holistic approach to gynecology: Parry \200\231s dictum \200\230It is more important to know what sort of patient has the disease than what kind of disease the patient has. \200 \231 Caleb Parry (1755 \200\2231822; fig 2) was a doctor in Bath who was fascinated by even ts in his patients \200\231 lives, and their connection with their diseases, some of which he described for the \201 rst time. These early descriptions are notable for their eff or tless intertwining of psy- chological and physical phenomena.1,2 y g o o c e a n y G All this suggests a serious, one-sided doctor, but this is wrong. To get away from it all, he became a keen balloonist, lending ideas and materials to Edward Jenner, who dedicated hi s magnum opus on smallpox to him. From the Royal Crescent in Bath, he launched his great hy drogen balloon (see OPPOSITE). l Fig 2. Caleb Parry, MD FRS, was a Welshman who chose to peruse his medical studies at Edinb urgh as the lectures there, by William Cullen, were given in English, not Latin (for the mo st part, the current edition of OHCS follows Cullen \200\231s practice). His aphorism is particularly relevant to this chapter because many of its diseases are chro nic, and the choices of treatment are many. Take endometrio- sis (p288), for example. If an examiner were to ask you \200\230what is the treatment Caleb Hillier Parry (1755 \200\223 1822). for endometriosis \200\231 \200\224you might well The James Lind Library. look at hi m thoughtfully, before reply- Roger Rolls, by kind permission. ing that it all depends o n who has got it \200\224where they are in their lives, how much the pain matters, what the plans are for future pregnancies, how these plans may be ambiguous and change, according t o work, relationships, and the onset of friendships. What does the patient feel about long- term medication with agents that can change her sexuality, and hence the person who is suff ering the disease? Some may tolerate doctor-induced hypoestrogenism ( \202 ushes, decreas ed libido, loss of bone density) thinking the price well worth paying for relief of endome- triosis symptoms; others will take the opposite view; in a few, their ability to take a de cision will be in \202 uenced by the drugs they are already taking. 3 . g n i v i r d e h t Sometimes rational choice is the hardest thing \200\234How can you expect me to make a rat ional choice until you sort out these dreadful periods of mine: o d t n e i t a p I cannot even think \200 \200\2354 \201\201Be optimistic; discourage passive dependency; l et the patient set e h t the agenda. \200\207take time \200\207understand your patient \200\207off er all op- tio ns, then let her choose. t e L History and examination History Let her tell the story. Note down her exact words. She may be reluc- tant to admit some problems, particularly if you are a man, so make sure you cove r them in your questions. A frustration for the medical student is that the story you are t old is diff erent to the one elicited by the consultant or the GP. But sometimes the \201 rst telling is the most valid. \200\207It is also true that none of us (doctors and patie nts) can tell the same story twice.1 1 Menstrual history: \200\207Date of last menstrual p eriod (LMP; 1st day of bleed- ing) or menopause. Was the last period normal? Cycles: number of days bleeding/number of days from day 1 of one period to day 1 of next (eg 5/26). Are t hey regular? If heavy, are there clots or \202 oods? How many pads/ tampons are needed (a n unreliable guide)? Are periods painful? Is bleed- ing intermenstrual (IMB), postcoital (P CB) or postmenopausal (PMB)? Age at menarche? 242 \200 2 Obstetric history: How many children? For each pregnancy: antenatal problems, delivery, g estation, outcome; weights of babies; puerperium? Terminations/miscarriages \200\224at what stage, why, and (terminations) how? 3 Symptoms: If she has pain what is it like? Uterine p ain may be colicky and felt in the sacrum and groins. Ovarian pain tends to be felt in the iliac fossa and radiates down front of the thigh to the knee. Ask about dyspareunia (painfu l intercourse). Is it super \201 cial (at the entrance) or deep inside? If she has vaginal discharge what is it like (amount, color, smell, itch)? When does she get it? Ask about pr olapse and incontinence. When? How bad? Worse whilst standing? Ask about bowel symptoms (ir ritable bowel can cause pelvic pain), and fecal incontinence. y g o o c e a n y G l 4 Sex and contraception: Is she sexually active? Are there physical or emo- tional problems with sex? What contraception is she using and is she happy with it? What has she tried pre viously? Has she had problems conceiving? If so, has she had treatment for subfertility? Wh at about sexually transmit- ted infections? Date and result of last cervical smear? 5 Other: General health, smoking. Previous gynecological treatment. Examination \200\207Ma ny women \201 nd pelvic examination painful, undigni \201 ed, and embarrassing, especial ly if you are male. Explain what you are going to do. Be gentle. Use a chaperone. Royal Col leges and the General Medical Council (UK) recommend chaperones for all intimate examinatio ns; use is increasing but not universal in general practice; training is needed, and they n eed to be friendly.5 General: Is she well or ill? Is she shocked? If so, treat it. Abdomen: Palpate for tenderness and peritonism. If there is a mass, could it be a pregnancy? Listen for a fetal heart (p40). Vaginal examination: (p246). Use your eyes to inspect the vulva, a speculum to examine the vagina and cervix and your \201 ngers to assess the uterus and adnexae bimanually. Examination is usually done with the patient on her back or in the left lateral position (best for detecting prolapse). Sims \200\231 speculum has 2 right-angle b ends, and is used for inspecting the vaginal walls, eg for prolapse and incontinence. Cusco \200\231s (bivalve) speculum is used for inspecting the cervix with the aid of a light. Wa rm under the tap (unless it \200\231s plastic). Lubricate with jelly. Insert closed, with b lades parallel to the labia, usually up to the hilt. When it is in, rotate it and open it a nd usually the cervix pops into view. If it does not, do a bimanual to check the position o f the cervix, and try again. Do swabs (p284) and a cervical smear (p270) if needed. Close t he speculum gradually, under direct vision, as you withdraw it, to avoid trapping the cervi x. 1 The \201 rst telling awakes memories which color or transform the next telling, which i tself in \202 uences the next telling in an in \201 nite regression in which one telling becomes the audience for the next. 243 Sexual health Sexual health is the enjoyment of sexual activity of one \200\231s choice, wi thout causing or suff ering physical or mental harm.6 Of course there is more to sex than e njoyment. \200\230Perhaps the sexual life is the great test. If we can survive it with cha rity to those we love, and aff ection to those we have betrayed, we needn \200\231t worry s o much about the good and the bad in us. But jealousy, dis- trust, cruelty, revenge, recrim ination \200 then we fail. The wrong is in that fail- ure even if we are the victims and n ot the executioners. Virtue is no excuse \200 \200\231 Graham Greene, The Comedians Once o ne understands that human sexuality is in \201 nitely complex, it is easier to appreciate statistics such as \200\230sexual dysfunction is a big health problem, aff ecting 43% of w omen and 31% of men \200\231.7 Enemies of sexual health include: \200 Disharmony in perso nal relationships, or simply too many relationships. \200 Pain, or any medical or gynecol ogical condition. \200 Anxiety (whether or not related to fear of failure); depression; f atigue. \200 Drugs (eg tamoxifen; the Pill; cyproterone; antidepressants; narcotics). \200 A multiplicity of irreconcilable roles (if your patient is trying to achieve as- cend ancy in her work, as well as being chief shopper, cook, housewife, moth- er, and friend, th en the role of lover may be eclipsed \200\224all the more if she also \201 nds herself in the role of being chief person to blame if things go wrong \200\224if the fridge is empty, if the money runs out, if the children do not get to school on time, or if her partner los es his job). y g o o c e a n y G l Myths about sexual performance (eg that all physical contact must lead to sex, that sex equ als intercourse, and that sexual relations should come natu- rally and easily).8 Gynecological anatomy The vulva comprises the entrances to the vagina and urethra, the stru ctures which surround them (clitoris, labia minora, and fourchette), and the encir- cling l abia majora and perineum. The hymen, when broken (by tampons or in- tercourse) leaves tags at the mouth of the vagina (carunculae myrtiformes). Look for: Rashes; atrophy; ulcers; lum ps (p266 & p268); de \201 cient perineum (you can see the back wall of the vagina); incont inence. The vagina is a potential space with distensible folded muscular walls. The content s of the rectum, which runs behind the posterior wall, are palpable through the vagina. The cervix projects into the vault at the top which forms a moat around it, deepest posteriorl y, conventionally divided into anterior, pos- terior, and 2 lateral fornices. From puberty until the menopause lactobacilli in the vagina keep it acidic (pH 3.8 \200\2234.4), discour aging infection. Look for: In \202 ammation; discharge (p284); prolapse (p290). The cervix is mostly connective tissue. It feels \201 rm, and has a dent in the center (the opening , or os, of the cervical canal). Mucin-secreting glands of the endocervix lubricate the vag ina. The os is circular in nulliparous women, but is a slit in the parous. Look for: Pain o n moving the cervix (excitation \200\224p262 & p286); ectopy; cervi- citis and discharge; p olyps, carcinoma (p272). The uterus has a thick muscular-walled body lined internally with columnar epithelium (the endometrium) connected to the cervix or neck. It is supported by t he uterosacral ligaments. The peritoneum is draped over the uterus. The valley so formed be tween it and the rectum is the rectovaginal pouch (of Douglas), and the fold of peritoneum in which the Fallopian tubes lie is known as the broad ligament. The size of the uterus is by convention described by comparison with its size at diff erent stages of pregnancy. Sinc e that is vari- able, estimates are approximate, but the following is a guide: non-pregnant \200\224 plum-sized; 6 weeks \200\224egg; 8 weeks \200\224small orange; 10 weeks \200\224l arge orange; 14 weeks \200\224 \201 lls pelvis. 244 \200 y g o o c e a n y G l In most women the uterus is anteverted, ie its long axis is directed forward and the cervix points backwards. The body then \202 ops forwards on the cer- vix \200\224ante \202 exe d. An anteverted uterus can be palpated between the hands on bimanual examination (unless s he is obese, or tense, or the bladder is full). In 20% it is retroverted and retro \202 exed (p246). Look for: Position (important to know for practical procedures); mobility (es- pecially if retroverted); size; tenderness (p262 & p286). Adnexae These are the Fallopian tubes, ovarie s, and associated connective tissue (parametria). They are palpated bimanually in the later al fornices, and if normal may not be felt. The ovaries are the size of a large grape and m ay lie in the rectovaginal pouch. Look for: Masses (p280) and tenderness (p286). 245 y g o o c e a n y G l Fig 1. Gynecological anatomy. Genital abnormalities Vagina and uterus These are derived from the M llerian duct system a nd formed by fusion of the right and left parts. Diff erent degrees of failure to fuse lead to duplication of any or all parts of the system. Vaginal septae are quite common (and oft en missed on examination). Duplication of the cervix and/or uterus may also be missed, eg u ntil the woman becomes pregnant in the uterus without the IUCD! 246 A partially divided (bicornuate) uterus or a uterus where one side has failed to develop (u nicornuate) may present as recurrent miscarriage, particularly in the second trimester, or as diffi culties in labor. Such abnormalities are di- agnosed by hysterosalpingogram. An absent uterus or a rudimentary uterus with absent endometrium is rare. They present with primary amenorrhoea. An absent or short vagina is uncommon but can be corrected by plastic surgery. The membrane at the mouth of the vagina where the M llerian and urogenital systems fuse (the hymen) ma y be imperforate. There is apparent primary amenorrhoea, with a history of monthly abdomina l pain and swell- ing, and the membrane bulging under the pressure of dammed up menstrual b lood (haematocolpos). It is relieved by a cruciate incision in the membrane. NB: in some co mmunities, female \200\230circumcision \200\231 (p247) is still practiced, and this is ano ther cause of haematocolpos. \200\207Renal system abnormalities often coexist with genital ones, so IVU and ultra- sound should be performed. Ovary Thin, rudimentary \200\230streak \200\231 ovaries are found in Turner \200\231s syndrome (p655). Ovaries are absent in test icular feminization syndrome, but primitive testes are present (p134). Remnants of developm ental tissue (eg the Wolffi an system) may result in cysts around the ovary and in the broa d ligament. y g o o c e a n y G l Uterine retroversion About 20% of women normally have a retroverted retro \202 exed uterus which is fully mobile. It is diffi cult to palpate bimanually unless you can push it into anteversion by pressure on the cervix. It causes no problems except (rarely) if it fails to lift out of the pelvis at 12 weeks of pregnancy, presenting with discomfort and retention of urine, eg at 14 weeks; catheterization and lying prone may relieve it. In \202 ammation in the pelvis (due to infection or endometriosis) can cause adhesions whi ch tether the uterus in a retroverted position. The patient may present with dysmenorrhoea, dyspareunia, or subfertility \200\224problems which can only be relieved by treatment of t he underlying disease. 247 Female genital cutting/mutilation/circumcision Circumcision is a misnomer, as it implies a parallel with male circumcision, which is incorrect. Another term is female genital cutting /mutilation (aff ected women prefer the term genital cutting). 140 million women are believ ed to be aff ected (2 million/year). The female \200\230operation \200\231 is carried out later (at 5 \200\2237yrs) and may be much more damaging and extensive, eg as practiced in S omalia. In the UK most aff ected women come from Somalia, Kenya, Eritrea, Ethiopia and the Yemen. It is common in Mali, Guinea and Egypt. Procedures include clitoridectomy infundi bulation (removal of the clitoris, labia minora and labia majora, with oversewing or apposi tion by thorns). Even the milder Sunna entails removal of part of the clitoris, and more ma y be removed than intended. At betrothal, an attendant cuts the scar tissue to allow interc ourse. Long-term problems include very slow urination, urinary tract infections, haematocol pos, dyspareunia or non-consummation, obstructed labor, in- creased susceptibility to HIV a nd other blood-borne diseases as well as emo- tional trauma. Social expectations are changi ng in countries that practice \200\230cutting \200\231 but parents believe the social harm of not cutting is greater than the physical, psychological and legal risk of \200\230cutt ing \200\231.10 De \201 bulation may be performed before marriage; ideally electively at 2 0 weeks \200\231 gestation, or in the 1st stage of labor. If not corrected antenatally de- liver in a unit with emergency obstetric care, having planned labor after ex- pert advice. If vaginal examination is poorly tolerated, or anterior episiotomy anticipated, off er epid ural. Only extreme anatomical distortion making de- \201 bulation impossible is an indica tion for cesarean section (but note that NICE guidelines 2011 allow for more patient choice ).11 Repair post-delivery should appose raw edges and control bleeding but must not result in a vaginal open- ing making intercourse diffi cult or impossible.12 In 2003 \200\2235 fem al genital cut- ting aff ected 1.4% of UK maternities and was implicated in 4 maternal deat hs.9 Labial cosmetic surgery is becoming more common in affl uent countries and is comparab le with more minor types of cutting, thereby posing ethical con- cerns.13 y g o o c e a n y G l Normal menstruation Puberty is the development of adult sexual characteristics. The sequenc e: breast buds \200\203growth of pubic hair \200\203axillary hair \200\203menses begin (men arche) from 10yrs onwards (mean 13yrs and falling \200\224earlier if low birth weight; Af rican; short & overweight in childhood; urban environment; various fascinat- ing pheromone- related family events mediating anti-inbreeding strategies).1 14 Investigate if no periods by 15yrs 15 (p250) or no signs of puberty by 14. A growth spurt (p184) is the 1st change i n puberty and is usually completed 2yrs after menarche when the epiphyses fuse. The menstru al cycle ( \201 g 1). The cycle is controlled by the \200\230hypothalamic \200\223pi- tui tary \200\223ovarian (HPO) axis \200\231. Pulsatile production of gonadotrophin-releasing h ormones by the hypothalamus stimulates the pituitary to produce the gon- adotrophins: folli cle-stimulating hormone (FSH) and luteinizing hormone (LH). These stimulate the ovary to pr oduce estrogen and progesterone. The ovar- ian hormones modulate the production of gonadotr ophins by feeding back on the hypothalamus and pituitary. 248 \200 Day 1 of the cycle is the \201 rst day of menstruation. Cycle lengths vary greatly (eg 20 \200\22345 days in adolescence); only 12% are 28 days. Cycles soon after me- narche and be fore the menopause are most likely to be irregular and ano- vulatory. In the \201 rst 4 d ays of the cycle, FSH levels are high, stimulating the development of a primary follicle in the ovary. The follicle produces estrogen, which stimulates the development of a glandular \200\230proliferative \200\231 endometrium and of cervical mucus which is receptive to sp erm. The mucus becomes clear and stringy (like raw egg white) and if allowed to dry on a sl ide produces \200\230ferning patterns \200\231 due to its high salt content. Estrogen also controls FSH and LH output by positive and negative feedback. y g o o c e a n y G l 14 days before the onset of menstruation (on the 16th day of the cycle of a 30-day cycle) t he estrogen level becomes high enough to stimulate a surge of LH. This stimulates ovulation . Having released the ovum, the primary follicle then forms a corpus luteum and starts to p roduce progesterone. Under this in \202 uence, the endometrial lining is prepared for impl antation: glands become convoluted ( \200\230secretory phase \200\231). The cervical mucus becomes viscid and hostile to sperm and no longer ferns. If the ovum is not fertilized the corpus luteum breaks down, so hormone levels fall. This causes the spiral arteries in the u ter- ine endothelial lining to constrict and the lining sloughs \200\224hence menstruation. Menstruation is the loss of blood and uterine epithelial slough; it lasts 2 \200\2237 days and is usually heaviest at the beginning. Normal loss is 20 \200\22380mL (median 28mL). Cl imacteric The ovaries fail to develop follicles. Without hormonal feedback from the ovary, gonadotrophin levels rise. Periods cease (menopause), usually at 50 years of age (p256). P ostponing menstruation (eg on holiday) Try norethisterone 5mg/8h PO from 3 days before the period is due until bleeding is acceptable, or take 2 packets of combined contraceptive Pil ls without a break. 1 The socioendocrinology of family life: Presence in the household of the biological father delays sexual maturation \200\224as does having a sister at home (esp. an elder sister). B rothers have no in \202 uence, but half- or step-brothers at home are associated with an e arlier menarche. In addition, stressful life events such as immigration for adoption is ass ociated with early menarche (risk of precocious puberty \200\200 \211\21020, p184). 249 y g o o c e a n y G l Fig 1. The menstrual cycle.