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In pregnancy virus 0 access buy 500 mg azimycin fast delivery, however, adenomatous hyperplasia may occur, and decidual changes are seen in 10% of the patients. Lately, an increased incidence of endocervical carcinoma has been observed in young women who have been on hormonal contraception use. Key Points n Process of Fertilization Certain changes are necessary before the primary oocyte can mature for fertilization. Oogonia that enter the prophase of the first meiotic division are known as primary oocytes. Whereas those oogonia which do not begin the first meiotic division and those not surrounded by granulosa layer undergo atrophy. This secondary oocyte completes its second meiotic division only after fertilization, and gives out second polar body. Thus, the first stage of maturation of the oocyte occurs within the Graafian follicle, but the second division occurs only after the fertilization in the fallopian tube. Tubular compartment is divided into 250­300 lobules, each lobule containing 1­3 convoluted seminiferous tubules. Further meiotic division results in secondary spermatocytes, spermatids and a mature sperm. The seminiferous tubule is surrounded by myofibroblasts which contract and propel the sperms into rete testis. These are reduced to about 400,000 at puberty and of these around 400 are available during the reproductive lifespan. Cyclic changes in the Graafian follicle-leading to ovulation, corpus luteum formation and menstruation- are under the control of the hypothalamus, which controls the release of gonadotropins from the anterior pituitary. Progesterone is responsible for secretory transformation of the endometrium rendering it favourable for implantation of the fertilized ovum. In present-day practice, serial ultrasound monitoring of the Graafian follicle is used to detect ovulation in patients undergoing treatment for infertility. Endometrial histology is required to diagnose endometrial tuberculosis, endometrial cancer and hormonal dysfunction. Describe the microscopic appearance of the endometrium during the proliferative phase. It is now well established that a normal menstrual cycle depends on cyclical ovarian steroid secretions, which in turn are controlled by the pituitary and the hypothalamus and, to some extent, are influenced by the thyroid and adrenal glands. It is therefore essential to understand the hypothalamus­pituitary­ovarian axis in normal women (H­P­O) and apply this knowledge in therapeutic management in infertility, family planning and various gynaecological disorders. Hypothalamus Hypothalamus with its several nuclei and extrinsic connections is now considered the main neuroendocrine gland and the regulatory factor in the chain of hypothalamic­ pituitary­ovarian­uterine axis. These hormones in turn are controlled by positive and negative feedback loops from ovarian hormones. Hypothalamus is located at the base of the brain behind optic chiasma and below the thalamus above the pituitary and forms the base of the third ventricle. The base of the hypothalamus forms tuber cinereum, which merges to form the pituitary stalk. The origin of this stalk is known as median eminence, which is rich in capillary loops as well as nerve endings. Median eminence is an important site of storage of chemical signals, which get transferred into portal circulation to reach the anterior pituitary gland. During late pregnancy and lactation, a low or absent inhibitory factor leads to a high secretion of prolactin that initiates and maintains lactation. Hypothalamus is also responsible for secretion of thyrotropin releasing factor, corticotropin releasing factor, insulinlike growth factor and melanocyte releasing factor. It is released in a pulsatile manner into the portal vessels and reaches the anterior pituitary gland. The pulsatility and amplitude of its release vary with the various phases of the menstrual cycle. Its suppressive effect on ovulation is also being tried as a contraceptive, but the drug has proved expensive as of today. Hypothalamus can be influenced by the higher cortical centres, especially the temporal lobe. Emotional upsets are known to stimulate or depress the H­P­O axis and disturb the menstrual cycles.

The uterine aspiration syringe or brush is found to be satisfactory for obtaining adequate samples bacteria unicellular or multicellular buy azimycin us. It can be utilized as an office procedure; about 90% accuracy with no falsepositive findings is claimed with this procedure. Colposcopy the colposcope is a binocular microscope giving a 10­20 times magnification. It is useful in locating abnormal areas and accurately obtaining directed biopsy from the suspicious areas on the cervix in women with positive Pap smears. A fine curette is introduced into the uterine cavity to obtain a small strip of the endometrial lining for histopathological examination. With the availability of ultrasonic noninvasive method for detection of ovulation, this procedure is now generally not employed. The scan can collaborate the clinical impression or uncover a hitherto unsuspected pathology. D3 ultrasound is now capable of providing three-dimensional images of the pelvic organs. Ultrasound is also used in certain therapeutic procedures such as in vitro fertilization and aspiration of a cyst or pelvic abscess. Other Imaging Modalities Radiological investigation such as hysterosalpingography is utilized for studying the patency of the fallopian tubes in an infertile patient. Sonosalpingography is employed in women with infertility and when uterine polyp is suspected. Gynaecological Endoscopy Both diagnostic laparoscopy and hysteroscopy are established useful tools in the armamentarium of the gynaecologist. The pelvis and the lower abdomen are scanned in both the longitudinal and transverse planes. In most cases, a transvaginal probe can be usefully employed Pelvic abscess Ectopic pregnancy in haematocele To detect malignancy in ascites with ovarian cyst the only therapeutic purpose is to drain the pus in pelvic abscess. The woman is placed in the lithotomy position and the posterior lip of the cervix drawn downwards and forwards with the vulsellum forceps while the speculum retracts back the posterior vaginal wall. After disinfecting the area, Chapter 6 · Gynaecological Diagnosis a long needle attached to an aspiration syringe is inserted into the pouch of Douglas, and aspiration done. The examination is best done in the operation theatre under full aseptic precaution with all readiness to proceed to laparoscopy or laparotomy if indicated. Outline details of documentation of physical examination observations in practice. What is the role of endoscopy and ultrasonography in the clinical practice of gynaecology? Pregnancy Test the first morning sample of urine is used in rapid immunological test to confirm pregnancy, by detecting the presence of human chorionic hormone. The pregnancy test becomes positive by the beginning of sixth week, from the last menstrual period. A wide range of investigations are now available with the gynaecologists which finally confirm the diagnosis, detect the extent of the disease and help in planning the management. Hormonal assays are necessary in in vitro fertilization and various hormonal disturbances. Although attempts at endoscopy date back to over a hundred years, the potential of this method as diagnostic and therapeutic tools was appreciated and came to the forefront only in the last three decades. When used appropriately, endoscopic surgery offers the advantages of a more accurate diagnosis, less invasiveness, reduced pain, faster recovery and shortened hospital stay or a day care. Advances in instrumentation and techniques now enable the endoscopist to accomplish several operative procedures hitherto performed only by open surgery, including cancer surgery. Advantages of laparoscopy: (a) lesser pain, (b) few analgesics, (c) short hospital stay, (d) quick return to daily work, (e) no scar-no scar hernia, (f) good cosmetic and (g) less pelvic adhesions. Disadvantages: (a) Longer procedure, more anaesthesia, expensive, expertise required. Laparoscopy Laparoscopy was developed by the 1970s, and operative laparoscopy has started gaining ground in the last two decades.

The hormonal suppression of spermatogenesis causes loss of libido and is toxic in high doses virus vs worm discount 250 mg azimycin with amex. Immunological methods of suppressing spermatogenesis have not yet been successful. Since 1956, when Pincus first brought out an oral contraceptive drug, more than 30 millions of women have used this method in one form or the other. A wide variety of hormonal preparations are now available for contraceptive use alone. The mode of action depends upon the hormone used, the mode of delivery and the time of administration. The tablets are taken starting on the second day of the cycle for 21 days (now started on 1st day). A new course of tablets should be commenced 7 days after the cessation of the previous course. At the same time, progestogen causes atrophic changes in the endometrium and prevents nidation. Progestogen also acts on the cervical mucus making it thick and tenacious and impenetrable by sperms. It also increases the tubal motility, so the fertilized egg reaches the uterine cavity before the endometrium is receptive for implantation. During the first cycle of use, ovulation may not be suppressed and the patient is advised to use an additional method to prevent pregnancy. Lately, starting the pill on the first day of the cycle has reduced the failure rate and the need to take the additional precaution in the first cycle. If she forgets to take the tablet more than once in a cycle, she is no longer adequately protected and must use a barrier method during that cycle. The majority of failures with oral combined pills are due to the failure to take the pills regularly. The bleeding is less in amount and shorter in duration than a normal menstrual period. As it causes regular and scanty menstruation, it is useful in menorrhagia and polymenorrhoea. It has proved to lower the incidence of benign breast neoplasia such as fibrocystic disease. It reduces the incidence of functional ovarian cyst (50%) and ovarian and uterine malignancy. The incidence of ovarian cancer is reduced by 40% and uterine malignancy by 50% if taken for 1 year, and this effect lasts as long as 10 years after stoppage. This effect is due to the thick cervical mucus caused by progestogen, preventing the organisms entering into the uterine cavity. Menstrual bleeding can become very scanty and occasionally a woman becomes amenorrhoeic causing undue fear of pregnancy. Those with previous menstrual irregularity (oligomenorrhoea) are likely to suffer amenorrhoea. Carcinoma of the endocervix has been reported if used for more than 5 years but dysplasia is more frequent. No adverse effect is noted on uterine fibroids, and it is oestrogen singly that increases their size. The combined pills should not be offered to a woman suffering from cancer of the breast. Some have reported the breast cancer in a nulliparous woman (25%) who has taken oral contraceptive pills before the age of 24 years for over a period of 4 years. This should be considered while prescribing oral pills to a young nulliparous woman. However, if breast cancer develops, it is well differentiated with good prognosis. Pituitary adenoma was attributed to the use of the pill but its exact role in its development is not clear and doubtful.

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