Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2572_Библиотеки_им_академика_М_И_Перельмана
.pdf
244 • THE REPRODUCTIVE SYSTEM
https://t.me/med1917
ABC
Fig. 11.10 Clinical examination of the breast. Examine each quadrant of the breast systematically, from the outside towards the nipple, including under the nipple.
• Palpate the regional lymph nodes. The axilla and supra-
clavicular fossa are best examined with the patient in a sitting
position.
• Support the full weight of the patient’s arm at the wrist
with your ipsilateral arm, place your contralateral hand
high into the axilla and move it upwards over the chest to
the apex. Compress the contents of the axilla against the
chest wall. Define the characteristics of any mass (see
Box 3.8 in the 14th edition).
• Palpate the neck for the supraclavicular lymph nodes from
behind (see Chapter 9).
Fig. 11.11 Malignancy in the upper outer quadrant of left breast: painless,
solid, irregular mass, fixed to the overlying skin.
11.2 Summary of examination findings in commonly
presented breast conditions
Commonly
Conditions Examination findings
Fibroadenoma
Breast cyst
Lactational
mastitis
Nonlactational
mastitis
Malignancy
• Extremely mobile, discrete,
rubbery lump
• Solitary or multiples in one or
both breasts
• Firm, discrete, smooth lump
• Solitary or in clusters
• Pain, localised erythema and
swollen breast
• Usually a history of cracked nipple
• Peri-areolar infection: peri-areolar
erythema and a mass or abscess
• Peri-areolar fistula
• Painless, solid, irregular mass,
which can be fixed to
surrounding tissues, leading to
other skin and nipple changes
(see Fig. 11.11)
affect
• Young
women
<35 years
• Perimeno-
pausal women
• Breastfeeding
women
• Young female
smokers
• Women
>50 years
Investigations
Any breast abnormality, especially a breast lump, should be
assessed by triple assessment: a combination of clinical, radiological and pathological examination.
Radiological examination options include mammography
(Fig. 11.12) and ultrasonography (Fig. 11.13). Digital breast
tomosynthesis (Fig.11.14) is sometimes used as an adjunct to
standard mammography. Mammography is offered to women
aged 40 or over, often in conjunction with ultrasonography, to
detect malignancy. For women under 40, ultrasound is often the
only imaging required. High breast density in younger women
decreases the sensitivity of mammography for the detection of
cancer. However, if there is a strong clinical and ultrasonographic
suspicion of malignancy, then mammography is performed.
Digital breast tomosynthesis increases cancer detection by
increasing visibility between overlapped dense breast tissue.
Breast MRI is the most sensitive technique for the detection of
breast cancer; in selected cases, it can be used to evaluate the
extent of cancer and for screening. It is also useful in assessing
breast implant integrity.
The pathological examination involves a biopsy (Box 11.3).
Image-guided biopsy improves diagnostic accuracy.
Anatomy and physiology • 245
https://t.me/med1917
X-ray
tube
Fig. 11.12 Digital mammogram. A spiculate opacity characteristic of a
cancer (arrow).
Fig. 11.13 Ultrasound of a breast cyst. A characteristic smooth-walled,
hypoechoic lesion (arrow).
Digital detector
Fig. 11.14 Digital breast tomosynthesis. The x-ray tube moves along an
acquisition angle obtaining projectional images (slices) of the compressed
breast. These stacked images are then reconstructed to create threedimensional images of the breast.
11.3 Fine-needle aspiration vs core biopsy
Fine-needle aspiration Core biopsy
Material
examined
Indications Aspiration of cysts
Advantages
and
disadvantages
Cells Tissue
Lymph node assessment
Sampling an area where
core biopsy is technically
not possible
Unable to distinguish
between non-invasive and
invasive cancer
Molecular markers difficult
to obtain
Breast lump assessment
Lymph node assessment
Can differentiate
between non-invasive
and invasive cancer
Enables tumour grade
and molecular markers
assessment
11
FEMALE REPRODUCTIVE SYSTEM
Anatomy and physiology
The female reproductive organs are situated within the bony pelvis
(Fig. 11.15). They cannot normally be felt on abdominal palpation.
A vaginal examination is required for their routine assessment.
The vulva (Fig. 11.16) consists of fat pads, called labia majora,
covered with hair. The labia minora are hairless skin flaps at each
side of the vulval vestibule, which contains the urethral opening
and the vaginal orifice. The clitoris is situated anteriorly where the
labia minora meet and is usually obscured by the prepuce. Posteriorly the labia meet at the fourchette, and the perineum is the
fibromuscular region posteriorly that separates it from the anus.
The vagina is a rugged tube 10–15 cm in length. There is an
irregular mucosal ring two centimetres into the vagina that represents the remnants of the hymen (see Fig. 11.16). Bulging into
the top of the vagina is the grape-sized fibrous uterine cervix,
r
246 • THE REPRODUCTIVE SYSTEM
https://t.me/med1917
Ovary
Uterus
Bladder
Fig. 11.15 Pelvis and pelvic organs.
Mons pubis
Frenulum of clitoris
Labium majus
Labium minus
Clitoris
Vestibule
Vestibule
Fourchette
Sacrum
Iliac
crest
Fallopian tube
Symphysis pubis
Posterior fornix
Anterior fornix
Lateral
fornix
Rectum
Cervix pouts into
apex of vagina
Bladde
Vagina
Fig. 11.18 Sagittal and coronal sections of the uterus. The vaginal
fornices are shown.
Pubic hair
Prepuce
External urethral orifice
(meatus)
Vaginal orifice
Hymen
Posterior commissure
Anus
Fig. 11.16 External female genitalia.
Suspensory
ligament
of ovary
cavity
Uterine body
Cervical canal
Vagina
Fig. 11.17 Section through the pear-shaped, muscular uterus. The
cervix, uterine body (corpus), fundus and Fallopian tubes, with the ligamentous
attachments of the ovary. The uterine mucosa is the endometrium. The
cervical canal has an internal and an external os.
with the external cervical os on its surface (Fig. 11.17). The
fornices are the areas of the top of the vagina next to the cervix
(Fig. 11.18).
Perineum
FundusUterine
Internal os
External cervical os
Fallopian
tube
Ampulla
Ovarian
ligament
Endometrium
Myometrium
Broad
ligament
The uterus is a muscular pear-shaped structure, about the size
of a large plum, situated in the midline and usually tilted anteriorly
over the bladder (Fig. 11.19). Its internal cavity is lined by
endometrium that proliferates, secretes and breaks down during
the menstrual cycle. The Fallopian tubes run laterally from the
uterine fundus towards the ovaries (see Fig. 11.17). Their distal
finger-like fimbriae collect the oocyte after ovulation.
The ovaries are about the size of a walnut and sit behind and
above the uterus close to the pelvic sidewall. At mid-cycle, one
ovary will have developed a fluid-filled preovulatory follicle
measuring around 2 cm in diameter. The female reproductive
tract is in close proximity to the bladder, ureter and lower
gastrointestinal tract (see Fig. 11.19).
The history
Identify the patient’s main symptoms, how these developed,
their day-to-day impact, how they cope and their ideas, concerns and expectations of the encounter. Document any previous investigations and management. Check the history, even
if an asymptomatic patient has come for a routine cervical
smear.
Sacral
https://t.me/med1917
promontory
The history • 247
Fig. 11.19 Lateral view of the female internal genitalia. The relationship to the rectum and bladder.
Take a gynaecological history by asking about:
• (in pre- or perimenopausal patients) last menstrual period
(LMP) and whether it was normal; always consider that these
patients might be pregnant
• past and present contraceptive use
• plans for fertility
• previous cervical smears, when taken, and any treatment
required for abnormalities
• prior abdominal surgery, pelvic infection or sexually transmitted disease
• prior pregnancies and their outcomes
• current or previous hormone replacement therapy
• other medication with potential gynaecological effects (see later).
Common presenting symptom s
Abnormal vaginal bleeding
If patients present with heavy periods, ask about:
• flooding: whether menstrual blood soaks through protection,
increased requirements for sanitary protection
• passing of blood clots.
Menstruation normally occurs monthly from the menarche
(average age 12) until the menopause (average age 51). Menstrual
bleeding for 3–6 days normally occurs every 22–35 days (average
28). A menstrual cycle with bleeding for 4–5daysevery25–29 days
is recorded as 4–5/25–29. Heavy menstrual bleeding (HMB, previously called menorrhagia) affects 20% of menstruating patients
over 35 and is defined as >80 mL blood loss during a period
(average 35 mL). As this is not quantified in routine practice, HMB is
subjective. Anaemia implies heavy bleeding.
Unexpected bleeding suggests endometrial or cervical pathology. Ask when the bleeding occurs:
• between periods (intermenstrual bleeding, IMB)
• after intercourse (postcoital, PCB)
Sacro uterine
ligament
Pouch of Douglas
Cervix
Fornix of vagina
Levator ani muscle
External
anal sphincter
Anus
Ureter
Fallopian tube
Ovarian ligament
Fundus of uterus
Body of uterus
Bladder
Vagina
Symphysis pubis
Urethra
Clitoris
Labium minus
Labium majus
• more than 1 year after menopause (postmenopausal
bleeding, PMB).
Approximately 4% of postmenopausal patients experience
bleeding, which must be investigated as 10% have endometrial
cancer.
Lack of periods (amenorrhoea) in the absence of pregnancy
implies ovarian dysfunction and affects 5–7% of females in their
reproductive years. Distinguish between:
• Primary amenorrhoea: periods have not started by age 16.
Both ovarian function and the structure of the reproductive
tract should be investigated.
• Secondary amenorrhoea: there have been no periods
for 6 months, but there was previous menstruation.
• Oligomenorrhoea: the menstrual cycle is longer than 35 days.
Thirty percent of patients experience vaginal bleeding in early
pregnancy. Establish if this is associated with lower abdominal
pain. Although the pregnancy may continue normally, bleeding is
associated with miscarriage and ectopic pregnancy. Further
investigation is required, particularly if the bleeding is associated
with lower abdominal pain.
Lower abdominal pain
Lower abdominal pain may arise from the reproductive organs or
the urinary or gastrointestinal tract or be musculoskeletal or
neurological in origin (p. 108). Psychological and social factors
may also contribute to the experience of pain.
To differentiate between the possible causes of lower
abdominal pain, ask about:
• site of the pain (unilateral, bilateral or midline)
• onset (sudden or gradual, cyclical/related to menstruation or
not).
Ovarian pain is often unilateral and can be physiological (Mit-
telschmertz is discomfort associated with ovulation). Ovarian cyst
accidents involving torsion (twisting on the vascular pedicle
11
248 • THE REPRODUCTIVE SYSTEM
https://t.me/med1917
causing acute ischaemia), haemorrhage or rupture can lead to
acute severe pain.
Primary dysmenorrhoea is pain arising from intense uterine
contractions just before and during peak menstruation. Secondary or progressive dysmenorrhoea, due to underlying pathology such as endometriosis or chronic infection, often
manifests as pain that lasts beyond the normal menstrual cycle.
Infection, pelvic adhesions and endometriosis can cause
generalised pain (Box 11.4).
Dyspareunia is pain during intercourse. Ask if it is felt around
the vaginal entrance (superficial) or within the pelvis (deep). Pain
due to an involuntary spasm of muscles at the vaginal entrance
(vaginismus) may make intercourse impossible. Persistent deep
dyspareunia suggests underlying pelvic pathology. Dyspareunia
can be due to vaginal dryness following menopause.
Iliac fossa pain in early pregnancy is commonly associated
with a corpus luteum cyst of the ovary but may indicate a tubal
ectopic pregnancy. Ruptured ectopic pregnancy results in
generalised abdominal pain, peritonism, haemodynamic instability and referred pain in the shoulder.
Abdominal distension and bloating
Pelvic masses can cause non-specific symptoms like abdominal
distension, bloating or urinary frequency due to pressure on the
bladder. They may also be asymptomatic and picked up during
routine abdominal or vaginal examination. Uterine masses
include pregnancy and benign leiomyoma tumours (fibroids).
Large ovarian cysts can also be midline, and malignant ovarian
cysts are associated with ascites.
Vaginal discharge
Discharge may be normal and variable during the menstrual
cycle. Prior to ovulation, it is clear, abundant and stretches like
egg white; after ovulation, it is thicker, does not stretch and is
less abundant. Abnormal vaginal discharge occurs with infection.
Ask about:
• consistency
• colour
• odour
• associated itch, pain or dysuria.
The most common non-sexually transmitted infection (caused
by Candida species) gives a thick, white, curdy discharge often
associated with marked vulval itching. Bacterial vaginosis is a
common, non-sexually acquired infection caused by multiple
bacteria, particularly Gardnerella vaginalis, producing a watery,
fishy-smelling discharge. The pH of normal vaginal secretions is
usually <4.5, but in bacterial vaginosis, it is >5. Sexually transmitted infections (STIs) can cause discharge, vulval ulceration or
pain, dysuria, lower abdominal pain and general malaise. They
may also be asymptomatic.
Urinary incontinence
Inappropriate and involuntary voiding of urine is severe in 10% of
cases, and its prevalence increases with age.
Stress incontinence occurs on exertion, coughing, laughing or
sneezing and is associated with pelvic floor weakness.
Urge incontinence is an overwhelming desire to urinate when
the bladder is not full due to detrusor muscle dysfunction.
Prolapse
In 30% of patients, the pelvic contents bulge into the vagina
(Fig. 11.20). They feel something ‘coming down’, particularly
when standing or straining. Uterine prolapse is associated with
previous childbirth and is classified as:
• Grade 1: halfway to the hymen.
• Grade 2: at the hymen.
• Grade 3: beyond the hymen.
• Grade 4 (procidentia): external to the vagina (Fig. 11.21).
11.4 Characteristics of pelvic pain
Site Midline Left or right iliac fossa Generalised lower abdomen; more on one
Onset Builds up before period Sudden, intermittent Builds up, acute on chronic Builds up, sudden
Character Cramping Gripping Shooting, gripping Shooting, cramping
Radiation Lower back and upper
Associated
symptoms
Timing With menstruation May be cyclical Acute, may be cyclical Builds up during
Exacerbating
factors
Severity Variable in spasms Intense Intense in waves Variable
Uterine pain Ovarian pain Adhesions or pelvic infection Endometriosis
side
thighs
Bleeding from vagina Known cyst, pregnancy, irregular
– Positional Movement, examination Intercourse, cyclical
Groin; if free fluid, to shoulder ––
Discharge, fever, past surgery Infertility
cycle
Variable
period
The physical examination • 249
https://t.me/med1917
11.5 Taking a sexual history
Fig. 11.20 Anterior vaginal wall prolapse.
Cystocoele
• Are you currently in a sexual relationship?
• How long have you been with your partner?
• Have you had any (other) sexual partners in the last 12 months?
• How many were male? How many were female?
• When did you last have sex with:
• Your partner?
• Anyone else?
• Do you use barrier contraception–sometimes, always or never?
• Have you ever had a sexually transmitted infection?
• Are you concerned about any sexual issues?
example, obesity is associated with an increased risk of gynaecological malignancy.
11
Sexual history
Sometimes a sexual history is required, but people often find it
difficult to talk about sexual matters. It is important for you to be
at ease and ask questions in a straightforward manner. Explain
why you need to enquire, use clear, unambiguous questions
(Box 11.5) and be non-judgemental. The sexual partners of patients with STIs should be informed and treated to prevent further
transmission and reinfection of the treated person. Confidentiality
is paramount, so do not give information to a third party. Do not
perform a pelvic examination on someone who has not been
sexually active.
Fig. 11.21 External prolapse of the uterus.
The top of the vagina (vault) can also prolapse after a previous
hysterectomy. More commonly, the bulge relates to the vaginal wall.
A cystocoele is a bulge on the anterior wall containing the bladder
(see Fig. 11.20), and a rectocoele is a bulge on the posterior wall
containing the rectum. An enterocoele is a bulge of the distal wall
posteriorly containing the small bowel and peritoneum.
Drug history
Tamoxifen has oestrogenic effects in postmenopausal patients,
antibiotics can cause vaginal candidiasis, antipsychotic drugs can
cause hyperprolactinaemia, and antiepileptic or antituberculous
drugs may reduce the effectiveness of oral contraceptives.
Family and social history
Family and social history, including smoking status and lifestyle,
may also have an impact on gynaecological conditions. For
The physical examination
A vaginal examination is required to perform a routine cervical
smear. Otherwise, the focus of gynaecological examination is to
detect abnormalities that could explain the symptoms or alter
treatment options (e.g. body mass index (BMI) and blood pressure assessment affect the use of the contraceptive pill). Signs of
gynaecological disease are not limited to the pelvis, and a general, as well as a pelvic, examination is required (Box 11.6). You
should offer a chaperone and record this in the records. The
examination area should be private, with appropriate equipment
and an adjustable light source available. The patient should have
an empty bladder and remove their clothing from the waist
down, along with any sanitary protection. Give them privacy to
do this.
Passing a speculum
Explain what you are going to do and why it is necessary, and
obtain verbal consent. Use a vaginal speculum to see the cervix
and the vaginal walls, carry out a cervical smear and take swabs
if required. Specula are metal or plastic and come in various sizes
and lengths. Metal specula may be sterilised and reused; plastic
specula are always disposable. A metal speculum is cold, so
250 • THE REPRODUCTIVE SYSTEM
https://t.me/med1917
11.6 Focus of the gynaecological examination
Clinical feature General examination Pelvic examination
Abnormal bleeding Anaemia
Underweight (hypogonadotrophic hypogonadism)
Galactorrhoea, visual field defects (hyperprolactinaemia)
Hirsutism, obesity, acanthosis nigricans (PCOS)
Pain Abdominal tenderness Uterine excitation (acute infection or peritonism)
Vaginal discharge Rash (associated with some STIs) Clear from cervix (chlamydia)
Urinary incontinence Obesity, chronic respiratory signs (stress incontinence)
Neurological signs (urge incontinence)
Abdominal distension or bloating Ascites, weight loss, lymphadenopathy, hepatomegaly (malignancy)
Pleural effusion (some malignant or benign ovarian cysts)
PCOS, Polycystic ovary syndrome; PMB, postmenopausal bleeding; STI, sexually transmitted infection.
warm it under the hot tap. Most patients find a speculum examination mildly uncomfortable, so always use a small amount of
lubricating gel on the tip of each blade. Clean your hands and put
on medical gloves. Ask the patient to lie on their back on the
couch, covered with a modesty sheet to the waist, with their
knees bent and apart (Fig. 11.22).
Enlarged uterus (fibroids, pregnancy)
Abnormal cervix
Open cervical os (miscarriage)
Vaginal atrophy (most common cause of PMB)
Fixed uterus (adhesions or endometriosis)
Adnexal mass (ovarian cyst)
Purulent from cervix (gonorrhoea)
Frothy with strawberry cervix (trichomoniasis)
Demonstrable stress incontinence
Uterine or vaginal wall prolapse
Pelvic mass (uterine, ovarian or indiscriminate)
Fixed uterus and adnexae
Abnormal vulva (skin disease or malignancy)
Examination sequence (Videos 22
and 22A)
• Look at the perineum for any deficiency associated with
childbirth; note abnormal hair distribution and clitoromegaly
(associated with hyperandrogenism). Note any skin abnormalities, discharge or swellings of the vulva, such as the
Bartholin’s glands on each side of the fourchette (Fig. 11.23).
• Ask the patient to cough while you look for any prolapse or
incontinence.
• Gently part the labia using your left hand (Fig. 11.24). With
your right hand, gently insert a lightly lubricated bivalve
speculum (Figs 11.25–11.26A), with the blades vertical, fully
into the vagina, rotating the speculum through 90 degrees so
that the handles point anteriorly and the blades are now
horizontal (see Fig. 11.26B). Someone who has been pregnant may need a larger or longer speculum or a bolster under
the sacrum if the cervix is very posterior. If they find the examination difficult, ask them to try to insert the speculum
themself.
• Slowly open the blades and see the cervix between them. If
you cannot see it, reinsert the speculum at a more downward
angle, as the cervix may be behind the posterior blade. Note
any discharge or vaginal or cervical abnormalities.
• Open the blades a little during the initial removal of the
speculum to avoid catching and pulling on the cervix.
Fig. 11.22 Position for pelvic examination.
To assess prolapse (Video 22B)
• Ask the patient to lie on their left side and bring their knees up
to their chest.
• Use a univalve Sims speculum, placing a small amount of
lubricating jelly on the blade.
The physical examination • 251
https://t.me/med1917
Fig. 11.23 Bartholin’s abscess.
Fig. 11.24 Inspection of the vulva.
A
11
B
Fig. 11.26 Bivalve speculum examination. A Insertion of the speculum.
B Visualisation of the cervix after rotation through 90 degrees.
Fig. 11.25 Bivalve speculum.
• Insert the blade to hold back the posterior wall.
• Ask them to cough while you look for uterine descent and the
bulge of a cystocoele (Fig. 11.27).
• Repeat, using the speculum to hold back the anterior vaginal
wall to see a rectocoele or enterocoele.
Taking a cervical smear
There are two ways of taking a smear:
• using liquid-based cytology
• using a microscope slide.
252 • THE REPRODUCTIVE SYSTEM
https://t.me/med1917
Fig. 11.27 Examination in the left lateral position using a Sims
speculum.
Liquid-based cytology is increasingly common, as it allows for
efficient processing and gives fewer inadequate smears. Many
screening services now test these for human papilloma virus
(HPV) rather than performing routine cytology.
Examination sequence (Video 22C)
• Always label the cytological medium or slide and ask the
questions required to fill in the request form before starting
the examination to avoid mixing specimens.
• Clearly visualise the entire cervix.
Liquid-based cytology
• Insert the centre of the plastic broom into the cervical os.
• Rotate the broom 5 times through 360 degrees (Fig. 11.28A).
• Push the broom 10 times against the bottom of the specimen
container.
• Twirl 5 times through 360 degrees to dislodge the sample.
• Firmly close the lid.
Conventional smear
• Insert the longer blade of the spatula into the cervical os.
• Rotate the spatula through 360 degrees (see Fig. 11.28B).
• Spread once across the glass slide.
• Place the slide immediately into fixative (methylated spirits) for
3–4 minutes.
• Remove it and leave it to dry in the air.
Cytology
specimen jar
A
Name
Date of birth
B
Glass slide
Fig. 11.28 Taking a cervical smear. A Liquid-based cytology. B Using
a spatula.
Bimanual examination
Examination sequence (Video 22D)
• Apply gloves and lubricate your right index and middle finger
with gel.
• Gently insert them into the vagina and feel for the firm cervix.
The uterus is usually anteverted (Fig. 11.29A), and you can
feel its firmness anterior to the cervix. If the uterus is retroverted and lying over the bowel (15%; Fig. 11.29B), you will
feel the firmness posterior to the cervix.
• Push your fingers into the posterior fornix and lift the uterus
while pushing on the abdomen with your left hand.
• Place your left hand above the umbilicus and bring it down,
palpating the uterus between both hands and note its size,
regularity and any discomfort (Fig. 11.30).
AB
Fig. 11.29 Coronal section. A Anteverted uterus. B Retroverted uterus.
Fig. 11.30 Bimanual examination of the uterus. Use your vaginal fingers
https://t.me/med1917
to push the cervix back and upwards, and feel the fundus with your abdominal
hand.
Investigations • 253
11
Fig. 11.31 Palpating an adnexal mass.
• Move your vaginal fingers into the anterior fornix and palpate
the anterior surface of the uterus, holding it in position with
your abdominal hand.
• Move your fingers to the lateral fornix and, with your left hand
above and lateral to the umbilicus, bring it down to assess
any adnexal masses between your hands on each side
(Fig. 11.31).
• If urinary leakage occurs when the patient coughs, try lifting
the anterior vaginal wall with your fingers and ask them to
cough again. This stops genuine stress incontinence.
The normal cervix os may be a slit after childbirth. The
vaginal squamous epit helium and the endocervic al columnar
epithelium meet on the cervix. The position of this squamocolumnar junction varies considerably, so the ce rvix can look
very different in individual p eople. If the transition zone is on
the cervix, this is called an ectopy and looks red and friable;
there may be small cysts called Nabot hian foll icles. The normal
uterus should feel regular and be mobile and the size of a
plum. The Fallopian tubes cannot be felt, and normal ovaries
are palpable only in the very slim.
Vulval changes include specific skin diseases, infections such
as herpes or thrush, and malignancy. Visual abnormalities of the
cervix such as ulceration or bleeding suggest cervical pathology,
including polyps or malignancy. Tender nodules in the posterior
fornix suggest endometriosis, and both endometriosis and pelvic
adhesions cause fixation of the uterus. Acute pain when touching
the cervix (cervical excitation) suggests an acute pelvic condition
such as infection, cyst accident or tubal rupture.
Fibroids can cause uterine irregularity and enlargement. The
size is related to that of the uterus in pregnancy. A tangerinesized uterus is 6 weeks, an apple at 8 weeks, an orange at
10 weeks and a grapefruit at 12 weeks. After 12 weeks, the
uterus can be palpated suprapubically on abdominal palpation. A
large midline mass may be ovarian or uterine. Push the mass
upwards with your left hand and feel the cervix with your right
hand; if the mass moves without the cervix, this suggests it is
ovarian.
Investigations
Common gynaecological investigations are summarised in
Box 11.7. Patients of reproductive age should be considered
potentially pregnant, and a pregnancy test is routine. The
mainstay of gynaecological investigation is a pelvic ultrasound
scan, which can be carried out abdominally or transvaginally
(Fig. 11.32). Endometrial biopsy is a common test, particularly for
PMB, and is performed during vaginal examination using a
suction catheter (Pipelle, Fig. 11.33). When a couple presents
with subfertility, the key female investigations are serum progesterone 1 week before expected menses to confirm ovulation
and a test of tubal patency (Fig. 11.34).
Соседние файлы в папке Библиотека им академика М.И. Перельмана