INVESTIGATIONS IN GYNAECOLOGY

VISHNU NARAYANAN M.R.

COMMON INVESTIGTIONS IN GYNAECOLOGY

1. Blood values2. Urine examination3. Urethral,vaginal,cervic

al discharge4. Exfoliative cytology5. Colposcopy

6. Imaging techniques7.Endomitrial sampling8. Biopsy9.Culdocentesis10.Endoscopy11.hormonal assays

BLOOD ROUTINE

• Hemoglobin estimation-Excessive bleeding

• Total and differential count PID• ESR• Platelet count,BT,CT—Pubertal

menorhagia • Serology-VDRL,australia antigen,HIV

URINALYSIS1. Urine routine and microscopy• Physical examination• Chemical estimation of protein and sugar• Pus cells,casts2. Culture and drug sensitivity• Indications—Pus cells>5 UTI Cystocele Urinary complaints Fistula 3.Urine pregnancy test– for diagnosis of pregnancy

Methods of urine collection

1. Midstream collection

2. Catheter collection

3. Suprapubic bladder puncture

CATHETERIZATION

Suprapubic bladder puncture

URETHRAL DISCHARGEMethod of collection• Urethra squeesed against symphysis

pubis from behind forwards using sterile gloved fingers.

• Discharge through external urethral meatus collected with sterile swabs

• Swabs—microscopy and culture

Vaginal dischargeMethod of collection• Patient not to have vaginal douche

for 24hrs• Cusco’s bivalve speculum introduced• Discharge from posterior fornix on

the blade of speculum or cervical canal taken with a swab

• microscopic examination-Discharge mixed with normal saline

• culture

Identification of organisms in the slide1.Normal discharge-normal vaginal cells with doderlein bacilli

2.Trichomonal vaginalis—hanging drop preparation shows motile flagellated organisms of varying shape

3.Gardnerella vaginosis(bacterial/non specific vaginitis)—clue cells,few inflammatory cells,free floating clumps of gardnerella,scanty lactobacilli

4.Vaginal candidasis• Vaginal discharge + equal amount of 10%

KOH

• Caustic potash dissolves all cellular

debris,leaving behind more resistant yeast like organisms

• Typical hyphae,budding spores or mycelia detected

EXFOLIATIVE CYTOLOGY-PAPANICOLAOU TEST

• Pap test-Screening test for cancer• First described by Papanicolaou and Traut in 1943• Routine gynaecological examination in females,esp

above 35 years• Yearly screening for 3 years followed by 5 yearly test • Uses—1.screening for cancer2.identification of local viral infections like herpes and condyloma accuminata3.Cytohormonal study

Pap smear-screening of cancer

PROCEDURE• Should be obtained prior to vaginal examination• Patient placed in dorsal position with labia

separated• Cusco’s self retaining speculum inserted without

lubricants• Cervix exposed,squamocolumnar junction

scraped with concave end of Ayre’s spatula by rotating all around

• Thin smear is prepared on a glass slide and fixed by equal amounts of 95% alcohol and ether

• After 30 min,slide air dried and stained with papanicolaou or Short stain

• Modifications1. Endocervical sampling –endocervix scraped with a cytobrush

and added to the slide2. Fixative spray—cytospray used in office setup

INTERPRETATIONS• Normal cells1.Basal cells-small,rounded basophilic with large nuclei2.Squamous cells from middle layer –transparent and basophilic with vesicular nuclei3.Cells from superficial layer-acidophilic with characterestic pyknotic nuclei4.Endometrial cells,histiocytes,blood cells and bacteria

ABNORMAL CELLS1)Mild dyskaryosis—• superficial/intermediate squamous cells • Angular borders,transcluscent cytoplasm• Nucleus < half of total area of cytoplasm• Binucleation is common• CIN-I

2)Moderate dyskaryosis—• Intermediate/parabasal/superficial squamous

cell type• More disproportionate nuclear enlaregement

and hyperchromasia• Nucleus-1/2-2/3 of total cytoplasm area• CIN II

3)SEVERE DYSKARYOSIS• Cells- basal type round/oval/polygonal/elongated singly/in clumps• Nucleus- almost fills the cell thick,dense,narrow rim of cytoplasm irregular with coarse chromatin pattern• CIN III• Fibre cells- severly dyskaryotic elongated cell• Tadpole cell- severly dyskaryotic cell with an elongated

tail of cytoplasm

4.Carcinoma in situ• Parabasal cells with

increased nucleo-cytoplasmic ratio

• Cytoplasm scanty• Nucleus-

irregular,sometimes multiple

• Chromatin pattern-granular

5.Invasive carcinoma• Cells-single/clusters• Tadpole cells• Irregular nuclei• Coarse clumping of

chromatin

6)Koilocytosis• Nuclear abnormalities due to HPV infection• Condyloma accuminata• Cells-perinuclear halo,peripheral conensation

of cytoplasm• Nucleus-irregularly enlarged,hyperchromatic

with multinucleation• Disappears with dysplasia

• Positive pap smear in genital herpes-giant cells with viral inclusion bodies

• Silver pap test– pap test+PCR– used for diagnosis of herpes

Reporting system• normal/abnormal• Abnormal-CIN/papilloma infection/invasive

malignancy• Doubtful/inconclusive smear-repeat smear

PAPANICOLAOU CLASSIFICATION-GRADINGI. Normal cellsII. Slightly abnormal-inflammatory changeIII. Cells suspicious of malignancy-biopsy indicatedIV. Few Distinctly abnormal,possibly malignant cellsV. Malignant cells seen-numerous

Papanicolaou World Health Bethesda System

Class I Normal Within normal limits

Class II AtypiaI inflammatorySquamous, glandular

Inflammation-HPVASCUS, AGCUS

Class III Mild dysplasia CIN-I Low SIL

Class IV Moderate dysplasia CIN -IISevere dysplasia CIN -III Carcinoma in situ

High SIL

Class V Squamous cell carcinomaAdenocarcinoma

Squamous cell carcinomaAdenocarcinoma

LIMITATIONS OF PAP SMEAR• Detect only 60-70% of cervical cancer and 70% of

endomitrial cancer• Reliability depends on slide preparation and skill of

cytologist• 10-15% false negative results• False positive results in presence of infections• Difficulty if squamocolumnar junction-indrawn as

in post menopausal women(10 day course of oestrogen cream suggested)

• Postradiation cytology difficult- scarring and atrophy of vagina

Liquid based cytology-cancer screening

• Plastic spatula after scraping placed in buffered methanol solution-hemolytic and mucolytic

• Cells separated by centrifugation and gently sucked thrrough a filter membrane

• Filter pressed onto a glass slide to form thin monolayer which is stained

CYTOHORMONAL EVALUATION• Exfoliative cytology• Non invasive study of epithelium for hormonal

status• Principle-vaginal epithelium highly sensitive to

oestrogen and progesterone. oestrogen—superficial cell maturation progesterone—intermediate cell maturation• Procedure—scrapings taken from lateral wall

of upper third of vagina

INFERENCE• Normal smear-parabasal,intermediate and

superficial cells

• Oestrogen predominant smear-large eosinophilic cells with pyknotic nuclei and clear back ground

• Progesterone predominant smear-predominantly basophilic cells with vesicular nuclei and dirty background

• Pregnancy-intremediate and navicular cells

• Post-menopausal smear- parabasal and basal cells

KARYOPYKNOTIC INDEX/MATURATION INDEX• KPI = Mature squamous cells Intermediate +basal cells• Proliferative phase-KPI>25%• Secretory phase-KPI-very low• KPI> 10% in pregnancy – progesterone

deficiency• KPI peaks on the day of ovulation

UTERINE ASPIRATION CYTOLOGY

• Screening test for endometrial cancer-endometrial sampling

• Sample obtained by endometreal pipelle/uterine aspiration syringe or brush

• 90% accuracy with no false positive findings

• Hormonal studies also done

ENDOMETRIAL BIOPSY• Most reliable method to study endometrium• Endometrial tissue obtained by curretage and

subjected for histopathologyIndications– • suspected cases of Endometritis,endometrial

cancer• Infertility• Abnormal menstrual bleeding• Diagnosis of corpus luteal phase defect

CERVICAL BIOPSY

• Confirmatory diagnosis of cervical pathology• Done at OP if pathology detectable• Wider tissue excision as in cone biopsy – IP

procedure

COLPOSCOPY• Colposcope-binocular microscope-

10-20 X• Use-colposcope directed biopsy colposcopic examination of cervix and vagina

CULDOCENTESIS• Transvaginal aspiration of peritoneal fluid from the pouch of

douglas• Diagnostic procedure- pelvic abcess ectopic pregnancy in haematocele detect malignancy in ascitis with ovarian cyst• Instruments- vulsellum forceps,posterior vaginal speculum,aspiration syringe

PROCEDURE• Patient-lithotomy position• Posterior lip of cervix-downwards and

forwards with vulsellum forceps• Speculum-retracts posterior vaginal wall• Area disinfected• Aspiration syringe inserted into the pouch and

aspirated• Done best in OT under full asceptic

precautions and to proceed laproscopy/laprotomy if indicated

HORMONAL ASSAYS

• RIA,ELISA• Hormones assayed-

FSH,LH,PRL,ACTH,T3,T4,TSH,progesterone, oestradiol,testosterone,aldosterone,cortisol, hCG,dehydroepiandrosterone,andostenedione

• Uses- Diagnosis of menopause,PCOD,prolactinemia Monitoring treatment regimes in ovulation induction and AST

IMAGING TECHNIQUES-Overview1.X-RAY• Plain x ray chest and intravenous urogram- pelvic malignancy esp

cervical cancer,prior to staging.

• Plain x ray pelvis- To locate misplaced IUCD Visualize bone/teeth in benign cystic teratoma

• Hysterosalpingography-to test tube patency, Intracavity uterine mass and mullerian anomalies of uterus

• Lymphangiography-to locate lymph nodes involved in pelvic malignancy

2.ULTRASONOGRAPHY• Simple,non invasive,painless,safe procedure• Pelvis and lower abdomen scanned longitudinally and

transversely• D3 ultrasound-3-D images of pelvic organs

Transabdominal sonography(TAS)-• Done with transducer operating at 2.5-3.5Mhz• Bladder full• Large masses examination –ovarian tumour/fibroid

Transvaginal sonography(TVS)• Probe placed close to organ• High frequency waves used-5-8MHz• No need of full bladder• Detailed evaluation of pelvic organs possible• Better image resolution but poor tissue

penetration• Difficulty in narrow vaginaTransvaginal colour doppler sonography• Information regarding blood flow to,from or

within the uterus or adnexa

Diagnostic USG in gynaecology• Infertility workup 1)folliculometry-measurement of ovarian follicle diameter 2)measurement of endometrial thickness 3)evidence of ovulation-internal echoes and free fluid in pouch of douglas 4)timing of ovulation-helps in ovulation induction,AI,ovum retrieval 5)sonographic guided oocyte retrtieval

• Ectopic pregnancy-tubal ring in adnexa with empty uterine cavity

• Evaluation of pelvic mass

• Oncology-to assess vascularity of tumour and confirm malignancy

• Endometrial study in DUB• Diagnose uterine pathology-fibroids,adenomyosis• Location of misplaced IUD• Falloposcopy-to study medial end of tube• Diagnose endometriosis• To study ovarian pathology-PCOD,ovarian

cyst,tumour• Congenital anomalies of uterus• Diagnose adnexal mass

3) Computed tomography• Supplements information from USG• Whole abdomen and pelvis visualised in one sitting after

taking 600-800ml of a dilute contrast medium 1 hour prior to procedure

• Patient scanned in supine position• Accurate in accesing local tumour invasion and enables

accurate localisation in biopsy• Diagnose pelvic vein thrombophlebitis, intraabdominal abcess

and other extra genital abnormalities• Metastatic implants and lymphnodes < 1 cm—not detected• Contraindicated in pregnancy

4) Magnetic resonance imaging• Well established cross sectional imaging modality• High soft tissue contrast resolution without air/bone

interference• Limitations-cost,time,availability• Indicated only when a sonar or CT fails to detect a lesion or to

differntiate post-tratment fibrosis or tumour

5)Positron emission tomography(PET)• To differentiate normal tissue from cancerous one based on

the uptake of 18F-FLURO-2DEOXYGLUCOSE

DIAGNOSTIC ENDOSCOPY-Overview

• To visualize body cavityLapraroscopy-• Diagnose uterine,tubal,ovarian,generalised

diseases affecting pelvic organs-endometriosis,PID,genital TB

• Staging of genital cancers• Infertility workup• a/c pelvic lesions-ectopic pregnancy,salphingitis

etc

2)Hysteroscopy• Visualise endometrial cavity• Diagnostic uses1. Unresponsive irregular uterine bleeding2. Congenital uterine septum3. Missing threads of IUD4. Intrauterine adhesions5. Endometrial polyps/ malignant growth

3)Salphingoscopy and falloposcopy• Visualise of fallopian tube• Permits selection of patients for IVF rather than tubal

surgery

4)Culdoscopy• Visualise pelvic structures via an incision in pouch

of Douglas

5)Cystoscopy• To evaluate cervical cancer prior to staging• Investigate urinary symptoms-

haematuria,incontinence and fistulae

6) Proctoscopy and sigmoidoscopy• To evaluate rectal invovement in genital

malignancy

INVESTIGATIONS FOR

INFERTILITY

INFERTILITY IN FEMALESTESTS FOR TUBAL PATENCY• Hysterosalpingography• Laproscopic chromotubation• Sonosalpingography• Hysterofalloscopy• Ampullary and fimbrial salpingography

TESTS FOR OVULATION• Basal body temperature• Examination of cervical mucus-fern test• Ultrasound• Hormonal assays-estrogen and progesterone

INFERTILITY IN MALES• Semen analyisis• Post-coital test-Sim’s test • Sperm penetration test• Semen-cervical mucus contact test• Urine examination• Patency of vas-vasogram• Testicular biopsy• Hormonal assays-FSH,LH,testosterone,prolactin• Chromosomal study• Immunological tests-ELISA, RIA• Ultrasound scanning

PRE-OPERATIVE INVESTIGATIONS IN GYNAECOLOGY

• Complete blood count• Urinalysis• FBS,PPBS• BT,CT• Blood group and Rh factor• RFT• LFT• Serology- VDRL• Serum electrolytes-Na,K,Cl,HCO3• Chest radiograph• ECG • IVP

• Tumour markers1. CA-125-Adenocarcinoma ovary2. CEA,α-fetoprotein,β-hCG—Ovarian teratomas

• Bacterial examination of genital tract1.Smear and microscopy2.Culture3.PCR

“VENIENTI OCCURITE MORBO”-

MEET THE DISEASE ON ITS FIRST

APPEARANCE

-PERSIUS

THANK YOU!!!