Gynecology (British) or gynecology (North American) literally means 'the science of women', but in medicine this is the specialty of diseases of the female reproductive system (uterus, vagina and ovaries). Gynecology is typically a consultant specialty. In most countries, women must see a general practitioner first. If their condition requires knowledge or equipment unavailable to the GP, they are referred to a gynecologist. However, in the United States, law and many health insurance plans allow gynecologists to provide primary care, and some women select that option.

Some of the investigations used in gynecology are:

· Abdominal ultrasound, to give a low-power view of the pelvic organs.
· Vaginal ultrasound-a probe is passed into the vagina, which allows a detailed view of the uterus and its contents.
· Blood tests. Levels of hormones such as estradiol, luteinizing hormone, follicle stimulating hormone and progesterone are measured, as well as prolactin.
· Hysteroscopy-a fine tube is passed into the uterus via the cervix under a general anesthetic.
· Laparoscopy-tubes are passed into the peritoneal cavity, which is then insufflated with carbon dioxide. This is commonly used to diagnose endometriosis.
· MRI and CT scans are rarely used, apart from tumor staging in gynecological cancer. Pelvic X-ray is rare. It can be used to delineate the uterine cavity with an injected dye (hysterosalpingogram) and to measure the pelvic girdle.

Diseases

The main conditions dealt with by a gynecologist are:
· Cancer of the cervix-the Papanicolaou (pap) smear is a means of detecting this, by obtaining a sample of cervical epithelial cells and examining them under a microscope for malignant changes. All women are encouraged to have pap smears at regular intervals after commencing intercourse.
· Incontinence of urine.
· Amenorrhea (absent periods)
· Dysmenorrhea (painful periods)
· Infertility
· Menorrhagia (heavy periods). This is a main indication for hysterectomy.
· Prolapse

Therapies

Occasionally gynecologists will use drugs, such as clomiphene (which stimulates ovulation), and, most famously, oral contraceptives (which are also used for dysmenorrhea). Surgery, however, is the mainstay of gynecological therapy. For historical reasons, gynecologists are not usually considered "surgeons" - this has always been the source of some controversy - though modern advancements in both fields have blurred many of the once rigid lines of distinction.

Some of the more common operations that gynecologists perform include:

· Termination of pregnancy
· Dilation and curettage (removal of the uterine contents, for various reasons, including miscarriage and menorrhagia; procedurally very similar to the above);
· Hysterectomy (removal of the uterus);
· Oophorectomy (removal of the ovaries);
· Tubal ligation;
· Exploratory laparoscopy or laparotomy (used to diagnose and treat sources of pelvic and abdominal pain, dysmenorrhea, vaginal bleeding, etc.)
· Colposuspension ('tightening' of the ligaments around the vagina, a common therapy for incontinence and discomfort in older women);
· Large Loop Excision of the Transition Zone (LLETZ), where the surface of the cervix, containing pre-cancerous cells identified on Pap smear are removed).

Obstetrics
Obstetrics (from the Latin obstare, "to stand by") is the surgical specialty dealing with the care of a woman and her offspring during pregnancy, childbirth and the puerperium (the period shortly after birth).

Antenatal care
In obstetric practice, the obstetrician will see a pregnant woman on a regular basis as her pregnancy progresses. The exact schedule varies depending on resources and risk factors, such as diabetes.

The main rationale for these visits is surveillance for diseases of pregnancy, which are detectable. Some examples are:

· Pre-eclampsia. The blood pressure and urine of a pregnant woman is checked at every opportunity to check for this.
· Placenta praevia. On ultrasound, the placenta is visible obstructing the birth canal
· Abnormal presentation (late pregnancy only). The fetus may be feet-first (breech), side-on (transverse), or at an angle (oblique presentation)
· IUGR (Intrauterine Growth Restriction), this is a general designation, where the fetus is too small for its gestational age. Causes can be intrinsic (in the fetus) or extrinsic (usually placental problems). IUGR refers to fetal growth that is less than 10% of what is expected at that gestational age.

Symptoms

Trimester
First trimester: elevated β-hCG (up to 100,000 mIU/mL by 10 weeks GA) can cause morning sickness, fatigue, mood swings and food cravings. The symptoms can last through 12 to 16 weeks of gestation.

Second trimester: The abdomen shows an obvious swelling arising from the pelvis, starting the "obvious phase" of pregnancy. Hyperpigmentation, including linea nigra may appear.

Third trimester: The mother may experience backaches due to increased strain. Typically, the curvature of the spine is changed as pregnancy evolves in order to counteract the change in weight distribution. The mother may also suffer mild urinary incontinence due to pressure on the bladder by the pregnant uterus, as well as heartburn (due to compression of the stomach).

Overall
· Bluish discoloration of vagina and cervix (Chadwick's sign)
· Softening and cyanosis of cervix after 4 weeks (Goodell's sign)
· Softening of uterus after 6 weeks (Ladin's sign)
· Breast swelling and tenderness
· Linea nigra from umbilicus to pubis
· Telangiectasias
· Palmar erythema
· Amenorrhea
· Nausea and vomiting
· Breast pain
· Fetal movement

Maternal physiology
During pregnancy, the woman undergoes many physiological changes, which are entirely normal, including cardiovascular, renal, hematologic, metabolic or respiratory changes that become very important in the event of complications.

Metabolism
During pregnancy, both protein metabolism and carbohydrate metabolism are affected. One kilogram of extra protein is deposited, with half going to the fetus and placenta, and another half going to uterine contractile proteins, breast glandular tissue, plasma protein, and hemoglobin.

Nutrition
· Increased caloric requirement by 300 kcal/day
· Gain of 20 to 30 lb (10 to 15 kg)
· Increased protein requirement to 70 or 75 g/day
· Increased folate requirement from 0.4 to 0.8 mg/day (important in preventing neural tube defects)
· All patients are advised to take prenatal vitamins to compensate for the increased nutritional requirements.

Cardiovascular
The woman is the sole provider of nourishment for the embryo and later, the fetus, and so her plasma and blood volume slowly increase by 40-50% over the course of the pregnancy to accommodate the changes. This results in overall vasodilation, an increase in heart rate (15 beats/min more than usual), stroke volume, and cardiac output. Cardiac output increases by ~50%, mostly during the first trimester. The systemic vascular resistance also drops due to the smooth muscle relaxation caused by elevated progesterone, leading to a fall in blood pressure. Diastolic blood pressure consequently decreases between 12-26 weeks, and increases again to prepregnancy levels by 36 weeks. If the blood pressure remains abnormal beyond 36 weeks, the woman should be investigated for pre-eclampsia, a condition that precedes eclampsia.

Pulmonary
· Increased tidal volume (30-40%)
· Decreased total lung capacity (TLC) by 5% due to elevation of diaphragm from uteral compression
· Decreased expiratory reserve volume
· Increased minute ventilation (30-40%) which causes a decrease in PaCO2 and a compensated respiratory alkalosis
· All of these changes can contribute to the dyspnea (shortness of breath) that a pregnant woman may experience.

Hematology
· The plasma volume increases by 50% and the red blood cell volume increases only by 20-30%.
· Consequently, the hematocrit decreases.
· White blood cell count increases and may peak at over 20 mil/mL in stressful conditions.
· Decrease in platelet concentration to a minimal normal values of 100-150 mil/mL
· The pregnant woman also becomes hypercoagulable due to increased liver production of coagulation factors, mainly fibrinogen and factor VIII.

Gastrointestinal
· nausea and vomiting ("morning sickness") due to elevated B-hCG, which should resolve by 14 to 16 weeks
· prolonged gastric empty time
· decreased gastroesophageal sphincter tone, which can lead to acid reflux
· decreased colonic motility, which leads to increased water absorption and constipation

Renal
· Increase in kidney and ureter size
· Increased glomerular filtration rate (GFR) by 50%, which subsides around 20 weeks postpartum
· Decreased BUN (blood urea nitrogen) and creatinine, and glucosuria (due to saturated tubular reabsorption)
· Persistent glucosuria can suggest gestational diabetes
· Increased renin-angiotensin system, causing increased aldosterone levels
· Plasma sodium does not change because this is offset by the increase in GFR

Endocrine
· Increased estrogen, which is mainly produced in the placenta
· Fetal well being is associated with maternal estrogen levels
· Causes an increase in thyroxine-binding globulin (TBG)
· Increased human chorionic gonadotropin (β-hCG), which is produced by the placenta. This maintains progesterone production by the corpus luteum
· Human placental lactogen (hPL) is produced by the placenta and ensures nutrient supply to the fetus. It also causes lipolysis and is an insulin antagonist, which is a diabetogenic effect.
· Increased progesterone production, first by corpus luteum and later by the placenta. Its main course of action is to relax smooth muscle.
· Increased prolactin
· Increased alkaline phosphatase

Musculoskeletal and dermatology
· Lower back pain due to a shift in gravity
· Increased estrogen can cause spider angiomata and palmar erythema
· Increase melanocyte-stimulating hormone (MSH) can cause hyperpigmentation of nipples, umbilicus, abdominal midline (linea nigra), perineum, and face (melasma or chloasma)

Others
Edema, or swelling, of the feet is common during pregnancy, partly because the enlarging uterus compresses veins and lymphatic drainage from the legs. For the sake of comfort, many pregnant women wear larger shoes or go without. This may have something to do with the origin of the phrase "barefoot and pregnant".

Trimester

The human gestation period of approximately 40 weeks between the time of the last menstrual cycle and delivery is traditionally divided into three periods of three months, or trimesters.

The first trimester is the period of time from the first day of the last menstrual period through 12 weeks of gestation. It is during this period that the embryo undergoes most of its early structural development. Most miscarriages occur during this period.

The second trimester is the period of time extending from the 13th to the 27th week of gestation. During this period the embryo, now known as a fetus, is recognizable as human in form, but is not developed enough to be viable if born.

The third trimester is the period of time extending from the 28th week of gestation to delivery. It is during this period that the fetus reaches viability, and may survive if born prematurely.

Female Reproductive System

The female reproductive system is very complex and interesting. It is responsible for production of female sex cell called ovum for union with male sex cell called sperm. It is also responsible for nurturing the developing fetus for a period of 9 months until parturition, with the delivery of a fully developed baby. Female reproductive organs may be divided into external organs and internal organs.

Anatomy and Physiology
The external genital organs of the female are collectively known as vulva and comprise Labia majora, labia minora, clitoris, and Bartholin glands.

Internal reproductive organs include ovaries, fallopian tubes, uterus, and vagina.

The human female reproductive system contains two main parts: the vagina and uterus, which act as the receptacle for the male's sperm, and the ovaries, which produce the female's ova. All of these parts are always internal; the vagina meets the outside at the vulva, which also includes the labia, clitoris and urethra. The vagina is attached to the uterus through the cervix, while the uterus is attached to the ovaries via the Fallopian tubes. At certain intervals, the ovaries release an ovum, which passes through the fallopian tube into the uterus.

If, in this transit, it meets with sperm, the sperm penetrate and merge with the egg, fertilizing it. The fertilization usually occurs in the oviducts, but can happen in the uterus itself. The zygote then implants itself in the wall of the uterus, where it begins the processes of embryogenesis and morphogenesis. When developed enough to survive outside the womb, the cervix dilates and contractions of the uterus propel the fetus through the birth canal, which is the vagina.

The ova are larger than sperm and are generally all created by birth. Approximately every month, a process of oogenesis matures one ovum to be sent down the Fallopian tube attached to its ovary in anticipation of fertilization. If not fertilized, this egg is flushed out of the system through menstruation.

So lets study about each part in detail.

Vagina

The vagina is the tubular tract leading from the uterus to the exterior of the body in female mammals, or to the cloaca in female birds and some reptiles. Female insects and other invertebrates also have a vagina, which is the terminal part of the oviduct.

The vagina is the place where semen from the man is deposited into the woman's body during sexual intercourse.

The human vagina is an elastic muscular tube about 4 inches (100 mm) long and 1 inch (25 mm) in diameter that connects the vulva at the outside to the cervix of the uterus at the inside. If the woman stands upright, the vaginal tube points in an upward-backward direction and forms an angle of slightly more than 45 degrees with the uterus. The vaginal opening is at the back (caudal) end of the vulva, behind the opening of the urethra. Above the vagina is Mons Veneris. The inside of the vagina is usually pink, as with all internal mucous membranes in mammals.

Length, width and shape of the vagina may vary. When a woman gives birth and during sexual intercourse, the vagina widens and lengthens up to 2-3 times.

Vaginal lubrication is provided by glands near the vaginal opening and the cervix and also seeps through the vaginal wall (which does not contain any glands).

The hymen—a membrane situated behind the urethral opening—partially covers the vagina in many organisms, including some human females, from birth until it is ruptured by sexual intercourse, or by any number of other activities including medical examinations, injury, certain types of exercise, introduction of a foreign object, etc.

Functions of the vagina
From a biological perspective, the vagina performs the following functions:

· Providing a path for menstrual fluids to leave the body.
· Giving birth
· Admitting the male penis for sexual intercourse

Sexual intercourse
The vagina admits the male penis for sexual intercourse and ultimately male sperm for the fertilization of ova for reproduction. The concentration of nerve endings particularly close to the mouth of the vagina causes pleasure to be experienced during sexual activity. The opening of the vagina is home to the clitoris, which is located at the anterior of the vaginal opening; for most women, the clitoris is the main source of sexual pleasure (although it can be too sensitive for direct stimulation in some women). Some women have a very sensitive erogenous zone called "the G-spot" inside their vagina (in the anterior of the vagina, about five cm. in from the entrance), which can produce very intense orgasms if stimulated properly, possibly responsible for the disputed female ejaculation. Not all women have a g-spot that is responsive to stimulation, however.

Sexual health and hygiene
Other than the penis, fingers or sexual devices, many women insert tampons during menstruation. These must be regularly changed - every four hours at most. Other objects inserted include diaphragms (placed against the cervix, blocking it from sperm), spermicidal cream and lubricant. Additionally, some women use vaginal douches, which serve to cleanse the vagina with a gentle soap intended to remove odor. These days such treatment is advised against by doctors, as it may upset the balance of bacteria in the vagina, rather than helping it. Thus, the vagina itself needs no particular treatment in the name of basic hygiene.

The vagina is examined during gynecological exams, often using an instrument called a speculum, which keeps the vagina open for visual inspection or taking of samples (see pap smear).

Various disorders can affect the vagina, including vaginal cancer and yeast infections.

Cervix
The cervix (from Latin "neck") is actually the lower, narrow portion of the uterus where it joins with the top end of the vagina. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall. Approximately half its length is visible with appropriate medical equipment; the remainder lies above the vagina beyond view. It is occasionally called "cervix uteri", or "neck of the uterus".

Anatomy

Ectocervix
The portion projecting into the vagina is referred to as the portio vaginalis or ectocervix. On average, the ectocervix is 3 cm long and 2.5 cm wide. It has a convex, elliptical surface and is divided into anterior and posterior lips.

External Os
The ectocervix opening is called the external os. The size and shape of the external os and the ectocervix varies widely with age, hormonal state, and whether the woman has had a vaginal birth. In women who have not had a vaginal birth the external os appears as a small, circular opening. In women who have had a vaginal birth, the ectocervix appears bulkier and the external os appears wider, more slit-like and gaping.

Endocervical Canal
The passageway between the external os and the uterine cavity is referred to as the endocervical canal. It varies widely in length and width, along with the cervix overall. Flattened anterior to posterior, the endocervical canal measures 7 to 8 mm at its widest in reproductive-aged women.

Internal Os
The endocervical canal terminates at the internal os which is the opening of the cervix inside the uterine cavity.

Cervical Mucus
Normally the external os is blocked by a thick mucus that prevents infection, however the mucus thins when ovum are ready to be fertilized, allowing spermatozoa to pass through the cervix. Most oral contraceptives increase their effectiveness by not allowing this mucus to thin, therefore blocking spermatozoa from passing even when ovum are ready to be fertilized. During pregnancy the cervix is completely blocked by a special antibacterial mucosal plug which prevents infection as before. The mucous plug comes out as the cervix dilates in labor or shortly before.

Cervical Cancer
In humans the cervix is associated with cervical cancer, a particular form of cancer which is detectable by cytological study of epidermal cells removed from the cervix in a process known as the Pap smear. Evidence now shows that those with exposure to HPV or Human Papilloma Virus are at increased risk for cervical cancer. This virus is related to the virus that causes warts.

Cervical cancer is a malignancy of the cervix. Worldwide, it is the second most common cancer of women. It may present with vaginal bleeding but symptoms may be absent until the cancer is in advanced stages, which has made cervical cancer the focus of intense screening efforts utilizing the Pap smear. Most scientific studies point to human papillomavirus (HPV) infection as a necessary pre-requisite for development of cervical cancer. Treatment is with surgery (including cryosurgery) in early stages and chemotherapy and radiotherapy in advanced stages of the disease.

Diagnosis is made by doing a biopsy of the cervix, which often involves colposcopy, or a magnified visual inspection of the cervix aided by using an acetic acid solution to produce color changes in precancerous or cancerous areas. A Pap smear is insufficient for the diagnosis. Many researchers recommend that since more than 99% of invasive cervical cancers worldwide contain human papillomavirus, HPV testing should be carried out together with routine cervical screening. Further diagnostic procedures are loop electrical excision procedure (LEEP) and conization, in which the inner lining of the cervix is removed to be examined pathologically. These are carried out if the biopsy confirms severe dysplasia.

Staging
Cervical cancer is staged by the FIGO staging system, which is based on clinical examination, rather than surgical findings. It allows only the following diagnostic tests to be used in determining the stage: palpation, inspection, colposcopy, endocervical curettage, hysteroscopy, cystoscopy, proctoscopy, intravenous urography, and X-ray examination of the lungs and skeleton, and cervical conization.

The TNM staging system for cervical cancer is analogous to the FIGO stage.

Stage 0 - full-thickness involvement of the epithelium without invasion into the stroma (carcinoma in situ)
Stage I - limited to the uterus
IA - diagnosed only by microscopy; no visible lesions
IA1 - stromal invasion less than 3 mm in depth and 7 mm or less in horizontal spread
IA2 - stromal invasion between 3 and 5 mm with horizontal spread of 7 mm or less
IB - visible lesion or a microscopic lesion with more than 5 mm of depth or horizontal spread of more than 7 mm
IB1 - visible lesion 4 cm or less in greatest dimension
IB2 - visible lesion more than 4 cm
Stage II - invades beyond uterus
IIA - without parametrial invasion
IIB - with parametrial invasion
Stage III - extends to pelvic wall or lower 1/3 of the vagina
IIIA - involves lower 1/3 of vagina
IIIB - extends to pelvic wall and/or causes hydronephrosis or non-functioning kidney
IVA - invades mucosa of bladder or rectum and/or extends beyond true pelvis
IVB - distant metastasis

Note that the FIGO stage does not incorporate lymph node involvement in contrast to the TNM staging for most other cancers.

Treatment
Microinvasive cancer (stage IA) is usually treated by hysterectomy (removal of the whole uterus including part of the vagina). For stage IA2, the lymph nodes are removed as well. An alternative for patients who desire to maintain fertility is a local surgical procedure such as a LEEP or cone biopsy.

Early stages (IB1 and IIA less than 4cm) can be treated with radical hysterectomy with removal of the lymph nodes or radiation therapy. Radiation therapy is given as external beam radiotherapy to the pelvis and brachytherapy (internal radiation). For patients treated with surgery who have high-risk features found on pathologic examination, radiation therapy with or without chemotherapy is given in order to reduce the risk of relapse.

Larger early stage tumors (IB2 and IIA more than 4cm) may be treated with radiation therapy and cisplatin-based chemotherapy, hysterectomy (which then usually requires adjuvant radiation therapy), or cisplatin chemotherapy followed by hysterectomy.

Advanced stage tumors (IIB-IVA) are treated with radiation therapy and cisplatin-based chemotherapy.

Clitoris
The clitoris (plural: clitorides) is a sexual organ in the body of female mammals. The visible knob-like portion is located near the anterior junction of the labia minora, above the opening of the vagina. The clitoris has no urethra and functions solely to induce sexual pleasure. The only known exception to this is in the Spotted Hyena, where the urogenital system is modified so that the female urinates, mates and gives birth via an enlarged, erectile clitoris.

Clitoral hood
In female human anatomy, the clitoral hood, (also called prepuce), is a fold of skin that surrounds and protects the clitoral glans. It develops as part of the labia minora and is homologous with the foreskin (equally called prepuce) in male genitals.

This is a protective hood of skin that covers the clitoris. There is no standard size or shape for the hood. Some women have large clitoral hoods that completely cover the tip of the clitoris.

Uterus
The uterus or womb is the major female reproductive organ of most mammals, including humans. One end, the cervix, opens into the vagina; the other is connected on both sides to the fallopian tubes. In mammals, the four main forms in which it is found are: bipartite, as in cows; bicornuate, as in pigs; simplex, as with the pear-shaped one found in humans and horses; and duplex, found in rabbits.

Anatomy
The uterus is located in the pelvis immediately dorsal (and usually somewhat rostral) to the urinary bladder and ventral to the rectum. It is held in place by eight ligaments (one anterior; one posterior; two lateral or broad; two uterosacrals; and two round ligaments). It is usually slightly anteverted (tipped forward) but is sometimes retroverted (tipped backwards). Outside of pregnancy, its size is several centimeters in diameter.

The uterus mostly consists of muscle, known as myometrium. The innermost layer of myometrium is known as the junctional zone, which becomes thickened in adenomyosis. The lining of the uterine cavity is called the endometrium. In most mammals, including humans, the endometrium builds a lining periodically which, if no pregnancy occurs, is shed or reabsorbed. Shedding of the endometrial lining in humans is responsible for menstrual bleeding (known colloquially as a woman's "period") throughout the fertile years of a female and for some time beyond. In other mammals there may be cycles set as widely apart as six months or as frequently as a few days.

The loose surrounding tissue is called the parametrium.

Function
The main function of the uterus is to accept a fertilized ovum, which becomes implanted into the endometrium, and derives nourishment from blood vessels, which develop exclusively for this purpose. The fertilized ovum becomes an embryo, develops into a fetus and gestates until childbirth. Due to anatomical barriers such as the pelvis, the uterus is pushed partially into the abdomen due to its expansion during pregnancy. Even in pregnancy the mass of a human uterus amounts to only about a kilogram (2.2 pounds).

Pathology

Some pathological states include:

· Prolapse of the uterus
· Carcinoma of the cervix - malignant neoplasm
· Carcinoma of the uterus - malignant neoplasm
· Ectopic pregnancy-an ectopic pregnancy is one in which the fertilized ovum is implanted in any tissue other than the uterine wall. Most ectopic pregnancies occur in the fallopian tube (so-called tubal pregnancies), but implantation can also occur in the cervix, ovaries, and abdomen.
· Fibroids - benign neoplasms
· Adenomyosis - ectopic growth of endometrial tissue within the myometrium

Uterine fibroids
Uterine fibroids (leiomyomata, singular leiomyoma) are the most common neoplasm in females, and may affect about of 25 % of white and 50% of black women during the reproductive years. Fibroids can be removed simply by means of a hysterectomy, but much more favorably by a uterine artery embolization, as it preserves the uterus.

Leiomyomas grossly appear as round, well circumscribed (but not encapsulated), solid nodules that are white, or tan whorled. The size varies, from microscopic to lesions of considerable size. Leiomyomas are estrogen sensitive and have estrogen receptors. They may enlarge rapidly during pregnancy due to increased estrogen levels. As estrogen levels decline with menopause, fibroids tend to regress after menopause. Hormonal therapy is based on these facts.

Symptoms
Fibroids, particularly when small, may be entirely asymptomatic. Generally, symptoms relate to the location of the lesion and its size. Important symptoms include abnormal gynecologic hemorrhage, pain, infertility, dysuria and urinary frequency. During pregnancy they may be the cause of miscarriage, bleeding, premature labor, or interference with the position of the fetus.

Fibroids may be single or multiple. Most fibroids start in an intramural location,- that is the layer of the muscle of the uterus. With further growth, some lesion may develop towards the outside of the uterus (subserosal or pedunculated), some towards the cavity (submucosal or intracavitary). Lesions affecting the cavity tend to bleed more and interfere with pregnancy. Secondary changes that may develop within fibroids are hemorrhage, necrosis, calcification, and cystic changes. Less frequently, leiomyomas may occur at the lower uterine segment, cervix, or uterine ligaments.

Diagnosis
Diagnosis is usually accomplished by bimanual examination, better yet by gynecologic ultrasonography. Sonography will depict the fibroids as focal masses with a heterogeneous texture, which usually cause shadowing of the ultrasound beam. In cases where a more precise assay of the fibroid burden of the uterus is needed, also magnetic resonance imaging (MRI) can be used to generate a depiction of the size and location of the fibroids within the uterus.

Treatment
The presence of a fibroid does not mean that it needs to be treated, many lesions are followed expectantly. Treatment of uterine fibroids that cause problems can be accomplished by:

· Surgery: Hysterectomy or myomectomy can be performed. Based on the size and location of the lesion different approaches can be considered: laparotomy, laparoscopy, or hysteroscopy.
· Uterine artery embolization (UAE): Using interventional radiology techniques, the Interventional physician occludes both uterine arteries and reducing blood supply to the fibroid(s).
· Medical therapy: This involves the use of medication to reduce estrogens in an attempt to create a medical menopause-like situation. Gonadotropin-releasing hormone analogs are used for this. Selective progesterone receptor modulators, such as Progenta, are under investigation as therapeutic agents. (2005)
· HIFU (High frequency focused ultrasound), also called MRgFUS (Magnetic Resonance guided Focused Ultrasound), is a non-invasive intervention (requiring no incision) that uses high intensity focused ultrasound waves to ablate (destroy) tissue in combination with Magnetic Resonance Imaging (MRI), which guides and monitors the treatment.

Fallopian tubes or oviducts
The Fallopian tubes, also known as oviducts and uterine tubes, are two very fine tubes leading from the ovaries of female mammals into the uterus.

There are two Fallopian tubes, attached to either side of the cranial end of the uterus, and each terminating at or near one ovary forming a structure called the fimbria.

When an ovum is developing in an ovary, it is encapsulated in a sac known as a ovarian follicle. On maturity of the ovum, the follicle and the ovary's wall rupture, allowing the ovum to escape and enter the Fallopian tube. There it travels toward the uterus, pushed along by movements of cilia on the inner lining of the tubes. This trip takes hours or days. If the ovum is fertilized while in the Fallopian tube, then it normally implants in the endometrium when it reaches the uterus, which signals the beginning of pregnancy. Occasionally the embryo implants into the Fallopian tube instead of the uterus, creating an ectopic pregnancy.

Ovaries
Ovaries are egg-producing reproductive organs found in female organisms. Ovaries are two almond-shaped glands placed on each side of the uterus, attached to the fallopian tube, suspended with the help of broad ligaments to the uterus. The main function of ovaries is to produce the female reproductive cell called ova. The ovaries contain a large number of immature ova called primary oocytes, which are sur-rounded by nutritive follicular cells. Every month, (at each menstrual cycle), one of these oocytes develop into a Graafian follicle. The Graafian follicle ripens and becomes distended with fluid. Increasing tension within the Graafian follicle causes it to rupture and ovum is released from the ovary into the opening of the uterine tube. (In the ovary; numerous Graafian follicles are present in different stages of development.) The ovaries also produce two hormones called estrogen and progesterone. These hormones play an important role in the menstrual cycle, secondary sexual characteristic development, and preparation of the endometrium of uterus for implantation of a fertilized ovum.

Bartholin's gland
The Bartholin's glands (also called Bartholin glands or greater vestibular glands) are two glands located slightly below and to the left and right of the opening of the vagina in women. They secrete mucus to provide lubrication, especially when the woman is sexually aroused, thus facilitating sexual activity. Bartholin's glands are homologous to Cowper's glands in males.

G-spot
The Gräfenberg spot, or G-spot, is a small area in the genital area of women behind the pubic bone and surrounding the urethra. It is named after German gynecologist Ernst Gräfenberg. It is the same as, or part of, the urethral sponge, the site of Skene's glands.

Stimulation of the G-spot (through the front wall of the vagina) is said to promote a more vigorous and satisfying orgasm, and is possibly the cause of female ejaculation from the Skene's glands, contained in the urethral sponge. Such stimulation requires a somewhat opposite thrust to that required to obtain maximal clitoral stimulation via the penis, called "riding high".

The stimulation of the G-spot is thought to be more intense for women beyond their thirties, because of changes in tissue structure inside the vagina allowing easier access to the G-spot. Some women believe their thirties are their sexual peak because of this reason.

Hymen
The hymen (also known under the slang names cherry and maidenhead) is a membrane, which completely or partially occludes the vaginal opening in human females. The term comes from a Greek word meaning "membrane", and is also the name of the classical Greek god of marriage.

Because sexual activity would usually tear this membrane, its presence has been considered a guarantor of virginity in societies that place a high value on female chastity before marriage. However, the hymen is a poor indicator of whether a woman has actually engaged in coitus, because the tissue may be torn or stretched through masturbation, or tampon use and other non-sexual acts before having sexual intercourse. Also, some females with intact hymens have had sexual intercourse.

The size and shape of this opening (or openings) vary greatly from person to person. Some women are born with no hymen at all, while others have a closed or imperforate hymen. These women may require a gynecologist to perform a medical procedure called a hymenotomy to allow menstrual products to escape. Still other women have unusually thick hymens that may require a hymenotomy to prevent pain for the woman during sex.

Some other common forms of hymen are:
Annular – in which the hymen forms a ring around the vaginal opening.
Septate – in which the hymen has one or more bands extending across the opening.
Cribriform – in which the hymen stretches completely across the vaginal opening, but is perforated with several holes.
Parous Introitus – which refers to the vaginal opening which has had a baby pass through it and consequently has nothing left of its hymen but a fleshy irregular outline decorating its perimeter.

Labium majora and minora

Labia majora (large lips, literally) are two thick and fleshy folds which form the sides of vulva. They contain fat and have sweat and sebaceous glands. After puberty, they become covered with thick hair. Situated between the upper parts of labia majora are two small folds of skin which surround the opening of the vagina and urethra and are called labia minora (small lips, literally). The opening of the vagina is called introitus. The two labia minora meet at the clitoris in front. The color of the outside skin of the labia majora is usually close to the overall skin colour of the individual, although there is considerable variation. The inside skin is often pink or brownish.

Skene's gland
In human anatomy, the Skene's glands (also known as the lesser vestibular or paraurethral glands) are glands located on the upper wall of the vagina, around the lower end of the urethra. They drain into the urethra and near the urethral opening. The location of the Skene's glands is also known as the Gräfenberg spot or G-spot; the general area is the urethral sponge. The Skene's glands are homologous with (that is to say, the female equivalent of) the prostate gland in males.

Some believe that the Skene's glands are the source of female ejaculation.

Urethra
In anatomy, the urethra is a tube, which connects the urinary bladder to the outside of the body. The urethra has an excretory function in both sexes, to pass urine to the outside, and also a reproductive function in the male, as a passage for sperm.
The external urethral sphincter is a striated smooth muscle that allows voluntary control over urination.

Anatomy
Men have a longer urethra than women. This means that women tend to be more susceptible to infections of the bladder (cystitis) and the urinary tract. The length of a male's urethra, and the fact it contains a number of bends makes catheterization more difficult.
In the human female, the urethra is about 1-1.5 inches (2.5-4 cm) long and opens in the vulva between the clitoris and the vaginal opening. In the human male, the urethra is about 8 inches (20 cm) long and opens at the end of the penis.

The urethra is divided into three parts in men, named after the location:

· The prostatic urethra crosses through the prostate gland. There is a small opening where the vas deferens enters.
· The membranous urethra is a small (1 or 2 cm) portion passing through the external urethral sphincter. This is the narrowest part of the urethra.
· The spongy (or penile) urethra runs along the length of the penis on its ventral (underneath) surface. It is about 15-16 cm in length, and travels through the corpus spongiosum.

Medical problems of the urethra:

· Hypospadias and epispadias are forms of abnormal development of the urethra in the male, where the opening is not quite where it should be (it occurs lower than normal with hypospadias, and higher with epispadias). A chordee is when the urethra develops between the penis and the scrotum.
· Infection of the urethra is urethritis, said to be more common in females than males. Urethritis is a common cause of dysuria (pain when urinating).
· Related to urethritis is so called urethral syndrome
· Passage of kidney stones through the urethra can be painful and subsequently it can lead to urethral strictures

Endoscopy of the bladder via the urethra is called cystoscopy.

Vulva
The external genital organs of the female are collectively known as the vulva (or pudenda).

In human beings this consists of the labia majora and labia minora (while these names translate as "large" and "small" lips, often the "minora" can be larger, and protrude outside the "majora"), clitoris, opening of the urethra (meatus), and the opening of the vagina. The main functions involving the vulva are urination, sexual behavior, menstruation, and childbirth.

Physical Assessment
The physical assessment starts with an evaluation inquiring about past gynecologic history which includes questions about menarche (age of onset of menstruation), frequency of cycle, regularity, duration of periods, amount of flow, and the last menstrual period date. She is then inquired regarding onset of pain or cramps during periods, heavy flow, and bleeding between periods, or bleeding after menopause. Last but not the least is inquiry about patient's sexual activity, use of birth control pills and other medications, use of hormones, or other contraceptive methods. The patient may also be asked questions regarding her past reproductive history like number of pregnancies, abortions, stillbirths, C-section, normal deliveries, or any complications during pregnancy. The physician inquires about pelvic pain, vaginal discharge, any infections, itching, rashes, discharge from nipples. The subject is also questioned about family history of gynecologic problems and any surgeries undergone in the past for gynecologic illnesses.

Thorough examination includes an examination of the external and internal genital organs as well as the breasts. The breasts are examined for irregularities, size, and shape, and then palpated for abnormal masses, lumps, tightened skin, and tenderness. The physician then performs pelvic examination, which is performed with the subject being placed in lithotomy position. The examining tables have heel or knee stirrups, which help the subject to maintain or hold this position. The physician first examines the external genital area, notes the distribution of hair in that area or any other abnormalities, lesions, inflammation, swelling, discoloration, and discharge. The examiner inspects the urinary meatus, Bartholin glands, and Skene glands by palpating them.

After inspecting the external genitalia, the physician then examines the deeper areas of vagina and cervix with the help of a lubricated speculum that spreads the walls of vagina apart for good visual examination. The cervix can be examined closely by passing a colposcope to look for signs of infection or cancerous growths. When this is over, a bimanual pelvic examination is performed. Herein, the examiner inserts the lubricated index and middle fingers of one gloved hand in to the vagina and places the other hand on the lower abdomen above the pubic bone. Between the two hands, the examiner can assess the uterus for its shape, firmness, position, size, and amount of tenderness, and can detect any masses if present. The physician then performs a rectovaginal exam by inserting an index finger in the vagina and the middle finger in the rectum and examines the back wall of vagina for its thickness, masses, or abnormal growths.

Pathology

Ectopic pregnancy/tubal pregnancy
An ectopic or tubal pregnancy occurs when the fertilized egg becomes implanted in one of the fallopian tubes and develops there (or elsewhere in the pelvic cavity) rather than the uterus (See Fig. 11.3). Tubal pregnancy is a leading cause of maternal death during the first trimester. As the embryo grows inside the fallopian tubes, it stretches it. If left untreated or unnoticed, it can result in rupture of the tube and sudden and massive bleeding. If the tube ruptures, immediate, surgery is necessary to save the woman's life.

Endometriosis
Endometriosis is a female reproductive system's disorder in which the endometrial tissue that normally lines the uterus, grows in other parts of the body, most likely on the pelvic area, including fallopian tubes, ovaries, outer surface of the uterus, colon, and other pelvic structures (See Fig. 11.4). The endometrial tissue responds to hormonal changes that occur during the menstrual cycle in the manner the endometrium itself does. During the menstruation just like endometrium, this endometrial tissue also breaks and bleeds but finds no outlet. As a result, the tissue becomes inflamed and swollen and results in intense cramps during latter days of menstruation. There is no cure for endometriosis but its growth can be slowed down by hormonal treatments.

Genital herpes
Genital herpes is a sexually transmitted disease in which red blister-like sores develop in the genital area and anorectal area. In women, these sores may be present in the vagina, cervix, and urethra. It is caused by herpes simplex virus type 2. In men, lesions appear on the glans penis, foreskin, or penile shaft.

Pelvic inflammatory disease
Pelvic inflammatory disease is a general term for the infection of woman's internal reproductive organs, which may be acute, subacute, or chronic in nature. It may include endometriosis or inflammation of lining or uterus, myometritis or inflammation of uterine muscles, cervicitis or inflammation of the cervix, oophoritis or inflammation of ovaries, or salpingitis or inflammation of fallopian tubes. Most pelvic inflammatory diseases are sexually transmitted. Gonorrhea and chlamydia are two very common causes underlying pelvic inflammatory disease. Symptoms of acute pelvic inflan1matory disease include severe abdominal pain, tenderness and high fever. Pelvic inflammatory disease, if left untreated, may lead to infertility. It also increases chances of ectopic pregnancy in females.

Premenstrual syndrome
Premenstrual syndrome is collection of numerous physical and psychological (emotional) symptoms associated with menstrual cycle/menstruation. Premenstrual symptoms usually begin a week before menstruation and disappear as soon as it starts. There are myriad manifestations of premenstrual syndrome. Common physical manifestations of premenstrual syndrome may include swelling of the breasts and tenderness, headaches, backaches, cramps, dizziness, digestive disorders, joint and muscle pain, flare up of acne, and palpitations. The psychologic symptoms may include mood swings, feelings of anxiety, irritability, depression, fatigue, foods cravings, insomnia aggressive behavior, lethargy, and panic attacks.

Toxic shock syndrome
Toxic shock syndrome is a rare but fatal disease caused by toxins produced by a strain of Staphylococcus aureus bacteria. Maximum percentages of those affected by toxic shock syndrome are women who use vaginal tampons and vaginal sponges. A painless red rash develops, starting on the trunk and quickly spreading to legs, arms, soles, and palms, followed a week or two later by peeling of skin, especially on the soles and palms. If left untreated, this disease can be fatal.

Vaginitis
Inflammation of vagina and often vulva as well is called vaginitis. Most common symptoms include intense itching, vaginal discharge which varies in color, odor, and consistency, depending upon the cause. It may also lead to painful intercourse or urination. It can be caused by protozoa Trichomonas vaginalis, which causes a profuse, frothy discharge with an unpleasant odor; by Gardnerella vaginalis bacterium, which produces blood-streaked, white or yellow discharge with fishy odor; or by Candida albicans which produces a cheesy discharge with yeast-like odor.

Procedures

Alpha-fetoprotein test
Alpha-fetoprotein is a globulin produced by liver and other tissues of the fetus and the newborn. Its level normally declines after one year of age. An elevation of alpha-fetoprotein may suggest hepatocellular carcinoma, viral hepatitis, hepatic cirrhosis, and various teratocarcinomas and embryonal carcinomas of gonadal origin. Elevation of alpha-fetoprotein (AFP) occurs in neural tube defects (anencephaly, spina bifida).

Amniocentesis
Amnion is the innermost membrane enveloping the embryo. Sometimes, to test the fetal abnormalities, a hollow needle is inserted into the uterus of a pregnant woman and tissue samples are drawn out. This puncture of amniotic sac and removal of amniotic fluid is known as amniocentesis. The tissue samples are cultured for biochemical and cytological studies.

Chorionic villus sampling
Chorionic villus sampling or CVS is used to detect chromosomal abnormalities and biochemical disorders of the fetus. A catheter is inserted into the cervix and in the outer portion of the cervix, and a sample of chorionic villi is obtained.

Colposcopy
Colposcope is a stationary low-power microscope used in conjunction with a vaginal speculum to inspect the cervix. Colposcopy facilitates the identification of cervical dysplasia in women with abnormal Pap smears and as an aid in biopsy and excision procedures.

C-section
C-section is carried out in cases of cephalopelvic disproportion, presence of STDs, fetal distress, and breech presentation. The abdomen and the uterus are incised (abdominal hysterotomy) to remove the fetus.

Culdoscopy
An endoscopic inspection of the cul-de-sac or the pouch of Douglas is known as culdoscopy. Cul-de-sac is the lowermost part of the peritoneal cavity and lies between the uterus and the rectum. Culdoscopy is performed under anesthesia, and the instrument, culdoscope, is inserted vaginally.

Dilatation and Curettage
The cervical canal is widened with a graded dilator, and the uterine endometrium is scraped with a curette. This procedure is resorted to in cases of cytologic examination, abnormal uterine bleeding, and as a therapeutic measure for incomplete abortion. This procedure is generally done in the operating room under anesthesia.

Endometrial smear/endometrial biopsy
Endometrial smear or endometrial biopsy refers to the microbiologic study of tissue samples from the endometrium. This histological study detects any abnormality or malignancy in the high-risk patients. Endometrial smear is performed during a gynecologic examination. This procedure is performed under local anesthesia and a thin, hollow curette is used to extract the endometrial tissue, which is then sent for laboratory studies.

Exfoliative cytology
Exfoliative cytology is the microscopic examination of the stained cells, which are usually brushed or scraped from the uterine cervix or the interior of the stomach. This cytology detects any malignant or premalignant changes.

Laparoscopy
Laparoscopy implies inspection of the abdominal cavity. An incision is made through the abdominal wall and an endoscope is inserted. This endoscope, which is a tubular instrument with illumination and magnification facility, is inserted though the incision, and the pelvic viscera are explored for any abnormality.

Papanicolaou test or Pap test
In this test, superficial cells are removed from the vagina and cervix for a cytologic examination. Hormonal effects are determined and abnormal cell changes detected. The reasons are generally traced to inflammation, infection, dysplasia, and sometimes actual malignancy. The samples of the exfoliative cells are taken from the following areas: the vaginal vault, the squamocolumnar junction, and the endocervical canal. Squamocolumnar junction refers to the transition line between the squamous epithelium of the vagina and the columnar epithelium of the endocervical canal. The specimens from the vaginal vault and the squamocolumnar junction are taken with the help of a wooden spatula (Ayre spatula in case of squamocolumnar junction). A bristle brush is used to secure the sampling of the columnar cells from the endocervical canal. The results are explained as per the Bethesda system. The adequacy of the specimen is assessed and effects of estrogen and progesterone are determined. Inflammatory, degenerative, dysplastic, and malignant changes in cells are identified. Other infections, like candida, trichomonas, herpes simplex, are detected.

Pregnancy test
The detection of chorionic gonadotropin in the serum is the basis for most serum pregnancy tests in current use. The result of this qualitative test may be reported as simply positive or negative. Urine pregnancy test depends on identification of chorionic gonadotropin in urine. Serum hCG levels rise rapidly in early gestation. Human chorionic gonadotropin can be measured by the following tests: bioassay, agglutination immunoassay, radioimmunoassay, radioreceptor assay, and immunometric assay. Immunoassay is one of the most important, rapid, inexpensive, and relatively reliable tests for pregnancy.

Tubal ligation
Tubal ligation is a contraceptive method (sterilization surgery) in which the continuity of uterine tubes or oviducts is interrupted by cutting, cautery, or by a plastic or metal device to prevent a future conception.

Ultrasonography
Ultrasonography is a radiographic procedure, during which ultrasonic waves are used to produce an image or photograph of a tissue or organ. Ultrasonic waves are passed through the tissues having different densities and resultant images are recorded. This is a non-invasive technique to evaluate the female reproductive system and the fetus.

Pharmacology

Contraceptives (steroidal, chemical)
Contraceptives inhibit ovulation and thereby act as a deterrent against pregnancy. They are available in the form of steroids and chemicals. Steroids are generally oral contraceptive pills (OCPs), a combination drug of estrogen and progesterone. On the other hand, chemical contraceptives come as foam, gel, cream, or other spermicidals, which are placed in the vagina before the intercourse. They prevent pregnancy by killing the sperms. Some of the oral contraceptives used are ethinyl estradiol and levonorgestrel, mestranol and norethindrone.

Estrogen hormones
Estrogen hormones are used as oral contraceptives as well as in the treatment of postmenopausal osteoporosis. They act by binding the estrogen nuclear receptors. However, prolonged use of this hormone can lead to skin rash, thromboembolism, and endometrial cancer. Estradiol (Estrace), estrogens and medroxyprogesterone (Prempro) are some examples.

Oxytocin
Oxytocin is a neurohypophyseal hormone that causes myometrial contractions at term and promotes milk release during lactation. Oxytocin is used for induction or stimulation of labor. They are also used to manage the postpartum hemorrhage and atony, e.g. Pitocin.

Important things to know:
· Female reproductive organs lie inside the bony pelvis, while male organs lie mainly outside the pelvis.
· Menstruation occurs due to loss of functional layer of the endometrium if conception does not take place. It lasts for an average of 3 to 6 days.
· The study of female reproductive system is called gynecology and the physician who specializes in it is called a gynecologist.
· In females, the reproductive cycle is called a menstrual cycle and is of approximately 28 days' duration; the ova is released in mid cycle.
· Obstetrics is the specialty concerned with pregnancy, parturition, or delivery of fetus and physician who specializes in this branch is known as obstetrician.

AB Abortion
AFP Alpha-fetoprotein (expressed by germ cell tumors and other cancers).
C-section Cesarean section.
CIS Carcinoma in situ.
CS Cesarean section.
CX Cervix.
D&C Dilatation and curettage.
DES Diethylstilbestrol.
DUB Dysfunctional uterine bleeding.
ECC Endocervical cell collector.
EDC Estimated or expected date of confinement.
EMB Eosin methylene blue agar.
ERT Estrogen replacement therapy.
FHT Fetal heart tones.
G Gravida.
GYN Gynecology.
HCG Human chorionic gonadotropin.
HSG Hysterosalpingography.
IUD Intrauterine device.
IUP Intrauterine pregnancy.
LH Luteotropic hormone.
LMP Last menstrual period.
OB Obstetrics.
OCP Oral contraceptive pills.
para Number of pregnancies.
Path Pathology.
Peds Pediatrics.
PID Pelvic inflammatory disease (CDC documentation).
PMS Premenstrual tension syndrome (late luteal phase dysphoric disorder).
Primip Primipara/primiparity.
TAH Total abdominal hysterectomy.
UC Uterine contractions