Ebook Jeffcoate’s principles of gynaecology (8/E): Part 1

Jeffcoate’s
PRINCIPLES OF GYNAECOLOGY

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Jeffcoate’s
PRINCIPLES OF GYNAECOLOGY
Eighth International Edition
Revised and updated from the Seventh Edition by

Narendra Malhotra  MD FICOG FRCOG (Honoris Causa)
Professor, Dubrovnik International University, Croatia
FOGSI Representative to FIGO
Consultant and Director, Global Rainbow Healthcare
Agra, Uttar Pradesh, India

Pratap Kumar  MD DGO FICOG
Professor and Head, Department of Obstetrics and Gynaecology
Kasturba Medical College, Manipal, Karnataka, India
Past Vice President, The Federation of Obstetric and Gynaecological Societies of India (FOGSI)
Jaideep Malhotra MD FICOG

Professor, Dubrovnik International University, Croatia

Honorary General Secretary, Indian College of Obstetrics and Gynaecology
President
The Asia Pacific Initiative on Reproduction (ASPIRE)
Consultant and Director, ART Rainbow-IVF
Agra, Uttar Pradesh, India

Neharika Malhotra Bora MD

Assistant Professor, Department of Obstetrics and Gynaecology
Bharati Vidyapeeth Medical College, Pune, Maharashtra, India

Parul Mittal MD

Consultant
Global Rainbow Healthcare
Agra, Uttar Pradesh, India

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Jeffcoate’s Principles of Gynaecology

First Edition
Fifth Edition
Sixth Edition
Seventh Edition
Eighth Edition

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: 2008
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The teachers of gynaecology and
the students

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Preface to the Eighth International Edition
We, Narendra Malhotra and Pratap Kumar, feel very honoured for being asked to revise again the best textbook on gynaecology
by Sir Norman Jeffcoate.
Dr Jaideep Malhotra (ART specialists) has especially added inputs in infertility, assisted reproductive technology and other
chapters.
In the rapidly advancing age of technology and rapidly changing trends in management, diagnosis, drugs and procedures,
it is of paramount importance to update books and manuals periodically. This book was earlier updated and edited (2008) by
us as an international edition (Seventh edition), but soon the publishers felt the need for revising it within a span of five years.
Professor Norman had expressed in 1974 that he had endeavoured to preserve his personal approach.
We have added many new chapters and rewritten a few chapters, all together trying to maintain Sir Jeffcoate’s style.
We have retained the description of Professor Jeffcoate’s original case discussions, photographs and pictures.
New additions have been made on the feedback from postgraduate students.
Dr Neharika Malhotra Bora, Assistant Professor, Bharati Vidyapeeth Medical College, Pune, Maharashtra, India, and
Dr Parul Mittal, Consultant, Global Rainbow Healthcare, Agra, Uttar Pradesh, India, have been instrumental in adding a lot of
inputs.
Dr Nidhi Gupta, Dr Pranay Shah, Dr Maninder Ahuja, Dr Kanta Singh, and Dr Narayan M Patel have painstakenly revised
and edited and updated many chapters.
We hope that the undergraduate and the postgraduate students will appreciate our efforts to update this Bible of
Gynaecology.

Narendra Malhotra
Pratap Kumar
Jaideep Malhotra
Neharika Malhotra Bora

Parul Mittal

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Preface to the Fifth Edition
It was inevitable that following Professor Sir Norman Jeffcoate’s retirement, there would be pressure to continue to publish the
Principles of Gynaecology.
In the last revision in 1974, Sir Norman emphasised that he had endeavoured to preserve his personal approach, bearing
in mind the objectives and principles outlined in the preface to the First Edition. In addition, some of Sir Norman’s comments
in the preface to his Fourth Edition are included to emphasise the guidelines the present author has taken in an attempt to
maintain the format of the Principles of Gynaecology.
Much of the material presented is retained from the last edition, since it also reflects the gynaecological training of the
author under Professor Jeffcoate in Liverpool. The views expressed are therefore personal ones from a pupil of Sir Norman
Jeffcoate against the background of all the information available. Once given, the views expressed mean that references are
excluded for the special reasons given in the preface to the First Edition.
In the process of being taught Obstetrics and Gynaecology by Sir Norman, one was encouraged to consider all the facts
about a case, to come to a conclusion and to be able to justify it. Even though a critical approach to each case was expected, we
were never allowed to forget that we were dealing with a woman, mother or child with a personal problem. Indeed, Professor
Jeffcoate’s personal approach was such that in a clinic with many students and postgraduates present, it was obvious that as
far as the patient was concerned Sir Norman was the only person there. I have never been able to achieve the same effect, but
I hope that my efforts in revising this book will be acceptable to an outstanding teacher, guide and friend. If so, then I am sure
it will benefit all those who read it.

Victor Tindall

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Extracts from the Preface to the First Edition





The book is meant to add to rather than replace clinical and tutorial instruction, so those matters which can best be taught
beside the patient, or which are easy for any student to learn and understand from other sources, receive little attention.
In planning the text, I recalled those subjects which I myself found (and still do find) difficult to master, or on which I had to
search far and long for information, and gave them disproportionate emphasis. This and other considerations resulted in a
disregard for the relative importance, as judged by their clinical frequency, of different conditions. Indeed, the reader will find
that quite rare conditions are mentioned, illustrated or described at length; and that all manner of asides—even some with an
obstetrical flavour—creep in. This is partly because they are of special interest to me but mainly because they appeared to offer
scope for presenting an attitude of mind; for discouraging loose thinking and empiricism; for inculcating a scientifically and
ethically honest outlook; for emphasising the art as well as the science of gynaecology.
I have not played safe by stating only generally accepted views, nor have I played fair by giving the differing views of various
authorities. Instead, after weighing the evidence, I have attempted to reach a conclusion which satisfies me as being as rational
as present knowledge allows. Without intended disrespect, mention by name of authors and workers has been avoided as
a rule; references clutter up the text, destroy continuity and are hardly ever used properly. On the other hand, I have not
hesitated to give my own views and have, at times, been more dogmatic than clinical experience ever really justifies. I have
even gone so far as to enunciate ideas which in many respects are conjectural, if not fanciful. I do not expect these all to be
accepted; if they are I shall be disappointed because their object is to provoke trains of thought and discussion.
In offering this book to fellow students, I remember with affection and gratitude William Blair-Bell, one of the great
gynaecologists of this century. He not only taught me gynaecology and a particular approach to it, he taught me to think and to
write. He, more than anyone else, provided me with the stimulus and the opportunity to obtain the experience which has led

to this work.

Norman Jeffcoate

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Acknowledgements

To edit a book written by a legend Professor Jeffcoate is a mammoth task. Professor Pratap Kumar, myself and Dr Jaideep
Malhotra did a lot of researches and asked all our students to suggest what more they wanted in the eighth edition. Dr Neharika
Malhotra Bora and Dr Parul Mittal have helped immensely in adding a lot of material to the chapters and updating many of
them.
We are thankful to the editorial board members for their contributions and valuable inputs.
We are grateful to all those who have helped us to do this mammoth job. Special appreciations and thanks are to:
1. We thank doctors and staff of Department of Obstetrics and Gynaecology, Kasturba Medical College, Manipal, Karnataka,
India.
2. We thank junior doctors of Malhotra Nursing and Maternity Home (P) Ltd. and Global Rainbow Healthcare, Agra, Uttar
Pradesh, India.
3. Our special thanks to the following, who have given valuable suggestions in various chapters: Professor Barun Sarkar,
Professor Arun Nagrath, Dr Richa Singh, Dr Anju Sharma, Dr Alka Saraswat, Dr Anupam Gupta, Dr Sunder Rajan
(Pondicherry), Dr Col R Puri (Jalandhar), late Dr Sakshi Tomar (PGI, Lucknow, Uttar Pradesh, India).
4. Special thanks to Dr Vivek Nahar for his contribution.
5. Special thanks to Dr Richa Saxena for getting the manuscript edited.
We are thankful to our families for bearing with us and sharing family time for work like this.
We thank Vidya, late Dr Prabha Malhotra, Deepali, Deepika, Dr RM Malhotra and Kehsav.
We hope the students of gynaecology will like what we have produced in the eighth edition.
We have tried to retain Professor Jeffcoate’s style and some of the valuable photographs from the first edition.

Narendra Malhotra

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Contents

1. A Clinical Approach to Gynaecology

1

Psychosomatic and Sociological Aspects of Gynaecology  1; Clinical Methods  2;
Physical Examination 5; Special Tests and Accessory Aids to Diagnosis 10; Endometrial
Sampling Procedures 10; Transvaginal Sonography 13; Transrectal Sonography 13;
Colour Doppler 13; Endoscopy 14; Laparoscopy 14; Hysteroscopy 16; Computed
Tomography 16; Magnetic Resonance Imaging 17

2. Anatomy

18

Vulva 18; Vagina 22; Uterus 26; Fallopian Tubes 30; Ovary 32; Urethra and Bladder 32; Ureter 36;
Sigmoid Colon 37; Rectum and Anus 37; Pelvic Peritoneum and Ligaments 38; Pelvic Musculature 39;
Pelvic Fascia and Cellular Tissue 40; The Supports of the Genital Organs 40; Blood Vessels of
the Pelvis 41; Lymphatic Drainage 46; Innervation of Pelvic Organs 46

3. Ovarian Functions

50

Production of Ova 51; Ovarian Hormones 61; Pituitary Hormones 66; Pituitary-Hypothalamic
Relations 67; Pituitary-ovarian Relations (Control of Ovulation) 69; Hormone Levels and Assays 70

4. Menstruation and Other Cyclical Phenomena

72

Normal Menstrual Cycle 72; Endometrial Cycle 72; Correlation of Endometrial and Ovarian Cycles 75
Uterine Bleeding 76; The Myometrial Cycle 78; Cyclical Changes in the Tube 78; The Cervical Cycle 78;
The Vaginal Cycle 79; Cyclical, Metabolic, Vascular and Psychological Changes 79

5. Clinical Aspects of Menstruation and Ovulation

80

Menstruation 80; The Menopause and the Climacteric 82; Abnormal Menopause 89; Ovulation 90

6. Puberty and Adolescent Gynaecology

99

Puberty and Adolescence 99; Puberty Menorrhagia 109

7. Conception

111

Fertilisation of the Ovum 111; Early Development of the Ovum 113; Implantation of the Ovum into
the Uterus 113; Formation of Foetus and Membranes 116; Hormonal Control of Early Pregnancy 119

8. Spontaneous Abortions (Including Recurrent Loss)

121

Spontaneous Abortions 121; Pathology of Spontaneous Abortions 121; Clinical Varieties of
Spontaneous Abortions 124; Recurrent Early Pregnancy Loss 127

9. Ectopic Pregnancy

130

Frequency of Ectopic Pregnancy 130; Sites of Ectopic Pregnancy 130; Aetiology of Ectopic
Pregnancy 131; Ectopic Pregnancy in Fallopian Tubes 133; Ovarian Pregnancy 143; Cornual
Pregnancy 144; Cervical Pregnancy 144; Abdominal Pregnancy 145; Intraligamentary Pregnancy 146

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10. Gestational Trophoblastic Disease

147

Epidemiology 147; Types of Tumours 147; Hydatidiform Mole 148; Persistent Gestational
Trophoblastic Tumour 154

11. Breast Function and its Disorders

159

Breast Development 159; Developmental Anomalies of Breast 161; Suppression of Lactation 163;
Drugs and Lactation 163; Endocrine Disorders (Galactorrhoea and Breast Atrophy) 164;
Benign Breast Condition 168; Screening for Breast Diseases 168; Benign Breast Disease 169;
Breast Cancer 171

12. Development of the Urogenital System

176

The Gonad 176; Wolffian System 176; Müllerian Ducts 180; Mesenteries and Ligaments 180;
Development of the Vagina, Bladder and Urethra 180; Development of the Vulva 181
13.

Malformations and Maldevelopments of the Genital Tract

182

Müllerian Duct Anomalies 182; Ovary 193; Fallopian Tube 194; Uterus 194; Vagina 195;
Vulva 197; Errors Arising in Connection with the Cloaca 199; Malformations of the
Urinary Tract 200

14. Sex Determination, Asexuality and Intersexuality

203

Physiological Considerations 203; Intersex 203; Sex Determination in the Foetus and
its Anomalies 204; Chromosomal Sex 204; Sex Chromosomal Intersex 210; Autosomal

Intersex 213; Gonadal Intersex 214; Hormonal Intersex 214; Psychological Sex 221;
Sex of Rearing 221; The Management of Aberrations of Sex Present at Birth 221;
Specialised Treatment Schedules 224; Intersex Developing after Birth 225; Feminism 225

15. Injuries

232

Foreign Bodies in the Genital Tract 232; Vaginal Burns 234; Direct Trauma to Vulva and
Vagina 234; Defective or Deficient Perineum 235; Complete Perineal Tear 236; Laceration
of the Cervix 237; Rupture and Perforation of the Uterus 239; Broad Ligament Haematoma 240;
Genital Tract Fistulas 240; Acquired Atresia and Stenosis of the Genital Tract 247

16. Pelvic Organ Prolapse

251

Uterine and Vaginal Prolapse 251; Prolapse of the Ovaries 268

17. Other Displacements of the Uterus

269

Upward Displacement of the Uterus 269; Lateral Displacement of the Uterus 269;
Forward Displacement of the Uterus 269; Backward Displacement of the Uterus 270;
Retroverted Gravid Uterus 274; Inversion of the Uterus 275; Chronic Inversion 276

18. Torsion of Pelvic Organs

279

Torsion of the Normal Organs 279; Torsion of Abnormal Organs 279; Aetiology 280;
Differential Diagnosis 281; Treatment 281

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19. Infections Including STD

282

The Natural Defences of the Genital Tract 282; Sexually Transmitted Diseases 283; Other Sexually
Transmitted Infections 289; Genital Tuberculosis 294; Sarcoidosis 301; Actinomycosis 302;
Schistosomiasis (Bilharzia) 302; Amoebiasis 302

20. Infections as they Affect Individual Organs

303

Vulvitis 303; Bartholinitis 307; Vaginitis 308; Cervicitis 315; Endometritis 317; Metritis 318;
Salpingo-oophoritis 318; Oophoritis 323; Pelvic Peritonitis 323; Pelvic Cellulitis 324;
Chronic Cellulitis 325; Pelvic Inflammatory Disease 326; Suppurative Thrombophlebitis
of the Pelvic Veins 329

21. Genital Tuberculosis

330

Clinical Profile 330

22. Endometriosis and Allied States

341

Endometriosis and Adenomyosis 341; Adenomyosis 357; Endosalpingiosis 359;
Cervical Endometriosis 359

23. Polycystic Ovary Syndrome

360

Puberty and PCOS 365; Menstrual Irregularities 365; Hirsutism 366; Metformin 367;
Long-term Monitoring 368

24. Hirsutism

369

Virilisation and Masculinisation 369; Diagnosis of Hyperandrogenism 372; Late-onset
Adrenal Hyperplasia 374

25. Epithelial Abnormalities of the Genital Tract

375

Vulva 375; Vagina 382; Cervix 383; Uterine Corpus 394; Fallopian Tube 397

26. Genital Cancers

398

Importance of Genital Cancer 398; Treatment and Results 398; Prevention of Pelvic Cancer 399;
Early Diagnosis 399; General Management of the Cancer Patient 403; Management of
Advanced Pelvic Cancer 404

27. Tumours of the Vulva

409

Swellings of the Vulva 409; Varicose Veins 410; Oedema 410; Retention Cysts 410;
Benign Neoplasms 411; Malignant Neoplasms 413; Tumours of Bartholin’s Gland 418;
Urethral Tumours 419; Tumours of the Inguinal Canal 422

28. Tumours of the Vagina

423

Swellings of the Vagina 423; Vaginal Cysts 423; Benign Neoplasms 424;
Malignant Neoplasms 426

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29. Tumours of the Cervix Uteri

432

Enlargements of Cervix 432; Cysts of the Cervix 432; Endometriotic or Endocervicotic Cysts 432;
Benign Neoplasms 433; Carcinoma of the Cervix 434; Relapse 449; Other Malignant Tumours
of the Cervix 451

30. Tumours of the Corpus Uteri

452

Enlargement of Uterus 452; Polyps 452; Benign Neoplasms 452; Tumours of the Corpus Uteri 452;
Malignant Neoplasms 472

31. Tumours of the Fallopian Tubes

484

Benign Neoplasms 484; Secondary Malignant Neoplasms 484; Primary Malignant Neoplasms 484

32. Tumours of the Pelvic Ligaments

487

Cysts of the Broad Ligament and Associated Structures 487; Neoplasms of the Pelvic Ligaments and
Connective Tissues 488; Neoplasms of the Peritoneum 489

33. Tumours of the Ovary

490

Ovarian Enlargements 490; Distension or Retention Cysts 490; Types 490; Ovarian Neoplasms 493;
Age 515; Pain and Tenderness 515; Ovarian and Parovarian Tumours and Pregnancy 526

34. Chemotherapy in Gynaecological Malignancies

528

Clinical Use of Chemotherapy 528; Assessment of Response to Chemotherapy 529; Chemotherapy
and the Cell Cycle 529; Stem Cell Theory 529; Cell-kill Hypothesis 529; Therapeutic Agents Used
in the Treatment of Gynaecological Cancer 531; Chemotherapy Resistance of Cancer Cells 532;
Poor Host Defences 532; Protected Tumour Sanctuaries 532; Route of Administration 533

35. Radiotherapy in Gynaecological Malignancies

534

The Biological Basis of Radiotherapy Treatment 534; Radiation Dosage 534; The Therapeutic
Ratio 535; Radiotherapy Machines 535; Brachytherapy 535; Radiotherapy in Endometrial
Cancer 535; Aggressive Histological Variants 536; Radiotherapy in Carcinoma Cervix 536;
Brachytherapy in Carcinoma Cervix 536; External Radiation Therapy Techniques 537;
Chemoradiation in Locally Advanced Carcinoma Cervix 537

36. Immunotherapy in Obstetrics and Gynaecology

538

Definition 538; Basics of Immunotherapy 538; Causes of Failure of Immunosurveillance 538;

Tumour-associated Antigens 538; Types of Immunotherapy 539; Monoclonal Antibodies
as Therapeutic Agents 541; Other Areas of Application of Immunotherapy in Obstetrics
and Gynaecology 542

37. Amenorrhoea, Hypomenorrhoea and Oligomenorrhoea

543

Amenorrhoea 543; Aetiology 543; Hypomenorrhoea 558; Oligomenorrhoea 558

38. Abnormal and Excessive Uterine Bleeding
Clinical Types 560; Causes of Abnormal Uterine Bleeding 561; Diagnosis 567; Treatment 569;
Mirena (Levonorgestrel Intrauterine Device) 573; Transcervical Endometrial Resection 573;
Microwave Endometrial Ablation 573; Special Clinical Types of Bleeding 575

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Contents

39. Dysmenorrhoea

579

Primary Dysmenorrhoea 579; Secondary Dysmenorrhoea 583; Membranous Dysmenorrhoea 585;
Other Conditions Simulating Dysmenorrhoea 585

40. Premenstrual Syndrome and Other Menstrual Phenomena

587

Premenstrual Syndrome 587; Menstrual Migraine 590; Premenstrual Mastalgia 591;
Recurrent (Cyclical) Buccal and Vulvar Ulceration 591; Pelvic Allergy 593; Vicarious
Menstruation 593; Cyclical Haemothorax and Pneumothorax 593; Menstrual Epilepsy 594

41. Hormone Therapy in Gynaecology

596

Oestrogens 596; Anti-oestrogens 602; Progestogens 603; Antiprogestogens 605; Androgens 605;
Antiandrogens 607; Types of Gonadotrophins 608; Antigonadotrophins 609; Hypothalamic
Hormones 611

42. Vaginal Discharge

613

General Considerations 613; Types and Causes 613; Investigation of Vaginal Discharge 616;
Syndromic Approach to Vaginal Discharge 617

43. Pruritus Vulvae and Vulvodynia

618

Definition and Incidence 618; Natural Defence Mechanisms 618; Pruritus Associated with Vaginal
Discharge (Leucorrhoea) 619; Pruritus without Vaginal Discharge 621; Vulvodynia 624

44. Low Backache and Chronic Pelvic Pain

630

General Considerations 630; Causes in the Genital Tract 630; Extragenital Causes 631;
Management and Treatment 632

45. Problems of Sex and Marriage

635

Physical Sex—Coitus 636; Masturbation 638; Apareunia and Dyspareunia 638; Female
Frigidity 641; Nymphomania 643; Coital Difficulties in the Male 644; Homosexuality 646;
Transvestism and Trans-sexuality 647; Premarital Chastity and Faithfulness in Marriage 648
46.

Infertility and Assisted Reproductive Technology

650

Infertility 650; Frequency 650; A Concept of Fertility 650; Causes of Infertility 651;
The Investigation of Infertility 655; Treatment 665; Assisted Reproductive Technology 672;
Results of Treating Infertility 679; Dangers of Investigating and Treating Infertility 679;
Adoption 680

47. Instruments in Gynaecological Procedures

682

Instruments 682; Some of the Instruments Mentioned Warrant Special Comments 682;
Specific Instruments Used only for Gynaecological Operations 685; Suture Materials 687;
Gynaecological Procedures 687

48. Ultrasonography in Gynaecology

691

Ultrasonography 691; Normal Female Pelvis 691; Ultrasound of the Uterus 694;
Diseases of the Cervix 705; Vagina 706; Ovarian Sonography 706; Gestational
Trophoblastic Disorders 715

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49. Endoscopic Surgery in Gynaecology

716

Laparoscopy 716; Hysteroscopy 727

50. Contraception

733

General Consideration 733; Epidemiology 733; Efficacy of Contraception 734; Indications for

Contraception 734; Contraceptive Methods 735; Natural Family Planning Method 735;
Barrier Methods 737; Intrauterine Contraceptive Devices 742; Combined Hormonal
Contraception 756; Emergency Postcoital Contraception (Morning after Pills) 770;
Other Methods of Contraception 772; Contraception and Litigation 775

51. Sterilisation and Termination of Pregnancy

776

Sterilisation 776; Female Sterilisation 777; Male Sterilisation 779; Compulsory Sterilisation 780;
Termination of Pregnancy 780; Abortion as a Means of Contraception 787

52. Urinary Problems

788

Bladder Dysfunction 788; Urethral Sphincter Dysfunction 791; Investigation of Urinary Problems 792;
Treatment of Urinary Problems 795; Incontinence of Urine 795; Enuresis 804; Urinary Retention
and Difficulty in Micturition 805; Urinary Tract Infections in Women 808

53. Menopause

811

History 811; Definitions and Staging of Menopause 811; Physiology of Menopause 813;
Problems Associated with Menopause 815; Effect of Oestrogen Deficiency 815;
Menstrual Problems 822; Cancer Screening in Menopause 823; Various Types of Hormonal and
Non-hormonal Pharmacological Agents Available 825; Use of Progesterone for HRT 826;
HT in Special Circumstances 827; Androgens in Menopause 828

54. Hysterectomy and its Aftermath

830

Indications for Hysterectomy 830; Types of Hysterectomy 830; Routes of Hysterectomy 831;
Should the Ovaries be Removed? 832; Should the Uterus be Removed at the Time of
Bilateral Oophorectomy? 833; The Aftermath of Hysterectomy 834

55. Conditions of the Lower Intestinal Tract

835

Rectal Prolapse  835; Incontinence of Faeces and Flatus 836; Diarrhoea 837;
Difficult Evacuation 837; Irritable Bowel Syndrome 838; Pruritus Ani 839;
Rectal and Anal Pain 839

56. Preoperative and Postoperative Management: Postoperative Complications

842

Fluid and Electrolytes 842; Preoperative Management 843; Postoperative Management 845;
Postoperative Examination 848; Postoperative Complications 849

57. Nutrition in Women from Adolescence to Menopause
Nutrition Basics 863; Proteins 864; Fats 864; Carbohydrates 866; Energy 868;
Adolescents Nutrition 869; Nutrition in Pregnancy 875; Nutrition in Elderly 878

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58. Exercise and Physiotherapy in Gynaecology



Contents

882

Active Muscle Exercises 882; Electrical Stimulation of Pelvic Muscles 883; Supporting
Pessaries 883; Vaginal Packing: Tamponade 886; Douching 886; Short-wave Therapy 886;
Infrared Radiation 887; Transcutaneous Electric Nerve Stimulation 887; Ultrasound 887

888







59. Applications of Laser in Gynaecology

Laser Surgery for Cervix 888; Laser Surgery of the Vulva 888; Laser Surgery of the Vagina 889;
Intra-abdominal Laser Surgery 889; Hysteroscopic Laser Surgery 889

890







60. Robotics Surgery

Features of Robotic Surgery 890; Overview 890; Advantages of Robotic Surgery 892;
Risks of Robotic Surgery 894; Innovations Used in Robotic Surgery 894; Indications for Use of
Robotic Surgery in Gynaecology 895; Endometriosis 896; Myomectomy 897;
Criticism and Controversies 898

901



Index

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1

CHAPTER

A Clinical Approach to
Gynaecology

“Mulier est hominis confusio—Madame, the sentence of this Latin is, ‘Woman is mannes joye and all his bits’. ”

•
•
•
•
•
•
•

• P
 sychosomatic and Sociological Aspects of
Gynaecology
• Clinical Methods
• Physical Examination
• Special Tests and Accessory Aids to Diagnosis
• Endometrial Sampling Procedures
• Transvaginal Sonography

INTRODUCTION
Gynaecology (from the Greek gyne, woman, and logos,
discourse) is the study of woman but usage restricts it
mainly to the study of the female organs of reproduction
and their diseases. This is convenient although the dividing

line between gynaecology and other branches of medicine
is ill-defined, and varies from time to time and from clinic
to clinic according to advances in knowledge, to custom
and to local working conditions. At one time, the breasts
were wholly within the domain of the gynaecologist but
now the general surgeon deals with certain breast disorders,
and the gynaecologist and obstetrician with the others.
The genital tract is so closely linked, embryologically and
anatomically, with the urinary tract and the large bowel
that certain conditions of the urethra, bladder and rectum
come to a greater or lesser extent within the province of the
gynaecologist. The whole endocrine system is concerned with
the control of genital functions while the psyche and sex are
inseparable.
It may be added that, according to definition, obstetrics
(the study of childbirth and its disorders) is merely one aspect
of gynaecology and, in practice, the two cannot properly be
separated.
These points merely serve to emphasise that it is impossible to consider the reproductive system except in relation to
the remainder of the body, and that it is necessary to interpret
gynaecology in the widest sense. Woman is more than just a

— Chaucer

Transrectal Sonography
Colour Doppler
Endoscopy
Laparoscopy
Hysteroscopy
Computed Tomography

Magnetic Resonance Imaging

container for a uterus and ovaries. The development of the
highly specialised gynaecological surgeon not only improves
operative technique but also may engender a narrow and
harmful outlook. Such a specialist can become a craftsman
first and a doctor second. The woman who seeks advice for
discomforts related to the genital organs is not usually in need
of an operation: her need is understanding—understanding
the woman as a whole—her outlook, her achievements and
failures, her domestic and social, as well as sexual problems.
The care of the whole woman will be threatened by the
development of subspecialties, such as gynaecological
endocrinology, foetal medicine, gynaecological oncology
and gynaecological urology, unless proper basic training
in obstetrics and gynaecology remains a prerequisite to
subspeciali­sation. These developments are justified only in a
few centres, to promote growth of knowledge and expertise;
otherwise they deprive the woman of the person she can look
for help at any time, one whom she knows has a personal
interest in, and responsi­bility for, her welfare.
Although covering all aspects of the physiology of the
female genital tract, gynaecology is basically a clinical
discipline and gynaecologists need to be primarily clinicians.

PSYCHOSOMATIC AND SOCIOLOGICAL
ASPECTS OF GYNAECOLOGY
Environment can cause or aggravate physical and mental
ill health; the psyche influences the development of organic

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2

Jeffcoate’s Principles of Gynaecology

CLINICAL METHODS

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The handling and examination of the patient can only be
properly taught and learned in the consulting room (office)
and at the bedside, and there is more than one way of doing
them well. A systematic account of clinical methods is as
wearisome to the writer as it is unprofitable to the reader.
In this chapter, it is proposed to comment only on certain
general principles and to offer suggestions for overcoming
common difficulties.
The diagnosis of the cause of the patient’s complaints
depends on a process of detection. Some clues are worthless
and misleading, others are small but important. The good
diagnostician is one who quickly realises what is significant
and what is not, one who will not dismiss evidence, bizarre
though it may appear, if it does not fit in with preconceived
ideas. Clinical intuition is no more than the capacity to take
intelligent notice (sometimes almost subconsciously) of
small points (Flow chart 1.1).

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disease in all parts of the body; illness begets anxiety and
this in turn begets illness; the reactions of doctor, relatives
and friends to illness can determine recovery or chronic
invalidism. These are not new discoveries but are as old
as the practice of medicine. Psychosomatic medicine and
social medicine are merely new names for old arts which are
practised almost automatically by the good doctor and which
find an important place in gynaecology. Thus, menstruation
can be inhibited for many months by a subconscious need to
attract attention, by a desire for pregnancy and by a change
in occupation or in living conditions. On the other hand,
menstruation may be precipitated by excitement and can
become regularly excessive in response to nervous tension
and domestic disharmony. A woman may develop pelvic
symptoms to escape the advances of her husband. Painful
menstruation, painful coitus and the like frequently have
fear, resentment or guilt over genital functions as their basis–
inculcated possibly by impressions and experiences gained
during childhood. Obesity is much more likely to be a mani

festation of an anxiety state or bad habit than evidence of
endocrine disturbance. Many women, when worried, find
solace in eating and drinking; if they are sleepless, they have
longer hours in which to solace themselves.
A woman faced with unwanted responsibilities, or with
any distasteful situation, may try to escape by blaming her
genital organs about which there remains an air of mystery
which secures for her the sympathy of other women and
of the oversolicitous husband. A gynaecologist must be a
psychologist although not necessarily a trained psychiatrist.
If the part played by emotional and environmental factors
in pelvic disease is recognised, only experience and wisdom
are required to elicit them. The majority of women are
unconscious of these factors in their illness, and when made
aware of them by sympathetic explanation, encouragement
and tact, can adjust themselves to ensure a cure. There are a
few, however, who deliberately set out to deceive and go to
such lengths to achieve their objective that they are not easily
found out. Take for example the following rare case:
A married woman aged 30 years, with two children,
complained of recurrent and persistent vaginal bleeding which
failed to respond to several lines of treatment. Ultimately her
uterus was removed, whereupon the bleeding continued and
was found to be coming from vaginal ulcers which refused to
heal even when repeatedly excised. It was then proved that
she deliberately injured the vagina to make it bleed.
Rather than confining psychosomatic gynaecology to a
single chapter, the aim in this book is to include it wherever
it belongs, in the hope of placing it in its proper context. If the
psychological aspects of gynaecology suffered from neglect in

the past there is now some danger of their being exaggerated.
In clinical practice it should be made a rule never to diagnose
neurosis or a psychogenic basis for symptoms until organic
disease is excluded for certain.

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Flow chart 1.1: An approach to a case with
gynaecological problems


3

A Clinical Approach to Gynaecology



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Symptoms
Trivial Symptoms
Whenever the symptom appears inadequate or atypical,
suspect that it is a cloak for another worry. The recently
married woman who complains of longstanding dysmenor
rhoea is probably suffering from painful coitus. The woman
without children after several years of marriage is often

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It is essential for the physician to communicate with a patient
in a manner that allows her to continue to seek appropriate
medical attention. It is necessary that a doctor listens to
a patient completely and if there is a good ear to listen the
diagnosis will be made easy. Not only the words used, but also
the patterns of speech, the manner in which the words are
delivered, even body language and eye contact, are important
aspects of the patient-physician interaction.
The most important evidence is always provided by the
history which the patient or her relatives can give, if allowed to
do so.The diagnosis can nearly always be made or reduced to
one of two or three possibilities based on the history without
any physical examination. Indeed, it can often be made by
telephone.
Physical signs are less reliable and should mainly be used

as confirmatory evidence. It is good practice never to examine
the patient without having a provisional diagnosis in mind.
The previous medical history, family history and the
account of symptoms as given by the woman can be boring,
but scrupulous attention to them saves time, trouble, special
investigations and mistakes. She appreciates the opportunity
to tell her story, and amongst irrelevances, invariably gives
vital clues. Moreover, many irrelevances can be avoided by
skilful guidance and by the occasional leading question.
A garrulous old woman aged 80 years was admitted to
hospital as an emergency case with the history of a sudden
onset of lower abdominal pain following a fall on getting
out of bed. A few leading questions did not reveal typical
features of any of the ordinary abdominal crises and, as the
physical signs were not remarkable, she was kept under
observation for 10 days during which time her discomfort
subsided. She then appeared well and was prepared for
discharge home. On the day the patient was due to leave
hospital, as a final check, she was referred for the opinion of a
gynaecologist. She was then, for the first time, allowed to tell
her own story, from which it became clear that the sequence
of events was (1) pain, (2) getting out of bed, (3) faintness
causing her to fall, (4) unconsciousness on the floor for a
few minutes, (5) residual abdominal pain and tenderness.
All that remained necessary was to recognise a faint bruise
around the umbilicus as “Cullen’s sign”, and the picture of
intraperitoneal haemorrhage was sufficiently complete to
justify laparotomy. This revealed the cause to be a small and
previously nonpalpable sarcoma in the fundus of the uterus.
Successful interrogation requires an inquisitive outlook.

Why has this woman come to see me today and not 6 months
ago? Why has she not had children during 3 years of marriage?
What was the illness which confined her to bed for 3 months
in childhood and what were its symptoms and treatment? At
what time in pregnancy did the two abortions occur? How
long did she breastfeed the last baby? Did she suffer fever
after any of the pregnancies? How old is her husband? Is she
only child? Have her aunts got hairy faces? What operation

was carried out 5 years ago? What were her symptoms at the
time and what was she told? Has she a home of her own? Does
she go out to work and who looks after the children while she
does? Why is she worrying about a trivial symptom or is her
mother worrying on her behalf? Is she afraid of cancer or of a
sexually transmitted disease?
History taking also requires tact, for it is concerned with
details of what some women regard as highly embarrassing
topics. It calls for privacy, kindness, courtesy and a deferment
of the more personal questions until confidence is established.
Previous illness and confinements are usually safe grounds,
although caution is necessary if a baby has been lost. A
woman may find it easier to talk about menstruation than
about discharge, while marital and domestic problems should
come last. A matter-of-fact and coldly scientific attitude
is the one most likely to encourage the patient to discuss
intimate matters without embarrassment. Attention to dress,
avoidance of jokes, formal behaviour and concentration on
the patient and her problems are especially important to
maintain the right atmosphere in a teaching clinic.
Importance should be given to the patient-physician

relationship. One needs to listen more and talk less. Encourage
the pursuit of topics important to patients. It is necessary to
realise that one should minimise controlling speech habits,
such as interrupting, issuing commands, and lecturing. Care
should be taken to understand discomfort of certain issues
and become aware of discomfort in an interview, recognise
when it originates in an attempt by the physician to take
control, and redirect that attempt. The confidence one gives
by assuring patients that they have the opportunity to discuss
their problem fully is very important. Sometimes all that is
necessary is to be there as a compassionate human being.
If clinical findings or confirmatory testing strongly suggest a
serious condition (e.g. malignancy), the gravity and urgency
of this situation must be conveyed in a manner that does
not unduly alarm or frighten the individual. Honest answers
should be provided to any specific questions the patient may
want to discuss.
Often during the course of examination, some fact of
which the patient is ashamed comes to light. Perhaps she
is pregnant, or has been pregnant, or has had a sexually
transmitted disease. Such confidential disclosures are to be
received impassively and naturally, without sign of approval
or disapproval, and the patient should not see that any record
is made of them.


History