Jeffcoate's Principles of Gynaecology Ninth Edition

Jeffcoate’s Principles of
GYNAECOLOGY
Prelims New.indd 1 09-Apr-18 3:10:04 PM

New Delhi | London | Panama
The Health Sciences Publisher
Revised and updated from the Eighth Edition by
Narendra Malhotra
MD FICOG FRCOG (Honoris Causa) FICS FMAS
Professor, Dubrovnik International University, Croatia
Past President, FOGSI
Managing Director, Global Rainbow Healthcare
Agra, Uttar Pradesh, India
Jaideep Malhotra
MD FICOG FICS FRCOG FRCPI
Professor, Dubrovnik International University, Croatia
President, FOGSI
Past President, The Asia Pacific Initiative on Reproduction (ASPIRE)
Managing Director, ART Rainbow-IVF
Richa Saxena
MBBS MD (Obstetrics & Gynaecology)
PG Diploma in Clinical Research
Obstetrician and Gynaecologist
New Delhi, India
Neharika Malhotra Bora
MD (Gold Medalist) DRM (Germany)
FMAS FICMCH ICOG (Reproductive Medicine)
Infertility Consultant, Rainbow-IVF, Agra
Assistant Professor, Department of Obstetrics and Gynaecology
Bharati Vidyapeeth Medical College, Pune, Maharashtra, India
Consultant, ART Rainbow-IVF
Jeffcoate’s Principles of
GYNAECOLOGY
NINTH INTERNATIONAL EDITION

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Jeffcoate’s Principles of Gynaecology
First Edition: 1957
Fifth Edition: 1987
Sixth Edition: 2001
Seventh Edition: 2008
Eighth Edition: 2014
Ninth Edition: 2019
ISBN 978-93-5270-477-4
Printed at

CONTRIBUTORS
Acharya Neema MBBS DGO DNB DFP FICOG
Professor
Department of Obstetrics and Gynaecology
Datta Meghe Institute of Medical Sciences
(Deemed University)
Wardha, Maharashtra, India
Agrawal Kavita MBBS MD (Obstetrics and
Gynaecology)
Assistant Professor
Lady Hardinge Medical College
New Delhi, India
Agrawal Mohit MBBS MD (Obstetrics and
Gynaecology)
Assistant Professor
Wardha, Maharashtra, India
Agrawal Ragini MBBS MS (Obstetrics and
Gynaecology) MS FICOG FICMCH
Director
W Pratiksha Hospital and IVF Centre
Gurugram, Haryana, India
Ahuja Maninder MBBS MD (Obstetrics and
Gynaecology)
Honorary Professor, Indian Medical
Association
Director, Ahuja Hospital and Infertility Centre
Faridabad, Haryana, India
Ali Hina MBBS MS (Obstetrics and
Gynaecology) Fellowship in Reproductive Medicine
Consultant, Rainbow-IVF
Anand Anupama DGO FICOG
Consultant
Nelson Mother and Child Hospital
Nagpur, Maharashtra, India
Bahadur Anupama MBBS MD (Obstetrics and
Gynaecology)
Sub-Dean (Academics)
Additional Professor
All India Institute of Medical Sciences
Rishikesh, Uttarakhand, India
Banerjee Dipanwita MBBS MS (Obstetrics and
Gynaecology) DPMIACA
Department of Gynaecological Oncology
Chittaranjan National Cancer Institute
Kolkata, West Bengal, India
Bansal Kanthi MD DGO FICOG
Director
Safal Fertility Foundation
Ahmedabad, Gujarat, India
Bansal Shemi MBBS DIPGO
Consultant, Rainbow Hospital
Baxi Dhaval MBBS DGO DNBn MCh
Resident
Department of Reproductive Medicine and
Surgery
Sri Aurobindo Medical College and
Postgraduate Institute
Indore, Madhya Pradesh, India
Bindra Vimee MBBS MS (Obstetrics and
Gynaecology) MHA
Consultant Gynaecologist and Obstetrician
Apollo Hospitals
Hyderabad, Telangana, India

Jeffcoate’s Principles of Gynaecologyvi
Bora Neharika M MD (Gold Medalist) DRM
(Germany) FMAS FICMCH ICOG (Reproductive Medicine)
Infertility Consultant, Rainbow-IVF, Agra
Assistant Professor, Department of Obstetrics
and Gynaecology
Bharati Vidyapeeth Medical College Pune,
Maharashtra, India
Consultant, ART Rainbow-IVF
Bora Rishabh MBBS MD (Radiology)
Rainbow Hospital
Dutta Indranil MBBS MS (Obstetrics and
Gynaecology) FIAOG FAGE
Associate Professor
IQ City and NH Medical College
Durgapur, West Bengal, India
Ganapule Chaitanya MBBS MD (Obstetrics and
Gynaecology)
Director
Pearl Women’s Hospital and Yash IVF
Pune, Maharashtra, India
Ganesh Deepa MBBS MS FMAS DMAS FICRS FIMA
Dip MIS (Germany) Dip ALS (France) Dip ACG (USA) FIMSA
Director
DG Laser and Cosmetic Gynecology Clinic
Chennai, Tamil Nadu, India
Garg Ruchika MBBS MD MRCOG 1 CIMP MAMS
FAMS FICMCH
Associate Professor
SN Medical College
Ghosh Chiranjit MBBS MD (Obstetrics and
Gynaecology) DGO
RG Kar Medical College and Hospital
Goswami Diksha MBBS MD DNB MRCOG FNB
(Reproductive Medicine)
Consultant
Rainbow-IVF
Gupta Shally DGO DNB
Consultant
Rainbow-IVF
Gupta Sushma MBBS MD (Obstetrics and
Gynaecology)
Consultant
Aakanksha Test Tube Baby Centre
Dr Kusum Gupta Nursing Home
Hafizur MBBS DGO DNB MNAMS FMAS FICOG Dip. MAS
(Germany)
Professor
Sikkim Manipal Institute of Medical Sciences
Gangtok, Sikkim, India
Hinduja Ritu MBBS MD MRM (UK) DRM (Germany)
Consultant
Department of Reproductive Medicine
Nova IVI Fertility
Mumbai, Maharashtra, India
Hokabaj Shaheen MBBS DNB FIRM FAGE
Gynae Endoscopy and Infertility Specialist
Sneh Infertility Centre
Indersen Amitha MBBS MD (Obstetrics and
Gynaecology)
Consultant and Head
Department of Fetal Medicine
Apollo Cradle Hospitals
Hyderabad, Telangana, India
Joshi Prasanna MBBS DNB (Gynae) DGO MNAMS
DGL (Germany) FICOG DIP ART (Germany)
Director
Ganesh Hopital
Amalner, Jalgaon, Maharashtra, India
Kale Ashish MBBS MD DNB MNAMS FICS DEPS
MICOG
IVF Consultant and Founder Director
Ashakiran Group of Hospitals and
Asha IVF Centre

Contributors vii
Kale Ashwani MBBS DGO DNB (Obstetrics and
Gynaecology)
IVF Consultant and Embryologist
Ashakiran Hospital and Asha IVF Centre
Kashyap Vivek MBBS MD (Radiology)
Chairman and Consultant
Dr Kashyap’s Diagnostics
New Delhi, India
KD Reubina MBBS MS (Obstetrics and Gynaecology)
Director
Grace IVF Centre
Chandigarh, India
Kharas Percy MBBS DGO MD
CEO, Gynaecology and Infertility Specialist
Excellent IVF and ICSI Centre
Valsad, Surat, Gujarat, India
Malhotra Hemant MBBS MD FRCP (London)
FACP (USA) MNAMS FICP FUICC FIMSA
Senior Professor
RK Birla Cancer Center
SMS Medical College and Hospital
Jaipur, Rajasthan, India
Malhotra Jaideep MD FICOG FICS FRCOG FRCPI
Professor
Dubrovnik International University, Croatia
President, FOGSI
Past President The Asia Pacific Initiative on
Reproduction (ASPIRE)
Managing Director, ART Rainbow-IVF
Malhotra Narendra MD FICOG FRCOG (Honoris
Causa) FICS FMAS
Professor
Dubrovnik International University, Croatia
Past President, FOGSI
Managing Director
Global Rainbow Healthcare
Malik Jyoti MBBS DGO DNB MNAMS FICS
J J Institute of Medical Sciences
Bahadurgarh, Haryana, India
Malik Sonia MBBS MD DGO
Director and Head
Southend Fertility and IVF
New Delhi, India
Mehta Manjeet PhD (Human Genetics)
Director, Neogenetics, New Delhi
Director-Technical
DNA Diagnostics Center, Gurugram
Director-Partner, Genetic World Mumbai,
Maharashtra, India
Mishra Sakshi MBBS MS (Obstetrics and
Gynaecology)
Senior Resident
NSCB Medical College
Jabalpur, Madhya Pradesh, India
Mittal Bhawana MBBS MS (Obstetrics and
Gynaecology)
Director, Shivam IVF Centre, Delhi
Consultant, Max IVF
Ghaziabad, Uttar Pradesh, India
Mukherjee Basab MBBS MD FRCOG FICOG
Consultant Gynaecologist
Naik Bijouy MBBS MS (Obstetrics and Gynaecology)
Senior Consultant
Manipal Hospital
New Delhi, India
Panchal Sonal MBBS MD (Obstetrics and
Gynecology)
Consultant
Dr Nagori’s Institute for
Infertility and IVF

Jeffcoate’s Principles of Gynaecologyviii
Pandey Jyotsana MBBS
Resident
Institute of Medical Sciences, Banaras Hindu
University
Varanasi, Uttar Pradesh, India
Pandey Seema MBBS MD FICOG FRM
Director
Chief, IVF and Reproductive Medicine
Consultant
Seema Hospital and Eva Fertility Clinic and
IVF Centre
Sanjeevani Nursing Home
Azamgarh, Uttar Pradesh, India
Pandey Uma MBBS MD FRCOG FICOG FIAOG
Associate Professor
Institute of Medical Sciences, Banaras Hindu
University
Varanasi, Uttar Pradesh, India
Pathak Jayshree MBBS MD (Obstetrics and
Gynaecology)
Rainbow-IVF
New Delhi, India
Patolia Hetal MBBS MD (Obstetrics and
Gynaecology)
Columbia Asia Hospital
Priyadarshini Neha MBBS MD (Obstetrics and
Gynaecology)
Consultant
SATVIK IVF
Dhanbad, Jharkhand, India
Priya Selva MBBS MD (Obstetrics and Gynaecology)
Clinical Director
NDJH GIFT Department of Fertility and Fetal
Medicine
Dr Jeyasekharan Hospital
Kanyakumari, Tamil Nadu, India
Raj Mala MBBS MD
Managing Director
Firm Hospital
Chennai, Tamil Nadu, India
Ray Chandrima MBBS DGO DNB (OBGYN) FMAS
Senior Resident, Department of
Gynaec-Oncology
Chittaranjan National Cancer Institute
Ray Rajat MBBS MD FICOG
Associate Professor
Hi-Tech Medical College
Rourkela, Odisha, India
Roy Priyankur MBBS MS FIRM FAGE
Senior Resident
North Bengal Medical College
Siliguri, West Bengal, India
Reddy Appoorva Pallam MBBS MS
(Obstetrics and Gynaecology) DNB
Apollo Cradle
Bengaluru, Karnataka, India
Reddy Yasodhara Pallam MBBS MD
(Obstetrics and Gynaecology)
Consultant, Department of High Risk
Pregnancy
Clinical Director, Sri Durga Hospital and IVF
Centre
Nellore, Andhra Pradesh, India
Saxena Richa MBBS MD (Obstetrics and
Gynaecology) PG Diploma in Clinical Research
Obstetrician and Gynaecologist
New Delhi, India
Shah Rupal MBBS MD (Obstetrics and Gynaecology)
Chief Consultant
Rupal Hospital for Women
Surat, Gujarat, India

Contributors ix
Sharma Esha MBBS MS DNB
Consultant
Ramkrishna IVF Centre
Siliguri, West Bengal, India
Sharma Manpreet MBBS MS (Obstetrics and
Gynaecology)
Consultant
Rainbow Hospital
Shinde Prerna MBBS MD DGO DICOG
Director
Shinde Hospital and Test Tube Baby Center
Ahmednagar, Maharashtra, India
Singh Amreen MBBS MD (Obstetrics and
Gynaecology)
Aspire Fellow
Rainbow Hospital
Singh Ankan MBBS MS (Obstetrics and
Gynaecology)
Fellow in Reproductive Medicine
Rainbow Hospital
Singh Kavita MS PhD (Gyn. Oncology) FICOG
FICMCH
Professor and Head
NSCB Government Medical College
Jabalpur, Madhya Pradesh, India
Singh Kuldeep MBBS MS (Obstetrics and
Gynaecology)
Dr Kuldeep Ultrasound and Color Doppler
Clinic
New Delhi, India
Singh Rakhi MBBS DGO FICOG FIAOG DRM ARCOG
Director
Abalone Clinic and IVF Center
Noida, Uttar Pradesh, India
Vats Garima MBBS MS (Obstetrics and Gynaecology)
Assistant Professor
Jaipur National University and Medical
College
Jaipur, Rajasthan, India
Yadav Himanshu MBBS MS (General Surgery)
MCh (Surgical Gastroenterology)
Associate Professor
SN Medical College
Yadav Nisha MBBS MD DNB DESA
Consultant
Department of Anaesthesiology and Critical
Care
Global Rainbow Healthcare

It is an honour yet again to update this “Bible of Gynaecology”, Prof Sir Norman Jeffcoate had written this book
on the basis of what he saw in those days. His style of describing gynaecology as a story telling is still appreciated.
However, from the years of Prof Jeffcoate the practice of medicine, especially in the field of gynaecology, has
changed a lot as there is an incorporation of transvaginal sonography, colposcopy and office hysteroscopy in the
clinic and this has simplified and quickened the diagnosis and treatment. Leaps of advances have occurred in
diagnosis, management, procedures and drugs.
In this revised edition, new chapters, pictures, photographs and discussions have been incorporated keeping
in mind the recent guidelines and updates in this field. New topics like genetics in gynaecology, precocious and
delayed puberty, pregnancy of unknown location, female genital mutilation, adenomyosis, assisted reproductive
technology, urinary tract infection, contraception, and single incision laparoendoscopic surgery, etc. have been
introduced.
We have tried to update all the chapters to include the latest evidences and preserving Prof Norman Jeffcoate
narrative style. This issue has been updated with the efforts of multiple authors and experts. We hope this updated
Bible of Gynaecology will be useful to all students, teachers and practitioners.
Happy Reading!
Narendra Malhotra
Jaideep Malhotra
Richa Saxena
PREFACE TO THE
NINTH INTERNATIONAL 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
PREFACE TO THE FIFTH 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
EXTRACTS FROM
THE PREFACE TO THE FIRST EDITION

To edit a book written by a legend Professor Jeffcoate is a mammoth task. I and Dr Jaideep Malhotra did a lot of
researches and asked all our students to suggest what more they wanted in the ninth edition. Dr Neharika Malhotra
Bora and Dr Richa Saxena have helped immensely in adding a lot of material to the chapters and updating many
of them.
We are thankful to all the contributors (names mentioned in the contributor list), for their valuable inputs and
contributions to update all the chapters.
We are grateful to all those who have helped us to do this mammoth job. Special appreciations and thanks to
Shri Jitendar P Vij (Group Chairman) and Mr Ankit Vij (Managing Director) of M/s Jaypee Brothers Medical
Publishers (P) Ltd, New Delhi, India. Simultaneously we would like to acknowledge the help of various doctors,
editorsandcontentstrategists(DrArunBhatia,KanavMidha,MampiDebnath,PriyankaDiwan,DrSudhaChamoli
and Shallu Mann), who helped in editing of the manuscript within a short span of time.
We are thankful to our families for bearing with us and sharing family time for work like this.
We thank Dr Prabha Malhotra, Dr Deepali, Dr Deepika, Dr RM Malhotra, Dr Rishab Bora and Dr Kehsav.
We hope the students of gynaecology will like what we have produced in the ninth edition.
We have tried to retain Professor Jeffcoate’s style and some of the valuable photographs from the first edition.
Narendra Malhotra
Jaideep Malhotra
Richa Saxena
ACKNOWLEDGEMENTS

Chapter 1: A Clinical Approach to Gynaecology 1
‰‰ Psychosomatic and Sociological Aspects of Gynaecology 2
‰‰ Clinical Methods 2
‰‰ Physical Examination 6
‰‰ Special Tests and Accessory Aids to Diagnosis 12
‰‰ Endometrial Sampling Procedures 12
‰‰ Transvaginal Sonography 14
‰‰ Transrectal Sonography 14
‰‰ Colour Doppler 14
‰‰ Endoscopy 16
‰‰ Laparoscopy 16
‰‰ Hysteroscopy 18
‰‰ Computed Tomography 19
‰‰ Magnetic Resonance Imaging 20
‰‰ PET Scan 21
Chapter 2: Anatomy 23
‰‰ Vulva 23
‰‰ Vagina 27
‰‰ Uterus 32
‰‰ Fallopian Tubes 36
‰‰ Ovary 38
‰‰ Urethra and Bladder 39
‰‰ Ureter 43
‰‰ Sigmoid Colon 43
‰‰ Rectum and Anus 44
‰‰ Pelvic Peritoneum and Ligaments 45
‰‰ Pelvic Musculature 46
‰‰ Pelvic Fascia and Cellular Tissue 47
‰‰ The Supports of the Genital Organs 47
‰‰ Blood Vessels of the Pelvis 48
‰‰ Lymphatic Drainage 52
‰‰ Innervation of Pelvic Organs 54
Chapter 3: Ovarian Functions 58
‰‰ Production of Ova 59
‰‰ Ovarian Hormones 71
‰‰ Pituitary Hormones 77
‰‰ Pituitary-Hypothalamic Relations 78
‰‰ Pituitary-Ovarian Relations (Control of Ovulation) 80
‰‰ Hormone Levels and Assays 81
CONTENTS

Jeffcoate’s Principles of Gynaecologyxx
Chapter 4: Menstruation and Other Cyclical Phenomena 83
‰‰ Normal Menstrual Cycle 83
‰‰ Endometrial Cycle 83
‰‰ Correlation of Endometrial and Ovarian Cycle 88
‰‰ Uterine Bleeding 90
‰‰ The Myometrial Cycle 94
‰‰ Cyclical Changes in the Tube 94
‰‰ The Cervical Cycle 94
‰‰ The Vaginal Cycle 95
‰‰ Cyclical, Metabolic, Vascular and Psychological Changes 95
Chapter 5: Clinical Aspects of Menstruation and Ovulation 97
‰‰ Menstruation 97
‰‰ The Menopause and the Climacteric 100
‰‰ Abnormal Menopause 108
‰‰ Ovulation 109
Chapter 6: Puberty and Adolescent Gynaecology 119
‰‰ Puberty and Adolescence 119
‰‰ Abnormalities of Puberty and Adolescence 123
‰‰ Prolactin 130
‰‰ Puberty Menorrhagia 132
Chapter 7: Conception 134
‰‰ Process 134
‰‰ Early Development of the Ovum 136
‰‰ Formation of Foetus and Membranes 137
‰‰ Hormonal Control of Early Pregnancy 141
Chapter 8: Spontaneous Abortions (Including Recurrent Loss) 143
‰‰ Spontaneous Abortions 143
‰‰ Pathology of Spontaneous Abortions 143
‰‰ Causes of Spontaneous Abortion 144
‰‰ Clinical Varieties of Spontaneous Abortions 148
‰‰ Recurrent Early Pregnancy Loss 150
‰‰ Risk Factors for Reccurent Miscarriage 151
‰‰ Investigations 154
‰‰ Management 154
Chapter 9: Ectopic Pregnancy and Pregnancy of Unknown Location 157
‰‰ Frequency of Ectopic Pregnancy 157
‰‰ Sites of Ectopic Pregnancy 157
‰‰ Aetiology of Ectopic Pregnancy 158
‰‰ Ectopic Pregnancy in Fallopian Tubes 159
‰‰ Management and Treatment Options of Ectopic Pregnancy 170
‰‰ Expectant Management 170
‰‰ Medical Management 171

Contents xxi
‰‰ Surgical Management 172
‰‰ Complications of Ectopic Pregnanccy 177
‰‰ Ovarian Pregnancy 177
‰‰ Cornual Pregnancy 178
‰‰ Cervical Pregnancy 178
‰‰ Abdominal Pregnancy 179
‰‰ Interstitial Pregnancy 180
‰‰ Intraligamentary Pregnancy 181
Pregnancy of Unknown Location 182
‰‰ Outcome of Ectopic Pregnancy 182
‰‰ Diagnosis 183
‰‰ Management of Pregnancy of Unknown Location 183
Chapter 10: Gestational Trophoblastic Disease 188
‰‰ Epidemiology 188
‰‰ Types of Tumours 188
‰‰ Aetiology 189
‰‰ Hydatidiform Mole 189
‰‰ Persistent Gestational Trophoblastic Tumour 196
Chapter 11: Breast Function and its Disorders 204
‰‰ Breast Development 204
‰‰ Developmental Anomalies of Breast 206
‰‰ Breast Feeding and Lactation 209
‰‰ Endocrine Disorders (Galactorrhoea and Breast Atrophy) 211
‰‰ Benign Breast Condition 214
‰‰ Screening for Breast Diseases 216
‰‰ Benign Breast Disease 217
‰‰ Breast Cancer 221
Chapter 12: Development of the Urogenital System 227
‰‰ The Gonad 227
‰‰ Wolffian System 228
‰‰ Müllerian Ducts 231
‰‰ Mesenteries and Ligaments 231
‰‰ Development of the Vagina, Bladder and Urethra 232
‰‰ Development of the Vulva 234
Chapter 13: Malformations and Maldevelopments of the Genital Tract 235
‰‰ Causes of Malformations 235
‰‰ Cytogenetics 237
‰‰ Uterine Anomalies 239
‰‰ Ovary 252
‰‰ Fallopian Tube 253
‰‰ Uterus 253
‰‰ Conical Cervix and Pinhole Ostium 255
‰‰ Vagina 255

Jeffcoate’s Principles of Gynaecologyxxii
‰‰ Vulva 258
‰‰ Errors Arising in Connection with the Cloaca 260
‰‰ Malformations of the Urinary Tract 261
Chapter 14: Disorders of Sexual Development, Asexuality and Intersexuality 263
‰‰ Determinants of Sexual Development in Humans 277
‰‰ Clinical Presentation 282
‰‰ Intersex Developing After Birth 287
‰‰ Feminism 287
‰‰ Virilism 288
‰‰ Ambiguous Genitalia 293
Chapter 15: Injuries 296
‰‰ Foreign Bodies in the Genital Tract 296
‰‰ Vaginal Burns 298
‰‰ Direct Trauma to Vulva and Vagina 299
‰‰ Defective or Deficient Perineum 301
‰‰ Complete Perineal Tear 301
‰‰ Laceration of the Cervix 303
‰‰ Rupture and Perforation of the Uterus 306
‰‰ Broad Ligament Haematoma 307
‰‰ Genital Tract Fistulas 308
‰‰ Acquired Atresia and Stenosis of the Genital Tract 315
Chapter 16: Female Genital Mutilation 320
‰‰ Indications 321
‰‰ Management in the UK Practice 322
‰‰ Complications 324
Chapter 17: Pelvic Organ Prolapse 327
‰‰ Uterine and Vaginal Prolapse 327
‰‰ Prolapse of the Ovaries 346
Chapter 18: Other Displacements of the Uterus 348
‰‰ Upward Displacement of the Uterus 348
‰‰ Lateral Displacement of the Uterus 348
‰‰ Forward Displacement of the Uterus 349
‰‰ Backward Displacement of the Uterus 349
‰‰ Retroverted Gravid Uterus 354
‰‰ Inversion of the Uterus 355
‰‰ Chronic Inversion 356

Contents xxiii
Chapter 19: Torsion of Pelvic Organs 359
‰‰ Torsion of the Normal Organs 359
‰‰ Torsion of Abnormal Organs 359
‰‰ Differential Diagnosis 363
‰‰ Treatment 363
Chapter 20: Infections Including Sexually Transmitted Diseases 365
‰‰ The Natural Defences of the Genital Tract 365
‰‰ Sexually Transmitted Diseases 367
‰‰ Other Sexually Transmitted Infections 367
‰‰ Genital Tuberculosis 381
‰‰ Sarcoidosis 389
‰‰ Actinomycosis 390
‰‰ Schistosomiasis (Bilharzia) 390
‰‰ Amoebiasis 390
Chapter 21: Infections as they Affect Individual Organs 392
‰‰ Vulvitis 392
‰‰ Bartholinitis 396
‰‰ Vaginitis 397
‰‰ Cervicitis 405
‰‰ Endometritis 407
‰‰ Metritis 407
‰‰ Salpingo-oophoritis 408
‰‰ Oophoritis 413
‰‰ Pelvic Peritonitis 414
‰‰ Pelvic Cellulitis 414
‰‰ Chronic Cellulitis 416
‰‰ Pelvic Inflammatory Disease 416
‰‰ Suppurative Thrombophlebitis of the Pelvic Veins 418
Chapter 22: Genital Tuberculosis 420
‰‰ Clinical Profile 421
‰‰ Classification 421
‰‰ Pathology of Pelvic Organs 431
Chapter 23: Endometriosis and Chronic Pelvic Pain 432
Endometriosis and Allied States 432
‰‰ Endometriosis and Adenomyosis 432
‰‰ Adenomyosis 451
‰‰ Endosalpingiosis 452
‰‰ Cervical Endometriosis 452
Low Backache and Chronic Pelvic Pain 453
‰‰ General Considerations 453
‰‰ Causes in the Genital Tract 453
‰‰ Extragenital Causes 455

Jeffcoate’s Principles of Gynaecologyxxiv
‰‰ Management and Treatment 455
‰‰ Chronic Pelvic Pain 456
‰‰ Step-wise Evaluation of Chronic Pelvic Pain 457
‰‰ Examination 457
‰‰ Diagnostic Investigations 457
Chapter 24: Polycystic Ovary Syndrome 460
‰‰ Puberty and Polycystic Ovarian Syndrome 466
‰‰ Menstrual Irregularities 467
‰‰ Infertility 468
‰‰ Weight Loss 469
‰‰ Clomiphene Citrate 469
‰‰ Metformin 469
‰‰ Laparoscopic Ovarian Drilling 470
‰‰ Gonadotrophin Therapy 470
‰‰ Long-Term Monitoring 471
Chapter 25: Hirsutism 473
‰‰ Virilisation and Masculinisation 473
‰‰ Diagnosis of Hyperandrogenism 477
‰‰ Late Onset Adrenal Hyperplasia 480
Chapter 26: Epithelial Abnormalities of the Genital Tract 481
‰‰ Pathology 481
‰‰ Symptoms 484
‰‰ Vulvar and Oral Epithelial Abnormalities 485
‰‰ Vulvar Intraepithelial Neoplasia 486
‰‰ Vagina 489
‰‰ Cervix 490
‰‰ Uterine Corpus 501
‰‰ Fallopian Tube 505
Chapter 27: Genital Cancers 514
‰‰ Importance of Genital Cancer 514
‰‰ Treatment and Results 514
‰‰ Prevention of Pelvic Cancer 516
‰‰ Early Diagnosis 516
‰‰ General Management of the Cancer Patient 520
‰‰ Management of Advanced Pelvic Cancer 521
Chapter 28: Tumours of the Vulva 527
‰‰ Swellings of the Vulva 527
‰‰ Varicose Veins 528

Contents xxv
‰‰ Oedema 528
‰‰ Retention Cysts 528
‰‰ Benign Neoplasms 529
‰‰ Malignant Neoplasms of Vulva 531
‰‰ Histology 531
‰‰ Tumours of Bartholin’s Gland 538
‰‰ Urethral Tumours 539
‰‰ Tumours of the Inguinal Canal 542
Chapter 29: Tumours of the Vagina 544
‰‰ Swellings of the Vagina 544
‰‰ Vaginal Cysts 544
‰‰ Malignant Neoplasms 547
‰‰ Squamous Cell Carcinoma 549
‰‰ Adenocarcinoma 550
‰‰ Melanoma 551
‰‰ Sarcoma 551
Chapter 30: Tumours of the Cervix Uteri 553
‰‰ Benign Neoplasms of Cervix 553
‰‰ Benign Tumours of Cervix 553
‰‰ Carcinoma of Cervix 555
‰‰ Screening for Cervical Cancer 558
‰‰ Other Malignant Tumours of the Cervix 572
Chapter 31: Tumours of the Corpus Uteri 573
‰‰ Enlargement of Uterus 573
‰‰ Polyps 574
‰‰ Malignant Neoplasms 595
Chapter 32: Adenomyosis 608
‰‰ Differential Diagnosis 610
‰‰ Medical Therapy 610
‰‰ Surgical Management 611
Chapter 33: Tumours of the Fallopian Tubes 613
‰‰ Primary Malignant Neoplasms 613
‰‰ Secondary Malignant Neoplasms 618
‰‰ Prevention of Fallopian Tube Cancer 618
‰‰ Recurrent Disease 618
‰‰ Coping with Disease 618

Jeffcoate’s Principles of Gynaecologyxxvi
Chapter 34: Tumours of the Pelvic Ligaments 619
‰‰ Cysts of the Broad Ligament and Associated Structures 619
‰‰ Neoplasms of the Pelvic Ligaments and Connective Tissues 621
‰‰ Neoplasms of the Peritoneum 621
Chapter 35: Tumours of the Ovary 623
‰‰ Ovarian Enlargements 623
‰‰ Distension or Retention Cysts 623
‰‰ Types 623
‰‰ Ovarian Neoplasms 626
‰‰ Features Suggestive of Malignancy 650
‰‰ Screening 651
‰‰ Borderline Tumours 651
‰‰ Staging of Ovarian Cancer 653
‰‰ Metastatic (Secondary) Ovarian Tumours 660
‰‰ Ovarian and Parovarian Tumours and Pregnancy 662
Chapter 36: Chemotherapy in Gynaecological Malignancies 665
‰‰ Clinical Use of Chemotherapy 666
‰‰ Assessment of Response to Chemotherapy 666
‰‰ Chemotherapy and the Cell Cycle 666
‰‰ Stem Cell Theory 666
‰‰ Cell-Kill Hypothesis 667
‰‰ Therapeutic Agents Used in the Treatment of Gynaecological Cancer 668
‰‰ Chemotherapy Resistance of Cancer Cells 669
‰‰ Poor Host Defences 669
‰‰ Protected Tumour Sanctuaries 670
‰‰ Route of Administration 670
Chapter 37: Radiotherapy in Gynaecological Malignancies 671
‰‰ The Biological Basis of Radiotherapy Treatment 671
‰‰ Radiation Dosage 671
‰‰ The Therapeutic Ratio 672
‰‰ Radiotherapy Machines 672
‰‰ Brachytherapy 672
‰‰ Radiotherapy in Endometrial Cancer 672
‰‰ Aggressive Histological Variants 673
‰‰ Radiotherapy in Carcinoma Cervix 673
‰‰ Brachytherapy in Carcinoma Cervix 674
‰‰ External Radiation Therapy Techniques 674
‰‰ Chemoradiation in Locally Advanced Carcinoma Cervix 674
Chapter 38: Immunotherapy in Obstetrics and Gynaecology 676
‰‰ Definition 676
‰‰ Basics of Immunotherapy 676
‰‰ Causes of Failure of Immunosurveillance 676

Contents xxvii
‰‰ Tumour-associated Antigens 677
‰‰ Types of Immunotherapy 680
‰‰ Monoclonal Antibodies as Therapeutic Agents 682
‰‰ Other Areas of Application of Immunotherapy in Obstetrics and Gynaecology 683
‰‰ Case Studies 685
Chapter 39: Amenorrhoea, Hypomenorrhoea, and Oligomenorrhoea 687
‰‰ Amenorrhoea 687
‰‰ Hypomenorrhoea 706
‰‰ Oligomenorrhoea 709
Chapter 40: Abnormal and Excessive Uterine Bleeding 711
‰‰ The Term Dysfunctional Uterine Bleeding is Obsolete Now and No Longer in Use 711
‰‰ Causes pf AUB-PALM COEIN 712
‰‰ Subserous Fibroid 714
‰‰ Intramural Fibroid 714
‰‰ Lasmaar Classification 714
‰‰ Submucous (SM2) Myoma by Lasmaar Classification 714
‰‰ Special Clinical Types of Bleeding 719
Chapter 41: Dysmenorrhoea 723
‰‰ Primary Dysmenorrhoea 723
‰‰ Secondary Dysmenorrhoea 727
‰‰ Membranous Dysmenorrhoea 730
‰‰ Other Conditions Simulating Dysmenorrhoea 730
Chapter 42: Premenstrual Syndrome and Other Menstrual Phenomena 732
‰‰ Premenstrual Syndrome 732
‰‰ Menstrual Migraine 735
‰‰ Premenstrual Mastalgia 736
‰‰ Recurrent (Cyclical) Buccal and Vulvar Ulceration 736
‰‰ Pelvic Allergy 738
‰‰ Vicarious Menstruation 738
‰‰ Cyclical Haemothorax and Pneumothorax 739
‰‰ Menstrual Epilepsy 740
Chapter 43: Hormone Therapy in Gynaecology 742
‰‰ Oestrogens 742
‰‰ Anti-oestrogens 748
‰‰ Progestogens 749
‰‰ Antiprogestogens 752
‰‰ Androgens 752
‰‰ Antiandrogens 754
‰‰ Types of Gonadotrophins 755
‰‰ Antigonadotrophins 756
‰‰ Hypothalamic Hormones 758

Jeffcoate’s Principles of Gynaecologyxxviii
Chapter 44: Vaginal Discharge 761
‰‰ Causes of Physiological Discharge 761
‰‰ Prognosis 765
‰‰ Risk Factors 765
‰‰ Therapy 767
‰‰ Prevention 769
Chapter 45: Pruritus Vulvae and Vulvodynia 770
‰‰ Definition and Incidence 770
‰‰ Pathophysiology 770
‰‰ Natural Defence Mechanisms 770
‰‰ Aetiological Classification of Pruritus Vulvae 771
‰‰ Causes of Pruritus According to Age Groups 771
‰‰ Evaluation of Patient with Pruritus 771
‰‰ General Measures for Women with Pruritus 772
‰‰ Differential Diagnosis of Pruritus 772
‰‰ Results 777
‰‰ Vulvodynia 778
Chapter 46: Problems of Sex and Marriage 782
‰‰ Physical Sex—Coitus 783
‰‰ Masturbation 785
‰‰ Apareunia and Dyspareunia 786
‰‰ Female Frigidity 790
‰‰ Nymphomania 793
‰‰ Coital Difficulties in the Male 793
‰‰ Homosexuality 797
‰‰ Transvestism and Transsexuality 797
‰‰ Premarital Chastity and Faithfulness in Marriage 798
Chapter 47: Male and Female Infertility Overview 800
‰‰ Infertility 800
‰‰ Frequency 800
‰‰ Concept of Fertility 800
‰‰ Causes of Infertility 801
‰‰ The Investigation of Infertility 806
Chapter 48: Assisted Reproductive Technology 828
‰‰ In Vitro Fertilisation and Embryo Transfer 828
‰‰ Controlled Ovarian Hyperstimulation 829
‰‰ Oocyte Retrieval 829

Contents xxix
‰‰ Insemination 829
‰‰ Embryo Transfer 831
‰‰ Outcome 832
‰‰ Cryopreservation 832
‰‰ Oocyte Donation 833
‰‰ Embryo Donation 834
‰‰ Surrogacy 834
‰‰ Intrauterine Insemination 834
‰‰ Donor Insemination 836
‰‰ Other ART Methods 836
‰‰ Results of Treating Infertility 838
‰‰ Dangers of Investigating and Treating Infertility 838
‰‰ Complications of ART 839
‰‰ Adoption 840
Chapter 49: Instruments in Gynaecological Procedures 842
‰‰ Instruments 842
‰‰ Gynaecological Procedures 849
Chapter 50: Ultrasonography in Gynaecology 852
‰‰ Indications for Gynaecology 852
‰‰ Techniques 852
‰‰ Normal Female Pelvic Anatomy 852
‰‰ Uterus 854
‰‰ Adenomyosis 860
‰‰ Endometrium 863
‰‰ Cervix 865
‰‰ Ovarian Anatomy 866
‰‰ Polycystic Ovary 872
‰‰ Ovarian Malignant Lesions 872
‰‰ Fallopian Tubes 877
Chapter 51: Ultrasound in Infertility 880
‰‰ Method 880
‰‰ Uterine Abnormalities 881
‰‰ Cycle Assessment Consists of Baseline Scan, Preovulatory Scan and Secretory Scan 899
Chapter 52: Ultrasound in Menopause 908
‰‰ Normal Uterus in Menopause 909
‰‰ Post-menopausal Bleeding 909
‰‰ Normal Atrophic Ovary 911
‰‰ Fluid in Pouch of Douglas 912
‰‰ Ovary and Ovarian Cancer Screening 912
Chapter 53: Robotics Surgery 914
‰‰ Features of Robotic Surgery 914
‰‰ Overview 916
‰‰ Advantages of Robotic Surgery 918

Jeffcoate’s Principles of Gynaecologyxxx
‰‰ Risks of Robotic Surgery 919
‰‰ Innovations Used in Robotic Surgery 919
‰‰ Indications for Use of Robotic Surgery in Gynaecology 921
‰‰ Endometriosis 921
‰‰ Myomectomy 923
‰‰ Criticism and Controversies 923
‰‰ Experience in Last Decade 925
Chapter 54: Endoscopic Surgery in Gynaecology 927
Laparoscopic Surgery 927
‰‰ Surgical Equipment 928
‰‰ Contraindications to Laparoscopy 938
‰‰ Preoperative Preparation 938
‰‰ Surgical Steps 939
‰‰ Postoperative Care 942
‰‰ Advantages 942
‰‰ Disadvantages 942
Hysteroscopic Surgery 944
‰‰ Preoperative Preparation 951
‰‰ Surgical Steps 952
‰‰ Postoperative Care 954
‰‰ Disadvantages 955
Laparo-endoscopic Single-Site Surgery 958
‰‰ Laparo-endoscopic Single-Site Surgical Techniques 959
Chapter 55: Contraception 965
‰‰ General Consideration 965
‰‰ Impact of Contraception Throughout the World 966
‰‰ Efficacy of Contraception 966
‰‰ Indications for Contraception 967
‰‰ Criteria for the Use of Various Contraceptive Methods 967
‰‰ Contraceptive Methods 967
‰‰ Natural Family Planning Method 967
‰‰ Barrier Methods 971
‰‰ Intrauterine Contraceptive Devices 978
‰‰ Hormonal Contraception Methods 994
‰‰ Progestogen-Only Contraception 1006
‰‰ Emergency Postcoital Contraception (Morning After Pills) 1014

Contents xxxi
‰‰ Other Methods of Contraception 1017
‰‰ Choice of Methods 1022
‰‰ Contraception Choice for Older Women 1022
‰‰ Contraception and Litigation 1023
Chapter 56: Sterilisation and Termination of Pregnancy 1026
‰‰ Sterilisation 1026
‰‰ Female Sterilisation 1027
‰‰ Male Sterilisation 1030
‰‰ Compulsory Sterilisation 1031
‰‰ Termination of Pregnancy 1031
‰‰ Abortion as a Means of Contraception 1039
Chapter 57: Urinary Incontinence 1040
‰‰ Bladder Dysfunction 1040
‰‰ Urethral Sphincter Dysfunction 1043
‰‰ Investigation of Urinary Problems 1045
‰‰ Treatment of Urinary Problems 1047
‰‰ Incontinence of Urine 1048
‰‰ Overview of Surgical Management 1053
‰‰ Enuresis 1060
‰‰ Urinary Retention and Difficulty in Micturition 1061
Chapter 58: Urinary Tract Infection 1066
‰‰ Clinical Pearls 1072
‰‰ Evidence-Based Medicine 1072
Chapter 59: Menopause 1074
‰‰ History 1074
‰‰ Definitions and Staging of Menopause 1074
‰‰ Physiology of Menopause 1076
‰‰ Problems Associated with Menopause 1078
‰‰ Effect of Oestrogen Deficiency 1079
‰‰ Menstrual Problems 1087
‰‰ Management of Menopause 1089
‰‰ Various Types of Hormonal and Non-hormonal Pharmacological Agents Available 1090
‰‰ Use of Progesterone for HRT 1092
‰‰ Hormone Therapy in Special Circumstances 1092
‰‰ Androgens in Menopause 1094
‰‰ Symptoms of Menopause 1094

Jeffcoate’s Principles of Gynaecologyxxxii
Chapter 60: Hysterectomy and its Aftermath 1095
‰‰ History 1095
‰‰ Operative Steps 1095
‰‰ Vaginal Hysterectomy 1098
‰‰ Total Laparoscopic Hysterectomy 1100
‰‰ Depression Following Hysterectomy and the Influencing Factors 1102
‰‰ Hysterectomy and Sexual Functioning 1102
Chapter 61: Conditions of the Lower Intestinal Tract 1103
‰‰ Rectal Prolapse 1103
‰‰ Incontinence of Faeces and Flatus 1106
‰‰ Diarrhoea 1107
‰‰ Difficult Evacuation 1107
‰‰ Irritable Bowel Syndrome 1108
‰‰ Pruritus Ani 1109
‰‰ Rectal and Anal Pain 1110
Chapter 62: Preoperative and Postoperative Management: Postoperative Complications 1113
‰‰ Fluid and Electrolytes 1113
‰‰ Preoperative Management 1114
‰‰ Postoperative Management 1117
‰‰ Fast-Track Protocol 1121
‰‰ Postoperative Examination 1122
‰‰ Postoperative Complications 1123
Chapter 63: Nutrition and Exercise in Women 1138
Nutrition in Women from Adolescence to Menopause 1138
‰‰ Nutrition Basics 1138
‰‰ Proteins 1139
‰‰ Fats 1139
‰‰ Carbohydrates 1141
‰‰ Energy 1143
‰‰ Adolescents Nutrition 1144
Exercise and Physiotherapy in Gynaecology 1152
‰‰ Active Muscle Exercises 1152
‰‰ Electrical Stimulation of Pelvic Muscles 1154
‰‰ Short-Wave Therapy 1154
‰‰ Infrared Radiation 1154
‰‰ Transcutaneous Electric Nerve Stimulation 1154
‰‰ Ultrasound 1155
Chapter 64: Applications of Laser in Gynaecology 1157
‰‰ Types of Lasers 1157
‰‰ Mechanism of Action 1157
‰‰ Laser Surgery for Cervix 1159
‰‰ Laser Surgery of the Vulva 1160
‰‰ Laser Surgery of the Vagina 1160
‰‰ Intra-abdominal Laser Surgery 1160

Contents xxxiii
‰‰ Gynaecologic Laser Laparoscopy 1160
‰‰ Hysteroscopic Laser Surgery 1161
Chapter 65: Genetics in Gynaecology 1162
‰‰ Genetics of Gynaecological Cancers 1163
‰‰ Family History of Gynaecological Cancers 1163
‰‰ Human Papillomavirus Integration and its Role in Cervical Malignant Progression 1163
‰‰ Hereditary Breast and Ovarian Cancer Syndrome 1163
‰‰ Genetic and Functional Analyses of Polymorphisms in the Human FSH Receptor Gene 1164
‰‰ Congenital Adrenal Hyperplasia 1164
‰‰ Genetics of Human Hypogonadotrophic Hypogonadism 1164
‰‰ Variation in the Timing of Puberty: Clinical Spectrum and Genetic Investigation 1165
‰‰ Genetic Counselling 1165
Index 1167

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