Jeffcoate’s Principles of GYNAECOLOGY

Jeffcoate’s Principles of GYNAECOLOGY

1. Jeffcoate’s Principles of
GYNAECOLOGY
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3. 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
Agra, Uttar Pradesh, India
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
Agra, Uttar Pradesh, India
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
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5. 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
Department of Obstetrics and Gynaecology
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
Agra, Uttar Pradesh, India
Anand Anupama  DGO FICOG
Consultant
Department of Obstetrics and Gynaecology
Nelson Mother and Child Hospital
Nagpur, Maharashtra, India
Bahadur Anupama  MBBS MD (Obstetrics and
Gynaecology)
Sub-Dean (Academics)
Additional Professor
Department of Obstetrics and Gynaecology
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
Agra, Uttar Pradesh, India
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
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6. Jeffcoate’s Principles of Gynaecology vi
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
Agra, Uttar Pradesh, India
Bora Rishabh MBBS MD (Radiology)
Rainbow Hospital
Agra, Uttar Pradesh, India
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
Department of Obstetrics and Gynaecology
SN Medical College
Agra, Uttar Pradesh, India
Ghosh Chiranjit  MBBS MD (Obstetrics and
Gynaecology) DGO
RG Kar Medical College and Hospital
Kolkata, West Bengal, India
Goswami Diksha  MBBS MD DNB MRCOG FNB
(Reproductive Medicine)
Consultant
Rainbow-IVF
Agra, Uttar Pradesh, India
Gupta Shally  DGO DNB
Consultant
Rainbow-IVF
Agra, Uttar Pradesh, India
Gupta Sushma  MBBS MD (Obstetrics and
Gynaecology)
Consultant
Aakanksha Test Tube Baby Centre
Dr Kusum Gupta Nursing Home
Agra, Uttar Pradesh, India
Hafizur  MBBS DGO DNB MNAMS FMAS FICOG Dip. MAS
(Germany)
Professor
Department of Obstetrics and Gynaecology
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
Ahmedabad, Gujarat, India
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
Pune, Maharashtra, India
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7. Contributors vii
Kale Ashwani  MBBS DGO DNB (Obstetrics and
Gynaecology)
IVF Consultant and Embryologist
Ashakiran Hospital and Asha IVF Centre
Pune, Maharashtra, India
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
Agra, Uttar Pradesh, India
Malhotra Narendra  MD FICOG FRCOG (Honoris
Causa) FICS FMAS
Professor
Dubrovnik International University, Croatia
Past President, FOGSI
Managing Director
Global Rainbow Healthcare
Agra, Uttar Pradesh, India
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
Department of Obstetrics and Gynaecology
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
Kolkata, West Bengal, India
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
Ahmedabad, Gujarat, India
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8. Jeffcoate’s Principles of Gynaecology viii
Pandey Jyotsana MBBS
Resident
Department of Obstetrics and Gynaecology
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
Department of Obstetrics and Gynaecology
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
Ahmedabad, Gujarat, India
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
Kolkata, West Bengal, India
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
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9. Contributors ix
Sharma Esha  MBBS MS DNB
Consultant
Ramkrishna IVF Centre
Siliguri, West Bengal, India
Sharma Manpreet  MBBS MS (Obstetrics and
Gynaecology)
Consultant
Department of Obstetrics and Gynaecology
Rainbow Hospital
Agra, Uttar Pradesh, India
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
Agra, Uttar Pradesh, India
Singh Ankan  MBBS MS (Obstetrics and
Gynaecology)
Fellow in Reproductive Medicine
Rainbow Hospital
Agra, Uttar Pradesh, India
Singh Kavita  MS PhD (Gyn. Oncology) FICOG
FICMCH
Professor and Head
Department of Obstetrics and Gynaecology
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
Agra, Uttar Pradesh, India
Yadav Nisha  MBBS MD DNB DESA
Consultant
Department of Anaesthesiology and Critical
Care
Global Rainbow Healthcare
Agra, Uttar Pradesh, India
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11. 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
Neharika Malhotra BoraPREFACE TO THE
NINTH INTERNATIONAL EDITION
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13. 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 TindallPREFACE TO THE FIFTH EDITION
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15. 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 JeffcoateEXTRACTS FROM
THE PREFACE TO THE FIRST EDITION
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17. 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,
editors and content strategists (Dr Arun Bhatia, Kanav Midha, Mampi Debnath, Priyanka Diwan, Dr Sudha Chamoli
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
Neharika Malhotra BoraACKNOWLEDGEMENTS
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19. 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  81CONTENTS
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20. Jeffcoate’s Principles of Gynaecology xx
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
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21. 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
‰‰Epidemiology 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
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22. Jeffcoate’s Principles of Gynaecology xxii
‰‰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
‰‰Aetiology 279
‰‰Clinical Presentation  282
‰‰Investigations 283
‰‰Management 284
‰‰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
‰‰Diagnosis 322
‰‰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
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23. Contents xxiii
Chapter 19: Torsion of Pelvic Organs 359
‰‰Torsion of the Normal Organs  359
‰‰Torsion of Abnormal Organs  359
‰‰Aetiology 361
‰‰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
‰‰Diagnosis 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
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24. Jeffcoate’s Principles of Gynaecology xxiv
‰‰Management and Treatment 455
‰‰Chronic Pelvic Pain 456
‰‰General Considerations 457
‰‰Step-wise Evaluation of Chronic Pelvic Pain 457
‰‰Examination 457
‰‰Diagnostic Investigations 457
‰‰Management 458
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
‰‰Aetiology 483
‰‰Symptoms 484
‰‰Diagnosis 484
‰‰Treatment 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
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25. 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
‰‰Benign Neoplasms  545
‰‰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
‰‰Benign Neoplasms  574
‰‰Malignant Neoplasms  595
Chapter 32: Adenomyosis 608
‰‰Aetiology 608
‰‰Diagnosis 609
‰‰Differential Diagnosis  610
‰‰Management 610
‰‰Medical Therapy  610
‰‰Surgical Management  611
‰‰Complications 611
Chapter 33: Tumours of the Fallopian Tubes 613
‰‰Benign Neoplasms  613
‰‰Primary Malignant Neoplasms  613
‰‰Secondary Malignant Neoplasms  618
‰‰Prevention of Fallopian Tube Cancer  618
‰‰Recurrent Disease  618
‰‰Coping with Disease  618
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26. Jeffcoate’s Principles of Gynaecology xxvi
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
‰‰Complications 652
‰‰Staging of Ovarian Cancer  653
‰‰Treatment 654
‰‰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
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27. 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
‰‰Aetiology 687
‰‰Treatment 703
‰‰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
Prelims New.indd 27 09-Apr-18 3:10:08 PM

28. Jeffcoate’s Principles of Gynaecology xxviii
Chapter 44: Vaginal Discharge 761
‰‰General Considerations  761
‰‰Causes of Physiological Discharge  761
‰‰Prognosis 765
‰‰Risk Factors  765
‰‰Diagnosis 765
‰‰Management 767
‰‰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
‰‰Investigations 772
‰‰General Measures for Women with Pruritus  772
‰‰Differential Diagnosis of Pruritus  772
‰‰Treatment 777
‰‰Results 777
‰‰Vulvodynia 778
‰‰Management 779
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
‰‰Treatment 817
Chapter 48: Assisted Reproductive Technology 828
‰‰In Vitro Fertilisation and Embryo Transfer  828
‰‰Controlled Ovarian Hyperstimulation  829
‰‰Oocyte Retrieval  829
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29. 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
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30. Jeffcoate’s Principles of Gynaecology xxx
‰‰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
‰‰Indications 934
‰‰Contraindications to Laparoscopy   938
‰‰Preoperative Preparation  938
‰‰Surgical Steps  939
‰‰Postoperative Care  942
‰‰Advantages 942
‰‰Disadvantages 942
‰‰Complications 942
Hysteroscopic Surgery  944
‰‰Surgical Equipment  944
‰‰Indications 948
‰‰Preoperative Preparation  951
‰‰Surgical Steps  952
‰‰Postoperative Care  954
‰‰Advantages 955
‰‰Disadvantages 955
‰‰Complications 955
Laparo-endoscopic Single-Site Surgery  958
‰‰Surgical Equipment  958
‰‰Indications 959
‰‰Laparo-endoscopic Single-Site Surgical Techniques  959
‰‰Advantages 961
‰‰Complications 962
Chapter 55: Contraception 965
‰‰General Consideration  965
‰‰Epidemiology 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
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31. 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
‰‰Management 1052
‰‰Overview of Surgical Management  1053
‰‰Enuresis 1060
‰‰Urinary Retention and Difficulty in Micturition  1061
Chapter 58: Urinary Tract Infection 1066
‰‰Aetiology 1067
‰‰Diagnosis 1067
‰‰Investigations 1068
‰‰Management 1069
‰‰Treatment 1069
‰‰Complications 1071
‰‰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
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32. Jeffcoate’s Principles of Gynaecology xxxii
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
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33. 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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