Fibroids are benign / non-cancerous tumors that originates from the
smooth muscle layer (myometrium) of the uterus.
Fibroids are benign tumors arising from the smooth muscle of the uterus.

 Other common names are :uterine leiomyoma, myoma, fibromyoma,

They occur usually after the age of 30 years and commonly in women who have not had children. Fibroids are more likely to arise in the body of the uterus than the cervix. They are composed of muscle and fibrous tissue may be single or multiple and may be from a pinhead size to enormous size.

Risk factors for uterine fibroids

  1. Age: Uterine fibroids are more common in women between the ages of 30 to 40 years.

  2. Parity: Women who have never given birth (nulliparous) or have had few pregnancies (low parity) are at a higher risk.

  3. Race: Uterine fibroids are more prevalent in individuals of African descent (negro or black) compared to those of Caucasian (white) ethnicity.

  4. Family History: If a woman has close relatives (such as mother, sister) with a history of uterine fibroids, her risk may be increased.

  5. Hyper-estrogenemia: Elevated levels of estrogen, a female hormone, can promote the growth of fibroids.

  6. Obesity: Being overweight or obese is associated with a higher risk of developing uterine fibroids.

  7. Early Onset of Menarche: Starting menstruation at a young age may be linked to an increased likelihood of fibroid development.

  8. Low Level of Vitamin D: Some studies suggest that insufficient vitamin D levels might be associated with a higher risk of uterine fibroids.

  9. Drugs (Estrogen Replacement Therapy): Long-term use of estrogen replacement therapy, particularly without progesterone, can be a risk factor for uterine fibroids.

Classes or types of Uterine fibroids

Classes or types of Uterine fibroids

  1. Submucosal Fibroids: These fibroids grow into the uterine cavity. They are located just beneath the inner lining of the uterus (endometrium). Submucosal fibroids can cause various symptoms, including heavy menstrual bleeding and infertility.

  2. Intramural Fibroids (Interstitial): Intramural fibroids are the most common type and grow within the muscular wall of the uterus, known as the myometrium. They may expand and distort the shape of the uterus, leading to pain, pressure, and other symptoms.

  3. Subserosal Fibroids: These fibroids grow on the outside surface of the uterus. They can project outward and may become quite large. Subserosal fibroids can cause pelvic pain and pressure on nearby organs.

  4. Cervical Fibroids: Located on the cervix, the lower part of the uterus, cervical fibroids are relatively rare. They may cause symptoms such as pain and discomfort, and in some cases, they can affect fertility or lead to difficulties during labor.

  5. Fibroid of the Broad Ligament: This type of fibroid develops in the broad ligament, which is a supportive structure that helps hold the uterus in place within the pelvis. Broad ligament fibroids are relatively uncommon and may require specific management depending on their size and location.

Location or Sites of Uterine Fibroids

The locations or sites of uterine fibroids can be described as follows:

I. Subperitoneal (Under the Peritoneal Surface): These fibroids grow on the outer surface of the uterus, just beneath the peritoneum (the thin, protective layer covering the abdominal organs). They can extend and project outward, leading to symptoms such as abdominal discomfort and pressure.

II. Submucous (Bulging/Protruding into the Endometrial Cavity): Submucous fibroids grow into the uterine cavity, bulging and protruding into the endometrial lining. They can cause heavy menstrual bleeding, irregular periods, and even affect fertility.

III. Pedunculated Fibroids: These fibroids are attached to the uterus by a narrow stalk or pedicle that contains blood vessels. Pedunculated fibroids can be either subserosal or submucous, depending on their location.

IV. Intramural (Within the Wall of the Uterus or Centrally within the Myometrium): Intramural fibroids are the most common type and grow within the muscular wall of the uterus (myometrium). They can cause the uterus to enlarge and lead to symptoms such as pelvic pain and pressure.

V. Subserosal (At the Outer Border of the Myometrium): Subserosal fibroids grow on the outer surface of the uterus, just beneath the serosa (the outermost layer of the uterus). These fibroids can be large and cause pelvic discomfort.

VI. Cervical Fibroids: Cervical fibroids are located on the cervix, the lower part of the uterus that connects to the vagina. They are relatively rare and can cause symptoms similar to other types of fibroids, such as pain and pressure.

Wondering what’s the difference?  The difference between “types” and “location” of uterine fibroids lies in what they describe:
  1. Types of Uterine Fibroids: The types of uterine fibroids refer to the different categories or classifications based on their specific characteristics and growth patterns. The main types of uterine fibroids are: a. Submucous (bulging into the endometrial cavity) b. Intramural (within the wall of the uterus or centrally within the myometrium) c. Subserosal (at the outer border of the myometrium) d. Pedunculated (attached to the uterus by a narrow stalk or pedicle) e. Cervical (located on the cervix) These types help healthcare professionals understand the nature of the fibroids and how they may be affecting the uterus and surrounding structures.
  2. Location of Uterine Fibroids: The location of uterine fibroids refers to the specific sites within or around the uterus where the fibroids are situated. The different locations are: a. Subperitoneal (under the peritoneal surface) b. Bulging/Protruding into the endometrial cavity (submucous) c. Attached to the uterus by a narrow pedicle containing blood vessels (pedunculated) d. In the wall of the uterus or centrally within the myometrium (intramural) e. At the outer border of the myometrium (subserosal) f. Cervical (located on the cervix) The location of the fibroids is crucial because it determines their proximity to other organs, how they may impact the uterine cavity or the cervical region, and how they might be approached for treatment.
In summary, the “types” of uterine fibroids describe the different categories based on their growth patterns, while the “location” refers to the specific sites within or around the uterus where the fibroids are found

Changes (degenerative) that can take place in the fibroid

Degenerative changes in uterine fibroids refer to alterations in the fibroid tissue that can occur over time or due to specific circumstances. 

  1. Red Degeneration: This type of degeneration often occurs during pregnancy. It happens when the fibroid’s blood supply is disrupted, leading to necrosis (cell death) of the fibroid tissue. The fibroid becomes reddish and soft, with a “beefy” appearance.

  2. Atrophy: After menopause, when hormone production decreases, fibroids may undergo atrophy. Atrophy refers to a decrease in size or wasting away of the fibroid due to the reduction in hormonal stimulation.

  3. Hyaline Degeneration: In hyaline degeneration, the fibroid tissue becomes soft, and the muscle fibers are replaced by a homogenous, structureless material.

  4. Parasitic Fibroid: This occurs when the blood supply to a fibroid is cut off due to torsion (twisting) of its pedicle. The fibroid then establishes a new blood supply from the surrounding tissues.

  5. Cystic Change: Following hyaline degeneration, the fibroid’s tissue can become fluid-filled, giving it a cystic appearance similar to an ovarian cyst.

  6. Fatty Change: The muscle fibers of the fibroid are replaced by fat tissue.

  7. Calcification: In calcification, calcium salts are deposited in the fibroid, causing it to harden and become similar to a stone.

  8. Eggshell Fibroid (Calcification): In this type of calcification, the calcium deposits form on the outside of the fibroid, leaving the inside with its usual consistency.

  9. Womb Stone: This term describes a fibroid that is entirely deposited with calcium salts, causing the entire fibroid to become hardened like a stone.

Causes of Uterine Fibroids.

Causes of uterine fibroids are not fully understood, but research suggests that hormones and genetics play significant roles in their development. Here’s a more detailed explanation:

  1. Hormones: The hormones estrogen and progesterone, which regulate the menstrual cycle, have a close association with the growth and development of uterine fibroids. During each menstrual cycle, the lining of the uterus (endometrium) thickens under the influence of estrogen and progesterone. These hormones also seem to stimulate the growth of fibroids. As a result, fibroids often grow and enlarge during the reproductive years when hormone levels are at their highest. Conversely, as hormone production decreases during menopause, fibroids tend to shrink and become less symptomatic.

  2. Genetics: There is evidence to suggest that genetics can play a role in the development of uterine fibroids. Women with a family history of fibroids are at a higher risk of developing them themselves. This suggests that certain genetic factors may predispose individuals to fibroid formation.

  3. Other Factors: Although hormones and genetics are the main factors associated with uterine fibroids, some other factors may contribute to their development or growth. These factors include obesity, race (fibroids are more common in women of African descent), and dietary factors.

Clinical Presentation of Uterine Fibroids.

Clinical Presentation of Uterine Fibroids.

  1. Painful and Prolonged Menstrual Periods: Fibroids can cause heavy and prolonged menstrual bleeding, leading to painful periods (dysmenorrhea).

  2. Vaginal Bleeding after Menopause: Postmenopausal women with fibroids may experience vaginal bleeding, which is abnormal after menopause.

  3. Difficulty with Urination and Constipation: Large fibroids or fibroids pressing on the bladder can cause frequent urination or difficulty emptying the bladder. Fibroids pressing on the rectum can lead to constipation.

  4. Pressure in the Pelvic Area: Women with fibroids may feel pressure or heaviness in the lower abdomen or pelvis.

  5. Fullness or Pressure in the Belly: Enlarged fibroids can cause the abdomen to appear distended and feel full.

  6. Lower Back and Leg Pain: Some women may experience lower back pain or pain in the legs due to the pressure exerted by fibroids on surrounding structures.

  7. Pain During Sex (Dyspareunia): Fibroids can cause pain or discomfort during sexual intercourse.

  8. Difficulty in Getting Pregnant (Infertility): Depending on their size and location, fibroids can interfere with the implantation of a fertilized egg or lead to difficulties in conception.

  9. Pressure Symptoms: Fibroids can create pressure on the bladder, leading to increased frequency of urination. They can also exert pressure on the rectum, causing constipation. Additionally, pelvic vein pressure can lead to hemorrhoids and varicose veins.

  10. Acute Degeneration: In some cases, fibroids may undergo acute degeneration, which can cause severe pain.

  11. Enlargement of the Abdomen: Large fibroids or multiple fibroids can cause the abdomen to become visibly enlarged due to their projection into the abdominal cavity.

investigations of fibroids

Diagnosis and Investigations

  1. History Taking: A comprehensive medical history is taken to understand the patient’s symptoms, menstrual patterns, reproductive history, and any relevant medical conditions. This helps in assessing the likelihood of uterine fibroids and guides further evaluation.

  2. Physical Examination: A physical examination is conducted to assess general health and look for specific signs related to uterine fibroids. This may include checking for signs of chronic anemia (pallor) due to heavy menstrual bleeding.

  3. Abdominal Examination: An abdominal examination is performed to detect any large pelvi-abdominal swelling, which can be associated with significant fibroid growth.

  4. Pelvic Examination: During a pelvic examination, the healthcare provider assesses the size, shape, and position of the uterus. Uterine fibroids may cause the uterus to be symmetrically or asymmetrically enlarged. A speculum examination may also reveal the presence of fibroid polyps.

  5. Investigations: Various diagnostic tests are used to confirm the presence of uterine fibroids and assess their characteristics. These investigations may include:

    • Pregnancy Test: To rule out pregnancy as a cause of symptoms.
    • Full Blood Count (FBC) and Iron Studies: To check for anemia, which can result from heavy menstrual bleeding caused by fibroids.
    • Pelvic Ultrasound (U/S): An ultrasound is a common imaging test used to visualize the uterus and detect fibroids. It is a non-invasive and relatively simple procedure.
    • Saline Hysterosonography: This procedure involves injecting saline into the uterus during an ultrasound to enhance visualization of the uterine cavity and identify submucous fibroids.
    • Hysterosalpingogram (HSG): An HSG is an X-ray procedure that uses contrast dye to visualize the uterine cavity and fallopian tubes. It can help detect intrauterine fibroids.
    • Transvaginal Ultrasound (TVUSS): This type of ultrasound involves inserting a small probe into the vagina for a clearer view of the pelvic organs, which can be especially useful in obese patients.
    • Hysteroscopy: A hysteroscope, a thin, lighted instrument, is used to directly visualize the uterine cavity, enabling the identification and removal of submucous fibroids.
    • Bimanual Examination: A two-handed examination of the pelvic organs to assess the size, shape, and mobility of the uterus and detect any abnormal masses.
    • MRI (Magnetic Resonance Imaging): Although not always necessary, MRI is highly accurate in providing detailed information about the size, location, and number of fibroids.

Management of Fibroids.

Most fibroids do not require treatment unless they are causing symptoms. After menopause, fibroids usually shrink, and it is unusual for fibroids to cause problems. The choice of management depends on several factors:

  • Age
  • Parity
  • Size and location of fibroids
  • Desire for uterine preservation
  • If need for more children

For example:

  • Multiple myomas and completed childbearing benefit from hysterectomy.
  • Nulliparous women may undergo myomectomy.
  • Submucosal myomas can be treated with hysteroscopic resection.
  • Subserosal pedunculated myomas can be removed through laparoscopic resection.

Emergency Treatment:

  • Blood transfusion is given to correct anemia.
  • Emergency surgery is indicated for infected myoma, acute torsion, and intestinal obstruction.

Medical Management:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can help manage pain.
  • Antifibrinolytic agents like tranexamic acid may reduce menorrhagia.
  • Low-dose birth control pills or an intrauterine device with a slow-release hormone (Mirena) can control heavy menstrual bleeding.
  • Haematenics like ferrous sulphate or folic acid are used to improve hemoglobin levels in cases of Menorrhagia.
  • Levonorgestrel intrauterine devices effectively limit menstrual blood flow and improve other symptoms with minimal side effects.
  • Gonadotropin-releasing hormone (GnRH) agonists like Lupron and Synarel can temporarily reduce estrogen and progesterone levels, leading to fibroid shrinkage.
  • Mifepristone (25-50mg twice weekly) is a progesterone receptor inhibitor that can reduce fibroid size and bleeding.
  • Danazol, an androgen, interrupts ovulation.

Surgical Management:

  • Myomectomy: Surgical removal of one or more fibroids, often recommended for women who want to preserve fertility.
  • Hysterectomy: Removal of the uterus, suitable for women with multiple myomas and completed childbearing.
  • Endometrial ablation: Removal of the uterine lining.
  • Uterine artery embolization: Limiting blood supply to the myoma by injecting polyvinyl particles via the femoral artery.
  • Radiofrequency ablation: Shrinking fibroids by inserting a needle-like device into the fibroid and heating it with radiofrequency.


  • Myomectomy: Young women who want more children, small or few fibroids, heavy or prolonged bleeding.
  • Hysterectomy: Possible malignant changes, large or numerous fibroids, desire to limit family size, or approaching menopause.
Pre and Post Operative Care/Management

This involves providing care for patients undergoing  surgery of gynecological procedures. 

1. Admission and History Taking:

  • Obtain personal, medical, social, and gynecological history.
  • Conduct a physical examination, including vital signs (temperature, respirations, blood pressure, and pulse), head-to-toe examination to rule out anemia, dehydration, jaundice, and vaginal examination to assess any abnormalities.
  • General assessment by the gynecologist.

2. Informed Consent:

  • Explain the reasons for the operation, its benefits, risks, and expected results to the patient and involve the partner if necessary.

3. Investigations:

  • Conduct various tests, including urinalysis, hemoglobin (HB) level, blood grouping and cross-match, abdominal ultrasound scan, urea and electrolytes, INR/PT (International Normalized Ratio/Prothrombin Time), and ECG/ECHO if required.

4. Patient Education:

  • Educate the patient about the surgery, its purpose, potential complications, and side effects of anesthesia.
  • Provide reassurance and counseling to relieve anxiety.

5. Preparing for Surgery:

  • Ensure the patient fasts from food and drinks on the day of the operation.
  • Arrange for IV line insertion, blood booking in the laboratory, and catheterization of the patient.
  • Administer pre-medications as prescribed.

6. Assisting with Theatre Preparation:

  • Help the patient change into theatre gown.
  • Continue providing counseling and emotional support.
Post-Operative Management:
  • After the operation, prepare the post-operative bed for the patient.
  • Obtain reports from the surgeon, recovery room nurses, and anesthetists.
  • Wheel the patient to the ward.
  • Receive the patient in a warm bed, keeping her in a flat position, or turning her to one side depending on the surgery type (supine for abdominal surgery or a comfortable position for vaginal surgery).


  • Monitor the patient closely, taking vital signs regularly (every ¼ hr for the first hour and every ½ hr for the next hour until discharge).
  • Observe temperature, pulse, respiration, blood pressure, and signs of bleeding or edema at the surgical site.
  • Check the IV line and blood transfusion line if applicable.

Upon Consciousness:

  • Gently welcome the patient from the theater, explain the surgery, and assist with face sponging.
  • Provide a mouthwash and change the gown.

Medical Treatment:

  • Administer analgesics, such as Pethidine 100mg every 8 hours for 3 doses, and switch to Panadol to complete 5 days.
  • Prescribe antibiotics, such as ampicillin or gentamicin, as ordered.
  • Offer supportive care with vitamins like vitamin C, iron, and folic acid.
  • Monitor and care for the wound in case of abdominal surgery, leaving the wounds untouched if bleeding occurs and re-bandaging if necessary.

Nursing Care:

  • Assist the patient with hygiene, including bed baths and oral care.
  • Allow the patient to feed herself as soon as she is able and provide plenty of fluids.
  • Encourage regular bowel and bladder emptying, offering assistance as needed.
  • Initiate chest and leg exercises to avoid swelling and bleeding in the wound.
  • Gradually increase the exercise routine to prevent deformities and contractures.

Vaginal Surgery Management:

  • Insert a vaginal pack to control hemorrhage and inspect it frequently for severe bleeding.
  • Apply vulval padding after pack removal until bleeding stops, changing it when necessary to prevent infections.
  • Swab or clean the vulva at least every 8 hours to prevent infection.

Advice on Discharge:

  • For Myomectomy patients, advise avoiding conception for 2 years following the operation and delivering via cesarian section.
  • For hysterectomy patients, inform them that they will not conceive again or have periods.
  • Recommend abstaining from sexual intercourse for about 6 weeks and avoiding douching. Vaginal bleeding may persist for up to 6 weeks.

Complications of Uterine Fibroids:

  • Menorrhagia (heavy menstrual bleeding)
  • Premature birth, labor problems, and miscarriage
  • Infertility
  • Twisting of the fibroids
  • Anemia
  • Urinary tract diseases
  • Postpartum hemorrhage

Complications during pregnancy and labor may include:

  • Antepartum hemorrhage (placenta previa, placental abruption)
  • Abortion
  • Fetal restricted growth
  • Malpresentation
  • Cesarean section
  • Labor dystocia
  • Premature labor
  • Uterine inertia leading to postpartum hemorrhage
  • Obstructed labor
  • Subinvolution of the uterus with increased lochia.




Pelvic Inflammatory Diseases (PID) refer to infections that affect the pelvic organs, pelvic peritoneum, and the pelvic vascular system.

 The pelvic organs include the Fallopian tubes, Ovaries, Cervix, and Endometrium.

Causes of Pelvic Inflammatory Diseases

  1. Ascending infections: These occur when bacteria from the vagina or cervix travel upwards into the reproductive organs, such as the Fallopian tubes and ovaries.

  2. Haematogenous infections: Infections that are spread through the bloodstream to reach the pelvic organs.

  3. Direct spread from infected neighboring organs: For example, an infected appendix can spread the infection to the pelvic region.

Causative Organisms

Several microorganisms can cause PID, including:

  1. Neisseria gonorrhoeae
  2. Chlamydia trachomatis
  3. Haemophilus influenzae
  4. Escherichia coli (E. coli)

Risk Factors

Certain factors increase the risk of developing PID, including:

  1. History of sexually transmitted infections (STIs), especially gonorrhea and Chlamydia.
  2. Bacterial vaginosis, an imbalance in vaginal bacteria.
  3. Having multiple sexual partners.
  4. Douching, which can disrupt the natural balance of vaginal flora.
  5. Previous history of PID, increasing the risk of recurrence.
  6. Use of intrauterine contraceptive devices (IUDs).
  7. Undergoing surgical procedures like dilation and curettage.
  8. Obstetric causes such as abortion, ectopic rupture, and puerperal sepsis.


PID is often caused by multiple microorganisms, with gonorrhea and Chlamydia being common culprits. The infection typically starts in the vagina and then ascends through the endocervical canal to reach the Fallopian tubes and ovaries. During menstruation, the endocervical canal is slightly dilated, facilitating the entry of bacteria into the uterus. Once inside the reproductive tracts, the bacteria rapidly multiply and can spread further to the fallopian tubes, ovaries, and even the peritoneum or other abdominal organs.

Clinical Manifestations

The clinical presentation of PID can vary, and common symptoms include:

On History Taking:

  1. Severe Lower Abdominal Pain: Approximately 70% of individuals with PID experience intense pain in the lower abdomen. This pain can be localized or diffuse and may worsen during movement or sexual activity.

  2. Acute Fever: Around 40% of PID cases present with a fever. The body’s elevated temperature is a response to the infection and inflammation.

  3. Purulent Vaginal Discharge: About 90% of PID patients have purulent (pus-like) vaginal discharge. The discharge may have a foul odor and appear yellowish or greenish.

  4. Menstrual Changes: PID can disrupt the normal menstrual cycle, leading to various menstrual irregularities. These changes may include dysmenorrhea (painful periods), menorrhagia (heavy or prolonged periods), or oligomenorrhea (infrequent or scanty periods).

On Examination:

During a physical examination, the following signs may be observed:

  1. Signs of Inflammation: Inflammatory responses, such as redness, warmth, and swelling, may be evident in the pelvic region.

  2. Peritoneal Signs: Abdominal examination may reveal signs of peritonitis, such as guarding (tensing of abdominal muscles), abdominal distension (swelling), and rebound tenderness (pain when pressure is released from the abdomen).

  3. Vaginal Examination: A pelvic examination is crucial to assess the condition of the pelvic organs.

    • Vaginal Changes: The vaginal walls may appear red, inflamed, and dry due to the ongoing inflammation.

    • Tender Fornices: Palpation of the vaginal fornices (areas around the cervix) may reveal tenderness, especially in cases of pyosalpinx (accumulation of pus in the Fallopian tubes).

    • Purulent Discharge: A healthcare provider may notice the presence of purulent discharge during the examination.


Cervicitis refers to the inflammation of the cervix, which is the lower part of the uterus that opens into the vagina. It is often caused by infections, most commonly sexually transmitted infections (STIs) like Chlamydia and Gonorrhea.

Signs and Symptoms of Cervicitis:

  1. Redness of the Cervix: Inflammation may cause the cervix to appear red and swollen when examined by a healthcare provider.

  2. Slight Bleeding on Intercourse: Cervicitis can lead to cervical friability, making the cervix more prone to bleeding, especially during sexual intercourse.

  3. Itching and Burning: Some individuals with cervicitis may experience itching and a burning sensation around the vaginal area.

  4. Vaginal Discharge (D/C): An abnormal vaginal discharge, which may be watery, yellowish, or greenish, can be present in cervicitis.

  5. Pelvic Pain: Some individuals may experience mild pelvic discomfort or pain.


Salpingitis is the inflammation of one or both fallopian tubes. It often occurs as a result of infections ascending from the vagina and uterus. Common causes of salpingitis include untreated or inadequately treated STIs, particularly Chlamydia and Gonorrhea.

Signs and Symptoms of Salpingitis:

  1. Abdominal or Back Pain: Salpingitis can cause lower abdominal or back pain, which may range from mild to severe.

  2. Dyspareunia: Pain during sexual intercourse, known as dyspareunia, can be a symptom of salpingitis.


Oophoritis is the inflammation of one or both ovaries. It can occur independently or in conjunction with other pelvic infections, such as salpingitis.

Signs and Symptoms of Oophoritis:

  1. Abdominal or Back Pain: Similar to salpingitis, oophoritis may cause abdominal or back pain.

  2. Dyspareunia: Pain during sexual intercourse may also be present in cases of oophoritis.



Endometritis is the inflammation of the endometrium, which is the inner lining of the uterus. 

It can be acute or chronic and is often caused by bacterial infections, most commonly occurring after childbirth, abortion, or the insertion of an intrauterine contraceptive device (IUD).

Signs and Symptoms of Endometritis:

  1. Fever: The patient may have an elevated body temperature as a response to the infection.

  2. Abdominal Pain: Pain or discomfort in the lower abdomen is a common symptom.

  3. Enlargement of the Uterus: In some cases, the uterus may appear larger than usual upon examination.

  4. Vaginal Discharge: Abnormal vaginal discharge may be present, which can be foul-smelling and may vary in color.



  • Prevent complications
  • Relieve pain
  • Prevent the disease from spreading


  • Admit the patient to a clean and well-ventilated gynecological ward for complete bed rest.
  • Start an I.V. line immediately to prevent dehydration and encourage oral fluids.


  • Place the patient in a comfortable position, especially semi-fowler’s, to aid discharge drainage.

Histories and Examination:

  • Take patient histories and conduct a comprehensive general examination.


  • Monitor vital signs (TPR & BP).
  • Observe and record color, amount, and smell of the discharge daily.
  • Monitor the general condition of the patient.


  • Conduct high vaginal swab for culture and sensitivity to identify the causative organism.
  • Perform urinalysis for culture and sensitivity.
  • Rule out malaria with a malaria slide.
  • Take a blood sample for culture and sensitivity to check for a hematogenous source.
  • Perform an ultrasound scan to rule out other causes of abdominal pain.


  • Advise the patient to take a highly nutritious diet with plenty of oral fluids.


  • Provide a bedpan or urinal and advise the patient to urinate whenever needed.
  • Observe and record the color, amount, and smell of the urine.
  • Disinfect urine and feces with JIK before disposal.


  • Make the bed daily and remove wrinkles for cleanliness.


  • Encourage the patient to do some physical exercise, such as walking around. Psychotherapy may be necessary.

Care of Mind:

  • Reassure the patient and relatives.
  • Provide newspapers, TV, radios, etc.

Medical Treatment:

  • Start treatment immediately while waiting for culture and sensitivity results.
  • Use broad-spectrum antibiotics (chloramphenicol 2 gm stat, then I gm 6 hourly for 5 days, gentamicin 160 mg OD for 5 days, ceftriaxone 2 gm daily for 5 days). If the discharge reduces, switch to oral antibiotics.
  • Use other drugs based on sensitivity results (metronidazole 500 mg TDS i.v., azithromycin 1g as a single dose, ciprofloxacin, tetracycline, doxycycline, Septrin).


  • Use narcotics for severe pain. Other options include Panadol, ibuprofen, Diclofenac to reduce pain and inflammation.

Advice on Discharge:

  • Reduce sexual partners, use condoms, avoid intrauterine contraceptive devices, seek early treatment for sexually transmitted infections, maintain hygiene, and follow prescribed drugs.
  • Instruct the patient to return for review in case of any problems like pain, discharges, or itching.


Untreated or poorly managed endometritis can lead to several complications, including:

  1. Pelvic Abscess: Accumulation of pus in the pelvic region.

  2. Infertility: Inflammation and scarring can affect the fallopian tubes and reduce fertility.

  3. Ectopic Pregnancy: An abnormal pregnancy outside the uterus, usually in the fallopian tubes.

  4. Chronic Pelvic Pain: Persistent pelvic pain lasting for an extended period.

  5. Pelvic Adhesions: Scar tissue formation that can cause organs to stick together.

  6. Salpingitis: Inflammation of the fallopian tubes.

  7. Peritonitis: Inflammation of the abdominal lining.

  8. Tubal Ovarian Mass: Formation of masses involving the fallopian tubes and ovaries.

  9. Intestinal Obstruction: Partial or complete blockage of the intestines.




Infertility is the inability of a couple to conceive or to get a child after one year of regular coitus without having used any form of contraception.

Infertility refers to failure to conceive inspite of regular unprotected sex during the child bearing age that is 15-49 years without any contraception for atleast one year.

Types of infertility

Primary infertility:  It is inability to conceive in a couple that has had no previous pregnancies.

OR Is the term used for a couple who have never achieved a pregnancy at any time after 1 year of unprotected sex.

Secondary infertility:  It is where one has ever conceived but then stops to produce when she is not on any method of family planning.

OR  Refers to a couple who have previously succeeded in achieving at least one pregnancy even if this ended in spontaneous abortion being unable to conceive again. 

Causes of infertility

In males
  • Depression
  • Release of immature sperms or abnormal or little or slow in movement.
  • Poor or failure to ejaculate
  • Extreme heat:  An increase in temperature of the testes from a prolonged fever or exposure to excessive heat can greatly reduce sperm count, vigor of sperm movement and it increases the number of abnormal sperms in semen.
  • Hydrocele ie excessive collection of the fluids in the scrotum. This prevents adequate production of sperms.
  • Varicocele ie varicose veins of the scrotum:  This abnormality may prevent proper supply and drainage of blood from the testes thus rising the temperatures and reducing the rate of sperm production. It also affects ejaculation.
  • Drugs of amoebiasis called amoebicides, anti-hypertensives like aldomet and diabetic drugs cause failure in erection.
  • Diseases like mumps cause a condition called orchiditis (inflammation of the testes)
  • Hormonal inadequate production of testosterone hormone may result into immature sperms.
  • Degenerative changes in sperms. This can be caused by nitrofurantoin.
  • Excessive smoking and alcohol consumption.
  • Obesity
  • Retrograde ejaculation: This is ejaculation into the bladder. It is assessed by urinalysis after ejaculation
  • Exposure to toxic chemicals or radiations affects the spermatogenesis.

Klineflters syndrome and Turners syndrome.

  •  KLINEFELTER’S SYNDROME:  A syndrome consisting of gynaecomastia, testicular atrophy, azoospermia and infertility.
    Testicular atrophy is a result of peritubular fibrosis which commence in childhood and progresses until all seminiferous tubules are replaced by fibrous tissue. Patients have 47 chromosomes
    instead of 46 with an extra X chromosome so that the sex chromosome constitution is XXY instead of XY. Loss of a Y chromosome leads to a body which is feminine.
    b) TURNER’S SYNDROME: It is caused by either the absence of or an abnormality in one of the two X chromosomes. Classical turner’s syndrome is a complete deletion of one X so that the karyotype is 45XO. They are females but have ovarian failure, widely spaced nipples, cardiovascular problems, squints, hypothyroidism and diabetes mellitus hence infertility. In adult life, they have problems of
Causes/factors in females

Are best discussed under the following headings;

  • – Defective Implantation
  • – Endocrine Disorders
  • – Ovarian Disorders
  • – Defective Transport
  • – Physical / Psychological Disorders
  • – Systemic Disorders


Major cause is tubal blockage due to PID (in Uganda especially). This contributes to 60 – 70%.

  • Salpingitis caused by infection after abortion or delivery by gonorrhoea, chlamydia or tuberculosis or by pelvic peritonitis from acute appendicitis may damage the tubal epithelium and in severe cases bring about tubal blockage. This mostly occurs at the outer end of the tube where the fimbriae adhere together but is also seen in the very narrow, interstitial part of the tube.
    When the tubes are not completely blocked, fertilization of the ovum may still take place but because of the damage to the ciliated epithelium the fertilized ovum may not be carried down the tube to the uterus and an ectopic pregnancy results.
  • Abnormalities of the uterus. Some people are born with no uterus or with a bicornuate uterus or Didelphys uterus with 2 horns).
  • Tubal factors. eg tubal blockage due to adhesions resulting from gonorrhea 
  •  Uterine fibroids (gross) causing an irregular implantation surface.
  •  Severe inflammation of the endometrium called uterus synechiae /endometritis. 
  • Intrauterine adhesions after myomectomy
  •  Over curreting of the uterus or surgery of the uterus i.e. Hysterectomy, Stenosed Cervix due to trauma or injury due to dilatation and curettage. May be acquired or congenital Gynaeatresia i.e. a very small hole with a blind end of the
  •  Endometriosis– A condition where patches of the endometrial like tissue develop outside the uterine cavity in abnormal locations such as ovaries, fallopian tubes and abdominal cavity. Can grow
    with hormonal stimulation causing pain, inflammation and scar tissue hence infertility.
  •  Trichomonas vaginalis (evidence of cause in Zambia).
  •  Use of barrier contraceptives e.g. condoms, IUDS and Spermicides
  •  Septate vagina and rigid hymen
  •  Congenital absence of fallopian tubes


  •  Hormones, Pituitary and Ovarian Inefficiency. There may be alteration of hypothalamic function resulting from stress (resulting in altered dopamine or noradrenaline transmission)
    Alteration of hypothalamic function due to some drugs e.g. rawolfia, phenothiazines or metaclopramide
    Weight loss or excessive weight gain causes unstable cerebrum and
    – May be a pituitary tumour which leads to production of excessive prolactin hormone hence causing Anovulation.
    These tumours are usually micro and macroadenomas which cause hyperprolactinaemia. Elevated levels of prolactin levels are normal during lactation and anovulation ensues as a result but if not
    lactating causes infertility.
  • Thyroid function:  Changes in thyroid function (hyperthyroidism or hypothyroidism) or in adrenal function (cushings syndrome or congenital adrenal hyperplasia) result in anovulation.
  •  Agemenopause. Fertility declines with age. Postponement of childbearing because of career can be a problem.


  • Ovary malfunction: Absence of FSH receptors in the follicle leads to failure of the ovary to respond to gonadotrophins (resistant ovary syndrome) or there may be disturbance in the interaction between FSH and the follicle. This disturbance may result in abnormal enzyme reaction- anovulation will result and the ovary becomes
    multicystic hence (polycystic ovarian syndrome). Failure of ovulation results in absence of secretory changes in the endometrium and the cervical mucus remains thick and impenetrable by the sperm.
  •  No eggs or no follicles in the ovary. Can be congenital.
  •  Premature menopause
  •  Surgery i.e. removal of the whole ovary mistakenly as in surgery of the ovary.
  •  Infection such as mumps can destroy the ovary substance
    PID = (adhesions (Ashermans Syndrome).
  • X-Ray Exposure: Chronic or excessive exposure to radioactive substances or x-ray. These could damage the ova.


  •  Allergy to the man’s sperms/cervical hostility – This is a condition in which the cervical mucus is unreceptive to spermatozoa either preventing their progressive advance or actually killing them. It may be due to infection or to the presence of sperm antibodies.
  •  Vaginal Ph ( acidic destroying the motility of the sperm)


 Other conditions preventing union of ova and sperm in female are;

  • Dyspareunia (painful or difficult sexual intercourse experienced by a woman due to psychological or physical factors) and vaginismus.
  •  Physical abnormality of the reproductive organs ie retroverted uterus.
  • Psychological factors like stress and depression. 
  • Wrong timing of sexual intercourse during infertile periods.


  •  Systemic diseases e.g. Diabetes Mellitus, hypertension and renal failure


Treat according to the cause.


  • Stop smoking
  • Reduction of alcohol consumption
  • Proper diet
  • Meeting at the right time
  • Reduction in stress and tension
  • Counselling
  • Artificial insemination


  • Depression
  • Divorce
  • Sexual immorality
  • Polygamy

Conditions that should be fulfilled for implantation to occur.

  • There should be 2 lovers
  •  Get unprotected coitus without contraception and both should actively get involved.
  •  Should be using the right sexual route – vagina for a woman with a penis (male).
  •  Should be within the age of conception, 14 to 49 years.
  •  There should be release of healthy semen containing normal spermatozoa.
  •  Normal, healthy ova must be released from the ovary.
  •  The ovum must unite with the sperms to be fertilized.
  •  The fertilized ovum must be implanted in the uterus.
    NB: The term sterility should be used only when there is no treatment possible to enable a couple to conceive (achieve pregnancy) such as when a man has no testes or a woman lacks a uterus.


All couples who complain of infertility should be investigated but the length to which the investigations should be carried out will vary.
Both partners should be seen for initial interview.



  1.  Menstrual history i.e. menarche and length of menstrual periods.
  2.  Previous gynecological history i.e. any previous contraceptive and its outcome, History of dilatation and curettage, salpingectomy etc.
  3. Any History of abortions or History of suggestive Pelvic inflammatory diseases.
  4.  Previous obstetric history i.e. previous pregnancies and number of children fathered by this
  5.  History of pelvic infection.
  6.  General state of health and nutrition.
  7.  Age of both man and woman. Above 50 in female is considered as menopause.

Her weight

  • Very lean thin and very obese woman have a problem. In the obese the ovary cannot secrete enough oestrodiol so they secrete more of oestrone hormone.
  •  Very thin – amenorrhoea – infertility.

Sight of the Woman

  • If one has a pituitary tumor she can’t see objects on the side.

Check for excessive prolactin
Check for hair distribution

  • i.e. pubic hair and general body hair distribution. If a lady has virilism – have Androgen – more masculine

Vaginal Examination 

  • On V/E check for normality of the vagina confirm with ultra sound.

 Hormonal Investigations

  • In a 28 cycle check for progesterone levels on day 21 to check for ovulation.


  • Serial ultra sound to see ovulation

FSH and LH

  •  Check FSH and LH especially in people with premature menopause or removal of the ovary.

 Post coital test to check whether the woman allergic to sperms.
Polycystic ovary common in the Europeans


Ovulation is confirmed by the lady taking her oral temperature every morning on waking up and records it on a special temperature chart. This must be done before rising or starting any activity.
A rise in the basal body temperature of about 0.5 degrees C in the last 14 days of the cycle indicates that ovulation has occurred continued x 6

Examination of the cervical mucus in the midcycle will reveal characteristic changes if ovulation has occurred.
Ovulatory mucus is clear copious and can be drawn out into a fine thread (spinnbarkeit).
On drying it crystallizes out into the characteristic fern pattern.
A sample of blood is taken off 1 week before a period is expected I.e. Day 21 or of a 28 day cycle a progesterone level of more than 20 mmol confirms that ovulation has taken place.

Histological examination of a premenstrual endometrial biopsy it will show secretory changes in the glands after ovulation.

This is a tubal patency test. It’s a premenstrual laporascopic exam of the tubes combined with injection of a dilute solution of methylene blue through a tightly fitting cannula placed in the cervical canal. The
uterus can be seen to be distended by the dye and if the tubes are patent they fill with dye which finally spills from the distal ends. Distal block is recognized if there’s no spill and medial block can be inferred if no dye enters.
NB: Pregnancy should be first ruled out.

It is an unreliable method where carbon dioxide is used,  passed via the vagina to the uterus. If there’s a problem in the uterus or tube the gas will be felt on Auscultation. An Xray is later done to Rule out blockage or no blockage.

Here an opaque radio aqueous solution through the cervix to the uterus and tubes is done under radiographic control the test is performed in the 1st 5 to 10 days of the cycle after menstrual bleeding has ceased but before Ovulation has occurred. An Xray is taken. Free spill of dye from the distal ends of the tubes proves patency and no spill indicates site of blockage.

Carried out at time of ovulation or 1 to 2 days before ovulation. 2-8 hours after unprotected intercourse, the cervix is exposed by a bivalve speculum and a sample of cervical mucus is withdrawn from the endocervical mucus with a wire loop or pipette placed on a warm slide and covered with a coverslip.
The number of progressively motile sperm in a number of high power fields is examined. Normally a large number of active sperm will be seen.

When prolactin level is higher than 800 m/u/l computerized tomography of the pituitary fossa is indicated to exclude a prolactin producing pituitary adenoma.

It is done 10- 12 days after ovulation.

– Presence of suspected pregnancy
– Presence of cervical erosion
– Presence of infection
– Serious heart and lung diseases.
– Patient in Menstrual periods or with Dysfunctional Uterine Bleeding
– Embolism
– Ascending Infection

  1.  Obesity – Diabetes Mellitus – Hypertension – Infertility
  2.  Hair distribution and development of genitalia
  3. For undescended testis – Operation before puberty is done
  4. Check breasts for enlargement, shows increased oestrogen
  5. Testes, size and situation.
  6. Decreased Androgen shows infertility.
  7. Blood test to evaluate FSH and LH levels.
  8. Sperm count/ seminal fluid analysis normal count is 20 million/ml. If below 10 million there’s a problem (Oligospermia)


  •  Normal volume ≥ 2ml or 2.5ml
  • pH- 7-8
  • Total sperm count- more than 20 million/ml
  • Liquefaction- complete in 1 hour
  • Motility ≥ 50% with forward motility
  • Morphology – 30% or more – with normal shape
  • Concentration ≥ 20 million/ml


  • Azoospermia: Lack of sperms in semen
  • Oligospermia: Little or few sperms less than 20 million/ml
  • Asthenospermia: Decreased motility of the sperms
  • Teratospermia: Excessive abnormality of the sperms in semen.



  1.  In Anovulatory Infertility, stimulate the ovary by giving Clomiphene Citrate (Clomid)
    > 50mgs daily for 5 days of onset of menstruation preferably on the second day or at any time if the cycles have ceased. If ovulation does not occur a second course of 100mgs daily for 5 days may
    be given starting as early as 30 days after the previous one,
    In general 3 courses of therapy are adequate to assess whether ovulation is obtainable.
    > Clomiphene induces ovulation by stimulating the Hypothalamic pituitary system.
    Key issues to note: This treatment often results into multiple pregnancy because the dose of the drug is difficult to adjust.
    Side effects
    > Visual disturbance
    > Abdominal discomfort
    > Headache
    > Insomnia
    > Ovarian by hyperstimulation
    > Hair loss
    > Breast tenderness
    > Depression
    > Hot flushes
    > Abnormal uterine bleeding
    > Inter menstrual spotting
    > Endometriosis
    > Dizziness
    > Nausea and vomiting
    > Menorrhagia
  2.  Give Tamoxifen 20mgs daily on days 2, 3, 4 and 5 of the menstrual cycles. Dose may be increased to 40mgs the 80mgs.
  3.  If patient has hyper prolactanaemic infertility give Bromocriptine (also called parlode lactodel, dopagon or Brameston).
    It is used to inhibit synthesis of release of prolactin by the pituitary gland.
    Initially 1.25mgs at bed time which is increased gradually to the usual dose of 2.5mgs 3 times a day with food. Increased if necessary to a maximum dose of 30mgs daily.
    Side Effects
    > Nausea
    > Headache
    > Nasal congestion
    > Fatigue
    > Dry mouth
    > Diarrhea
    > Constipation
    > Drowsiness
    > Hypotension
    > Dizziness
    > Abdominal cramps
    Drug Interactions
    1. Erythromycin may increase plasma concentration hence risk of toxicity of Bromocriptine.
    2. Bromocriptine is antagonized by antipsychotics and domperidone plus metoclopramide.
    3. In patients with hypothalmic dysfunction leutinising hormone administration is given to induce a pituitary response.
    10-25 micrograms released via a syringe pump every 90 minutes. It’s given intravenously or subcutaneously.
    The treatment is continued throughout the menstrual cycle
    The success rate of 60-70% has been shown.
  4.  Tubal Blockage
    Surgery is performed in an attempt to unblock them and remove adhesions. Success rate is low.
    This is when peritubal adhesions around the ampullary ends of the tubes are divided and
    function restored.
    This is when the fimbriae are turned back to produce a new opening of the tube.
    Tubal Anastomosis and Repair
    This is usually done when the blockage is at the Isthmus. The blocked segment is incised and cut ends anastomosed.
    If interstitial portion, re-implantation after dividing the tube close to the uterus is done and coring out the blocked segment is carried out.

Anovulatory Infertility

  1.  Synthetic Human Chorionic Gonadotrophin hormone may also be given. It is identical in action to leutinizing hormone and can trigger ovulation. Intercourse should be advised around the time of administration for successful results.
  2.  Human Menopausal Gonadotrophin HMG (Pregonal) or Pure FSH (Metrodin) may be used if clomiphene has failed.
  3. Uterine, cervix or vaginal problems are corrected. If uterine fibroids (Myomectomy).


  1.  Human Gonadotrophin Therapy give clomiphene citrate to stimulate sperm production.
  2. Testosterones to stimulate sexual desire. It should not be given in cases of impaired spermatogenesis
  3. Surgery Measures
    > Is done to relieve reproductive tract obstruction.
    > If inguinal hemia – hemia repair is done.
    > If vericocele – surgical ligaturing of the internal spermatic vein.

In Vitro Fertilization
Robert Edwards received the noble prize in Physiology for development of IVF. It was developed in 1978. IVF needs a healthy ova, sperms that can fertilize it and a uterus that can maintain pregnancy. Is an infertility treatment of women who are unable to conceive naturally. An ovum is obtained from the woman herself or it may be donated put in a test tube and mixed with the sperms of the husband or donor sperms later the embryo is implanted in the uterus to grow. The treatment often results in multiple pregnancies because many fertilized ova are transferred to the woman to increase the likelihood of implantation.
IVF can be combined with surrogacy (egg donation) and pre implantation genetic diagnosis (PGD) to rule out presence of genetic disorders (similar to a general test called pre implantation genetic haplotyping)

Collection of contents from the fallopian tubes or uterus after natural ovulation is done, and then mixed with semen and re inserted into the uterus.

ADDITIONAL TECHNIQUES to make chances of conception higher are used:

  1.  Ovarian hyper stimulation by GnRH agonist and FSH to retrieve multiple eggs.
  2.  Ultra sound guided transvaginal oocyte retrieval directly from the ovaries by an injection of HCG (the trigger shot)which acts as an analogue of luteinizing hormone is done. Ovulation is expected between 38 and 40 hours where as egg retrieval is between 34 and 36 hours prior to follicle rupture. This should be done with caution to prevent hyper stimulation ovarian syndrome which could lead to ovarian disorders thereafter.
  3.  Egg and sperm preparation by sperm washing to remove excess semen and purification from microbes and viruses .i.e. HIV is done.
  4.  Finally selection of the resultant embryos to be transferred to the uterus is done.
  5.  ICSI Intra cytoplasmic sperm injection may be performed alongside IVF. It may assist in male infertility where there is a defect in sperm quality or where sperms have difficulty penetrating the egg or where sperm numbers are very low. Sperm cells are injected directly into the egg cell before implantation in the uterus.

Surrogate Parents
In the absence of a uterus, the woman’s ova may be fertilized with the husbands sperms as above and later the embryo implanted in another woman’s uterus for her to carry the pregnancy for the couple.
As soon as the baby is born the surrogate mother hands over the child to the rightful parents.

Adoption of Children
If still eager to have children, they can visit an adoption centre fill in forms and apply for adoption of a child of choice.

Artificial Insemination by a Sperm Donor (AID)
This is considered when a male partner is infertile. The semen of a fertile donor is used for a woman who is potentially fertile to achieve pregnancy.


  1.  Anxiety and fear related to unknown procedures, treatment and outcome evidenced by patient’s verbalization.
  2.  Low self esteem related to inability to conceive evidenced by low mood, negative attitude and social isolation.
  3.  Knowledge deficit related to the process of ovulation, pregnancy and sexual relationship evidenced by inadequate verbalization of correct sexual behavior information.
  4.  Knowledge deficit related to sexual anatomy and physiology/ causes of infertility evidenced by inadequate verbalization of related information.

Infertility Read More »

Ectopic Pregnancy


Ectopic pregnancy is a condition in which a fertilized egg implants and grows outside the uterus. Instead of the fertilized egg traveling to and implanting in the uterus as it should during a normal pregnancy, it implants in a location where it cannot develop properly.

Ectopic pregnancy is when the fertilized ovum embeds outside the uterine cavity.

Causes of Ectopic Pregnancy.

  1. Fallopian tube damage: Scarring or blockage in the fallopian tubes,  caused by previous infections, surgeries, or conditions like endometriosis, can interfere with the the movement of the fertilized egg through the tube and increase the likelihood of implantation outside the uterus. Congenitally long tubes which are liable to kink, Congenital narrowing of the fallopian tube also increases the risk.

  2. Hormonal factors: Certain hormonal imbalances or abnormalities can affect the movement and implantation of the fertilized egg, increasing the risk of ectopic pregnancy.

  3. Previous ectopic pregnancy: Women who have had an ectopic pregnancy in the past are at a higher risk of experiencing another ectopic pregnancy in the future.

  4. Reproductive system abnormalities: Structural abnormalities of the reproductive system, such as a misshapen uterus or an abnormally located fallopian tube, can contribute to the occurrence of ectopic pregnancy.

  5. Pelvic inflammatory salpingitis. This cause destruction or erosion of Cilia, formation of adhesions interfering with peristalsis in the tubes.

  6. Tumours: pressing on adjacent sides of the tube causing partial or complete blockage of the tube.

  7. Endometriosis ie development of the endometrium in other places other than the uterus.

  8. Repeated induced abortions

  9. Tubal surgery ie surgical procedures on the fallopian tubes may cause intraluminal or extraluminal adhesions.

  10. Intra Uterine Devices. This can interfere with implantation of the fertilized ovum.

Ectopic Pregnancy


The commonest is the uterine tube but can also occur in the broad ligament, ovary and abdominal cavity.

  • Fallopian tubes(commonest)
  • Ovary
  • Intraperitoneal abdominal cavity 
  • Cervix
Tubal pregnancy

This is when a fertilized ovum embeds it self in the fallopian tubes.

Sites for tubal pregnancy

  • Ampulla(commonest)
  • Isthmus (e most dangerous because it has tendency to rupture
    very early sometimes even before the mother realizes she is pregnant)
  • Fimbriated end(infundibulum) – rare
  • Interstitial part(rare)


  • Tubal mole: The zygote dies but it is retained in the fallopian tubes surrounded by a blood clot. This may result into a slow leaking ectopic pregnancy
  • Tubal abortion:  The zygote separates from the fallopian tube lining and it is expelled through the fimbriated end. It may die out or continue to survive on abdominal organs resulting into abdominal pregnancy which can go up to term.
  • Tubal rapture: The tube becomes too small for the growing zygote so it raptures causing internal bleeding into the abdominal cavity. 
  • It is one of the obstetric emergencies since it causes a lot of internal bleeding and thus shock. 
  • Tubal erosion: The zygote erodes the fallopian tube lining causing bleeding in to the abdominal cavity.
Signs and symptoms ectopic pregnancy (tubal rapture)

On history taking

  • History of amenorrhea 6 – 10 weeks
  • Patient complains of a feeling of fainting, dizziness, thirsty and vomiting.
  • Patient complains of acute abdominal pain localized in the iliac fossa which is colicky in nature. It can be referred to the shoulder especially on lying down due to blood irritating the diaphragmic nerve and peritoneum. 

On examination

  • Signs of pregnancy are present. eg darkening of areolar. 
  • Signs of shock i.e. cold, clammy skin, rapid and thread pulse, low blood pressure and temperature.
  • Patient is anxious and restless.
  • Pallor of the mucous membrane.

On palpation

  • Abdominal tenderness especially on the affected side
  • Abdominal muscles become rigid due to mother guarding against pain.
  • Abdominal distension due to presence of blood in the abdominal cavity

On vaginal examination

  • Amount of bleeding doesn’t correspond to the mother’s condition.
  • Tenderness on movement of the cervix and a mass is felt in the lateral fornix of the vagina.
  • Painful mass in the pouch of Douglas
  • Dark brown blood on the examining finger.


  • Ultra sound scan will reveal the rupture and collection of blood on the affected side. Ultrasound scan will confirm the diagnosis
  • Blood for Hb, grouping and cross match.
  • On CBC, Haemoglobin level will be low
  •  Pregnancy test is positive
  •  In an emergency if scan is not available a puncture into the Pouch of Douglas fresh blood will be found on aspiration

Differential diagnosis

  • Salpingitis if associated with irregular menses
  • Appendicitis
  • Abortion
  • Twisted ovarian cyst
  •  Urinary tract infection

Management of Ectopic Pregnancy

In health centre.

This is an emergency and everything must be done as quickly as possible to save life of the mother.


  • To prevent shock
  • To relieve pain
  • To reassure the patient
  1.  Admission:  Mother is admitted temporarily on gynaecological ward. Histories are taken, general examination, observations, abdominal and vaginal examination done. A diagnosis is then made.
  2. Histories: these are taken including personal, social, surgical, medical, obstetrical history, how the condition started etc
  3. Examination: This is carried out from head to toe to rule out anaemia, dehydration, shock etc
  4. Observation: Temperature, pulse, respiration and blood pressure are taken and recorded to assess functioning of vital organs.
  5. Resuscitation:  A drip of normal saline is put up and morphine 15 mg given intramuscularly. The foot of the bed should be raised to allow blood to move to vital centers.
  6. Transport: Send for transport as soon as possible and inform the patient and relatives about the decision made and why it is necessary.
  7. Transfer:  The decision is explained to the patient and relatives, a well written note made stating time of admission, treatment given condition on arrival and leaving. Transport is arranged then the mother is transferred to hospital. The midwife escorts the mother and hands her over to the hospital staff.
  8. Treatment: Put up intravenous infusion of normal saline to prevent or treat shock. This is to elevate the low blood pressure. Administer morphine or pethidine to relieve pain as prescribed.
  9. Nursing care: The vulva is swabbed and a clean pad is applied. Send the patient to hospital with a written note stating when the patient reported to the center, condition on admission and at time leaving and treatment given.
Hospital Management

In the hospital

It is a gynecological emergency, so everything must be done quickly as possible and all nurses must work as a team to see that the patient is taken for operation as soon as possible.


  1. To treat anaemia
  2. To prevent or treat shock
  3. To reassure the patient
  4. To prevent complications
  5. Admission: Admit the patient in a well-ventilated room and warm admission bed. Establish a good nurse patient relationship.
  6. Histories :Histories are taken from the patient if able or from the relatives if patient is unable (collateral history).These will include social, medical, surgical, obstetrical, gynaecological histories. More emphasis is put on history of the presenting complaint i.e. when the condition started, amount of bleeding, site of pain, any vomiting or if any treatment has been given. Weeks of amenorrhoea are estimated.
  7. The doctor is then informed
  8. General examination: This carried out from head to toe to rule out anemia, shock, dehydration etc
  9. Observations: Vital observations like temperature, pulse, respiration and blood pressure.
  10. Investigations: On arrival of the doctor, he orders for the following investigations;
    > Haemoglobin estimation to rule out malaria
    > Blood group and cross matching because blood transfusion may be necessary
    > Pregnancy test to confirm that the mother was pregnant and the pain is not due to other conditions
    > Ultra sound scan to confirm the diagnosis
    > Urinalysis to rule out urinary tract infection
  11. Resuscitation: Intravenous Normal saline is started to prevent or treat shock. Morphine 15 mg I.M. will be given as ordered by doctor. If mother is in shock it is also managed. Intravenous fluids eg normal saline are put up and fluid balance chart is maintained.
  12. Blood transfusion: This carried out depending on the haemoglobin results.
  13. Pain relief: Analgesics such as morphine is administered to relieve pain as prescribed by the doctor.
Pre-operative care

The doctor will determine the operation.

Preparation for theatre

Nursing care

  • A bed bath is given, theatre gown offered, observations done and recorded, all charts collected then the patient is wheeled to theatre. 
  • Explain the nature of operation to the patient and obtain an informed consent.
  • Reassure the patient to allay anxiety
  • Theatre staffs are informed
  • Pass an intravenous line for infusion
  • Vulva swabbing is done to minimize infections
  • Catheterization is done and a fluid balance chart is started.
  • Pass a naso-gastric tube for aspiration gastric or stomach contents or an anti-acid like magnesium trisilicate is given to make the stomach contents alkaline. This prevents aspiration of acidic contents into the lungs.
  • Pre- medication is given like atropine to dry the secretions.
  • Repeat vital observations and compare with the baseline observations and record.
  • Compile the clinical charts and notes, dress the patient in gown and transport her carefully to theatre.
  • In theatre give a full report to the theatre nurse about the patient.
  • Book about 1-2 units of blood.
  • The patient is handed over to the theatre staff and if possible the ward nurse stays with the patient until she is anesthetized. The nurse goes back to the ward and makes a post-operative bed with all its requirements. 

In theatre

  • Laparatomy and salpingectomy is done to remove the ruptured portion and repair the area to control bleeding. The other tube is examined for patency and unblocked if possible. If the rupture was acute and the blood is fresh it may be collected, sieved into an anticoagulant (sodium citrate) and re-transfused into the patient. This is known as auto transfusion. If this is not possible cross matched blood is transfused.

Post- operative care

  • Post-operative bed should be made with all its accessories such as a drip stand, oxygen machine, vital observation tray, emergency tray, resuscitation tray e.t.c. ready to receive the patient.
  • When the operation is complete, the ward staff are informed and two qualified nurses go to theatre to collect the patient.
  • In theatre, receive a full report from the anesthetic and the theatre nurse in a recovery room should report the condition of the patient.
  • Confirm the report while patient is still in the recovery room by;
  • Checking airway, breathing and circulation.
  • Taking vital observations
  • Observing the site of operation for bleeding
  • Observe the catheter to see if it is draining well and in good position.
  • After confirming, the patient is gently wheeled to ward in a recumbent position with the head turned to one side meanwhile observing the airway.

On ward

  • The patient is lifted from the trolley with care to a well made post-operative bed with all its accessories close to the nurse’s station for close observations.
  • The patient is put in a recumbent position with the head turned to one side to allow drainage of secretions and also to prevent falling back of the tongue. 

Observations and records

  • Vital observations of temperature, respiration, blood pressure and pulse are taken1/4 ,1/2, 1, 2 hourly according to surgeon’s instructions and duration is increased as the patient stabilizes.

These observations are continued until the patient is discharged.

  • Observe the site of operation for bleeding
  • Observe the catheter if it is draining well, colour and the quantity of urine passed. 
  • Maintain a fluid balance chart and balance it every 24 hours to rule out renal failure.
  • On gaining consciousness, the patient is welcomed from theatre, face is sponged, theatre gown changed, mouth wash is done to remove anesthetic smell and a pillow is offered.


  • Intravenous 0.9% are continued to replace lost fluids.
  • Observation of IV infusion are done such as observing the cannular site for swelling, drip rate and incase of anything it should be corrected.
  • Keep monitoring fluid intake and out put to avoid over hydration.
  • IV fluids are stopped when bowel sounds are heard and the patient is able to take by mouth.
  • Cannula is also removed when if patient has completed intravenous drugs.

Drug therapy

Administer prescribed antibiotics to counteract infections and administer prescribed strong analgesics for pain relief.

  • Antibiotics
    > Ampicillin 500 mg 6 hourly for 5 days
    > Ceftriaxone 2 gm o.d. for 5 days
    > Metronidazole 500 mg 8 hourly for 5 days
    > Gentamycin 160 mg o.d. for 5 days
    > Pethidine 100mg 8 hourly for 3 doses
    > Diclofenac 75 mg 8 hourly for 12 hours
    > Panadol 1 gm 8 hourly to complete 5 days as soon as patient can take orally.
  • Monitor the patient for side effects of the drugs given.
  • Supportive drugs such as ferrous and folic acid are given to prevent anaemia.

Wound care

  • Observe the wound for bleeding and if so add more dressing if soiled change the dressing. Also check signs of infections.
  • Carry out daily wound dressing.
  • Stitches are removed on the 7th and 8th day alternatingly.


  • Encourage the patient to do deep breathing exercise to prevent chest complications like hypostatic pneumonia.
  • Also encourage the patient to start with passive exercises such as limb movement then active exercises like walking around to prevent deep vein thrombosis.


  • In addition to the psychological care given to the patient pre-operatively, she is continuously reassured to allay anxiety.


  • First carryout digestion test and if positive the bowel sounds are heard, start the patient on small sips of water. Soft foods are introduced and given according to the tolerance and should be rich in;
  • Proteins to help in tissue repair
  • Roughages to prevent constipation
  • Carbohydrates for energy

NB: The nasal gastric tube is removed as long as the patient can take orally without any complaint.


  • Carryout bed bath on the first day of operation when the patient is still weak and later assist her to the bathroom.
  • Carryout mouthcare to prevent neglected mouth complaints like stomatitis, halitosis e.t.c.
  • Ensure that the patient’s clothing, bed linen and the surrounding environment are clean.

Bowel and bladder care

  • If urine is clear in 24-48 hours, the urethral catheter is removed and patient is encouraged to pass urine.
  • The patient is encouraged to pass stool, offered privacy and also given foods rich in roughages to prevent constipation.
  • Incase of constipation and conservative measures have failed, give purgatives such as bisacodyl 5-10mg O.D or NOCTE. 

Rest and sleep

  • The patient is kept in a quiet well-ventilated room, visitors restricted, bright light avoided so as to create a conducive environment for the patient to sleep and rest.

Advice on discharge

When the patient is fit for discharge advise on the following;

  • Should have enough rest at home
  • Avoid heavy lifting so as to avoid straining the abdominal muscles.
  • To come back for review on appointed dates
  • To attend ANC clinics when pregnant
  • To bring the husband for treatment if the cause of ectopic pregnancy was PIDs.
  • To complete the prescribed medications
Complications of ectopic pregnancy

Immediate complications

  • Shock 
  • Peritonitis
  • Dehydration

Long term complications

  • Sepsis
  • Anaemia
  • Fibrosis
  • Adhesions following surgery
  • Recurrence

Ectopic Pregnancy Read More »


Menstrual Disorders

Menstrual disorders are abnormalities in menstruation during reproductive life.

Common disorders associated with menstruation are as follows;

  1. Amenorrhoea
  2. Dysmenorrhoea
  3. Menorrhagia
  4. Metrorrhagia
  5. Polymenorrhoea (epimenorrhoea)
  6. Dysfunctional uterine bleeding
  7. Endometriosis


Amenorrhoea refers to absence of menstruation which occurs in female during their reproductive age.

Types of Amenorrhoea
  1. Primary amenorrhoea. This is the failure of menses to occur by 16 years of age. It could be due to imperforated hymen when she has been menstruating but  when blood does not come out.
  2. Secondary amenorrhoea. This is the cessation of menses in a woman who has previously menstruated. It is regarded as secondary when she takes a period of 6 month and above without seeing her menses.
Causes of Amenorrhoea
  • Physiological like pregnancy and lactation, during pregnancy the levels of oestrogen and progesterone remains high thus ensuring the integrity of the endometrium resulting into amenorrhoea.
  • During lactation– soon after delivery prolactin is secreted in large quantities by the anterior pituitary. There is partial suppression of LH production so that the ovarian follicles may grow but ovulation does not occur resulting into amenorrhoea.
  • Hypothalamic dysfunction-such kind of patients have lower levels of follicle stimulating hormone(FSH) and  luteinizing hormone (LH). Several congenital syndromes associated with abnormal hypothalamic- gonadal function have been described and these conditions present with primary amenorrhoea and absence of secondary sex characteristics. It is also due to failure to the development of central structures of hypothalamus.
  • Pituitary disorder, this is associated with elevated levels of prolactin (hyperplolactinemia).
  • Congenital abnormalities , like imperforated hymen, vaginal septum, no uterus, no endometrium but with uterus, absence of ovaries, cervical stenosis, and  absence of hypothalamus (kallmann’s syndrome). This is a congenital hypogonadotrophic hypogonadism disorder characterized by absence of secondary sex characteristics.
  • Change of environment or occupation.
  • Fear, anxiety or excitement
  • Pseudoamenorrhoea, pseudo means false. Here a woman psychologically thinks that she is pregnant yet she is not.
  • After hysterectomy or bilateral removal of ovaries
  • Full doses of radiation
  • Drugs ,like contraceptives especially hormonal methods
  • Debilitating diseases like, TB, HIV/AIDS, DM etc
  • Tumours of the pituitary gland, hypothalamus, ovaries and uterus
  • Early onset of menopause
  • Idiopathic
Diagnosis and investigation
  • A detailed history taking (history of change in weight, presence of stress, questions about excessive weight, presence of excessive body or facial hair) and physical examination.
  • Urine for HCG to rule out pregnancy
  • Ultra sound scans of the pelvis to visualize the contents or organs of the pelvic cavity.
  • Blood for hormone analysis to rule out hormonal imbalance.
  • Computerized tomography (CT) scans to visualize the organs.
Management of Amenorrhoea

This will depend on the cause. It may be medical, surgical, or psychological.

Nursing Management:

  • Assessment: Conducting a comprehensive evaluation of the woman’s medical and menstrual history, as well as performing a physical examination to identify the underlying cause of amenorrhea.
  • Emotional Support: Offering empathetic and non-judgmental support to address any emotional distress associated with the condition.
  • Education: Providing information on menstrual health, reproductive anatomy and physiology, and the potential causes and treatment options for amenorrhea.
  • Lifestyle Modifications: Encouraging women to adopt a healthy lifestyle, including regular exercise, balanced nutrition, stress reduction, and sufficient sleep, as these factors can contribute to hormonal balance regulation.
  • Contraception Counseling: Discussing contraceptive methods and family planning options to prevent unintended pregnancies.

Medical Management:
Medical management of amenorrhea  encompasses treating the root cause identified through investigations done. Various medical management options include:

  • Hormone Therapy: If hormonal imbalance, such as polycystic ovary syndrome or hypothalamic dysfunction, is determined as the cause of amenorrhea, hormone therapy may be prescribed to regulate hormone levels and restore menstruation.
  • Medications: Certain medications like progestins or combined oral contraceptives may be prescribed to induce menstruation or regulate the menstrual cycle.
  • Treatment of Underlying Conditions: If amenorrhea is a result of an underlying medical condition, such as a thyroid disorder or a pituitary tumor, appropriate medical treatment will be initiated to address the specific condition.
  • Hyperprolactinaemia is treated by administration of bromocriptine. This is an ergot alkaloid which directly opposes prolactin secretion. Radiotherapy is reserved for those patients who fails to respond to medical therapy.

Surgical Management:
Surgical management is rarely required for the treatment of amenorrhea. However, in certain cases, surgery may be necessary to address structural abnormalities or correct anatomical issues contributing to the condition. For example:

  • Hysteroscopic Surgery: This minimally invasive procedure involves the insertion of a thin, illuminated tube called a hysteroscope through the vagina and cervix to visualize and treat abnormalities within the uterus, such as polyps or adhesions.
  • Imperforated hymen is treated by incision and drainage. Very large amount of blood may be released, and if the septum is particularly thick, some form of plastic operation may be required.
  • Surgical Intervention: In some instances, surgical intervention may be essential to correct structural abnormalities in the reproductive organs or to remove tumors or cysts that are interfering with normal menstruation.

Psychological Management:
Psychological management plays a crucial role in providing support for women with amenorrhea, as it significantly impacts their emotional well-being. It involves:

  • Counseling: Offering psychological counseling or referring women to mental health professionals who can assist them in coping with the emotional distress associated with amenorrhea.
  • Support Groups: Suggesting participation in support groups or facilitating connections with other women who have faced similar challenges to foster a sense of community and validation.
  • Body Image and Self-esteem: Addressing concerns related to body image and promoting a positive self-image by emphasizing that amenorrhea does not define  femininity or a woman’s worth.


Dysmenorrhea is a medical term used to describe painful menstrual cramps that occur just before or during menstruation (the monthly shedding of the uterine lining). OR These are painful menstrual periods.

 Nearly 50% of all women have some degree of pain associated with their periods. About 10% are unable to perform their normal activities because of this pain. Dysmenorrhoea can occur at any age, though uncommon in the first 6 months after the onset of menses and relatively uncommon in the years prior to menopause. The most common ages for this problem to occur are in the late teens and early twenties.


The exact cause of primary dysmenorrhea is not fully understood, but it is believed to be related to the release of certain chemicals called prostaglandins in the uterus. This is due to release of a chemical substance called prostaglandins from the lining cells of the uterus at the time of menstrual period. The prostaglandin causes contractions of the muscle wall of the uterus, that are called menstrual cramps.

Types of dysmenorrhoea

Primary dysmenorrhoea.

This refers to painful menstruation that starts few years after puberty and usually no exact cause can be identified.

Pre-disposing factors
  • Narrow cervical OS (stenosis) ,which results into tension during contraction of muscles.
  • Reduced blood supply to the endometrium (ischaemia)
  • Hormonal imbalance
  • Retroverted uterus, that is , when the uterus leans backwards resulting into tension.
  • Psycological or social stress, fear or anxiety
Signs and symptoms

Dysmenorrhea is cyclic with pain most often occurring just before or during the first few days of each period.

  • Lower abdominal pain (LAP) that varies in severity among individuals, ranging from mild to colicky or crampy, extending to the back, thighs and legs.
  • Nausea and vomiting
  • Constipation or diarrhea
  • Fainting, headache, malaise
  • Irritability, nervousness, depression
  • History taking: It is through history taking, ask about the nature of pain, duration and when it occurs. This is often confirmatory.
  • Physical examination: It is also through physical examination to rule out pelvic tumours, endometriosis which is often absent.

Treatment options for dysmenorrhea depend on the severity of symptoms and the underlying cause.

  • For primary dysmenorrhea, Non steroidal anti inflammatory drugs (NSAIDS) like Iboprufen, mefenamic acid, diclofenac and others. These prevent the formation of prostaglandins in the uterine lining cells. They are more effective if taken before the onset of cramps.
  • Antispasmodics like Buscopan
  • Antiemetics like Phenegan for nausea and vomiting.
  • Heat therapy in the form of a hot water bottle or heating pad applied to the abdomen can also provide relief.
    • Drugs
    • Mild analgesics to relieve pain eg ibuprofen 400mg tds.
    • Prostaglandin synthetase inhibitors eg. Mefenamic acid 250-500mg tds or Flufenamic acid 100-200mg tds
    • Oral contraceptives eg COCs. These decrease endometrial proliferation.
    • Progesterones. Eg dydrogesterone 10mg b.d taken from day 5 of the cycle for 20 days. Mechanism of action is presumably myometrial relaxation.


  • Begin treatment 2 days before menstruation periods begins and continue until 2 days after the period has stopped.
  • Avoid additive drugs since this treatment is for long period.
  • Contraceptive drugs like COCs may be given to suppress ovulation and relieve pain. Usually given for 4-6 months and many get permanent relief after this treatment has been stopped.
  • Dilatation and Curettage (D&C) may be of help to remove necrotic tissue of endometrium, but usually not encouraged since it increases the risk of infections.
  • Cervical stenosis can be treated by surgical widening of the canal.
  • Effective counseling is important since pain is usually psychological to avoid drug dependence and abuse.
  • Delivery or with age will finally treat pain since there will be relaxation of uterine muscles and reduce ischaemia.
  • Encourage enough rest and sleep as well as exercises, hygiene and good diet.
  • Other management options may include hypnotherapy and acupuncture.

Secondary dysmenorrhoea

This refers to painful periods which start many years following normal and well established menstrual periods. It is more of pathological occurrence and on investigations the cause is easily established.

  • Pelvic inflammatory diseases (PID)
  • Uterine fibroids. This results into the partial contraction of the uterus resulting into pain.
  • Endometriosis: This is the growth of the endometrial tissue in other area rather than the uterus.
  • Endometritis: This is the inflammation of the endometrium.
Signs and symptoms

In addition to signs and symptoms found in primary dysmenorrhoea, there is;

  • Lower abdominal pain (LAP) usually happens 3-4 days or even a week before menstruation and either pain becomes better or worsens with menstruation.
  • There may be backache
  • Signs and symptoms of menorrhagia
  • Painful coitus
  • Inability to conceive.

Investigate and treat the cause.


Nursing diagnosis

  1. Acute pain related to increased uterine contractility evidenced by verbalization of the girl or woman.

Nursing interventions

  • Warm the abdomen, this causes vasodilation and reduces the spasmodic contractions of the uterus.
  • Massage the abdominal area that feels pain, this reduces pain due to the stimulus of therapeutic touch.
  • Perform light exercises ,to blood flow to the uterus and improves muscle tone.
  • Perform relaxation techniques to reduce pressure to get relaxed.
  • Administer analgesics as prescribed to block nociceptive receptors
  1. Ineffective individual coping related to emotional stress evidenced by patient’s verbalization.

Nursing interventions

  • Assess patient’s understanding of the condition. This is because patient’s anxiety of the pain is greatly influenced by knowledge.
  • Provide an opportunity to discuss how the pain is. Help the patient identify coping mechanisms.
  • Provide the patient with periods of sleep or rest. Ensures relaxation of the body and mind.
  1. Risk for imbalanced nutrition less than body requirements related to nausea and vomiting.

Nursing interventions

  • Provide the patient with periods of sleep or rest ,this is to ensure relaxation of the body.
  • Encourage small frequent feeds. These are easily tolerated by the patient.
  • Administer anti-emetic drugs like promethazine. This blocks the emetic centres.
Nursing Concerns:
  • Assessing the severity and characteristics of the pain, including its location, intensity, and duration.
  • Monitoring vital signs and assessing for any signs of complications or worsening symptoms.
  • Assessing menstrual patterns, including the duration and heaviness of bleeding.
  • Evaluating the impact of dysmenorrhea on the patient’s quality of life, emotional well-being, and ability to carry out daily activities.
  • Assessing for any associated symptoms or complications, such as nausea, vomiting, headaches, or anemia.
Nursing Interventions:
  • Providing pain management: Administering prescribed pain medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs), as ordered by the healthcare provider. Monitoring the effectiveness of pain relief and reassessing pain levels after medication administration.
  • Applying heat therapy: Instructing the patient on the use of heat therapy, such as a hot water bottle or heating pad, to relieve pain. Educating the patient on the proper technique and duration of heat application.
  • Assisting with relaxation techniques: Teaching relaxation techniques, deep breathing exercises, and guided imagery to help the patient manage pain and reduce stress.
  • Promoting rest and comfort: Encouraging the patient to rest in a comfortable position during painful episodes. Providing supportive pillows, blankets, or cushions to enhance comfort.
  • Educating the patient about the condition: Providing information about the underlying cause of secondary dysmenorrhea, its management, and treatment options. Answering any questions or concerns the patient may have.
  • Collaborating with the healthcare team: Communicating and collaborating with the healthcare provider, gynecologist, or other specialists involved in the patient’s care to ensure appropriate management of the underlying condition.
  • Offering emotional support: Acknowledging and validating the patient’s pain and emotional distress. Providing a supportive environment for the patient to express her feelings and concerns. Referring to counseling or support groups if needed.


Menorrhagia is a condition characterized by abnormally heavy or prolonged menstrual bleeding. Can be heavy or prolonged menstrual bleeding or both.

  1. Hormonal imbalances: Fluctuations in estrogen and progesterone levels can disrupt the normal menstrual cycle and lead to excessive bleeding.
  2. Uterine fibroids: These noncancerous growths in the uterus can cause heavy menstrual bleeding.
  3. Adenomyosis: The condition where the inner lining of the uterus (endometrium) grows into the muscular wall of the uterus can result in heavy bleeding.
  4. Polyps: Small, benign growths on the lining of the uterus can contribute to menorrhagia.
  5. Endometrial hyperplasia: Abnormal thickening of the uterine lining can cause heavy bleeding.
  6. Inherited bleeding disorders: Certain inherited conditions, such as von Willebrand’s disease, can lead to excessive bleeding during menstruation.
  7. PID (pelvic inflammatory disease)
  8. Retroverted uterus
  9. Cancers like cancer of the cervix and endometrial cancer
Signs and symptoms
  • Menstrual bleeding lasting longer than seven days.
  • Soaking through one or more sanitary pads  every hour for several consecutive hours.
  • Passing large blood clots during menstruation.
  • Fatigue and tiredness due to excessive blood loss.
  • Shortness of breath or rapid heart rate caused by anemia.
  • Feeling lightheaded or dizzy.
  • Menstrual periods that disrupt daily activities.
  • Complete medical history and physical examination.
  • Blood tests to assess blood count, iron levels, and hormonal imbalances.
  • Transvaginal ultrasound to evaluate the structure of the uterus and detect any abnormalities.
  • Endometrial biopsy to examine a sample of the uterine lining for abnormalities or cancer.
  • Hysteroscopy, a procedure using a thin, lighted tube inserted into the uterus, to directly visualize the uterine cavity.
  •  Bleeding time to test for coagulopathy
  • Prothrombin time to test for coagulopathy.
  • Clotting time to test for availability of platelets.
  • In the above three tests, results will be abnormal.
  • Full haemoglobin levels and hormone analysis to rule out hormonal imbalance.

The best management is to investigate  and treat the cause

Medical Management of Menorrhagia:

  1. Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs) can help reduce pain and bleeding. Hormonal contraceptives, such as birth control pills or hormonal intrauterine devices (IUDs), can regulate menstrual cycles and decrease bleeding.
  2. Iron supplementation: If anemia is present due to excessive bleeding, iron supplements may be recommended to restore iron levels.
  3. Endometrial ablation: A minimally invasive procedure that destroys the lining of the uterus to reduce menstrual bleeding.
  4. Uterine artery embolization: A procedure in which small particles are injected into the blood vessels supplying the uterus to reduce blood flow and control bleeding.

Nursing management

  1. Symptom management: Assisting patients in managing pain and discomfort during heavy bleeding episodes.
  2. Emotional support: Acknowledging the emotional impact of menorrhagia and providing a safe space for patients to express their concerns.
  3. Education: Providing information on menstrual hygiene, use of sanitary products, and available treatment options.
  4. Lifestyle modifications: Advising patients to maintain a healthy lifestyle, including a balanced diet and regular exercise, to promote overall well-being.

Nursing diagnosis

Ineffective tissue perfusion related to excessive bleeding evidenced by pallor.

Nursing interventions

  • Assess patient’s vital signs. To obtain baseline data.
  • Lift the foot of the bed. To allow blood flow to vital centres of the body like brain, kidneys, lungs, heart and liver.
  • Administer intravenous fluids. To maintain the circulatory volume of fluids.
  • Administer vitamin k as prescribed to reduce bleeding. Vitamin k activates coagulation factors.
  • Administer whole blood as prescribed. To maintain circulatory volume of blood.


Metrorrhagia is a medical term used to describe irregular or abnormal uterine bleeding that occurs between menstrual periods. Can also be defined as cyclic bleeding at normal intervals, the bleeding is either excessive in amount (>80 ml) or duration or both.

This is a symptom of some underlying pathology which may be organic or functional.

  • Fibroid uterus
  • Adenomyosis (A disorder of the glands that secrete cervical mucus and fluids)
  • Pelvic endometriosis(The presence of endometrium elsewhere than in the lining of the uterus causing premenstrual pain and dysmenorrhea)
  • Chronic tubo-ovarian mass
  • Retroverted uterus-due to congestion
  • Uterine polyp. This is due to vast blood supply to the polyp which makes it bleed easily.
  • Cervical erosions. This is due to the presence of a wound and an increase in blood supply resulting into bleeding.
  • Cancer of the cervix or endometrial cancer.
  • Chronic threatened abortion or incomplete abortion
  • Retained pieces of placenta. This interferes with contraction of the uterus to seal off blood vessels after birth.
  • Mole pregnancy. This is due to an abnormal uterine mass which grows after fertilization and is supplied with a lot of blood capillaries resulting into bleeding.
  • Ovulation bleeding
  • Short cycles like polymenorrhoea.
Signs and symptoms
  1. Bleeding between menstrual periods.
  2. Irregular menstrual cycles.
  3. Heavier or lighter bleeding than usual during menstrual periods.
  4. Prolonged bleeding that lasts longer than normal.
  5. Pelvic pain or discomfort.
  6. Fatigue or tiredness due to excessive blood loss.
  7. Anemia symptoms, such as shortness of breath, dizziness, or weakness.
  • Medical history and physical examination: A detailed history of menstrual cycles, symptoms, and any relevant medical conditions is obtained. A pelvic examination may be performed to assess the reproductive organs.
  • Hormone level assessment: Blood tests may be conducted to evaluate hormone levels, including estrogen, progesterone, and thyroid hormones.
  • Transvaginal ultrasound: This imaging test can provide visualization of the uterus, ovaries, and any structural abnormalities.
  • Endometrial biopsy: A sample of the uterine lining may be obtained for microscopic evaluation to check for abnormalities or cancer.
  • Hysteroscopy: A procedure in which a thin, lighted tube is inserted into the uterus to visualize the uterine cavity and detect any abnormalities. 
  • Digital and speculum examination, to visualize the cervix for any abnormality.
  • Pelvic scan, to visualize pelvic organs and rule out any abnormality.

The best management to investigate and treat the cause.

Medical and Nursing Management of Metrorrhagia:

  1. Hormonal therapy: Depending on the underlying cause, hormonal medications, such as birth control pills or progestin therapy, may be prescribed to regulate the menstrual cycle and reduce abnormal bleeding.
  2. Nonsteroidal anti-inflammatory drugs (NSAIDs): These medications can help manage pain and reduce bleeding during episodes of metrorrhagia.
  3. Treatment of underlying conditions: If metrorrhagia is caused by conditions such as fibroids, polyps, or infections, appropriate treatment strategies will be implemented to address the specific cause.
  4. Surgical interventions: In some cases, surgical procedures may be necessary to remove uterine abnormalities or address the underlying cause of metrorrhagia.
  5. Supportive care: Nursing management focuses on providing emotional support, educating patients about menstrual hygiene and symptom management, and promoting overall well-being.
  6. Monitoring and follow-up: Nurses play a vital role in monitoring patients’ response to treatment, assessing the effectiveness of interventions, and ensuring appropriate follow-up care.


Polymenorrhea, also known as epimenorrhoea, is a medical condition characterized by frequent menstrual periods that occur more frequently than the normal menstrual cycle. Also refers to menstruation periods that occurs at shorter intervals than usual (14-21 days), but they are frequent and regular.

Causes of Polymenorrhea/Epimenorrhoea:

  1. Hormonal imbalances: Fluctuations in estrogen and progesterone levels can disrupt the normal menstrual cycle and result in more frequent periods.
  2. Thyroid disorders: Overactive thyroid (hyperthyroidism) or underactive thyroid (hypothyroidism) can affect hormone production and menstrual regularity.
  3. Polycystic ovary syndrome (PCOS): This condition is characterized by hormonal imbalances, enlarged ovaries with cysts, and irregular menstrual cycles.
  4. Uterine abnormalities: Conditions such as uterine fibroids, polyps, or adenomyosis can cause abnormal bleeding and frequent periods.
  5. Stress and lifestyle factors: Chronic stress, excessive exercise, drastic weight changes, and poor nutrition can disrupt the hormonal balance and contribute to polymenorrhea.
Signs and Symptoms of Polymenorrhea/Epimenorrhoea:
  1. Menstrual cycles shorter than 21 days.
  2. More frequent periods, with menstrual bleeding occurring every two weeks or less.
  3. Lighter or heavier bleeding than usual.
  4. Increased menstrual discomfort or pain.
  5. Fatigue or tiredness due to frequent blood loss.
  6. Emotional and psychological impact, such as anxiety or mood swings.
Investigations for Polymenorrhea/Epimenorrhoea:
  1. Medical history and physical examination: A thorough evaluation of the menstrual patterns, symptoms, and any underlying medical conditions is conducted. A pelvic examination may be performed to assess the reproductive organs.
  2. Hormone level assessment: Blood tests may be done to measure hormone levels, including estrogen, progesterone, thyroid hormones, and other relevant hormones.
  3. Pelvic ultrasound: This imaging test can provide visual information about the ovaries, uterus, and any structural abnormalities.
  4. Endometrial biopsy: A sample of the uterine lining may be obtained and examined to rule out any abnormalities or cancer.

Medical and Nursing Management of Polymenorrhea/Epimenorrhoea:

  1. Hormonal therapy: Depending on the underlying cause, hormonal medications, such as oral contraceptives or hormone-regulating medications, may be prescribed to regulate the menstrual cycle and reduce the frequency of periods.
  2. Treatment of underlying conditions: If polymenorrhea is caused by conditions such as PCOS or uterine abnormalities, appropriate treatment strategies will be implemented to address the specific cause. Carry out dilatation and curettage (D&C) to remove retained products if its the cause.
  3. Lifestyle modifications: Stress reduction techniques, maintaining a balanced diet, regular exercise, and adequate sleep can help regulate hormonal balance and promote overall well-being.
  4. Supportive care: Nursing management focuses on providing emotional support, educating patients about menstrual hygiene, symptom management, and lifestyle modifications.
  5. Monitoring and follow-up: Monitoring patients’ response to treatment, assessing the effectiveness of interventions, and ensuring appropriate follow-up care should be put into considerations.


Dysfunctional uterine bleeding (DUB) refers to abnormal uterine bleeding that occurs in the absence of organic causes or underlying medical conditions. It is typically characterized by irregular, prolonged, or heavy menstrual bleeding. Can also refers to abnormal bleeding resulting from hormonal changes rather than from trauma, inflammation, pregnancy or a tumour.


The prevalence varies widely  but an incidence 10% among patients attending the outpatient seems logical. The bleeding may be abnormal in frequency ,amount or duration or combination of both.

  • It is due to sustained levels of oestrogen leading to thickening of the endometrium which shed incompletely and irregularly.
  • In most cases, abnormal bleeding is caused by local causes in the endometrium.
  • However,there is some disturbance  of the endometrial blood vessels and capillaries and coagulation of blood in and around these vessels.
  • These are caused by alteration in the ratio of endometrial prostaglandins which are delicately balanced in hemostasis of menstruation  and may be related to incoordination in the  hypothalamo-pituitary –ovarian axis.
Signs and Symptoms of Dysfunctional Uterine Bleeding:
  1. Irregular menstrual cycles: Menstrual periods may occur more frequently or infrequently than usual.
  2. Prolonged bleeding: Menstrual bleeding may last longer than the typical duration.
  3. Heavy menstrual bleeding: Excessive or abnormally heavy bleeding during menstrual periods.
  4. Intermenstrual bleeding: Bleeding that occurs between menstrual cycles.
  5. Fatigue or tiredness due to excessive blood loss.
  6. Anemia symptoms: Weakness, lightheadedness, shortness of breath, or pale skin.

NOTE : A diagnosis of dysfunctional uterine bleeding is made only when all other possibilities of causes of bleeding have been excluded.

  • Ultra sound scan to rule out new growth
  • Blood analysis for hormonal imbalance
  • Biopsy for histology
  • Treatment depends on various factors like age, condition of the uterine lining and the woman’s plans regarding pregnancy.
  • Total hysterectomy is indicated if the woman is over 35 years, uterine lining thickened and contains abnormal cells and she does not want to become pregnant.
  • When the uterine lining is thickened but contains normal cells, heavy bleeding may be treated with high dose of oral contraceptive oestrogen and progestin(COC) or oestrogen alone usually intravenously, then followed by a progestin given by mouth. Bleeding generally stops within 12-24 hours and then low doses of oral contraceptives may be given in usual manner for atleast 3 months.
  • Women who have lighter bleeding may be given low doses from the start.
  • If a woman has contraindications to oestrogen containing drug, progestin only pills may be given by mouth for 10-14 days each month.
  • D&C may be used if response or hormonal therapy proves ineffective.
  • If a woman wants to become pregnant, clomiphene drug may be given orally to induce ovulation.


Endometriosis is a chronic and often painful condition in which tissue similar to the lining of the uterus, called the endometrium, grows outside the uterus. This abnormal tissue growth can occur in various areas of the reproductive system, such as the ovaries, fallopian tubes, and pelvic lining.

Can also refer to growth or presence of endometrial tissue outside the uterus. It may be referred to as a misplaced endometrial tissue.


  • 10-15% of women between 25 and 45 years. 25-50% in infertile women.

Common sites that may be affected

Abdominal organs, ovaries, ligaments, intestines, ureters, urinary bladder, vagina, vulva, naval, lungs, nose, conjunctiva and rarely on normal skin.


The actual cause is not known. But has the following predisposing factors.

  1. Retrograde menstruation: One possible cause is the backward flow of menstrual blood into the fallopian tubes and pelvic cavity, allowing endometrial tissue to implant and grow outside the uterus.
  2. Hormonal imbalance: Estrogen may play a role in promoting the growth of endometrial tissue outside the uterus.
  3. Genetic factors: Having a close relative with endometriosis increases the risk of developing the condition.
  4. Immune system dysfunction: A weakened immune response may allow the abnormal growth and survival of endometrial tissue outside the uterus.
  5. Environmental factors: Exposure to certain chemicals and toxins may contribute to the development of endometriosis.
  6. Surgery involving the uterus like C/S, D&C.
  7. Too late prime para (over 30 years)
  8. Genetic makeup (tend to run in families) especially first degree relatives like mother, sister, daughter.
  9. Race-common in Caucasians
  10. Abnormal uterus like retroverted uterus
Signs and symptoms
  • Some are asymptomatic
  • Lower abdominal pain
  • Irregular periods like spotting before periods
  • Infertility
  • Painful coitus (dyspareunia)
  • Pain during bowel opening
  • Rectal bleeding during menstruation. This is due to the presence of endometrial tissue in the rectum.
  • Bleeding from the site during menstruation
  • Palpable mass (endometrioma)
  • Adhesions
Diagnosis / investigations
  • Presence of endometrial tissue in the site after microscopic examinations confirms the disease (biopsy)
  • To view the tubes and ovaries for the presence of endometrial tissue.
  • Ultra sound scan. To visualize pelvic organs for any abnormality.
  • Barium enema with x-ray. To locate the site of the tissue.
  • Computerized Tomography (CT ) scan. To visualize the tissue.
  • Magnetic Resonance Imaging (MRI ).
  • Blood for marker cell (CA-125 ) and antibodies to endometrial tissue.
  • Medical history and symptom assessment: The healthcare provider will discuss the patient’s symptoms, menstrual patterns, and medical history.
  • Pelvic examination: A pelvic exam may be performed to check for abnormalities or areas of tenderness.
  • Imaging tests: Transvaginal ultrasound or MRI may be used to visualize the pelvic organs and detect the presence of endometrial growths.
  • Laparoscopy: This minimally invasive surgical procedure allows for direct visualization and biopsy of the abnormal tissue, confirming the diagnosis of endometriosis. 
Nursing, Medical, and Surgical Management of Endometriosis:
  1. Pain management: Provide education on pain management strategies, including the use of over-the-counter pain relievers or prescribed medications.
  2. Hormonal therapy: Medications such as birth control pills, hormonal patches, or progestin-only therapies may be prescribed to regulate the menstrual cycle and reduce symptoms. 
  3. Drugs that suppress the activity of ovaries and slow the growth of endometrial tissue like COCs, progestin and GnRH agonists.
  4. Surgical intervention: In cases of severe pain or infertility, laparoscopic surgery may be performed to remove or destroy endometrial growths. Surgical intervention is primarily to remove as much of the misplaced endometrium tissue as possible
  5.  Combination of drugs and surgery or Total hysterectomy when all other treatments fail.
  6. Fertility treatments: Assisted reproductive technologies, such as in vitro fertilization (IVF), may be recommended for individuals experiencing infertility due to endometriosis.
  7. Supportive care: Provide emotional support, educate patients about the condition, and help individuals cope with the physical and emotional challenges associated with endometriosis.
Complications of Endometriosis:
  1. Infertility: Endometriosis can affect fertility by causing scarring, adhesions, and structural abnormalities in the reproductive organs.
  2. Ovarian cysts: Endometriomas, also known as “chocolate cysts,” can form on the ovaries and may require surgical removal.
  3. Adhesions: Endometriosis can lead to the formation of scar tissue, causing organs and tissues to stick together.
  4. Chronic pain: Severe and persistent pelvic pain can significantly impact a person’s quality of life.


Introduction To Gynaecology

Introduction To Gynaecology

Gynaecology is the study of diseases affecting the female reproductive system.

As the genital tract is closely linked anatomically with the urinary tract and the large bowel, certain disorders of the urethra, bladder and rectum may lead the woman to a gynaecologist.

General causes of gynaecological problems

  • Congenital abnormalities: eg absence of the vagina, ovaries, uterus or divided uterus.
  • EnvironmentThis can cause physical or mental stress or anxiety that can lead to absence of menstruation.
  • Pathological agentsIn relation with entry of pathogenic micro-organisms which may lead to vaginitis, vulvitis etc.
  • TraumaGenetic organs may be traumatized by instruments leading to fistula.

Clinical methods of assessing a gynaecological patients.

  • History taking

The most important information is always provided by the patient or relatives. History taking tactics are required for it is concerned with discussing intimate matters. Therefore, privacy is essential in order to get reliable information from the patient.

  1. Personal dataThis includes name, age, address, next of kin, occupation, religion, tribe etc.
  2. Presenting complaints: eg Pain onset
  • Where it is felt
  • Intensity
  • Defecation or micturition
  • Dyspareunia

      3. History of presenting complaints.

  1. Obstetric history: Number of pregnancies, abortion, type of delivery, history of trauma, prolonged labour etc.
  2. Menstrual cycle: Menarche, regularity, duration and length of cycles, volume of blood loss etc. 
  3. Social history: Look out for marital status, life style, smoking, alcohol, occupation etc. 
  4. Past medical and surgical history: Has she ever suffered from a serious disease eg. Tuberculosis, had an accident which involved the spine, pelvis and lower limbs or any operation on her pelvic organs.
  5. Gynaecological history: Has she ever had any gynaecological condition like fibroids, rectal vaginal fistula, vesicle vaginal fistula, perennial tears, abortions etc., any operations on the cervix or dilation and curettage. 

        4.  Examination 

  1. General examination

The general examination is important in gynaecology. This is done from head to toe. Note. 

  • General appearance of the patient
  • Behavior
  • Look out for signs of anaemia
  • Examine breasts: Look for signs of pregnancy and any discharge.  Examine the breast to exclude malignancies.
  • Abdomen It is inspected for size and shape and palpated for tumours.
  • Pelvic examination: This is the last examination done to confirm the diagnosis already suspected during history taking.


  • The patient should consent for the examination, if not married, parents can consent for her because the hymen can be broken.
  • The patients bladder and bowels must be empty.
  • Good light is also needed.

      2. Vaginal examination

Each part of the genital tract should be examined in a logical sequence;

  • Vulva
  • Vagina
  • Cervix (inspect for tears, prolapse etc.)
  • Body of the uterus
  • Pouch of Douglas

NB: The cervix and uterus should be examined for size, shape, position and tenderness.

Special procedures and investigations

These are useful to fill gaps which remain after history taking during clinical assessment.

  1. EvacuationIt refers to removal of the contents of a cavity. It is done when pelvic examination has not been possible. Its disadvantage is that important signs of tenderness are missed out. (examination is done under anaesthesia)
  2. Curettage:  Refers to scrapping of the internal surface of an organ or body cavity by means of a spoon shaped instrument called a curette. It is done to; Remove retained products of conception and to obtain a specimen for diagnostic purposes
  3. Biopsy:  This is the removal of a small piece of leaving tissue from an organ or part of the body for microscopic examination so as to exclude certain diseases. It can be obtained from the cervix, endometrium etc.
  4. Ultra sound scanThe use of ultrasound produces images of structures in the human body using sound waves of high frequency. This is now used widely to detect diseases of the pelvic organs and pregnancy.
  5. HysterosalpingographyRefers to x-ray imaging of the uterus and fallopian tubes. It is useful in diagnosing;
  • Tubal obstruction
  • Peritubal and intrapelvic adhesions
  • Malformations of the uterus
  • Small intracavity tumours
  • Detect the internal os of the cervix causing abortion and premature labour.

      6. LaparoscopyExamination of abdominal structures by means of a laparoscope (type of endoscope). This is passed through a small incision in the wall of the abdomen. Used when;

  • Taking a biopsy
  • Aspirating cysts
  • Dividing adhesions
  • Collecting ova for vitro fertilization


  • Hysterectomy: This is surgical removal of the uterus.

    Types of hysterectomy

  1. Wertheim’s hysterectomyIt’s a radical operation performed for cervical cancer involving removal of the entire uterus, the connective tissue and lymph nodes close to it, fallopian tubes, ovaries and the upper part of the vagina.
  2. Subtotal hysterectomySurgical removal of the body of the uterus leaving the neck (cervix) in place.
  3. Total hysterectomySurgical removal of the entire uterus.


  • Fibroids 
  • Cancers
  • Raptured uterus
  • Salpingectomy : Refers to surgical removal of the fallopian tubes.


  • Raptured ectopic pregnancy
  • Chronic salpingitis
  • Vesico-vaginal fistula repair :This is an operation done to repair an abnormal communication between the bladder and vagina.
  • Oophorectomy :This is the surgical removal of the ovary(s)


  • Tumours of the ovary
  • Chronic oophoritis
  • Myomectomy : Refers to surgical removal of one or more fibroids from the uterus.
  • Rectal vaginal fistula : An operation done to repair an abnormal communication between the rectum and vagina.
  • Mastectomy : Surgical removal of the breast.


  1. Radical mastectomySurgical removal of the breast with the skin and all lymphatic tissue of the armpit. It is performed when breast cancer has spread to involve the lymph nodes.
  2. Simple mastectomySurgical removal of the breast retaining the skin and if possible the nipple. It is performed for extensive but not necessarily invasive tumours.
  • Tubal ligation :An operation done by tying and cutting of fallopian tubes which is used as a permanent family planning method.
  • VulvectomySurgical removal of the vulva.


  1. Simple vulvectomyExcision of the labia majora, minora and clitoris to eradicate a non-malignant growth.
  2. Radical vulvectomyExcision of the labia majora, minora, clitoris and all regional lymph nodes on both sides together with the skin covering these areas. It is carried out in malignant growths.
  • Dilatation and curettage

An operation in which the cervix(neck) neck of the uterus is dilated using a dilator (heggar’s dilators) and the endometrium is lightly scrapped off with a manual curette or removed by suction using an aspirator.


  • Removal of any retained products after abortion
  • Obtaining endometrial biopsy for histological examination.
  • Perineoplasty: An operation done to enlarge the vaginal opening by incising the hymen and part of the perineum.
  • Perineorrhaphy: Surgical repair of a damaged perineum. The damage is usually as a result of a tear sustained during child birth.

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