This document discusses various management options for uterine bleeding and prolapse in women. It describes conservative treatments that can help avoid hysterectomy such as medical management using hormones, the Mirena IUD, and minimally invasive procedures. It also discusses the importance of considering conservative therapies and not assuming the uterus is vestigial after childbearing. Surgical options for fibroids like myomectomy and embolization are presented. Conservative surgeries for prolapse in young patients like cervicopexy and sling procedures are also mentioned.

1. SAVING UTERUS, SAVING OVARY

2. MODERATORS
•Dr. Suvarna Khadilkar •Dr. Niranjan Chavan

5. INTRODUCTION
• Large number of women undergo hysterectomy,
recommended by gynecologists when surgery can be
avoided with medical management or local therapy.
• Hysterectomy should be considered as a last resort for
the resolution of the pathology.
• A large number of women undergo anesthesia exposure
and surgical exposure when it can be avoided.
•

6. NEW PALM-COEIN FIGO CLASSIFICATION
CAUSES OF ABNORMAL UTERINE
BLEEDING IN NON-GRAVID WOMEN OF REPRODUCTIVE AGE
• FIGO recommend not to use terminology DUB, but use
HMB FIGO, IJGO 2011
Polyp Coagulopathy
Adenomyosis Ovulatory dysfunction
Leiomyoma Endometrial
[submucosal and other] Iatrogenic
Malignancy and Hyperplasia Not yet classified

7. MODALITIES OF MANAGEMENT OF AUB
• MEDICAL : hormonal /non hormonal ,
• PROGESTERONE RELEASING IUCD
• MINIMALLY INVASIVE PROCEDURES : balloon ablation
/TCRE
• DEFINITIVE SURGERY: CONVENTIONAL /ENDOSCOPIC
Can we not give patients a choice from wide
variety of conservative treatments ??

9. • A group of Lambada tribal women in Kannaram
village of Medak district in Andhra Pradesh
• Most women in this village of 125 households have
had a hysterectomy even the girls in their 20s
• Doctors had done hysterectomy for the patients who
had routinely visit for pain in abdomen
• as they were told they would ‘die’ of bleeding and
pain if they don’t undergo this procedure

10. UTERUS REMOVAL RACKET
UNDER RAJIV GANDHI SCHEME
• 9 districts of Maharashtra including Latur and Osmanabad
• Unindicated hysterectomy done for several women of age 20-
30s in private hospitals to siphon off insurance money
• 50% were told to undergo hysterectomy for heavy bleeding,
21.8 % were told for white discharge
• 6% were told that if they don’t undergo hysterectomy they can
have cancer

11. IS THE UTERUS A VESTIGIAL ORGAN AFTER REPRODUCTION
IS COMPLETE?
IS THE OVARY A REDUNDANT ORGAN AFTER MENOPAUSE

12. CASE-1
• 40 year old, female, P3L3 tubectomised, complained of
heavy and painful periods since past 2 years
• Menstrual history- 5-6 days menses/ 18-23 days cycle,
regular, 7-8 pads per day, passage of clots
• N/h/o any medical or surgical history

13. ON EXAMINATION
GC-fair, afebrile, Pallor +
P-88/min, Bp-120/80, CVS/RS-NAD
P/A- soft, no GTR
p/s- Cervix and Vagina healthy, no bleeding/white
discharge
P/V- Uterus-8-10 wks size, bilateral adnexa clear

14. INVESTIGATIONS
• Hb-8.8
• TLC-7900
• PLT-2,43,000
• PT-INR- 15.3/ 1.01
• USG findings: TVS - Uterus
uniformly enlarged, Myometrium
shows salt and pepper appearance,
loss of endomyometrial interface
• ET-9 mm
• Endometrial aspirate shows -
Secretory endometrium

15. • WHAT IS YOUR IMPRESSION ?
• HOW WILL YOU MANAGE ?
• MEDICAL/SURGICAL ?

16. Adenomyosis

17. • LNG IUCD
• GnRH agonist with Add back therapy

19. LNG-IUCD
• Progestin releasing intrauterine device
• T shape
• Polyethylene frame
• Contains 52mg levonorgestrel
• Release 20 ug LNG daily
• Has to be changed after 5 years
• Prevent endometrial proliferation
• Provide contraception additionally as it
thicken cervical mucus & Inhibit sperm
motility

20. • Why??? Patient not happy comes back, now wants
hysterectomy what will you do ?
• If you decide to go ahead with hysterectomy will you
also remove ovaries ?
• If yes why ? if no

21. SAVING OVARIES: OVARIAN CONSERVATION
OR BILATERAL OOPHORECTOMY AT
HYSTERECTOMY?

22. ADVANTAGES OF PROPHYLACTIC OOPHORECTOMY
• Reduction in risk of developing ovarian cancer
Incidence 1.7%
• If the ovaries are normal, the chance of cancer later in
life appears to be around 0.25%.
• No conclusive medical evidence exists to support this
fact
• Reduction in risk of developing breast cancer especially
receptor positive cancer
• Relief of bothersome symptoms causing chronic pelvic
pain.

23. DISADVANTAGES OF PROPHYLACTIC OOPHORECTOMY
• Surgical menopause
• Loss of natural ovarian hormones
• Increase in risk of cardiovascular disease
Oophorectomy age of 50 increases risk of
developing an MI by 40%
• Increase in risk of osteoporosis
• Oophorectomy age 40 increases risk of hip fx by
50%

24. DISADVANTAGES CONTD………..
Increase in risk of neurologic impairments:
• Cognitive impairment affecting short term memory and
general dementia.
• Parkinson’s
• Adverse occular changes
• Decline in psychological well being Irritability, mood
swings
• Hot flushes
• Adverse skin and body composition changes
• Decline in sexual function
• Vaginal dryness

25. Natural Menopause
• Estradiol and testosterone levels
fairly constant,gradual decline
• Hormone levels start changing
several years before menopause
and stabilize about 2 years after
menopause.
• E2 10-25 pg/ml
• Woman's body has already
become used to lower levels.
• Hence lower dosages may suffice
Surgical Menopause
•Rapid drop of both estradiol and
testosterone
•Woman needs testosterone
supplements, it would be at the
time of ovary removal if she is not
yet menopausal.
E2< or~ 10 pg/ ml
 Estrogen replacement needs to be
at higher levels, eg., conjugated
estrogens 1.25 mg or estradiol 2
mg,

26. HIGH RISK FACTORS FOR OVARIAN CANCER
• The lifetime incidence of a woman developing
ovarian cancer is about 1.8% .and her chance of
dying from the disease is 1%
• Age:The older population , higher chance that
they will get ovarian cancer; in fact at age 85
there may be as high as a 17% chance of ovarian
cancer.

27. • Family History: The rate goes up to about 2.3% if there is a
family history of colon or breast cancer mutations BRCA1 and
2.
• Hormone intake :The rate is lower than 1.5% if a woman has
used oral contraceptives for 5 years or more. Higher if
ovulation inducing agents taken
• Ethnicity:Women of African American descent will have about
a 20% lower incidence of ovarian cancer compared to
Caucasian women.
Howlader N, Noone AM, Krapcho M, Neyman N, Aminou R, Waldron W, et al. SEER Cancer Statistics Review, 1975–2008, National Cancer
Institute. Bethesa, MD, http://seer.cancer.gov/csr/1975_2008/, based on November 2010 SEER data submission, posted to the SEER web site, 2011.

28. LONG-TERM HEALTH OUTCOMES AND MORTALITY
AFTER OVARIAN CONSERVATION OR OOPHORECTOMY
IN NURSES HEALTH STUDY , PARKER ETAL 2009
• Number of Women 29,380 (16345 Vs13035)
• Bilateral oophorectomy before age 50 was
associated with an increased risk of all-cause
mortality, CHD, and stroke in never users of
estrogen
• One additional death would be expected for
every 9 oophorectomies if they lived up to 35
years after surgery
• Oophorectomy decreased risk of breast and
ovarian cancer,

29. SELECTION OF CASES FOR PROPHYLACTIC
OOPHORECTOMY IN LOW RISK WOMEN FOR CANCER
• Severe endometriosis
• Pelvic infection
• Benign ovarian neoplasms
• Chronic pelvic pain
These have a higher probability of undergoing BSO as
have a significantly higher risk of repeat surgery.

30. SURVIVAL RATES AFTER BILATERAL
OOPHORECTOMY AT <45, 45-50,
>50 YEARS OF AGE
ROCCA ETAL 2006, LANCET

31. CAN WE SAVE OVARY AND SACRIFICE TUBE: TO BE OR NOT
TO BE?? ??
PARADIGM SHIFT FROM OOPHORECTOMY TO
SALPINGECTOMY?
OPPORTUNISTIC AND INTERVENTIONAL PROPHYLACTIC
SALPINGECTOMY:

32. 2001-2010 several reports of coexistent tubal dysplasia
and malignancy at risk reducing benign hysterectomy
2015 Lucas Minig, etal concluded that Prophylactic
salpingectomy at the time of benign hysterectomy in
premenopausal women is safe and feasible and does
not worsen surgical outcomes or the incidence of
intraoperative and postoperative complications.

33. WHAT HAPPENS TO THE CONSERVED
OVARIES AFTER HYSTERECTOMY/
SALPINGECTOMY??
• 5% chance of reoperation for cysts
• 47% chance in endometriosis
• Hysterectomy will affect the blood supply of ovaries
and the women get premature menopause,
observational data suggests so!!

34. • Despite this complete dysfunction of ovaries over time
(generally over period of 2-3 years) after hysterectomy
leaving ovaries where they are will benefit overall
hormonal health … provided they are healthy.
• After a careful salpingectomy ovarian function will be
unaffected while protecting women of the epithelial
ovarian cancer
Hence consider saving uterus to prevent premature
menopause and opt for more conservative therapies to
save uterus and ovaries

35. DOES RISK REDUCING
OOPHORECTOMY PREVENT CANCER ?
Primary peritoneal cancer

36. CASE-2
• 28 years old, Married since 4 years, working in corporate
sector P1L1, came in opd with complaint of heavy and
painful menses since last 2 years
• Menstrual history- Regular/ 28 days cycle/ lasting for 4-
5 days/with 5 pads per day
• N/H/O any major surgical or medical illness

37. ON EXAMINATION
• GC fair, pallor, afebrile, p-84, BP-110/70
• P/A- mass of 20 -22weeks size in infraumbilical region,
firm in consistency, side to side mobility+, non tender.
• P/S-cervix and vagina healthy+.
• P/V- uterus 14 wks size, firm, movements of cervix can
be transmitted to mass.

38. INVESTIGATIONS
• HB-9.O
• TLC-8200
• PLT- 3,21,000
• PT/INR- 14/1.0
• USG- 10 X 8X 8 cm anterior wall intramural fibroid
pushing the endometrium posteriorly.
• ET- 14mm

39. MRI OR CT SCAN ??

40. • Magnetic resonance imaging (MRI) is the most effective
modality for visualizing
• the Size &
• Location of all uterine myomas and
• can distinguish among Leiomyomas
• Adenomyosis and
• Adenomyomas.

41. FIBROID MAPPING

43. What is the Next Step?

44. •Pap smear
•Dilation and Curettage for endometrial biopsy

45. • Endometrial biopsy is Secretory Endometrium
• What is your preferable line of management?

47. • Open Myomectomy or Lap myomectomy?

48. LAP MYOMECTOMY
• Fibroid size <10cm
• Number of fibroid<3

49. LAP MYOMECTOMY?
• Vasopressin yes or no?
• Power morcellation yes or no?
• In bag morcellation is it a must?

50. OPEN MYOMECTOMY
• What are merits and demerits?
• Role of ureteric stenting?

51. URETRIC STENTING ?
• Cervical, Broad Ligament Fibroid or
Ovarian Mass, TLH & Severe
Endometriosis
• Most ureteral injuries occur near the
cardinal and uterosacral ligaments and
are caused by either thermal-
electrocautery or sharp dissection
• Ureteral catheters in laparoscopy may
enhance identification and make
dissection easier

52. Role of Pre-op Uterine Artery Embolization?

53. UTERINE ARTERY EMBOLIZATION

54. • Uterine artery embolization (UAE) is a minimally invasive
interventional radiological procedure to occlude the
arterial supply to the uterus.
• Occluding material used is
• Polyvinyl alcohol
• trisacryl gelatin microsphere
• gelatin sponge

55. COMPLICATION

56. What is MRI focus High Frequency Ultrasound

57. MRI FOCUS HIGH FREQUENCY ULTRASOUND SURGERY
• High-intensity focused ultrasound (HIFU) is
a non-invasive therapeutic technique that
uses non-ionizing ultrasonic waves to heat
tissue.
• An electronic ultrasound source within the
MR table produces and focuses multiple
sound waves to a very narrow 2-4 cm
portion of the targeted fibroid, killing it as
it heats up above 60o C (> 100 o F),
without affecting any of the other tissues
around the fibroid.
• Non invasive, effective and safe ,
procedure
• Done by Gynaecs & Interventional

58. Advantages of MRI Guided Focussed Ultrasound
?

59. ADVANTAGES
• Effective alternative to surgery and hormonal treatment
• Completely non-invasive - no surgery and no blood loss
• No hospital stay
• Quick return to normal activities
• Preserves the uterus, cervix and ovaries
• Significant improvement in your quality of life decrease
in menstrual bleeding from symptomatic fibroids
decrease in urinary dysfunction, pelvic pain and/or
pressure

60. CASE-3
• 26 years, G2P1l1, with previous FTND with 38 weeks
DCDA twin gestation delivered both babies normally
and went in Atonic PPH.

61. • 4 Ts of PPH?

62. • Trauma (to genital tract)
• Tissue (Retained placental products)
• Tone (Abnormal uterine tone-Uterine Atony)
• Thrombin

63. What is the Next Step?

64. MEDICAL MANAGEMENT??

65. Oxytocin- 40 u in 500 ml N.S at 125ml/hr
Methergin-500 mcg
Carboprost- 0.25 mg may be repeated at interval not less
than15 min to a maximum 8 doses
Carboprost IM / Intramyometrial:- 0.25-0.5 mg
Misoprost PR- 1000mcg per rectal

66. • Mechanical Methods?
• Mimanual compression

67. BAKRI BALLOON

68. UTERINE PACKING

69. COMPRESSION SUITS DURING
TRANSIT

70. • Surgical Management?
B-Lynch
CHO

72. • Last Resort

73. CASE-4
• 35 years, P1L1 with complaints of something coming out
of vagina since 2-3 years
• Complaint of burning micturition since past 2 weeks
• Mentrual history: 5-6 days menses, 28-30 days
duration, 2-3 pads per day
• Obst. History: Married since 5 years,P1L1, 3 years old
male child FTND with application of forceps

74. ON EXAMINATION
• GC fair, afebrile, P-84, BP-110/80 mm Hg, CVS/RS-
NAD
• P/A- soft No GTR
• P/S- 3rd degree UV prolapse
• UCL-5 inches,
• Grade 1 cystocele
• No rectocoele/enterocoele
• P/V- uterus bulky, bilateral adnexa clear

75. WHAT ARE THE CONSERVATIVE
SURGERIES IN YOUNG PATIENT WITH
PROLAPSE
• Purandare cervicopexy
• Shirodkar Abdominal Sling
• Fothergills
• Nadkarni Sleeve Resection
• Virkuds Sling
• Khanna Sling

76. CASE-5
• 42 Yrs old , P2L2, obese female with complaint of heavy
menstrual bleeding for 3 years
• Known case of diabetes, on oral hypoglycemics
• N/H/O any other major surgical and medical illness

77. ON EXAMINATION
BMI- 30.0 kg/m2
GC Fair, afebrile, P-84/min, BP- 120/80 mm Hg
• P/A- Soft, No GTR
• P/S- Cervix and vagina healthy
• P/V- Uterus 6 weeks, Bilateral adnexa clear

78. INVESTIGATIONS
• Hb- 10 TLC-9900
• TVS- uterus is enlarged, ET-11mm, B/L ovaries
normal, No free fluid
• Endometrial biopsy shows endometrial
hyperplasia without atypia

79. Next Line Of Management
Medical/ surgical?

81. Role of Hysteroscopy?

83. • How to follow up with such patients?

85. • Are Endometrial ablation surgeries recommended for
treatment endometrial Hyperplasia???

86. •Endometrial Abalation not recommended by
RCOG

87. •WHY???

88. • Complete and persistent endometrial destruction cannot
be ensured
• Intrauterine adhesion formation may preclude future
endometrial surveillance

89. CASE-6
• 21 years, unmarried nulligravida, came with acute
abdomen, fever( Pain in right iliac fossa) in emergency
with vomiting
• Menstrual history- LMP- 2 months back,
• Irregular/5-6 days menses/2-3 months cycle/3-4 pads
per day
• N/H/O any major surgical/medical illness

90. ON EXAMINATION
• P/A- soft, Tenderness+, Guarding + over right illaic fossa
• P/R- Cystica mass of size 5 x 6x 6 cm on right side
• Uterus size- Normal

91. • What are the Differential Diagnosis ?

92. • Torsion ovary
• Ruptured ovarian cyst
• Appendicitis
• Ectopic Pregnancy
• Tubo-ovarian mass
• Diverticulitis
• Pelvic inflammatory Disease
• UTI

93. • What is the Next Line of Management?

94. • UPT- Negative
• Ultrasonography- Right sided ovarian simple unilocular
cyst of 6 x5 x 6 cm with ? Torsion
• Doppler- No arterial Blood supply to ovary
accompanied with venous congestion suggestive of
right ovarian torsion

95. • Surgical Approach- Laparotomy v/s laparoscopy?

96. INTRA-OP FINDINGS
• Blue-Black ovary with 3 twists in infundibulopelvic
ligaments
• Choice of surgery-
Detorsion+ Cystectomy with Ovarian Reconstruction.
V/s
Oophorectomy

97. • Does the blue black ovary implies functional loss?
• Is there risk of malignancy in previously twisted ovaries
left insitu?
• Whether there is any way to predict which ovary will do
better?
• Whether there is role of oopheropexy to prevent
recurrence?
• Is there a risk of pulmonary embolism following
detorsion?

98. •

101. CASE-7
• Miss XYZ , a 13 year old girl, resident of Belapur
unmarried was transferred from surgery department,
Sion hospital in view of Large abdominal mass and
severe pain in abdomen for 2 to 3 days on 27t h
November 2018, to Dept. of Obstetrics& Gynaecology,
Sion under Dr. N. N. Chavan Unit
• Patient had fever since 2-3days.without rigors and chills

102. • GC – Fair
• T – Febrile, 39 0 C
• P- 98 / min.
• BP- 110/70 mm Hg
• P/A- 30 weeks size right side, firm, non tender mobile,
lower margin could not be reached.
• she was given antibiotics, anti-inflammatory for next 5
days.

103. • What is the investigation of choice for this case?

104. • Ultrasonography -
Showed a complex solid cystic, multilocular
heterogeneous highly vascular Right adnexal mass of 14 x
10 cm not separately seen from right ovary
• CT scan -
confirmed it to be a malignant mixed solid & cystic right
ovarian tumor, size of 14.5x9.1x13.6 cm.

105. • What are the differential diagnosis for adnexal mass in
adolescent girls?

106. DIFFERENTIALS OF OVARIAN MASSES

107. • Uterine
Mullerian Anomalies
Tubal
• Hydrosalpinx
Tubo-ovarian mass
Pyoslpinx

108. Tumour markers expected to be raised in Germ Cell
Tumours?

110. • Beta HCG-51449 5 mlU/mL
• CA-125- 135 U/mL
•
• LDH- 2245.6 /L
• CEA-1.8 ng/mL
• were remarkably raised.
• UPT – positive

112. PHOTO OF DYSGERMINOMA

113. Should we do Open Laparotomy knowing fully well before
hand that’s Malignant or Laparoscopic Treatment ?
Management of Germ Cell Tumor?
Role of Neoadjuvant Chemotherapy?
Debulking or Cytoreductive Surgery ?
Follow-up & Surveillance in Stage 1A?
Fertility preservation surgery?

114. • Management of Germ Cell Tumour
• Role of Neoadjuvant Chemotherapy ?
• Debulking or Cytoreductive Surgery ?
• Follow-up & Surveillance in Stage 1A?

115. SURGICAL PRINCIPLES
• Suspect diagnosis
• Pre-operative markers
• Conservative- fertility preserving surgery
• Staging-controversial- careful inspection of peritoneum,
omentum, contralateral ovary and nodes with washings and
biopsies of suspicious areas adequate
• Unilateral oophorectomy with debulking if advanced stage

116. Surgery
• Importance of staging in earl of staging in early disease
• Fertility-sparing surgery often required
• Can preserve uterus for future IVF, even if BSO
• Debulking improves outcome
Chemotherapy
• BEP
• Bleomycin 20 U/m2 weekly x 9
• Etoposide 100 mg/m2 days 1-5 q 3 weeks x 3
• Cisplatin 20 mg/m2 days 1-5 q 3 weeks x 3

117. How will you follow up the case?

118. • Markers HCG AFP LDH CA125
• 1st year every 2 weeks x 6 m and then monthly x 6
• 2nd year monthly
• 3rd year every 3/12
• 4th year every 4/12
• Subsequent years 6/12

119. • Clinical exam
• 1st year monthly
• 2nd year every 2 months
• 3rd year every 3 months
• 4th year every 4 months
• 5-10 every 6 months
• Imaging
• Chest X ray alternate visits
• Abdo-pelvic US every 3rd visit for first 2 years followed by
annual abdo-pelvic ultrasound subsequent years

121. OVARIAN TRANSPOSITION
• Picture

122. CASE 8
• 24 yrs female, P1L1, with complaint of white discharge
since 2-3 months presented in OPD
• N/ H/ O any surgical/medical illness
• Menstrual history- Regular menses, 28-30 days
cycle,lasting for 3-4 days with soakage of 2-3 pads per
day

123. ON EXAMINATION
• P/A- Soft, no GTR
• P/S- Cervical erosion, vagina healthy, pap smear taken
• P/V- uterus normal size, bilateral fornices free

124. • PAP suggestive of squamous cell Ca
• Next step??

125. Cervical Biopsy

126. • Cervical biopsy confirmed squamous cell Ca of cervix
• MRI suggestive of squamous cancer stage 1 b1
Next line of Management ?

127. RADICAL TRACHELECTOMY
• The word radical is used as, in addition to
the cervix, the parametria and vaginal cuff are also
excised as a part of the operation. It is usually
done with a lymphadenectomy, to assess for
tumour spread to the lymph nodes
• Disadvantages:
• Cervical stenosis
• Preterm labour, premature rupture of membranes
• 2nd trimester loss
• Boss et al reported 70% conception with 49% term
delivery
• Plante et al reported 46% conception with ¾ term
deliveries

129. COUNSELING
Counsel patients who have to undergo a hysterectomy
the pros and cons of elective oophorectomy.
 Risk and benefit balance
Morbidity and mortality of reoperation as well as
operative risks of oophorectmy
Cost factor
Natural estradiol and testosterone and their benefits
over HRT versus the long term risk of developing ovarian
cancer at a future date.

130. CONCLUSIONS
• Medical management should be preferred over the
surgical management as it decreases the exposure to
anaesthesia and unnecessary surgical complications
which could be avoided beforehand
• Uterus conserving procedures should be preferred in
young age to prevent infertility
• Community education is necessary to decrease such
disheartening events like in Usmananabad and Latur
• Ovaries conserving procedures should be done to
prevent infertility in adolescents and to decrease the
need of HRT in postmenopausal women

132. SAVE EARTH, SAVE NATURE,
SAVE UTERUS SAVE OVARIES