DEFINITION

The Papanicolaou (Pap) smear is an exfoliative cytology test used to screen for premalignant and malignant lesions of the cervix by examining cells shed from the transformation zone.

TECHNIQUE

With the cervix exposed by a speculum, cells are scraped from the squamo-columnar junction using an Ayre's spatula and endocervical brush (or collected in liquid medium), smeared/fixed and stained by the Papanicolaou method.

REPORTING (BETHESDA SYSTEM)

• NILM — negative for intraepithelial lesion/malignancy.
• ASC-US / ASC-H — atypical squamous cells.
• LSIL and HSIL — low- and high-grade squamous intraepithelial lesions.
• Squamous-cell carcinoma / glandular abnormalities (AGC).

WHEN AND HOW OFTEN

Screening starts at age 21 (or 3 years after first intercourse) and is repeated every 3 years (or with co-testing for HPV every 5 years). An abnormal smear is evaluated by colposcopy and biopsy.

PREREQUISITES AND LIMITATIONS

The smear is best taken in the mid-cycle, avoiding menstruation; the woman should not have douched or used vaginal medication/intercourse for 24–48 hours, and active infection is treated first. It is a screening, not a diagnostic, test and has a false-negative rate (inadequate sampling, an endocervical lesion), so a positive result always needs colposcopy and biopsy for confirmation.

ADVANTAGES

It is simple, inexpensive, painless and performed in the out-patient clinic without anaesthesia, and detects disease in the long premalignant phase — making it ideal for mass screening.

LIQUID-BASED CYTOLOGY & HPV TESTING

Liquid-based cytology (LBC) gives fewer unsatisfactory smears and allows reflex HPV testing from the same vial. Visual inspection with acetic acid (VIA) and HPV-DNA testing are the other screening tools, the latter being highly sensitive and increasingly used as a primary or co-test.

DEFINITION

Cervical intraepithelial neoplasia (CIN) is a premalignant lesion of the cervix in which atypical (dysplastic) squamous cells are confined to the epithelium above the basement membrane (no invasion). It is the precursor of invasive squamous-cell carcinoma.

GRADING

• CIN I — mild dysplasia; atypical cells in the lower one-third of the epithelium.
• CIN II — moderate dysplasia; lower two-thirds.
• CIN III — severe dysplasia/carcinoma in situ; full thickness involved.

(The Bethesda cytology system groups these as LSIL = CIN I and HSIL = CIN II–III.)

DIAGNOSIS

An abnormal Pap smear leads to colposcopy (acetowhite areas, abnormal vessels) and a directed/punch biopsy for histological confirmation.

MANAGEMENT

• CIN I — often regresses; may be observed with follow-up cytology/colposcopy.
• CIN II–III — treated by excision (LEEP/LLETZ or cold-knife conisation) or ablation (cryotherapy); conisation also provides histology.

NATURAL HISTORY

CIN is caused by persistent high-risk HPV (16, 18) infection. Low-grade lesions (CIN I) frequently regress spontaneously, whereas high-grade lesions (CIN II–III) are more likely to persist and progress to invasive cancer over 10–15 years if untreated — the long latent phase that makes screening effective.

COLPOSCOPY FINDINGS

After acetic acid, CIN shows acetowhite epithelium with punctation, mosaicism and atypical vessels, and is iodine-negative on Schiller's test; the most abnormal area is biopsied.

PREVENTION AND FOLLOW-UP

HPV vaccination and regular screening prevent and detect CIN early. After treatment, women remain under cytology/HPV "test-of-cure" follow-up because the lesion can recur or persist.

DEFINITION

Tests of ovulation are investigations used in the work-up of infertility to confirm whether and when ovulation is occurring, since ovulation is one of the three essentials of conception.

INDIRECT / CLINICAL TESTS

• Menstrual history — regular cycles with molimina suggest ovulation.
• Basal body temperature (BBT) — a biphasic curve with a mid-cycle rise of ~0.5°C (progesterone thermogenic effect) indicates ovulation has occurred.
• Cervical mucus — loss of ferning/spinnbarkeit after ovulation.

HORMONAL / DIRECT TESTS

• Mid-luteal (day-21) serum progesterone > 10 ng/mL — the best single confirmation of ovulation.
• Urinary LH-surge kits — detect the pre-ovulatory LH surge (ovulation ~24–36 h later).
• Serial transvaginal ultrasound (folliculometry) — follows follicular growth and collapse with appearance of the corpus luteum and free fluid.
• Endometrial biopsy in the luteal phase — secretory endometrium indicates ovulation (now rarely used).

MARKERS OF ANOVULATION

Conversely, a monophasic basal-temperature chart, a low mid-luteal progesterone, and a proliferative (non-secretory) endometrium indicate that ovulation has not occurred — directing attention to ovulation induction in the infertility work-up.

OTHER SUPPORTIVE EVIDENCE

Mid-cycle pain (mittelschmerz), the mid-cycle change to clear elastic mucus, and a premenstrual secretory endometrium on biopsy all support ovulation; the only absolute proof of ovulation, however, is an achieved pregnancy.

DEFINITION

Emergency (post-coital) contraception is the use of a contraceptive method after an act of unprotected or inadequately-protected intercourse to prevent an unintended pregnancy.

METHODS

• Levonorgestrel 1.5 mg orally, as a single dose within 72 hours (the commonest method); earlier is more effective.
• Ulipristal acetate 30 mg orally within 120 hours (a progesterone-receptor modulator, more effective than levonorgestrel).
• Yuzpe regimen — combined oral pills (ethinyl-oestradiol + levonorgestrel) in two doses within 72 hours.
• Copper IUCD inserted within 5 days — the most effective method and gives ongoing contraception.

MECHANISM

Mainly inhibition/delay of ovulation (hormonal methods); the copper IUCD also prevents fertilisation and implantation. It is not an abortifacient and does not disturb an established pregnancy.

INDICATIONS

Unprotected intercourse, a missed or delayed contraceptive (forgotten pills, late injection), a burst or slipped condom, a displaced diaphragm/IUCD, and after sexual assault.

SIDE-EFFECTS

Nausea and vomiting (repeat the dose if vomiting occurs within 2–3 hours), menstrual irregularity, breast tenderness and headache; it does not protect against subsequent acts in the same cycle.

EFFICACY

The copper IUCD is the most effective (failure < 1%); the oral methods reduce expected pregnancies by about 75–85% and work better the earlier they are taken.

COUNSELLING AND FOLLOW-UP

It gives no protection against later acts in the same cycle, so a regular method should be started; the woman is told to return if the next period is over a week late to exclude pregnancy.

DEFINITION

Red (carneous) degeneration is an aseptic necrobiosis of a large fibroid, occurring characteristically in the second half of pregnancy and the puerperium. The cause is thought to be vascular (interference with the blood supply of a rapidly-growing fibroid).

PATHOLOGY

The cut surface has a "raw-beef" (red) appearance with a fishy odour (from fatty acids), the colour being due to haemolysed red cells and haemoglobin; microscopy shows necrosis with thrombosed vessels. Partial recovery is possible — hence the term necrobiosis.

CLINICAL FEATURES

In a pregnant woman — acute localised abdominal pain with tenderness over the fibroid, mild fever, vomiting and a moderate leucocytosis; it is an important cause of acute abdomen in pregnancy.

MANAGEMENT

• Conservative — it is self-limiting; treat with rest, analgesics and reassurance.
• Surgery is avoided in pregnancy unless complications (e.g. torsion) supervene.

DIFFERENTIAL DIAGNOSIS

Other causes of acute abdomen in pregnancy must be considered — torsion of a pedunculated fibroid or ovarian cyst, acute appendicitis, abruptio placentae, ureteric colic and accidental haemorrhage; the localised tenderness over a known fibroid and the absence of peritonism point to red degeneration.

INCIDENCE

It complicates about 5–10% of fibroids in pregnancy, typically in the second or early third trimester when a fibroid outgrows its blood supply.

INVESTIGATIONS

Mainly clinical; ultrasound may show a fibroid with mixed echogenicity/cystic change, with a mild leucocytosis and low-grade fever. Other causes of an acute abdomen in pregnancy must be excluded.

COURSE AND PROGNOSIS

It is self-limiting — the pain settles over 3–7 days with conservative care and the prognosis is good; myomectomy is avoided in pregnancy owing to the risk of severe haemorrhage.

DEFINITION

A Krukenberg tumour is a metastatic (secondary) tumour of the ovary, characteristically bilateral, arising from a gastrointestinal primary — most often the stomach (also colon, breast), and composed of mucin-secreting "signet-ring" cells in a cellular stroma.

PATHOLOGY

The ovaries are usually bilateral, solid and enlarged, retaining the ovarian shape with a smooth surface. Microscopy shows the diagnostic signet-ring cells (mucin pushing the nucleus to one side) scattered in the stroma. Spread to the ovary is transcoelomic, lymphatic and haematogenous.

CLINICAL FEATURES

Features of the primary gastrointestinal cancer, an abdominal/pelvic mass and ascites; the tumour may be hormonally active (oestrogen/androgen), producing menstrual disturbance or post-menopausal bleeding or virilisation.

SPREAD TO THE OVARY

Tumour reaches the ovaries by transcoelomic seeding, lymphatic and haematogenous routes; the bilateral, solid enlargement with preservation of the ovarian outline is characteristic. Peritoneal deposits and ascites are usually present, indicating advanced disease.

GROSS AND MICROSCOPIC APPEARANCE

The ovaries are bilaterally enlarged, solid and smooth, retaining the ovarian shape. Microscopy shows the diagnostic "signet-ring" cells (mucin displacing the nucleus) scattered in a cellular (sarcoma-like) stroma.

INVESTIGATIONS AND MANAGEMENT

Ultrasound shows bilateral solid masses; tumour markers and gastrointestinal endoscopy are done to find the primary. Treatment is directed at the primary tumour with cytoreduction where feasible; the response to chemotherapy is poor.

DEFINITION

A hydatidiform mole is a form of benign gestational trophoblastic disease characterised by abnormal proliferation of the trophoblast with hydropic (vesicular) swelling of the chorionic villi, so that the products resemble a "bunch of grapes".

TYPES

CLINICAL FEATURES

Amenorrhoea followed by vaginal bleeding, a uterus large for dates, severe hyperemesis, early pre-eclampsia, expulsion of grape-like vesicles, and bilateral theca-lutein cysts.

INVESTIGATIONS AND MANAGEMENT

• Ultrasound — a "snow-storm" appearance with no fetus; a very high serum β-hCG.
• Suction evacuation of the uterus, with anti-D for Rh-negative women.
• Serial β-hCG follow-up with contraception to detect persistent/malignant GTN (which follows 15–20% of complete moles).

COMPLICATIONS

Haemorrhage and anaemia, hyperemesis and early pre-eclampsia, hyperthyroidism (hCG cross- reactivity), trophoblastic pulmonary embolisation at evacuation, and progression to persistent/malignant GTN.

DEFINITION

A vesicovaginal fistula (VVF) is an abnormal communication between the urinary bladder and the vagina, resulting in continuous, involuntary escape of urine through the vagina.

CAUSES

• Obstetric (commonest in developing countries) — pressure necrosis from prolonged/obstructed labour, and instrumental/operative delivery injury.
• Gynaecological/surgical — injury during hysterectomy or pelvic surgery.
• Radiation for pelvic malignancy, and advanced cervical/vaginal carcinoma.

CLASSIFICATION

VVF is classified by site (juxta-urethral, mid-vaginal, juxta-cervical/vault), by size, and by complexity (simple vs complex — large, scarred, radiation-induced, or involving the ureter/urethra), which together determine the route and difficulty of repair.

CLINICAL FEATURES AND DIAGNOSIS

Continuous dribbling of urine per vaginum with a constantly wet, excoriated vulva. Diagnosis is by speculum examination, the dye (methylene-blue/three-swab) test to locate and distinguish it from a ureterovaginal fistula, and cystoscopy with imaging (IVU) to assess the ureters.

MANAGEMENT

• Small, fresh fistulae — continuous bladder catheter drainage may allow spontaneous healing.
• Surgical repair — usually after about 3 months (once inflammation settles), by the vaginal or abdominal route, with interposition of healthy tissue.

INVESTIGATIONS (DETAIL)

The three-swab (dye) test — methylene blue is instilled into the bladder and three swabs are placed in the vagina; staining of the upper swab suggests a ureterovaginal and of the lower/middle swab a vesicovaginal fistula. Cystoscopy, examination under anaesthesia and intravenous urography define the site, size and ureteric relations.

PRINCIPLES OF REPAIR

Repair is by the vaginal or abdominal route with wide mobilisation and tension-free, layered closure and, where needed, interposition of healthy tissue (e.g. Martius graft); a catheter is left for continuous drainage afterwards.

DEFINITION

Adenomyosis is the presence of endometrial glands and stroma within the myometrium (at least one high-power field below the endo-myometrial junction), with surrounding myometrial hypertrophy. It is sometimes called "internal endometriosis".

PATHOLOGY

The uterus is uniformly and symmetrically enlarged (rarely beyond 12 weeks' size) with a thickened, trabeculated myometrium; the cut surface shows whorled muscle with small haemorrhagic cystic spaces. It may be diffuse or, less often, localised (an adenomyoma), and frequently coexists with fibroids and endometriosis.

CLINICAL FEATURES

— progressively severe

secondary dysmenorrhoea

and

menorrhagia

, with a

uniformly enlarged, bulky, tender uterus

("globular" uterus).

DIAGNOSIS

Transvaginal ultrasound (a heterogeneous, asymmetrically thickened myometrium with cysts) and MRI (a thickened junctional zone) suggest it; the definitive diagnosis is histological after hysterectomy.

MANAGEMENT

• Medical — symptomatic relief with NSAIDs and tranexamic acid; the levonorgestrel-IUS, progestins or GnRH analogues reduce bleeding and pain.
• Definitive — hysterectomy in women who have completed their family and failed medical treatment.

ASSOCIATIONS AND INVESTIGATIONS

It is associated with multiparity and previous uterine surgery/curettage and commonly coexists with fibroids and endometriosis. On transvaginal ultrasound the myometrium is heterogeneous with cystic spaces, and MRI shows a thickened junctional zone (> 12 mm) — both suggestive but not diagnostic.

DEFINITION

Amenorrhoea is the absence of menstruation. Primary amenorrhoea — failure to menstruate by 15 years with normal secondary sexual characteristics (or by 13 years in their absence). Secondary amenorrhoea — cessation of menstruation for 6 months (or three cycles) in a woman who previously menstruated.

PHYSIOLOGICAL CAUSES

Before puberty, during pregnancy and lactation, and after the menopause.

PATHOLOGICAL CAUSES (BY LEVEL)

• Outflow tract/uterus — imperforate hymen, transverse vaginal septum, Müllerian agenesis (Rokitansky), and Asherman's syndrome (intra-uterine adhesions).
• Ovary — gonadal dysgenesis (Turner's syndrome), premature ovarian failure and PCOS.
• Pituitary — prolactinoma/hyperprolactinaemia and Sheehan's syndrome.
• Hypothalamus — stress, excessive exercise, weight loss/anorexia, and chronic illness.

INVESTIGATIONS

A pregnancy test first, then serum FSH/LH, prolactin and TSH, a progesterone challenge, and ultrasound/karyotype as indicated to localise the cause.

MANAGEMENT (PRINCIPLE)

Treatment is directed at the cause — relieving an outflow obstruction (e.g. cruciate incision of an imperforate hymen), dopamine agonists for hyperprolactinaemia, ovulation induction or cyclical oestrogen-progestogen for ovarian/hypothalamic causes, and hormone replacement in premature ovarian failure or gonadal dysgenesis.

DEFINITION

Menopause is the permanent cessation of menstruation due to loss of ovarian follicular activity, diagnosed retrospectively after 12 months of amenorrhoea. It occurs at an average age of about 50 years.

FEATURES (OF OESTROGEN DEFICIENCY)

• Vasomotor — hot flushes and night sweats.
• Urogenital atrophy — vaginal dryness, dyspareunia and urinary symptoms.
• Long-term — osteoporosis (fracture risk) and an increased cardiovascular risk; mood and sleep disturbance.

HORMONE REPLACEMENT THERAPY (HRT)

• Composition — oestrogen for symptom relief, combined with a progestogen in women with a uterus (to protect the endometrium from unopposed-oestrogen hyperplasia/cancer); oestrogen alone after hysterectomy.
• Indications — troublesome vasomotor/urogenital symptoms and premature menopause; benefits include symptom relief and bone protection.
• Risks — venous thromboembolism, a small increase in breast cancer (combined HRT) and endometrial cancer (unopposed oestrogen).
• Contraindications — oestrogen-dependent cancer, undiagnosed bleeding, active thromboembolism and severe liver disease.

DIAGNOSIS AND NON-HORMONAL MEASURES

The diagnosis is clinical (12 months' amenorrhoea at the appropriate age), with a raised FSH where confirmation is needed. Non-hormonal options for those who cannot take HRT include lifestyle measures, SSRIs/SNRIs or clonidine for flushes, vaginal moisturisers/local oestrogen for atrophy, and calcium/vitamin-D with bisphosphonates for bone protection.

DEFINITION

Vaginal candidiasis (moniliasis) is a fungal infection of the vagina and vulva, most commonly caused by Candida albicans, producing a characteristic itchy, curdy discharge.

PREDISPOSING FACTORS

Pregnancy, diabetes mellitus, broad-spectrum antibiotics, immunosuppression (HIV), corticosteroids and oral-contraceptive use — conditions that alter the vaginal flora or glycogen content.

CLINICAL FEATURES

Intense vulval pruritus with a thick, white, curdy ("cottage-cheese") discharge, vulval erythema, soreness and superficial dyspareunia; the vaginal pH usually remains normal (< 4.5).

DIAGNOSIS AND TREATMENT

• Diagnosis — a wet-mount / KOH preparation showing budding yeasts and pseudohyphae, or culture.
• Treatment — topical imidazoles (clotrimazole pessary/cream) or oral fluconazole; correct the predisposing factors and treat recurrent/severe disease for longer.

RECURRENT AND COMPLICATED DISEASE

Recurrent candidiasis (four or more episodes a year) warrants a search for diabetes or immunosuppression and a longer suppressive course. In pregnancy it is common (high oestrogen and glycogen) and treated with topical azoles; oral fluconazole is generally avoided.

PATHOPHYSIOLOGY

*Candida* is a commensal of the vagina and gut; disease results when altered conditions (raised oestrogen/glycogen, antibiotics suppressing lactobacilli, immunosuppression) allow overgrowth and tissue invasion of the vulvovaginal epithelium.

DEFINITION

The Manchester (Fothergill) operation is a uterus-conserving operation for uterovaginal prolapse, particularly when there is cervical (supravaginal) elongation, in a woman who wishes to retain her uterus.

COMPONENTS (THREE STEPS)

• Amputation of the elongated cervix.
• Plication and shortening of the cardinal (Mackenrodt) ligaments in front of the cervix (the Fothergill stitch), which elevates and supports the uterus.
• Anterior colporrhaphy (for the cystocele) and posterior colpoperineorrhaphy as required.

INDICATIONS

Uterovaginal prolapse with cervical elongation in a younger woman wishing to preserve the uterus/ menstruation or who is unfit for hysterectomy.

ADVANTAGES AND LIMITATIONS

Advantages — the uterus is conserved, it is quicker and less major than hysterectomy, and it corrects the cystocele and cervical elongation. Limitations — it does not remove the (potentially diseased) uterus, is unsuitable when childbearing is complete, and has the complications below.

OUTCOME AND CONTRAINDICATIONS

It corrects the prolapse while conserving the uterus and menstruation. It is not suitable when further childbearing is desired (risk of cervical incompetence) or when the uterus itself is diseased, and the cardinal- ligament plication may make a subsequent pregnancy high-risk.

DEFINITION

Medical termination of pregnancy (MTP) is the legally permitted, deliberate termination of pregnancy by a registered medical practitioner under the provisions of the MTP Act, 1971 (amended 2021) in India.

LEGAL GESTATIONAL LIMITS (INDIA)

• Up to 20 weeks — on the opinion of one registered medical practitioner.
• 20–24 weeks — on the opinion of two practitioners, for specified categories (e.g. survivors of rape, minors, change in marital status, fetal abnormality, disability).
• Beyond 24 weeks — only for substantial fetal abnormality, on the approval of a Medical Board.

INDICATIONS

Risk to the life or physical/mental health of the woman, substantial fetal abnormality, pregnancy from rape/incest, and contraceptive failure (for any woman and her partner).

METHODS

• Medical — mifepristone followed by misoprostol (up to about 9 weeks).
• Surgical — suction evacuation / manual vacuum aspiration (up to ~12–14 weeks), and dilatation and evacuation later.

COMPLICATIONS

Immediate — haemorrhage, uterine perforation, cervical injury and anaesthetic complications. Delayed — incomplete abortion, pelvic infection/sepsis, and failed termination with a continuing pregnancy. Remote — cervical incompetence, intra-uterine adhesions and (with repeated procedures) menstrual disturbance.

PRE-REQUISITES

The procedure requires the informed written consent of the woman, performance by a registered medical practitioner with the prescribed training, at a government-approved place, with maintenance of the woman's confidentiality.

DEFINITION

A Bartholin's cyst is a retention cyst formed by obstruction of the Bartholin's (greater vestibular) gland duct, with accumulation of secretion; a Bartholin's abscess is an infected, suppurating cyst.

CAUSE

Blockage of the duct (by inflammation/inspissated secretion); the abscess is usually caused by E. coli, gonococcus, staphylococci and anaerobes.

CLINICAL FEATURES

Cyst — a painless, tense, cystic swelling in the posterolateral part of the introitus (lower third of the labium majus). Abscess — a painful, hot, red, tender swelling with difficulty in sitting/walking, sometimes with fever.

MANAGEMENT

• Small asymptomatic cyst — observation.
• Symptomatic cyst — marsupialisation (creating a permanent new duct opening) to preserve gland function.
• Abscess — incision and drainage (or marsupialisation) with antibiotics; a Word catheter may be placed to keep the cavity draining.

COMPLICATIONS AND RECURRENCE

An untreated abscess may rupture spontaneously or recur; recurrence after simple incision is common (hence marsupialisation is preferred), and a chronic cyst may cause dyspareunia. Cellulitis of the vulva and, rarely, necrotising infection can complicate an abscess.

ANATOMY AND DIFFERENTIAL DIAGNOSIS

The Bartholin's (greater vestibular) glands lie in the posterolateral wall of the lower vagina and secrete lubricating mucus through a duct opening into the vestibule. The swelling is distinguished from a cyst of the canal of Nuck, an inclusion/sebaceous cyst, and — in the elderly — carcinoma of the gland.

DEFINITION

Trichomoniasis is a sexually transmitted infection of the vagina caused by Trichomonas vaginalis, a flagellated motile protozoan.

CLINICAL FEATURES

A profuse, frothy, greenish-yellow, offensive vaginal discharge with vulval itching and soreness, dysuria and dyspareunia; on examination a "strawberry" cervix (punctate haemorrhages) may be seen, and the vaginal pH is raised (> 4.5).

DIAGNOSIS

Wet-mount microscopy of the discharge shows the motile, flagellated trichomonads; culture and NAAT are more sensitive. A positive amine (whiff) test may coexist.

TREATMENT

• Metronidazole (single 2 g dose or a 7-day course) — oral, since the infection is vaginal and urethral.
• Treat the sexual partner simultaneously (it is an STI) and advise abstinence until both are cured; screen for other sexually transmitted infections.

COMPLICATIONS

Trichomoniasis is associated with preterm labour and low birth weight in pregnancy, an increased risk of acquiring and transmitting HIV and other sexually transmitted infections, and ascending infection/PID; the "strawberry cervix" reflects the intense inflammation.

ORGANISM AND TRANSMISSION

*Trichomonas vaginalis* is an anaerobic flagellated protozoan transmitted almost exclusively sexually; it infects the vagina, urethra and paraurethral glands, with an incubation period of about 4–28 days.

NOTE ON TREATMENT

The patient is advised to avoid alcohol while taking metronidazole (a disulfiram-like reaction); metronidazole is also used (with caution) in pregnancy.

DEFINITION

Tumour markers are substances (usually proteins) produced by tumour cells or by the body in response to a tumour, measurable in blood and used mainly to monitor treatment response and detect recurrence (and to support diagnosis), rather than for screening.

IMPORTANT GYNAECOLOGICAL MARKERS

PRINCIPLE AND LIMITATIONS

An ideal marker is both specific and sensitive; in practice most gynaecological markers lack the specificity needed for screening (CA-125 is raised in many benign conditions) and are used chiefly for supporting a diagnosis, monitoring the response to treatment and detecting recurrence of a known tumour.

DEFINITION

Dilatation and curettage (D&C) is a gynaecological procedure in which the cervix is dilated and the endometrium is scraped (curetted) for diagnostic or therapeutic purposes.

INDICATIONS

• Diagnostic — endometrial sampling in abnormal/post-menopausal uterine bleeding (to exclude hyperplasia/ malignancy) and to investigate infertility (now often replaced by Pipelle biopsy and hysteroscopy).
• Therapeutic — evacuation of retained products of conception (incomplete/missed abortion), removal of an endometrial polyp, and evacuation of a molar pregnancy.

TECHNIQUE

Under anaesthesia, with the patient in lithotomy and full aseptic precautions: the uterine size/position is assessed, the cervix dilated with Hegar's dilators, and the cavity curetted with a sharp/blunt curette (or emptied by suction); products are sent for histology.

FRACTIONAL CURETTAGE

In suspected malignancy, a fractional (separate) curettage is done — the endocervix is curetted first and then the uterine cavity, the specimens being labelled separately — to determine whether disease has involved the cervix, which alters the stage and management.

TYPES AND CONTRAINDICATIONS

Types include simple, fractional (separate endocervical then endometrial), and suction curettage. It is contraindicated in pregnancy (unless the aim is evacuation), in acute pelvic infection and with an uncorrected bleeding disorder; an acute infection is treated first.

PREPARATION

It is performed under general/regional anaesthesia in the lithotomy position with full asepsis, after a bimanual examination to assess uterine size and position.

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