Gynaecology Image Library

Chapter 1

Figure 1.1 A: Cross-section diagram of the posterior abdominal wall showing the genital ridge; B: diagrammatic representation of the embryological pathways of male and female development. (DHT: dihydrotestosterone.)
Figure 1.2 Caudal parts of the paramesonephric ducts (top) fuse to form the uterus and Fallopian tubes.
Figure 1.3 Sagittal section of the female pelvis.
Figure 1.4 Pelvic floor musculature.
Figure 1.5 A: The round and broad ligaments; B: the cervical and uterine ligaments.
Figure 1.6 Blood supply of the pelvis and perineum.
Figure 1.7 Lymphatic drainage of the pelvis and perineum.
Figure 1.8 Nerve supply of the pelvis and perineum.
Figure 1.9 Müllerian structural abnormalities.
Figure 1.9 Müllerian structural abnormalities.

Chapter 2

Figure 2.1 A patient in the correct position for abdominal examination, showing obvious abdominal distension.
Figure 2.2 The normal vulva.
Figure 2.3 A: Cusco’s speculum; B: Cusco’s speculum in position. The speculum should be inserted at about 45° to the vertical and rotated to the vertical as it is introduced. Once it is fully inserted, the blades should be opened up to visualize the cervix.
Figure 2.4 A: Sim’s speculum; B: Sim’s speculum inserted with the patient in the left lateral position. The speculum is being used to hold back the posterior vaginal walls to allow inspection of the anterior wall and vault. The speculum can be rotated 180° or withdrawn slowly to visualize the posterior wall.
Figure 2.5 A: Bimanual examination of the pelvis assessing the uterine position and size; B: bimanual examination of the lateral fornix.
Figure 2.6 A: Transvaginal ultrasound (TVUSS) of normal uterus. B: TVUSS of left and right ovaries; C: TVUSS of haemorrhagic cyst; D: TVUSS of multiseptated cyst.
Figure 2.6 A: Transvaginal ultrasound (TVUSS) of normal uterus. B: TVUSS of left and right ovaries; C: TVUSS of haemorrhagic cyst; D: TVUSS of multiseptated cyst.
Figure 2.6 A: Transvaginal ultrasound (TVUSS) of normal uterus. B: TVUSS of left and right ovaries; C: TVUSS of haemorrhagic cyst; D: TVUSS of multiseptated cyst.
Figure 2.6 A: Transvaginal ultrasound (TVUSS) of normal uterus. B: TVUSS of left and right ovaries; C: TVUSS of haemorrhagic cyst; D: TVUSS of multiseptated cyst.
Figure 2.7 A: Magnetic resonance imaging (MRI) of normal pelvis (long arrow, endometrium; short arrow, inner ­myometrium and cervix; arrowhead, outer myometrium); B: axial MRI of pelvis in a patient with uterus didelphys and double cervices (long arrows, ovaries; short arrows, cervices; arrowhead, follicle). C: coronal MRI in a patient with uterus didelphys (long arrow, right ovary; short arrows, cervices). (Images courtesy of Dr Sarah Natas, Consultant Radiologist.)
Figure 2.7 A: Magnetic resonance imaging (MRI) of normal pelvis (long arrow, endometrium; short arrow, inner ­myometrium and cervix; arrowhead, outer myometrium); B: axial MRI of pelvis in a patient with uterus didelphys and double cervices (long arrows, ovaries; short arrows, cervices; arrowhead, follicle). C: coronal MRI in a patient with uterus didelphys (long arrow, right ovary; short arrows, cervices). (Images courtesy of Dr Sarah Natas, Consultant Radiologist.)
Figure 2.7 A: Magnetic resonance imaging (MRI) of normal pelvis (long arrow, endometrium; short arrow, inner ­myometrium and cervix; arrowhead, outer myometrium); B: axial MRI of pelvis in a patient with uterus didelphys and double cervices (long arrows, ovaries; short arrows, cervices; arrowhead, follicle). C: coronal MRI in a patient with uterus didelphys (long arrow, right ovary; short arrows, cervices). (Images courtesy of Dr Sarah Natas, Consultant Radiologist.)
Figure 2.8 Endometrial sampler.

Chapter 3

Figure 3.1 Hypothalamus–pituitary axis. (E2, oestrogen; FSH, follicle-stimulating hormone; GnRH, gonadotrophin-­releasing hormone; LH, luteinizing hormone; P4, progesterone.)
Figure 3.2 Changes in hormone levels, endometrium and follicle development during the menstrual cycle.
Figure 3.3 Tissue sections of normal endometrium during proliferative (A) and secretory (B) phases of the menstrual cycle.
Figure 3.4 Photomicrograph of endometrial pinopods from the implantation window.
Figure 3.5 Tanner staging.
Figure 3.6 Gross appearance of a polycystic ovary (A) and transvaginal ultrasound scan image (B).
Figure 3.6 Gross appearance of a polycystic ovary (A) and transvaginal ultrasound scan image (B).
Figure 3.7 Algorithm for the treatment of premenstrual syndrome (PMS). (GP, general practitioner; GnRH, gonadotrophin-releasing hormone; HRT, hormone replacement therapy; NAPS, National Association for Premenstrual Syndrome.) (Adapted with permission from Guidelines for the National Association for Premenstrual Syndrome, www.pms.org.uk.)

Chapter 4

Figure 4.1 Endometrial polyps.
Figure 4.2 An outpatient hysteroscopy set.
Figure 4.3 Microwave ablation (Microsulis™).

Chapter 5

Figure 5.1 Preimplantation development and intrauterine implantation.
Figure 5.2 Image of an early intrauterine pregnancy with yolk sac and pole (~5–6 weeks).
Figure 5.3 Image of tubal ectopic pregnancy taken at laparoscopy.

Chapter 6

Figure 6.1 The oral contraceptive pill.
Figure 6.2 A: Combined hormonal patch. B: combined hormonal vaginal contraceptive ring.
Figure 6.3 Missed pill guidelines. (Adapted from Faculty of Sexual and Reproductive Healthcare, CEU Statement, 2011.)
Figure 6.4 Nexplanon.
Figure 6.5 Sayana®-press single-dose container.
Figure 6.6 A: Female condom; B: male condom.
Figure 6.7 A: The cap; B: correct siting of a cap.
Figure 6.7 A: The cap; B: correct siting of a cap.
Figure 6.7 A: The cap; B: correct siting of a cap.
Figure 6.8 Filshie clip.
Figure 6.9 Essure® hysteroscopic sterilization. (Courtesy of Justin Clark.)
Figure 6.9 Essure® hysteroscopic sterilization. (Courtesy of Justin Clark.)
Figure 6.10 Vasectomy.

Chapter 7

Figure 7.1 The natural conception rate over a 3-year period.
Figure 7.2 Causes of subfertility.
Figure 7.3 A: Hysterosalpingogram (HSG) showing normal patency of the Fallopian tubes; B: pictorial illustration of a normal HSG; C: abnormal HSG with pocketed areas suggesting blocked tubes.
Figure 7.4 A: Photograph of the normal fimbrial end of Fallopian tube; B: photograph of right hydrosalpinx.
Figure 7.5 Pictorial in-vitro fertilization (IVF) cycle. (ICSI, intracytoplasmic sperm injection.)
Figure 7.6 Intracytoplasmic sperm injection.

Chapter 8

Figure 8.1 Age of menopause and mean life expectancy in the UK since 1850.
Figure 8.2 Population projections. Females over 50 years in the UK. Office for National Statistics Projection data 2012–2037, extracted and plotted by Author.
Figure 8.3 Vaginal epithelium in a (A) premenopausal woman and (B) a postmenopausal woman showing ­atrophic changes. Note the loss of epithelial structure and architecture. (Reproduced with permission, Whitehead MI, Whitcroft SIJ, Hillard TC (1993). An Atlas Of The Menopause. Carnforth, Lancs, UK: Parthenon.)
Figure 8.4 Electron micrograph of trabecular bone showing (A) normal structure and (B) osteoporotic bone. Note the loss of architecture and density in (B) making the bone weaker and more prone to fracture. (Reproduced with permission, Whitehead Malcolm I, Whitcroft SIJ, Hillard TC (1993). An Atlas Of The Menopause. Carnforth, Lancs, UK: Parthenon.)
Figure 8.5 The principal stages of the bone remodelling cycle represented diagrammatically (left) with corresponding light micrographs of iliac crest biopsies (right). A: Resorption by osteoclasts (OC); B: reversal with disappearance of OC; C: OC formation with the deposition of osteoid by osteoblasts (OB); D: mineralization of the osteoid; E: completion of the cycle with bone lining cells on the surface (LC). (Light micrographs reproduced with permission, Dempster DW [1992]. Disorders of the Bone and Mineral Metabolism. New York: Raven Press.)

Chapter 9

Figure 9.1 Vaginal and cervical flora (×1,000 magnified). A: Normal: lactobacilli – seen as large gram-positive rods – predominate. Squamous epithelial cells are gram-negative. with a large aount of cytoplasm. B: Candidiasis: there are speckled gram-positive spores and long pseudohyphae visible. There are numerous polymorphs present and the bacterial flora is abnormal, resembling bacterial vaginosis. C: Bacterial vaginosis: there is an overgrowth of anaerobic organisms, including Gardnerella vaginalis (small gram-variable cocci), and a decrease in the numbers of lactobacilli. A ‘clue cell’ is seen. This is an epithelial cell covered with small bacteria so the edge of the cell is obscured. D: Trichomoniasis: an unstained ‘wet mount’ of vaginal fluid from a woman with Trichomonas vaginalis infection. There is a cone-shaped, flagellated organism in the centre, with a terminal spike and four flagella visible. In practice, the organism is identified under the microscope by movement, with amoeboid motion and its flagella waving.
Figure 9.2 Gram-stained smear of cervical secretions showing polymorths and gram-negative intracellular diplococci (×1,000). This appearance is highly suggestive of gonorrhoea.
Figure 9.3 Fitz-Hugh–Curtis syndrome showing perihepatic adhesions (typical violin string appearance).
Figure 9.4 A: Peritubal adhesions of the left Fallopian tube; B: ectopic pregnancy within hydrosalpinx; C: left Fallopian tube hydrosalpinx; D: large hydrosalpinx of the left Fallopian tube with a smaller hydrosalpinx on the right side.
Figure 9.5 Global burden of human infection. (Adapted from UNAIDS data, 2014.)
Figure 9.6 UK data from the national study of human immunodeficiency virus (HIV) in pregnancy and childhood demonstrating efficacy of maternal antiretroviral therapy (ART) in preventing mother-to-child transmission (MTCT) of HIV. (Adapted from CROI data, 2007.)

Chapter 10

Figure 10.1 Mechanism of continence. In normal women, the bladder neck is supported above the pelvic floor and so abdominal pressure increases are transmitted to the bladder neck (A). Loss of bladder neck support results in descent of the bladder neck and loss of pressure transmission, resulting in leaking when coughing, straining, etc (stress incontinence) (B). Detrusor overactivity causes increased sensation; leakage only occurs if the contraction pressure exceeds the pelvic floor and sphincter pressure (C).
Figure 10.2 An example of a bladder diary, including columns for recording fluid intake (volume and amount), voided volume, the amount of leakage and the severity of urgency.
Figure 10.3 Flowchart of patient management (based upon UK NICE guidance). (TVT, tension-free vaginal tape.)
Figure 10.4 A urodynamic investigation (cystometry) records bladder pressure and abdominal pressure (usually via a rectal pressure catheter), and calculates detrusor pressure by subtraction (A). During filling, the patient is asked to report the occurrence of first desire to void (usually about 150 ml), strong desire and urgency (at functional bladder capacity) (B). With urodynamic stress incontinence, leakage is seen with increases in abdominal pressure (e.g. coughing) with no change in detrusor pressure (B). With detrusor overactivity, detrusor contractions are seen during the filling phase (C). These may or may not result in leakage, but normally will be associated with increased sensation.
Figure 10.5 The relationship between symptoms and urodynamic diagnosis.
Figure 10.6 The position of tension-free vaginal (TVT) and transobturator (TOT) midurethral tapes. The TVT lies under the midurethra and in the retropubic space between the pelvis and bladder. The introducing trocars pass through the urogenital diaphragm and the rectus sheath. The TOT lies in a more horizontal position under the midurethra and exits through the obturator foramen, piercing the obturator muscle and the adductor longus tendon in the thigh.
Figure 10.7 A sketch of a colposuspension through a Pfannenstiel incision. The patient’s head is at the bottom of the picture, and interrupted sutures are being placed in the paravaginal fascia at the level of the bladder neck through the pectineal ligament on the posterior surface of the superior pubic ramus.
Figure 10.8 Cystoscope images showing an open bladder neck (A) before injection and a closed bladder neck after injection (B).
Figure 10.9 Fascial supports of the pelvic organs. Level 1 support is provided by the uterosacral ligaments, suspending the uterus and attached vaginal vault. Level 2 (midvagina) support is provided by the fascia lying between the vagina and the bladder or rectum that fuses laterally and runs to attach on the pelvic side wall. Level 3 support is provided by the perineal body, which has the posterior vaginal fascia fused to its upper surface.
Figure 10.10 Development of prolapse. The pelvic floor and ligaments work together to provide support against increases in abdominal pressure (A). Prolapse is almost invariably associated with perineal body damage causing an enlarged vaginal opening. Prolapse can then occur if the apical (level 1) support is lost (B), or if the pelvic floor muscles are ineffective (C) or directly as a result of perineal body deficiency (D). Often, a combination of factors is at work.
Figure 10.10 Development of prolapse. The pelvic floor and ligaments work together to provide support against increases in abdominal pressure (A). Prolapse is almost invariably associated with perineal body damage causing an enlarged vaginal opening. Prolapse can then occur if the apical (level 1) support is lost (B), or if the pelvic floor muscles are ineffective (C) or directly as a result of perineal body deficiency (D). Often, a combination of factors is at work.
Figure 10.11 Vaginal support pessaries.

Chapter 11

Figure 11.1 Transvaginal ultrasound scan. A: Simple ovarian cyst; B: corpus luteum cyst; C: dermoid cyst.
Figure 11.2 Torsion of a dermoid cyst at laparotomy.
Figure 11.3 Laparoscopic view of endometriosis. A: Red lesions on peritoneum; B: black ‘matchstick’ lesions; C: white fibrous lesion.

Chapter 12

Figure 12.1 Benign changes in the cervix. A: Cervical ectropion; B: nabothian follicle; C: cervical polyp.
Figure 12.2 A hysteroscopic view of an endometrial polyp.
Figure 12.3 Diagram showing the typical sites of uterine fibroids.
Figure 12.4 Pedunculated, subserosal fibroid on a hysterectomy specimen.
Figure 12.5 Magnetic resonance imaging of an enlarged fibroid uterus.
Figure 12.6 MRI showing adenomyosis – note the bright reflections of the central endometrium and flecks of ectopic endometrium in the underlying myometrium.

Chapter 13

Figure 13.1 Keyes punch biopsy.
Figure 13.2 Lichen sclerosus.
Figure 13.3 Bartholin’s cyst.
Figure 13.4 Types of female genital mutilation.
Figure 13.5 Geographical distribution of female genital mutilation. (Adapted from UNICEF 2013 data.)

Chapter 14

Figure 14.1 Advanced ovarian cancer illustrating diaphragmatic peritoneal disease.

Chapter 15

Figure 15.1 Histological comparison of endometrial adenocarcinoma (A) with endometrial serous carcinoma (B).
Figure 15.2 Transvaginal ultrasound scan of the uterus showing thickened endometrium.
Figure 15.3 Hysteroscopic picture of endometrial carcinoma.
Figure 15.4 Magnetic resonance imaging of stage 1B endometrial carcinoma.
Figure 15.5 Radical hysterectomy showing cervical invasion of endometrial cancer.

Chapter 16

Figure 16.1 Normal cervix with transformation zone.
Figure 16.2 Normal cervix with nabothian follicle.
Figure 16.3 Liquid-based cytology – normal cytology.
Figure 16.4 Liquid-based cytology – severe dyskaryosis.
Figure 16.5 Colposcope.
Figure 16.6 Cervix with acetic acid.
Figure 16.7 Cervix with cervical intraepithelial neoplasia and new vessels.
Figure 16.8 Large loop excision of transformation zone.
Figure 16.9 Cervical cancer.
Figure 16.10 Linear accelerator.
Figure 16.11 Vulval cancer.

Chapter 17

Figure 17.1 Incisions used in gynaecological surgery.
Figure 17.2 WHO surgical safety check list. (Adapted from WHO, 2009.)
Figure 17.3 Flexible fibreoptic hysteroscope.
Figure 17.4 View of endometrial cavity demonstrating Asherman’s adhesions.
Figure 17.5 Schematic diagram showing laparoscope.
Figure 17.6 Laparoscopic view of bilateral endometriomas.
Figure 17.7 Laproscopic view showing Filshie clip on the right Fallopian tube.
Figure 17.8 Diagram showing the cystoscopic procedure.
Figure 17.9 Cystoscopic view of bladder papilloma.