Archive for the ‘Gynocology’ Category

ch. 18 PAP Test

Posted: April 8, 2013 in Gynocology

The Papanicolaou test (also called Pap smear, Pap test, cervical smear, or smear test) is a screening test used to detect potentially pre-cancerous and cancerous processes in the endocervical canal (transformation zone) of the female reproductive system.

Pap test

Pap test

Pap test

Pap test


Types of PAP Test :

  1. Conventional Pap—In a conventional Pap smear, samples are smeared directly onto a microscope slide after collection.
  2. Liquid based cytology—The Pap smear sample is put in a bottle of preservative for transport to the laboratory, where it is then smeared on the slide.

The patient may also be referred for HPV DNA testing, which can serve as an adjunct to Pap testing.

Summary of pap test indications
woman’s characteristic indication rationale
never had sexual contact no test HPV usually transmitted by sexual contact
under age 21, regardless of sexual history no test more harms than benefits
age 20–25 until age 50–60 test every 3–5 years if results normal broad recommendation
over age 65; history of normal tests no further testing recommendation of USPSTFACOG,ACS and ASCP;
had total hysterectomy for non-cancer disease – cervixremoved no further testing harms of screening after hysterectomy outweigh the benefits
had partial hysterectomy – cervix remains continue testing as normal  
has received HPV vaccine continue testing as normal vaccine does not cover all cancer-causing types of HPV
post-operative transgender woman no test the neo-vagina does not contain a cervix and cannot be evaluated with a pap smear



ch. 17 Leopold’s maneuvers

Posted: April 2, 2013 in Gynocology

Maternal abdominal examination of the fetus by Leopold’s maneuvers is a common and systematic way to determine the position of a fetus inside the woman’s uterus.

• The lie is the relationship between the longitudinal axis of fetus and mother: longitudinal, oblique, and transverse.


Presentation is the relationship between the leading fetal part and the pelvic inlet: cephalic, or breech. The presenting part may be the fetal heard or the breech. Ordinarily, the head is flexed sharply so that the chin is in contact with the thorax. In this circumstance, the occipital fortanel is the presenting part, and such a presentation is usually referred to as a vertex or occiput presentation.

Position is the relationship between definite part of the fetus (back) to the right or left side of maternal pelvis. With each presentation there may be two position: right (II-second) or left (I-first). About two thirds of all vertex presentations are in the left occiput position and the one third in the right.

Fetus Back Presentations Examples. Step 1 (Right) Step 2 (Left)

Fetus Back Presentations Examples. Step 1 (Right) Step 2 (Left)

Variety is the relation of the back of fetus to the anterior and or posterior side of the mother’s pelvis. There may be two variety anterior or posterior. 
Engagement – the fetal is engaged if the widest leading part (typically the widest circumference of the head) is negotiating the inlet. 
With the mother lying comfortably on her back, the examiner faces the patient for the first 3 steps, and faces towards her feet for the fourth.


1. FIRST maneuver. Having established the height of the fundus, the fundus itself is gently palpated with the fingers of both hands, in order to discover which pole of the fetus (breech or head) is present. The head feels hard and round, and is easily movable and ballotable. The breech feels soft, triangular and continuous with the body. A professional can also determine the level of the uterine fundal height (but not in cm, on the levels; on the level of umbilicus, ribs, xiphoid process).

2. SECOND maneuver. The palms hands are now placed on the sides of the abdomen. On one side there is the smooth, firm curve of the back of the fetus, and on the other side are fetal extremities (arms, legs) that are felt like small irregularities and protrusions. It is often difficult to feel the fetus well when the patient is obese, when there is a lot of liquor or when the uterus is tight, as in some primigravidas.

3. THIRD maneuver. The examiner grasps the lower portion of the abdomen, just above the symphysis pubis, between the thumb and fingers of one hand. The objective is to feel for the presenting part of the fetus and to decide whether the presenting part is loose above the pelvis or fixed in the pelvis. If the head is loose above the pelvis, it can be easily moved and balloted. The head and breech are differentiated in the same way as in the first step.

4. FOURTH maneuver. The objective of the step is to determine the amount of head palpable above the pelvic brim, if there is a cephalic presentation. The examiner faces the patient’s feet, and with the tips of the middle 3 fingers palpates deeply in the pelvic inlet. In this way the head can usually be readily palpated, unless it is already deeply in the pelvis. The amount of the head palpable above the pelvic brim can also be determined.

ch 16. Gynocological Cancers

Posted: May 19, 2012 in Gynocology

Gynecologic cancer is a group of cancers that affect the tissue and organs of the female reproductive system. Each type of cancer is named after the organ it originates.

Types of gynecologic cancer include:

  1. Cervical
  2. Endometrial
  3. Fallopian Tube
  4. Gestational Trophoblastic Disease
  5. Ovarian
  6. Vulvar
  7. Vaginal

Cervical Cancer :

Cervical cancer is cancer that starts in the cervix, the lower part of the uterus (womb) that opens at the top of the vagina. It’s 12% of  all gynecologic cancers.

  •  Mean age is 47.
  •  20% of cases in women >65yrs
  •  10% of cases in women >75yrs

Types :

  1.       Squamous Cell      85-90%
  2.       Adenocarcinoma   10-15%
  3.       Numerous others   <5%

Etiology :

The primary risk factor for developing cervical cancer is the human papillomavirus (HPV). HPV is a common sexually transmitted infection that is spread through sexual, skin-to-skin contact. The virus can cause changes in cervical cells that could develop into cervical cancer if left undetected, unmonitored, or untreated.

Cervical human papillomavirus (HPV) : HPVs establish productive infections only in keratinocytes of the skin or mucous membranes. While the majority of the known types of HPV cause no symptoms in most people, some types can cause warts (verrucae), while others can – in a minority of cases – lead to cancers of the cervix, vulva, vagina, penis, oropharynx and anus.

  • 80% of sexually active women will acquire HPV.
  • 70% of infections are gone in 1 year and ninety percent in 2 years.
  • However, when the infection persists — in 5% to 10% of infected women — there is high risk of developing precancerous lesions of the cervix, which can progress to invasive cervical cancer.

    HPV With HIV(+) Female Patient.

Human Papillovirus

Cervical Cancer Stages

Endometrial Cancer :

Syn : Endometrial adenocarcinoma; Uterine adenocarcinoma; Uterine cancer; Adenocarcinoma – endometrium; Adenocarcinoma – uterus; Cancer – uterine; Cancer – endometrial; Uterine corpus cancer .

Most common Gynocological Cancer.Endometrial cancer is cancer that starts in the endometrium, the lining of the uterus (womb).Mean age is 61 yrs.

Types :

Endometrial Carcinoma : Most endometrial cancers are carcinomas (usually adenocarcinomas), meaning that they originate from the single layer of epithelial cells that line the endometrium and form the endometrial glands.There are many microscopic subtypes of endometrial carcinoma.

  1. Endometrioid type (most common)
  2. Papillary serous carcinoma (more aggressive)
  3. Clear cell endometrial carcinomas (aggressive and high recurence rate

Endometrial Sarcoma : In contrast to endometrial carcinomas, the uncommon endometrial stromal sarcomas are cancers that originate in the non-glandular connective tissue of the endometrium. Uterine carcinosarcoma, formerly called Malignant mixed müllerian tumor, is a rare uterine cancer that contains cancerous cells of both glandular and sarcomatous appearance – in this case, the cell of origin is unknown.

Fallopian tube cancer :

Primary fallopian tube cancer (PFTC), often just tubal cancer, is a malignant neoplasm that originates from the fallopian tube.ubal cancer is thought to be a relatively rare primary cancer among women accounting for 1 – 2% of all Gynocological Cancers.

Diagnosis : A pelvic examination may detect an adnexal mass. A CA-125 blood test is a nonspecific test that tends to be elevated in patients with tubal cancer. More specific tests are a gynecologic ultrasound examination, a CT scan, or an MRI of the pelvis. Occasionally, an early fallopian tube cancer may be detected serendipitously during pelvic surgery.

Gestational trophoblastic disease (GTD) :

Gestational trophoblastic disease (GTD) is a term used for a group of pregnancy-related tumours.The cells that form gestational trophoblastic tumours are called trophoblasts and come from tissue that grows to form the placenta during pregnancy.

Features :

  1. This tissue may grow at the same rate as a normal pregnancy.
  2. Can produces chorionic gonadotropin, a hormone which is measured to monitor fetal well-being.
  3. Common in child-bearing age, it may rarely occur in postmenopausal women.

The main types of gestational trophoblastic diseases are:

  • Hydatidiform mole ( Benign)
  • Invasive mole (Malignant)
  • Choriocarcinoma (Malignant)
  • Placental-site trophoblastic tumor (Malignant)

Hadatidiform Mole : Hydatidiform mole is an overgrowth of placental tissue or an abnormal growth that develops from a non-viable, fertilized egg at the beginning of a pregnancy. It often is referred to as a molar pregnancy. Instead of the normal embryonic cell division that results in the development of a fetus, the placental material grows uncontrolled and develops into a shapeless mass of watery, small, blister-like sacs (vesicles). The cause of hydatidiform mole is unknown, but is thought to be caused in part by chromosomal abnormalities .

Invasive mole : An invasive mole (formerly known as chorioadenoma destruens) is a hydatidiform mole that has grown into the muscle layer of the uterus. Invasive moles can develop from either complete or partial moles, but complete moles become invasive much more often than do partial moles.

Choriocarcinoma : Choriocarcinoma is a malignant form of GTD. It is much more likely than other types of GTD to grow quickly and spread to organs away from the uterus.Choriocarcinoma most often develops from a complete hydatidiform mole.


Placental-site trophoblastic tumor :

Placental-site trophoblastic tumor (PSTT) is a very rare form of GTD that develops where the placenta attaches to the lining of the uterus. This tumor most often develops after a normal pregnancy or abortion, but it may also develop after a complete or partial mole is removed.

Ovarian Cancer :

Ovarian cancer

Ovarian cancer is cancer that starts in the ovaries. The ovaries are the female reproductive organs that produce eggs.Ovarian cancer affects females of any ages.Cancer should be suspected in any woman between 40 and 80 with persistent gastrointestinal symptoms cannot be diagnosed.Diagnosis is difficult.  70% of diagnoses are stage III or IV.

Types :

  1.       Epithelial—About 85-90% (>50 yrs)
  2.       Germ cell—10-15%  (<20yrs)
  3.       Gonadal stroma—5-10%
  4.       Mesenchymal

Symptoms :

Ovarian cancer symptoms are often vague.

Woman should see herr doctor if she has the following symptoms on a daily basis for more than a few weeks:

  1. Bloating or swollen belly area
  2. Difficulty eating or feeling full quickly
  3. Pelvic or lower abdominal pain; the area may feel “heavy” to you (pelvic heaviness)

Other symptoms are also seen with ovarian cancer. However, these symptoms are also common in women who do not have cancer:

  1. Abnormal menstrual cycles
  2. Digestive symptoms:
  3. Constipation
  4. Increased gas
  5. Indigestion
  6. Lack of appetite
  7. Nausea and vomiting
  8. Unexplained back pain that worsens over time
  9. Vaginal bleeding that occurs in between periods
  10. Weight gain or loss
  11. Other symptoms that can occur with this disease:
  12. Excessive hair growth that is coarse and dark
  13. Sudden urge to urinate
  14. Needing to urinate more often than usual

Vaginal cancer :

Vaginal cancer is any type of cancer that forms in the tissues of the vagina. Primary vaginal cancer is rare in the general population of women and is usually a squamous carcinoma. Metastases are more common.

Feature :

  1. Common at +50 Years
  2. Can affects at any age ,even in Infancy.
  3. 5 – 10% of patients have no symptoms.

Types :

  1. Squamous cell carcinoma (Vaginal squamous cell carcinoma arises from the thin, flat squamous cells that line the vagina. This is the most common type of vaginal cancer. It is found most often in women aged 60 or older.)

Adenocarcinoma (aginal adenocarcinoma arises from the glandular (secretory) cells in the lining of the vagina that produce some vaginal fluids. Adenocarcinoma is more likely than squamous cell cancer to spread to the lungs and lymph nodes. It is found most often in women aged 30 or younger.)

Vaginal Cancer

Vulvar cancer :

Vulvar cancer is a rare type of cancer. It forms in a woman’s external genitals, called the vulva. The cancer usually develops slowly over several years. First, precancerous cells grow on vulvar skin. This is called vulvar intraepithelial neoplasia (VIN), or dysplasia. Not all VIN cases turn into cancer, but it is best to treat it early.

Often, vulvar cancer doesn’t cause early symptoms. However, see your doctor for testing if you notice

  • A lump in the vulva
  • Vulvar itching or tenderness
  • Bleeding that is not your period

Being older and having a human papillomavirus infection are risk factors for vulvar cancer. Treatment varies, depending on your overall health and how advanced the cancer is. It might include laser therapy, surgery, radiation or chemotherapy.

Types :

  1. Squamous cell carcinoma.
  2. Melanoma
  3. Basal cell carcinoma
  4.  Adenocarcinoma
  5.  Sarcoma.

Patient with vulvar cancer after 4 weeks ( A) and 6 weeks ( B) of chemoradiation.

ch 15. Uterine fibroids

Posted: May 17, 2012 in Gynocology

Uterine fibroids ;Leiomyoma ; Fibromyoma ; Myoma ; Fibroids :  A leiomyoma  is a benign smooth muscle neoplasm that is very rarely (0.1%) premalignant. They can occur in any organ, but the most common forms occur in the uterus, small bowel and the esophagus.

Etiology :

  1. Etiology is unknown.
  2. Originates from Single Muscle Cell (Could be Embryonic Cells or Sooth Muscle Cell from blood vessels)
  3. Estogens : no evidence that it is a causative factor , it has been implicated in growth of myomas
  4. Myoma contains estrogen receptors in higher concentration than surrounding myometrium,so Estrogen helps Myoma to be enlarged.
  5. Progestrone helps Myoma for further cell division (Mitosis).
Features :
  1. Occurring frequently at 50 yr. and very rare before 20 yr.
  2. 25% in white women
  3. 50% in black women

Types: They are classified by anatomic locations. Most frequently,

  1. Subserous (beneath the peritoneum)
  2. Intramural (within the uterine wall)
  3. Submucous (beneath the endometrium)

a = Subserosal fibroids
b = Intramural fibroids
c = Submucosal fibroid
d = Pedunculated submucosal fibroid
e = Fibroid in statu nascendi

Microscopic Stracture of Myoma :

  1.  Nonstriated muscle fibers are localized  in different directions
  2. Pseudocapsule of areolar tissue (a type of loose connective tissue esp. made of collagens) & compressed myometrium
  3. Arteries are less dense than myometrium & do not have a regular pattern of distribution
  4. 1-2 major vesseles are found at the base or pedicle

Symptoms :

Depends on size and location

■Asymptomatic – small (and some large ones) – detected on routine examination

■Menorrhagia – if submucous. May lead to anaemia, with symptoms associated with this.

■Crampy pains may result from contraction of the uterus.

■Pressure symptoms from large fibroids

  • Dysuria
  • Constipation or backache
  • Pelvic pain and sometimes, impossible intercourse from cervical myoma
  • Subfertility and Recurrent miscarriage from submucous fibroids

Differential Diagnosis : Exclude other causes of abnormal bleeding

  1. Endometrial hyperplasia
  2. Endometrial or tubal Cancer
  3. Uterine sarcoma
  4. Ovarian Cancer
  5. Polyps
  6. Adenomyosis
  7. DUB (Dysfunctional Uterine Bleeding)
  8. Endometriosis
Exogenouse estrogens Endometrial biopsy or D&C is essential in the evaluation of abnormal bleeding to exclude endometrial Cancer
Complications :
For Pregnant Women :
  1. Uterine inertia
  2. Malpresentation
  3. Obstruction of the birth canal
  4. Cervical or isthmeic myoma
  5. Postpartum Hemorrhage

For Non-Pregnant Women :

  1. Heavy bleeding with anemia is the most common
  2. Urinary or bowel obstruction from large parasitic myoma is much less common
  3. Malignant transformation is rare
  4. Ureteral injury or ligation is a recognized complication of surgery for Cervical  Myoma
Treatments :

Treatment for the symptoms of fibroids may include:

  1. Birth control pills (oral contraceptives) to help control heavy periods
  2. Intrauterine devices (IUDs) that release the hormone progestin to help reduce heavy bleeding and pain
  3. Iron supplements to prevent or treat anemia due to heavy periods
  4. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naprosyn for cramps or pain
  5. Short-term hormonal therapy injections to help shrink the fibroids

Surgery and procedures used to treat fibroids include:

  1. Hysteroscopic resection of fibroids: Women who have fibroids growing inside the uterine cavity may need this outpatient procedure to remove the fibroid tumors.
  2. Uterine artery embolization: This procedure stops the blood supply to the fibroid, causing it to die and shrink. Women who may want to become pregnant in the future should discuss this procedure with their health care provider.
  3. Myomectomy: This surgery removes the fibroids. It is often the chosen treatment for women who want to have children, because it usually can preserve fertility. More fibroids can develop after a myomectomy.
  4. Hysterectomy: This invasive surgery may be an option if medicines do not work and other surgeries and procedures are not an option.

ch 14. Endometriosis

Posted: May 17, 2012 in Gynocology
  • Every month, a woman’s ovaries produce hormones that tell the cells lining the uterus (womb) to swell and get thicker. The body removes these extra cells from the womb lining (endometrium) when she gets her period.
  • If these cells (called endometrial cells) implant and grow outside the uterus, endometriosis results.Women with endometriosis typically have tissue implants on the ovaries, bowel, rectum, bladder, lining of the pelvic area and other Ectopic Locations.

Etiology :

  1. The cause of endometriosis is unknown.
  2. Retrograde menstruation :One theory is that the endometrial cells shed when you get your period travel backwards through the fallopian tubes into the pelvis, where they implant and grow. This is called .
  3. Aging : Endometriosis is typically diagnosed between ages 25 – 35, the condition probably begins about the time that regular menstruation begins.
  4. Genetics : Changes in Chromosome 10 can create Endometriosis.Any past family history of Endometriosis.
  5. Biomarkers : The one biomarker that has been used in clinical practice over the last 20 years is CA-125. However, its performance in diagnosing endometriosis is low, even though it shows some promise in detecting more severe disease.

    Retrigrade Menstuation

    Can for Endometrial Cyst or Chocolate cyst as a further complication.

Stages of Endometriosis :

Stage 1 (Minimal): Just a few endometrial implant; mostly found in the cul-de-sac and pelvic area.
Stage 2 (Mild): Moderate levels of endometriosis to mild levels that not only affect the above areas but can now affect the ovaries.
Stage 3 (Moderate): Moderate amount of disease and in extensive places around the pelvic cavity, with adhesions.
Stage 4 (Severe) : Extensive endomtrial implants sprinkled all throughout the pelvic cavity with adhesions; higher probability of infertility.

Symptoms :

  1. Dysmenorrhea – painful, sometimes disabling cramps during menses; pain may get worse over time (progressive pain), also lower back pains linked to the pelvis
  2. Chronic pelvic pain – typically accompanied by lower back pain or abdominal pain
  3. Dyspareunia – painful sex
  4. Dysuria – urinary urgency, frequency, and sometimes painful voiding

Diagnosis :

  1. Laparoscopy:  A surgical procedure where a camera is used to look inside the abdominal cavity
  2. Ultrasound and magnetic resonance imaging (MRI) : Use of imaging tests may identify endometriotic cysts or larger endometriotic areas. It also may identify free fluid often within the Recto-uterine pouch.
  3.  Biopsy : The diagnosis is based if Endometrium like tissues can be found on ectopic Locations.

ch. 13 Infertility

Posted: May 17, 2012 in Gynocology

Infertility means She/He cannot make a baby (conceive).

Types :

  • Primary infertility refers to couples who have not become pregnant after at least 1 year of unprotected sex (intercourse).
  • Secondary infertility refers to couples who have been pregnant at least once, but never again.
Requirements for Normal Reproduction :
1)Release of a normal preovulatory oocyte.
2)Production of adequate spermatozoa.
3)Normal transport of the gametes to the ampullary portion of the fallopian tube (where fertilization occurs).
4)Subsequent transport of the cleaving embryo into the endometrial cavity for implantation and development.

Etiology :

Female infertility :

  1. A fertilized egg or embryo does not survive once it sticks to the lining of the womb (uterus)
  2. The fertilized egg does not attach to the lining of the uterus
  3. The eggs cannot move from the ovaries to the womb
  4. The ovaries have problems producing eggs

Female infertility may be caused by:

  1. Autoimmune disorders, such as antiphospholipid syndrome (APS)
  2. Cancer or tumor
  3. Clotting disorders
  4. Diabetes
  5. Growths (such as fibroids or polyps) in the uterus and cervix
  6. Birth defects that affect the reproductive tract
  7. Excessive exercising
  8. Eating disorders or poor nutrition
  9. Use of certain medications, including chemotherapy drugs
  10. Drinking too much alcohol
  11. Obesity
  12. Older age
  13. Ovarian cysts and polycystic ovary syndrome (PCOS)
  14. Pelvic infection or pelvic inflammatory disease (PID)
  15. Scarring from sexually transmitted infection or endometriosis
  16. Thyroid disease
  17. Too little or too much hormones
Male infertility :
  1. A decrease in sperm count
  2. Sperm being blocked from being released
  3. Sperm that do not work properly

Male infertility can be caused by:

  1. Environmental pollutants
  2. Being in high heat for prolonged periods
  3. Birth defects
  4. Heavy use of alcohol, marijuana, or cocaine
  5. Too little or too much hormones
  6. Impotence
  7. Infection
  8. Older age
  9. Cancer treatments, including chemotherapy and radiation
  10. Scarring from sexually transmitted diseases, injury, or surgery
  11. Retrograde ejaculation
  12. Smoking
  13. Use of certain drugs, such as cimetidine, spironolactone, and nitrofurantoin

 Tests for diagnosis Female Infertility :

  1. Transvaginal Ultrasonography (TVUS)
  2. Hysterosalpingography (HSG)
  3. Hysteroscopy
  4. Laparoscopy
  5. History of Past Diseases

Tests for diagnosis Male Infertility :

  1. Scrotal Ultrasonography
  2. Transrectal Ultrasonography (TRUS)
  3. Complete Blood Count (CBC)
  4. FSH, Testosterone
  5. GC/Chlam, UA
  6. Renal and Liver Function
  7. Semen analysis
  8. Postejaculatory urinalysis
  9. Past sexually transmitted infection (STI).
  10. Varicocele  (widening of the Varicose veins along the cord that holds up a man’s testicles)
  11. Hernia
  12. History of Past Diseases

Infertility Treatment :

  • Treatment of infertility depends on the cause, diagnosis, duration of infertility, age of the partners and many personal preferences.
  • Some causes of infertility cannot be corrected.
  • A woman can still become pregnant with assisted reproductive technology or other procedures to restore fertility.
Increase frequency of intercourse: Two to three times a week of intercourse may improve fertility.

Sperm survive in the female reproductive tract for up to 72 hours, and an egg can be fertilized for up to 24 hours after ovulation.

General sexual problems:  Addressing impotence or premature ejaculation can improve fertility.
Treatment for these problems often is with medication or behavioral approaches.

 Lack of sperm: surgery or hormones to correct the problem or use of assisted reproductive technology is sometimes possible.

Varicocele can often be surgically corrected.

Stimulating ovulation with fertility drugs: Fertility drugs are the main treatment for women who are infertile due to ovulation disorders.These medications regulate or induce ovulation, and work like natural hormones to trigger ovulation such as: Follicle-stimulating hormone (FSH) and Luteinizing hormone (LH).

Commonly used fertility drugs include:

  1.  Clomiphene citrate
  2. Human menopausal gonadotropin, or hMG (Repronex)
  3. Follicle-stimulating hormone, or FSH (Gonal-F, Follistim, Bravelle)
  4. Human chorionic gonadotropin, or HCG (Ovidrel, Pregnyl)
  5. Gonadotropin-releasing hormone (Gn-RH) analogs
  6. Letrozole (Femara)
In Vitro Fertilization
Normal Menses : 
  • Flow lasts 2-7 days
  • Cycle 21-35 days in length
  • Total menstrual blood loss 20-60 mL
Other Causes of Vaginal Bleeding :
  1. Pregnancy related causes
  2. Medications
  3. Anatomic causes
  4. Infectious disease
  5. Endocrine abnormalities: Thyroid, DM
  6. Bleeding disorders
  7. Endometrial hyperplasia
  8. Neoplasms

Descriptive Term

Bleeding pattern

Menorrhagia Regular cycles, prolonged duration, excessive flow
Metrorrhagia Irregular cycles
Menometorrhagia Irregular, prolonged, excessive
Hypermenorrhea Regular, normal duration, excessive flow
Polymenorrhea Frequent cycles
Oligomenorrhea Infrequent cycles