Гинекология = Gynecology

Л.В. Гутикова
М.А. Павловская
Ю.В. Кухарчик

МИНСК
«ВЫШЭЙШАЯ ШКОЛА»
2022

Допущено
Министерством образования
Республики Беларусь
в качестве учебного пособия
для  иностранных студентов
учреждений высшего образования
по специальности «Лечебное дело»

Approved
by the Ministry of Education
of the Republic of Belarus
as a textbook
for foreign students 
of higher education institutions
in the specialty “General Medicine”

L.V. Gutikova
М.А. Pavlovskaya
Y.V. Кukharchyk
GYNECOLOGY

ГИНЕКОЛОГИЯ

УДК 618.1(075.8)-054.6
ББК 57.1я73
 
Г97

Р е ц е н з е н т ы: кафедра акушерства и гинекологии с курсом ФПКиП 
УО «Гомельский государственный медицинский университет» (доцент кафедры 
кандидат медицинских наук, доцент И.А. Корбут; заведующий кафедрой кандидат 
медицинских наук, доцент Т.Н. Захаренкова); доцент кафедры акушерства и гинекологии 
ГУО «Белорусская медицинская академия последипломного об разования» 
кандидат медицинских наук, доцент Л.М. Небышинец; доцент кафедры современных 
технологий перевода УО «Минский государственный лингвистический университет» 
кандидат филологических наук, доцент Т.И. Голикова

Гутикова, Л. В.
Гинекология = Gynecology : учебное пособие / Л.В. Гутико-
ва, М.А. Павловская, Ю.В. Кухарчик. – Минск : Вышэйшая 
школа, 2022. – 368 с. : ил.
ISBN 978-985-06-3414-6.

В пособии отражены наиболее актуальные вопросы гинекологии, представлены 
современные данные о причинах развития, способах диагностики, 
клинических проявлениях заболеваний и алгоритме лечебных и профилактических 
мероприятий. 
Отдельные главы посвящены современным методам обследования в 
гинекологии, менструальному циклу и его нарушениям, воспалительным 
заболеваниям женских половых органов, нейроэндокринным синдромам, 
врожденным аномалиям развития половых органов, планированию семьи и 
контрацепции, бесплодному браку, неотложным состояниям в гинекологии 
и типичным гинекологическим операциям.
Для иностранных студентов медицинских специальностей, практикующих 
врачей, преподавателей учреждений образования.

УДК 618.1(075.8)-054.6
ББК 57.1я73

The presented textbook includes 11 chapters that reflect the most current issues 
of gynecology, present modern data on the causes of development, diagnostic 
methods, clinical manifestations and the algorithm of treatment and preventive 
measures.

Все права на данное издание защищены. Воспроизведение всей книги или любой ее части 
не может быть осуществлено без разрешения издательства.

ISBN 978-985-06-3414-6 
  Гутикова Л.В., Павловская М.А., 
Кухарчик Ю.В., 2022
 
  Оформление. УП «Издательство 
“Вышэйшая школа”», 2022

Г97

LIST OF ABBREVIATIONS

17-КS – 17-ketosteroids
17-ОP – 17-oxyprogesterone
17-ОКS – 17-oxyketosteroids
17-ОНР – 17-hydroxyprogesterone
А4 – androstenedione
ACTH – adrenocorticotropic hormone
ADS – adrenogenital syndrome
AH – arterial hypertension
AUB – abnormal uterine bleeding
BMI – body mass index
BV – bacterial vaginosis
СA-125 – carbohydrate antigen 125
Са – calcium
CDAC – congenital dysfunction of the adrenal cortex
CFU – colony-forming units
CGT – chorionic gonadotropin
CMI – cytomegalovirus infection
COC – combined oral contraceptives
COG – cyclooxygenase
CS – climacteric syndrome
DHEA – dihydroepiandosterone
DHEA-S – dihydroepiandosterone sulfate 
DHT – dihydrotestosterone
DM – diabetes mellitus
DOT – directly observed therapy
Е1 – estriol
Е2 – estradiol
EEG – electroencephalography
FFA – free fatty acids
FSH – follicle-stimulating hormone
GC – glucocorticoids
GH – genital herpes
GI – hyperinsulinemia
GnRH – gonadotropin-releasing hormone
HA – hyperandrogenism
НЕ-4 – human epididymis protein 4

HDLP – high density lipoproteins
HLA-complex – human leukokyte antigens (human tissue com-
patibility gene system)
HPV – human papillomavirus
HSV – herpes simplex virus
IFN – interferon
IgG – immunoglobulins class G
IgM – immunoglobulins class М
IGF – insulin-like growth factor
ILP – insufficiency of the luteal phase
IR – insulin resistance
IUC – intrauterine contraceptive
К – potassium
KPI – karyopyknotic index
LH – luteinizing hormone
MC – mineralocorticoids
MRI – magnetic resonance imaging
MS – metabolic syndrome
NAID – non-steroidal anti-inflammatory drugs
PCOS – polycystic ovary syndrome
PCR – polymerase chain reaction
PVI – papillomavirus infection
REG – rheoencephalography
ROS – resistant ovary syndrome
SDC – separate diagnostic curettage of the uterus
SSBG – sex steroid binding globulin
SSG – sex steroid binding globulin
STH – somatotropic hormone
STI – sexually transmitted infections
Т – testosterone
Т3 – triiodothyronine
Т4 – thyroxine
TG – triglycerides
TNF-α – tumor necrosis factor α
TSH – thyroid-stimulating hormone
UAE – uterine artery embolization
UF – uterine fibroids
UGC – urogenital chlamydia
US – ultrasound
VFM – violation of fat metabolism
VVC – vulvovaginal candidiasis

FOREWORD

Gynecology (from Latin “gyne” – woman, “logos” – science) is 
the science of the physiology and pathology of the female reproductive 
system, the state and activity of the female genital organs in normal 
and pathological conditions, biological functions inherent in women, 
excluding childbirth. Historically, gynecology is one of the oldest med-
ical sciences. The first known historical literary sources are the Egyp-
tian papyri (“gynecological papyrus”) from Kahun, dated to the 3rd 
century BC. The well-known works of the founder of medicine Hip-
pocrates (460–377 BC) are: “On the nature of women”, “On female 
diseases”, “On infertility”. Many scientists contributed to the devel-
opment of gynecological science: Filumenos (1st century BC), Aulus 
Cornelius Celsus (1st century AD), Soranus of Ephesus (1st century 
AD), Avicenna (980–1037), Paracelsus (1493–1541), Fallopius (1532–
1562), Ambroise Paré (1517–1590). The first major Russian scientist 
obstetrician and gynecologist was Professor N.М. Maksimovich- 
Ambodik (1744–1812), “Medicine doctor of Midwifery”. Modern gy-
necology relies on advances in the study of anatomy, histology, phy-
siology, biochemistry of the body and the reproductive system in par-
ticular. To the collection of anamnesis and examination of patients, 
modern biochemical, microbiological and histological studies were 
added, as well as non-invasive imaging methods: X-ray, ultrasound, 
computed and magnetic resonance imaging.
The study of gynecology at a medical university is aimed at the 
formation of relevant professional competencies – the ability and 
readi ness to form a systematic approach to the analysis of medical in-
formation, based on the comprehensive principles of evidence-based 
medicine, finding solutions using theoretical knowledge and practical 
skills in order to improve professional activity.
The teaching aid sets out classical concepts, supplemented by 
modern approaches and recommendations in accordance with the 
Clinical Protocol “Medical observation and medical care for women 
in obstetrics and gynecology”: decree of the Ministry of Health of the 
Republic of Belarus dated 19.02.2018 №17.
The presented textbook is written in accordance with the current 
program and curriculum for training students of the Faculty of foreign 
students (specialty “General Medicine”).

CHAPTER   1 

METHODS OF RESEARCH  
IN GYNECOLOGY

1.1. CLINICAL DIAGNOSTIC METHODS

At the first stage of the patient’s examination, a correctly collect-
ed anamnesis reveals the characteristic symptoms of the disease. An-
amnesis data are the basis for prescribing additional special research 
methods and making a preliminary diagnosis. Only on the basis of 
summarizing the results of clinical, laboratory and instrumental re-
search methods, a clinician can correctly make a diagnosis and devel-
op an adequate treatment tactics.
The scheme for collecting anamnesis of gynecological patients:
•• main complaints;
•• additional complaints;
•• past illnesses;
•• menstrual and reproductive functions, contraception;
•• gynecological diseases and operations on the genitals;
•• family history;
•• lifestyle, nutrition, bad habits, working and living conditions;
•• history of present illness.
On examination, the body type is determined:
•• female;
•• male (tall, broad shoulders, long torso, narrow pelvis);
•• eunuchoid (tall, narrow shoulders, narrow pelvis, long legs, 
short torso).
Significant body type deviations give an idea of the characteristics 
of puberty. So, with hyperandrogenism in puberty, a male or viril type 
of physique is formed, and with insufficient hormonal function of the 
ovaries, the physique acquires eunuchoid features. Phenotypic features: 
dysplasias and dysmorphias (micro- and retrognathia, arched palate, 
wide flat nose, low auricles, short stature, short neck with skin folds, 
barrel chest, etc.), characteristic of various clinical forms of develop-
mental disorders sex glands.
Hair growth and condition of the skin: excessive hair growth, skin 
condition (increased greasiness, acne, folliculitis, increased porosity), 
stretch stripes, their color, number and location.

The condition of the mammary glands: size, hypoplasia, hyper-
trophy, symmetry, changes in the skin. In a woman, in a standing and 
lying position, sequential palpation of the outer and inner quadrants 
of the gland is performed. It is necessary to note the absence or pre-
sence of the discharge from the nipples, its color, consistency and na-
ture. Brown discharge from the nipples or an admixture of the blood 
indicates a possible malignant process or papillary growths in the ducts 
of the mammary gland; liquid transparent or greenish discharge is char-
acteristic of cystic changes in the gland. Nodules in the mammary 
glands, determined by palpation, serve as an indication for ultrasound 
of the mammary glands and mammography.
Determination of body length and weight is necessary to calculate 
the body mass index (BMI) – the ratio of body weight to the square of 
the body length: BMI = body weight (kg) / body length2 (m).
Normally, the BMI of a woman of a reproductive age is 20–
26 kg/m2. The BMI of more than 40 (corresponds to grade IV obesity) 
indicates a high probability of metabolic disorders. With overweight, it 
is necessary to find out when obesity began: since childhood, puberty, 
after the onset of sexual activity, after abortion or childbirth.
Palpation of the abdomen is performed with the patient supine. 
During the exploration the size of individual organs is determined, ex-
cluding ascites, flatulence, and masses. Palpation begins with deter-
mining the position, consistency and shape of the edge of the liver. The 
size of the liver is determined by percussion. Then, clockwise, palpate 
the rest of the abdominal organs. After that, abdominal auscultation is 
performed. Intestinal peristalsis is noted. By palpation, the condition 
of the abdominal wall is determined (tone, muscle protection, diastasis 
of the rectus abdominis muscles), painful areas, the presence of tumors 
in the abdominal cavity, infiltrates. The examination of the abdomen 
can provide with very valuable information. So, if a woman with a large 
pelvic mass is found to have a mass in the epigastric or umbilical re-
gion, ovarian cancer with metastases in the greater omentum should 
be excluded.
Gynecological examination is carried out on a gynecological chair. 
The woman’s legs lie on the supports, her buttocks on the edge of the 
chair. In this position, you can examine the vulva and easily insert the 
speculum into the vagina.
Examination of the external genital organs: condition and size of the 
labia minora and majora; the state of the mucous membranes (juici ness, 
color, state of cervical mucus); the size of the clitoris; the development 

of the hairline; condition of the perineum; the presence of pathologi-
cal processes (inflammation, tumors, ulceration, condylomas, fistulas, 
scars). Hypoplasia of the labia minora and labia majora, pallor and 
dryness of the vaginal mucosa indicate hypoestrogenism.  The juiciness 
and cyanoticity of the vulvar mucosa, abundant transparent secretion 
are signs of hyperestrogenism. Hypoplasia of the labia minora, an in-
crease in the head of the clitoris, an increase in the distance between 
the base of the clitoris and the external opening of the urethra (more 
than 2 cm) in combination with hypertrichosis indicate a congenital 
adrenogenital syndrome. Also pay at-
tention to the gaping of the genital 
fissure; inviting the woman to push, 
determine if there is prolapse or pro-
lapse of the walls of the vagina and 
uterus.
Examination of the vagina and 
cervix in mirrors is performed for 
women who are sexually active. 
Timely recognition of cervical can-
cer, erosions, polyps and other dis-
eases related to precancerous condi-
tions is possible only with the help of 
mirrors (Figure 1.1).
Particular attention is paid to the fornix of the vagina, as there are 
often masses and genital warts.
When examined in mirrors, smears are taken for flora, cytological 
examination, biopsy of volumetric formations of the cervix and vagina 
is possible (Figure 1.2). 
Bimanual examination is performed after removing the mirrors. 
The index and middle fingers of one gloved hand (usually the right) 
are inserted into the vagina. The other hand (usually the left) is placed 
on the anterior abdominal wall. With the right hand, palpate the walls 
of the vagina, its fornices and the cervix, note any volumetric forma-
tions and anatomical changes. Then, carefully introducing the fingers 
into the posterior fornix of the vagina, the uterus is shifted forward 
and upward and palpated with the second hand through the anterior 
abdominal wall. Note the position, size, shape, consistency and 
mobility of the uterus, pay attention to the volumetric formations 
(Figu re 1.3).

Figure 1.1. Cusco type 
folding mirror

Figure 1.2. Examination of the cervix in the mirrors

Figure 1.3. Bimanual exploration
Figure 1.4. Rectovaginal examination

Rectovaginal examination is mandatory in postmenopausal wo-
men, as well as in all cases when it is necessary to clarify the condition 
of the uterine appendages. Some authors suggest that it should be car-
ried out for all women over 40 years to exclude concomitant diseases 
of the rectum. During rectal examination, the tone of the sphincters 
of the anus and the condition of the muscles of the pelvic floor are de-
termined, excluding volumetric formations: internal hemorrhoids, tu-
mor (Figure 1.4 – rectovaginal examination).

1.2. METHODS OF FUNCTIONAL DIAGNOSTICS

Functional diagnostic methods are used to determine the func-
tional state of the reproductive system.
The pupil symptom allows one to judge the production of estrogen 
by the ovaries. With a biphasic menstrual cycle, the external opening 
of the cervical canal from the 5th day of the cycle begins to expand, 
reaching a maximum by the time of the ovulation. In the second phase 
of the cycle, the external uterine pharynx begins to gradually close, 
with no mucus in its lumen.
The symptom of cervical mucus stretching also allows one to judge 
the production of estrogen by the ovaries. The maximum stretching of 
the mucus thread from the cervical canal occurs at the time of the 
ovula tion and reaches 10–12 cm.
Karyopyknotic index (KPI) is the ratio of keratinizing and inter-
mediate cells in microscopic examination of a smear from the poste-
rior fornix of the vagina. During the ovulatory menstrual cycle in the 
first phase KPI is 25–30%, during ovulation – 60–80%, in the middle 
of the second phase – 25–30%.
Basal temperature (temperature in the rectum) depends on the 
phase of the menstrual cycle. In an ovulatory cycle with a full-fledged 
first and second phases, the basal temperature rises by 0.5°C imme-
diately after the ovulation and remains at this level for 12–14 days. The 
rise in temperature is due to the effect of progesterone on the center 
of thermoregulation (Figure 1.5).

37,2
37,1
37
36,9

36,7
36,8 

36,6
36,5
36,4
36,3
36,2
36,1
36
35,9
35,8
35,7

 

1 2 3 4
5
6 7
8 9 10 11 12 13 14 15 16 17
19
18
20 21 22 23 24 25 2627 28
Days of the menstrual cycle

Normal two-phase graph

Basal temperature

1
2
3 4
5
6 7
8 9 10 11 12 13 14

Figure 1.5. Basal temperature chart