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GYNAECOLOGY 20th EDITION
by Ten Teachers
K26886_Book.indb 1 3/30/17 6:05 PM

GYNAECOLOGY 20th EDITION
by Ten Teachers
Edited by
Helen Bickerstaff MD, MRCOG
Senior Lecturer in Medical Education
King’s College London
London, UK
and
Honorary Consultant Obstetrician and Gynaecologist
Guy’s and St Thomas’ NHS Foundation Trust
London, UK
Louise C Kenny MBChB (Hons), MRCOG, PhD

Professor of Obstetrics and Gynaecology
University College Cork
Cork, Ireland
and
Director
The Irish Centre for Fetal and Neonatal Translational Research (INFANT)
Cork, Ireland
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CRC Press
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not necessarily ref lect the views/opinions of the publishers. The information or guidance contained in this book is
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K26886_Book.indb 4 3/30/17 6:05 PM

Dedication
This book is dedicated to the first and best teachers we ever had:
My Dad, Frank (HB)

My Mum, Elizabeth (LCK)
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Contents
Preface...................................................................................................................................... ix
Contributors............................................................................................................................... xi
Abbreviations............................................................................................................................xiii
eResources..............................................................................................................................xvii
CHAPTER 1 The development and anatomy of the female sexual organs and pelvis............ 1
Helen Bickerstaff
CHAPTER 2 Gynaecological history, examination and investigations.................................. 19
Helen Bickerstaff
CHAPTER 3 Hormonal control of the menstrual cycle and hormonal disorders.................. 33
Helen Bickerstaff
CHAPTER 4 Disorders of menstrual bleeding.................................................................... 49
Helen Bickerstaff
CHAPTER 5 Implantation and early pregnancy.................................................................. 59
Andrew Horne
CHAPTER 6 Contraception and abortion........................................................................... 69
Sharon Cameron
CHAPTER 7 Subfertility..................................................................................................... 91
Stuart Lavery
CHAPTER 8 The menopause and postreproductive health............................................... 105
Edward Morris
CHAPTER 9 Genitourinary problems............................................................................... 121
Margaret Kingston
CHAPTER 10 Urogynaecology and pelvic floor problems................................................... 135
Douglas Tincello
CHAPTER 11 Benign conditions of the ovary and pelvis.................................................... 155
T Justin Clark
CHAPTER 12 Benign conditions of the uterus, cervix and endometrium............................ 169
T Justin Clark
CHAPTER 13 Benign conditions of the vulva and vagina, psychosexual disorders and
female genital mutilation............................................................................. 181
Leila CG Frodsham
CHAPTER 14 Malignant disease of the ovary.................................................................... 193
Emma J Crosbie
CHAPTER 15 Malignant disease of the uterus................................................................... 205
Emma J Crosbie
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viii Contents
CHAPTER 16 Premalignant and malignant disease of the lower genital tract..................... 213
Emma J Crosbie
CHAPTER 17 Gynaecological surgery and therapeutics..................................................... 229
Douglas Tincello
Index..................................................................................................................................... 249
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Preface
Gynaecology by Ten Teachers was first published in 1919 as ‘Diseases of Women’ and is one of the oldest, most
respected and accessible texts on the subject. Gynaecology by Ten Teachers has informed generations of gyn-
aecologists, and now has a wide international audience. There is great responsibility in revising this landmark
20th edition, to ensure its accessibility and relevance are maintained into the next century.
The 20th edition has been almost entirely rewritten to reflect both changing undergraduate medical cur-
ricula and changing diagnostic and management protocols in gynaecology. The ‘Ten Teachers’ are all inter-
nationally renowned experts in their fields and all actively involved in the delivery of undergraduate and
postgraduate teaching in the UK. This volume has been edited carefully to ensure consistency of structure,
style and level of detail, in common with those of its sister text Obstetrics by Ten Teachers. The books can
therefore be used together or independently as required. New self assessment sections are presented consis-
tently throughout, with detailed clinical scenarios for each subject in a structure similar to those used in most
medical schools.
The global status of women’s and girls’ sexual and reproductive health and rights is disturbing. Millions
of women have no access to contraception, undergo female genital mutilation and receive no gynaecological
care. It is fitting, therefore, that the 20th edition, published almost 100 years after the first, maintains a global
aspect throughout.
The aim of the text now, as it was a century ago, is to prepare students for their undergraduate examina-
tions, and to continue to be useful afterwards in postgraduate studies and clinical practice. It is a text that
the editors used as students, which inspired us to practice and teach in the specialty, and which we still enjoy
reading because it is concise yet comprehensive. We hope that in addition to supporting medical students
throughout their studies, general practitioners, trainees and allied health care professionals will find it useful
in their work.
It has been a privilege and an honour to be the editors of this textbook as it approaches this important
milestone; we echo a century of previous editors in hoping that this book will enthuse a new generation of
doctors to become gynaecologists and work to improve the health and the safety of women through all repro-
ductive ages.
Helen Bickerstaff
Louise C Kenny
ix
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Contributors
Helen Bickerstaff MD, MRCOG Margaret Kingston BMBS, BMed Sci, FRCP,
Senior Lecturer in Medical Education DipGUM, DFSRH MSc
King’s College London Consultant Physician
and Genitourinary Medicine and Associate
Honorary Consultant Obstetrician and Gynaecologist Medical Director
Guy’s and St Thomas’ NHS Foundation Trust Central Manchester Foundation Trust
London, UK Manchester, UK
Sharon Cameron MD, MFSRH, FRCOG Stuart Lavery MBBCh, MSc, FRCOG
Consultant Gynaecologist and Clinical Lead for Consultant Gynaecologist
Sexual Health Services Director IVF Hammersmith
NHS Lothian Chalmers Centre and
Edinburgh, UK Queen Charlotte’s and Chelsea Hospital
and
T Justin Clark MB ChB, MD(Hons), FRCOG Honorary Senior Lecturer Imperial College
Consultant Gynaecologist London
Birmingham Women’s Hospital London, UK
and
Honorary Professor in Gynaecology Edward Morris MD, FRCOG
University of Birmingham Consultant Gynaecologist
Birmingham, UK Norfolk and Norwich University Hospital NHS
Foundation Trust
Emma J Crosbie BSc, MB ChB, PhD, MRCOG Norwich, UK
Senior Lecturer and Honorary Consultant and
Gynaecological Oncologist Vice President, Clinical Quality
University of Manchester Royal College of Obstetricians and Gynaecologists
St Mary’s Hospital London, UK
Manchester, UK
Douglas G Tincello BSc, MBChB, MD, FRCOG, FHEA
Leila CG Frodsham, MB ChB, MRCOG Professor of Urogynaecology
Consultant Gynaecologist Department of Health Sciences
Chair of the Institute of Psychosexual Medicine College of Medicine, Biological Sciences and
(2012–15) Psychology
University of Leicester
Leicester, UK
Andrew Horne PhD, FRCOG
Personal Chair in Gynaecology and Reproductive
Sciences
Honorary Consultant Gynaecologist
MRC Centre for Reproductive Health
University of Edinburgh
Edinburgh, UK
xi
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Abbreviations
AFC antral follicle count D&C dilatation and curettage

AFP α-fetoprotein DHEA dehydroepiandrosterone
AIDS acquired immune deficiency syndrome DHT dihydrotestosterone
ALO actimomyces-like organism DNA deoxyribonucleic acid
AMH anti-Müllerian hormone DO detrusor overactivity
APS antiphospholipid syndrome DSD disorders of sexual development
ART assisted reproductive treatment DUB dysfunctional uterine bleeding
AUB abnormal uterine bleeding
AUC area under the curve EB endometrial biopsy
AZF azoospermic factor EC emergency contraception
ECG electrocardiography
BBV blood-borne virus EGF epidermal growth factor
BEO bleeding of endometrial origin EIA enzyme immunoassay
BEP bleomycin, etoposide and cisplatin EP ectopic pregnancy
BMD bone mineral density EVA electrical vacuum aspiration
BMI body mass index
BNF British National Formulary FAB fertility awareness-based method
BOT borderline ovarian tumour FBC full blood count
BRCA breast ovarian cancer syndrome FGF fibroblast growth factor
BSO bilateral salpingo-oophorectomy FGM female genital mutilation
BV bacterial vaginosis FH fetal heartbeat
FIGO International Federation of Gynecology
CAH congenital adrenal hyperplasia and Obstetrics
CAIS complete androgen insensitivity FSH follicle-stimulating hormone
syndrome
CBT cognitive-behavioural therapy GFR glomerular filtration rate
CGIN cervical glandular intraepithelial GnRH gonadotrophin-releasing hormone
neoplasia GP general practitioner
CHC combined hormonal contraception GTA gynaecology teaching associate
CIN cervical intraepithelial neoplasia GTD gestational trophoblastic disease
CL corpus luteum
CLIA chemiluminescence immunoassay HAART highly active retroviral therapy
CNS central nervous system (β) hCG (beta-) human chorionic gonadotrophin
COCP combined oral contraceptive pill HDL high-density lipoprotein
COX cyclooxygenase HFEA Human Fertilisation and Embryo
CPP chronic pelvic pain Authority
CRP C-reactive protein HIV human immunodeficiency virus
CT computed tomography HMB heavy menstrual bleeding
Cu-IUD copper intrauterine device HNPCC hereditary non-polyposis colorectal cancer
CVD cardiovascular disease HPO hypothalamo–pituitary–ovarian (axis)
xiii
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xiv Abbreviations
HPV human papilloma virus OAB overactive bladder

HRT hormone replacement therapy OCP oral contraceptive pill
HSG hysterosalpingography 17-OHP 17-hydroxyprogesterone
HSIL high-grade squamous intraepithelial OHSS ovarian hyperstimulation syndrome
(lesion) OI ovulation induction
HSV herpes simplex virus OPH outpatient hysteroscopy
HVS high vaginal swab
HyCoSy hysterocontrast synography PAC preassessment clinic
PAF platelet activating factor
ICSI intracytoplasmic sperm injection PCB postcoital bleeding
Ig immunoglobulin PCOS polycystic ovary syndrome
IGF insulin-like growth factor PCR polymerase chain reaction
IMB intermenstrual bleeding PG prostaglandin
ISD intrinsic sphincter deficiency PGD preimplantation genetic diagnosis
IUD intrauterine device PGI prostacyclin
IUI intrauterine insemination PID pelvic inflammatory disease
IUS intrauterine releasing system PMB postmenopausal bleeding
IVF in-vitro fertilization PMS premenstrual syndrome
POCT point of care test
LARC long-acting reversible methods of POF premature ovarian failure
contraception POI premature ovarian insufficiency
LAVH laparoscopic-aided vaginal POP progestogen-only pill
hysterectomy PPC primary peritoneal carcinoma
LBC liquid-based cytology PPH postpartum haemorrhage
LDL low-density lipoprotein PUL pregnancy of unknown location
LH luteinizing hormone
LLETZ large loop excision of transformation REM rapid eye movement
zone RCOG Royal College of Obstetricians and
LMP last menstrual period Gynaecologists
LMWH low-molecular weight heparin RMI Risk of Malignancy Index
LNG-IUS levonorgestrel intrauterine system RNA ribonucleic acid
LOD laparoscopic ovarian drilling RPOC retained products of conception
RPR rapid plasma reagin
MAS minimal access surgery RR relative risk
MBL mean blood loss
MDT multidisciplinary team SCJ squamocolumnar junction
MEC medical eligibility criteria SERM selective oestrogen receptor
MRI magnetic resonance imaging modulator
MRKH Mayer–Rokitansky–Kuster–Hauser SFA semen fluid analysis
syndrome SHBG sex hormone-binding globulin
MSU midstream urine sample SIS saline instillation sonography
MTCT mother-to-child transmission SPRM selective progesterone receptor
MVA manual vacuum aspiration modulator
SSR surgical sperm retrieval
NAAT nucleic acid amplification test SSRI selective serotonin-reuptake inhibitor
NICE National Institute for Health and Care STI sexually-transmitted infection
Excellence STIC serous tubal intraepithelial carcinoma
NSAID non-steroidal anti-inflammatory drug STOP surgical termination of pregnancy
K26886_Book.indb 14 3/30/17 6:05 PM

Abbreviations xv
TAUSS transabdominal ultrasound scan UPT urinary pregnancy test

TCRF transcervical resection of fibroid USS ultrasound scan
TED thromboembolic stocking
TGF transforming growth factor VaIN vaginal intraepithelial neoplasia
TLH total laparoscopic hysterectomy VDRL Venereal Disease Reference Laboratory
TOT transobturator tape VEGF vascular endothelial growth factor
TPHA T. pallidum haemagglutination assay VIN vulval intraepithelial neoplasia
TPPA T. pallidum particle assay VTE venous thromboembolism
TV Trichomonas vaginalis
TVT tension-free vaginal tape WCC white cell count
TVUSS transvaginal ultrasound scan WHI Women’s Health Initiative
TZ transformation zone WHO World Health Organization
UAE umbilical/uterine artery embolization

UPA ulipristal acetate
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eResources
Chapter 2 Gynaecological history, examination and investigations

eResource 2.1 The gynaecological consultation
http://www.routledgetextbooks.com/textbooks/tenteachers/gynaecologyv2.1.php
eResource 2.2 Ultrasound imaging in gynaecology
Chapter 3 Hormonal control of the menstrual cycle and hormonal disorders

eResource 3.1 Polycystic ovary syndrome (PCOS)
eResource 3.2 Premenstrual syndrome (PMS) patient guidance
Chapter 4 Disorders of menstrual bleeding

eResource 4.1 Heavy menstrual bleeding (HMB) history and examination
eResource 4.2 Endometrial ablation
Chapter 5 Implantation and early pregnancy

eResource 5.1 Pregnancy between 5 and 12 weeks’ gestation
eResource 5.2 Ectopic pregnancy
Chapter 6 Contraception and abortion

eResource 6.1 Laparoscopic sterilization
Chapter 7 Subfertility
eResource 7.1 Tubal blockage
eResource 7.2 Normal and abnormal sperm
http://www.routledgetextbooks.com/textbooks/tenteachers/gynaecologyv7.2.php xvii
K26886_Book.indb 17 3/30/17 6:05 PM

xviii eResources
eResource 7.3 Egg collection using transvaginal ultrasound (TVUSS)

eResource 7.4 Transvaginal ultrasound (TVUSS) guided embryo transfer
eResource 7.5 Embryo biopsy for preimplantation genetic diagnosis (PGD)
Chapter 11 Benign conditions of the ovary and pelvis

eResource 11.1 Ovarian cysts
eResource 11.2 Transvaginal ultrasound (TVUSS) of the pelvis with endometriosis
Chapter 12 Benign conditions of the uterus, cervix and endometrium

eResource 12.1 Endometrial polyps
eResource 12.2 Surgical treatment of fibroids
Chapter 14 Malignant disease of the ovary

eResource 14.1 Surgery for epithelial ovarian cancer
Chapter 15 Malignant disease of the uterus

eResource 15.1 Surgical treatment of endometrial cancer
Chapter 17 Gyaecological surgery and therapeutics

eResource 17.1 Laparoscopy
You can access the resources (video clips and still images) that are referenced above and indicated in the text
with the icon by entering the URLs provided in the browser of your choice.
In addition, the videos and images from this book can be accessed via the companion website that accom-
panies this textbook www.routledge.com/cw/kenny where you will also find resources for the sister volume,
Obstetrics by Ten Teachers, 20th Edition. Additional video clips and still images will be added to this library
over time.
K26886_Book.indb 18 3/30/17 6:05 PM

The development and CHAPTER
1
anatomy of the female
sexual organs and pelvis
HELEN BICKERSTAFF
Sexual differentiation of the fetus and development Structural problems of pelvic organs.................................15
of sexual organs..................................................................1 Further reading..................................................................16
Female anatomy..................................................................4 Self assessment................................................................16
LEARNING OBJECTIVES
• Understand that sexual differentiation and • Understand the innervation of the perineum
development begin in early embryonic life. and pelvis.
• Understand the embryonic development and the • Understand the vulnerability of certain structures
anatomy of the perineum, the vagina, cervix and in gynaecological surgery.
uterus, the adnexa and ovary and the bladder • Describe the structural anomalies resulting from
and ureters. Müllerian tract disorders.
• Describe the blood supply and lymphatics of the
perineum and pelvis.
causes the gonad to begin development into a testis.

Sexual differentiation of In the past, ovarian development was considered a
the fetus and development ‘default’ development due solely to the absence of
of sexual organs SRY, but in the last 10 years ovarian-determining
genes have also been found that actively lead to the
The gonadal rudiments appear as the ‘genital ridge’ development of a female gonad.
overlying the embryonic kidney in the intermediate The fetus has two sets of structures called the
mesoderm during the fourth week of embryonic life, Müllerian (or paramesonephric) ducts and Wolffian
and they remain sexually indifferent until the sev- (or mesonephric) ducts, which have the potential to
enth (Figure 1.1). The undifferentiated gonad has the develop into male or female internal and external
potential to become either a testis or an ovary, and genitalia respectively.
hence is termed bipotential, and the chromosomal
complement of the zygote determines whether the Development of the
gonad becomes a testis or an ovary. The develop-
ment of either the testis or ovary is an active gene-
male sexual organs
directed process. In the male the activity of the SRY As the gonad develops into a testis, it differenti-
gene (sex-determining region of the Y chromosome) ates into two cell types. The Sertoli cells produce 1
K26886_Book.indb 1 3/30/17 6:05 PM

2 The development and anatomy of the female sexual organs and pelvis
Mesonephric
duct
Hindgut
Genital
ridge
Mesonephros
Gonad
Mesonephros
Müllerian duct
SRY gene
Wolffian duct
Testis determing
factor
Indifferent stage
Anti-Müllerian hormone
Testosterone
DHT
B Male Female
Figure 1.1 A: Cross-section diagram of the posterior abdominal wall showing the genital ridge; B: diagrammatic represen-
tation of the embryological pathways of male and female development. (DHT: dihydrotestosterone.)
anti-Müllerian hormone (AMH) and the Leydig The urogenital folds fuse along the ventral surface
cells produce testosterone. AMH suppresses further of the penis and enclose the urethra so that it opens at
development of the Müllerian ducts whereas testos- the tip of the penis.
terone stimulates the Wolffian ducts to develop into
the vas deferens, epididymis and seminal vesicles. In Development of the
addition, in the external genital skin, testosterone is
converted by the enzyme 5-alpha-reductase into dihy-
female sexual organs
drotestosterone (DHT). This acts to virilize the exter- In the primitive ovary granulosa cells, derived
nal genitalia. The genital tubercle becomes the penis from the proliferating coelomic epithelium, sur-
and the labioscrotal folds fuse to form the scrotum. round the germ cells and form primordial follicles.
K26886_Book.indb 2 3/30/17 6:05 PM

Sexual differentiation of the fetus and development of sexual organs 3
Each primordial follicle consists of an oocyte within ‘sinovaginal bulbs’. The caudal extension of the
a single layer of granulosa cells. Theca cells develop Müllerian ducts projects into the posterior wall
from the proliferating coelomic epithelium and are of the urogenital sinus as the Müllerian tubercle.
separated from the granulosa cells by a basal lam- The Müllerian tubercles and the urogenital sinus
ina. The maximum number of primordial follicles is fuse to form the vaginal plate, which extends from
reached at 20 weeks’ gestation when there are six to the Müllerian ducts to the urogenital sinus. This
seven million primordial follicles present. The num- plate begins to canalize, starting at the hymen
bers of these reduce by atresia and at birth only 1–2 and proceeding upwards to the cervix in the sixth
million remain. Atresia continues throughout life embryonic month.
and by menarche only 300,000–400,000 are present,
and by menopause none.
The development of an oocyte within a primor-
External female genitalia
dial follicle is arrested at the prophase of its first The external genitalia do not virilize in the absence
meiotic division. It remains in that state until it of testosterone. Between the fifth and seventh
undergoes atresia or enters the meiotic process pre- weeks of life, the cloacal folds, which are a pair of
ceding ovulation. swellings adjacent to the cloacal membrane, fuse
In the female, the absence of testicular AMH anteriorly to become the genital tubercle. This
allows the Müllerian structures to develop and the will become the clitoris. The perineum develops
female reproductive tract develops from these paired and divides the cloacal membrane into an ante-
ducts. The proximal two-thirds of the vagina develop rior urogenital membrane and a posterior anal
from the paired Müllerian ducts, which grow in a membrane. The cloacal folds anteriorly are called
caudal and medial direction and fuse in the midline. the urethral folds, which form the labia minora.
The midline fusion of these structures produces the Another pair of folds within the cloacal membrane
uterus, cervix and upper vagina, and the unfused form the labioscrotal folds that eventually become
caudal segments form the Fallopian tubes, as shown the labia majora. The urogenital sinus becomes
in Figure 1.2. the vestibule of the vagina. The external genitalia
Cells proliferate from the upper portion of are recognizably female by the end of the twelfth
the urogenital sinus to form structures called the embryonic week.
Mesonephric
Paramesonephric KEY LEARNING POINTS
(Müllerian) ducts • The primitive gonad is first evident at 5 weeks of
ducts
embryonic life and forms on the medial aspect of the
mesonephric ridge.
• The undifferentiated gonad has the potential to
Fallopian become either a testis or an ovary.
Gubernaculum
tube Ovary • The paramesonephric duct, which later forms the
of ovary
Müllerian system, is the precursor of female genital
development.
• The lower end of the Müllerian ducts fuse in the
midline to form the uterus and upper vagina.
Developing • Most of the upper vagina is of Müllerian origin, while
Degenerating uterus the lower vagina forms from the sinovaginal bulbs.
mesonephric
• Primordial follicles contain an oocyte arrested in
duct Müllerian prophase surrounded by granulosa cells separated by
tubercle a basement membrane from Leydig cells.
Urogenital • The maximum number of primordial follicles is
sinus reached at 20 weeks’ gestation. These reduce by
Figure 1.2 Caudal parts of the paramesonephric ducts (top) atresia throughout childhood and adult life.
fuse to form the uterus and Fallopian tubes.
K26886_Book.indb 3 3/30/17 6:05 PM

but they probably add support to the distal vaginal

Female anatomy wall to enhance its rigidity during penetration.
The Bartholin’s glands are bilateral and about the
External genitalia size of a pea. They open via a 2 cm duct into the ves-
The external genitalia are commonly called the tibule below the hymen and contribute to lubrication
vulva and include the mons pubis, labia majora and during intercourse.
minora, the vaginal vestibule, the clitoris and the The hymen is a thin covering of mucous mem-
greater vestibular glands. The mons pubis is a fibro- brane across the entrance to the vagina. It is usually
fatty pad covered by hair-bearing skin that covers perforated, which allows menstruation. The hymen
the bony pubic ramus. is ruptured during intercourse and any remaining
The labia majora are two folds of skin with tags are called ‘carunculae myrtiformes’.
u nderlying adipose tissue lying either side of the
vaginal opening. They contain sebaceous and Internal reproductive
sweat glands and a few specialized apocrine glands. organs (Figure 1.3)
In the deepest part of each labium is a core of fatty
tissue continuous with that of the inguinal canal The vagina
and the fibres of the round ligament, which termi- The vagina is a fibromuscular canal lined with
nate here. stratified squamous epithelium that leads from
The labia minora are two thin folds of skin that the uterus to the vulva. It is longer in the posterior
lie between the labia majora. These vary in size and wall (approximately 9 cm) than in the anterior wall
may protrude beyond the labia major where they (approximately 7 cm). The vaginal walls are nor-
are visible, but may also be concealed by the labia mally in apposition, except at the vault where they
majora. Anteriorly, they divide in two to form the are separated by the cervix. The vault of the vagina
prepuce and frenulum of the clitoris (clitoral hood). is divided into four fornices: posterior, anterior and
Posteriorly, they divide to form a fold of skin called two lateral.
the fourchette at the back of the vagina introitus. The midvagina is a transverse slit while the lower
They contain sebaceous glands, but have no adipose vagina is an H-shape in transverse section. The vag-
tissue. They are not well developed before puberty inal walls are lined with transverse folds. The vagina
and atrophy after the menopause. Both the labia has no glands and is kept moist by s ecretions from
minora and labia majora become engorged during the uterine and cervical glands and by transudation
sexual arousal. from its epithelial lining. The epithelium is thick and
The clitoris is an erectile structure measuring rich in glycogen, which increases in the postovula-
approximately 0.5–3.5 cm in length. The body of the tory phase of the cycle. However, before puberty
clitoris is the main part of the visible clitoris and and after the menopause, the vagina is devoid of
is made up of paired columns of erectile tissue and glycogen due to the lack of oestrogen. Doderlein’s
vascular tissue called the ‘corpora cavernosa’. These bacillus is a normal commensal of the vaginal flora
become the crura at the bottom of the clitoris and and breaks down glycogen to form lactic acid, pro-
run deeper and laterally. The vestibule is the cleft ducing a pH of around 4.5. This has a protective role
between the labia minora. It contains openings of for the vagina in decreasing the growth of patho-
the urethra, the Bartholin’s glands and the vagina. genic bacteria.
The vagina is surrounded by two bulbs of erectile The upper posterior wall forms the anterior
and vascular tissue that are extensive and almost peritoneal reflection of the pouch of Douglas. The
completely cover the distal vaginal wall. These have middle third is separated from the rectum by pel-
traditionally been named the bulb of the vaginal vic fascia and the lower third abuts the perineal
vestibule, although recent work on both dissection body. Anteriorly, the vagina is in direct contact
and magnetic resonance imaging (MRI) suggests with the base of the bladder, while the urethra runs
that they may be part of the clitoris and should be down the lower half in the midline to open into
renamed ‘clitoral bulbs’. Their function is unknown the vestibule. Its muscles fuse with the anterior
K26886_Book.indb 4 3/30/17 6:05 PM

Female anatomy 5
Suspensory ligament
of ovary
Uterine Right
tube ureter
Ligament Ovary
of ovary
Rectouterine
External iliac fold
vessels
Uterovesical pouch
Fundus
of uterus
Posterior part
of fornix
Vesicouterine
recess
Cervix
uteri
Bladder
Rectal
Urethra ampulla
Vagina Anal canal

Figure 1.3 Sagittal section of the female pelvis.
vagina wall. Laterally, at the fornices, the vagina is each Fallopian tube is termed the ‘cornu’ and that
related to the cardinal ligaments. Below this are the part of the body above the cornu is called the ‘fun-
levator ani muscles and the ischiorectal fossae. The dus’. The uterus tapers to a small constricted area,
cardinal ligaments and the uterosacral ligaments, the isthmus, and below this is the cervix, which
which form posteriorly from the parametrium, projects obliquely into the vagina. The longitudinal
support the upper part of the vagina. axis of the uterus is approximately at right angles to
At birth, the vagina is under the influence of the vagina and normally tilts forward. This is called
maternal oestrogens so the epithelium is well devel- ‘anteversion’. In addition, the long axis of the cervix
oped. After a couple of weeks, the effects of the is rarely the same as the long axis of the uterus. The
oestrogen disappear and the pH rises to 7 and the uterus is also usually flexed forward on itself at the
epithelium atrophies. At puberty, the reverse occurs isthmus – antiflexion. However, in around 20% of
and finally at the menopause the vagina tends to women, the uterus is tilted backwards – retroversion
shrink and the epithelium atrophies once again. and retroflexion. This has no pathological signifi-
cance in most women, although retroversion that is
The uterus fixed and immobile may be associated with endome-
The uterus is shaped like an inverted pear taper- triosis. This has relevance in gynaecological surgery
ing inferiorly to the cervix and in its non-pregnant and is referred to again in Chapter 2, Gynaecological
state is situated entirely within the pelvis. It is hol- history, examination and investigations.
low and has thick, muscular walls. Its maximum The cavity of the uterus is the shape of an
external dimensions are approximately 7.5 cm long, inverted triangle and when sectioned coronally the
5 cm wide and 3 cm thick. An adult uterus weighs Fallopian tubes open at lateral angles The constric-
approximately 70 g. In the upper part, the uterus is tion at the isthmus where the corpus joins the cervix
termed the body or ‘corpus’. The area of insertion of is the anatomical os. Seen microscopically, the site
K26886_Book.indb 5 3/30/17 6:05 PM

of the histological internal os is where the mucous Age changes to anatomy

membrane of the isthmus becomes that of the cervix. The disappearance of maternal oestrogens from the
The uterus consists of three layers: the outer circulation after birth causes the uterus to decrease
serous layer (peritoneum), the middle muscular layer in length by around one-third and in weight by
(myometrium) and the inner mucous layer (endome- around one-half. The cervix is then twice the length
trium). The peritoneum covers the body of the uterus of the uterus. During childhood, the uterus grows
and posteriorly it covers the supravaginal part of the slowly in length, in parallel with height and age. The
cervix. The peritoneum is intimately attached to average longitudinal diameter ranges from 2.5 cm
a subserous fibrous layer, except laterally where it at the age of 2 years, to 3.5 cm at 10 years. After the
spreads out to form the leaves of the broad ligament. onset of puberty, the anteroposterior and transverse
The muscular myometrium forms the main bulk diameters of the uterus start to increase, leading to a
of the uterus and is made up of interlacing smooth sharper rise in the volume of the uterus. The increase
muscle fibres intermingling with areolar tissue, in uterine volume continues well after menarche and
blood vessels, nerves and lymphatics. Externally, the uterus reaches its adult size and configuration
the muscle fibres are mostly longitudinal, but the by the late teenage years. After the menopause, the
thicker intermediate layer has interlacing longitu- uterus atrophies, the mucosa becomes very thin, the
dinal, oblique and transverse fibres. Internally, they glands almost disappear and the wall becomes rela-
are mainly longitudinal and circular. tively less muscular.
The inner endometrial layer has tubular glands
that dip into the myometrium. The endometrial layer The Fallopian tubes
is covered by a single layer of columnar epithelium. The Fallopian tube extends outwards from the uter-
Ciliated prior to puberty, this epithelium is mostly ine cornu to end near the ovary. At the abdominal
lost due to the effects of pregnancy and menstrua- ostium, the tube opens into the peritoneal cavity,
tion. The endometrium undergoes cyclical changes which is therefore in communication with the exte-
during menstruation, as described in Chapter 3, rior of the body via the uterus and the vagina. This
Hormonal control of the menstrual cycle and hor- is essential to allow the sperm and egg to meet. The
monal disorders, and varies in thickness. Fallopian tubes convey the ovum from the ovary
towards the uterus and promote oxygenation and
The cervix
nutrition for sperm, ovum and zygote should fertil-
The cervix is narrower than the body of the uterus ization occur.
and is approximately 2.5 cm in length. Lateral to The Fallopian tube runs in the upper margin
the cervix lies cellular connective tissue called the of the broad ligament, known as the mesosalpinx,
parametrium. The ureter runs about 1 cm laterally which encloses the tube so that it is completely cov-
to the supravaginal cervix within the parametrium. ered with peritoneum, except for a narrow strip
The posterior aspect of the cervix is covered by the along this inferior aspect. Each tube is about 10 cm
peritoneum of the pouch of Douglas. long and is described in four parts:
The upper part of the cervix mostly consists of
involuntary muscle, whereas the lower part is mainly • The interstitial portion.
fibrous connective tissue. The mucous membrane • The isthmus.
of the cervical canal (endocervix) has anterior and • The ampulla.
posterior columns from which folds radiate out, the
‘arbour vitae’. It has numerous deep glandular fol-
• The infundibulum or fimbrial portion.
licles that secrete clear alkaline mucus, the main The interstitial portion lies within the wall of
component of physiological vaginal discharge. The the uterus, while the isthmus is the narrow portion
epithelium of the endocervix is columnar and is adjoining the uterus. This passes into the widest and
also ciliated in its upper two-thirds. This changes to longest portion, the ampulla. This, in turn, termi-
stratified squamous epithelium around the region of nates in the extremity known as the ‘infundibulum’.
the external os and the junction of these two types of The opening of the tube into the peritoneal cavity
epithelium is called the ‘squamocolumnar junction’. is surrounded by finger-like processes, known as
K26886_Book.indb 6 3/30/17 6:05 PM

Female anatomy 7
fimbria, into which the muscle coat does not extend. Structure of the ovary
The inner surfaces of the fimbriae are covered by The ovary has a central vascular medulla consist-
ciliated epithelium that is similar to the lining of ing of loose connective tissue containing many
the Fallopian tube itself. One of these fimbriae is elastin fibres and non-striated muscle cells. It has
longer than the others and extends to, and partially an outer thicker cortex, denser than the medulla,
embraces, the ovary. The muscular fibres of the wall consisting of networks of reticular fibres and fusi-
of the tube are arranged in an inner circular and an form cells, although there is no clear-cut demarca-
outer longitudinal layer. tion between the two. The surface of the ovaries
The tubal epithelium forms a number of branched is covered by a single layer of cuboidal cells, the
folds or plicae that run longitudinally; the lumen of germinal epithelium. Beneath this is an ill-defined
the ampulla is almost filled with these folds. The layer of condensed connective tissue called the
folds have a cellular stroma, but at their bases the ‘tunica albuginea’, which increases in density with
epithelium is only separated from the muscle by a age. At birth, numerous primordial follicles are
very scanty amount of stroma. There is no submu- found, mostly in the cortex, but some are found in
cosa and there are no glands. The epithelium of the the medulla. With puberty, some form each month
Fallopian tubes contains two functioning cell types: into the graafian follicles under gonadotrophic
the ciliated cells, which act to produce constant cur- control, to ovulate and subsequently form corpus
rent of fluid in the direction of the uterus, and the lutea and ultimately the atretic follicles, the corpora
secretory cells, which contribute to the volume of albicans.
tubal fluid. Changes occur under the influence of the
menstrual cycle, but there is no cell shedding during The bladder, urethra and ureter
menstruation.
The bladder
The ovaries The bladder wall is made of involuntary muscle
The size and appearance of the ovaries depends arranged in an inner longitudinal layer, a middle
on both age and stage of the menstrual cycle. In circular layer and an outer longitudinal layer. It is
a child, the ovaries are small structures approxi- lined with transitional epithelium and has an aver-
mately 1.5 cm long; however, they increase to adult age capacity of 400 ml.
size in puberty due to proliferation of stromal cells The ureters open into the base of the bladder
and commencing maturation of the ovarian fol- after running medially for about 1 cm through
licles. In the young adult, they are almond-shaped the bladder wall. The urethra leaves the bladder
and measure approximately 3 cm long, 1.5 cm below the ureteric orifices. The triangular area lying
wide and 1 cm thick. After the menopause, no between the ureteric orifices and the internal meatus
active follicles are present and the ovary becomes of the urethra is known as the ‘trigone’. At the
smaller with a wrinkled surface. The ovary is the internal meatus, the middle layer of muscle forms
only intra-abdominal structure not to be covered anterior and posterior loops round the neck of the
by peritoneum. Each ovary is attached to the cornu bladder, some fibres of the loops being continuous
of the uterus by the ovarian ligament and at the with the circular muscle of the urethra.
hilum to the broad ligament by the mesovarium, The base of the bladder is adjacent to the cervix,
which contains its supply of nerves and blood ves- with only a thin layer of tissue intervening. It is sep-
sels. Laterally, each ovary is attached to the suspen- arated from the anterior vaginal wall below by the
sory ligament of the ovary with folds of peritoneum pubocervical fascia that stretches from the pubis to
that becomes continuous with that of the overlying the cervix.
psoas major.
Anterior to the ovaries lie the Fallopian tubes, The urethra
the superior portion of the bladder and the utero- The female urethra is about 3.5 cm long and is
vesical pouch. Posterior to the ovary lies the ureter lined with transitional epithelium. It has a slight
where it runs downwards and forwards in front of posterior angulation at the junction of its lower
the internal iliac artery. and middle thirds. The smooth muscle of its wall
K26886_Book.indb 7 3/30/17 6:05 PM

is arranged in outer longitudinal and inner circular

Box 1.1 Ureteric damage during
layers. As the urethra passes through the two lay-
hysterectomy
ers of the urogenital diaphragm, it is embraced by
the striated fibres of the deep transverse perineal Because of its close relationship to the cervix,
muscle (also known as the compressor urethrae) the vault of the vagina and the uterine artery,
and some of the striated fibres of this muscle form the ureter may be damaged during hysterec-
a loop on the urethra. Between the muscular coat tomy. Apart from being cut or tied, in radical
procedures, the ureter may undergo necrosis
and the epithelium is a plexus of veins. There are a
because of interference with its blood supply.
number of tubular mucous glands and in the lower It may be displaced by scar tissue or by fibro-
part a number of crypts that occasionally become myomata or cysts that are growing between
infected. In its upper two-thirds, the urethra is the layers of the broad ligament and may
separated from the symphysis by loose connective suffer injury if its position is not noticed at
tissue, but in its lower third it is attached to the surgery.
pubic ramus on each side by strong bands of fibrous
tissue called the ‘pubourethral tissue’. Posteriorly,
it is firmly attached in its lower two-thirds to the
anterior vaginal wall. This means that the upper The rectum
part of the urethra is mobile, but the lower part is The rectum extends from the level of the third
relatively fixed. sacral vertebra to a point about 2.5 cm in front
Medial fibres of the pubococcygeus of the levator of the coccyx where it passes through the pelvic
ani muscles are inserted into the urethra and vagi- floor to become continuous with the anal canal.
nal wall. When they contract, they pull the anterior Its direction follows the curve of the sacrum and
vaginal wall and the upper part of the urethra for- is about 11 cm in length. The front and sides
wards forming an angle of about 100° between the are covered by the peritoneum of the rectovagi-
posterior wall of the urethra and the bladder base. nal pouch. In the middle third only the front is
On voluntary voiding of urine, the base of the blad- covered by peritoneum. In the lower third there
der and the upper part of the urethra descend and is no peritoneal covering and the rectum is sepa-
the posterior angle disappears so that the base of the rated from the posterior wall of the vagina by the
bladder and the posterior wall of the urethra come to rectovaginal fascial septum. Lateral to the rectum
lie in a straight line. are the uterosacral ligaments, beside which run
some of the lymphatics draining the cervix and
The ureter vagina.
As the ureter crosses the pelvic brim, it lies in front
of the bifurcation of the common iliac artery. It The pelvic muscles, ligaments and fascia
runs downwards and forwards on the lateral wall of
the pelvis to reach the pelvic floor and then passes
The pelvic diaphragm (Figure 1.4)
inwards and forwards attached to the peritoneum The pelvic diaphragm is formed by the levator ani
of the back of the broad ligament to pass beneath muscles, which are broad, flat muscles the fibres of
the uterine artery. It next passes forward through a which pass downwards and inwards. The two mus-
fibrous tunnel, the ureteric canal, in the upper part cles, one on either side, constitute the pelvic dia-
of the cardinal ligament. Finally, it runs close to phragm. The muscles arise by linear origin from the
the lateral vaginal fornix to enter the trigone of the following points:
bladder.
Its blood supply is derived from small branches • The lower part of the body of the os pubis.
of the ovarian artery, from a small vessel arising
near the iliac bifurcation, from a branch of the uter-
• The internal surface of the parietal pelvic fascia
along the white line.
ine artery where it crosses beneath it and from small
branches of the vesical artery. • The pelvic surface of the ischial spine.
K26886_Book.indb 8 3/30/17 6:05 PM

Female anatomy 9
Urethra Pubococcygeus
Vagina
Rectum
Iliococcygeus
Figure 1.4 Pelvic floor musculature.
The levator ani muscles are inserted into the fol- and the bladder base. During micturition, this loop
lowing points: relaxes to allow the bladder neck and upper urethra
to open and descend.
• The preanal raphe and the central point of the
perineum, where one muscle meets the other on Urogenital diaphragm
the opposite side.
The urogenital diaphragm (also known as the tri-
• The wall of the anal canal, where the fibres blend angular ligament) is made up of two layers of pelvic
with the deep external sphincter muscle. fascia that fill the gap between the descending pubic
• The postanal or anococcygeal raphe, where again rami and lies beneath the levator ani muscles. The
one muscle meets the other on the opposite side. deep transverse perineal muscles (compressor ure-
• The lower part of the coccyx. thrae) lie between the two layers and the diaphragm
is pierced by the urethra and vagina.
The muscle is described in two parts:
The perineal body
• The pubococcygeus, which arises from the pubic
bone and the anterior part of the tendinous arch This is a mass of muscular tissue that lies between
of the pelvic fascia (the ‘white line’). the anal canal and the lower third of the vagina. Its
apex is at the lower end of the rectovaginal septum
• The iliococcygeus, which arises from the posterior
at the point where the rectum and posterior vaginal
part of the tendinous arch and the ischial spine.
walls come into contact. Its base is covered with skin
The medial borders of the pubococcygeus mus- and extends from the fourchette to the anus. It is the
cle pass on either side from the pubic bone to the point of insertion of the superficial perineal muscles
preanal raphe. They thus embrace the vagina and and is bounded above by the levator ani muscles
on contraction have some sphincteric action. The where they come into contact in the midline between
nerve supply is from the third and fourth sacral the posterior vaginal wall and the rectum.
nerves. The pubococcygeus muscles support the
pelvic and abdominal viscera, including the blad- The pelvic peritoneum
der. The medial edge passes beneath the bladder and The peritoneum is reflected from the lateral borders
runs laterally to the urethra, into which some of its of the uterus to form, on either side, a double fold of
fibres are inserted. Together with the fibres from the peritoneum – the broad ligament. Despite the name,
opposite muscle, they form a loop that maintains this is not a ligament but a peritoneal fold and it does
the angle between the posterior aspect of the urethra not support the uterus. The Fallopian tube runs in
K26886_Book.indb 9 3/30/17 6:05 PM

the upper free edge of the broad ligament as far as the white line) lies on the side wall of the pelvis. It is
the point at which the tube opens into the peritoneal here that the levator ani muscle arises and the cardi-
cavity. The part of the broad ligament that is lateral nal ligament gains its lateral attachment. Where the
to the opening is called the ‘infundibulopelvic fold’ parietal pelvic fascia encounters bone, as in the pubic
and in it the ovarian vessels and nerves pass from region, it blends with the periosteum. It also forms
the side wall of the pelvis to lie between the two lay- the upper layer of the urogenital diaphragm.
ers of the broad ligament. The mesosalpinx, the por- Each viscus has a fascial sheath that is dense
tion of the broad ligament that lies above the ovary, in the case of the vagina and cervix and at the
is layered; between its layers are seen any Wolffian base of the bladder, but is tenuous or absent over
remnants that may remain. Below the ovary, the base the body of the uterus and the dome of the blad-
of the broad ligament widens out and contains a con- der. From the point of view of the gynaecologist,
siderable amount of loose connective tissue called certain parts of the visceral fascia are important,
the ‘parametrium’. The ureter is attached to the pos- as follows:
terior leaf of the broad ligament at this point.
The ovary is attached to the posterior layer of the • The cardinal ligaments (transverse cervical liga-
broad ligament by a short mesentry (the mesovar- ments) provide the essential support of the uterus
ium) through which the ovarian vessels and nerves and vaginal vault. These are two strong fan-
enter the hilum. shaped fibromuscular bands that pass from the
cervix and vaginal vault to the side wall of the
The ovarian ligament and round pelvis on either side.
ligament (Figure 1.5A) • The uterosacral ligaments run from the cervix
and vaginal vault to the sacrum. In the erect posi-
The ovarian ligament lies beneath the posterior layer
tion, they are almost vertical in direction and sup-
of the broad ligament and passes from the medial
port the cervix.
pole of the ovary to the uterus just below the point of
entry of the Fallopian tube. • The bladder is supported laterally by condensa-
The round ligament is the continuation of the tions of the vesical pelvic fascia, one each side,
same structure and runs forwards under the anterior and by a sheet of pubocervical fascia, which lies
leaf of peritoneum to enter the inguinal canal, end- beneath it anteriorly.
ing in the subcutaneous tissue of the labium major.
The blood supply (Figure 1.6)
The pelvic fascia and pelvic Arteries supplying the pelvic organs
cellular tissue (Figure 1.5B) Because the ovary develops on the posterior abdomi-
Connective tissue fills the irregular spaces between nal wall and later migrates down into the pelvis, it
the various pelvic organs. Much of it is loose cellu- carries its blood supply with it directly from the
lar tissue, but in some places it is condensed to form abdominal aorta. The ovarian artery arises from the
strong ligaments that contain some smooth muscle aorta just below the renal artery and runs down-
fibres and which form the fascial sheaths that enclose wards on the surface of the psoas muscle to the pel-
the various viscera. The pelvic arteries, veins, lym- vic brim, where it crosses in front of the ureter and
phatics, nerves and ureters run through it. The then passes into the infundibulopelvic fold of the
cellular tissue is continuous above with the extra- broad ligament. The artery divides into branches
peritoneal tissue of the abdominal wall, but below that supply the ovary and tube and then run on to
it is cut off from the ischiorectal fossa by the pelvic reach the uterus, where they anastamose with the
fascia and the levator ani muscles. The pelvic fascia terminal branches of the uterine artery.
may be regarded as a specialized part of this connec-
tive tissue and has parietal and visceral components. The internal iliac (hypogastic) artery
The parietal pelvic fascia lines the wall of the pel- This vessel is about 4 cm in length and begins at
vic cavity covering the obturator and pyramidalis the bifurcation of the common iliac artery in front
muscles. The thickened tendinous arch (known as of the sacroiliac joint. It soon divides into anterior
K26886_Book.indb 10 3/30/17 6:05 PM

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Eoanthropus Dawsoni 40
Eolithen 40
Extrapolation 39
Exzentrizität 24
Finniglaziale Epoche 31
Geer, de 27–32
Gilbert 37
Gotiglaziale Epoche 31
Grabau 39
Häckel 46
Halbwertszeit 52
Heim 34
Helium 51
Heliummethode 62, 63, 67
Hildebrandt 26
Holmes 60, 64, 73
Homo Heidelbergensis 40
Interpolieren 69
Irawadi 14
Jahresringe 10, 28
Joly 15
Keilhack 33
Kepler 24
Lawson 64
Litorinazeit 32
Lyell 43, 45
Matthew 43
Mauer b. Heidelberg 40
Mellard Reade 15
Muota 35
Murray 15
Neandertalrasse 41
Neckar 12
Niagarafälle 36
Nüesch 35
Olbricht 33, 39
Penck 22, 43
Pendeluhren 10, 26
Pilgrim 26
Po 14
Präzessionsbewegung 24
Radium 48
Ragunda 32
Reuß 14, 35
Röntgen 47
Rutherford 50
Salz, zyklisches 16
Sanduhren 20
Scharnhausen 13
Schelfregion 17
Schürmann 12
Schweizersbild 35
Soddy 50
Sollas 17
Spencer 37
Steck 35
Strutt 60
Taylor 37
Tertiär 43
Thomson 70
Thorium 55, 62
Thuner See 35
Uranblei 56
Uranreihe 54
Uranuhr 59, 61, 72, 73
Vierwaldstätter See 34
Walcott 45
Wasseruhren 9, 20, 61
Werth 33, 39
Wintermoränen 30
Zerfall 50
Folgende seit Bestehen des Kosmos
erschienene Buchbeilagen
erhalten Mitglieder, solange vorrätig zu
Ausnahmepreisen:
1. Gruppe 1904–1907. Broschiert M 1050.—,

gebunden M 1660.—
Bölsche, W., Abstammung des Menschen. — Meyer, Dr. M. W.,
1904 Weltuntergang. — Zell, Ist das Tier unvernünftig? (Dopp.-Bd.)
— Meyer, Dr. M. W., Weltschöpfung.
Bölsche, Stammbaum der Tiere. — Francé, Sinnesleben der
1905 Pflanzen. — Zell, Tierfabeln. — Teichmann, Dr. E., Leben und
Tod. — Meyer, Dr. M. W., Sonne und Sterne.
Francé, Liebesleben der Pflanzen. — Meyer, Dr. M. W., Rätsel
1906 der Erdpole. — Zell, Dr. Th., Streifzüge durch die Tierwelt. —
Bölsche, W., Im Steinkohlenwald. — Ament, Dr. W., Die Seele
des Kindes.
Francé, Streifzüge im Wassertropfen. — Zell, Dr. Th.,
1907 Straußenpolitik. — Meyer, Dr. M. W., Kometen und Meteore. —
Teichmann, Fortpflanzung und Zeugung. — Floericke, Dr. K.,
Die Vögel des deutschen Waldes.

gebunden M 1660.—
Meyer, Dr. M. W., Erdbeben und Vulkane. — Teichmann, Dr. E.,
1908 Die Vererbung. — Sajó, Krieg und Frieden im Ameisenstaat. —
Dekker, Naturgeschichte des Kindes. — Floericke, Dr. K.,
Säugetiere des deutschen Waldes.
Francé, Bilder aus dem Leben des Waldes. — Meyer, Dr. M.
1909 W., Der Mond. — Sajó, Prof. K., Die Honigbiene. — Floericke,
Kriechtiere und Lurche Deutschlands. — Bölsche, W., Der
Mensch in der Tertiärzeit.
Koelsch, Pflanzen zwischen Dorf und Trift. — Dekker, Fühlen
1910 und Hören. — Meyer, Dr. M. W., Welt der Planeten. —
Floericke, Säugetiere fremder Länder. — Weule, Kultur der
Kulturlosen.
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1911
und Schmecken. — Bölsche, Der Mensch der Pfahlbauzeit. —
Floericke, Vögel fremder Länder. — Weule, Kulturelemente der
Menschheit.

gebunden M 2075.—
Gibson-Günther, Was ist Elektrizität? — Dannemann, Wie
1912 unser Weltbild entstand. — Floericke, Fremde Kriechtiere und
Lurche. — Weule, Die Urgesellschaft und ihre Lebensfürsorge.
— Koelsch, Würger im Pflanzenreich.
Bölsche, Festländer und Meere. — Floericke, Einheimische
1913 Fische. — Koelsch, Der blühende See. — Zart, Bausteine des
Weltalls. — Dekker, Vom sieghaften Zellenstaat.
Bölsche, Wilh., Tierwanderungen in der Urwelt. — Floericke, Dr.
1914 Kurt, Meeresfische. — Lipschütz, Dr. A., Warum wir sterben. —
Kahn, Dr. Fritz, Die Milchstraße. — Nagel, Dr. Osk., Romantik
der Chemie.
Bölsche, Wilh., Der Mensch der Zukunft. — Floericke, Dr. K.,
1915 Gepanzerte Ritter. — Weule, Prof. Dr. K., Vom Kerbstock zum
Alphabet. — Müller, A. L., Gedächtnis und seine Pflege. —
Besser, H., Raubwild und Dickhäuter.
Bölsche, Stammbaum der Insekten. — Fabre, Blick ins
1916 Käferleben. — Sieberg, Wetterbüchlein. — Zell, Pferd als
Steppentier. — Bölsche, Sieg des Lebens.

gebunden M 1660.—
Besser, Natur- und Jagdstudien in Deutsch-Ostafrika. —
1917 Floericke, Dr., Plagegeister. — Hasterlik, Dr., Speise und Trank.
— Bölsche, Schutz- und Trutzbündnisse in der Natur.
Floericke, Forscherfahrt in Feindesland. — Fischer-Defoy,
1918 Schlafen und Träumen. — Kurth, Zwischen Keller und Dach. —
Hasterlik, Dr., Von Reiz- und Rauschmitteln.
Bölsche, Eiszeit und Klimawechsel. — Zell, Neue
1919 Tierbeobachtungen. — Floericke, Spinnen und Spinnenleben.
— Kahn, Die Zelle.
Fischer-Defoy, Lebensgefahr in Haus und Hof. — Francé, Die
1920 Pflanze als Erfinder. — Floericke, Schnecken und Muscheln. —
Lämmel, Wege zur Relativitätstheorie.
Weule, Naturbeherrschung I. — Floericke, Gewürm. —
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Gynaecology by Ten Teachers. 20th Edition ISE Helen Bickerstaff Download PDF

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Dewhurst's Textbook of Obstetrics & Gynaecology 9th

Oxford Textbook of Obstetrics and Gynaecology 1st

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Louise C Kenny MBChB (Hons), MRCOG, PhD

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© 2017 by Taylor & Francis Group, LLC

No claim to original U.S. Government works

Printed on acid-free paper

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and the CRC Press Web site at

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My Dad, Frank (HB)

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K26886_Book.indb 8 3/30/17 6:05 PM

K26886_Book.indb 9 3/30/17 6:05 PM

K26886_Book.indb 11 3/30/17 6:05 PM

AFC antral follicle count D&C dilatation and curettage

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HPV human papilloma virus OAB overactive bladder

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TAUSS transabdominal ultrasound scan UPT urinary pregnancy test

UAE umbilical/uterine artery embolization

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Chapter 2 Gynaecological history, examination and investigations

Chapter 3 Hormonal control of the menstrual cycle and hormonal disorders

Chapter 4 Disorders of menstrual bleeding

Chapter 5 Implantation and early pregnancy

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eResource 7.3 Egg collection using transvaginal ultrasound (TVUSS)

Chapter 11 Benign conditions of the ovary and pelvis

Chapter 12 Benign conditions of the uterus, cervix and endometrium

Chapter 14 Malignant disease of the ovary

Chapter 15 Malignant disease of the uterus

Chapter 17 Gyaecological surgery and therapeutics

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causes the gonad to begin development into a testis.

K26886_Book.indb 1 3/30/17 6:05 PM

K26886_Book.indb 2 3/30/17 6:05 PM

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but they probably add support to the distal vaginal

K26886_Book.indb 4 3/30/17 6:05 PM

Vagina Anal canal

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of the histological internal os is where the mucous Age changes to anatomy

K26886_Book.indb 6 3/30/17 6:05 PM

K26886_Book.indb 7 3/30/17 6:05 PM

is arranged in outer longitudinal and inner circular