Current - Gynecologic Disorders

Question 1

Abnormal Premenopausal Vaginal Bleeding Essentials

Answer 1

• Heavy or irregular intermenstrual bleeding warrants investigation
• Excessive bleeding, often with the passage of clots, may occur at regular menstrual intervals (menorrhagia) or irregular intervals (metrorrhagia)
• Age-related factors are an important consideration in the evaluation

Question 2

Treatment Abnormal Uterine Bleeding

Answer 2

• Give medroxyprogesterone acetate, 10 mg once daily orally, or norethindrone acetate, 5 mg once daily orally, for 10 days, following which withdrawal bleeding (medical curettage) occurs
• Treatment can be repeated for several cycles starting medication on day 15 of subsequent cycles, or can be reinstituted if amenorrhea or dysfunctional bleeding recurs
• In women who are bleeding actively
– Any combination oral contraceptive can be given four times daily for 1 or 2 days followed by two pills daily through day 5 and then one pill daily through day 20
– After withdrawal bleeding occurs, pills are taken in the usual dosage for three cycles

Question 3

Treatment Heavy Abnormal Uterine Bleeding

Answer 3

• For intractable heavy bleeding, a gonadotropin-releasing hormone agonist can be used for up to 6 months to create a temporary cessation of menstruation by ovarian suppression; for example
– Depot leuprolide, 3.75 mg monthly intramuscularly
– Nafarelin, 0.2–0.4 mg twice daily intranasally
• Alternatively, danazol, 200 mg four times daily orally, may also create to create an atrophic endometrium, but is generally no longer used due to its androgenic side effects
• For cases requiring hospitalization, intravenous conjugated estrogens, 25 mg every 4 hours for three or four doses, can be used followed by oral conjugated estrogens, 2.5 mg once daily orally, or ethinyl estradiol, 20 mcg once daily orally, for 3 weeks, with the addition of medroxyprogesterone acetate, 10 mg once daily orally for the last 10 days of treatment, or a combination oral contraceptive daily for 3 weeks
– This will thicken the endometrium and control the bleeding

Question 4

Menorrhagia Treatment

Answer 4

• Nonsteroidal anti-inflammatory drugs in the usual anti-inflammatory doses will often reduce blood loss in menorrhagia—even that associated with a copper intrauterine device
• Prolonged use of a progestin, as in a minipill, in injectable contraceptives, or in the therapy of endometriosis, can also lead to intermittent bleeding, sometimes severe
– In this instance, the endometrium is atrophic and fragile
– If bleeding occurs, it should be treated with estrogen as follows: ethinyl estradiol, 20 mcg once daily orally for 7 days, or conjugated estrogens, 1.25 mg once daily orally for 7 days

Question 5

Postmenopausal Vaginal Bleeding Essentials

Answer 5

• Vaginal bleeding that occurs 6 months or more following cessation of menstrual function
• Bleeding is usually painless
• Bleeding may be a single episode of spotting or profuse bleeding for days or months

Question 6

Postmenopausal Vaginal Bleeding Treatment (medical)

Answer 6

Treat simple endometrial hyperplasia with cyclic or continuous progestin therapy for 21 or 30 days of each month for 3 months
– Medroxyprogesterone acetate, 10 mg once daily orally
– Norethindrone acetate, 5 mg once daily orally
• Levonorgestrel intrauterine system (LNG-IUS) is also a treatment option

Question 7

Postmenopausal Vaginal Bleeding Treatment (surgical)

Answer 7

Endometrial biopsy or D&C may be curative
• Repeat sampling should be performed if symptoms recur
• Hysterectomy is necessary if endometrial hyperplasia with atypia or carcinoma of the endometrium is found

Question 8

Premenstrual Syndrome Essentials

Answer 8

• Recurrent, variable cluster of troublesome physical and emotional symptoms that develops during the 5 days before the onset of menses
• Symptoms subside within 4 days after menstruation occurs
• In about 10% of affected women, the syndrome may be severe

Question 9

Premenstrual Syndrome Treatment (tension, irritability, dysphoria)

Answer 9

Serotonin reuptake inhibitors such as fluoxetine, 20 mg once daily orally

Question 10

Premenstrual Syndrome Treatment (physical symptoms)

Answer 10

– A combined oral contraceptive containing ethinyl estradiol 20 mcg plus drospirenone 3 mg with a 4-day pill-free interval has been approved by the US Food and Drug Administration for treating premenstrual dysphoric disorder
– Nonsteroidal anti-inflammatory drugs—eg, mefenamic acid, 500 mg three times daily orally—will reduce a number of symptoms, although not breast pain
– When the above regimens are not effective, ovarian function can be suppressed with 20–30 mg/d of oral medroxyprogesterone acetate [DMPA] or 150 mg of DMPA orally every 3 months or GnRH agonist with add-back therapy, such as conjugated equine estrogen, 0.625 mg orally daily, with DMPA, 2.5–5 mg orally daily

Question 11

Premenstrual Syndrome Treatment (non-pharmacologic/alternative)

Answer 11

• A diet emphasizing complex carbohydrates can be recommended
– Foods high in sugar content and alcohol should be avoided to minimize reactive hypoglycemia
– Use of caffeine should be minimized whenever tension and irritability predominate
• Increase in dietary calcium (to 1200 mg/d) and vitamin D or magnesium can also be helpful
• A program of regular conditioning exercise, such as jogging, can decrease depression, anxiety, and fluid retention

Question 12

Dysmenorrhea (Primary vs. Secondary)

Answer 12

• Primary dysmenorrhea is menstrual pain associated with menstrual cycles in the absence of pathologic findings
• Secondary dysmenorrhea is menstrual pain for which an organic cause exists, such as endometriosis or uterine fibroids

Question 13

Primary Dysmenorrhea Treatment

Answer 13

• Nonsteroidal anti-inflammatory drugs (ibuprofen, ketoprofen, mefenamic acid, naproxen) and the COX-2 inhibitor celecoxib are generally helpful
• Drugs should be started 1–2 days before expected menses
• Symptoms can be suppressed by
– Oral contraceptives
– Depot-medroxyprogesterone acetate
– Levonorgestrel-containing IUD
• Continuous use of oral contraceptives can be used to suppress menstruation completely and prevent dysmenorrhea
• For women who do not want to use hormonal contraception, consider thiamine, 100 mg/d orally, or vitamin E, 200 units/d orally from 2 days prior to and for the first 3 days of menses

Question 14

Secondary Dysmenorrhea Treatment

Answer 14

Secondary dysmenorrhea
• Periodic use of analgesics, including the nonsteroidal anti-inflammatory drugs given for primary dysmenorrhea, may be beneficial
• Oral contraceptives may give relief, particularly in endometriosis
• Danazol and gonadotropin-releasing hormone agonists are effective in the treatment of endometriosis
• Levonorgestrel-releasing intrauterine system (LNG-IUS), uterine artery embolization, or hormonal approaches to endometriosis are used to treat adenomyosis

Question 15

Vaginitis Essentials

Answer 15

• Vaginal irritation, pruritus, pain, or unusual discharge

Question 16

Normal vaginal pH is ____

Predominant organism in vagina ______

Answer 16

pH is 4.5 or less

Lactobacillus is predominant

Question 17

Vulvovaginal Candidiasis (About & Findings)

Answer 17

• Pregnancy, diabetes, and use of broad-spectrum antibiotics or corticosteroids predispose to Candida infections
• Heat, moisture, and occlusive clothing also contribute to the risk
• Pruritus
• Vulvovaginal erythema
• White curd-like discharge that is not malodorous

Question 18

Vulvovaginal Candidiasis (Treatment)

Answer 18

• Women with uncomplicated vulvovaginal candidiasis will usually respond to a 1- to 3-day regimen of a topical azole
• Women should receive 7–14 days of a topical regimen or two doses of oral fluconazole 3 days apart for complicated infection, which includes
– Four or more episodes in 1 year
– Severe signs and symptoms
– Nonalbicans species
– Uncontrolled diabetes
– HIV infection
– Corticosteroid treatment
– Pregnancy (pregnant women should use only topical azoles)
• Single-dose regimens
– Miconazole (1200-mg vaginal suppository)
– Tioconazole ointment (6.5%, 5 g vaginally)
– Butoconazole sustained-release (2% cream, 5 g vaginally)
– Fluconazole (150-mg oral tablet)
• Three-day regimens
– Butoconazole (2% cream, 5 g) once daily
– Clotrimazole (2% cream, 5 g) once daily
– Terconazole (0.8% cream, 5 g, or 80-mg suppository) once daily
– Miconazole (200-mg vaginal suppository) once daily
• Seven-day regimens
– Clotrimazole (1% cream) once daily
– Miconazole (2% cream, 5 g, or 100-mg vaginal suppository) once daily
– Terconazole (0.4% cream, 5 g) once daily
• Fourteen-day regimen
– Nystatin (100,000-unit vaginal tablet once daily)
• Recurrent vulvovaginal candidiasis (maintenance therapy for up to 6 months)
– Clotrimazole (500-mg vaginal suppository) once weekly or clotrimazole (200 mg cream) twice weekly
– Fluconazole (100, 150, or 200 mg orally) once weekly
• In recurrent non-albicans infections, 600 mg of boric acid in a gelatin capsule intravaginally once daily for 2 weeks is ~70% effective

Question 19

Trichomonas Vaginalis (About & Findings)

Answer 19

• This protozoal flagellate infects the vagina, Skene ducts, and lower urinary tract in women and the lower genitourinary tract in men
• It is sexually transmitted
• Pruritus and a malodorous frothy, yellow-green discharge
• Diffuse vaginal erythema and red macular lesions on the cervix in severe cases (“strawberry cervix”)

Question 20

Trichomonas Vaginalis (Treatment)

Answer 20

• Recommend treatment of both partners
– Metronidazole or tinidazole, 2 g orally, single dose
– For treatment failure with metronidazole in the absence of reexposure, retreat with metronidazole, 500 mg twice daily for 7 days, or tinidazole, 2 g orally as a single dose
– If this is not effective, metronidazole and tinidazole susceptibility testing can be arranged with the Centers for Disease Control and Prevention
– Women infected with T vaginalis are at increased risk for concurrent infection with other STDs

Question 21

Bacterial Vaginosis (About & Findings)

Answer 21

• This condition is considered to be a polymicrobial (overgrowth of Gardnerella vaginalis and other anaerobes) and is not sexually transmitted
• Increased malodorous discharge without obvious vulvitis or vaginitis
• Discharge is grayish, frothy

Question 22

Bacterial Vaginosis (Treatment)

Answer 22

• Metronidazole, 500 mg twice daily orally for 7 days
• Clindamycin vaginal cream (2%, 5 g), once daily for 7 days
• Metronidazole gel (0.75%, 5 g), twice daily for 5 days
• Alternatives
– Clindamycin, 300 mg twice daily orally for 7 days
– Clindamycin ovules, 100 g intravaginally at bedtime for 3 days
– Tinidazole, 2 g orally once daily for 3 days
– Tinidazole, 1 g orally once daily for 7 days

Question 23

Condyloma Acuminata (About & Findings)

Answer 23

• Caused by various types of the human papillomavirus
• Sexually transmitted
• Pregnancy and immunosuppression favor growth
• Warty growths on the vulva, perianal area, vaginal walls, or cervix
• Vulvar lesions: obviously wart-like
• Fissures may be at the fourchette
• Vaginal lesions may show diffuse hypertrophy or a cobblestone appearance

Question 24

Condyloma Acuminata (Treatment)

Answer 24

• For vulvar warts
– Podophyllum resin 10–25% in tincture of benzoin (do not use during pregnancy or on bleeding lesions). Wash off after 2–4 hours
– 80–90% trichloroacetic or bichloroacetic acid. Apply carefully to avoid the surrounding skin
• Freezing with liquid nitrogen
• Patient-applied regimens
– Useful when the entire lesion is accessible to the patient
– Include podofilox 0.5% solution or gel, imiquimod 5% cream, or sinecatechins 15% ointment
• Vaginal warts may be treated with cryotherapy with liquid nitrogen or trichloroacetic acid
• Interferon is not recommended for routine use

Question 25

Wet Mount (pH, microsopic exam, KOH, wiff)

Answer 25

• pH is frequently > 4.5 in infections due to trichomonads (pH of 5.0–5.5) and bacterial vaginosis
• Examine a specimen of vaginal discharge microscopically
– In a drop of 0.9% saline solution (wet mount) to search for motile organisms with flagella (trichomonads) and epithelial cells covered with bacteria to such an extent that cell borders are obscured (clue cells)
– In a drop of 10% potassium hydroxide to search for the filaments and spores of Candida and an amine-like “fishy” odor of Bacterial Vaginosis or Trichomonas.

Question 26

Cervical Polyp (About & Findings)

Answer 26

• Commonly occur after menarche and are occasionally noted in postmenopausal women
• The cause is not known, but inflammation may play an etiologic role
• Must be differentiated from polypoid neoplastic disease of the endometrium, small submucous pedunculated myomas, large nabothian cysts, and endometrial polyps
• Cervical polyps rarely contain dysplasia (0.5%) or malignant (0.5%) foci
• Discharge and abnormal vaginal bleeding
• Abnormal bleeding should not be ascribed to a cervical polyp without sampling the endocervix and endometrium

Question 27

Cervical Polyp (Treatment)

Answer 27

• Asymptomatic polyps in women under age 45 may be left untreated
• Cervical polyps can generally be removed in the office by avulsion with a uterine packing forceps or ring forceps
• If the cervix is soft, patulous, or definitely dilated and the polyp is large, surgical D&C is required (especially if the pedicle is not readily visible)
• Hysteroscopy may aid removal and lead to identification of concomitant endometrial disease
• Because of the possibility of endometrial disease, cervical polypectomy should be accompanied by endometrial sampling, and all tissue removed should be submitted for microscopic examination

Question 28

Bartholin Duct Cysts & Abscesses (Findings)

Answer 28

• Periodic painful swelling on either side of the introitus and consequent dyspareunia
• A fluctuant swelling 1–4 cm in diameter lateral to either labium minus is a sign of occlusion of Bartholin duct
• Tenderness is evidence of active infection

Question 29

Bartholin Duct Cysts & Abscesses (Treatment)

Answer 29

• Pus or secretions from the gland should be cultured for Chlamydia and other pathogens
• Treat according to culture results
• Frequent warm soaks may be helpful
• If an abscess develops, aspiration or incision and drainage are the simplest forms of therapy, but the problem may recur
• Marsupialization (in the absence of an abscess), incision and drainage with the insertion of an indwelling Word catheter, or laser treatment will establish a new duct opening. Antibiotics are unnecessary unless cellulitis is present
• An asymptomatic cyst does not require therapy

Question 30

Classification Systems for Papanicolaou Smears

Answer 30

Dysplasia - CIN - Bethesda System
Benign - Benign - Normal
Benign with inflammation - Benign with inflammation - Normal, ASC-US
Mild dysplasia - CIN I - Low-grade SIL
Moderate dysplasia - CIN II - High-grade SIL
Severe dysplasia - CIN III
Carcinoma in situ
Invasive cancer=Invasive cancer=Invasive cancer

Question 31

Cervical Dysplasia Treatment:

Conization - surgical removal of the entire transformation zone and endocervical canal

Answer 31

• It should be reserved for cases of severe dysplasia or carcinoma in situ (CIN III), particularly those cases with endocervical extension

Question 32

Cervical Dysplasia Treatment:

Cauterization or cryosurgery

Answer 32

• The use of either hot cauterization or freezing (cryosurgery) is effective for noninvasive small lesions visible on the cervix without endocervical extension

Question 33

Cervical Dysplasia Treatment:

CO2 laser

Answer 33

• It may be used with large visible lesions

* It involves the vaporization of the transformation zone on the cervix and the distal 5–7 mm of the endocervical canal

Question 34

Cerfical Dysplasia Treatment: Loop excision

Answer 34

• When the CIN is clearly visible in its entirety, a wire loop can be used for excisional biopsy
*Local anethesia

Question 35

When To Do Pap Smear

Answer 35

• Screening begins at age 21 w/ ctyology every 3 years & HPV every 5 years.
• USPTSF says stop screening older than 65 with adequate screening and no risk

Question 36

When to Do Colposcopy

Answer 36

Pap: ASC-US w/ neg HPV, followed up in 1 year, remains unchanged –> Colp
Pap: SIL or atypical glandular cells –> Colp
Pap: CIN II or III –> cytology and colp at 4-6 mo intervals for 2 yrs.
Pap: CIN I –> cytology at 6 mo, cytology & HPV at 12 mo. If normal, return to routine screening

Question 37

Carcinoma of the Cervix (About & Findings)

Answer 37

• Early on, cervical cancer usually does not cause signs or symptoms
• Increased risk in women with HIV and high risk HPV types as well as in smokers
• Watery vaginal discharge, intermittent spotting, or postcoital bleeding may be signs of a lesion
• Cervical lesion may be visible on inspection as a tumor or ulceration
• Most common signs
– Metrorrhagia
– Postcoital spotting
– Cervical ulceration
• Bloody or purulent, odorous, nonpruritic discharge may appear after invasion
• Bladder and rectal dysfunction or fistulas and pain are late symptoms

Question 38

Carcinoma of the Cervix (Treatment)

Answer 38

Carcinoma in situ (Stage 0) - total hysterectomy ideally if finished childbearing. cervical conization or ablation if want to keep uterus.
Invasive carcinoma - hysterectomy, radical, radiation, chemo, combo, lymph node dissection

Question 39

Leiomyoma of the Uterus (About & Findings)

Answer 39

• Irregular enlargement of the uterus (may be asymptomatic)
• Heavy or irregular vaginal bleeding, dysmenorrhea
• Acute and recurrent pelvic pain if the tumor becomes twisted on its pedicle or infarcted
• Symptoms due to pressure on neighboring organs (large tumors)

Question 40

Leiomyoma of the Uterus (Treatment - Medications pre surgery)

Answer 40

• Depot medroxyprogesterone acetate (150 mg every 28 days intramuscularly) or gonadotropin-releasing hormone analogs (depot leuprolide, 3.75 mg intramuscularly monthly, or nafarelin, 0.2–0.4 mg intranasally twice daily)
– Used as preoperative treatment for marked anemia as a result of heavy menstrual periods
– Slows or stops bleeding
• Because the risk of surgical complications increases with the increasing size of the myoma, preoperative reduction of myoma size is desirable
• Low-dose mifepristone (5–10 mg/d) and other selective progesterone-receptor modulators have shown some promise for long-term medical treatment of myomas

Question 41

Leiomyoma of the Uterus (Treatment - Surgery)

Answer 41

• Emergency surgery is required for acute torsion of a pedunculated myoma
• The only emergency indication for myomectomy during pregnancy is torsion; abortion is not inevitable
• Surgical measures: available for treatment are myomectomy and total or subtotal abdominal, vaginal, or laparoscopy-assisted vaginal hysterectomy
• Myomectomy is the treatment of choice for women who wish to preserve fertility
• Myomas do not require surgery on an urgent basis unless they cause significant pressure on the ureters, bladder, or bowel or severe bleeding leading to anemia or unless they are undergoing rapid growth
• Cervical myomas larger than 3–4 cm in diameter or pedunculated myomas that protrude through the cervix must be removed
• Submucous myomas can be removed using a hysteroscope and laser or resection instruments
• Uterine artery embolization
– Minimally invasive
– Clinician uses a slender, flexible tube (catheter) to inject small particles into the uterine arteries, which supply blood to the uterus
– The goal is to block tiny vessels that lead to the fibroids, starve the fibroids and cause them to necrose

Question 42

Carcinoma of the Endometrium (About

Answer 42

• Abnormal bleeding is the presenting sign in 80% of cases
• Papanicolaou smear frequently negative
• After a negative pregnancy test, endometrial tissue is required to confirm the diagnosis

Question 43

Carcinoma of the Endometrium (Diagnostics)

Answer 43

• Endocervical and endometrial sampling is the only reliable means of diagnosis

Question 44

Carcnoma of the Endometrium (Treatment)

Answer 44

• Advanced or metastatic endometrial adenocarcinoma may be palliated with large doses of progestins, eg, medroxyprogesterone, 400 mg weekly intramuscularly, or megestrol acetate, 80–160 mg daily orally
• The role of chemotherapy alone or with irradiation is under investigation, although one study has shown a modest increase in survival with chemotherapy alone compared to whole abdominal radiation alone in women with stage III–IV disease
• Treatment consists of total hysterectomy and bilateral salpingo-oophorectomy. Peritoneal material for cytologic examination is routinely taken
• Preliminary external irradiation or intracavitary radium therapy is indicated if the cancer is poorly differentiated or if the uterus is definitely enlarged in the absence of myomas

Question 45

Carcinoma of the Vulva (About & Findings)

Answer 45

• History of genital warts
• History of prolonged vulvar irritation, with pruritus, local discomfort, or slight bloody discharge
• Early lesions may suggest or include nonneoplastic epithelial disorders
• Late lesions appear as a mass, an exophytic growth, or a firm, ulcerated area in the vulva
• Biopsy is necessary for diagnosis

Question 46

Carcinoma of the Vulva (Diagnostic)

Answer 46

Biopsy is essential for the diagnosis and should be performed with any localized atypical vulvar lesion, including white patches

Question 47

Carcinoma of the Vulva (Treatment - Medication)

Answer 47

• A 7:3 combination of betamethasone and crotamiton is particularly effective for itching
• After an initial response, fluorinated steroids should be replaced with hydrocortisone because of their skin atrophying effect
• For lichen sclerosus
– Apply clobetasol propionate cream 0.05% twice daily for 2–3 weeks, then once daily until symptoms resolve
– Application one to three times a week can be used for long-term maintenance therapy

Question 48

Carcinoma of the Vulva (Treatment - Surgery)

Answer 48

Excised with a wide margin, laser therapy or superficial surgical removal of vulvar skin, wide local excision, inguinal lymphadenectomy, preoperative radiation, preoperative chemo

Question 49

Endometriosis (About & Findings)

Answer 49

• Pelvic pain related to menstrual cycle
• Dysmenorrhea
• Dyspareunia
• Increased frequency among infertile women

Question 50

Endometriosis (Treatment - Medical)

Answer 50

• Nonsteroidal anti-inflammatory drugs may be helpful
• Progestins, specifically oral norethindrone acetate and subcutaneous DMPA, have been approved by the US Food and Drug Administration (FDA) for treatment of endometriosis-associated pain
• Low-dose oral contraceptives can also be given cyclically; prolonged suppression of ovulation will often inhibit further stimulation of residual endometriosis, especially if taken after one of the therapies mentioned here
• Any of the combination oral contraceptives, the contraceptive patch, or the vaginal ring
– May be used continuously for 6–12 months
– Breakthrough bleeding can be treated with conjugated estrogens, 1.25 mg daily orally for 1 week, or estradiol, 2 mg daily orally for 1 week
• The optimum duration of therapy is not known
• Gonadotropin-releasing hormone analogs
– Nafarelin nasal spray, 0.2–0.4 mg twice daily, or long-acting injectable leuprolide acetate, 3.75 mg monthly intramuscularly, used for 6 months, suppress ovulation
– Side effects consisting of vasomotor symptoms and bone demineralization may be relieved by “add-back” therapy with conjugated equine estrogen, 0.625 mg or norethindrone, 5 mg daily orally
• Danazol
– Used for 4–6 months in the lowest dose necessary to suppress menstruation, usually 200–400 mg twice daily orally
– Has a high incidence of androgenic side effects, including decreased breast size, weight gain, acne, and hirsutism
• Intrauterine progestin use with the levonorgestrel intrauterine system also has been shown to be effective in reducing endometriosis-associated pelvic pain and should be tried before radical surgery
• Aromatase inhibitors, such as anastrozole or letrozole, have been evaluated in women with chronic pain resistant to other forms of medical management or surgical management; although promising, there are insufficient data to recommend their routine use

Question 51

Endometriosis (Treatment - Surgical)

Answer 51

• Surgical treatment of endometriosis—particularly extensive disease—is effective both in reducing pain and in promoting fertility
– Laparoscopic ablation of endometrial implants along with uterine nerve ablation significantly reduces pain
– Ablation of implants and, if necessary, removal of ovarian endometriomas enhance fertility, although subsequent pregnancy rates are inversely related to the severity of disease
– Women with disabling pain who no longer desire childbearing can be treated definitively with total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO)

Question 52

Uterine Prolapse (Staging)

Answer 52

– Stage I prolapse: the uterus descends only partway down the vagina
– Stage II prolapse: the corpus descends to the introitus and the cervix protrudes slightly beyond
– Stage III prolapse: the entire cervix and uterus protrude beyond the introitus
– Stage IV prolapse: the vagina is inverted

Question 53

Cystocele
Urethrocele
Rectocele
Enterocele

Answer 53

• Cystocele is a hernia of the bladder wall into the vagina, causing a soft anterior fullness
• Urethrocele, which is not a hernia but a sagging of the urethra after its detachment from the pubic symphysis during childbirth
• Rectocele is a herniation of the terminal rectum into the posterior vagina, causing a collapsible pouch-like fullness
• Enterocele is a vaginal vault hernia containing small intestine, usually in the posterior vagina and resulting from a deepening of the pouch of Douglas

Question 54

Treatment for (Uterus prolapse, cystocele, rectocele, and enterocele)

Answer 54

• Pelvic muscle training (Kegel exercises)
• type of surgery depends on extent of prolapse and the desire for menstruation, pregnancy, and coitus
• The simplest, most effective procedure is vaginal hysterectomy with repair of the cystocele, rectocele or enterocele as needed
• If pregnancy is desired, a partial resection of the cervix with plication of the cardinal ligaments can be attempted
• For older women who do not desire coitus, partial obliteration of the vagina is surgically simple and effective
• For vaginal hernias, supportive measures include a high-fiber diet and laxatives to improve constipation. Weight reduction in obese patients and limitation of straining and lifting are helpful
• The only cure for symptomatic cystocele, rectocele, or enterocele is corrective surgery
• The prognosis after an uncomplicated procedure is good
• A well-fitted vaginal pessary (eg, inflatable doughnut type, Gellhorn pessary) may reduce uterine prolapse, cystocele, rectocele, or enterocele temporarily and are helpful in women who do not wish surgery or are poor surgical candidates

Question 55

Pelvic Inflammatory Disease PID (About & Findings)

Answer 55

• Uterine, adnexal, or cervical motion tenderness
• Abnormal discharge from the vagina or cervix
• Absence of a competing diagnosis
• Symptoms may include
– Lower abdominal pain
– Chills and fever
– Menstrual disturbances
– Purulent cervical discharge
– Cervical and adnexal tenderness

Question 56

Pelvic Inflammatory Disease PID (Treatment)

Answer 56

Inpatient regimens
• Cefotetan 2 g intravenously every 12 hours or cefoxitin 2 g intravenously every 6 hours plus doxycycline 100 mg orally or intravenously every twelve hours
• Clindamycin 900 mg intravenously every 8 hours plus gentamycin, a loading dose 2 mg/kg intravenously or intramuscularly followed by a maintenance dose of 1.5 mg/kg every 8 hours (or as a single daily dose, 3-5 mg/kg)
• These regimens should be continued for a minimum of 24 hours after the patient shows significant clinical improvement
• Then, an oral regimen should be started to complete a total of 14 days of therapy with either doxycycline, 100 mg orally twice a day, or clindamycin, 450 mg orally four times a day
• If a tubo-ovarian abscess is present, clindamycin should be given because it provides better anaerobic coverage
Outpatient regimens
• Single dose of cefoxitin, 2 g intramuscularly, with probenecid, 1 g orally, with doxycycline 100 mg orally twice daily for 14 days; or ceftriaxone 250 mg intramuscularly plus doxycycline, 100 mg orally twice daily, for 14 days
• Adding metronidazole (500 mg orally twice daily for 14 days) to either of these regimens treats bacterial vaginosis that is frequently associated with PID
Surgery
• Tubo-ovarian abscesses may require surgical excision or transcutaneous or transvaginal aspiration
• Unilateral adnexectomy is acceptable for unilateral abscess
• Hysterectomy and bilateral salpingo-oophorectomy may be necessary for overwhelming infection or in cases of chronic disease with intractable pelvic pain

Question 57

Ovarian Cancer & Ovarian Tumors (Essentials)

Answer 57

• Vague gastrointestinal discomfort
• Pelvic pressure and pain
• Many cases of early-stage cancer are asymptomatic
• Pelvic examination and ultrasound are mainstays of diagnosis

Question 58

Ovarian Cancer and Ovarian Tumors (Treatment)

Answer 58

Medications
• Except for women with low-grade ovarian cancer in an early stage, postoperative chemotherapy is indicated (Table 39–12)
• Several chemotherapy regimens are effective, such as the combination of cisplatin or carboplatin with paclitaxel, with clinical response rates of up to 60–70% (Table 39–13)
Surgery
• Most ovarian masses in postmenopausal women require surgical evaluation
• However, a postmenopausal woman with an asymptomatic unilateral simple cyst < 5 cm in diameter and a normal serum CA 125 level may be monitored closely with TVS. All others require surgical evaluation
• Exploratory laparotomy has been the standard approach in postmenopausal women
• For ovarian cancer in an early stage, the standard therapy is complete surgical staging followed by abdominal hysterectomy and bilateral salpingo-oophorectomy with omentectomy and selective lymphadenectomy
• With more advanced disease, removal of all visible tumor improves survival
• For benign neoplasms, tumor removal or unilateral oophorectomy is usually performed
Therapeutic Procedures
• In a premenopausal woman, an asymptomatic, mobile, unilateral, simple cystic mass < 8–10 cm may be observed for 4–6 weeks
– Most will resolve spontaneously
– If the mass is larger or unchanged on repeat pelvic examination and TVS, surgical evaluation is required
• Laparoscopy may be considered for a small ovarian mass in a premenopausal woman
• If malignancy is suspected because of findings on transvaginal ultrasound with morphologic scoring, color Doppler assessment of vascular quality, and serum CA 125 level, then laparotomy is preferable

Question 59

Polycystic Ovary Syndrome PCOS (About & Findings)

Answer 59

• Clinical or biochemical evidence of hyperandrogenism
• Oligoovulation or anovulation
• Polycystic ovaries on ultrasonography (“pearl necklace”)
• Often presents as a menstrual disorder (from amenorrhea to menorrhagia) and infertility
• Skin disorders due to peripheral androgen excess, including hirsutism or acne, are common
• Patients may show signs of insulin resistance and hyperinsulinemia, and these women are at increased risk for early-onset type 2 diabetes and metabolic syndrome

Question 60

Polycystic Ovary Syndrome PCOS (Treatment)

Answer 60

Medications
• If the patient wishes to become pregnant
– Clomiphene or other drugs can be used for ovulatory stimulation
– The addition of dexamethasone, 0.5 mg orally at bedtime, to a clomiphene regimen may increase the likelihood of ovulation
– If unresponsive to clomiphene, adding metformin, 500 mg three times daily orally, may enhance likelihood of ovulation
• If the patient does not desire pregnancy
– Medroxyprogesterone acetate, 10 mg daily orally for the first 10 days of each month
– If contraception is desired, a low-dose combination oral contraceptive can be used; this is also useful in controlling hirsutism, for which treatment must be continued for 6–12 months before results are seen
• Hirsutism
– Dexamethasone, 0.5 mg orally each night, is helpful in women with excess adrenal androgen secretion
– Spironolactone, an aldosterone antagonist, is also useful in doses of 25 mg three or four times daily orally
– Flutamide, 125–250 mg once daily orally, and finasteride, 5 mg once daily orally, are also effective
– Because spironolactone, flutamide, and finasteride are potentially teratogenic, they should only be used with secure contraception
– Topical eflornithine cream applied to affected facial areas twice daily for 6 months may be helpful
Therapeutic Procedures
• In obese patients with polycystic ovaries, weight reduction is often effective; a decrease in body fat will lower the conversion of androgens to estrone and thereby help restore ovulation
• Hirsutism may be managed with depilatory creams, electrolysis, and laser therapy

Question 61

Infertility

Answer 61

Pregnancy does not result after 1 year of normal sexual activity without contraception

• General physical exam for man and woman
• Labs: CBC, UA, Cervical culture, TSH, FSH, LH, Estradiol, Prolactin
• Hysterosalpingogram
• Semen analysis
• Hysteroscopy, Laparoscopy

Question 62

Infertility - Medications to Stimulate Ovulation

Answer 62

 Clomiphene citrate
– After a normal menstrual period or induction of withdrawal bleeding with progestin, give clomiphene 50 mg once daily orally for 5 days, typically on days 3–7 of the cycle
– If ovulation does not occur, increase dosage to 100 mg once daily for 5 days
– If ovulation still does not occur, the course is repeated with 150 mg once daily for 5 days, and then 200 mg once daily for 5 days, with the addition of chorionic gonadotropin, 10,000 units intramuscularly, 7 days after clomiphene
• In the presence of increased androgen production (DHEA-S > 200 mcg/dL)
– Addition of dexamethasone, 0.5 mg orally at bedtime, or prednisone, 5 mg orally at bedtime, improves the response to clomiphene
– Dexamethasone should be discontinued after pregnancy is confirmed
• Letrozole
– Dose is 5–7.5 mg daily, starting on day 3 of the menstrual cycle
– Appears to be at least as effective as clomiphene for ovulation induction in women with polycystic ovary syndrome
– Advantages include a reduced risk of multiple pregnancy, a lack of antiestrogenic effects, and a reduced need for ultrasound monitoring
• Bromocriptine
– Used only if PRL levels are elevated and there is no withdrawal bleeding following progesterone administration (otherwise, clomiphene is used)
– Initial dosage is 2.5 mg once daily orally, increased to two or three times daily in increments of 1.25 mg
– Discontinue once pregnancy has occurred

Question 63

Menopausal Syndrome (About & Findings)

Answer 63

• Cessation of menses due to aging or to bilateral oophorectomy
• Hot flushes and night sweats (in 80% of women)
• Decreased vaginal lubrication; thinned vaginal mucosa with or without dyspareunia
• Menstrual cycles generally become irregular as menopause approaches
• Anovular cycles occur more often, with irregular cycle length and occasional menorrhagia
• Menstrual flow amount diminishes
• Finally, cycles become longer, with missed periods or episodes of spotting only
• When no bleeding has occurred for 1 year, the menopausal transition has occurred
• Hot flushes
– Feelings of intense heat over the trunk and face, with flushing of the skin and sweating
– Can begin before the cessation of menses and are more severe after surgical menopause
– When they occur at night, they often cause sweating and insomnia and result in fatigue on the following day
• Vaginal atrophy and decreased vaginal lubrication
• The introitus decreases in diameter
• Pelvic examination reveals pale, smooth vaginal mucosa and a small cervix and uterus
• The ovaries are not normally palpable after the menopause

Question 64

Menopausal Syndrome (Treatment)

Answer 64

Medications
Natural menopause
• Oral conjugated estrogens, 0.3 mg or 0.625 mg; estradiol, 0.5 or 1 mg; or estrone sulfate, 0.625 mg; or estradiol can be given transdermally as skin patches that are changed once or twice weekly and secrete 0.05–0.1 mg of hormone daily
• Unless the patient has undergone hysterectomy, a combination regimen of the estrogen with a progestin such as medroxyprogesterone, 1.5 or 2.5 mg, or norethindrone, 0.1, 0.25 or 0.5 mg, should be used to prevent endometrial hyperplasia or cancer; a patch containing estradiol and levonorgestrel is also available
– Give estrogen on days 1–25 of each calendar month, with 5–10 mg of oral medroxyprogesterone acetate added on days 14–25. Withhold hormones from day 26 until the end of the month, which will produce a light, generally painless monthly period
– Alternatively, give the estrogen along with a progestin daily without stopping. This causes initial bleeding or spotting, but within a few months it produces an atrophic endometrium that will not bleed
– If the patient has had a hysterectomy, a progestin need not be used
• Explain that hot flushes will probably return if the hormone is discontinued
• Women should not use combination progestin-estrogen therapy for more than 3 or 4 years
• Alternatives to hormone therapy for vasomotor symptoms include
– Selective serotonin reuptake inhibitors such as paroxetine 12.5 mg or 25 mg/d orally, or venlafaxine 75 mg/d orally
– Gabapentin, an antiseizure medication, is also effective at 900 mg/d orally
– Clonidine given orally or transdermally, 100–150 mcg daily, also may reduce the frequency of hot flushes, but its use is limited by side effects, including dry mouth, drowsiness, and hypotension
– Soy isoflavones may be effective in treating menopausal symptoms
• Women who cannot find relief with alternative approaches may wish to consider continuing use of combination therapy after a thorough discussion of the risks and benefits
• Estradiol vaginal ring, left in place for 3 months, is suitable for long-term use. Progestin therapy to protect the endometrium is unnecessary
• Short-term use of estrogen vaginal cream will relieve symptoms of atrophy, but because of variable absorption, therapy with either systemic hormone replacement or the vaginal ring is preferable
• A low-dose estradiol tablet (10 mcg) is available and is inserted in the vagina daily for 2 weeks and then twice a week for long-term use
• Testosterone propionate, 1–2%, 0.5–1.0 g, in a vanishing cream base used in the same manner is also effective if estrogen is contraindicated
• A bland lubricant such as unscented cold cream or water-soluble gel can be helpful at the time of coitus
• Women should ingest at least 800 mg of calcium daily and 1200 mg of elemental calcium should be taken as a daily supplement at the time of the menopause and thereafter
– Calcium supplements should be taken with meals to increase their absorption
– Vitamin D, 400–800 international units/d from food, sunlight, or supplements, enhances calcium absorption and maintains bone mass
• Daily energetic walking and exercise help maintain bone mass
• The use of long-term hormone replacement therapy for prevention is no longer indicated. Clinicians should review with women and carefully consider the risks and benefits
• Current indications for hormone therapy (estrogen and progestin) are for treatment of vasomotor symptoms, which resolve within several months to a few years
• Postmenopausal women with decreased sexual desire may be treated successfully with testosterone along with estrogen or estrogen/progestin therapy
– The transdermal route of testosterone delivery, rather than the intramuscular or oral route, should be used to avoid first-pass effect
– A compounded preparation of 1% testosterone gel, cream, or ointment, 0.5 g/d, will deliver the desired dose of 5 mg daily
– Testosterone preparation formulated for men should not be used because the doses are far higher than are necessary for women
Surgical menopause
• If not contraindicated, estrogen replacement is generally started immediately after surgery
• Conjugated estrogens 1.25 mg orally, estrone sulfate 1.25 mg orally, or estradiol, 2 mg orally is given for 25 days of each month
• After age 45–50 years, this dose can be tapered to 0.625 mg of conjugated estrogens or equivalent