General gynaecology Flashcards
What is the frequency of menstrual cycle?
Duration of flow?
Volume of blood loss?
Regularity of cycle?
Frequency: 21-35 days
Duration of flow = 8 days
Volume of blood loss = 5-80ml
Regularity of cycle = cycle to cycle variation +2-20 days over 12 months
What is the normal range of menarche and menopause?
Menarche = 10-16 years (average = 12)
Menopause = 40-55 years (average = 51)
Define frequent periods, infrequent periods
Frequent periods = menses occur more frequently than every 12 days over 6 months
Infrequent periods = menses occur less frequently than every 35 days over 6 months
Define primary and secondary amenorrhea
Primary: absence of spontaneous onset of period by age of 16
Secondary: absence of periods for > 6 months when a patient has regular period before and patient has irregular cycles all along >12 months
What is prolonged vs shortened menstrual bleeding?
Prolonged menstrual bleeding: menstrual periods > 7 days on a regular basis
Shortened menstrual bleeding: menstrual period <2 days on a regular basis
What is heavy vs light menstrual bleeding?
Heavy menstrual bleeding: >80ml of blood loss per cycle. Excessive menstrual blood loss which interferes womens physical, emotional, social and material QoL. Change pads <2 hour on the day of heaviest bleeding.
Light menstrual bleeding: <5ml of blood loss per cycle
What is irregular menstrual bleeding defined as?
Variation defined as shortest to longest cycle length: variation >7-9 days
What are the hormonal changes in the follicular phase?
- Hypothalamus secretes GnRH
- GnRH stimulates the pituitary gland to secrete FSH and LH
- LH and FSH stimulates the production of estrogen from thecal and granulosa cells
- FSH stimulates the growth of the follicles
- Estrogen at low level inhibits hypothalamus to secrete GnRH. Inhibits the pituitary gland to secerete FSH to prevent the ovary from developing another follicle
What are the hormonal changes in the ovulatory phase?
- Estrogen is high which stimulates the hypothalamus to secrete GnRH. Stimulates the pituitary gland to secrete large amounts of FSH and LH
- Progestoerone low level: potentiates the effect of estrogen on LH surge
- LH and FSH at high level stimulates ovulation. Detection of high level of LH in blood is evident of occurrence of ovulation
What are the hormonal changes in the luteal phase?
LH (high level): stimulate ruptured follicle to develop into corpus luteum. Stimulates corpus luteum to secrete estrogen and progesterone
Estrogen (high level): promote growth of uterine lining preparing for implantation. Inhibit the hypothalamus to secrete GnRH. Inhibit the pituitary gland to secrete FSH and LH.
What are the hormonal changes in menstruation?
- LH (low level): corpus luteum degenerates and stops secreting estrogen and progesteorne
- Estrogen and progesterone (low level): break down of the thickened uterine lining. Remove inhibition on pituitary gland to secrete FSH
What are the changes in the endometrium over the menstrual cycle?
- Proliferative phase: estrogen effect is predominant. Causes proliferation of endometrial glands
- Secretory phase: progesterone effect if predominant, inhibit proliferative changes. Stimulates the secretory function of endometrial glands to provide hospitable environment for implantation
How to assess menorrhagia in historuy taking?
Defined as excessive cyclic menstrual bleeding defined as >80ml of menstrual loss
- Number of pads used
- Frequency of changing pads each day (change every <2 hours suggest heavy menses)
- Degree of soiling of pads (half soaked/fully soaked)
- Flooding sensation
- Presence of large blood clots
- Activitiy limitation: interferes with daily activities suggests heavy menses (staining clothes or sheets, waking patients from sleep)
What is the most common cause of menorrhagia?
What is its pathophysiology?
Dysfunctional uterine bleeding (dx of exclusion and there is no underlying organic cause)
Anovulatory DUB: common at extremes of reproductive age including early puberty when menarche just started and perimenopausal women. Absence of ovulation and therefore corpus luteum is not formed and progesterone cannot be produced.
Unopposed estrogen leads to continuous proliferation of endometrial glands leading to overgrowth of uterine lining. Delayed period leading to irregularity and when menstruation occurs it will be heavy and prolonged.
Ovulatory DUB: unknown mechanism but may be related to inadequate production of progesterone from corpus luteum
What is the PALM-COEIN classification for menorrhagia?
PALM (structural causes)
* Polyps
* Adenomyosis: benign invasion of myometrium by ectopic endometrium. Accompanied by hyperplasia of adjacent smooth muscle
* Leiomyoma (fibroids): benign overgrowth of myometrium
* Malignancy
COEIN (non structural causes)
* Coagulopathy
* Ovulatory dysfunction
* Endometrial disorders
* Iatrogenic
* Not classified
How to classify causes of menorrhagia by age group?
Premenarche
* Infection
* Sexual abuse
* Foreign body
* Ovarian cancer
* Precocious puberty
Early post menarche
* Infection
* Pregnancy
* Platelet disorders or coagulopathy
* Stress
* Dysfunctional uterine bleeding (DUB)
Reproductive age
* Infection
* Pregnancy
* Platelet disorders or coagulopathy
* Stress (psychogenic or excercise induced)
* Dysfunctional uterine bleeding
* Gential tract disorders: endometrial/cervical/vaginal polyps. Adenomyosis, leiomyoma
* Endocrine dysfunction: PCOS, thyroid disease
* Drug induced: hormonal contraceptives/intrauterine device (IUCD)
Menopausal transition
* Anovulation
* Ovarian/endometrial/cervical/vaginal/vulvar cancer
* Genital tract disorders: endometrial/cervical/vaginal polyops. Adenomyosis, leiomyoma (fibroids)
Classify causes of menorrhagia according to genital tract disorders
Classify causes of menorrhagia according to pregnancy
Classify causes of menorrhagia according to systemic diseases
Classify causes of menorrhagia according to drugs
What is the history taking for menorrhagia?
Confirm reproductive status: premenarche/early post menarche/reproductive/menopausal transition/menopause. All post menopausal bleeding is abnormal and requires evaluation
Confirm source of bleeding:
* volume of blooding (size of blood clots –> indicates severity of bleeding)
* color of bleeding (brown staining represents old blood due to light bleeding or spotting from uterus, cervix and upper vagina, red staining can be from any sites in genital tract). Red staining can be any sites in genital tract.
* Timing of bleeding: post coital bleeding typically suggests cervical pathology but can be due to contact during intercourse in lower genital tract such as vagina and vulva
* Haematuria/haematuria/melena: certain from the vagina? Blood in the toilet only or after urination or defacation? Do you see the blood only when you wipe with toilet tissues? Which part of the pad is the bleeding located?
HPI
* Fever, lower abd pain and vaginal discharge: endometritis, PID
* Dysmenorrhea, dyspareunia and infertility: endometriosis, adenomyosis
* Hirsutism, hot flushes, heat or cold intolerance: thyroid disease, PCOS
* Changes in bladder and bowel function: fibroids (mass effect), malignancy (mass effect)
Menstrual history
* Frequency/duration/volume/regularity
* Last menstrual period
Sexual history
* Determine patients risk for pregnancy or STDs
* Contraceptive methods
Medical history
* Thyroid diseases
* Thrombocytopenia or coagulopathy
* Liver failure (decreased synthesis of coagulation factors)
* Renal failure (platelet dysfunction in uremia)
Drug history: anticoagulants
Family history: gynecological malignancy, bleeding disorders, thyroid diseases
Social history: stress (hypothalamic dysfunction), excessive excercise (hypothalamic dysfunction), eating disorders (hypothalamic dysfunction)
What is the PE for menorrhagia?
General exam: vital signs (tachycardia), pallor, goiter
Pelvic and speculum examination: presence of adnexal mass, cervical polyp
Size and contour of uterus
* Enlarged uterus: pregnancy/adenomyosis/uterine leiomyoma/uterine malignancy
* Limited uterine motility: pelvic mass or adhesions
* Uterine tenderness: pelvic inflammatory disease (PID)/endometritis
What are the basic and invasive Ix done for menorrhagia?
- CBC D/C: anemia, leukocytosis to look for infection, thrombocytopenia to look for platelet disorders
- Clotting profile: PT, aPTT to look for coagulopathy
- Iron profile: look for underlying iron deficiency
- LFT/RFT: liver and renal failure that leads to platelet dysfunction and coagulopathy
- TFT: thyroid diseases
- Pregnancy test: all patients of reproductive age should recieve pregnancy test to rule out possible pregnancy complications
Endometrial biopsy: pregnancy must be excluded before endometrial sampling. Performed in suspected endometrial hyperplasia or cancer. Indications: - All women age >40
- Women aged <45 with persistent AUB
- Women aged <45 with history of unopposed estrogen exposure (chronic anovulation)
- Women aged <45 with high risk of endometrial cancer (e.g. tamoxifen)
- Pap smear: routine cervical screening
- High vaginal and endocervical swab: in suspected cervicitis asnd pelvic inflammatory disease
What are the radiological Ix that can be done for menorrhagia and their indications?
- Transabd or transvaginal USG: indicated if structural abnormality is suspected
- Hysteroscopy: direct visualization of endometrial cavity effective in diagnosing endometrial polyp and leiomyoma. Indications: suspected endometrial polyp or submucosal fibroid Failed endometrial aspiration or results inconclusive. Irregular bleeding while on hormonal therapy >3 months
- Saline infusion sonohysterography (SIS): better than hysteroscopy as it can assess depth of extension of leiomyoma and identify leiomyoma at other sites to help surgical planning. Can also identify asymmetric or focal endometrial thickeninig in endometrial hyperplasia
What is the medical treatment for menorrhagia?
- Tranexamic acid: anti fibrinolytics which competitively blocks the conversion of plasminogen to plasmin thereby reducing fibrinolysis. Taken only during menses rather than daily usually from day 1 of menstruation to the end of heaviest flow.
- Mefenamic acid (ponstan): NSAIDs which decreases synthesis of prostaglandings including PGE2 and PGF2a in the endometrium leading to vasoconstriction and reduced bleeding
- COC pills: helps control mentrual cycle which is beneficial for irregular periods. Additional contraceptive effects
- Progestogen (norethisterone): indicated in patients with contraindications to combined pills. This is not a form of contraceptive
- Levonorgestrel releasing intrauterine system (Mirena)
What are the surgical treatment options for menorrhagia?
What are the complications?
Hysteroscopic endometrial ablation
* Only indicatesd for menorrhagia due to dysfunctional uterine bleeding
* Absence of large uterine fibroid or coexisting symptomatic adenomyosis or endometriosis in view of potentially worsening of dysmenorrhea after ablation.
* Preop endometrial preparation with GnRH agonist (e.g. IM leuprolide) to thin the endometrium to facilitate tissue destruction
* Preop cervical preparation with vaginal misoprostol which is a cervical riepning agent to dilate the cervix and avoid complications related to difficult passage of hysteroscope through cervical canal
Benefits of procedure
* 40-45/100 have lighter period, 40-45/100 stop menstruation, 4-10/100 have persistent or recurrent abnormal periods
Consequences: pregnancy is contraindicated after endometrail ablation and is recommended only for women with completed family and definitely sure they no longer wish to have more children
Procedure
* GA/RA
* Uterine cavity distended with glycine (conduction agent of monopolar)
* Dilatation of cervix and passage of resectoscope with roller ball electrode (endometrial ablation) or shaved off with a cutting loop (endometrial resection) under hysteroscopic control
Complications
* Frequent complications: bleeding, uterine cramps, mild fluid overload
* Serious complicatuions: hypoNa (absorption of glycine leading to fluid overload and electrolyte disturbances), cervical tear, failure to gain entry into uterine cavity, uterine perforation, pelvic infection, recurrence
Hysterectomy: definitive treatment for uterine bleeding –> no fertility desires–> high patient satisfaction because it is curative and no drug related side effects
How to classify dysmenorrhea?
Primary dysmenorrhea: presence of recurrent, crampy, lower abd pain that occurs during menses in the absence of demonstratable disease that could account for these symptoms
Secondary dysmenorrhea: occurs in women with an organic or psychological causes that can account for their symptoms such as adenomyosis, endometriosis or fibroids
What are the causes of secondary dysmenorrhea?
- Adenomyosis: usually occurs in multiparous women, presents with painful vaginal bleeding (i.e. with dysmenorreha), dyspareunia and regularly enlarged uterus
- Endometriosis
- Submucosal fibroids: usually happen in primiparous or multiparous women, presents with painless vaginal bleeding and irregularly enlarged, non tender uterus. Fibroids are usually not painful and therefore dysmenorrhea is not typical. Submucosal fibroids can sometimes cause dysmenorrhea during attempted expulsion of submucosal fibroids (when it becomes fibroid polyp and when uterus tries to expel the fibroid polyp)
- Chronic PID
- Ovarian cysts
- Asherman syndrome/intrauterine or pelvic adhesions: intrauterine adhesions (synechiae) caused by endometrial infection or currettage after miscarriage or abortion with partial or complete obliteration of uterine cavity
What is the pathogenesis of dysmenorrhea?
- Prostaglandins released from endometrial sloughing at the beginning of menses causes vasoconstrictions and myometrial contractions
- Contractions are non rhythmic or incoordinate, occuring in high frequency and result in high intrauterine pressures
- When intrauterine pressure exceeds arterial pressure, uterine ischemia develops and anaerobic metabolites accumulate which stimulates type C pain neurons resulting in pain
What are features of primary dysmenorrhea?
- Pain over lower abd or suprapubic area radiating down to anterior aspects of thigh
- Cramping and intermittently intense but may be a continuous dull ache
- Onset at 1-2 days before menses or on the day of menses
- Lasts for 2-3 days
- Usually develops within first 2 years of menarche
- Associated with nausea, vomiting, diarrhea, headache, dizziness and fatigue
- Resolution of symptoms with NSAIDs
What are features suggestive of presence of pelvic pathology consistent with secondary dysmenorrhea?
- Age of onset: onset after age 25 as secondary dysmenorrhea usually develops later in reproductive age. Occurs in first few cycles of menarche: congenital uterine outlet obstruction). Late onset without a history of previous dysmenorrhea
Clinical features
* AUB: menorrhagia/oligomenorrhea/intermenstrual bleeding
* Non midline pelvic pain
* Presence of dyspareunia
* Progression in symptom severity
* Absence of nausea, vomiting, diarrhea, headache, dizziness and fatigue
Treatment related: little/no response to NSAIDs or hormonal contraception or both
What is the PE and results pointing towards secondary dysmenorrhea?
General treatment principle and medical treatment for dysmenorreha?
Define amenorrhea and cryptomenorrhea
Amenorrhea: absence of menses and can be transient, intermittent or permanent condition resulting from dysfunction of hypothalamus, pituitary, ovaries, uterus or vagina
Cryptomenorrhea: hidden menstruation –> endometrial shedding occurs but menstrual loss cannot escape due to blockage of parts of lower genital tract usually due to congenital malformations.
What is the classification of amenorrhea?
- Primary amenorreah: absence of menses by age 14 with failure to grow properly or develop secondary sexual characteristics. Absence of menses by age 16 in the presence of normal growth and normal secondary sexual characteristics
- Secondary amenorrhea: absence of menses for >3 consecutive cycles (total of at least 3 of the previous cycle intervals) in women who have menses before or. Absence of menses for >6 months in women who have menses before
- Oligomenorrhea: cycle lengths >6 weeks in most of the cycles or number of menses <5 per year
What is the WHO classification of anovulatory disorders?
What is the HPO axis?
What is the summary of primary and secondary amenorrhea causes?
What are the physiological causes of amenorrhea?
What are the causes of primary amenorrhea (organize in HPO axis structure)?
Hypothalamus
* Functional hypothalamic amenorrhea: stress, anorexia, nervosa, weight loss, excessive excercise, severe illness
* Idiopathic hypogonadotrophic hypogonadism: isolated GnRH deficiency
* Kallmann syndrome: isolated GnRH deficiency + anosmia
* Irradiation of sellar tumors
* Traumatic brain injury
Pituitary
* Hyperprolactinemia: uncommon cause of primary amenorrhea (usually secondary)
* Pituitary tumors: craniopharyngioma, meningioma
Ovary
* Fragile X syndrome
* Turner syndrome: female with classical karyotype 45, XO. Gonadal dysgenesis with oocytes and follicles undergo apoptosis and hence no ovarian estrogen secretion
* Swyer syndrome (46, XY, gonadal dysgenesis): pure gonadal dysgenesis. Male genotype with female phenotype. Fibrous streak gonad cannot secrete anti-Mullerian hormone resulting in persistent mullerian structures. Uterus and fallopian tubes are normally formed but gonads not functional
* Polycystic ovarian syndrome (PCOS): ovulatory dysfunction and hyperandrogenism. Rotterdam criteria: oligo-ovulation or anovulation, hyperandrogenism (clinical/biochemical), polycystic ovaries (sonographic)
Uterus/outflow tract
* Imperforate hymen
* Transverse vaginal septum
* Vaginal agenesis (MRKH syndrome): agenesis or hypoplasia of Mullerian duct system (also known as Mullerian agenesis).
* Androgen insensitivity syndrome (testicular feminization syndrome): X linked recessive disorder with 46, XY karyotypine. Male genotype with female phenotype. External genitilia is female in appearance but tetes may be palpable in the labia or inguinal area. Undescended tests along normal cource of descent. Testes produce Mullerian inhibiting substance which causes regression of all Mullerian structures including fallopian tubes, uterus and upper third of the vagina. Normal breast development occurs (peripheral conversion of androgen to estrogen). Little or no pubic and axillary hair (requires androgen to mature).
Others: constitutional delay of puberty
What are the HPO axis causes of secondary amenorrhea?
What are the endocrinopathy causes of secondary amenorrhea?
What history taking for amenorrhea?
What PE done for amenorrhea?
What are the biochemical tests for amenorrhea?
- Pregnancy test: measurement of serum/urine B-hCG level (always rule out pregnancy as 1st step)
- TFT: TSH to detect hypothyroidism or hyperthyroidism. Hypothyroidism as a cause of hyperprolactinemia should be ruled out
- Serum prolactin level: stress, sleep, excercise, intercourse and meals can cause serum prolactin transiently and thus prolactin level should be repeated once before pituitary MRI is ordered. Screening for hypothyroidism is necessary since it will lead to hyperprolactinemia
- Serum FSH and estradiol (E2) level: assessment of estrogen status to interpret with FSH values and guide therapy in hypoestrogenic patients which require estrogen therapy for preventing bone loss.
Decreased E2 and increased FSH level: dx of ovarian insufficiency can be made if serum FSH >25IU/L on 2 occasions separates by >4 weeks apart. Indicates hypergonadotrophic hypogonadism such as primary and secondary ovarian insufficiency
Decreased E2 and FSH level: indicates hypogonadotrophic hypogonadism such as hypothalmaic or pituitary disorders - Progesterone withdrawal test (MPA): progestational challenge with MPA 10mg/day for 7 days. Assessment of estrogen status to interpret with FSH values and guide therapy in hypoestrogenic patients which requires estrogen therapy for preventing bone loss.
Presence of withdrawal bleeding = endogenous estrogen production + dx of anovulation can be made.
Absence of withdrawal bleeding = hypoestrogenism (OR) outflow tract disorder - Combined estrogen and progesterone withdrawal test (CEPWT): give COCs to check for withdrawal bleeding. Absence of withdrawal bleeding = outflow tract disorders (or) non functioning endometrium (asherman syndrome)
- Karyotyping: vaginal (mullerian) agenesis)MRKH) = 46XX (arrange USG urinary tract to look for associated abnormalities). Turner syndrome = 45XO (monosomy X). Swyer sndrome = 46XY (advise gonadectomy due to risk of maignant transformation. Androgen insensitivity syndrome (testicular feminization syndrome): 46XY
- Serum LH level: increased LH: FSH ratio in PCOS although it is no longer 1 of the diagnostic criteria
- Serum testosterone, DHEAS and 17-hydroxyprogesterone level: patients with hirsutism should have blood taken for serum testosterone and 17-hydroxyprogesterone. Performed in the presence of clinical hyperandrogenism for biochemical confirmation. Severe biochemical hyperandrogenism followed by checking erum 17-hydroxyprogesterone to rule out 21 hydroxylase deficiency (CAH). Suggests PCOS and androgen secreting tumors.
How to interpret the biochemical test results for amenorrhea and what is the follow up action?
What are further Ix after biochemical tests for amenorrhea?
What is the diagnostic flowchart for amenorrhea?
What is the general treatment principle for amenorrhea?
What is the management of amenorrhea according to the type of amenorrhea?
Define menopause vs climacteric
Menopause is the permanent cessation of menstrual period due to loss of ovarian follicular activity and is defined after 1 year of amenorrhea without any other obvious physiological or pathological cause
Climacteric: critical period around menopause when ovarian function is gradually declining. Extended period that begins years before and lasting yearsr after menopause itself. Menopause transition or peimenopuase begins on average 4 years before the final menstrual period.
* Time of decreasing estrogen level and elevated FSH deu to hypothalamic-pituitary hyperactivity from the lack of negative feedback by follicular hormones.
What are the different types of menopause?
- Natural menopause
- Premature menopause: defined as menopause that occured before 40 years old. Referred to as primary ovarian insufficiency (premature ovarian failure)
- Surgical menopause: surgery that involves removal of ovaries (oophorectomy)
What are the beneficial and potential adverse effects of estrogen?
Beneficial effects
* Improvement in lipid profiles (decreased LDL and increased HDL)
* Enhanced endothelial dysfunction
* Improved insulin sensitivity
Potential AE of estrogen
* Increase in serum triglyerides level
* Prothrombotic effect including reduction in serum fibrinogen, factor 7 and antithrombin 3
* Proinflammatory effect including increase in hepatic synthesis of vascular inflammatory markers such as CRP
What are the causes of menopause?
- Natural
- Iatrogenic menopause: oophorectomy, hysterectomy, post chemo, post radio
- Infection: TB, post mumps infection
- Autoimmune disease
What are the climacteric symptoms of menopause?
How to make a dx of menopause?
Normally retrospective dx
What are the indications for starting HRT In menopause?
What are the benefits?
What are the contraindications?
What is the evaluation before HRT prescription for menopause?
What HRT preparations are there for menopause?
What different kinds of regimen?
What are the routes of admin for HRT in menopausal women?
What is duration of treatment of HRT for menopausal women?
Discontinuation of treatment?
Counselling and advise?
Follow up?
What is the use of local vaginal estrogen in HRT for menopausal women?
What is the FIGO classification for uterine fibroids?
Which types most commonly cause symptoms?
Which types are the most common site of fibroids?
What is the classical clinical manifestations for uterine fibroid (leiomyioma)?
What is history taking and PE for uterine fibroid?
What further Ix after biochemical Ix done for suspected uterine fibroid (leiomyoma)?
What are the non surgical treatment approach for uterine fibroids?
What are frequent complications of uterine artery embolization for uterine fibroid?
What are serious complications?
Describe HIFU for uterine fibroid
What are the frequent/serios complications that can arise?
Procedures
* Under consious sedation
* IV set and catheter inserted into urinary bladder
* USG beam burns the uterine fibroid from outside the body
* IV fluids and analgesics continued after procedure
* Discharged from hospital when pain is under control and can eat adequately
What is the consequences after a bilateral salpingooopherectomy (BSO)?
What are the frequent and serious complications?
- Unable to get pregnant
- No menstruation
- Does not affect coitus
- Does not affect hormonal status if ovaries are not removed but ovarian failure may occur 2-4 years earlier than natural menopause by unknown mechanism possibly due to impairment in ovarian blood supply.
What are the complications of uterine fibroids?
What are the specuific complications during pregnancy?
Compare endometriosis and adenomyosis by RF, symptoms, PE and treatment
What is treatment for adenomyosis?
What are the anatomical sites of endometriosis in decreasing order of frequency?
How can endometriosis lesions in pelvis be categories?
What is the pathogenesis of endometriosis?
What is histological features of endometriosis?
What are the SS of endometriosis?
What is the manifestation for different types of endometriosis?
What is PE and Ix done for suspected endometriosis?
What is the surgical treatment options for endometriosis?
What is the classification of ovarian cyst?
What is the cutoff size for pathological cyst?
Physiological cyst: follicular cyst, corpus luteal cyst
Pathological cysts: endometrioma, cystic component of benign or malignant neoplasm
Cutoff size is 7cm for physiological cyst and any cysts >7cm are unlikely to be physiological.
USG repeated in physiological cyst in around 4 months to allow cyst to resolve
What is the IOTA (international ovarian tumor analysis) criteria for ovarian tumor features?
What imaging done for ovarian cyst?
What findings are indicative of benign causes?
What surgery is indicated for ovarian cyst in premenopausal vs postmenopausal women?
What are the frequent and serious complications with surgical approach for ovarian cyst removal?
What are SS of PCOS?
What are long term complications?
What is the diagnostic criteria for PCOS?
Rotterdam consensus
*20 or more follicles (has been changed)
What is history taking and PE for PCOS?
What are the basic Ix and imaging Ix done for suspected PCOS?
What are the general treatment principles for PCOS?
What is the PCOS treatment of hyperandrogenism?
What are the RF of PID?
What is the micbio of PID?
What is the ddx of PID?
What are the SS of PID?
What are SS of complications?
What history taking and PE for PID?
What basic Ix done for PID
What non basic Ix may be indicated for PID?
What is outpatient and in patient treatment regimen for PID?
What is surgical treatment regimen for PID?
What are early and late complications of PID?
What are the causes of vaginitis?
What is SS of vaginitis?
What are the ddx?
What is the diagnostic criteria for vaginitis?
What is the history taking for vaginitis?
What is the PE and possible findings for vaginitis?
What biochemical tests for vaginitis?
What are the summary of biochemical test results for vaginitis?
What is the treatment of vaginitis?
What are the complications of vaginitis?
