Gynecology

Question 1

Define endometriosis.

Answer 1

the presence of endometrial glands and storm in any extrauterine site

Question 2

Endometriosis

Answer 2

• the presence of endometrial glands and stroma in any extrauterine site
• thought to arise from retrograde menstruation, vascular or lymphatic dissemination, or coelomic metaplasia
• more common in women of reproductive age and those who are nulliparous; most commonly found on the ovaries, typically bilaterally
• presents with progressive, cyclic dysmenorrhea and dyspareunia with deep penetration; chronic pain may arise if endometriosis gives rise to adhesions or pelvic scarring
• less commonly, there may be GI or urinary symptoms, nodularity of the uterosacral ligaments, fixed and retroflexed uterus, palpable ovarian endometriomas, or an acute abdomen if there is torsion/rupture of an endometrioma
• diagnosed based on tissue biopsy demonstrating two of the following: endometrial glands, endometrial stroma, endometrial epithelium, or hemosiderin-laden macrophages
• US, most useful for pelvic or adnexal masses, typically reveals cysts containing low-level, homogenous internal echoes consistent with old blood
• gross appearance varies widely from small clear, white, dark red, or brown lesions; chocolate cysts; or dark red or blue domes, which are frequently surrounded by reactive fibroses or dense adhesions
• may be treated expectantly, medically, or surgically

Question 3

Describe three theories for the pathogenesis of endometriosis and one observation that supports each.

Answer 3

• retrograde menstruation, consistent with the occurrence of pelvic endometriosis and its predilection for the ovaries and peritoneum
• vascular/lymphatic dissemination, which explains distant sites of endometriosis
• coelomic metaplasia, possibly in response to irritation caused by retrograde menstruation, consistent with endometriosis in some adolescents before the onset of menstruation

Question 4

Describe the gross appearance of endometriosis.

Answer 4

the gross appearance varies widely and can appear as…

• small, clear or white lesions
• small, dark red or brown lesions, known as mulberry or powder burn lesions
• cysts filled with dark red or brown hemosiderin-laden fluid, known as a chocolate cyst
• dark red or blue domes that may reach 15-20 cm in size

Question 5

Where and in whom is endometriosis most common?

Answer 5

• most common in women of reproductive age who are nulliparous
• most commonly involves the ovaries bilaterally

Question 6

How does endometriosis typically present?

Answer 6

• dysmenorrhea which is progressive and cyclical, following the menstrual cycle, which is often unresponsive to oral contraceptives and NSAIDs
• dyspareunia, especially with deep penetration when endometriosis involves the uterosacral or deep posterior cul-de-sac
• chronic pelvic pain may arise if endometriosis gives rise to adhesions and/or pelvic scarring
• pelvic exam may reveal the classic uterosacral nodularity; less commonly, the uterus may be fixed and retroflexed because of extensive adhesions
• ovarian endometriosis may be tender, palpable, and freely mobile in the pelvis
• endometriosis may also give rise to infertility, especially if the fibrosis distorts pelvic anatomy
• GI symptoms such as rectal bleeding and dyschezia may be seen if there is involvement of the bowel
• may present with an acute abdomen if there is rupture or torsion of an endometrioma

Question 7

Endometriosis in what location is most often associated with dyspareunia?

Answer 7

involvement of the uterosacral ligaments or deep posterior cul-de-sac

Question 8

How is endometriosis diagnosed?

Answer 8

• may be suspected based on direct visualization during laparoscopy or laparotomy
• however, because lesions are highly variable in gross appearance, tissue biopsy demonstrating two or more of the following is required: endometrial epithelium, endometrial glands, endometrial stroma, or hemosiderin-laden macrophages

Question 9

CA-125 may be elevated by what sorts of conditions?

Answer 9

• ovarian epithelial cancer
• pelvic inflammation
• uterine fibroids
• endometriosis
• some non-gyn sources such as cirrhosis and pancreatic or lung cancers

Question 10

What role does imaging play in those with endometriosis?

Answer 10

it is typically reserved for cases in which there is a pelvic or adnexal mass and in these cases it usually reveals cysts containing low-level, homogenous internal echoes consistent with old blood

Question 11

What are the goals when treating endometriosis?

Answer 11

• no treatment provides a permanent cure

- reasonable goals are, instead, reduction of pain, minimizing surgical intervention, and preserving fertility

Question 12

Describe the expectant management of endometriosis.

Answer 12

• it is an option for those with limited disease whose symptoms are minimal or nonexistent and for those who are attempting to become pregnant
• additionally, older patients with mild symptoms may opt to wait until menopause when there is a natural decrease in sex hormones

Question 13

Describe the medical management of endometriosis.

Answer 13

• useful for symptomatic patients with more than minimal disease who desire future pregnancy
• medical management involves drugs capable of inducing atrophy of the endometrial tissue
• oral contraceptives in conjunction with NSAIDs are first line therapy as they induce decimal reaction; progesterone therapy can also be used as it suppresses the HPO axis and directly affects the uterine endometrium
• danazol is a medication that suppresses LH and FSH mid-cycle surges, but it has hypoestrogenic and androgenic side effects including acne, spotting, hot flashes, oily skin, facial hair, decreased libido, atrophic vaginitis, and deepening of the voice; some of which don’t resolve with discontinuation; may raise HDL and lower LDL
• GnRH agonists down regulate the pituitary gland and suppress FSH and LH like danazol without androgenic side effects; the hypoestrogenic side effects of hot flashes, night sweats, and bone density loss persist; add-back therapy consisting of low-dose cOCPs is often used to mitigate the side effects without disrupting the therapeutic benefit
• does not affect adhesions and fibrosis and recurrence is common

Question 14

What is danazol?

Answer 14

• a synthetic androgen, which suppresses LH and FSH mid-cycle surges
• as such, it is often used for the treatment of endometriosis
• side effects are related to the hypoestrogenic and androgenic effects; this includes acne, spotting, hot flashes, oily skin, facial hair, decreased libido, atrophic vaginitis, and deepening of the voice
• added benefits are a reduction in LDL and rise in HDL

Question 15

Describe the surgical management of endometriosis.

Answer 15

• conservative surgery involves excision, cauterization, or ablation of visible endometriosis lesions; normalization of anatomy; and preservation of the uterus and other organs
• extirpative surgery is reserved for cases in which the disease is so extensive that conservative therapy is not feasible or when the patient has completed her family
• extirpative surgery involves a total abdominal hysterectomy, salpingo-oopherectomy, lysis of adhesions, and removal of endometriosis implants
• one or both ovaries may be spared if they are uninvolved but this increases the risk of recurrence; if the oophorectomy is bilateral, estrogen replacement therapy can be initiated with little risk of reactivating residual disease

Question 16

What is vulvovaginitis?

Answer 16

a spectrum of conditions that cause vaginal or vulvar symptoms such as itching, burning, irritation, and abnormal discharge

Question 17

What are the most common causes of vulvovaginitis?

Answer 17

bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis

Question 18

Describe the vulvar and vaginal epithelium.

Answer 18

• both are lined by a stratified squamous epithelium
• the vulvar epithelium contains hair follicles, sebaceous, swat, and apocrine glands
• the vagina is non-keratinized and lacks these other specialized elements

Question 19

What promotes lactobacilli growth in the vaginal tract?

Answer 19

estrogen-driven maturation of the vulvovaginal epithelium, which leads to an increase in glycogen levels, which supports this growth

Question 20

Why are lactobacilli critical for a normal vulvovaginal ecosystem?

Answer 20

because they convert glycogen, produced by mature epithelial cells, to lactic acid, lowering the vaginal pH

Question 21

What is a normal pre-pubertal and post-pubertal vaginal pH? What is responsible for this change?

Answer 21

• pre-pubertal is 6-8
• post-pubertal is 3.5-4.7
• this change is driven by estrogen, which triggers maturation of epithelial cells, leading to an increase in glycogen, which supports lactobacilli, which convert glycogen to lactic acid

Question 22

What is a normal anaerobic to aerobic bacterial ratio in the vagina and why?

Answer 22

5:1 anaerobic to aerobic because the vagina is a potential space rather than an open tube

Question 23

Describe the origins of the normal vaginal discharge.

Answer 23

• the majority of the liquid portion consists of mucus from the cervix
• there is small amount of moisture contributed by endometrial fluid, exudates from accessory glands, and vaginal transudate
• the white to off-white color comes from exfoliated squamous cells from the vaginal wall

Question 24

What is the purpose of normal vaginal discharge?

Answer 24

to prevent dryness and irritation

Question 25

Bacterial Vaginosis

Answer 25

• a polymicrobial infection characterized by a lack of normal hydrogen peroxide-producing lactobacilli and an overgrowth of facultative anaerobic organisms
• presents with an increase in vaginal discharge which is thin, adherent, gray-white to yellow, and has a musty or fishy odor
• the vagina has a pH greater than 4.5 and KOH produces a positive whiff test; a wet mount shoe an increase in WBC count, fewer lactobacilli, and many clue cells
• oral or intravaginal metronidazole or clindamycin are the preferred treatments
• treatment of women with high-risk pregnancies reduces the incidence of PROM and preterm delivery; there is no indication for treating asymptomatic women or partner’s of women with BV
• associated with PID and postoperative infections and increases the risk of acquiring HIV and herpes simplex

Question 26

What are clue cells?

Answer 26

epithelial cells seen on wet prep with numerous coccoid bacteria attached, indicative of bacterial vaginosis

Question 27

Vulvovaginal Candidiasis

Answer 27

• caused by a ubiquitous airborne fungi, most often Candida albicans
• risk factors include pregnancy, diabetes, obesity, immunosuppression, oral contraceptive use, corticosteroids, and broad spectrum antibiotics
• more common in reproductive years because Candidal species tropically require estrogenized tissue
• typically presents with itching, burning, external dysuria, dyspareunia, irritation, and a thick, odorless, white, “cottage cheese-like” discharge; vaginal pH is normal
• diagnosis requires visualization of blastospores or pseudohyphae on saline or KOH prep or a positive culture
• treated with intravaginal synthetic imidazole for seven days or single-dose oral fluconazole; recurrent cases in non pregnant women are most likely to benefit from weekly oral fluconazole for 6 months
• it is not sexually transmitted and treatment of partners is not recommended
• complicated cases are those that are recurrent, associated with severe symptoms, non-Candida albicans infections, or found in women with diabetes, severe medical illness, or immunosuppression

Question 28

What role does fluconazole have in the treatment of vulvovaginal candidiasis in pregnant women?

Answer 28

although high daily doses of fluconazole have been associated with birth defects, single-dose oral therapy for vulvovaginal candidiasis is safe

Question 29

Trichomonal Vulvovaginitis

Answer 29

• infection with a flagellated protozoan, T. vaginalis
• transmitted via fomites and through sexual contact
• presents with itching, burning, dysuria, dyspareunia, postcoital bleeding, edema and erythema of the vulva, and a “strawberry cervix” with numerous petechiae
• the discharge is often copious, thin, frothy, and yellow-green to grey with a rancid odor
• associated with PID, endometritis, infertility, ectopic pregnancy, preterm birth, low birth weight, and PROM; it often co-exists with other STDs and bacterial vaginosis and facilitates HIV transmission
• vaginal pH is greater than 4.5 and a wet mount shows mature epithelial cells, WBCs, and protozoa
• treat with oral metronidazole or tinidazole; partners should be treated and the pair should avoid intercourse until the regimen is complete and each is asymptomatic
• metronidazole is used for treatment during pregnancy but may not prevent complications

Question 30

What is the major side effect of metronidazole?

Answer 30

it produces a disulfiram-like reaction to alcohol

Question 31

Compare and contrast the findings and treatment for bacterial vaginosis, candidal vulvovaginitis, and trichomoniasis.

Answer 31

• bacterial vaginosis: a thin, white, adherent discharge with a fishy odor; increased WBCs, clue cells, and fewer lactobacilli on microscopy; treat with metronidazole or clindamycine
• candidiasis: a thick, curdy, white discharge; find hyphae or buds on microscopy; treat with imidazoles or fluconazole
• trichomoniasis: a yellow-green, frothy, adherent discharge; find normal epithelial cells, WBCs, and trichomonads on microscopy; treat with metronidazole or tinidazole

Question 32

Atrophic Vaginitis

Answer 32

• atrophy of the vaginal epithelium due to diminished estrogen levels, which leads to a loss of cellular glycogen and therefore lactic acid
• most commonly in postmenopausal women but can be seen in those who are premenopausal
• leads to a higher pH, thinned epithelium, loss of connective tissue elasticity, shortening, and narrowing
• presents with decreased vaginal discharge, dryness, itching, burning, and dyspareunia
• diagnosed on the basis of vaginal pHH and the presence of parasol or intermediate cells on microscopy
• treated with local water-based moisturizing or topical or oral estrogen therapy

Question 33

Withdrawal of estrogen causes what changes in the vagina?

Answer 33

• leads to a loss of cellular glycogen and therefore lactic acid
• yielding a vagina that has a higher pH, thinned epithelium, loss of connective tissue elasticity, shortening, and narrowing

Question 34

Desquamative Inflammatory Vaginitis

Answer 34

• seen in perimenopausal and postmenopausal women
• presents with a purulent discharge and vulvovaginal burning and erythema
• microscopy shows relatively few lactobacilli and an overgrowth of gram-positive cocci, typically streptococci while vaginal pH is greater than 4.5
• may be mistaken clinically for trichomoniasis but microscopy shows no protozoans and cultures are negative for T. vaginalis
• treated with topical clindamycin for 14 days

Question 35

Lichen Sclerosus

Answer 35

• a benign thinning of the epidermis and fibrosis of the dermis of the vulvar skin most common in post-menopausal women
• presents as a ivory papules or hypopigmentation, with “parchment-like” skin, itching, burning, and often obliteration of the labia minor
• treatment involves topical corticosteroids
• carries some risk for squamous cell carcinoma of the vulva (more than Lichen simplex chronicus)

Question 36

Lichen Simplex Chronicus

Answer 36

• a hyperplasia of the vulvar squamous epithelium with an inflammatory cell infiltrate
• caused by a cycle of scratching, itching, and epidermal thickening
• presents as a leukoplakia with thick, leathery skin
• treated with corticosteroids and behavioral changes to break the itch/scratch cycle
• benign and with no risk for squamous cell carcinoma

Question 37

How does lichen sclerosus compare with lichen simplex chronicus?

Answer 37

• Lichen Sclerosus is a thinning of the epidermis and fibrosis of the dermis that results in thinning of the skin and carries a risk for squamous cell carcinoma
• Lichen Simplex Chronicus is a hyperplastic thickening of the skin that poses no risk for carcinoma

Question 38

Lichen Planus

Answer 38

• an inflammatory skin condition that can affect the oral cavity, skin, vulva, and vagina
• may present with burning, itching, insertional dyspareunia, contact bleeding, and profuse vaginal discharge
• there is often a lacy, reticular pattern on the labia and perineum with or without scarring and erosions
• overtime adhesions form, the normal architecture is lost, and the vagina may obliterate

Question 39

Squamous Cell Hyperplasia of the Vagina

Answer 39

has a pink-red appearance with an overlying white keratin

Question 40

Vestibulodynia

Answer 40

• a constellation of symptoms limited to the vestibule, which include intense pain with touch or attempted entry, tenderness to pressure, and erythema
• often has an abrupt onset with the pain described as sharp, burning, and raw
• treated with TCAs to block sympathetic pain loops, topical anesthetics, or pelvic floor rehabilitation

Question 41

Mucopurulent Cervicitis

Answer 41

• defined by a mucopurulent exudate visible in the endocervical canal
• caused by Chlamydia or gonorrhea, but in most cases, neither organism can be isolated
• the need for treatment should be based on culture/PCR unless the likelihood of infection is high or the patient is unlikely to return for follow-up
• treatment is with ceftriaxone and azithromycin

Question 42

For patients with a history of endometriosis who are struggling to get pregnant, what is the appropriate therapy?

Answer 42

ovarian stimulation with intrauterine insemination

Question 43

What is the difference between primary and secondary dysmenorrhea?

Answer 43

• primary is due to an excess of prostaglandins, leading to painful uterine muscle activity
• secondary is due to some other clinically identifiable cause

Question 44

How do we define chronic pelvic pain?

Answer 44

as noncyclic pelvic pain (not solely associated with menstruation), lasting 6 months or more

Question 45

Primary Dysmenorrhea

Answer 45

• painful menstruation due to an excess of prostaglandins, specifically PGF2a, leading to painful uterine muscle activity
• most common in women in their late teens to early twenties, becoming more rare with age
• the pain is usually diffusely located in the lower abdomen and suprapubic region, with radiation around or through the back; the fetal position is often relieving
• often presents with diarrhea, n/v, headache, or dizziness because the prostaglandins cause smooth muscle contraction outside of the uterus as well; dyspareunia should suggest a secondary cause
• a diagnosis of exclusion
• typically responds to NSAIDs, the application of heat, exercise, or psychotherapy and reassurance
• management may ultimately necessitate use of hormonal therapy including cOCPs or progesterone-based LARCs; rarely do patients require a presacral neurectomy

Question 46

Secondary Dysmenorrhea

Answer 46

• painful menstruation due to some clinically identifiable cause, most often endometriosis, adenomyosis, adhesions, PID, leiomyomata
• increasingly common with greater age
• the pain often begins for menstruation, gets worse during menstruation, and persists longer than the menstrual period
• more likely to be associated with dyspareunia than primary dysmenorrhea
• endometriosis is supported by finding painful nodules in the posterior cul-de-sac, adenomyosis by an enlarged, boggy uterus, leiomyomata by a rubbery, solid, oddly contoured uterus, and adhesions by limited uterine mobility
• in many cases exploratory laparotomy is needed to establish a diagnosis
• NSAIDs, cOCPs, progesterone-based LARCs, and presacral neurectomy are possible therapies

Question 47

Which prostaglandins are responsible for primary dysmenorrhea and primary menorrhagia?

Answer 47

• dysmenorrhea: PGF2a, which causes contractions of smooth muscle
• menorrhagia: PGE2, a potent vasodilator and inhibitor of platelet aggregation

Question 48

What is the normal role of PGF2a in the uterus? What drives production?

Answer 48

• progesterone drives production of PGF2a, reaching a peak around the start of menstruation
• with the onset of menstruation, formed prostaglandins are released form the shedding endometrium

Question 49

Why is primary dysmenorrhea often accompanied by diarrhea, n/v, headache, dizziness, etc.?

Answer 49

because it is mediated by PGF2a, which causes smooth muscle contraction outside of the uterus as well

Question 50

What are the most common causes of secondary dysmenorrhea?

Answer 50

• endometriosis
• adenomyosis
• leiomyomata
• PID
• adhesions

Question 51

How does the pain associated with primary dysmenorrhea differ from that associated with secondary dysmenorrhea in regards to quality of the pain?

Answer 51

• primary is described as diffusely located in the lower abdomen or suprapubic region; radiates around or through the back; is accompanied by n/v, diarrhea, headache, etc.; and is confined to the menstrual period
• secondary is more likely associated with dyspareunia than the other symptoms and is more likely to come before and persist after the menstrual period

Question 52

If a patient presents with secondary dysmenorrhea, what exam findings would be consistent with:

• endometriosis
• adenomyosis
• leiomyomata
• adhesions

Answer 52

• endometriosis: painful nodules in the posterior cul-de-sac and restricted uterine motion
• adenomyosis: an enlarged, boggy-feeling uterus
• leiomyomata: a rubbery, solid, consistency to an irregularly contoured uterus
• adhesions: restricted uterine motion

Question 53

How is dysmenorrhea treated?

Answer 53

• first line therapy is NSAIDs, which tend to be more helpful for those with primary dysmenorrhea
• second line therapy includes cOCPs or progesterone-based LARCs
• presacral neurectomy is a treatment of last resort

Question 54

Chronic Pelvic Pain

Answer 54

• the preferred definition is noncyclic pain lasting for more than 6 months that localizes to the anatomic pelvis and is of sufficient severity to cause functional problems
• most common causes include endometriosis, gynecologic malignancies, PID, history of abuse, depression, interstitial or radiation cystitis, IBS/IBD, abdominal wall myofascial pain
• treatment depends on the etiology but adding psychotherapy to medical treatment improves outcomes

Question 55

Interstitial Cystitis

Answer 55

• a chronic inflammatory condition of the bladder
• thought to be caused by a disruption of the glycosaminoglycan layer that normally coats the mucosa of the bladder
• often presents with pelvic pain, urinary urgency and frequency, and dyspareunia
• treatment includes dietary modification, agents aimed at decreasing inflammation and pain signals, dimethyl sulfoxide