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Vaginitis + Diseases of the Vulva 1. 27 year old female ℅ vaginal discharge x 3 days, assoc w itching/burning. Had sinus infection last week. First test you'll do a. KOH wet prep b. Prob has candida → itching + was just on abx 2. 75 yo woman ℅ vaginal discharge, yellow color. Vaginal dryness + disco...

Vaginitis + Diseases of the Vulva 1. 27 year old female ℅ vaginal discharge x 3 days, assoc w itching/burning. Had sinus infection last week. First test you'll do a. KOH wet prep b. Prob has candida → itching + was just on abx 2. 75 yo woman ℅ vaginal discharge, yellow color. Vaginal dryness + discomfort. Wet prep will show… a. Parabasal cells b. Prob gardnerella vaginalis (BV) →Tx w metronidazole 3. Trichomonas → motile trophozoites (flagella) a. Tx w metronidazole + treat partner 4. 23 yo woman w vag discharge + severe pelvic pain, hurts when she walks and has intercourse. Temp is 101.5. Tachycardic (120 bpm). Check cervix and she hits you a. IV abx → cervical motion tenderness/Chandelier’s sign (Pelvic Inflam Disease) 5. BV + Trich are basic (pH>4.5) + Candida acidic (pH<4.5) 6. Bartholin cyst→ treat with incision + drainage 7. 67 yo female ℅ vulvar itching. Looks pale, scarring around the clitoris, and not tender to touch. She has had this issue for 6 mo. a. Dx→ biopsy 8. Low grade SIL→ follow w pap every 6 mo until normal → no treatment a. HGSIL→ ablation or excision HPV, Pap, Colposcopy, + Cervical Cancer 1. High risk HPV causing cervical cancer →HPV 16/18 2. CIN risk factors→ persistent of HPV, multiple partners, immunosuppression, smoking 3. Screening for HPV → don't just do HPV have to do cytology as well a. 21-30: cytology q 3 yrs b. 30-65: HPV + cytology q 5 yrs or cytology q 3 yrs c. Can stop at 65 unless they have h/o cervical dysplasia in past 20 yrs 4. If evidence of cervical dysplasia on cytology→ a. If <25 → repeat pap in 1 yr, >25 → colposcopy b. AGUS→ colposcopy + endometrial biopsy 5. If you cannot see whole extent of dysplasia, ECC positive or 2 grade discrepancy between pap and biopsy→ LEEP/excision 6. When do you treat with cryotherapy based on pap smear a. YOU DON'T!! Never treat based on pap smear→ NEED BIOPSY 7. Cervical cancer is clinically staged (not surgical) Primary + Secondary Amenorrhea 1. Primary amenorrhea→ no menarche before 13 w/o secondary sex characteristics or no menarche before 15 yo w secondary sex characteristics 2. AIS→ undescended testes, no uterus ovaries or tubes a. Primary amenorrhea, CANNOT induce period w hormone replacement 3. Swyer → defective SRY gene→ no MIS→ have uterus tubes and ovaries and all female characteristics a. Testes never develop b. Could induce a period with estrogen/progesterone 4. Eugonadotropic hypogonadism→ imperforate hymen, AIS, mullerian dysgenesis 5. Hypogonadotropic hypogonadism→ Turner Syndrome, Kallman syndrome (anosmia) 6. 18 yo female, never had period; what labs will you do a. FSH, pregnancy test (hCG), TSH, prolactin, karyotype b. Elevated TSH → hypothyroidism→ give levothyroxine (T4) 7. Orchiectomy for AIS + Swyer (any XY)→ ↑cancer risk 8. 21 yo female, had regular periods since menarche, but has not had a period in 6 mo a. Tests→ pregnancy test first!! b. FSH is very high→ premature ovarian failure (menopause <40 yo) 9. Same girl→ what can you do to decide if its premature ovarian failure or she isn't ovulating a. Progesterone test! Give progesterone and if she gets a period→ she was not ovulating 10. Secondary amenorrhea→ >3-6 mo of amenorrhea 11. PCOS→ diagnosis? a. NEED 2: Ultrasound, hyperandrogenism (testosterone) , hirsutism, menstrual irregularity b. What if she has hirsutism + anovulation→ can STILL diagnose PCOS (DON'T NEED ULTRASOUND) 12. Lady w PCOS and has hirsutism and it bothers her→ a. Give spironolactone → blocks androgen receptors b. Estrogen (BC) → ↑SHBG → decrease free testosterone→ less hair growth Abnormal Uterine Bleeding + Leiomyoma 1. 35 yo female, periods every 28 days but she has intermenstrual bleeding a. Polyp → hysteroscopy 2. 35 yo female ℅ severe heavy/painful periods but regular. She has to take meds to go to work. Uterus is enlarged but smooth a. Adenomyosis → endometrial glands in myometrium 3. Leiomyoma → dx w transvaginal US→ heavy painful bleeding with irregular large uterus 4. Postmenopausal bleeding → worried about endometrial cancer a. Dilation + curettage → gold standard b. Could also do endometrial biopsy, US for endometrial stripe c. Usually will be endometrial atrophy → loss of estrogen 5. 13 yo female comes in with heavy menstrual bleeding for 6 weeks after starting the first period. a. Von Willebrand’s 6. 27 yo comes in and has irregular spotting/bleeding. Been on BC pills x 3 yrs. a. Iatrogenic → breakthrough bleeding Chronic Pelvic Pain: 1. How to evaluate if imaging, labs and all are normal→ diagnostic laparoscopy 2. Dysmenorrhea (painful menstruation) a. Primary→ first 6 mo of menarche b. Secondary→structural disease of uterus c. Cant see adenomyosis on US, need a biopsy 3. Endometriosis → rectal bleeding when she's on her period a. Uterosacral nodularity b. Know tx: progesterone over BC, leuprolide, (GnRH agonist), Orlissa (GnRH antagonist), mirena IUD c. Gunpowder lesion on laparoscopy, chocolate cyst (ground glass) on US 4. Vulvodynia → burning pain, usually younger women, neuropathic pain a. NOT STIs or physical abuse 5. Acute pelvic pain→ pregnancy test first! a. Imaging→ if you're thinking appendicitis → get a CT first Endometrial Hyperplasia + Endometrial Cancer 1. Due to unopposed estrogen→ a. SMOKING not a risk factors 2. Type I endometrial cancer: endometrioid a. Arises from endometrial hyperplasia (estrogen dependent) 3. Type II endometrial cancer: serous or clear cell a. Estrogen INDEPENDENT, from atrophic endometrium 4. 58 yo female w postmenopausal bleeding, try to do biopsy but cervix is stenotic what do you do next a. Ultrasound → endometrial stripe is >10 mm b. Next to a D&C 5. How do we stage endometrial cancer → SURGICALLY a. Hysterectomy + bilat salpingo-oophorectomy + para-aortic/pelvic LN dissection b. Find that it extends into cervix → Stage 2 6. Most prognostic indicator in endometrial cancer→ GRADE a. Grade I (<5% solid), Grade II (6-50% solid), Grade III (>50%) Urinary Incontinence + Pelvic Organ Prolapse 1. Stress incontinence→ involuntary urinary leakage when intra-abdominal pressure exceeds urethral pressure a. Treatment: kegels, surgery (sling) 2. 57 yo female comes into the office and she's having to wear a diaper bc when she laughs she leaks on herself and I want you to fix it. a. How to diagnose? →Q tip test, UA, post void urine test i. +Q tip test→ Q tip goes up when you put it in urethra and ask them to cough 3. Post void residual and have 300cc of urine→ overflow incontinence 4. 5. 6. 7. a. DO NOT operate →Teach them to self cath Urge incontinence→ latch key: go pee before you get to bathroom a. Tx: vaginal estrogen 57 yo female comes in for an annual check up. Has no complaints. Do pap + pelvic exam but you notice a bulge coming out of vagina and its coming from anterior wall of vagina a. Cystocele → don't do ANYTHING unless she's symptomatic Rectocele → difficulty defecating (has to put her hand in her vag while pooping → splinting) Uterine prolapse (cervix prolapse through vag) → uncomfortable for patient a. Can take cervix out or put it back up Menopause 1. 40 yo female comes in ℅ hot flashes, night sweats, and vaginal dryness. PMH has hysterectomy for fibroids and GB removal. No illnesses. She wants to be treated, what do you give? a. Hormone replacement (estrogen), NO progesterone bc she had hysterectomy b. If she had uterus→ estrogen + progesterone c. Only vagina dryness and dyspareunia → vaginal estrogen 2. What affects age of menopause→ SMOKING 3. Osteoporosis screening → DEXA scan a. If <65 and 10 year fracture risk >65 yo or women >65 Ovarian Neoplasms 1. Biggest risk factor is AGE; also nulliparity, infertility, never been on OCP a. BRCA 1&2 genes, Lynch syndrome 2. #1 imaging→ transvaginal ultrasound is gold standard 3. Mc benign tumor on ovary→ cystic teratoma→ calcifications, hair, sweat glands, fat, teeth a. Can have ovarian torsion or rupture (peritonitis) 4. Germ Cell Tumors a. Know the tumor markers and the different kinds of tumors 5. Granulosa cell (sex cord) → estrogen secreting, may have postmenopausal bleeding 6. Fibroma→ Meigs syndrome: ascites, hydrothorax, ovarian fibromas 7. Tx for ovarian cancer→ REMOVE ovaries a. Almost all cancers need adjuvant CHEMO if epithelial b. Tumor debulking→ <1cm → optimally debulked 8. Follow CA125 → monitor recurrence Common Gynecologic Surgical Procedures 1. Even if you get informed consent→ does NOT waive liability (know PREPARED) a. Procedure, Reasons for procedure, Expectations, Preference, Alternatives, Risks, Expense, Decision 2. Colposcopy→ bc need tissue diagnosis to treat 3. Hysterosalpingogram w fluoroscopy→ view cavity + patency of tubes a. Good for seeing uterine anomalies 4. Endometrial biopsy → do this unless stenotic cervix a. D&C is gold standard 5. Hysteroscopy → Dx + Tx → use low viscosity fluids (saline) 6. Tubal ligation→ PLAIN GUT 7. Better now to take out tubes completely→ decrease risk of ovarian cancer a. Late 20s pt and wants tubes tied → wouldn't take entire tube out bc may change their mind and want a reversal 8. Laparoscopy→ ovarian torsion, CPP, ectopic pregnancy (dx and tx) 9. Hysterectomy → if you leave cervix → supracervical hysterectomy 10. Radical hysterectomy→ take out upper vagina and side walls, LN, uterus, tubes→ CERVICAL cancer 11. Preferred route of hysterectomy→ VAGINAL → cost effective + safest