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Reproductive System - PANCE 2025 Blueprint  Breast Disorders Abscess, Fibroadenoma, Fibrocystic Changes, Galactorrhea, Gyne...

Reproductive System - PANCE 2025 Blueprint  Breast Disorders Abscess, Fibroadenoma, Fibrocystic Changes, Galactorrhea, Gynecomastia, Mastitis Abscess Fibroadenoma Fibrocystic Breast “Disease” Etiology: Epidemiology: Epidemiology: Staph (m.c.c.) African American Women 30-50 y.o. Women (RARE af ter Menopause) Consider inflammatory carcinoma in a nonlactating breast Clinical Manifestations: Risk of Cancer Increases with Clinical Manifestations: Fluctuant, Tender Mass Complex History Adjacent Proliferative Disease Breast Pain Fever, Malaise, Painful Inflammation FHx of Breast CA Palpable Mass Diagnosis: CBC, Chemistries, Blood Cx, US Clinical Manifestations: Physical Exam Treatment: Discrete, Firm, Round, Rubber-Like, Non-Tender, Relatively Single or Multiple Bilateral Painful Cysts Varying in Size Non-Lactating: I & D Moveable Mass Lactating: I & D when Necessary Bilateral in 10-15% of Cases Treatment: Antibiotics: Diagnosis: - Dicloxacillin OR Cephalexin If symptoms are consistent and there is a prior diagnosis, Core Needle Biopsy follow up with monthly BSE and annual exam by a provider - Clindamycin OR Bactrim for MRSA - Vancomycin if Severe Treatment: Continue Breastfeeding or Pumping Monitor or Excise Hormonally Responsive Galactorrhea Gynecomastia Mastitis Nipple Discharge benign proliferation of the gallbladder tissue of the male breast defined as breast Inflammation of breast tissue that may or may not be accompanied by an infection Etiology: tissue extending outside the nipple ≥ 2 cm Etiology: Lactational, Abscess, Cellulitis, Spontaneous Gangrene, Bite Wounds Pathophysiology: Cancer (m.c.c.) increased estrogen to androgen activity inducing breast growth Introduction Papilloma Etiology: Lactational Mastitis Fibrocystic Change Physiologic: Aging, Obesity, Neonatal Period Etiology: Endocrine Endocrine: Hyperprolactinemia, Male Hypogonadism, Hypo/Hyperthyroid Staph (m.c.c.), Strep, E. Coli, Corynebacterium Systemic Disease: CKD, Liver Disease Clinical Manifestations: OCPs Neoplasm: Adrenal, Pituitary Tumor Others (Metoclopramide, Imipramine, Methyldopa, Amphetamine) Drugs: Androgens, Amiodarone, Anti-Psychotics, CCB, Metoclopramide Localized, Painful Inflammation Physical Exam: Fever, Chills, Malaise Diagnosis: true glandular enlargement may be tender while fatty tissue is diffuse and non- Treatment: tender (fatty pseudogynecomastia) Symptomatic: Ibuprofen, Ice Mammography >>> Galactography if NO Findings Diagnosis: Labs (BMP, Estrogen Levels, Endocrine Testing), Imaging (bil Mammogram and Chest CT) Antibiotics Treatment: Treatment: - Dicloxacillin OR Cephalexin Treat the Underlying Pubertal: Resolves spontaneously in 1-2 years - Clindamycin OR Bactrim for MRSA Drug Induced: Resolves af ter stopping offending drug - Vancomycin if Severe Painful and Persistent: Medical Therapy - SERM Therapy (Raloxifene) or Aromatase Inhibitor (Anastrozole) Continue Breastfeeding or Pumping Cervical Disorders Cervicitis, Dysplasia Cervicitis Cervical Dysplasia/Cancer Etiology: Pathophysiology: the transformation zone holds the least mature cells in the cervix most vulnerable to changes Infectious: Gonorrhea, Chlamydia, Mycoplasma Epidemiology: third m.c. cancer worldwide in women around 47 y.o. Non-Infectious: Mechanical/Chemical, Irritation RF: Genes, Early Sex Onset, Mult Partners, h/o Genital Warts, Multiparity, Factors Affecting the Immune System (Smoking, Nutrition, etc.) Clinical Manifestations: Etiology: HIV (blunts immune system, directly related to immunosuppression, inversely related to CD4), HPV (16 & 18), Genes E7 & E8 (inactivate tumor suppressors) (Muco)purluent Discharge Diagnosis: Screen with Pap Smear. Easily Induced Bleeding 65 y.o. No Screening Recommended if priors have been negative Identify Etiology/Test for Infections (NAAT for BV, WC, Trich) Special Pop. Women with Diethylstilbestrol (DES) Exposure Treatment:. Empiric AbX Abnormal Pap: Diagnostic Excisional Procedure Recurrent Symptoms should be Re-Evaluated for Re-Exposure Colposcopy: Evaluate Abnormal Cervical Cytology High Risk: < 25 y.o. and/or new sexual partner, concurrent sexual partner - 3.5% acetic acid applied to cervix to visualize cancerous and pre-cancerous lesions Basal Basal > 2/3rd or partner with known ST I - MUST visualize SCJ to be satisfactory 1/3rd 2/3rd Excise w/o Chronic Cervicitis: usual causes of acute cervicitis have been treated yet Inadequate Colposcopy >>> Endometrial Sampling Delay abnormal signs persist at least 3 months (usually due to a noninfectious source) Treatment: LEEP, Cold Knife Conization, Crytotherapy (ADR: diffuse watery discharge)  Contraceptive Methods Barrier Options Emergency Options IUD Options External Condom Internal Condom 87% Effective 79% Effective Pills: Progestin EC (Plan B) or Ulipristal Acetate (Ella), etc. Copper IUD Dual Protective 58-94% Effective (Ella 85%) Non-Hormonal Dual Protection Use Polyurethane Condom if Allergic Available at Pharmacies (Ella Requires Rx) >99% Effective to Latex Can be taken up to 5 days af ter unprotected sex FDA Approved for 10 years ADR: Stomach Upset/Nausea Can become pregnant immediately af ter removal Ella less effective with BMI > 30 and not effective ≥ 35 ADR: Cramps, Heavy Monthly Bleeding Vaginal Acidifying Gel Diaphragm 86% Effective 83% Effective Lowers vaginal pH reducing sperm Needs Rx Copper IUD Hormonal IUD motility and function Can be placed up to 5 days af ter unprotected sex >99% Effective Always use with Spermicide Liletta and Mirena (8 years), Kyleena (5 years), Skyla (3 years) Effective af ter 7 days Vaginal Spermicide Cervical Cap 79% Effective 71-86% Effective CI: Current PID or PID within the last 3 months, Current Can be bought at many stores 3 sizes inserted each time you have sex Insert 10-15 minutes each time before Cervicitis or High Risk Women you have sex; only lasts 1 hour Prior ST I, Nulliparity or Adolescents NOT considered CI Fertility Awareness Patch, Ring, Shot Pill Checking fertility status daily by checking temperature, vaginal Combined Oral Contraception mucus or tracking monthly bleeding Patch 99.7% effective with perfect use 85% Effective 93% Effective MOA: stops a dominant follicle from being selected and ovulated Temperature: Apply a new patch once a week for three weeks then no patch during Use back up protection x 7 days if not started during menses Non-Ovulation: 97 - 97.5˚F week 4 CI: h/o VT E, Known Thrombogenic Mutations, Migraines with Aura, HTN, Lupus Post Ovulation: 97.6 - 98.6˚F Less effective > 198 lbs. with APS Cervical Mucus: Use back up protection x 7 days if not started during menses Non-Ovulation: thick, white and dry Ovulation: clear and slippery Ring Monthly Bleeding: 93% Effective Continuous Pill Avoid sex around ovulation (day 12-14) Monthly vs Yearly Ring Estrogen + Progesterone Use back up protection x 7 days if not started during menses Shot 96% Effective Progestin Only Pill Get one shot every 3 months Take daily within a 3 hour window ADR: decrease monthly bleeding, spotting, no monthly bleeding, weight gain, MOA: thicken mucus making it harder to penetrate depression, skin/hair or sex drive changes Use back up protection if not started during menses Use back up protection x 7 days if not started during menses Indications: Migraine with Aura, Postpartum, Breastfeeding, HTN, h/o Blood Clots, HOW TO BE REASONABLY CERTAIN A PERSON IS NOT PREGNANT CHOICE OF HORMONES PHARMACOLOGICAL EFFECTS ON CONT RACEPT ION No Symptoms + ONE of the Following Irregular/Painful periods/PMS/PMDD: Low progestin, low androgen pills as well as no-period pills Rifampicin and Rifabutin ≤ 7 days af ter the start of normal menses Minimize Weight gain: Low estrogen, low progestin Serious - Use Alternative and a Back Up until 28 days af ter last dose Doxycycline has not had sex since the start of last menses PCOS: Low androgen, low progestin Monitor Closely - Use back up entire length of ABX has been consistently using a reliable method of contraception Acne/Unwanted Hair: Higher estrogen, lower androgen Tetracycline, Ampicillin, Amoxicillin ≤ 7 days af ter spontaneous or induced abortion Breakthrough Bleeding/Ovarian Cysts: Higher estrogen, higher progestin, lower androgen Monitor Closely - Use back up entire length of ABX plus 7 days af ter within 4 weeks postpartum Breast Soreness: Lower estrogen, lower progestin pill, or progestin-only pill Griseofulvin and Nystatin fully or nearly fully breastfeeding, amenorrheic and < 6 months postpartum Depression, moodiness, irritability: Lower progestin Monitor Closely - Use back up one month af ter last dose Phenobarbital, Carbamazepine and Topiramate Endometriosis: Lower estrogen, higher progestin or “no-period” pills May recommended non-estrogen based contraception Headaches: Low estrogen, low progestin Some Antiretroviral Drugs for HIV Severe Menstrual cramps: Higher progestin or no period pills St. John’s Wort Serious - Use Alternative **Medscape Interaction Center Human sexuality and gender identity  Infertility Infertility Failure to achieve a successful pregnancy af ter 12 months or more of regular, unprotected sexual intercourse categorized as either primary (never been pregnant) or secondary (pregnant at least once) Trying 12 months in women < 35 y.o. Trying 6 months in women ≥ 35 y.o. Definitions: Fecundity: capacity to have a live birth More immediate evaluation may be warranted in women > 40 y.o. Fecundability: probability of achieving a pregnancy in a single menstrual cycle with adequate sperm exposure and no contraception resulting in a live birth Fertility: ability to have a clinical pregnancy RF: Age, ST Is, Sx, Chemo/Radiation, Weight, Genetics Sterility: permanent state of infertility Time to Pregnancy: length of time that it takes a couple to conceive Etiology: Diagnosis: Female H&P (ask about sexual intercourse process) Anatomic Assessment of Ovarian Reserve: Day 3 Labs and Pelvic US - Tubal Disease AMH, FSH, LH, Estradiol, Inhibin B, Age Comparison, Predictive Egg Retrieval Scores - Uterine Anomaly Assessment of Fallopian Tube Patency: HSG or FemVue - Uterine Cavity Obstruction Assessment of Uterine Cavity: HSG or Saline Sonogram - Diminished Ovarian Reserve - Endometriosis Assessment of Sperm Quantity and Quality (Count, Morphology, Motility): SA Endocrine - Ovulation Disorder (i.e. PCOS) Treatment: Male Treat Underlying Cause Obstructive Azoospermia Lifestyle Modifications: Smoking Cessation, Weight Management Non-Obstructive Azoospermia Pharmacological Therapy: Vitamins if Trying to Conceive; Letrozole, Clomiphene Citrate for Ovulation Induction Low Sperm Quantity/Quality Unexplained Procedural Therapy: IUI, IVF, Intracytoplasmic Sperm Injection (ICSI) for Severe Male Factor Infertility Genetics Third Party: Donor Eggs, Sperm or Embryos Extra: Genetic Analysis of Embryos, Epididymal and Testicular Sperm Extraction Menopause Menopause Premature Ovarian Failure: menopause before 40 y.o. Diagnosis: FSH NOT Required Perimenopause: af ter reproductive years but before menopause with irregular cycles and symptoms beginning as hot flashes < 40: Must Work-Up Menopause: 12+ months of amenorrhea WITHOUT other causes 40-45 with Irregular Cycles: ß-hCG, Prolactin, TSH > 45 with Symptoms: No Work-Up Needed Pathophysiology: inhibin B decreases, FSH increases maintaining estradiol but decreasing progesterone causing ovulation to decline LAT E: high FSH and low Estradiol Treatment: Want to predict the final cycle as it prompts accelerated bone loss and cardiovascular risk factors Initially: Lifestyle Modifications, Supplements for Osteoporosis, Topical Estrogens, SSRIs for Depression Clinical Manifestations: Menopausal Hormone Therapy (MHT) for Hot Flashes Irregular Menstruation - CI: Breast CA, CHD, h/o VT E, h/o Stroke, Unexplained Bleeding, Acute Liver Hormonal Fluctuations Disease, High Risk Endometrial CA, T IA Hot Flashes - Black Box risk of Endometrial CA, CVD, Breast CA, Dementia, Breast Development Sleep Disturbances - ADR: Breast Tenderness, Mood Changes, Bloating, Bleeding Vaginal Dryness - Perimenopause: start LOW and increase to effect - Menopause: start at full dose and titrate down for no more than 5 years Mood Changes  Menstrual Disorders Amenorrhea Dysmenorrhea PMS/PMDD Primary: absence of spontaneous menstruation by 16 y.o. with secondary sex Painful cramping in lower abdomen of ten accompanied by other symptoms PMS: physical mood and behavioral changes occurring during the luteal phase characteristics OR 14 y.o. in the absence of secondary sex characteristics including sweating, tachycardia, ha, n/v, diarrhea disruptive to a patient’s life Secondary: a women who has previously menstruated and has had an absence of Primary: excess prostaglandins PMDD: more severe PMS with the patient being markedly depressed, anxious, menses for 3 months (if menses is irregular, then the absence for 6 months) most angry, lethargic, etc. commonly caused by PREGNANCY Secondary: pelvic conditions/other pathology Etiology: Primary Amenorrhea Epidemiology: 30-40 y.o. women with prior h/o postpartum depression or other Level I (Outflow Tract) Level II (Ovarian) mood disorders Normal FSH High FSH Etiology: Serotonin Levels, Endocrinologic, Endorphins, Diet, Vitamin Deficiencies, Transvaginal Septum Premature Ovarian Failure failure of complete canalization located at any level of the vagina gonadal agenesis/dysgenesis (i.e. Turner’s) Prostaglandins Imperforate Hymen Low or Absent Estrogen & Elevated Gonadotropins located at junction of vestibule and vagina (FSH/LH) Clinical Manifestations: recurrent symptoms during the luteal phase followed by a Müllerian Agenesis normal ovarian development, endocrine function & sex development Chemo symptom free period Adrenal, Thyroid or Pituitary Deficiencies shortened/absent vagina, no uterus/cervix, 46XX karyotype Diagnosis: Level III (Pituitary) Level IV (Hypothalamic) Low-Normal FSH Low-Normal FSH (DSM-5 Criteria) 5+ symptoms the week prior to menses with one being Tumors (m.c.c.) Psychogenic/Functional (m.c.c.) behavioral and one physical Prolactinomas, Craniopharyngioma Stress, Anorexia, Wt Loss, Exercise Sheehan Syndrome Tumors Panhypopituitarism Infiltrative Hamartoma Infection Etiology: Behavioral Sarcoidosis, Hemochromatosis, TB, Metastatic (RARE) Syphilis, TB Kallmann’s Syndrome 1˚: Prostaglandin F2a & E2 Mood Swings, Sudden Sadness, Increased Sensitivity to Rejection 2˚: Cervical Stenosis (scant menses and severe cramping), Anger, Irritability Clinical Manifestations: HA, Visual Field Defect, Acne, Hirtuism, Sense of Hopelessness, Depressed, Self-Critical Thoughts Endometriosis, Tumors, Leiomyomata, Adenomyosis, Polyps, Infections, Short Stature Tension, Anxiety, Feeling on Edge IUDs Diagnosis: Physical Pelvic Exam & ß-hCG, TSH Clinical Manifestations: Difficulty Concetrating Change in Appetite, Food Cravings, Overeating Progesterone Challenge Test (Primary) low-midline wave like cramping that radiates to back/ Diminished Interest in Activities thighs, N/V, diarrhea, ha Easy Fatiguability, Decreased Energy Bleeding No Bleeding Feeling Overwhelmed or Out of Control Anovulation Obstruction, Lack of Estrogen Treatment: Breast Tenderness, Bloating, Wt Gain, Aches Proliferation or Hypogonadism Sleeping too Much or Not Enough Tx: Cyclic Progesterone/OCPs (Primary) NSAIDs, Warm Compress, Supplements, COC, DMPA, Implant, IUD Course of Estradiol/Progesterone x 2 Treatment: Bleeding No Bleeding Outflow Tract and Mild: Education, Reassurance, Symptomatic Treatment RARE Endometrium WORKING Mod-Severe: A Problem with the Body MRI of the Head First Line: SSRIs (Fluoxetine, Sertraline, Paroxetine, Citalopram) Stimulating Estrogen Second Line: Different SSRI, OCP Check FSH & LH Third Line: GnRH Agonist Elevated FSH & LH Normal FSH & LH LH > FSH Menopause r/o neoplasia Chronic Anovulation Premature Ovarian Failure (PCOS) Endometrial Bx Get a Karyotype Endometrial Bx Treatment: Anatomic Disorders: Surgery Ovarian Failure: Hormone Replacement Chronic Anovulation: OCP Pituitary Prolactinoma: Cabergoline or Bromocriptine Other Tumors: Surgery Hypothalamic Disorders; Surgery or Hormone Replacement  Neoplasms of the Breast and Reproductive Tract Benign, Malignant Breast Carcinoma Ovarian Cancer Endometrial Cancer m.c. cancer in women and second m.c. cancer death Types: Epithelial >> Germ Cell >> Sex Cord Stroma >> Krukenberg Epidemiology: m.c. gynecological cancer, 62 y.o. RF: Obestiy, Nulliparous, Late Menopause, Unopposed Estrogen, Epidemiology: Epidemiology: 62 y.o. Atypical Hyperplasia, DM, HTN 60 y.o. Caucasian (African American more likely to be large and advanced) Pathology: Increased Risk: Increased Ovulation (Low Parity, Early Menarche, Late Menopause), Endometrioid (80%), Papillary Serous Uterine (3%), Clear Endometriosis, Age, FHx of Breast or Ovarian CA, Talc, Smoking, Obesity RF: PMHx of Breast CA, Age > 50, FHx of Breast CA, FHx of Ovarian CA, Decreased Risk: OCPs, Tubal Ligation, Hysterectomy, Breastfeeding Cell ( 2 cm but < 5 cm, No Nodal Involvement OR Tumor < 2 cm WITH Lymph III: Tumor > 5 cm and LOCAL Nodal Involvement Treatment: Hyperplasia: WHO Classification IV: Metastatic Treatment: Simple without Atypia 1% Estrogen Effect Endometrial Hyperplasia Hormonal Therapy. Advanced: remove BOTH Ovaries, Fallopian Tubes, Uterus Complex without Atypia 3% Treatment: Simple Atypical 8% Precancer Endometrial Intraepithelial Hormonal or Surgical and Omentum Complex Atypical 29% Neoplasia Therapy Radical or Modified Mastectomy, Lumpectomy, Breast Implant - Alternative: Chemo Adenocarcinoma Cancer Adenocarcinoma Based on Stage Adjuvent Therapy, SERM (Tamoxifen), Aromatase Inhibitors - Optimal Cryoreductive Surgery Surgical Options: Hysterectomy, BSO, Washings, Careful Palliative Care (IV) REMOVE AS MUCH CANCER AS POSSIBLE Inspection, Lymphadenectomy - f/u with oncologist for 5 years minimum Vulvar Cancer Vaginal Cancer Benign Ovarian Neoplasms Epidemiology: RARE; 65 y.o. Epidemiology: RARE; 65 y.o. Prophylactic BSO af ter childbearing for those at high genetic risk to bring ovarian RF: HPV, Chronic Irritation 80-90% are Malignant cancer risk down 96% and breast cancer risk down 50-80%. Pathology: Squamous (90%), Melanoma (5%), Other (5%) Cannot be touching cervix or vulva to be considered vaginal cancer RF: HPV, h/o Cervical CA Borderline Tumors: characterized by lack of invasion Diagnosis: H&P, Imaging, Bx aka Tumor of Low Malignant Potential Pathology: Adult: Squamous, Young Adult: Clear Cell (DES), Infant: Rhabdo Epidemiology: Premenopausal Women STAGING Clinical Manifestations: Pathology: Most are Serous I: Confined to Vulva or Perineum; NO Lymph Nodes Painless Vaginal Bleeding/Discharge Prognosis: 100% 5-year survival in early stages and 80% in advanced A: < 2 cm & Stromal Invasion < 1 mm Tenesmus with Posterior Tumor. B: > 2 cm OR Stromal Invasion > 1mm Germ Cell Tumors of the Ovary: II: Any Size Spread to Lower 1/3 Urethra, Vagina or Anus Pelvic Pain due to Extension Subtypes: Choriocarcinoma (hCG), Teratomas, Embryonal (AFP & hCG),. III: Any Size with Adjacent Spread to Lower 1/3 WITH Lymph Node Invasion STAGING Dysgerminoma (LDH), Endodermal Sinus/Yolk Sac (AFP) IVA: Invades Upper Urethra, Vagina or Rectal Mucosa Fixed to Pelvis or Nodes I: Limited to Vaginal Wall/Mucosa Epidemiology: 10-30 y.o. IVB: Distant Metastasis II: Involves Submucosa but NOT Extending to Pelvic Sidewall Treatment: can conserve uterus, other ovary and fallopian tube if not involved. III: Extends to Pelvic Sidewall Treatment: IVA: Invades Bladder and/or Rectal Mucosa Sex Cord Stromal Tumors: IVB: Distant Spread Subtypes: Granulosa Cell (inhibin B), Sertoli-Leydig (testosterone), Fibroma, Thecoma, Radical Vulvectomy with T RIPLE Incision, Chemo & Radiation. Gynandroblastoma - AVOID Colostomy, Urostomy Treatment: Epidemiology: incidence increases to 70s Prognosis: overall excellent Stage I - TAH for Upper Vag, Vulvectomy for Lower Vag, Excision if Superficial. Stage II-IV - Chemoradiation & Ovarian Transposition in Young Pts Krukenberg Tumors: metastatic to the ovary from another site stomach >> breast >> small intestine >> colon >> appendix Ovarian Disorders Cysts, Polycystic Ovarian Syndrome, Torsion POST-MENOPAUSAL CYSTS ARE MALIGNANT UNT IL PROVEN OTHERWISE Cysts PCOS Ovarian Torsion Follicular Cysts: when follicles fail to rupture or grow and ovulation does NOT occur Endocrine disorder affecting the ovaries that can lead to wide spread effects EMERGENT complete or partial rotation of the ovary on its ligamental supports Clinical Manifestations: Epidemiology: Women of Reproductive Age and vascular supply resulting in ischemia that can compromise blood flow Asymptomatic, Unilateral Pelvic/Lower Abdominal Pain, Amenorrhea/Menstrual Changes Clinical Manifestations: Oligomenorrhea/Amenorrhea, Acne, Hirtuism, Infertility, Diagnosis: RF: Mobile Ovarian Mass > 5 cm, h/o Prior Torsion Pelvic US - Simple Cyst WITHOUT Thick Septations, Sof t-Tissue Elements, Evidence of Internal Truncal Obesity Clinical Manifestations: or External Excrescences or Papillations PE: HTN, Male pattern baldness, Acanthosis nigricans, Bilateral, enlarged smooth mobile ovaries, Treatment: most resolve on their own in 6 wks, if not then repeat US and possible surgery Impaired glucose tolerance, DMII, Anxiety, Depression, Sleep Issues Abrupt onset of mod-severe pelvic pain, N/V, Fever Rest, NSAIDs, Repeat US af ter 1-2 Menstrual Cycles Diagnosis: Labs, TVUS (“String of Pearls”) PE: > 8-10 cm requires surgery. Abdominal tenderness A ruptured cyst will result in acute pain treated with short term pain meds Exclude ALL Other Causes and Need 2 of the Following: Oligo-Ovulation or Anovulation +/- Palpable Mass Corpus Luteum Cysts: cyst once ≥ 3 cm failing to degenerate post-ovulation Biochemical or Clinical Evidence of Hyperandrogenism Hemorrhage Polycystic-Appearing Ovaries on US First Type: slightly larger corpus luteum that Second Type: rapidly enlarging luteal phase cyst with - 12+ Follicles on Each Ovary 2-9cm in Size Diagnosis: continues to produce progesterone > 14 days delaying subsequent hemorrhage menstruation days - wks. Pelvic US with Doppler Treatment: Weight Loss, OCPs, Letrozole/Climophene +/- Metformin, Statins SXS ipsilateral dull lower quadrant pain, secondary amenorrhea acute pain in luteal phase, potential hypovolemia ß-hCG PE DX enlarged, tender, cystic or solid adnexal mass ß-hCG, TVUS (complex, thick-walled cyst hemoperitoneum, hypovolemia, no pelvic mass but tenderness TVUS, CT COMPLICAT IONS: increased r/o metabolic syndrome, DM, CVD, dyslipidemia, CBC with peripheral vascularity) self-limiting though may need surgery endometrial hyperplasia, endometrial CA Direct Visualization of Rotated Ovary (Definitive) TX self-limiting depending on amount of hemorrhage Pregnancy COMPLICAT IONS: spontaneous abortionrate is 20-40% higher than the Treatment: baseline Theca Lutein Cysts: excess ß-hCG causing hyperplasia Laparoscopic Surgery with Detorsion RF: Mult Gestations, Trophoblastic Disease, Ovulation Induction with ß-hCG & Clomiphene - if not viable or malignant: salpingo-oophorectomy Hyperthecosis: more severe form of pcos Clinical Manifestations: Typically Bilateral  Pelvic Inflammatory Disorder PID TOA Infection of the upper female reproductive tract occurring when a vaginal/cervical infection spreads to sterile uterus and adnexa A complication of PID most of ten due to recurrent infection on damaged necrotic tissue. Includes: Salpingits, Endometritis, Oophoritis, Tubo-Ovarian Abscess and could extend to include Fitz-Hugh Curtis Syndrome Epidemiology: women undergoing egg retrieval OR young, low parity women with h/o PID. Etiology: ST Is (m.c.c.), IUD, Puerperal Infection, Post-Op, Post-Abortion, Direct/Hematogenous/Lymph Spread Etiology: Polymicrobial. Clinical Manifestations: Clinical Manifestations: Abnormal Bleeding unilateral mass acute or chronic pain Purulent Discharge fever/chills Fever discharge 2 wks af ter menses Constant Diffuse Abdominal Pain. Diagnosis: Cervical Motion Tenderness Labs (CBC, Chem Panel, ß-hCG, GC/Chlamydia, HIV, RPR, Blood Cx) & Imaging (US, Diagnosis: Clinical CT) Labs (ß-hCG, ESR/CRP, CBC, Chem, HIV, GC/Chlamydia, KOH, RPR, UA, NAAT, etc.) - Leukopenia/Leukocytosis, Sterile Pyuria on UA, Elevated ESR/CRP. TVUS (rules out TOA but does NOT rule out PID if no findings) Treatment: Laparoscopy is the GOLD standard, but barely used Unruptured, Small, Asymptomatic: IV AbX & Serial US Treatment: Drainage +/- Tube Removal if no improvement in 2-3 weeks Lower Abdominal Pain OR Adnexal Pain OR Cervical Motion Tenderness without another cause Ruptured, Symptomatic: Hospitalize with IV AbX & Support Consult IR for Drainage FIRST Line AbX: AbX (x14 days) BEFORE Culture and Presumptive PID Diagnosis Cefotetan + Doxycycline Acute Tx: Bed Rest, Analgesics, Cef triaxone, Doxycycline or Metronidazole Ruptured: Surgical EMERGENCY Cefoxitin + Doxycycline Abdominal Laparotomy with Removal of Abscess Clindamycin + Gentamicin Hospitalization Criteria: Pregnant, Possible Surgical Cause, Illness with Suspected TOA or Severe PID, Compliance to Meds in Question, OR Fail OP Therapy Uterine Disorders Endometriosis, Leiomyoma, Prolapse Endometriosis Leiomyoma Prolapse Abnormal growth of tissue resembling endometrial tissue responsive Single or multiple benign smooth muscle tumors Cystocele: posterior bladder prolapsing into anterior vagina to hormones OUTSIDE the uterus Enterocele: small bowel prolapsing into upper vagina Epidemiology: African American; REGRESS Postmenopause Rectocele: rectum prolapsing into posterior vagina RF: FHx, Prolonged Estrogen Exposure, Heavy Bleeding during Menses, Obstruction of Menstrual Flow, High Fat Diet RF: Early Menarche, AA, DES, Obesity, Red-Meat, High Beet Intake, FHx, HTN PF: Multiparous, Late Menarche, Extended Lactation Intervals, Omega-3 Fatty PF: Parity, h/o Resolved Fibroids, Long-Acting POC, Plant Diet Uterine: downward displacement of the uterus into the vaginal canal Acids Etiology: Classification: Intramural, Submucosal (0-II), Subserosal, Cervical Increase Pelvic Floor Pressure, Weakness of Pelvic Support Clinical Manifestations: Structures Dull/Crampy Pain 1-2 before Menses Infertility RF: Pregnancies, Giving Birth to a Large Baby, Age, Obesity, Prior Pelvic Sx, Dysmenorrhea Chronic Constipation, FHx Dyspareunia Dyschezia Clinical Manifestations: Vaginal Heaviness Diagnosis: NO Specific Labs Falling Out” Sensation Physical Exam, Low Back/Abdominal Pain Clinical Manifestations: Laparoscopy Worse with Standing Heavy/Prolonged Bleeding Bx (Definitive Diagnosis) Urgency/Frequency Pelvic Pressure/Pain TVUS Stress Incontinence. Reproductive Dysfunction STAGING: I - minimal disease, no adhesions Diagnosis: Diagnosis: II - mild disease, superficial implants < 5 cm, no adhesions Physical Exam (bulging mass especially with increased pressure) Exam & hCG >>. III - moderate disease, superficial & deep implants, possible adhesions GRADING IV - severe disease, superficial & deep implants, adhesions TVUS (whorled appearance and rim-like calcifications) >> 0 - no descent. Hysteroscopy >> Treatment: I - uterus descent into upper 2/3 of vagina MRI II - cervix approaches introitus Mild: Observation (Pathology NOT Needed) III - cervix outside introitus Mod: Hormone Agents and Prostaglandin Inhibitors Initially IV - entire uterus outside vagina - GnRH Agonists if SXS Remain Treatment:. Treatment: Sev: Surgery Asymptomatic NOT Treated - Total Hysterectomy, Bilateral Salpingoophorectomy, Lysis of Adhesions Lifestyle Changes, Pelvic Floor PT, Pessaries, Surgery NSAIDs Ferrous Sulfate Complications: Displacement of Vaginal Lining or Prolapse of Other Organ COC, Progestin-Only Pills GnRH Agonists!!! (Zoladex, Lupron, Synarel) Pelvic Organ Prolapse - ADR: Bone Loss over 12m of Therapy Diagnosis: Based on Compartment, POP-Q Surgery for Complications (i.e. hysterectomy). STAGING 0 No Prolapse I Most Distal Portion > 1 cm ABOVE Hymen II Most Distal Portion < 1 cm ABOVE or BELOW Hymen Leiomyosarcoma III Most Distal Portion > 1 cm BELOW Hymen IV Complete Eversion Endometrioma RARE, aggressive, smooth muscle neoplasm possibly coexisting w/ benign leiomyomas. Epidemiology: 60 y.o. African American m.c. form of endometriosis most of ten benign in the ovary Clinical Manifestations: Post-menopausal Bleeding Diagnosis: Diagnosis: Endometrial Biopsy dark, fluid-filled chocolate cyst where the fluid is thick and dark with stagnant blood **Leiomyomas are NOT precursors to leiomyosarcomas** Treatment: Treatment: same as endometriosis > 4 cm or severe, chronic pain then surgery and rule out Asymptomatic - Mild Symptoms: Observation, Non-Surgical Tamoxifen has a black box warning due to the risk if uterine sarcoma development malignancy Mod - Severe Symptoms: Non-Surgical vs. Surgical  Vaginal/Vulvar Disorders Bartholin Gland Cysts, Vaginitis, Prolapse/Cystocele/Rectocele Bartholin Gland Cysts Vaginitis Development of cyst secondary to fluid build up/blockage of the gland Disorders of the vagina caused by infection, inflammation or changes in normal flora Etiology: Clinical Manifestations: Candida vulvovaginitis (YEAST) Vulvar Mass Bacterial vaginosis (BACT ERIAL) Pain with Walking, Sitting or Sex Trichomoniasis (PROTOZOA) Abscess (E. Coli): Severe Pain, Swelling, Erythema Clinical Manifestations: PE: Discharge Changes Erythema Cyst: Sof t, Non-Tender Unilateral Mass 1-3 cm in siz Pruritis Dyspareunia Abscess: Sof t, Tender, Warm, Fluctuant, Unilateral Mass 3-6 cm in size Spotting Burning Irritation Dysuria Diagnosis: Clinical Diagnosis: H&P Treatment: Labs (pH, Amine/Whiff Testing, KOH, NAAT/ST I Swabs, Cultures) Warm Compress, Sitz Bath, I & D, Word Catheter x 4 weeks, Bimanual Exam AbX - f/u in 1 month or sooner Candidiasis Bacterial Vaginosis Trichomoniasis RF: Reproductive Age, Pregnancy, DM, Obesity, Immunosuppression, Meds, Polymicrobial infection characterized by the lack of normal hydrogen peroxide Infection by protozoan trichomonas vaginalis Warm/Moist Vagina producing lactobacilli and an overgrowth of anaerobic organisms. Clinical Manifestations: RF: Reproductive Age, Sexual Activity, Douching/Other Hygiene Products, Clinical Manifestations: Itching Smoking, Recent AbX, Frequent Bathing Vulvar Itching Dyspareunia. Burning Clinical Manifestations: Vulvar Burning Dysuria External Dysuria FISHY Vaginal Odor Copius Discharge Post-Coital Bleeding Dyspareunia Gray-White to Yellow Discharge Odor PE: Thick, Odorless, White “Cottage Cheese” Discharge with pH of 4-5 PE: Frothy, Yellow/Green Gray Discharge, pH > 4.5, Vulvar Edema/Erythema, Mild Irritation Diagnosis: H&P, KOH (Spores and Hyphae), Positive Culture. Strawberry Cervix Treatment: directed towards relief of symptoms and no treatment Diagnosis: Gold Standard - Gram Stain needed if found on pap smear Criteria (need 3/4): abnormal gray discharge, pH > 4.5, positive whiff test or Diagnosis: presence of clue cells Uncomplicated: Imidazole, Oral Fluconazole or Topical Nystatin Confirmed Microscopic Exam, NAAT, Cx (Screen for ST Is if +) AVOID Speculum Exam, Diagnosis WITHOUT Testing, Culture, Pap Smear or Complicatied: Cytology, & Treatment of Asymptomatic Pts - Initial: Topical Imidazole. Treatment: Treat ALL Symptomatic and Asymptomatic Pts with Confirmed Infection Treatment: - Severe: 2-3 Fluconazole Doses Metronidazole 500 mg x 7 days Not Pregnant: Metronidazole (oral or topical), Clindamycin (topical) - Recurrent: Weekly Fluconazole x 6 months - Do NOT Use MET RO VAGINAL GEL, it is ineffective Pregnant/Lactating: Metronidazole or Clindamycin (oral) Uncomplicated Candidiasis Complicated Candidiasis All sexual partners must be treated & remain abstinent from sexual Procedure - Asymptomatic but Confirmed: Depends on Pregnancy Status Sporadic/Infrequent Episodes Pregnant activity Not Pregnant Recurrent Episodes Asymptomatic: Observation Mild-Mod Symptoms Severe Symptoms Proven or Suspected Infection Recurrent (3+ in 1 year): Extended Metronidazole, Vaginal Boric Acid Proven Infection DM, Illness or Immunocompromised Repeat NAAT testing 3 weeks - 3 months af ter completing treatment Immunocompetent Patient Adjuncts: Probiotics, Boric Acid (can cause DEATH if consumed orally)  Not Included but Lectured On: AUB, DUB, Adenomyosis, Breast Screening, Cervical Polyps, Nabothian Cysts, Infectious Disorders, Gyne Procedures ABNORMAL UT ERINE BLEEDING DYSFUNCT IONAL UT ERINE BLEEDING Menstrual bleeding of abnormal quantity, duration or schedule Irregular bleeding consisting of anovulatory cycles with an absence of pathology or illness and disrupted cycles Etiology: PALM-COEIN Polyp Coagulopathy Pathophysiology: Adenomyosis Ovulatory Dysfunction Loss of endometrial stimulation leading to proliferation withOUT shedding Leiomyoma Endometrial Malignancy Iatrogenic Etiology: Not Yet Classified Estrogen/Progesterone Withdrawal Estrogen Excess Diagnosis: H&P, Labs, TVUS, Hysterectomy Endocrinopathy Diagnosis of Exclusion; if no underlying etiology then it is Dysfunctional Uterine Bleeding Treatment: Treatment: Anti-Prostaglandins, Anti-Fibrinolytics, COC, Progestin, GnRH, Surgery Medroxyprogesterone for LIGHT bleeding COC for HEAVY bleeding D&C if unresponsive to hormonal therapy ADENOMYOSIS BREAST SCREENING Glandular muscle condition in which the endometrium breaks through the muscle wall of the uterus Self-Exam: multiple positions assessed at the same time monthly for women under 20 years old causing hypertrophy and hyperplasia of the myometrium Clinical Exam: upright and supine position best assessed in vertical stripe pattern Epidemiology: 40-50 y.o. nulliparous women with endometriosis or leiomyomas Mammography: Clinical Manifestations: < 40: Not Suggested Heavy/Painful Menstrual Bleeding, Pelvic Fullness, Chronic Pain, Asymptomatic 40-49: Every 2 Years Diagnosis: 50-74: Every 2 Years Physical Exam: Boggy Uterus ≥ 75: Every 2 Years if Life Expectancy is ≥ 10 Years Imaging: TVUS >> MRI >> Bx (endometrial tissue within myometrium) Treatment of Choice - Hysterectomy if NOT desiring fertility BI-RADS (If desiring fertility) Density 0: Incomplete; lesion not fully evaluated by standard screening 1: Completely Negative Exam Ablation, Resection, UAE, Electrocoagulation or Excision A: Almost Entirely Fatty 2: Benign findings; CA is not a concern Progestins: Preganes, Estranes, Gonanes B: Scattered Areas of Fibro Glandular Density 3: Does not have benign features; likelihood of malignancy < 2%; f/u 6 mo C: Heterogenously Dense (may obscure small masses) 4: Suspicious for malignancy GnRH: Zoladex, Lupron, Synarel D: Extremely Dense (lowers sensitivity of mammography) 5: Highly suggestive for malignancy Aromatase Inhibitors: Arimidex, Aromasin, Femara 6: Biopsy proven malignancy CERVICAL POLYPS NABOTHIAN CYSTS Epidemiology: Reproductive Years af ter 40 y.o. Vary from microscopic to several centimeters appearing translucent or opaque Treatment: Etiology: Remove if symptomatic, large (≥ 3 cm) or appear atypical by POLYPECTOMY Minor Trauma Childbirth Clinical Manifestations: Asymptomatic Diagnosis: Unclear (can be opened) Treatment: ONLY if painful or a feeling of fullness INFECT IOUS DISORDERS REVIEW GYNECOLOGICAL PROCEDURES GENITAL HERPES Treatment: Acyclovir, Valacyclovir or Famiciclovir Acyclovir, Valacyclovir and Famciclovir: Pregnancy Category B Colposcopy CHLAMYDIA Endometrial Biopsy Treatment: Doxycycline or Azithromycin/Levofloxacin Etonogestrel Implant IUD Insertion & Removal GONORRHEA Tubal Sterilization Treatment: Cef triaxone or Gentamicin, Cefixime Vasectomy D&C MYCOPLASMA GENITALIUM Hysterectomy Treatment: Cervical Conzation Empiric: Multi Dose Doxycycline or Single Dose Azithromycin Endometrial Ablation Confirmed Case: Moxifloxacin  Pregnancy Abruptio placentae, Breech presentation, Cervical insufficiency, Cesarean and operative delivery, Classifications of abortion, Ectopic pregnancy, Fetal distress, Gestational diabetes, Gestational trophoblastic disease, Hypertensive disorders of pregnancy, Labor/delivery, Multiple gestation, Placenta previa, Postnatal/postpartum care, Postpartum hemorrhage, Postpartum pituitary disorders, Postpartum psychiatric disorders, Preconception/prenatal care, Prelabor rupture of membranes, Rh incompatibility, Shoulder dystocia, Umbilical cord prolapse Abruptio Placentae Breech Presentation Cervical Insufficiency Premature separation of a normally implanted placenta from the the fetus in the longitudinal lie with the buttocks or lower extremity Recurrent, painless cervical dilation leading to second trimester uterine wall af ter 20 weeks gestation entering the pelvis first pregnancy losses Etiology: Ruptured Maternal Vessel Types: RF: Cervical Trauma, Congenital Defect, Short Cervical Length Frank Breech RF: Trauma, Preeclampsia/Hypertensive Disorders, Increased Parity, Increasing Complete Breech Clinical Manifestations: Minimal to None Maternal Age, Shortness of Umbilical Cord, Smoking, Cocaine Use, Polyhydramnios PE: Cervical dilation and effacement INCONSIST ENT with Incomplete Breech the degree of uterine activity Clinical Manifestations: External Cephalic Version (ECV): Painful 3rd Trimester Bleeding Diagnosis: