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doi:10.1111/j.1447-0756.2012.01858.

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J. Obstet. Gynaecol. Res. Vol. 38, No. 4: 615–631, April 2012

Guidelines for office gynecology in Japan: Japan Society of Obstetrics and Gynecology and Japan Association of Obstetricians and Gynecologists 2011 edition
Takashi Takeda1, Tze Fang Wong1, Tomoko Adachi3, Kiyoshi Ito1, Shigeki Uehara2, Yasushi Kanaoka14, Masaharu Kamada17, Hiroaki Kitagawa4, Satoshi Koseki18, Hideto Gomibuchi5, Juichiro Saito19, Kazuhiro Shirasu20, Kou Sueoka6, Mitsuhiro Sugimoto7, Mitsuaki Suzuki21, Toshiyuki Sumi15, Satoru Takeda8, Keiichi Tasaka16, Yasuyuki Noguchi22, Shunsaku Fujii23, Tsuneo Fujii24, Michihisa Fujiwara25, Tsugio Maeda26, Koji Matsumoto27, Mikio Momoeda9, Mineto Morita10, Kazuaki Yoshimura28, Yasuo Hirai11, Toshiro Kubota12, Noriaki Sakuragi29, Masakiyo Kawabata13, Hiroyuki Yoshikawa27, Hiroshi Kobayashi30 and Nobuo Yaegashi1
jog_1858 615..631

Departments of Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, 2Obstetrics and Gynecology, Kosai Hospital, Sendai, Miyagi, 3Obstetrics and Gynecology, Aiiku Hospital, 4Obstetrics and Gynecology, Toranomon Hospital, 5Obstetrics and Gynecology, National Center for Global Health and Medicine, 6Obstetrics and Gynecology, Keio University Graduate School of Medicine, 7Obstetrics and Gynecology, Tokyo Red Cross Hospital, 8Obstetrics and Gynecology, Jikei University School of Medicine, 9Obstetrics and Gynecology, St Luke’s International Hospital, 10Obstetrics and Gynecology, Toho Medical University, 11Obstetrics and Gynecology, Tokyo Women’s Medical University, 12Obstetrics and Gynecology, Tokyo Medical and Dental University, 13Obstetrics and Gynecology, Douai Memorial Hospital, Tokyo, 14 Obstetrics and Gynecology, Iseikai Hospital, 15Obstetrics and Gynecology, Osaka City University School of Medicine, 16 Tasaka Clinic, Suita, Osaka, 17Department of Obstetrics and Gynecology, Health Insurance Naruto Hospital, Naruto, Tokushima, 18Koseki Clinic, Departments of 19Obstetrics and Gynecology, St Marianna University School of Medicine Yokohama Seibu Hospital, Yokohama, 20Obstetrics and Gynecology, Odawara Municipal Hospital, Odawara, Kanagawa, 21 Obstetrics and Gynecology, Jichi Medical University School of Medicine, Simino, Tochigi, 22Obstetrics and Gynecology, Aichi Medical University, Nagakute, Nagoya, 23Tachizaki Ladies’ Clinic, Aomori, 24Fujii Ladies’ Clinic, Hiroshima, 25 Department of Obstetrics and Gynecology, Kawasaki Medical University, Kurashiki, Okayama, 26Maeda Clinic, Yaizu, Shizuoka, Departments of 27Obstetrics and Gynecology, Tsukuba University Graduate School of Medicine, Tsukuba, Ibaragi, 28 Obstetrics and Gynecology, University of Occupational and Environmental Health, Kitakyusyu, Fukuoka, 29Obstetrics and Gynecology, Hokaido University Graduate School of Medicine, Sapporo, Hokaido and 30Obstetrics and Gynecology, Nara Medical University, Kashihara, Nara, Japan

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Abstract
Gynecology in the office setting is developing worldwide. Clinical guidelines for office gynecology were first published by the Japan Society of Obstetrics and Gynecology and the Japan Association of Obstetricians and Gynecologists in 2011. These guidelines include a total of 72 clinical questions covering four areas (Infectious disease, Malignancies and benign tumors, Endocrinology and infertility, and Healthcare for women). These clinical questions were followed by several answers, backgrounds, explanations and references covering common problems and questions encountered in office gynecology. Each answer with a recommendation level of A, B or C has been prepared based principally on evidence or consensus among Japanese gynecologists.

Reprint request to: Dr Takashi Takeda, Department of Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan. Email: take@med.tohoku.ac.jp

© 2012 The Authors Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology

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was published in February 2011. In this case. (C) Implications of ‘A’. In spite of its growing importance. Diagnosis may be possible from historytaking and clinical observation of typical clinical cases. patient serum can be tested for viral antibodies (enzyme-linked immunosorbent assay) or specific Ig (immunoglobulin) G and IgM. and ‘C’ Recommendation Levels Several tests and/or treatments for gynecologic outpatients are presented as answers with a recommendation level of A. Japan Society of Obstetrics and Gynecology (JSOG) and the Japan Association of Obstetricians and Gynecologists (JAOG) decided to publish guidelines describing standard care practices for gynecologic outpatients in 2008. Introduction Gynecology in the office setting is developing worldwide. Today. The original version of ‘Guidelines for Office Gynecology in Japan 2011’ contains backgrounds. Subsequently. If samples cannot be obtained directly from the lesions. Level A indicates a stronger recommendation than level B. Key words: guidelines. health care and so on. Answers with a recommendation level of C are possible options that may favorably affect the outcome but for which some uncertainty remains regarding whether the possible benefits outweigh the possible risks. Technological advances have enabled the transition of inpatient operations to day surgery procedures. care corresponding to answers with a recommendation level of C does not necessarily need to be provided. Thus. It is the most frequent contact between the female patient and her gynecologist. In such cases. oncology. consisting of 72 Clinical Questions and Answers (CQ&A). Oncology and benign tumors (CQ201 – CQ224) Chapter C. explanations and references. the office gynecologists must refer the patient to an appropriate institution. Consequently. such as infectious disease. B or C to each clinical question. Infectious disease CQ101 How do we diagnose and treat genital herpes? Answer 1 Test for antigens in samples taken directly from the lesions. evaluate the serum test carefully. office practice. Takeda et al. Endocrinology and Infertility (CQ301 – CQ314) Chapter D. hysteroscopy. infertility. Contents Chapter A. The answers and recommendation levels are principally based on evidence or consensus among Japanese gynecologists when the evidence is considered to be weak or lacking. Infectious disease (CQ101 – CQ112) Chapter B. Answers with a recommendation level of A or B are regarded as current stan- 616 © 2012 The Authors Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology . less time away from work and cost-savings for patients. Healthcare for women (CQ401 – CQ422) A. (A) 4 For mild diseases. the first edition. gynecology. Thus. women’s health. the answers are not necessarily based on ‘evidence’. These criteria are essentially the same as described previously in ‘Guidelines for obstetrical practice in Japan: Japan Society of Obstetrics and Gynecology (JSOG) and Japan Association of Obstetricians and Gynecologists (JAOG) 2011 edition’. These guidelines would promote a better understanding of the current standard care practices for gynecologic outpatients in Japan. It deals with a wide range of areas concerning women’s health. (B) 3 Treat using acyclovir or valacyclovir. topical acyclovir or topical vidarabine may be adequate. there was no guideline for office gynecology in the world. Under these circumstances. informed consent is required when office gynecologists do not provide care corresponding to an answer with a level of A or B. endocrinology. endometrial ablation and cervical loop excision are some of the most widely performed gynecological procedures in Japan. these sections have been omitted because of space limitations. However. ‘B’.T. (B) 2 Antigen test is conducted by direct immunofluorescence against viral antigen and can be combined with cytology. Some answers with a recommendation level of A or B include examinations and treatments that may be difficult for general office gynecologists to provide. dard care practices in Japan. These outpatient procedures offer quick recovery. ‘Guidelines for Office Gynecology in Japan 2011’.

(B) 5 Post-treatment evaluation should be conducted at least 2–3 weeks after the completion of treatment. © 2012 The Authors Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology 617 . orally (Up to 10 days for initial episode) Every 8 h for 7 days Once daily for 1 year. lactobacillary grade on vaginal saline lavage.v. and laser vaporization. nucleic acid amplification tests (NAAT) or enzyme immunoassay (EIA). prophylaxis against recurrence is advisable. (B) Content 250 mg/tablet 2 g/dry syrup 200 mg/tablet 500 mg/tablet 100 mg/vial Dosage 1000 mg. cryotherapy. electrocauterization. (B) 2 Treat with topical creams containing 5% imiquimod. Biopsy and pathological evaluation can be performed when necessary. Klaricid Cravit Minomycin 3 Treat using oral macrolides or fluoroquinolone antibiotics. (B) 3 Surgical therapy involving direct excision. (C) 2 Treat locally (vaginally) or orally using chloramphenicol or metronidazole. (C) CQ104 How do we diagnose and treat bacterial vaginosis? Answer 1 Nugent score on vaginal discharge. (B) 6 Sexual partner(s) of patient should be tested and treated. orally CQ102 How do we diagnose and treat chlamydial cervicitis? Answer 1 Diagnose by testing cervical smear for chlamydia using nucleic acid hybridization tests. (B) Brand name Zovirax (200 mg) Valtrex (500 mg) Zovirax (5 mg/kg/session) Valtrex (500 mg) Dosage 5 times daily for 5 days. single dose orally 2000 mg. for 3–5 days CQ103 How do we diagnose and treat vulva condyloma acuminatum? Answer 1 Clinical symptoms and presentation are usually sufficient for diagnosis.Guidelines office gynecology in Japan 5 For cases with more than six recurrences within a year. (A) 2 Sample should be tested simultaneously for gonorrhea when using NAAT. (A) 4 For pelvic inflammatory disease (PID) or Fitz– Hugh–Curtis syndrome. once daily for 7 days 100 mg.v. orally Twice daily for 2 days. (B) Main examples of prescription Generic name Azithromycin Oral Intravenous Clarithromycin Levofloxacin Minocycline Brand name Zithromax Zithromax SR Clarith. acyclovir Oral valacyclovir toms. (B) Main examples of prescription Chloramphenicol vaginal tablet Metronidazole vaginal tablet Metronidazole tablet Chlomy vaginal tablet 100 mg Flagyl vaginal tablet 250 mg Flagyl tablet 250 mg Once daily Once daily 4 tablets twice daily Intravaginally for 6 days Intravaginally for 6 days Orally for 7 days The duration of treatment can be prolonged as needed. twice daily for 7 days 500 mg orally. or Amsel criteria can be used for objective diagnosis. or recurrences presenting with severe sympMain examples of prescription Generic name Initial episode. i. recurrences Mild to moderate symptoms Severe symptoms Recurrence suppression Oral acyclovir Oral valacyclovir i. twice daily. single dose orally 200 mg orally. oral antibiotics can be administered if the symptoms are mild.

Takeda et al. (B) 4 Sexual partner(s) must be treated simultaneously with the same oral drug. CQ105 How do vaginitis? Answer we diagnose and treat trichomonas 1 Check vaginal discharge microscopically for trichomonads. give topical creams. perform vaginal lavage. 3 Treatment is considered successful if subjective symptoms disappear or vaginal discharge improves. (B) Content per tablet 250 mg 200 mg 500 mg 250 mg 200 mg Dosage 500 mg/day. culture the sample. then intravaginal administration of antifungal medication. For vulva candidiasis. in combination with clinical symptoms. withhold treatment for 1 week before repeating treatment. (B) Table 1 For continuous daily treatment Generic name Clotrimazole Miconazole nitrate Oxiconazole nitrate Brand name 2 For treatment. (C) 3 Treat systemically by giving oral metronidazole or tinidazole as ascending infection involving the upper urinary tracts cannot be ruled out. (A) Dosage One tablet daily One tablet daily One tablet daily Duration 6 days 6 days 6 days Empecid vaginal tablet 100 mg Florid vaginal suppository 100 mg Okinazol vaginal tablet 100 mg Table 2 For patients who cannot receive regular follow ups Generic name Isoconazole nitrate Oxiconazole nitrate Brand name Adestan vaginal tablet 300 mg Okinazol vaginal tablet 600 mg Dosage 2 tablets daily One tablet daily Frequency Once a week Once a week Table 3 For topical treatment Generic name Clotrimazole Miconazole Isoconazole nitrate Oxiconazole nitrate Brand name 1% Empecid cream 1% Florid D cream 1% Adestan cream 1% Okinazol cream Dosage 2–3 times daily 2–3 times daily 2–3 times daily 2–3 times daily Duration 5–7 days 5–7 days 5–7 days 5–7 days 618 © 2012 The Authors Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology . or culture (agar plates with specialized medium or liquid medium with pH indicator can be used as well) of vulvovaginal discharge. Flagyl vaginal tablet Haisigyn vaginal tablet CQ106 How do we diagnose and treat Candida vulvovaginitis? Answer 1 Diagnose by microscopic examination for yeast. twice daily for 10 days 400 mg/day. twice daily for 7 days 2000 mg. single dose One tablet daily for 10–14 days One tablet daily for 7 days If the trichomoniasis persists. (A) Tables 1–3.T. (B) Main examples of prescription Antitrichomonal agents Oral formulations Vaginal tablets Metronidazole Tinidazole Metronidazole Tinidazole Brand name Flagyl Haisigyn 2 If no organisms are found microscopically.

v. (A) 2 When pharyngeal infection is suspected. the physician who makes the diagnosis should report the case in accordance with the Infectious Disease Law by the Japanese government.0 g/vial Dosage 1. Cefixime (i. ampicillin). (A) 3 Follow up by evaluating test results of serologic test (STS). CQ109 How do we diagnose pelvic inflammatory disease (PID)? Answer Diagnosis should be made following the criteria as stated below.0g i. Treponema pallidum hemagglutination assay or fluorescent treponemal antibody absorption test in combination for confirmatory diagnosis and determination of disease stage. (Additional diagnostic criteria) (B) 1 Body temperature 38°C 2 Leukocytosis 3 Elevated C-reactive protein (Specific diagnostic criteria) (C) 1 Identification of (intrapelvic) abscess by magnetic resonance imaging (MRI) or transvaginal ultrasonography. © 2012 The Authors Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology 619 . perform the above tests on samples from pharyngeal swab. perform gonorrhea culture or nucleic acid amplification test (NAAT) on cervical swab samples to detect for the presence of gonorrhea bacteria.. Treat primary syphilis for 2–4 weeks.0g i. (C) Main examples of prescription Generic name Injection drug Ceftriaxone Cefodizime Spectinomycin Brand name Rocephin Kenicef Trobicin 3 Samples should be tested simultaneously for chlamydia when NAAT is used. Pasetocin Viccilin Bicillin secondary syphilis for 4–8 weeks.v.8 million units Regimen 3 times daily 4 times daily 3 times daily Duration Primary syphilis: 2–4 weeks Secondary syphilis: 4–8 weeks Tertiary syphilis: 8–12 weeks Some formulations are not covered by national health-care insurance even if the same drugs in other formulations are..v.). 2 Aspiration of purulent material via the Pouch of Douglas. 2 Uterine or adnexal tenderness with palpation. (Minimum diagnostic criteria) (A) 1 Lower abdominal pain.) are first-line therapies for genitourinary gonococcal infections. single dose 1. (A) 2 First-line treatment with oral penicillins (amoxicillin. and tertiary syphilis for 8–12 weeks with oral antibiotics. (B) Content 1. (A) 4 When syphilis is confirmed. single dose 2. (A) Daily dosage 1.v. tenderness with palpation.m.0g i.5 g 2.0 g/vial 2. (B) Single dose of dry syrup containing 2g azithromycin can also be prescribed.m. (gluteal).Guidelines office gynecology in Japan CQ107 How do we diagnose and treat gonococcus infections? Answer 1 For diagnosis of genital infection.0 g/vial 1.) and Spectinomycin (i. (B) 4 Single treatment using Ceftriaxone (i.0 g 1. single dose CQ108 How do we diagnose and treat syphilis? Answer 1 Use serologic tests for syphilis (STS). 3 Laparoscopic abnormalities suggestive of inflammation consistent with PID. First-line drugs Generic name Amoxicillin Ampicillin Benzylpenicillin Abbreviation AMPC ABPC PCG Brand name Sawacillin. (C) 5 Sexual partner(s) of patient should be tested and treated.

v.v. tests for trichomonas (vaginal discharge). twice daily for 5–7 days 2) Flomoxef (Flumarin) 1–2g in a single dose. twice daily for 5–7 days 2) Doripenem (Finibax) 0.v. intravenous administration of cephem (up to secondgeneration) can also be considered.v.T. once to twice daily for 5–7 days 2. (B) 620 © 2012 The Authors Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology . i.25g in a single dose. burning sensation during urination or sensation of incomplete bladder emptying. or where the patient is unable to receive inpatient treatment). administer intravenous third. i. i. 2 For mild to moderate cases.v. 2–3 times daily for 5–7 days CQ111 How do we screen for sexually transmitted diseases (set test)? Answer 1 The set test includes tests for four major sexually transmitted diseases: chlamydia (cervix). (B) 2 For patients at risk for pharyngeal or throat infection. i. (C) 2 Treat with oral cephalosporins. (B) B. Cephems for injection 1) Cefmetazole (Cefmetazon) 1–2g in a single dose. and urine test findings are useful for diagnosis. hospitalization is indicated. i. Oncology and benign tumors CQ201 What is the appropriate way of obtaining samples for cervical cytology? Answer Collect cervical cells with a brush or a spatula. (C) 3 If the patient requested extra tests. hepatitis B and C antibody (blood) can be added. CQ110 How do we treat pelvic inflammatory disease (PID)? Answer Treat as stated below. test pharyngeal samples for chlamydia and gonorrhea. twice daily for 5–7 days 3) Cefpirome (Broact) 1–2g in a single dose. chlamydial antibody (blood). penicillins. vomiting or high fever • The patient has a tubo-ovarian abscess. (B) Treatment for mild to moderate PID 1. Carbapenems for injection 1) Imipenem (Tienam) 0. (A) Urine culture yielding more than 105 colonyforming units (CFU)/mL of one type of bacteria indicates the pathogen responsible for the infection. Takeda et al. i. Oral quinolones 1) Levofloxacin (Cravit) 500 mg orally once daily for 5–7 days 2) Tosufloxacin (Ozex) 150 mg orally 3 times daily for 5–7 days 3) Ciprofloxacin (Ciproxan) 100–200 mg orally 3 times daily for 5–7 days Treatment for severe PID 1. or quinolones. twice daily for 5–7 days 4) Ceftriaxone (Rocephin) 1–2g in a single dose. or carbapenem antibiotics. 1 Outpatient treatment is usually adequate unless. For moderate cases. (C) CQ202 How do we manage and treat CIN1/2 (mild to moderate dysplasia)? Answer 1 CIN1 (mild dysplasia) confirmed with biopsy should receive follow-up observation with Pap smear and colposcopy every 6 months. Combined therapy using i. Oral cephems 1) Cefditoren (Meiact) 100 mg orally 3 times daily for 5–7 days 2) Cefcapene (Flomox) 100 mg orally 3 times daily for 5–7 days 3) Cefdinir (Cefzone)) 100 mg orally 3 times daily for 5–7 days 2.v. as in cases as stated below. prescribe oral cephem or quinolone antibiotics. (C) CQ112 How do we diagnose and treat cystitis? Answer 1 Clinical history and presentation characterized by frequent urination. HIV infection (blood). gonorrhea (cervix). (B) 3 For severe cases (with no indication for hospitalization. (A) 3 Differential diagnosis of other medical conditions that may present with an overactive bladder should be taken into consideration. (B) 2 CIN2 (moderate dysplasia) confirmed with biopsy should receive careful and consistent follow up with Pap smear and colposcopy every 3–6 months.v.5–1g in a single dose.or higher generation cephem. (B) • When emergency requiring surgical intervention (such as appendicitis) cannot be ruled out • The patient is pregnant • Oral antibiotics are not effective • The patient cannot take oral antibiotics • The patient has nausea. clindamycin or minocycline is also an option. syphilis (blood).

(B) CQ205 What is the clinical utility of high-risk human papillomavirus (HPV) test and HPV genotyping? Answer 1 High-risk HPV test (e. and subsequent follow ups do not show any regression of the lesion. AGC. CIN2 cases that have difficulty receiving proper follow up can opt for treatment. perform a biopsy immediately. Labor and Welfare’s emergency policy to promote vaccination. (B) 5 HPV testing should not be used to decide whether a woman is eligible for vaccination. (B) 2 CIN2 (moderate dysplasia) is seen on a biopsy of the cervix. and when the patient shows strong determination to receive treatment. This is only recommended among young patients with CIN3. (B) 4 Women who have current evidence or history of low-grade cervical abnormalities can receive vaccination. androgen insensitivity. and subsequent follow ups do not show any regression of the lesion. (B) CQ204 What is the indication for minimally invasive conization of the cervix procedures. Women who test positive for HPV16. (B) (Only facilities that meet the standard requirements are allowed to perform HPV-testing by an eligible doctor under the Japanese National Health Insurance system. (B) 3 High-risk HPV test or HPV genotyping can be used for women treated for CIN 2/3 to detect residual or recurrent diseases during post-treatment follow up. if the follow-up Pap smear performed immediately or 6–12 months after the suspicious Pap smear is graded as ASC-US or higher. LSIL. (A) (According to the Japanese Ministry of Health. HPV45.Guidelines office gynecology in Japan 3 Excluding pregnant patients. such as loop electrosurgical excision procedure (LEEP) and laser vaporization? Answer LEEP is conducted as a mean of diagnosis and treatment when: 1 CIN3 (severe dysplasia or carcinoma in situ) is seen on a biopsy of the cervix. SCC. HSIL. (B) CQ206 Who should be vaccinated against human papillomavirus (HPV)? Answer 1 Girls 10–14 years of age are the most highly recommended group.) 2 When a Pap smear is graded as ASC-H. (C) CQ203 What is the indication for further testing with colposcopy-directed biopsy after a Pap smear? Answer 1 A Pap smear graded as ASC-US that revealed test results such as the following: • Positive results for high-risk human papillomavirus (HPV) (B) • For facilities that are unable to perform HPVtesting. or HPV58 are considered to be at increased risk of disease progression. HPV33. until the end of 2011. (B) Laser vaporization is conducted as a mean of treatment when: 3 CIN3 is seen on multiple biopsies of the cervix in a young female patient. they should be managed separately from women who are negative for these eight genotypes. and the extent of the lesion can be identified by colposcopy and the lesions have not extended deep within the endocervix. and when the patient shows strong determination to receive treatment. (C) 4 HPV genotyping should be used for women with histologically confirmed CIN1/2 to characterize their risk of disease progression more precisely. HPV52. HPV18. (B) © 2012 The Authors Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology 621 . (C) 4 CIN2 is seen on a biopsy of the cervix. HPV31.g. Hybrid Capture II or AMPLICOR HPV assay) can be used as an adjunct to cytology for cervical cancer screening to improve the accuracy of screening. (A) 3 Women 27–45 years of age can receive HPV vaccination. (C) 2 High-risk HPV test should be used for women with ASC-US cytology to decide who needs colposcopy.) 2 Young women 15–26 years of age are the next most highly recommended group. HPV35. Japanese female students from the first year of junior high to the first year of high school (13–16year-olds) can receive free HPV vaccination from clinics or health-care institutions receiving contracts from their respective regional administrative councils.. and the extent of the lesion can be identified by colposcopy and the lesions have not extended within the endocervix. adenocarcinoma or other malignancies. Therefore.

or total endometrial curettage for definitive diagnosis and treatment. (C) 5 Among post-menopausal patients. anaphylaxis or seizures can occur after vaccination. (A) 2 When treatment is indicated. and who are the screening targets? Answer 1 Uterine endometrial samples can be obtained by scraping or by suction. 6 Pregnant women are not included in the recommendations for HPV vaccine. (C) CQ210 How do we diagnose and treat endometrial hyperplasia without atypia? Answer 1 When a Pap test indicates endometrial abnormalities. (B) 4 Vaccinated women should also have routine cervical cancer screening. (B) 3 Girls and women not yet sexually active can be expected to receive the full benefit of vaccination. perform hysteroscopic surgery. (A) 6 The possible adverse events. (A) 2 The vaccine should be shaken well before administration. (B) • Symptomatic cases • An infertile patient whose infertility may be attributable to the endometrial polyp • Asymptomatic. follow-up observation is indicated. (B) 3 Endometrial hyperplasia in adolescents should be treated with combined estrogen–progestin formulations. 1–2 and 6 months. (C) CQ211 How do we diagnose and manage endometrial polyps? Answer 1 Perform screening with transvaginal ultrasonography. (A) 2 Diagnose using sonohysterography or hysteroscopy. vaccine providers should observe women for 30 min after they receive HPV vaccine. and swelling at the injection site (the arm). such as pain. fertility treatment that includes ovulation induction can be started after treatment No. When atypia is suspected. (A) 3 The vaccine is injected intramuscularly (i. redness. 5 For all other cases besides those described in ‘Answer No. administer cyclic medroxyprogesterone acetate.m. or when increased endometrial thickness is observed. headache. For girls and women not yet sexually active. (C) CQ207 What should vaccine recipients know before receiving the HPV vaccine? Answer 1 The vaccine protects against HPV16 and HPV18 infections. if abnormal bleeding persists and abnormalities continue to be identified in subsequent tests. Takeda et al. (B) 4 The HPV vaccine should not be administrated for 27 days after receiving a live vaccine or for 6 days after receiving an inactivated vaccine. and shock etc. 2 or No. or women with predisposing risk factors are selected for screening.T. (B) 3 Perform biopsy to rule out malignancy. diagnose by performing a total endometrial curettage. (A) 2 The vaccine does not have any therapeutic effect on existing HPV infection or cervical diseases. fainting. (B) 2 Women over the age of 50 or post-menopausal patients experiencing abnormal vaginal bleeding. 3. (C) 4 For cases below. (B) 5 The three-dose schedule (0.) in the deltoid muscle as a three-dose schedule at 0. but malignancy suspected. hysterectomy should be performed. (B) 622 © 2012 The Authors Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology . A frozen vaccine should not be used. perform endometrial biopsy for definitive diagnosis. Therefore. (C) 4 For patients hoping to conceive. (A) CQ208 How should HPV vaccine be administered? Answer 1 A woman’s medical fitness (conditions and circumstances) for vaccination should be assessed with comprehensive pre-vaccination health screening. (B) 7 Lactating women can receive HPV vaccine. 6 months) and the cost. (A) CQ209 What is the appropriate way of obtaining samples for endometrial cytology. the vaccine can be expected to provide 60–70% prevention against cervical cancer. (A) 5 Syncope. 4’. 1–2 months.

perform the necessary tests to rule out ectopic pregnancy. (C) 4 If surgery is not indicated. size of the cyst(s). which includes observation. medication or surgery. ultrasonography. dienogest. the follow-up schedule should be arranged according to the first upcoming menstrual cycle: the first follow up being 1–3 months later. (B) 4 When excessive hemorrhage is suspected. the first-line therapy is either combined oral contraceptive (COC) or dienogest.Guidelines office gynecology in Japan CQ212 When is hysteroscopy indicated? Answer 1 Diagnosis for conditions as stated below. emergency surgical intervention should be performed. surgery is recommended for cases whereby the existence of a tumor is confirmed. and the vital signs of the patient are not favorable. cyst size and the presence of solid components within the © 2012 The Authors Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology 623 . abdominal examination. gonadotrophinreleasing hormone (GnRH) agonist or danazol are usually chosen. (B) Endometrial polyps Submucosal fibroids Septate uterus Intrauterine adhesions (Asherman’s syndrome) CQ213 How do we treat endometriosis without cystic lesions? Answer 1 Prescribe analgesics (non-steroidal antiinflammatory drugs [NSAIDs]) for pain. (C) Endometrial polyps Submucosal fibroids Uterine anomalies Intrauterine adhesions (Asherman’s syndrome) Endometrial hyperplasia Endometrial cancer Spontaneous abortion or residues after expulsion of hydatidiform mole Residual placenta. (B) 3 Even for small cysts. infection or malignant transformation of the cyst. (C) 3 In the case of intraperitoneal bleeding. (B) 2 Surgery is recommended for large cysts (more than 6 cm in diameter) or when symptoms due to the cyst are observed. nontumor lesions and functional cysts. MRI etc. ultrasonography. COC. and GnRH agonist can be prescribed. (C) 5 Explain to patients that the accuracy of the diagnosis is limited if no surgery is performed. and the patient’s desire to conceive. culdocentesis (extraction of fluid through the Pouch of Douglas) can be performed. vaginal examination. (A) CQ215 How do we diagnose hemorrhaging corpus luteal cyst or ovarian hemorrhage? Answer 1 Perform a general evaluation by history-taking. should be performed. basal body temperature measurement. placental polyp Intrauterine object (IUD) 2 Preoperative diagnosis for conditions as stated below. (B) 2 If the diagnosis of intraperitoneal hemorrhage is difficult in a case presenting with an ovarian mass and peritoneal fluid on ultrasonography. tumor marker tests.to 6-month intervals. or when the hemoglobin count of the patient decreases dramatically. and the subsequent follow ups at 3. (B) 2 The type of surgical procedure is chosen based on the balance between curativeness of endometriosis and preservation of ovarian function. (B) 2 When analgesics are inadequate or the patient’s endometriosis requires treatment. (B) 3 When a patient’s cyst is considered to possess a high malignant potential depending on her age. (B) CQ216 How do we treat ovarian endometrial cyst (chocolate cyst)? Answer 1 The choice of treatment. perform surgery to cauterize/excise endometriotic lesions and to remove adhesion. indicating the presence of persistent hemorrhage. Surgery is usually prioritized due to fear of rupture. (B) 4 To prevent recurrence of endometriosis in patients who do not wish to conceive. (C) 3 When medication does not work. (C) CQ214 What are the differential diagnoses and management of suspected benign ovarian cysts? Answer 1 To differentiate between malignant tumors. or when the patient suffers from infertility. is made based on the patient’s age. as second-line therapy. history-taking.

(B) 2 For asymptomatic patients with low risk for malignancy. and computed tomography scans etc. Takeda et al. (B) 3 For pregnant patients whose polyps may be the source of cervical insufficiency or chorioamnionitis. (B) 3 As a curative measure. (B) 2 Even for patients who do not wish to become pregnant. for differential diagnosis against uterine fibroids or uterine sarcomas. with analgesics and hormonal treatment. i. and then resection. tumor markers. internal examination. perform hysterectomy. recurrent Bartholin’s abscess. (B) 2 Bartholin’s abscess presenting with acute symptoms should receive emergency treatment by drainage of purulent material (either via incision or fine-needle aspiration). endometrial or ovarian cancer)? Answer 1 The follow-up intervals are recommended as follows: every 1–3 months for 3 years. (B) 5 Adenocarcinoma of Bartholin’s gland is very rare. MRI should be undertaken. age of the patient and the patient’s prospects in conceiving. and cases suspicious of carcinoma of Bartholin’s gland should undergo surgical resection. (C) 4 The method of resection depends on the size and morphology of the polyp: (i) Pull or twist the polyp to detach it using Péan forceps.e. (B) CQ219 What are the considerations for a patient with intramural and/or subserosal uterine fibroids who wishes to opt for conservative therapy? Answer The type of treatment should be chosen based on the location and size of the fibroids. whether or not the patient has menorrhagia or anemia. and ultrasonography can provide the appropriate diagnosis. and (iii) electrocauterization. cystic mass. ultrasonography. (B) CQ221 How do we manage Bartholin’s cysts? Answer 1 Asymptomatic cases with minimal swelling do not require treatment. However. treatment should be given as necessary (resection or antibiotics). (A) CQ220 How do we manage patients with cervical polyps? Answer 1 The polyp should be resected for pathological evaluation. (B) CQ218 When do we perform operative hysteroscopy/ transcervical resection (TCR) for submucosal fibroids? Answer 1 The usual criteria for the procedure are small uterine fibroids (less than 30 mm in size) and more than 50% protrusion in the uterine cavity. skilled surgeons may not be constrained by these criteria.. Culture the infected material for bacteria and treat the infection using antibiotics. (C) 2 The follow up includes interval history and physical examination (including pelvic examination). she should have her diseased ovary removed surgically. instead of conducting a biopsy. are some of the methods chosen. chest X-ray. (C) 624 © 2012 The Authors Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology . (C) CQ217 How do we diagnose and treat adenomyosis? Answer 1 Clinical findings. (B) CQ222 What should be recommended for post-treatment follow up of patients with gynecological malignancies (cervical. a surgical treatment that preserves the function of Bartholin’s gland. (C) CQ223 How is breast cancer screening conducted? Answer 1 All women above 50 years of age should receive mammography screening. When malignancy is suspected. (A) 2 Women in their 40s should receive mammography screening. perform histopathological exploration and evaluation. with cytology. (B) 3 Women above 40 years of age can receive optional screening using ultrasonography.T. the patients should receive follow-up observation. and then annually. (B) 2 Treat the symptoms of adenomyosis in the same manner as endometriosis. operative hysteroscopy/TCR may be chosen for its low invasiveness. However. (ii) ligation. every 6 months for another 2 years. (B) 3 Perform marsupialization. (B) 4 Recurrent cases despite marsupialization.

In such cases. (C) • For those who are looking forward to conceiving. (C) 2 Administer antifibrinolytics (tranexamic acid. or mammography in combination with ultrasonography. induce ovulation. (A) 2 Keep in mind the possibility of pregnancy when conducting patient interviews and examinations. Such cases should receive follow ups in coordination with an institution specializing in breast cancer. such as oral contraceptives. endocrine tests etc. (B) • Administer combined estrogen–progestin. ‘mastopathy’ as an exclusive diagnosis for breast cancer should not be made casually. (B) 4 Cases that are histologically confirmed with atypical proliferation (ductal. (A) 3 When malignancy is suspected. conduct hormonal therapy. (A) © 2012 The Authors Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology 625 . hysterectomy or endometrial ablation can be performed. (B) • Administer cyclic progestins for euestrogenic amenorrhea. such as Transamin). (A) CQ306 How do we diagnose hyperprolactinemia? Answer 1 Measure serum prolactin levels when the patient presents with menstrual abnormalities or galactorrhea.Guidelines office gynecology in Japan 4 Women below 40 years of age should receive ultrasonography for breast cancer screening. (C) 3 Consider surgical treatment when pharmacotherapy is either ineffective or not a viable option. (B) 2 Administer Japanese herbal medicine (Kampo) or anti-cramp medicine. Endocrinology and Infertility CQ301 How do we treat functional dysmenorrhea? Answer 1 Prescribe and administer analgesics (such as NSAIDs) or low-dose combined oral contraceptive. perform cytology and biopsy. (B) CQ224 How is mastopathy managed? Answer 1 Clinically. dysfunctional uterine bleeding is diagnosed. (C) 2 For those who do not wish to retain their uterus and/or fertility. (B) 2 For those who do not wish to conceive. • Polymenorrhea or oligomenorrhea caused by anovulatory menstrual cycles should be treated with cyclic progestins. (C) CQ303 What are other treatment options besides pharmacotherapy for menorrhagia without any underlying pathology? Answer 1 Perform dilation and curettage for acute bleeding. (B) 2 As a rule. (C) 5 Interval in between screenings is 1–2 years. cases suspected for mastopathy should receive consultation from specialized institutions. (A) 4 When pregnancy and underlying pathology are ruled out. (B) • Administer cyclic estrogen–progestin for hypoestrogenic amenorrhea. (A) C. (B) CQ305 What are the important points when we see a woman of child-bearing age with a chief complaint of abnormal vaginal bleeding? Answer 1 Perform systematic differential diagnosis via patient interviews and physical examinations. ‘suspicious for mastopathy’ should be indicated instead. (C) CQ304 How do we manage abnormal menstrual cycle due to anovulation? Answer 1 Investigate the cause behind the abnormal menstrual cycle from patient interviews. (B) 3 Cases with proliferative lesions that are histologically ruled out for atypia should receive consistent screenings as the risk of breast cancer is elevated. (C) CQ302 What should we prescribe for menorrhagia without any underlying pathology? Answer 1 Administer low-dose combined oral contraceptive. lobular) (including those with a history of proliferative atypia) have an increased risk for breast cancer. physical findings.

(C) 626 © 2012 The Authors Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology . perform gonadotrophin treatment or laparoscopic ovarian drilling. (B) 4 Surgical treatment is indicated for pituitary infarction.T. (B) 3 Interview the patient about the drugs taken (psychiatric. (C) CQ308 How do we diagnose and treat polycystic ovarian syndrome (PCOS)? Answer 1 Diagnose according to the 2007 diagnostic guidelines laid out by the Japan Society of Obstetrics and Gynecology. consult an endocrinologist or a neurosurgeon. drug-resistant cases and cases that cannot tolerate pharmacotherapy. refer the patient to either an endocrinologist or a neurosurgeon. (B) CQ307 How do we treat hyperprolactinemia? Answer 1 Treat using dopamine agonists in hyperprolactinemia caused by pituitary disorders. (B) 5 When serum prolactin levels exceed 100ng/mL. monitor closely and consider management at an advanced medical institution if the symptoms or the test results are not improved. (B) 5 Gonadotrophin treatment should be performed using either recombinant or pure FSH in a chronic low-dose method. (B) 4 Check both breasts for galactorrhea. (B) 6 Severe cases should receive inpatient treatment at a hospital. Treatment using dopamine-agonist is still the main approach. (A) 2 For women who do not wish to conceive: • Advise obese patients to make lifestyle adjustments in order to lose weight (B) • Induce withdrawal bleeding at consistent intervals. use metformin in combination with clomiphene when the patients have any of the conditions. When necessary. to identify the cause of POF. underlying conditions). choose cyclic estrogen–progestin combination therapy. headaches. Takeda et al. direct patients to take sufficient fluids and to avoid physical exercises and sexual intercourse. (C) 4 For cases with clomiphene-resistance. 2 If serum prolactin levels are elevated. such as checking the patient’s endocrine profile. (B) 3 In patients confirmed with prolactinoma. (B) 2 Choose hormone replacement therapy for patients who do not wish to conceive. and visual field defects. (B) 2 Cancel human chorionic gonadotrophin (hCG) administration when the risk for developing OHSS is high during ovulation induction in routine infertility practice. (B) 3 When the risk of developing OHSS is high during ovarian stimulation in assisted reproductive technology procedures: • Do not use hCG for luteal support (A) • Reduce or delay (coasting) treatment using hCG administration alternative to LH surge (B) • Cancel embryo transfer and freeze all embryos. (C) 5 For moderate OHSS or pregnant patients with OHSS. If ovulation cannot be achieved. (B) CQ309 How do we prevent the occurrence or severe progression of ovarian hyperstimulation syndrome (OHSS)? Answer 1 Use recombinant or pure FSH in a chronic low-dose method for gonadotrophin treatment in patients with PCOS or history of OHSS. administer high-dose human menopausal gonadotrophin (hMG) therapy. glucose intolerance or insulin resistance. consult the doctor who prescribed the medication to either reduce the dosage or replace the problematic drug. (B) 3 For women who wish to conceive: • Advise obese patients to lose weight (B) • Use clomiphene as a first-line ovulation induction (B) • For cases who did not respond to clomiphene alone. (B) CQ310 How do we manage premature ovarian failure (POF)? Answer 1 Perform the necessary tests. pituitary tumors with accompanying visual field defects. such as obesity. (A) 3 For patients who wish to conceive. perform MRI to rule out prolactinoma. (A) 2 For drug-induced hyperprolactinemia. check the patient’s thyroid function as well. the presence of thyroid disease symptoms. (B) 4 For mild OHSS.

Ask the patient to check up at the clinic again when necessary. (C) 2 A single dose of levonorgestrel is administered. (C) 4 Switch to assisted reproduction technology procedures if AIH is not successful in repeated attempts. such as erectile dysfunction. (C) 4 For women with a history of pregnancy. a coppercontaining intrauterine device can be used when necessary. (C) 5 Inform the patient that even with emergency contraception. (A) Endocrine tests. (C) 6 Infertility treatment should be conducted in coordination with a urologist when the male patient presents with sexual dysfunction. (C) 5 Explain the possible adverse events. 1 Efficacy and safety: OC is the most effective reversible method of contraception available. (B) 6 Semen analysis. such as bleeding. (B) 3 Choose in vitro fertilization and intracytoplasmic sperm injection for severe oligozoospermia and severe asthenozoospermia. (C) CQ314 How do we manage recurrent pregnancy loss in association with chromosomal anomalies? Answer 1 Provide genetic counseling to couples with a history of recurrent pregnancy loss who are taking tests for chromosomal anomalies. (B) CQ313 How do we treat male infertility? Answer 1 Pharmacotherapy for oligozoospermia. (C) 2 Perform artificial insemination with husband’s sperm (AIH) for mild oligozoospermia and mild asthenozoospermia. (B) 7 Test for cervical factors. It is also very safe. (B) 1 2 3 4 CQ312 What are the important points for artificial insemination with husband’s sperm (AIH)? Answer 1 Perform AIH between the moment before and after ovulation. (B) 3 Sexually transmitted diseases: OC does not prevent sexually transmitted infection. artificial insemination with donor’s sperm can be an option. Healthcare for women CQ401 How should we perform emergency contraception? What are the pitfalls concerning emergency contraception? Answer 1 Perform emergency contraception to reduce the probability of pregnancy in unprotected sexual intercourse. and should have received ethical clearance by an internal review board. (C) 3 Preimplantation genetic diagnosis should be carried out in adherence to the principles laid out by the Japan Society of Obstetrics and Gynecology. (C) 3 Stimulate ovulation using clomiphene or gonadotrophin in order to increase pregnancy success rate. (B) 2 Provide genetic counseling in conjunction with karyotype test of tissues from spontaneous abortions. (B) 2 Use washed and concentrated spermatazoa suspension. pain and infection. (A) Ultrasonography. (B) Chlamydial antibody test or chlamydial antigen (nucleic acid identification) test. menorrhagia etc. (B) 5 If pregnancy is impossible with the husband who is diagnosed with azoospermia. (B) 5 Hysterosalpingogram. there is still a risk of pregnancy. (B) 4 Consult a urologist specializing in infertility to identify the cause of azoospermia and severe oliogozoospermia and decide on the treatment. (A) D. (B) 2 Additional benefits: OC may ameliorate the symptoms of menstrual problems.Guidelines office gynecology in Japan CQ311 What are initial tests to identify the causes of the infertility? Answer Below are the recommended tests. (B) CQ402 What should we tell the patient when prescribing oral contraceptives (OC)? Answer Provide information based on the ‘Guidelines concerning the use of low-dose oral contraceptives (year 2007 revision)’. (B) 3 Use the Yuzpe method. Basal body temperature measurement. such as dysmenorrhea. (B) © 2012 The Authors Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology 627 .

For XY complete gonadal dysgenesis. coarctation of the aorta. (A) 2 Visit the doctor as soon as a pregnancy is suspected. (B) 2 Provide careful follow up as the risk for gonadal tumor development is high. (B) CQ403 What should we inform the patient when an intrauterine device (IUD) (including the intrauterine system) is chosen for contraception? Answer Provide information as below. Management of patient can be carried out in coordination with a pediatrician/endocrinologist. (A) CQ407 What are the important points when we perform medical examinations on an adolescent? Answer 1 Medical interviews are very important. surgically remove the abnormal gonads at the appropriate timing. perform cyclic estrogen–progestin therapy as soon as the diagnosis is made. (B) 3 Hormone replacement therapy is recommended. (B) 6 Cancer risk: cervical cancer risk increases with longterm usage. (B) 4 Possible complications. 4 Target age: any woman of reproductive age should be able to receive treatment. (B) 8 Caution and contraindication: hypertension. (B) CQ405 How should we provide care for XY female patients? Answer 1 After definitive diagnosis is made. glucose intolerance. Takeda et al. (A) 2 Vaginoplasty should be performed according to the patient’s wishes after sufficient counseling. (B) 7 Side-effects: OC may contribute to gastrointestinal symptoms but is not associated with weight gain.to 3-year intervals. 1 It does not prevent pregnancy without fail. smoking (more than 15 cigarettes per day). physical examination. advanced age (more than 40 years old) are some of the criteria that call for caution and may be a reason for contraindication. (B) 3 Peritoneal lesions caused by endometriosis should also be considered as one of the reasons of dysmenorrhea in an adolescent patient. (B) 2 Even for girls with no prior experience of sexual intercourse (virgins). perforation etc. (B) CQ404 How do we manage Turner’s syndrome? Answer 1 For patients diagnosed before puberty. (A) 3 Vaginoplasty should be carried out at a specialized and experienced institution. (A) CQ406 How do we provide care for patients with Mayer– Rokitansky–Küster (–Hauser) syndrome? Answer 1 Provide information for the patient regarding her medical condition in a timely and approachable manner. Reduces the risk of ovarian and endometrial cancer. may occur. The risk of myocardial infarction among smokers is also increased. infection. (A) 3 For patients with androgen insensitivity. while taking care of the patient’s emotional condition. (A) 2 For patients diagnosed before puberty. After reaching puberty. Increase the dosage in 2. (C) 5 Complications: OC increases the risk of cerebral stroke and venous thromboembolism. ultrasonography (transrectal or transabdominal) should be performed to achieve proper diagnosis. and can be conducted with or without the accompaniment of a family member. (B) 5 Provide care for patients in coordination with respective specialists for complications. provide estrogen replacement therapy after total gonadectomy. provide appropriate counseling for both the patient and her parents. (A) 3 Receive consistent follow up after the IUD has been fitted to make sure that the device is in the right position or to exchange the device.T. such as hemorrhage. (C) CQ408 What are the important points when treating a female adolescent? 628 © 2012 The Authors Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology . low-dose estrogen should be administered starting from puberty (from about 12 years of age). growth hormone may be needed for treatment. obesity (BMI > 30). gonadal tumors etc. such as thyroid abnormalities. rectal examination. (A) 4 Provide counseling. Breast cancer risk is not affected. when providing explanation about her fertility.

but should be paid by the police department. especially cases that are associated with endometriosis.Guidelines office gynecology in Japan Answer 1 For amenorrhea. use cyclic progestins therapy or cyclic estrogen–progestin therapy once every 2–3 months. (A) 2 The symptoms may be caused by estrogen withdrawal or other causes or the combination of estrogen withdrawal and other causes. administer combined EP or norethisterone from the follicular phase until the desired period of prolongation. (C) 7 For other symptoms. (A) 3 Observe and document any physical trauma. (B) CQ411 What are the important points in the diagnosis of climacteric disorder? Answer 1 Suspect climacteric disorder in a woman who has already undergone menopause that comes with a myriad of complaints. traditional Japanese herbal medicine (Kampo) can be used. such as the patient’s age at onset and symptoms. (B) 6 The medical expenses incurred from the medical examination. counseling or psychiatric medication should be considered. should be treated with either NSAIDs or combined oral contraceptive. Make the proper diagnosis and evaluation based on those possibilities. and thyroid diseases due to the overlapping characteristics. (B) 4 Among the differential diagnoses. (C) 5 Start the treatment for depression using antidepressants. (C) 6 Recommend lifestyle changes if any problems are detected. (B) 2 To prolong the menstrual cycle. (C) CQ412 How should we treat climacteric disorder? Answer 1 Hormone replacement therapy is effective for symptoms caused by autonomous nervous system dysregulation. (B) CQ410 How do we help patients modify their menstrual cycle? Answer 1 To shorten the menstrual cycle. tests and treatment should not be charged to the victim. Such cases should be advised to regain weight through lifestyle improvement and referred for counseling. (A) 2 Collection of crime evidence during medical examination of the victim(s) should be done with the victim(s)’ consent under the supervision of a police officer. watch out for depression. insomnia etc. sweating. (A) 3 For non-specific complaints that encompass a myriad of symptoms. choose the best treatment according to the case at hand. administer combined estrogen–progestin (EP) or norethisterone from the 3rd to 7th day of the menstrual cycle for 10–14 days. (C) 4 For cases with severe mood-related disorders. such as flushing. scratches. (C) 2 Watch out for decreased bone mass in prolonged amenorrhea. (B) CQ409 What should we do when we encounter a sexual assault victim? Answer 1 Victims who have not reported their ordeal to the law enforcement authorities should be reported to the police after obtaining their consent before any medical examination takes place. (B) 4 Dysmenorrhea that is not caused by underlying genitourinary deformities. such as external injuries. malignancy. estrogen and progesterone should be given in combination. (C) © 2012 The Authors Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology 629 . (B) 4 Issue a medical certificate. (B) 3 To prolong the menstrual cycle. (C) 3 Exclude underlying pathologies that may contribute to the complaints. otherwise. (B) 5 Emergency contraception should be provided. estrogen only can be given to post-hysterectomy patients. bruises etc. (C) 3 Do not induce menstruation in amenorrhea associated with extremely low bodyweight (less than 70% of ideal bodyweight). administer moderate-dose combined EP therapy or norethisterone 5–7 days expected menstruation until the desired period of prolongation. such as selective serotonin reuptake inhibitors (SSRI) and serotonin–norepinephrine reuptake inhibitors (SNRI). (B) 2 As hormone-replacement therapy.

(B) CQ417 How should we treat mood-related disorders and nonspecific medical complaints? Answer 1 Prescribe hormone replacement therapy for depressive mood and symptoms associated with menopause. (B) CQ418 How do we diagnose and manage premenstrual syndrome? 630 © 2012 The Authors Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology . Takeda et al. 2 Rare adverse effects that may occur are: (B) Breast cancer. endometrial hyperplasia etc. (B) 2 Depression associated with menopause should be treated with SSRI or SNRI. and what are the strategies for early detection and treatment? Answer 1 Advise the patients to exercise regularly and have adequate calcium intake to prevent osteoporosis. and changing the route of administration and the duration of treatment. CQ413 How should we provide information regarding the side-effects of hormone replacement therapy and the corresponding strategies for treatment? Answer 1 The minor side-effects are: (A) Abnormal vaginal bleeding. thromboembolism. (B) CQ414 What are the recommended traditional Japanese herbal medicines (Kampo) or alternative therapies for climacteric disorder? Answer 1 Kampo formulations. ischemic cerebral stroke. by choosing the right drugs.T. (A) 7 Watch out for side-effects unrelated to bone metabolism when using estrogen (conjugated estrogen. (C) 2 Isoflavones derived from soy and red clover may be effective for menopausal hot flushes. dyspareunia. Kamishoyosan etc. such as Tokishakuyakusan. opting for (or excluding) combined luteal hormone therapy. (B) CQ416 How do we prevent postmenopausal osteoporosis. for women over the age of 65 or for women below the age of 65 with high risk of fracture. mastalgia (breast pain). peripheral DXA scan or quantitative ultrasonometry (QUS) of the calcaneus can also be performed. (C) 3 Patients who complain of dysmenorrhea. and vulvodynia without underlying pathologies should receive psychiatric evaluation and may be treated with psychiatric medication. (B) 4 Each adverse or side-effect can be managed. coronary vascular disease. (B) 6 The first-line drugs for osteoporosis are bisphosphonates and selective estrogen receptor modulators. cholecystitis. (B) CQ415 How do we treat atrophic vaginitis? Answer 1 Prescribe vaginal estriol tablet for symptomatic cases. cholelithiasis. (B) 3 Bone density measurement is usually carried out using dual X-ray absorptiometry (DXA) scan of the axial skeleton. uterine fibroids. (B) 2 Take spine X-ray or measure bone density for early detection of osteoporosis. taking into account factors such as the age of the patient and the number of years passed since menopause. such as migraine. (C) 5 The aim of treatment is to prevent fractures. (C) 3 Even traditional Japanese herbal medicine (Kampo) and alternative therapies have side-effects and the necessary precautions should be taken. (B) 2 Administer estrogen systemically when topical treatment using vaginal estriol tablet is a difficult option for the patient. (B) 3 Prescribe hormone replacement therapy for patients with postmenopausal syndrome. lung cancer. Keishibukuryogan. can be used. (C) 4 Biomarkers for bone metabolism are measured to help choose the right drugs and/or evaluate the efficacy of treatment. 3 Provide explanation regarding relative contraindications. Alternatively. thus patients at risk may start their treatment with osteoporosis medication even if they are not fulfilling the diagnostic criteria for osteoporosis. (C) 4 Recommend consultation with a psychiatrist or a psychosomatic medicine specialist when symptoms persist. ovarian cancer. 17bestradiol). breast swelling.

after obtaining informed consent from the patient. (B) 3 For patients whose lowest point of prolapse is adjacent to the hymen (POP stage II and above). the patient should be referred to a urologist for a complete evaluation for diseases such as bladder cancer. such as vaginal erosions. initiate treatment using pessaries. (C) 2 For severe psychological symptoms. (B) 4 Urge incontinence is one of the manifestations of an overactive bladder. physical and psychological symptoms. (B) 4 Use selective serotonin reuptake inhibitor (SSRI) for the treatment of moderate to severe premenstrual syndrome and premenstrual dysphoric disorder. medication (such as symptomatic treatment. (B) 2 Pharmacotherapy for stress incontinence consists of either estriol or clenbuterol. (B) 6 Bladder control and pelvic floor muscle exercises as behavioral therapy. follow up every 1–3 months in the first year. such as oral contraceptives. and every 2–6 months afterwards. (B) 4 Perform urine test to check for hematuria and pyuria. surgical treatment is recommended. to check for the fit and complications. initiate treatment with pelvic floor muscle exercises. can be effective for physical symptoms. (C) CQ419 How do we diagnose urinary incontinence? Answer 1 The type of urinary incontinence is diagnosed by patient interview. Hence. refer the patient to either a psychiatrist or a psychosomatic medicine specialist. (B) 3 Perform gynecological exam to check for diseases within the pelvis. (C) 3 Counseling. prioritize the treatment of the underlying condition. (A) 4 If hematuria is persistent or found in multiple urine tests. it is treated in the same manner as overactive bladder (refer to CQ421). such as sagging. diuretics) are some of the chosen treatments. (C) 3 Surgical treatment is recommended if outpatient management of urinary incontinence is deemed difficult or the patient wishes to be treated surgically. vaginal bulging etc. © 2012 The Authors Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology 631 . (C) 6 If outpatient management is difficult or the patient has expressed her wish to receive surgery. (B) 2 Interview the patient to identify any history of neurological illnesses. (C) 5 Low-dose combined estrogen–progestin formulations. (B) 2 Referral to a specialist is recommended when the residual urine volume exceeds 50–100 mL after bladder voiding. (B) Disclosure The authors declare that there is no conflict of interest that would prejudice the impartiality of this scientific work. (A) Diagnostic guidelines set up by the American College of Obstetrics and Gynecology are used. (B) 3 Perform gynecological exam to check for pelvic diseases. (A) CQ421 How do we manage overactive bladder in an outpatient setting? Answer 1 Diagnose overactive bladder by asking the questions in the Overactive Bladder Symptom Score (OABSS). (A) CQ422 How do we manage pelvic organ prolapse (POP) in an outpatient setting? Answer 1 Start initial treatment for pelvic organ prolapse when the patient complains of discomfort from symptoms. (B) 5 Administer estriol for vaginal sores caused by pessary placing. (C) 7 Anticholinergics as pharmacotherapy. If any underlying pathologies that may contribute to urinary incontinence are found.Guidelines office gynecology in Japan Answer 1 The diagnosis of premenstrual syndrome is made based on the period of onset. lifestyle management. (B) 2 For patients whose lowest point of prolapse is far from the hymen (POP stage I and below). (B) 5 Measure residual urine volume right after voiding or micturition. (A) CQ420 How do we treat urinary incontinence? Answer 1 Perform pelvic floor muscle exercises as a behavioral therapy for stress incontinence. sedatives. (B) 4 After placing the pessary.