GYNECOLOGY NOTES

Legal Issues and Ethics

Informed consent
- Required for all procedures when patient is alert and hasn’t received any narcotics or med that
affect decision-making. Not required in true emergency situations that would risk the patient’s life.

Elective cesarean section

- Can be done just because the patient is afraid of pain. Do it at 39 weeks.

Patient privacy
- Patient privacy is the responsibilty of physicians - can be fined or assessed criminal penalties for
violating the privacy of patient’s protected health information

Justice - requires physicians to educate patients about all treatment options in a nonjudgmental way
regardless of the nature of treatment and the patient’s socioeconomic status

Conflicts of interest
- Drug companies can support conferences at which physicians receive CME credit
- Investigators can do research for companies in which they own stock, if they declare the COI and
it is addressed

Development

Puberty
- Typically thelarche → adrenarche → growth spurt → menarche

Delayed puberty
- No secondary sex characteristics by age 14 → delayed puberty.
- Primary amenorrhea = no period by 16
- No sex characteristics at all
- Could be brain problem (no GnRH or no FSH) or ovarian problem (no estrogen)
- Most common cause gonadal dysgenesis, most often because of chromosomal
abnormalities - Turner’s is most common, can also see 46XY and 46XX. If XY,
remove gonads due to risk of cancer.
- Brain: Kallman syndrome is failure of GnRH neurons to migrate to
hypothalamus. Also impaired sense of smell. Boys often born with micropenis.
Treat with hormone replacement.
- Noonan syndrome: Autosomal dominant. Short, webbed neck, triangular
shaped face, delayed puberty, learning problems
- No period, normal breasts, normal pubic/axillary hair
- Get a pregnancy test! Could be pregnant.
- Most likely Mullerian agenesis - uterus just doesn’t form. But have normal ovaries b/c
they aren’t Mullerian structures.
- 1/3 will have renal anomalies - missing kidney, etc.
- No period, normal breasts, minimal pubic/axillary hair: Most likely androgen insensitivity. 46XY

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 - In androgen insensitivity, get breast development due to estrogen - mostly from
peripheral conversion. The gonads and adrenals also make a little bit.
- Recall XY genotype can also have gonadal dysgenesis rather than androgen insensitivity
- difference is that will not have any secondary sexual characterisitics
- Remove gonads after puberty
- Workup:
- Start with TSH, prolactin, bone scan. Only then add FSH to distinguish between brain
and ovarian causes of delayed puberty. Also free T4, adrenal and gonadal steroid levels
- Physical exam - visual field defect, goiter
- Skull imaging
- Treatment:
- Goals are to promote development, prevent osteoporosis, and promote full height
potential - can use OCPs + growth hormone
- If phenotypic female is 46 X,Y → remove gonads because they are predisposed to cancer.
Can leave Turner streak ovaries in place.

Precocious puberty
- Onset of secondary sex characteristics more than 2 standard deviations below the mean - 7 in
white girls, 6 in African American girls
- Causes
- Most often idiopathic - GnRH pulse generator just gets turned on.
- But other central causes include tumor, hydrocephalus, head trauma,
hypothyroidism.
- Hypothyroidism is unique because it causes delayed bone age while most
other causes of precocious puberty cause accelerated bone age.
- Peripheral causes include granulosa cell tumors or adrenal tumors
- Treat with GnRH agonist → disrupts pulsatile GnRH!
- If not treated, girl will at first grow fast, but then long bone epiphysis will close early → eventual shorter
height
- Variations
- Period before hair or breasts: McCune Albright
- Hair with high levels of DHEA and DHEA-S: Congenital adrenal hyperplasia/21
hydroxylase deficiency

Hypogonadotropic hypogonadism (Low FSH, Low estrogen)

- Poor nutrition or eating disorders
- Extremes in exercise
- Chronic illness, stress
- Primary hypothyroidism
- Cushing syndrom
- Pituitary adenoma
- Craniopharyngioma

Annual exam

Test all sexually active < 25 yrs for gonorrhea and chlamydia

Infections

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- KOH prep lyses RBCs and lymphocytes, making diagnosis easier. Very positive whiff test with
BV, postive whiff test with trichomonas (but less so than BV), and psuedohyphae with candida.
- Bacterial vaginosis
- Diagnosis based on 3 of 4 Modified Amsel criteria: Thin gray homogenous discharge,
pH > 4.5, positive whiff test, clue cells
- Assoc’ed with preterm delivery, postpartum endometritis, and pelvic inflammatory
disease
- Treat with metronidazole. Warn about disulfiram reaction with alcohol (flushing, HA,
hypotension, tachycardia, dizziness, nausea, vomiting)
- Trichomonas
- Yellow-green frothy discharge, no fever or pain. Strawberry cervicitis because it’s highly
inflammatory (BV is not).
- Trichomonads are unicellular protozoans - can see them moving across the slide with
flagella
- Drop of KOH → fishy odor = positive whiff test
- Treat with metronidazole - partner needs treatment, too!
- Candida vaginitis
- Thick white clumpy discharge, erythema, swelling, intense itching
- KOH → hyphae
- Herpes
- Painful genital ulcerations, fever, dysuria. Resolution of the acute episode must happen
before speculum can be inserted for endocervical gonorrhea and chlamydia testing. If
she was high risk, could offer prophy for G & C
- Multinucleate giant cells and inflammation. Culture is the gold standard for diagnosis, but
it has a 10-20% false negative rate! Serum antibody testing would only indicate lifetime
exposure, not identify the cause of a particular lesion.
- Syphilis
- Painless ulcer with rolled edges in primary, then 9 weeks later copper penny lesion rash
on palms and/or soles. May also have condylomata lata - flat moist lesions on vulva. ⅓
will progress to tertiary syphillis (CNS, CV involvement)
- If high suspicion,do treponemal specific tests - not the nontreponemal tests (VDRL or
RPR), which are non-specific (e.g. false positive RPR with lupus). But the treponemal
tests remain positive for life! Also early serology may be negative if antibodies haven’t
developed yet.
- If pregnant, treat all stages with penicillin G (IV or IM). If not pregnant, can consider
doxycycline or tetracycline except for CNS involvement. Can give one dose for early
syphillis, but late disease requires 3 weeks. Monitor titers after.
- Chancroid
- Tender ulcer with ragged edges on a necrotic base. Tender LAD.
- Haemophilus ducreyi is a small, gram negative rod
- Hepatitis B
- If a patient has not been vaccinated and has unprotected sex with a person who has Hep
B, treatment depends on HBsAg status of the partner. Always vaccinate the patient, but if
partner is HBsAG+, then also give Hepatitis B immunoglobulin.
- Acute salpingitis = pelvic inflammatory disease:
- Lower abdominal pain (mild to severe), adnexal tenderness, fever, cervical motion
tenderness, new foul-smelling discharge, +/- dysuria and painful defecation. Can have
RUQ if have perihepatic adhesions = Fitz Hugh and Curtis Syndrome.
- Risk factors: nulliparity, IUD around time of placement (disrupts endocervix)

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 - Can be caused by ascending vaginal flora (especially if after menses) or by STIs. Usually
polymicrobial!
- Gonorrhea:
- Mucopurulent cervicitis with exacerbation during and after period.
- May have septic arthritis (migratory arthritis of large joints), pharyngitis,
or disseminated gonorrhea (eruptions of painful pustules on
erythematous base - do gram stain and culture).
- Can cause blindness in baby - presents by day 5, vs. chlamydia which
presents > 5 days later. Erythromycin ointment only protects against
gonorrhea, not chlamydia - that requires 14 days of oral erythromycin.
- Chlamydia:
- Often associated with gonorrhea.
- Most common cause of mucopurulent discharge (though gonorrhea
also causes). Doesn’t cause pharyngitis (lacks pili).
- In pregnancy, treat with amoxicillin, azithromycin (single dose), or
erythromicin. Outside of pregnancy, do one dose of azithromycin or 7
days of doxycycline
- Can also cause lymphogranuloma venereum, large and very painful
lymphadenopathy with small, painless (or even absent) ulcers
- Note that G/C don’t typically cause vaginitis - more cervicitis and upper tract
infections.
- Generally treat for both, even with a negative gram stain (chlamydia is
intracellular, gonorrhea can have false negatives), but negative results on nucleic
acid amplification are reliable - only treat for whatever is positive.
- Management
- Inpatient; If significant fever, admit and give inpatient IV abx to prevent scarring
of fallopian tubes and possible infertility (IV cefotetan or cefoxitin and IV or oral
doxycycline, or clindamycin + gentamicin). Treat before cultures return.
Continue IV abx for 24 hours after clinical improvement, then doxy for 14 days as
an outpatient.
- Outpatient: If fever is low grade, can tolerate oral meds, no peritoneal signs, can
follow up, and not at the extremes of age. Ceftriaxone, cefoxitin or other 3rd gen
cephalosporin (single injection IM) AND doxycycline for 2 weeks, with or without
metronidazole for 2 weeks. Follow up in 48 hrs!
- If G/C - recent partners should be informed with or without consent and treated.
- Consider ultrasound to look for TOA.
- If persistent hydrosalpinx and pelvic pain, do laparoscopy to investigate and then
consider salpingectomy
- Big risk of tubal infertility - 12% after one episode, 25% after two episodes, 50% after
three. Also risk of chronic pelvic pain and ectopic pregnancy. Counsel on avoiding future
episodes.
- Tuboovarian abscess
- Can be bilateral! Symptoms = severe abdominal pain (diffuse abdominal and bilateral
adnexal tenderness), diarrhea, nausea, fever. Can see 3-4 cm complex masses on
pelvic ultrasound
- Cause: Most often STIs like gonorrhea and chlamydia, but can be ascending infection
from the GI or GU tract. Aerobic and anaerobic polymicrobial infection. E Coli,
Klebsiella, Garderella vaginalis, prevotella, GBS, enterococcus.
- Treatment

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 - Need anaerobic coverage! Clinda or metronidazole. Can often be treated without
surgical drainage, but rupture is a surgical emergency.

Urinary tract infections

- Most often caused by E coli
- Low pelvic pain, urinary frequency, urinary urgency, hematuria, or new issues with incontinence
- If urinary symptoms with negative urinalysis/culture, then suspect urethritis - chlamydia,
gonorrhea, or trichomonas. Do a swab.

PAP smears
- Schedule:
- Start at age 21, regardless of age of sexual activity, unless patient is immune compromised (lupus,
HIV, steroids, etc.) → then do at onset of sexual activity (twice first year and then annually)
- Age 21 to 65, do cytology alone every 3 years
- Age 30 to 65, can do cytology and HPV (cotesting) every 5 years.
- Discontinue between 65 and 70 if 3 consecutive negative smears or 2 negative
consecutive cotesting in 10 years and no history of high grade intraepithelial
neoplasia or cancer. Still need yearly bimanual and rectovaginal exams!
- Not necessary after hysterectomy, unless it was done for cervical cancer or high grade
dysplasia
- Exceptions: Doesn’t apply to women who have had cervical cancer, who are infected with
HPV, have a weak immune system, or were exposed to DES in utero (risk of clear cell
vaginal cancer - usually in teens or 20’s! Also risk for genital tract anomalies in both
women and men)
- Abnormal PAP
- If atypical squamous cells of undetermined significance (ASGUS) → send HPV type. If high risk
HPV → colposcopy with biopsy, or as an alternative, can repeat PAP in 12 months and if normal,
return to routine screening.
- Only initiate further therapy with biopsy-confirmed dx of cervical dysplasia

Mammograms
- American cancer society and ACOG: yearly at age 40. USPSTF: every two years at age 50.
- BRCA screening: may be appropriate if 1st and 2nd degree relatives on the same side of the
family have breast and ovarian cancer (once cancer type per person)

Colon cancer
- Colonoscopy at 50 and repeat every 10 years, or signmodioscopy at 50 and repeat every 5 years

Bone density
- DEXA scan beginning at age 65.
- Consider early screening if: early menopause, steroids, sedentary, alcohol, smoking,
hyperthyroid, anticonvulsants, Vit D deficiency, family history, chronic liver or kidney disease,
dowager hump, etc.
- Osteopenia = -1 to -2.5 - should be interpreted with risk factors for fracture. If no risk factors, do
counseling on calcium and Vit D intake and reduce risk factors in order to delay need for meds.
- Risk factors for fracture: previous fractures, FH of osteoporosis, race, dementia, falls,
poor nutrition, smoking, low BMI, estrogen deficiency, alcoholism, insufficient physical
activity

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 - Compression fractures of thoracic spine is most common.
- Treatment:
- Lifestyle: Balanced diet with calcium and Vit D, 1200 mg calcium per day, exercise, avoid
lots of alcohol, quit smoking
- If risk factors for osteoporosis and an osteoporotic fracture, treat with bisphosphates.
Before starting, do a DEXA scan and then repeat every two years
- HRT not recommended for long term disease prevention - especially in patients with
CV disease

Labs
- Start CV related labs at age 45: Lipid panel every 5 yrs through age 75, fasting blood glucose
every 3 years. Thyroid screening every 5 years starting at age 50
- Urinalysis if 65+ because the risk of urosepsis

Vaccinations
- Pregnancy or the possibility of pregnancy w/in 4 weeks is a contraindication to MMR and varicella
vaccines!
- Tetanus, Hep B, and pneumococcal vaccines are okay in pregnancy
- Varicella vaccine at age 60. It’s a live attenuated vaccine - give even if the patient has already
had shingles!
- Don’t give HPV vaccine if pregnant! Usually give to girls 9-26 and boys 9-21 (or up to 26 in
men who have sex with men)

Nutrition
- Folate lowers homocysteine levels → reduces nonfatal MIs and fatal coronary events in women. Dietary
intake is not enough! Women of reproductive age should take a daily 400 microgram supplement.

Menopause

Average age of menopause is 51 yrs. Technically means the last period, but used to describe the chapter
in life after that point. Perimenopause/climacteric is the transitional period.
- Symptoms: Hot flashes, night sweats, vaginal dryness. Some women are asymptomatic due to
peripheral conversion of androgens to estrogen. Hot flashes usually increase in frequency up to
menopause and then continue for several years after.
- Diagnosis: Clinical, but AMH decline is the earliest marker, followed by inhibin B, then estradiol.
- Treatment:
- Estrogen (+/- progesterone) is most effective treatment. HRT = estrogen plus
progesterone, indicated if she has a uterus. Do smallest effective dose for shortest
possible time.
- Don’t use to prevent CV disease because of slight increase in risk for breast
cancer and cardiovascular disease (MI, stroke). No increased risk from 6 months
of treatment, no increased CV risk in women in their 50s.
- Reduced risk of osteoporosis and colon cancer.
- Added benefit on lipid profile: Increase HDL and reduce LDL - but not
recommended for primary prevention of heart disease
- Other less effective options: Clonidine, soy products, SSRIs, anti-seizure meds

Contraceptive counseling

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Endometrium grows with estrogen and progresterone. Progesterone maintains it, estrogen stabilizes it

OCPs
- Reduce risk of PID, endometriosis, ovarian cancer, endometrial cancer benign breast disease,
and ectopic pregnancy. Maybe also slight decrease in breast cancer risk.

Patch
- Twice the rate of DVTs as compared to OCPs

Combined: Pill, patch, ring

- Have similar rates of efficacy - 10% failure on average, but < 1% failure with perfect use
- Estrogens are all the same, progesterones are different - more or less androgenic (can cause or
improve acne). Can look up this scale.
- Levonorgesterol: more androgenic
- Can use perpetuously, but likely to have breakthrough bleeding because lining is thin. Can then
decide to take a break after spotting happens if she wants.
- Average age of menopause is 51.5 yrs - can discontinue around then. Menopause - no period for
1 year.

LARCs: Long acting reversible contraception

● Equally effective as tubal ligation

Estrogen
● Anything under 50 micrograms is low dose - that's true of all OCPs now.
● Slight gradation of VTE risk - still only 1 in 1000 per year. Pregnancy is like 30 per 10,000, post
partum is 300 per 10,000

Emergency contraception
- Multiple OCPs: do ASAP, esp within 72 hours and no later than 120 hours. Then just begin OCPs
as contraception immediately after, don’t wait until next period. Biggest side effect is nausea and
vomiting.
- Plan B = levonorgestrel: - take it twice. Most common side effect is nausea - give zofran - but less
nausea than with OCP method. 75% effective for up to 3 days, just like taking OCPs
- Ella = ulipristal: Selective progesterone agonist/antagonist. 75% effective for up to 5 days
- Paraguard: Can do for up to 7 days! 99% effective - the best emergency contraception.
- Usual rules of thumb about contraindications for OCPs don’t apply ! Benefits outweigh the risks
even if CV disease, etc.

Progesterone
● Good for women with migraines, women who are breastfeeding, can start right away after
delivery - does not increase stroke risk?
● Good for smokers, people with hypertension, other CV risk markers - obesity, diabetes
● Still ovulate with progesterone! Someone who has ovulatory pain might want to avoid
progesterone only.
● Depo-provera:
○ Given every 3 months
○ Fertility can take 6 months to 1.5 years to come back - unlike pill, which is instant.

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 ○ Might not be good for women who want to get pregnant right away
○ Black box warning - can lose bone mineral density after two years, might not regain it.
Also have bone density loss with pregnancy and breast feeding - but this is
reaccumulated afterwards
○ Good for women with sickle cell or epilepsy - get fewer episodes with depo!
● Nexplanon
○ Matchstick implant for 3 years
○ Progesterone only
○ Some of the highest rates of unscheduled bleeding
● Mirena
○ 5 years, but data on it for cycle control up to 7 - contraceptive efficacy up to 5.
○ Creates a thin endometrium by having a foreign body, also creates thicker cervical
mucous and impairs fallopian cilia movement
○ 80-90% reduction in bleeding. 20% have no periods. Also have less pain because of
reduced progestins. But bleeding is unscheduled - especially for 3-6 months

Paraguard
● Copper IUD for 10 years
● Main impact on sperm swimming
● Heavier bleeding - might be a good choice for women who have light periods at baseline, not
good for women who have heavy periods

Skyla
● Basically mirena, good for three years

IUDs in general
- Small infection risk at the time of placement - maybe 1%? No long term risk
- Contraindicated if current STI, PID currently or within the past three months.

Guideline for the discussion:

1) Failure rates
2) Ask what things are easy or hard for her
3) Taking the pill
● Take it the same time every day
● What to expect:
○ Periods will be regular, women will start to bleed anywhere from 0-4 days after last
hormonal pill.
○ Shorter placebo stretch: Good for women who have migraines, or can have seasonal -
have a period every few months
○ Lighter periods --> less pain (reduced prostaglandins):
■ Progesterone makes the endometrium decidualize (thinner), estrogen stabilizes
the lining.
○ Better skin: more sex hormone binding globulin from the liver
○ Weight gain: Studies show it's not associated with the pill, except for Depo-Provera
because it's a huge dose of intramuscular progesterone. Stimulates appetite.
■ Biggest weight gain is in adolescent women who are already overweight - be
careful giving Depo to this group

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 ○ Nausea: usually gets better over time
○ Mood disorder: usually if prone to mood disorders
○ Breast tenderness, transient hot flashes
● Contraindications
○ Migraines: STOP THE PILL IF MIGRAINES WITH AURAS - increased stroke risk. But
they can take progesterone only forms of contraception - progesterone doesn't increase
clot risk.
○ Poorly controlled HTN
○ Smoking over age 35
○ Previous history of clots or strong family history
○ History of hormone positive cancer - OCPs don't cause breast cancer
● Missed pills:
○ Miss one pill: take both the next day. Miss two pills, take two for two days - use back up
method
○ Miss three pills - have a period and start a new pill pack. Maybe not a good method for
them
4) The patch
● Change it weekly, new area of skin, one week don't wear it
● Same risks/benefits/CIs as the pill
● Less effective in women over 200 lbs - same is actually true for the pill
5) Ring
● Wear it three weeks, take it out for one week
● May have increased vaginal discharge. If it falls out, rinse it off and put it back in within three
hours. Can take it out for sex, but have to put it back in within 3 weeks
● Put it in with circle vertical, not horizontal
● Store it in the fridge

PERMANENT CONTRACEPTION

Essure
● Placed in the FT with a hysteroscope? Made of fibers that cause local inflammation and tube
grows into it.
● Takes three months to become effective. Then have to have a hysterosalpingogram to ensure
that it worked. Is actually a fairly painful procedure. Basically no failures when tubal occlusion is
confirmed
● Do it immediately after a period - during it's hard to see, and with thin lining easier to see the
openings. Can also take OCPs before to suppress the lining. Give toradol before hand.
● Not candidate:
○ people who might want to be pregnant in the future.
○ Nickel allergies! Can't wear cheap jewelry or get a rash at the belt buckle. If questionable,
go to derm for skin patch testing
○ Previous surgery on tubes -need to get the op report to know whether one or both FTs is
still there

Laproscopic or post partum tubal ligation

● CREST Study: 2% failure rate over 10 years
● Certain types of ligations are more likely to fistulize and recanulate
● Increased risk of ectopic pregnancy if they do get pregnant - also true with IUDs

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 ● Slightly reduces risk of ovarian cancer. Does not reduce risk of breast, cervical, or endometrial
cancer. No decrease in menstrual flow.

Abortion

Medical abortion
- Start with mifepristone (anti-prostaglandin), follow with misoprostol (induces uterine
contractions).Oxytocin has a high failure rate.
- More bleeding than surgical procedures. If bleeding is very heavy, then do a D&C - e.g.,
soaking more than a pad per hour for several hours. Do D&C even if she is asymptomatic.

Surgical abortion
- Manual vacuum aspiration: okay up to 8 weeks.
- Dilation and curettage: less than 16 weeks
- Dilation and evacuation: Can be done after 16 weeks

PMS/PMDD

Risk factors: Family history of PMS, vitamin B6, calcium deficiency, or Mg deficiency. More common with
older age, symptoms tend to get worse with time.

Treatment:
- OCPs
- Correct deficiencies in Vitamin A, E, and B6

Irregular Vaginal Bleeding

If heavy periods → consider fibroids.

If intermenstrual bleeding, also consider endometrial hyperplasia, endometrial polyp, uterine cancer
If irregular periods → suggests anovulatory process

Menorrhagia
- Fibroids = leiomyomata
- Usually asymptomatic, but most common symptom is very heavy periods w/out
spotting in between periods - maybe b/c increased surface area, ulceration of fibroids, or
disrupted hemostatic mechanisms during menses
- Other symptoms/signs:
- May have enlarged uterus and symptoms from compression of adjacent organs -
urinary frequency from bladder compression or constipation from compression of
sigmoid colon.
- Note: enlarged uterus, urinary frequency, and constipation are not seen
with adenomyosis or endometriosis.
- Pressure, pain if fibroid on pedicle twists, submucosal fibroid can prolapse through cervix
→ labor like contractions.
- Irregular midline mass that moves w/ cervix. If subserosal, may feel bumpy
uterus on exam
- Submucosal fibroids → recurrent abortions

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 - On biopsy - well circumscribed non-encapsulated myometrium. If > 10 mitotic
figures PHF, then leiomyosarcoma.
- Red degeneration/carneous degeneration = center of fibroid becomes red, painful due to
rapid growth
- Differential: ovarian mass, tubo-ovarian mass, pelvic kidney, endometrioma
(dysmenorrhea, dyspareunia)
- Diagnosis: Symptoms + exam, do ultrasound to confirm. Lateral, fixed, or fluctuant are
not typical for fibroids!
- Still have to rule out endometrial cancer in women over 40! Do endometrial
biopsy
- Treatment:
- If asymptomatic, observe.
- Intervene if anemic.
- Meds:
- Start with NSAIDs
- Progestin if small. Can’t use an IUD if uterine cavity is irregular
- GnRH agonist to shrink fibroids temporarily, correct anemia, or
make surgery easier. Will regrow, so not typically used except as
prep for surgery.
- Surgery
- If no pregnancy desired:
- Hysterectomy if symptoms despite medical treatment
and no desire for pregnancy. Most common indication
for the procedure!
- Uterine artery embolization - 5 year 75% effective.
Increased risk of placental abnormalities.
- If pregnancy desired
- Myomectomy if symptomatic but want to become
pregnant - 25% will need hysterectomy in 20 years.
Does increase risk of uterine rupture - do c-section if
endometrial cavity entered during the procedure.
- Risk: Small risk of progressing to cancer.
- Suspect if rapid growth (> 6 week size in one year). Especially if post-
menopausal, because fibroids grow in response to estrogen
- Radiation is a risk factor.

Adenomyosis
- Endometrial glands and stroma penetrates the myometrium → tries to slough off during menstruation but
gets trapped → regular but heavy periods, prolonged periods painful cramps or pain all the time, bloating.
- Risk Factors: women 35-50 who have had prior things mess with the uterus - pregnancy, C-
section, d&c, other surgery, etc.
- Diagnosis: Enlarged, soft, boggy uterus on physical exam. Diagnose with transvaginal ultrasound
- Treatment: GnRH agonist is first line, but will recur. Hysterectomy is the next best option, but if
don’t want that, can do progesterone IUD or endometrial ablation

Clotting disorder - Von Willebrand Disease

- Heavy periods right from the start, not helped by OCPs

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 Secondary Amenorrhea

Amenorrhea can result from any one of four main causes: Hypothalamic, pituitary, ovarian, or
uterine/outflow tract

Hypothalamic:
- Excessive exercise, wt loss, stress, hypothyroid, hyperprolactinemia
- Hyperprolactinemia [see below for causes of hyperprolactinemia]
- Prolactin inhibits pulsatile GnRH → low FSH → low estradiol → thin, dormant
endometrium and risk of osteoporosis
- Hypothyroid
- Increased TRH stimulates prolactin secretion → amenorrhea and can also have galactorrhea

Pituitary:
- Sheehan, irradiation or surgery on pituitary
- Sheehan syndrome:
- Hypotension after delivery → hemorrhagic pituitary necrosis.
- The pituitary gland is particularly vulnerable b/c of hypertrophy and hyperplasia of the
lactotrophs during pregnancy without any increase in vascular supply. Does not affect
posterior pituitary, because that gland has its own arterial blood supply
- Low TSH, FSH, LH (monophasic body temp), ACTH, prolactin. Will bleed in response to
estrogen and progestin.

Ovarian:
- PCOS, premature ovarian failure

Uterine/outflow tract:
- Cervical stenosis
- Risk after cervical conization. If untreated → severe endometriosis
- Adhesions
- Diagnose adhesions with hysterosalpingogram = radiologic study with radio-opaque
dye, used to evaluate the cavity or the fallopian tubes, or saline infusion
sonohysterography = vaginal u/s with saline to enable enhanced visualization of the
cavity
- Treat with operative hysteroscopy. Maybe insert UID or pediatric foley catheter to prevent
adhesions from reforming. Consider combined estrogen/prgoesterone and reevaluate
cavity before trying to conceive.

Galactorrhea

Can be caused by: pituitary adenoma, pregnancy, breast stim, meds, chest wall trauma, or
hypothyroidism!

Hyperprolactinemia causes
- Drugs: tranquilizers, TCAs, antihypertensives, narcotics, OCPs, anti-psychotic meds
- Hypothyroidism - TRH stimulates prolactin secretion!
- Hypothalamic causes (decreased dopamine): craniopharyngioma, sarcoidosis, histiocytosis,
leukemia

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 - Pituitary causes: adenoma, empty sella, acromegaly
- Hyperplasia of the lactotrophs
- Renal disease - acute or chronic
- Chest surgery or trauma - herpes, breast implants!

Work up
- Prolactin can be elevated from stimulation of the breast during physical exam! Most accurate if
patient is fasting - get fasting prolactin before proceeding with further work up.
- If prolactin is mildly elevated (20-60) → measure TRH
- If prolactin is seriously elevated, normal, or patient has neuro symptoms → MRI
- Pituitary adenoma is especially likely if estrogen is very low (< 40)

Management
- Just watch
- If galactorrhea but normal menses and normal serum prolactin
- If microadenoma and do not want to conceive, have no estrogen deficiency
- Bromocriptine or cabergoline (dopamine agonists) if want to have kids. Bromocriptine can be
used during pregnancy!
- Can treat with estrogen
- If estrogen levels are adequate, can treat with periodic progestin withdrawal

Infertility

10-15% of couples are affected by infertility. For a normal couple, 20-25% chance of getting pregnant in a
given month.
- Do simple tests before more complicated ones - e.g., if woman and man both seem okay but are
experiencing trouble conceiving, do semen analysis before hysterosalpingogram.

Basically six possible etiologies of infertility:

1) Ovulatory dysfunction - 30-40% of infertility
○ Caused by hypothalamic disturbances (hypothyroid, hyperprolactinemia), PCOS, and
premature ovarian failure.
■ Exercise induced hypothalamic cause: normal FSH with low estrogen.
■ Premature ovarian failure: can be caused by chemo, radiation, autoimmune,
fragile X, turner syndrome. Usually FSH > LH because LH is cleared faster.
○ Test with basal body temp (0.5 degree rise w/ progesterone), LH surge, or progesterone
level.
○ Treat with clomid.
○ Evaluation
■ OTC ovulation kits are good, they look for LH in urine - ovulation happens 36
hours after LH surge.
(1) Can’t use body temp, because it retroactively registers ovulation and the
egg is only good for 24 hours.
(2) Can conceive if have sex < 3 days before ovulation (sperm can live up
to 5 days), can be fertilized for up to 12 hours after ovulation.
■ Endometrial bx for secretory tissue
■ Over age 30: Day 3 FSH, AMH testing
2) Uterine dysfunction

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 ○ Fibroids, do hystosalpingogram to dx, treat with hysteroscopic procedure
3) Tubal dysfunction
○ Suspect if hx of chlamydia or gonorrhea, dx with hystosalpingogram (laparoscopy is
gold standard), could try tx with laparoscopy but generally bad - IVF is better
○ But most women have no hx of gonorrhea or chlamydia - these infections are often
asymptomatic.
4) Cervical dysfunction (rare)
○ Suspect if thick viscid cervical mucus before ovulation. Inject washed sperm through a
catheter to bypass cervix.
5) Male factor - DO A SPERM ANALYSIS IF THE WOMAN SEEMS NORMAL!!!
○ Varicocele, hernia, mumps, klinefelter (xxy). Might need IVF (can’t swim)
○ Can’t dx based on one test - repeat in 2-3 months because spermatogonia → sperm takes 74 days
○ Test even if the man has fathered other children
6) Peritoneal factor (endometriosis) - 0.5-5% of fertile women and 25-40% of infertile
○ 3 D’s of Endometriosis: dysmenorrhea, dyspareunia, dyschezia. But can be
asymptomatic!
○ Dx with laparoscopy (lesions can be clear to red to the classic “powder burn” color),
○ Treatment in general:
■ First try OCPs and NSAIDs. Can also do GnRH agonists for the short term - will
downregulate release of FSH and LH.
■ Laparoscopy with ablation/excision of endometriosis in patients who are planning
pregnancy
■ If no pregnancy desired, remove ovaries with or without a hysterectomy.
○ Treatment of infertility
■ Hysterosalpingram to check the tubes
■ If tubes are patent, give clomid and consider IUI
○ Endometrioma: Complex ovarian cysts made up of endometrial tissue

ART
- 1-2% of pregnancies in the US! Do for severe tubal factor, male factor, endometriosis, or other
unexplained infertility not responsive to medical therapy

Androgenism

PCOS
- Ratio of LH to FSH is often a supporting diagnostic factor, but inconsistent and unreliable
- Signs of hyperandrogenism - acne, hirsutism, alopecia. Caused by perpetual anovulation?
- Consider other causes of hyperandrogenism
- congenital adrenal hyperplasia, hyperprolactinemia, adrenal/ovarian tumors, Cushing,
thyroid
- DHEA-S is made by adrenal gland, testosterone is from ovaries

Hyperthecosis: Like PCOS, but more severe androgenism - difficult to induce ovulation

Cushing’s syndrome
- Can cause hirsutism! Order dexamethasone suppression test or 24 hour urine cortisol

Other causes:

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 - Congenital adrenal hyperplasia:
- Congenital aromatase deficiency: Prevents conversion of androgens to estrogens - in utero
can even lead to masculinization of the mother that resolves after delivery. Will be XX with
ambiguous external genitalia and normal internal genitalia. Have delayed puberty, osteoporosis,
undetectable circulating estrogens, high gonadotropins, and polycystic ovaries.

Breast mass

Breast cancer generally:

- Age is the most important risk factor - 1 in 30 at 60 yrs. Infiltrating intraductal cancer is most
common.
- Do clinical breast exam every 3 years for women 20-39 yrs. Mammogram annually over 40 yrs.
- BRCA1 and BRCA2 screening - autosomal dominant!
- Do if 2 first degree relatives with breast cancer.
- BRCA1 - 50-70% chance of breast cancer, 30% chance of ovarian. BRCA2 is slightly
lower.

Work up of dominant breast mass = mass felt to be separate from the rest of the tissue.
- Triple assessment: Physical exam + imaging + core needle biopsy. If all three agree → 99%
chance that it is not cancer. If any one is suspicious, remove the mass
- Imaging:
- Ultrasound or MRI is best in young patient, not hampered by dense breast tissue.
Consider MRI if at high risk for breast cancer
- Mammograms
- Have 10% false negative and false positive rates - still need to do histology of
any palpable mass even if normal mammogram!
- No increased risk of cancer from radiation - dose is too low
- Suspicious findings:
- Small clusters of calcifications - especially if linear and wispy,
spiculated and invasive borders, architectural distortion, asymmetric
increased tissue density when compared with prior studies, or
corresponding area in the opposite breast
- Fat necrosis can look identical to breast cancer, with ill defined mass with
cluster of calcifications. FN is more likely dx than breast cancer if patient recalls
trauma, but still have to do a biopsy.
- Biopsy: greater risk of breast cancer → need more tissue. Do core needle or excisional if red flags - older
patient, family history, fixed, bloody nipple discharge, nipple retraction.
- FNA is acceptable if low risk. Can distinguish fibroadenoma from cyst, sometimes
r/o cancer. But can’t distinguish in situ from invasive cancers
- If fluid from a cyst is straw colored and mass disappears → don’t need to send for
cytology.
- If fluid is not straw colored (e.g, bloody) or if mass doesn’t disappear → send for
cytology or just do excisional biopsy.
- Core needle: removes more tissue than FNA, but bruising and pain. If not palpable, can
do stereotactic or needle localization for bx
- Stereotactic localization uses 3d view of the breast. Can still miss 2-4%.
- Needle localization - excises more tissue, good for “borderline” histologic
conditions like DCIS. Can still miss 3-5%.

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 - Excisional: Removes the entire mass, more bruising and pain.

Fibrocystic change:
- Cyclic, painful, engorged breast, lumpy bumpy, more pronounced just before menstruation,
occasionally associated with serous or green discharge.
- Decrease caffeine - it can increase the pain associated with fibrocystic change, take
NSAIDs, OCPs or progestin

Random benign masses

- Fibroadenoma: Firm, nontender, rubbery, mobile. Does not change with menses (= dominant
mass). Can just monitor, but many women will want it removed.
- Galactocele: cystic mammary gland tumor, occur when obstruction of milk flow in lactating breast

Bloody nipple discharge

- If no mass and only one duct - most often intraductal papilloma. Small, benign tumor. But must do
ductal exploration to r/o cancer.
- Cancer is second most common cause!

Mastitis
- Can accompany pregnancy or nursing. Most often 2nd-4th week after delivery.
- Treat with oral or IV abx, depending on severity. May use ibuprofen in addition to acetaminophen
for pain. Keep breastfeeding or expressing milk.
- No ultrasound needed unless worried about breast abscess
-
GynOnc

HPV
- 16, 18, 31, 45 are high risk. 6, and 11 are low risk.
- Gardasil vaccine covers 6, 11, 16, 18 - 16 and 18 cause 50% of cervical cancer and dysplasia
- 20% of population has HPV, usually transient.

HPV and cervical cancer

- Transformation zone: area of columnar → squamous metaplasia. Moves up endocervical canal,
beginning at os.
- Screen with PAP - use biopsies to look at actual lesions
- Start at age 21 regardless of age of onset of sexual intercourse.
- If hysterectomy for benign reasons → no more PAP. But if hysterectomy w/ a history of
cervical dysplasia, still need annual PAP smears!
- Findings on PAP
- ASCUS (atypical squamous cells of undetermined significance) - can triage
management based on HPV typing. Not true for LSIL or HSIL.
- LSIL (low grade) or HSIL (high grade) → follow with colposcopy
- Atypical glandular cells → colposcopy, endocervical curettage, endometrial biopsy
because it could be endometrial, cervical, or vaginal cancer.
- Colposocopy
- Treat with ascetic acid → squamous epithelium is pink and smooth, columnar is red and irregular.
Transformation is ghost white.

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 - Acetowhite change = intraepithelial lesions turn white with acetic acid. They also have
vascular changes
- Punctations = new vessels on their endpoints,
- mosaicism = new blood vessels on their sides.
- Atypical vessels = biggest red flag. Corkscrew, hairpin, etc = more serious
angiogenesis.
- Biopsy suspicious lesions seen on colposcopy
- CIN1 = lower ⅓ is atypical, 60% regress. 1% chance of cancer without treatment
- Expectant management. Follow with Pap smears at 6 months and 1 year, or do
HPV DNA testing at 1 year. Don’t do excisional or ablative procedures.
- CIN2 lower ⅔ atypical, 40% regress, 5% would progress to cancer without treatment
- Expectant management if patient is younger than 25, just like CIN1. If older, have
to remove it - LEEP (office) or cold knife cone (OR)
- CIN3 = Carcinoma in Situ = full thickness, ⅓ regresses. > 12% would progress to
cancer without treatment
- Microinvasive cancer: Invasion of < 3 mm beyond the basement membrane
- Treatment:
- ASCUS: Do HPV testing or repeat Pap in 12 months. If HPV is negative, then just
resume routine screening and do Pap in 3 years. If HPV is positive or repeat Pap at 1
year is still ASCUS or higher, then do colposcopy with ECC and directed biopsies. If
patient is 21-24 yrs, then follow the protocol but only do colposcopy if Pap shows HSIL,
can’t rule out high grade lesion, or is AGC (atypical glandular cells).
- CIN1 or CIN 2 in younger than 25 yrs: expectant management. Follow with Pap
smears at 6 months and 1 year, or do HPV DNA testing at 1 year. Don’t do excisional or
ablative procedures.
- CIN2 & CIN3: immediate treatment
- Ablation with cryotherapy or laser, but then no dx info
- Excise with LEEP (office or OR, uses a loop) or cold knife cone (remove entire
transformation zone with scalpel in OR)
- In general, do cold knife cone if
- Unsatisfactory colposcopy - including inability to visualize the entire
transformation zone
- Positive endocervical curettage,
- Pap smear showing adenocarcinoma in situ
- Cervical biopsies that can’t rule out invasive cancer
- Discrepancy between Pap smear and biopsy results! E.g., if Pap shows HSIL
but biopsies are benign, then do cold knife cone!

Cervical cancer
- Usually squamous, can be adenocarcinoma
- Symptoms: post coital bleeding! Most common cause of death is bilateral ureteral obstruction → uremia.
Also suspect advanced disease if flank tenderness or leg swelling.
- Risk factors: early age of coitus, STDs (indicates higher likelihood of exposure to high risk HPV),
early childbearing, low socioeconomic status, HPV, HIV, cigarette smoking, multiple sexual
partners, exposure to DES
- Treatment:
- Early cervical cancer (within cervix) - can do radical hysterectomy or radiation. In
women who want to become pregnant, can do radical trachelectomy!

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 - Advanced cervical cancer: radiation (brachy and tele) with chemo (usually platinum
based to sensitize to radiation). Lose sexual function and ovarian function - that’s why
surgery can be a better treatment for women who are eligible.

Endometrial hyperplasia
- Increased gland to stroma ratio due to chronic exposure to estrogen. Can progress to endometrial
cancer.
- Four classifications based on two categories
- Architecture: simple (with space between glands) or complex (crowded glands)
- Presence or absence of atypia - increased nuclear to cytoplasm ratio
- Simple no atypia = 1% progression to cancer
- Complex without atypia = 3% risk
- Simple with atypia = 8% risk
- Complex with atypia = 29% chance of progression
- Risk factors
- Age 50-70
- Obesity - increased estrogen because of aromatase (testosterone → estrodiol, androstenedione →
estrone)
- Nulliparity - more exposure to estrogen in life, late menopause, early menarche
- Diabetes - independent risk factor for endometrial hyperplasia and cancer
- Tamoxifen - SERM, estrogen agonist on uterus
- Estrogen replacement therapy if taken without progresterone
- Hereditary nonpolyposis colorectal cancer = Lynch syndrome. 40-60% risk of
endometrial cancer
- Granulosa cell tumor - makes estrogen
- Diagnosis
- Abnormal vaginal bleeding or post menopausal bleeding → endometrial biopsy, D&C in OR, or
ultrasound (post menopause < 5mm endo stripe = low risk)
- Treatment
- Progesterone: stroma decidualization and thinning of endometrium, oral or IUD. Repeat
endometrial biopsy in 3-6 months
- If atypia are present: Progesterone if desire to maintain fertility, otherwise hysterectomy
is first line

Endometrial cancer
- Most common female genital tract cancer. Usually detected early because associated with early
symptom of abnormal uterine bleeding - that is the most common symptom, too.
- Can also have abnormal vaginal discharge and lower abdominal discomfort. Can
increase uterine size, but usually not the most common finding given the early diagnosis
of the cancer
- Risk factors: Unopposed estrogen (not HRT!), early menarche, late menopause, diabetes,
estrogen-secreting ovarian tumors, hypertension, family history (HNPCC or Lynch Syndrome)
- OCPs decrease risk due to progesterone
- Types
- Type 1 Endometrial cancer
- Typical endometrioid cell type, estrogen-dependent. Happens during menopause
or soon after in patients with classic risk factors of unopposed estrogen. Usually
low grade and not as aggressive

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 - Type 2 Endometrial cancer
- Late menopause, thin patients, or those with regular periods - i.e., the atypical
patient. Usually papillary serous or clear cell, estrogen independent (ER neg)
and aggressive.
- Diagnosis:
- Must work up any woman over 35 with abnormal uterine bleeding, and women younger
than 35 if risk factors
- Do an endometrial biopsy, and then maybe a D&C for diagnostics.
- Once diagnosis is known, turn to staging
- If early stage, do a chest x-ray. If suspcious for later stage, do a CT, MRI, PET,
etc. CA-125 may be helpful in predicting which patients may have extrauterine
spread, but is not absolutely necessary
- Treatment
- Surgery is most important, even if stage 1! Usually total abdominal hysterectomy,
BSO, bilateral pelvic and para aortic lymphadenectomy for staging. Can do TVH with or
without BSO if medically unstable or contraindications to major surgery. Ideally, only do
that with well-differentiated endometroid adenocarcinomas, avoid in aggressive types like
clear cell carcinoma, papillary serous carcinomas.
- Do radiation if high suspicion for spread, and chemotherapy if surgery shows
metasis.
- If Grade 1 and want to get pregnant, can do high dose progestin with endometrial
sampling in 2-3 months with hysterectomy after childbirth

Vulvar cancer
- Can have no signs or symptoms! Or can present with itching/ Biopsy any suspicious lesion on
post menopausal women.
- Average age is 65. Lichen sclerosus or any state of chronic vaginal itching is a risk factor. But
can get in 30’s - HPV, cigarette smoking, immune suppression.
- Precursors include VIN1, VIN2, VIN3
- HPV related VIN 3: Presents as dark spots on the vulva, occasionally itchy, may be
there for a few years before person seeks treatment.
- Treatment:
- VIN2: Best treatment for diffuse lesions is a skinning vulvectomy, but that is
disfiguring and involves removal of the clitoris. Can also do CO2 laser ablation
of the lesions to maintain sexual function.
- VIN3: Wide local excision. High rate of recurrence, need close surveillance.
- If cancer is diagnosed:
- Radical vulvectomy, including wurgical staging with removal of primary tumor and the
ispilateral inguinal lymph nodes.
- Only microinvasive squamous cell cancer can be treated by wide local excision - applies
to small lesions that are well differentiated with invasion of less than 1 mm.
- Usually squamous, but can have melanoma and basal cell
- Paget’s disease of the vulva: white plaque like lesions and poorly demarcated
erythema, no discrete mass. It’s an in situ carcinoma of the vulva, associated with breast
cancer.
- Verrucous carcinoma: Cauliflower like lesions
- Melanoma: Can first appear as an in situ lesion - just a pigmented spot. 5% of
melanomas are vaginal, which is suprising given the lack of surface area and the lack of
sun.

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Bartholin’s gland
- Can get adenocarcinoma! Fixed firm mass, fast onset
- Differential includes Bartholin gland cyst - but any new BG cyst in a post menopausal woman has
to be investigated.
- Can also get BG abscesses - common sign of gonorrhea infection

Post Menopausal Bleeding

Differential dx of post menopausal bleeding:

- Endometrial cancer: see above
- Endometrial polyp:
- Endometrial glands and stroma on a stalk; can cause postmenopausal bleeding. Can see
with hysteroscopy or saline infusion sonohysterography
- Could be malignant! Still need to have surgery to remove them if > 1.5 cm!
- Atrophic endometrium:
- The most common cause of postmenopausal bleeding! Friable endometrium or
vaginal tissue due to low estrogen

Workup of post menopausal bleeding:

1.) Endometrial biopsy - 90-95% sensitive.
2.) If endometrial biopsy is benign, but the patient has a lot of risk factors for cancer, then do direct
visualization of the uterine cavity with hysteroscopy

Adnexal Masses

Adnexal mass:
- Defined: something off of the uterus
- DDx: Gynecologic and nongynecologic (urologic, GI). Benign or malignant.
- Uterine fibroid - typically midline and irregular
- TOA - typically adnexal tenderness
- Sertoli-Leydig - usually androgen
- Endometrioma - usually less than 8 cm, associated with dysmenorrhea and dyspareunia
- Ovarian: functional cyst, ectopic pregnancy,

Evaluation
- Age:
- Helps predict risk and type of malignancy
- Premenopausal mass: unlikely to be cancer, if it is, most likely germ cell (dermoid cyst is
the most common). Post menopause: 29-35% risk of cancer.
- Family history:
- 5-10% hereditary.
- Increased risk of BRCA (Frank criteria) in families with
- Breast cancer in 2 or more relatives < 50 OR one or more < 50 AND ovarian
cancer
- Ovarian cancer: 2 or more cases
- Male breast cancer and any other breast or ovarian cancer
- Ashkenazi Jewish and any breast or ovarian cancer

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 - HNPCC Amersterdam
- Colon cancer < 50 yrs in any family member
- Colon cancer in 3 or more family members
- No history of FAP
- Physical exam:
- Size, location, consistency, tenderness, mobility
- Metastatic disease - ascites, lymphadenopathy
- Rectovaginal exam
- Imaging
- Transvaginal ultrasound is first! Great sensitivity and specificity. Nodularity and solid
components are concerning
- Reserve CT and MRI for specific situations
- Blood tests
- Premenopausal: Rule out pregnancy with serum beta HCG or urine test, also AFP, LDH.
CA-125 only if concerned about cancer
- Post menopause: CA 125
- Other: CEA, CA 19-9

Management of adnexal mass: Depends on age and ovarian size

- If prepubertal and > 2 cm → likely neoplasm, operate.
- If menopausal and > 5 cm → likely neoplasm, operate
- If reproductive age and > 10 cm → likely neoplasm, operate.
- Observe if small (< 5 cm). Most likely to be a follicular cyst or corpus luteum
- If 5-10 cm, operate if septations, solid, or excrescenses (= abnormal outgrowth),
otherwise observe for a month.

Functional cysts: Can cause unpleasant symptoms but unlikely to stick around for very long. Usually a
unilocular simple cyst without evidence of blood, soft tissue, or excrescenses.
- Follicular
- Corpus luteum
- Hemorrhagic: Consider if the patient is 3 weeks into her cycle. Can form a complex cyst.

Ovarian torsion
- Sudden onset of colicky abdominal pain (unilateral, abdominal or pelvic!), nausea +/- vomiting,
and presence of cyst (maybe free fluid) on ultrasound. Maybe hypoactive bowel sounds. Tender
abdomen with involuntary guarding
- Risk: 14 weeks pregnancy when the uterus rises above the pelvic brim, or immediately
postpartum when the uterus involutes
- Treatment: Needs immediate surgical exploration. If untwisting adnexa results in reperfusion,
then can just do ovarian cystectomy. But if perfusion can’t be restored, then do oophorectomy.

Ovarian cancer
- Germ cell, stromal cell, or epithelial
- Germ most common in young women (especially dermoid cysts), epithelial most common
later (most common kind of tumor overall). True for both benign and malignant. Stromal
are rare
- Highest mortality among gynecologic cancers

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 - Risk factors: Nulliparity, low parity, delayed childbearing, PCOS, hereditary cancer
syndromes (HNPCC, BRCA)
- Protective: pregnancy, birth control pills, tubal ligation, hysterectomy,
- Symptoms: mostly GI symptoms, less common gynecologic. Usually 3 months before seeking
care.
- Diagnosis: Do CT of abdomen and pelvis.
- Management
- Surgical debulking and staging, with chemo for advanced disease - carboplatin and
paclitaxel. Remove both sides and uterus if done with child bearing, lymph node removal
- If pleural effusion, thoracentesis to rule out malignant pleural effusion.
- 60-80% remission, but 80% relapse
- Serum markers
- CA-125: best marker, but not great. Also less sensitive and less specific in young women.
- False positives: peritoneal inflammation (endometriosis, PID)
- LDH: dysgerminoma
- Beta HCG: choriocarcinoma, embryonal carcinoma
- AFP: endodermal sinus
- Inhibins, estradiol: granulosa
- Testosterone: sertoli-leydig

Ovarian Tumors
- Germ cell - most common ovarian cancer in young women.
- Symptoms: Often presents with pelvic mass and pain due to rapid growth. Usually found
early.
- Benign teratomas are the most common kind, and the most common tumor in women of
all ages.
- All 3 cell layers, can have solid and cystic components, can produce TRH!
- Prone to torsion! Often present with severe acute abdominal pain, especially
during pregnancy, puerperium, and in children or younger patients.
- Can rupture! Uncommon, presents with shock and hemorrhage.
- Treatment: Surgical cystecomy or unilateral oophorectomy, inspect
contralateral ovary (15-20% are bilateral).
- Malignant teratomas - only 1% of teratomas.
- Usually early in life. Often have immature neural tissue - that quality determines
grade.
- If grade 1, just do surgery. If grade 2 or 3 and implants or reoccurrences → chemo
- Struma ovarii = germ cell tumor made all or partly of thyroid tissue. 10% malignant.
- Malignant ovarian tumors include:
- Dysgerminoma
- Endodermal sinus tumor (yolk sac)
- Immature teratoma
- Rare (embryonal, choriocarcinoma)
- Epithelial - ⅔ of ovarian tumors, most common in patients > 30 years, most common cause of
ovarian cancer deaths.
- Often caught very late! Tend to spread to peritoneum and bowel. Can have early GI
symptoms -bloating, early satiety, increased girth, pain - but frequently noted only in
retrospect.
- Often CA-125 positive, more specific in older women
- Serous - most common tumor (usually benign), usually bilateral

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 - Mucinous - can be large in size (30 cm!), loculated, can rupture and cause mucous in
peritoneum (psuedomyxoma peritonei) → repeat bouts of bowel obstruction
- Endometrioid: can coexist with primary endometrial cancer in the uterus
- Clear cell:
- Treatment of epithelial cancer: Maximum debulking, chemotherapy with platinum agent
- Stromal
- Stromal tumors are solid! Makes sense because they are stromal tissue.
- Fibroma (fibroadenoma)
- Solid firm benign tumor
- Sometimes associated with ascites and pleural effusions (Miggs syndrome)
- Granulosa-theca cell tumor:
- Solid, usually yellow tumor.
- The granulosa cells make estrogen, inhibin. Cause endometrial hyperplasia and
post menopausal bleeding.
- Sertoli Leydig tumors
- Secrete androgens → masculinization and hirsutism

Dermatologic

Lichen simplex chronicus

- Chronic itching → thick, purplish leathery skin
- Treat with high dose topical corticosteroids and antihistamines to control the itching

Lichen sclerosis
- Chronic inflammatory derm condition w/ itching and pain.
- Affects vulva and anus, spares vagina → painful intercourse, defecation.
- Happens in women > men, usually prepubertal or post menopausal. Thin epidermis, hyperkeratosis,
elongation of the rete pegs → fragile, thin, crinkled skin. White skin.
- DDx: lichen planus (usually involves the vagina, LS doesn’t), psoriasis, VIN, vitiligo
- No definitive cure, treat with corticosteroids, avoid irritants, wear cotton undies
- Cancer of vulva often presents with itching and can be assoc’ed with LS - worry if a bump
appears! 5% risk of cancer.

Lichen Planus
- Inflammatory mucocutaneous eruptions with remissions and flaires. Lacy reticulated pattern of the labia
and perineum, can cause scarring and erosions, adhesions → obliteration of the vagina!
- Treatment is challenging since no single agent is universally effective

Psoriasis
Can get psoriasis in the vulva! Suspect if silvery white lesions elsewhere.

Vulvar candidiasis
- Diabetes is a risk factor!
- Can cause fissures in the labial folds → tears on the labia and burning on the skin with urination

Bartholin’s gland abscess

- usually polymicrobial and not sexually transmitted
- Bx in women over 40 - can be assoc’ed with cancer

23
 Miscellaneous

Vulvar vastibulitis
- Syndrome with symptoms and findings limited to the vulvar vestibule, including severe pain on
vestibular touch or attempted vaginal entry, tenderness to pressure and erythema.
- Treat with TCAs, topical anesthetics

Hysterectomy and oopherectomy have a risk of ureteral injury - whether ligation, thermal injury, etc. Can
present post-op like pyelonephritis. Ligation will present fast, thermal injury or ischemia (e.g., from over
dissection and destruction of blood supply) can take a week.

Post op fever:
- Wind: pneumonia, atelectasis on Day 1
- Water: UTI on Day 3
- Walking: DVT or PE on Day 5
- Wound infection: Day 7
- Wonder Drugs: > 7 days

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Sexual violence
- Offer prophy abx to all rape victims
- Don’t do an exam on a kid unless seriously have to
- Kids can get yeast infections after abx

25