Obstetrics and Gynecology

OMS III Clinical Rotation

Module 8

Topics: Please see syllabus for corresponding objectives

18. Pelvic Support Defects and Urinary Incontinence
19. Menopause
20. Gynecologic Oncology (excluding GTD)

Readings: Beckmann: pp, 262-270;345-352;379-399;406-414 ;415-426

Videos:

APGO Educational Video: Topic 29- Incontinence

https://www.apgo.org/basic-science/

APGO Educational Video: Topic 17- Menopause

https://www.apgo.org/basic-science/

APGO Educational Video: Topic 24: Pelvic Organ Prolapse

https://www.apgo.org/basic-science/

APGO Basic Science Video: Topic 22: Ovarian Neoplasms

https://www.youtube.com/watch?v=iFMApEy1X24

Articles:

ACOG Committee opinion # 603 Incontinence evaluation

https://www.acog.org/~/media/Committee%20Opinions/Committee%20on
%20Gynecologic%20Practice/co603.pdf?dmc=1&ts=20140623T1217247000

Hormone Replacement Guidelines

https://www.jwatch.org/na33279/2014/01/13/new-guidance-acog-treatment-women-
with-menopausal-symptoms

Bio-identical Hormone Replacement

https://www.acog.org/~/media/Committee%20Opinions/Committee%20on
%20Gynecologic%20Practice/co532.pdf?dmc

ACOG Practice Bulletin #83- Workup of Adnexal Mass

http://obgyn.azurewebsites.net/wp-content/uploads/2014/04/ACOG-PB-Management-
of-Adnexal-Masses.pdf
 Case 1

A 64-year-old female presents to the clinic for her annual gynecologic examination. She relates a 6-
month history of uncontrolled urinary leakage that requires that she use pads for protection. She
changes the pads at least 3 times daily. She has no chronic medical problems and takes no
medications. She requests evaluation and management of her urinary incontinence.

Types of Urinary Incontinence

1. What are the different types of urinary incontinence?

o Stress, urge, overflow, mixed
2. What questions could be asked in order to distinguish between these types of
incontinence?
o Amount lost, urgency, what brings on the event, flow
3. What would you expect to find on physical exam regarding the different types of
incontinence?
o Urge: normal PE, stress: leakage of urine with increase abdominal pressure
(Valsalva, laug), Overflow: increased post-void residual (distended -0bladder)
4. What special office tests could be performed to aid in the diagnosis?
o Cystometry, ultrasound to look at bladder for post void residual

Management of Incontinence

1. If the patient has urge incontinence, what medications might be useful in treatment?
What behavioral modifications might be useful? What surgeries might be helpful?
o Oxybutynin, botulinum toxin, nerve stimulation, cystoplasty or a suprapubic
catheter
2. If the patient has stress incontinence, what medication might be useful? What
behavioral modifications might be useful? What surgical procedures might be helpful?
o Duloxetine, alpha agonists, Kegel exercises, or a sling procedure

Complete the chart

Type of Incontinence Symptoms Physical Findings Management

Stress Urine leakage with Urine leakage with Kegel exercises
increase IAP cough or laugh

Urge Urgency, nocturia, Normal Oxybutynin

complete emptying
 Overflow Fullness, pressure, Distended bladder Bethanecol
not relieving full
bladder
Mixed  some
combination of two
above

Fistula, irrative Continuous leakage Suprapubic pain, Surgery to repair

(rectum, vagina) urine in rectum,
feces in vagina

Case 2

A 70-year-old female presents to the office complaining of a large bulge presenting out of the vaginal
opening for the past three months. She first noticed this about six months ago but has noted that it
has gradually increased in size since then. This bulge causes a great deal of discomfort primarily in the
sitting position and seems larger after prolonged standing. She desires evaluation and management.

1. What are the risk factors for pelvic organ prolapse?

a. Hysterectomy, multiple pregnancies, trauma, heavy lifting, loss of estrogen

2. What are the different types of pelvic organ prolapse?

a. Urethrocele, rectocele, cystocele, uterine prolapse

3. Label the different types of pelvic organ prolapse below..(hint: A is normal)

a. B: cystocele, C: rectocele, D: uterine prolapse
4.

5. What are some questions in taking a history that might be helpful to delineate the prolapse
type?
a. Incontinence, urine frequency and urgency, low hanging vagina, UTIs

6. What physical findings could be expected with each type of prolapse?

a. Cystocele: urine leaking with Valsalva, urine urgency, anterior wall falling during
speculum exam; Rectocele: posterior wall seen on speculum exam; Uterine prolapse:
uterus seen in vaginal canal; Enterocele: bowel seen on pelvic exam

7. How does the patient’s symptoms affect management?

a. They can be observed if asymptomatic; if symptoms exist, they can either get them
surgically fixed or non-surgical options like a pessary.

8. What are some non-surgical alternatives for management?

a. Kegels and pessaries

9. If surgery is recommended, how does the physical exam determine the type of surgery
recommended?
a. It indicates which organ is prolapsed
 Case 3

A 51-year-old female presents to the clinic with complaints of new onset vaginal dryness for the last
two months. Her last menstrual period was 13 months ago. She has no co-existing problems and
takes no medications. She expresses that she has noted significant discomfort with intercourse
primarily in the vaginal canal.

1. What criteria are used to diagnose menopause?

o The absence of a period for 12 months.

2. What are the physiologic changes in the Hypothalamic-Pituitary-Ovarian axis associated with
Menopause?
o Increase in FSH due to no negative feedback. The ovaries become resistance to FSH
and stop producing estrogen.

3. What are some other organ system changes associated with menopause?
o Bone loss, vaginal dryness, sleep disturbances, hot flashes, decrease collagen
synthesis, mood changes

4. What are some treatment options for the patient described above?
o HRT, vaginal estrogen or moisturizers/lubricants for the vagina

5. What criteria are used for treatment of menopause?

o 12 consecutive months without a period, hot flashes, vaginal dryness, mood changes

6. What are the risks and benefits of those treatments?

o HRT can lead to DVT/PE, strokes, coronary artery disease; benefits can be decrease
risk of colon cancer, hip fractures b/c increase in BMD, and improved overall quality of
life

A review of systems on this patient reveals that she also is having significant hot flashes and night
sweats that interfere with sleeping.

1. How is this connected with the patient’s diagnosis?

o Hot flashes are one of the first and most common signs of menopause, from decrease
in estrogen.

2. How will this change the treatment recommended for her presenting complaint?
o People with debilitating hot flashes usually benefit from HRT.

3. What are the risks and benefits of this treatment? What are the contraindications to treatment?
o Risks include CAD, DVT, PE, stroke: Benefits include better quality of life and decrease
risk of fractures. Contraindications include: smokers, previous thromboembolism,
CAD, pregnancy

The patient states she would like to consider Bio-identical hormone replacement.
 1. What guidelines can you give her regarding bio-identical hormones regarding safety and
efficacy?
o There is little evidence that shows long term improvement. There is also little quality
control.

Case 4

A 59-year-old female presents to the clinic with a 3-day history of vaginal bleeding. She had her last
menstrual period 6 years ago and has no history of bleeding until now. She denies any other
symptoms. She is sexually active and monogamous. Her past medical history reveals no previous
surgeries or chronic medical problems. She has taken estrogen and progesterone replacement in the
past but not in the last 3 years.

1. What other questions could you ask regarding risk factors for bleeding in this patient?
o Endometrial cancer in her family, bleeding disorder, pap smears, sexually active, STI
infections, trauma

2. What specifically in the physical exam would be important in assessing this patient and arriving
at a correct diagnosis?
o Vaginal atrophy, enlarged uterus, ultrasound assessing the endometrial stripe

3. What tests/procedures could be offered to make a diagnosis?

o Endometrial biopsy, endometrial stripe length on US

She has a test performed and the result reveals simple hyperplasia of the endometrium. She wants to
avoid surgery if possible. She is no longer bleeding and remains asymptomatic.

1. What treatment options could be recommended?

o Progesterone pills or IUD

The patient receives treatment; follow up in 3 months reveals that the patient has had another
episode of bleeding. A procedure is performed, and pathology returns endometrial cancer.

1. What questions regarding the pathology would be important regarding prognosis and
treatment?
o The most important factor will be the grade of the endometrial proliferation. Also
important would be if it has invaded or not.

2. What is the primary treatment of choice in this patient?

o Hysterectomy

3. How is endometrial cancer staged? (clinically or surgically)

o Surgically
4. How does stage affect prognosis in this patient?
o Staging helps determine the spread of cancer
 Case 5

A 55-year-old female presents to the clinic for her annual gynecologic exam. She has no complaints or
problems. She relates a concern about ovarian cancer because her grandmother died of ovarian
cancer at age 65. The patient has no previous surgical or medical history. She currently takes estrogen
and progesterone replacement due to post- menopausal hot flashes and night sweats. She also used
combination oral contraceptive pills for 15 years prior to menopause. She has a BMI of 35, Blood
pressure is 149/90 mmHg and pulse is 88 bpm .She smokes ½ pack of cigarettes per day.

1. What are risk factors for ovarian cancer?

o White, older age, nulliparity, early menarche and last menopause, endometriosis,
BRCA, lynch syndrome

2. What significant past medical history might be protective against ovarian cancer?
o OCPs, multiple pregnancies, late menarche and early menopause

3. What are the early warning signs regarding ovarian cancer?

o Abdominal fullness, weight gain, fatigue, virilization/hirsutism, PMB, back pain

The physical exam reveals what feels to be a right adnexal mass/fullness. The mass is non-tender and
mobile. The uterus palpates at normal size and consistency and is retroverted and retroflexed. The
remainder of the exam is unremarkable.

1. What test or tests would be considered useful at this point in making the diagnosis?
o Transvaginal U/S, CA125

Scenario 1

An ultrasound reveals a simple cyst 6 centimeters in size and her lab work is in the low normal range.

1. What would be the recommendations regarding management in this case?

o Follow up in 2-3 months for another ultrasound to see if cyst has resolved, but simple
cyst so not worrisome right now.

Scenario 2

An ultrasound revealed a complex mass with solid and cystic components at 6 centimeters and her lab
work is normal.
 1. What would be the recommendations regarding management in this case?
a. Removal of the ovary

2. How is ovarian cancer staged? What is the most common stage at presentation?
a. It is staged based on spread and histological evaluation. Most patients are diagnosed
in advanced stages due to no real screening tool.

3. What is the most common cell type of ovarian malignancies?

a. Epithelial

Common Epithelial Tumors of the Ovary

Type Distinguishing Characteristics

Serous (example) Psammoma bodies

M- mucious cystadenocarcinoma Pseudomyxomatous peritonei
E- endometriod “chocolate cyst”
O- clear cell Epithelial cells with a clear cytoplasm

4. After surgery, what types of treatments might be required to improve survival and disease-free
intervals?
a. Chemo and radiation

Case 6

A 60-year-old female presents to the clinic for an annual exam. She complains of a one-month history
of a vulvar ulceration, which is associated with itching and burning. She was recently married 6
months ago. She has tried multiple over the counter medications as well as home remedies without
relief. She denies any other symptoms including fever, chills, vaginal discharge.

1. What other questions might you ask to aid in the diagnosis?

a. LMP, when menopause occurred, sexually active, history of STI

2. What particular portion of the physical exam would be important?

 a. Inspection of the vulva and vaginal canal during a speculum/vaginal exam
After taking further history, you perform a physical exam. Exam of the vulva reveal the following:

1. After completing the physical exam what tests or procedures would you recommend in order to
make a diagnosis?
a. Biopsy

2. If a diagnosis of vulvar cancer were made, what lymph nodes would most likely be involved?
a. Inguinal lymph nodes; femoral as well

3. What is a risk factor for vulvar cancer and or vulvar intraepithelial dysplasia?
a. HPV

4. What are some treatment options for vulvar cancer?

a. Excision, removal of lymph nodes, radiation and chemo