Endometrial Bx?

→ Verbal Consent

Postcoit Bleeding = Cervical Bleeding

Mitral Stenosis? → Forceps

D&C then Amenorrhea occurs? → Basils

Most Significant Examination for General Check Up? → Inspection

Myosarcoma = Postmeno w/ AUB w/ TVUS show fibroid and Endometrial 14mm thick

↑↑ Breast Cancer Risk? = Age

Uterine Evacuation? → Perforation

Smoking Cessation Pregnant? → CBT (Bupropion is C/I)

MDD postpartum? → Involve Family

Lymph Drainage of Uterus Fundus? → Para-Aortic

Puberty
- ♂ → 1st big balls
- ♀ → Thelarche (breast)→Pubarche(pubic hair)→speedy growth → Menarche

Menstrual Cycle
→ Menses (day 0)
→ ↑ GnRH
→ ↑ FSH
→ Follicle Growth → Dominant Follicle
→ ↑ E2 (→ Proliferative Phase)
→ LH Surge (day 13)
→ Ovulation (day 14)
→ Corpus Luteum (day 15, Luteal Phase)
→ Progesterone (→ Secretory Phase)
→ no fertilization?
→ ↓LH, ↓P2, ↓E2
→ no -ve Feedback on FSH
→ ↑ FSH
→ Menses

Amenorrhea
→ no menses?
→1ry:no menses by 15yo w/ boobs, no menses by 13 w/o boobs?
→ Pelvic Ex, USG
→ Uterus Present?
→ FSH
→ ↑ → karyotyping (Gonadal Dysgenesis, HyperGnRH)
→ ↓ → MRI head(Hypothalamus, HypoGnRH, Kalman’s)
→ Uterus Absent?
→ Karyotyping, TST
 → 46, XX = Female = Mullerian Development, MRKH’s
→ 46, XY = Male= Androgen Insensitivity Syndrome
→2ry:no menses for >3 cycles OR >6mo?
→ Pregnancy Test (hCG)
→ +ve → pregnancy
→ -ve?
→ Hx Uterine procedure, infection? → Hysteroscopy
→ prolactin, TSH, FSH
→ ↑ Prolactin → MRI Head
→ ↑ TSH → HypoT
→ ↑ FSH → premature ovarian failure

- PCOS → Premenopausal Amenorrhea → Risk Endometrial Cancer

- Menopause → Amenorrhea → Risk Osteoporosis

Toxic Shock Syndrome = caused by Staph. A in reproductive ♀ who leaves her tampon for too long
→ supportive + remove foreign material + broad spectrum Abx

PID = Chlamydia > Neisseria (OOphoritis, Salpingitis, Endometritis, Adenexitis, Cervicitis)

→ <30yo w/ 1. Abdominal Pain 2. Adnexal Mass 3. Cervical Motion tenderness PLUS ↑ WBC OR ↑ ESR OR
Purulent Cervical Discharge?
→ Pregnancy Test (to rule out ectopic)
→ START Abx (do not delay for culture)
→ ↑fever, pregnancy, fail PO Abx, non compliance?
→ Yes? → Inpatient = Doxycycline PLUS Cefoxitin OR Cefotetan for 14ds
→ No? → Outpatient = IV Doxycycline PLUS IV Ceftriaxone

Infertility = no pregnancy upon 1yr of unprotected sex

- conception %
- 75% by 1st 6mo
- 85% by 1st yr
- 90% by 1st 2yrs
- ET 30% ♀, 30% ♂, 25% unexplained
- PID (mc in menstruating <30yo ♀) → 70% closed tubes
- PCOS (mc in DUB <30yo ♀)
- Endometriosis (mc in mensutrating >30yo ♀)

Hyperprolactinemia
→ Nipple Discharge?
→ Unilateral?
→ <30yo? → U/S
→ >30yo? → Mammogram
→ malignancy?
→ Bx
→ Bilateral? (Galactorrhea)
→ Prolactin
→ High?
→ hCG, TSH, Cr
→ ↑hCG? → Pregnancy
→ ↑TSH? → HypoT
→ ↑Cr? → CKD
→ ALL normal?
 → MRI Head
→ Prolactinoma?
→ Asymptomatic Microprolactinoma (<10mm)? → No Tx
→ Symptomatic Micro OR Macro (>10mm)?
→ Tx
→ <3cm
→ Cabergoline > Bromocriptine
→ monitor q3mo (if N q1yr)
→ ↑ size ? → Resection
→ >3cm → Resection

Vaginitis (→ vaginal swab) vs STD (→ cervical swab)

DDx of Vaginitis

Bacterial Vaginosis Trichomoniasis Candida Vaginitis

Dx
Gareneralla Vagnilis Trichomonas Vaginalis Candida Albicans

Discharge

Ex whute, fishy smell yellow-green, frothy, bad cottage cheese,

smell itchiness

no inflammation vaginal inflammation

pH >4.5 pH >4.5 pH 3.8-4.5

Labs
Clue Cells, +ve Whiff’s motile trichomonads pseudohyphae

Tx metronidazole OR Clindamycin Metronidazole (both) Fluconazole

Viral

HPV 6, 11 → mc Condyloma Acuminata 5-Fluorouracil

HSV-2 Genital Herpes Oral Acyclovir

HBV HBV Oral Entecavir

Bacterial

Chlamydia Trachomatis D-K Urethritis → PID

Chlamydia Trachomatis L1-3 Lymphogranuloma venereum Doxycycline OR Azithromycin

Klebsiella Granulomatis Granuloma Inguinale

Haemophilus ducreyi Chancroid

IM Ceftriaxone + Oral Azithro
Neisseria gonorrhoeae Urethritis → PID

→Penicillin G IM (Benzathine)
Treponema pallidum Syphilis →Allregry ?
→Doxycycline

Parasitic
Trichomonas vaginalis cervicitis Oral Metronidazole for both

Entamoeba Histolytica Amebiasis → Heterosexuals

Giardia Lamblia Giardiasis → Gays

Genital Lesions

Painful

LymphAdenopathy → Painful Rapid →direct fluorescent Ab

painful red Bumps (ulcer) Accurate → PCR, Culture

HSV-1, 2
inCubation 2-7 ds Confirmatory → Tzanck

vaginal Discharge Herpes TANK→+ve TzANcK

LymphAdenopathy → Painful G stain → G-ve

H. Ducreyi necrotic gray Base lesion

Confirmatory → Culture
do cry = ducreyi , cry (painful)

After Sex, Burn the Foul, under a Green Tree

tricHomonas - Burning sensation smear→motile trophozoites
vaginalis - Smell is Foul w/ multiple flagella
- Green Discharge
- Trichomonas (strawberry cervix)

Painless

HPV 6, 11 condylomata acuminata→exophytic/cauliflower Clinical

Screen → VDRL (False +ve)

- Virus (EBV, HBV)
- Drugs
Treponema 1ry → Chancre (painless Sore) - RF
Pallidum 2ry → rash, flu, meningitis - Lupus
3ry → Neuri, cardio - Pregnancy

Confirmatory → TPHA

Darkfiled m/c → Spirochetes

Tertiary Syphilis

Cardio Syphilis, Neuro Syphilis, Gumma Ulcer

Chlamydia L1, L2 → Lymphogranuloma (groove sign) Dx → PCR

Klebsiella Granuloma inguinale Confirm→donovan body

Ulcer LN Pus

inguinale painless - -
 Syphilis painless painless -

venereum painless painful +

herpes painful painful -

chancroid painful painful +

Bartholin Gland Abscess

→ young ♀ w/ unilateral pain w/ sitting, walking relief w/ discharge?
→ I/D
→ Recur?
→ Marsupialization

AUB = menstruation >5ds and >1pad every 2hr w/ irregular frequency

- ET → PALM-COEIN
- PALM ‘structural’
- Polyp
- Adenomyosis
- Leiomyoma
- Malignancy/hyperplasia
- COEIN ‘non structural’
- Coagulopathy
- Ovulatory dysfunction
- Endometrial
- Iatrogenic
- Not yet classified
- DDx
- Birth → Estrogen Withdrawal
- 0-10y → FB, inFection, Sarcoma
- 13-45y → Anovulation, Pregnancy, Uterine ‘infection, fibroid’
- 50y → Pelvic Ca, Polyp, atroPhic vaginitis

- Dx?
→ Premenopausal OR Postmenopausal?
→ Premenopausal?
→ pregnancy test
→ CBC, Coags ‘vWD =young w/ heavy bleed’ , TSH
- Also
- Pelvic U/S → post miscarriage heavy bleed (AV malformation)
→ -ve?
→ Endometrial Sampling
→ Postmenopausal?
→ TVUS
→ thickening?
→ Endometrial Sampling
- Tx?
→ DUB?
→ Absent Cause (Infection, Endocrine, Estrogen-tumors)?
→ Desire Pregnancy?
→ No → OCP (severe → Progesterone)
→ Yes → NSAID
Dysmenorrhea
- 1y → Painful Menses w/o disease → NSAID → fail? → OCP
- 2y → Painful Menses w/ disease → Treat Disease
Menopause
- ET
- Average? 51yo by follicular atresia
- Premature? <40yo by ovarian failure ‘autoimmune,Turner, Infection’
- PE HAVOCS:
- Hot flashes (vasomotor Sx → main HRT indication) /Heat intolerance
- Atrophy of Vagina
- Osteoporosis
- Coronary artery disease
- Sleep impairment
- Dx → Clinical (amenorrhea of 1yr)
- Tx HRT for <5yr ( prevent → HAVOCS, OP, CAD)
- HRT indications (not for all menopausal only for)
- Persistent severe symptoms (affect quality)
- Premature menopause
- Post-oophorectomy (surgical menopause)
- Uterus? → E+P
- No Uterus? → E (and for vaginal dryness → E cream )

PCOS (Stein-Leventhal Syndrome) ↑↑ing risk of Endometrial Cancer

- Dx (Rotterdam) >2 of the following PLUS excluded HypoT, HyperP, CAH, Cushing’s
- Androgen ↑↑ : Labs or Sx
- 80% amenorrhea
- 74% Infertility
- 69% Hirsutism
- 49% obesity
- 35% Impaired Glucose
- 10% DM
- Acne
- Alopecia
- Anovulation (no high FSH) OR OLigo
- US polycystic ovaries (>10 mL ovary volume, >12 follicles ‘Pearl Sign’)
- Tx
- Cut weight (loss)
- Combined OCP (for ↑ androgen and menstrual dysfunction) → C/I? → Spironolactone
- Clomiphene (for ovulation induction)
- Coexist DM? → Metformin (esp. if BMI >35)

Hirsutism?
→ Mild?
→ Period?
→ Regular = idiopathic
→ Irregular = PCOS 70% → OGTT ‘DM’
→ Severe?
→ Total TST
→ >150? → TVUS
→ Ovarian Tumor
→ No Ovarian Tumor?
→ Adrenal CT
→ <150? → Rapid Progression? → TVUS
Contraception
- Emergency (most to least effective)
- Copper IUD 0-120hr
- Ulipristal Pill 0-120hr
- Levonorgestrel Pill 0-72
- OCP 0-72
- Progestins → (-) LH surge, ↓Tube Motility, Endometrial Decidualization, Thick
Cervix mucus
- Combined → Suppress Ovulation
- Contraindications
- CNS → migraine w/ aura, Hx stroke
- Endo → Breast Ca
- PULL → Hx VTE
- CVS → Hx IDH, HTN (>160/100), >35yo smoking +15 cigars
- GIT → Cirrhosis, Liver Ca, Hyperlipidemia
- GU → <3wk postpartum, suspected pregnancy, unDx bleeding

Endometriosis = endometrial tissue outside uterine cavity (mc → Ovary)

→ <30yo NP w/ Dyspareunia + Dysmenorrhea + Dyschezia?
→ C/I Meds, Concern Ca, Definitive Dx, Hx infertility?
→ No → NSAID + OCP (menstrual suppression is main Tx)
→ Yes → Laparoscopy (Gold Standard Dx)
→ Dx?
→ Initial → laparoscopic excision w/ ablation of endometrial implants
→ Gold → Hysterectomy w/ bilateral salpingo-oophorectomy
→ Endometriosis ↑ing Ovarian Cancer

Adenomyosis = endometrial glands w/i uterine muscle

→ >40yo MG w/ new dysmenorrhea + heavy menstrual bleed + ‘boggy’ uterus, + Hx Endometriosis, Fibroids,
Parity?
→ Pelvic U/S
→ OCP, levonorgestrel, IUD
→ Fail?
→ Hysterectomy Tx and Dx

POP
→ Abdominal pressure, Birth per V/D, CTD, DM, Excision (Hysterectomy)?
→ Vaginal Fullness, Back Pain, Incontinence, Prolapse, + in postmenopasue?
→ Determine Degree
- 0 no prolapse
- 1 1cm above hymen
- 2 <1cm below hymen
- 3 >1cm below hymen
- 4 vagina is completely everted OR Procida
→ POP?
→ Conservative (Pessary, Kegel’s)
→ Fails OR Symptomatic OR refused?
→ Surgery

Incontinence
→ Urine leakage?
→ U/A (to rule out UTI)
→ PVR (to rule out Overflow)
→ Type?
→ Leak after Valsalva? → Stress (Cystocele, obesity, pregnancy, multiparity, pelvic surgery,
menopause)
→ Kegel’s
→ Fail
→ Sling Surgery (TOT, TVT)
→ Poor Candidate?
→ Pessary
→ Leak after sudden Urge? → Urge (detrusor, ↑↑ by pessary)
→ pelvic exercises + bladder training
→ no response?
→ oxybutynin (Antimuscarinic)
→ Leak after w/o trigger? → Total
→ Leak w/ ful bladr no urge? → Overflow
→ bethanechol
→ Acute? → Catheter
→ Leak painless from vagina?→ VVF (OBSE surgery, TB, FB, IBD, radiation)
- VVF
- ET
- Pelvic Surgery (ischemia)
- Pelvic irradiation
- Prolonged labor or trauma
- PE → w/i a month of surgery
- Dx → Dye Test, Cystoyretorscopy (for small fistula)
- Tx → post OP catheter prevent small fistula

Tumors

Pelvic Mass
- Ovary
- Benign
- Functional Cyst
- Hemorrhagic Cyst
- Corpus Luteal (pregnant+mass)
- Dermoid Cyst (mc, Tx by Ovarian Cystectomy)
- Endometrioma (→ Tx by Ovarian Cystectomy)
- Cancer
- >40yo → Epithelial Cell
- <20yo → Germ Cell
- Tube → Ectopic, Hydrosplanix, Cyst, Cancer
- Uterus
- Symmetric? → Pregnancy, Adenomyosis, Cancer
- Asymmetrical → Leiomyoma, Leiomyosarcoma
- Non gyne → Adhesions, Appendicular Mass, Abdominal Pregnancy

Adnexal Mass
→ Adnexal Mass?
→ TVUS
→ Age?
→ Premenopause
→ Pregnancy Test (rule out ectopic)
→ TVUS
 → Solid, Septations, Loculations, >10 cm?
→ Yes → Refer
→ No → serial TVUS
→ persistent?
→ Refer
→ Postmenopuase?
→ CA-125
→ ↑? → CT, MRI for mets + exploratory surgery (refer)
→ N?
→ Solid, Septations, Loculations, Large?
→ Yes → CT, MRI for mets + exploratory surgery
→ No → Serial TVUS, CA-125

Benign

Leiomyoma (Fibroid, <1% Ca risk ): mc ♀ tumor, mc ET hysterectomy

- Submucosal/Intramural → heavy bleed
- Submucosal/Intracavitary → recurrent miscarriages
- Subserosal/Pedunculated → Stress Incontinence

- Dx → U/S, CBC (anemia)

- Tx
- Asymptomatic/Perimenopausal? → Follow up U/S q1yr
- Symptomatic (Anemia)? → Surgery
→ OCP
→ Surgery (Fertile → Myomectomy, Fertile → Hysterectomy)

Vulvar Lesions
- Hyperplastic Dystrophy → postemenopuase, itchy → corticosteroids
- Lichen Sclerosis (precancerous)
→ postemnopusal w/ white patches + thin minora + "paper” vulva?
→ Punch Bx
→ high potency topical steroids (clobetasol)

Endometrial (Hyperplasia) ET is unopposed estrogen (PCOS, granulosa, HRT)

→ AUB?
→ Endometrial Bx
→ Hyperplasia w/o Atypia? (Simple/Cystic 1% Ca risk, Complex/Adeno 3% Ca risk)
→ Progestin Tx
→ Repeat Bx 3mo later
→ Hyperplasia w/ Atypia (Simple/Cystic 8% Ca risk, Complex/Adeno 29%) Ca risk
→ No plan for pregnancy? → Hysterectomy
→ Planning pregnancy? → Progestin
→ Repeat Bx 3mo later

Cancer

Ovarian Postmenopausal > Premenopausal

→ Hx Breast Cancer <50yo OR Ovarian Cancer?
→ Screen BRCA (→ +ve PLUS completed bearing? → BSO ‘best ↓ing risk)
→ SOB, Constipation, Pelvic Pain, Adnexal Mass? (Epithelial)
→ TVUS +CA-125 (>35 units)
→ Exploratory laparotomy w/ cancer resection and paraaortic LN dissected (best Dx)
 → Chemo (after surgery)
→ Precocious Puberty OR Postmenopuasal Bleeding w/ Adnexal Mass? (Granulosa)
→ TVUS (to rule out concomitant Endometrial Ca)
→ Thick?
→ Endometrial cancer
→ Surgical Excision

Endometrial = mc GYNE cancer (average 60yo) Thick Endometrial + mass ↑ing Size
- RF COLD NUT
- Cancer (breast, ovary, colon)
- Obesity
- Late menopause
- DM
- NP
- Unopposed E2 (PCOS, Anovulation, HRT)
- Tamoxifen chronic use
- Mx?
→ AUB
→ Age?
→ Postmenopause (any bleeding “even spotting”)?
→ TVUS (b/c mc is atrophy)
→ >5mm?
→ US-guided Endometrial Bx
→ Premenopause (metrorrhagia, menometrorrhagia, amenorrhea >6mo, unopposed estrogen
‘DM, Obese’
→ Endometrial Bx
→ Endometrial Cancer?
→ Postmenopausa, Premenopausal not desiring pregnancy?
→ Yes → Total Hysterectomy w/ BSO + para-aortic LN (external iliac)
→ No → Progestin

Cervical
- ET → HPV “16” → 95% SCC (PAP reduce death by 10yr)
-
- Vaccine?
- ALL ♀ 9-26yo even w/ warts,+PAP,+DNA (EXCEPT pregnant)
- ALL ♂ 9-21yo
- HIV’s 9-26yo
- Screening
- HIV, SLE? → onset of intercourse then q6mo then q1yr
- <21yo? → No Screening
- 21-29yo? → Cytology (PAP) q3yr
- 30-65yo? → Cytology (PAP) q3yr OR PAP PLUS DNA q5yr
- >65yo? →No Screening if -ve prior test
- Mx? (Speculum found fungating mass? → Colposcopy)
→ PAP?
→ ASC-US?
→ Age?
→ <25yo?
→ Repeat Pap by 12mo
→ >ASC-US? → Colposcopy
→ <ASC-US OR LSIL OR -ve?
→ Repeat Pap by 12mo
 → >ASC?
→ Yes → Colposcopy
→ No → Routine Screening
→ >25yo?
→ HPV DNA
→ +ve → Colposcopy
→ -ve → Repeat PAP PLUS DNA by 3yrs
→ ASC-H? → Colposcopy
→ LSIL?
→ Age?
→ <30yo?
→ Colposcopy
→ >30yo?
→ HPV DNA
→ +ve → Colposcopy
→ -ve → Repeat PAP PLUS DNA by 3yrs
→ HGSIL?
→ Age?
→ <25yo? (+ screen chlamydia+gonorrhea)
→ Colposcopy
→ CIN 2, 3?
→ Yes → Manage
→ No → Repeat Colposcopy PLUS PAP q6mo for 2yrs
→ 2 -ve in row?
→ Yes → routine screening
→ No → Bx
→ >25yo?
→ Pregnant?
→ Yes → Colposcopy
→ -ve → repeat PAP + Colposcopy 6wks after delivery
→ +ve → Biopsy of Area
→ CIN 2, 3?
→ Repeat PAP and Bx after 12 wks
→ No → Colposcopy then Excision (can skip colposcopy)

- Tx?
→ CIN?
→ CIN 1?
→ preceded by ASC-US, ISIL, DNA +ve?
→ Age?
→<30? → PAP by 12mo
→ <ASC-US? → PAP by 12 mo
→ >ASC-US? → Colposcopy
→>30? → PAP PLUS DNA by 12mo
→ >ASC OR +DNA? → Colposcopy
→ both are -ve? → routine screening
→ preceded by ASC-H, HSIL?
→ Age?
→<30? → PAP by 12mo
→ <ASC-US? → PAP by 12 mo
→ >ASC-US? → Colposcopy
→>30? → PAP PLUS DNA by 12mo
→ >ACS OR +DNA? → Colposcopy
→ HSIL? → Excision
 OR
→ Excisional Bx

→ CIN 2, 3? → Ablations (Cryo, Laser), LEEP

Vulvar (i → by HPV 16,18,31 / ii → by atrophy)

→ postmenopausal w/ vulva pain+pruritus+ulcer that bleeds on touch?
→ Punch Bx (90% SCC)
→ Stage?
→ 1 → Superficial Vulvectomy
→ 2 → Radical Vulvectomy
→ 3 → Chemo

Leiomyosarcoma = Normal Endometrium + mass ↑ing Size (<4 in postmenopausal)

Ovarian Torsion
→ Sudden-onset unilateral pain w/ N/V?
→ pregnancy test
→ -ve?
→ TVUS
→ inconclusive?
→ MRI contrast
→ Torsion?
→ Emergency Exploratory Laparoscopy (a must for all torsion)

PMS vs. PMD

→ mood swings, irritability, headache, breast tenderness Start 1-2 wk before menses and stop upon menses?
→ repeatedly and predictably = PMS
→ SSRI (fluoxetine) and Stop Caffeine