Gynecology

Notes by MedSN
 GYNECOLOGY

MENSTRUAL CYCLE ...................................................................................................................................... 1

PERIMENOPAUSE ........................................................................................................................................ 1
MENOPAUSE .............................................................................................................................................. 2
ATROPHIC VAGINITIS ................................................................................................................................... 4
VULVAR LICHEN SCLEROSUS .......................................................................................................................... 6
VITILIGO .................................................................................................................................................... 8
VULVAR CANCER ......................................................................................................................................... 8
PERIANAL STREPTOCOCCAL DERMATITIS .......................................................................................................... 9
EMANCIPATED MINORS................................................................................................................................ 9
SEXUALLY TRANSMITTED INFECTIONS ............................................................................................................ 10
GONORRHEA & CHLAMYDIA........................................................................................................................ 12
SYPHILIS .................................................................................................................................................. 13
SEXUAL ASSAULT ...................................................................................................................................... 14
POSTEXPOSURE PROPHYLAXIS IN SEXUAL ASSAULT .......................................................................................... 14
UTI ........................................................................................................................................................ 15
RECURRENT UTIS ...................................................................................................................................... 15
ABNORMAL UTERINE BLEEDING ................................................................................................................... 16
INDICATIONS FOR SOME INVESTIGATIONS....................................................................................................... 17
CLOMIPHENE CITRATE ................................................................................................................................ 18
HCG ....................................................................................................................................................... 19
ATYPICAL GLANDULAR CELLS ON PAP TESTING................................................................................................ 19
OVARIAN MASS IN POSTMENOPAUSAL PATIENT ............................................................................................. 19
EPITHELIAL OVARIAN CARCINOMA................................................................................................................ 20
OVARIAN TUMORS AND THEIR MARKERS ....................................................................................................... 21
AROMATASE DEFICIENCY ............................................................................................................................ 22
SERTOLI-LEYDIG CELL TUMOR ...................................................................................................................... 23
CAUSES OF HIRSUTISM ............................................................................................................................... 24
MANAGEMENT OF SUSPECTED ECTOPIC PREGNANCY ....................................................................................... 26
HPV ....................................................................................................................................................... 27
CONDYLOMA ACCUMINATA ........................................................................................................................ 28
PAP TEST ................................................................................................................................................. 29
PAP SMEAR REQUIRING ENDOMETRIAL SAMPLING .......................................................................................... 29
HELLP SYNDROME .................................................................................................................................... 30
LACTATIONAL AMENORRHEA ....................................................................................................................... 30
HPO AXIS ............................................................................................................................................... 31
NORMAL PUBERTAL GROWTH IN GIRLS ......................................................................................................... 32
TANNER STAGES ....................................................................................................................................... 33
PRIMARY DYSMENORRHEA ......................................................................................................................... 34
SECONDARY DYSMENORRHEA...................................................................................................................... 36
PELVIC ORGAN PROLAPSE ........................................................................................................................... 36
UTERINE PROCIDENTIA ............................................................................................................................... 36

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PREMENSTRUAL SYNDROME (PMS) ............................................................................................................. 39

GRANULOSA CELL TUMOR .......................................................................................................................... 40
CHORIOCARCINOMA .................................................................................................................................. 41
RECTOVAGINAL FISTULA ............................................................................................................................. 42
VESICOVAGINAL FISTULA ............................................................................................................................ 42
CERVICAL CANCER ..................................................................................................................................... 43
MANAGEMENT OF CIN3............................................................................................................................. 45
CERVICAL CANCER IN HIV-POSITIVE PATIENTS ................................................................................................ 46
PRIMARY OVARIAN INSUFFICIENCY (POI) ...................................................................................................... 47
HYPOTHALAMIC AMENORRHEA.................................................................................................................... 48
PRIMARY OVARIAN INSUFFICIENCY IN FRAGILE X SYNDROME............................................................................. 49
ENDOMETRIOSIS ....................................................................................................................................... 50
PCOS ..................................................................................................................................................... 53
TUBO-OVARIAN ABSCESS ............................................................................................................................ 54
PID TREATMENT ....................................................................................................................................... 54
OCPS PROFILE .......................................................................................................................................... 55
MIGRAINE THERAPY .................................................................................................................................. 56
ABNORMAL UTERINE BLEEDING ON OCPS ..................................................................................................... 56
EMERGENCY CONTRACEPTION ..................................................................................................................... 57
VAGINAL CANCER...................................................................................................................................... 58
DESQUAMATIVE INFLAMMATORY VAGINITIS .................................................................................................. 59
TAMOXIFEN ............................................................................................................................................. 59
SECONDARY AMENORRHEA ......................................................................................................................... 60
PELVIC INFLAMMATORY DISEASE.................................................................................................................. 61
INTRAUTERINE ADHESIONS.......................................................................................................................... 62
URETHRAL PROLAPSE ................................................................................................................................. 63
ACUTE CERVICITIS ..................................................................................................................................... 63
LABIAL ADHESIONS .................................................................................................................................... 64
VAGINITIS DIFFERENTIALS ........................................................................................................................... 65
VULVOVAGINAL CANDIDIASIS ...................................................................................................................... 66
BACTERIAL VAGINOSIS ............................................................................................................................... 67
AMSEL CRITERIA ....................................................................................................................................... 68
OBESITY AND ANOVULATION....................................................................................................................... 68
HIDRADENITIS SUPPURATIVA....................................................................................................................... 69
5-Α-REDUCTASE DEFICIENCY........................................................................................................................ 70
ANDROGEN INSENSITIVITY SYNDROME .......................................................................................................... 71
KLINEFELTER SYNDROME ............................................................................................................................ 72
INDICATIONS OF ENDOMETRIAL BIOPSY ......................................................................................................... 73
PAP TESTS RESULTS REQUIRING ENDOMETRIAL BIOPSY .................................................................................... 73
BARTHOLIN DUCT CYST .............................................................................................................................. 74
STRESS URINARY INCONTINENCE .................................................................................................................. 76

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MIXED URINARY INCONTINENCE MANAGEMENT ............................................................................................. 77

URINARY INCONTINENCE SUMMARY ............................................................................................................. 77
INTERSTITIAL CYSTITIS ................................................................................................................................ 78
CANDIDA VULVOVAGINITIS ......................................................................................................................... 78
INTRADUCTAL PAPILLOMA .......................................................................................................................... 80
BREAST PATHOLOGIES................................................................................................................................ 81
MAMMARY PAGET DISEASE ........................................................................................................................ 81
PHYSIOLOGIC GALACTORRHEA ..................................................................................................................... 82
INFLAMMATORY BREAST CARCINOMA........................................................................................................... 83
LACTATIONAL MASTITIS.............................................................................................................................. 84
SIMPLE BREAST CYST ................................................................................................................................. 86
MASTALGIA ............................................................................................................................................. 87
APPROACH TO POSTMENOPAUSAL BLEEDING ................................................................................................. 88
TOXIC SHOCK SYNDROME ........................................................................................................................... 89
DISSEMINATED GONOCOCCAL INFECTION....................................................................................................... 89
ACUTE PELVIC/ABDOMINAL PAIN IN WOMEN DIFFERENTIALS ........................................................................... 90
MANAGEMENT FOR ACUTE ABDOMINAL PAIN ................................................................................................ 90
INVESTIGATIONS FOR PALPABLE ADNEXAL MASS ............................................................................................. 90
PUDENDAL NEURALGIA .............................................................................................................................. 90
MULLERIAN AGENESIS................................................................................................................................ 91
VULVAR SQUAMOUS CELL CARCINOMA ......................................................................................................... 92
OVARIAN RESERVE .................................................................................................................................... 93
CERVICAL INSUFFICIENCY ............................................................................................................................ 94
ADENOMYOSIS ......................................................................................................................................... 95
EROSIVE LICHEN PLANUS ............................................................................................................................ 97
SICCA SYNDROME ..................................................................................................................................... 98
CONTRACEPTION ....................................................................................................................................... 99
CONTRAINDICATIONS OF IUD PLACEMENT ..................................................................................................... 99
PRIMARY INFERTILITY............................................................................................................................... 100
BREAST CANCER RISK FACTORS .................................................................................................................. 100
BRCA CARRIER RISK ................................................................................................................................ 100
ENDOMETRIAL CANCER ............................................................................................................................ 101
CANDIDA INTERTRIGO .............................................................................................................................. 102
GENITO-PELVIC PAIN/PENETRATION DISORDER ............................................................................................ 103
OVARIAN TORSION.................................................................................................................................. 103
MATURE CYSTIC TERATOMA...................................................................................................................... 104
OVARIAN HYPERSTIMULATION SYNDROME .................................................................................................. 105
HSV ..................................................................................................................................................... 106
URETHRAL DIVERTICULUM ........................................................................................................................ 107
GESTATIONAL AGE ASSESSMENT ................................................................................................................ 108
ANOGENITAL WARTS IN CHILDREN ............................................................................................................. 109

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PHYSIOLOGIC LEUKORRHEA ....................................................................................................................... 110

OVARIAN HYPERTHECOSIS ........................................................................................................................ 110
IMPERFORATE HYMEN.............................................................................................................................. 111
RUPTURED OVARIAN CYST ........................................................................................................................ 111
INTIMATE PARTNER VIOLENCE SCREENING ................................................................................................... 111
OSTEOPOROSIS RISK FACTORS ................................................................................................................... 112
IDIOPATHIC INTRACRANIAL HYPERTENSION .................................................................................................. 113

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 GYNECOLOGY

MENSTRUAL CYCLE

PERIMENOPAUSE
1. It is the menopausal transition which can occur years before the final menstrual period
2. Ovulation still occurs during this time, however conception rates are low
3. Symptoms
a. Irregular menstrual periods
b. Insomnia
c. Fatigue
d. Weight gain

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MENOPAUSE

1. Defined as absent menses for 12 months

a. Menopausal transition and initial symptoms may begin a few years before the final
menstrual period and commonly occurs at age >45
2. Loss of ovarian function → hypoestrogenemia → sequelae:
a. Vasomotor symptoms
i. Hot flashes
ii. Sleep disturbances
b. Vulvovaginal atrophy
c. Osteoporosis
3. Rule out thyroid etiology before diagnosing the case as menopause
4. Menopause diagnosis is confirmed clinically by ≥12 months of amenorrhea. However, in patients
without previously normal menstrual cycles (eg, prior hysterectomy, endometrial ablation), the
diagnosis of menopause cannot be made clinically because vasomotor symptoms and
vulvovaginal atrophy can be due to other etiologies (eg, thyroid disorder, malignancy).
Therefore, these patients require an elevated serum FSH for diagnosis of menopause
5. Treatment of vasomotor symptoms
a. Mild: lifestyle modification
i. Wearing layers
ii. Weight loss
b. Severe: HRT
i. Patients with contraindications to HRT are treated with SSRIs
6. Hormone Replacement Therapy
a. Indications
i. Only indication of HRT is vasomotor symptoms in women age <60 who have
undergone menopause within past 10 years

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b. Contraindications
i. History of coronary heart disease
ii. Thromboembolism
iii. Transient ischemic attack/stroke
iv. Breast cancer
v. Endometrial cancer

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 GYNECOLOGY

ATROPHIC VAGINITIS
1. Also called genitourinary syndrome of menopause
2. Caused by ↓ estrogen due to menopause
a. Normally estrogen maintains moisture, blood flow and collagen content of vulvovaginal
tissues
3. Symptoms are due to effects of estrogen deficiency:
a. Thinning of vulvar skin → itching
b. Narrowing of vaginal introitus → dyspareunia
c. Loss of natural lubrication → dryness
4. Other features of atrophic vaginitis are:
a. ↓ vulvar elas city
b. Labial retraction
c. Smooth, non-rugated vaginal epithelium with areas of patchy erythema
5. Menopause can lead to following urinary problems:
a. Urgency incontinence
i. ↓ collagen, elas city and blood flow in bladder trigone and urethra (which are
estrogen-sensitive tissues) → urogenital atrophy → urgency incon nence
b. Recurrent UTIs
i. ↓ glycogen content → loss of vaginal lactobacilli and ↑ vaginal pH → ↑ risk of
recurrent UTIs
ii. Note: postcoital antibiotics can be given in patients with recurrent UTIs (≥2
within 6 months)
c. Dysuria
i. ↓ glycogen at vulva → thin, easily denuded vulvovaginal epithelium → dysuria
when contact with urine occurs
6. Physical examination
a. Pale, easily-denuded, retracted, atrophic vulvovaginal epithelium → clitoral shrinkage
7. Treatment
a. 1st line: lubricants or moisturizers
b. Persistent or severe symptoms: vaginal estrogen
8. Differentials
a. Lichen planus
i. Chronic inflammatory skin dystrophy
ii. Erythematous vulvar lesions with a purple hue
iii. White reticular lines (ie, Wickham striae) present
b. Lichen sclerosus
i. Does not affect vaginal moisture
ii. Thin, wrinkled skin
iii. Thickened white plaques → obliterate labia majora and minora
iv. Involve perianal region
c. Vulvodynia

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i. Dyspareunia due to a sharp, burning pain on the vulvar vestibule often triggered
by touch (eg, positive Q-tip test)
ii. Vestibular erythema
iii. No vaginal tissue narrowing or clitoral shrinkage
9. Differentials of urinary incontinence in atrophic vaginitis

Differentials Differentiating Points

Chronic Bladder Pain Syndrome  Bladder pain that worsens with filling and
is relieved with emptying
 No associated urinary incontinence
Urethral hypermobility  Cause of stress incontinence

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 GYNECOLOGY

VULVAR LICHEN SCLEROSUS

1. It is a chronic, benign inflammatory disease common in prepubertal, perimenopausal or

postmenopausal women
a. Associated with autoimmune diseases
2. Clinical features
a. Vulvar involvement
i. Thin wrinkled skin, causing:
1. Hypopigmented areas
2. Intense pruritis
ii. Loss of labia minora and clitoral hood, leading to:
1. Narrowing of vaginal introitus
2. Dyspareunia
3. Dysuria
b. Perianal involvement
i. Painful defecation
ii. Anal fissures

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3. Vulvar punch biopsy is recommended to confirm the diagnosis and rule out vulvar cancer
(which can occur in patients with persistent and prolonged lichen sclerosus)
4. Treatment
a. Superpotent topical corticosteroids (eg, clobetasol)
5. Differentials
a. Lichen simplex chronicus
i. Due to excessive scratching
ii. Leads to thick leathery vulvar skin
b. Streptococcal dermatitis
i. It has perianal pruritis and anal fissures. However, patients have bright,
erythematous perianal rash with sharply demarcated borders, instead of thin
white skin

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VITILIGO

VULVAR CANCER

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PERIANAL STREPTOCOCCAL DERMATITIS

EMANCIPATED MINORS

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SEXUALLY TRANSMITTED INFECTIONS

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GONORRHEA & CHLAMYDIA

1. Most common STI in women age <25
2. Most commonly they are asymptomatic
3. All sexually active females <25 and women age ≥25 with risk factors (eg, multiple sexual
partners, inconsistent condom use) are advised C trachomatis and N gonorrhea screening
annually in addition to Pap testing

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 GYNECOLOGY

SYPHILIS
1. Syphilitic chancres form at the site of direct inoculation of Treponema pallidum
a. Only single lesion forms at a time
b. They are extremely infectious
c. Most chancres resolve spontaneously within 6-8 weeks if untreated but systemic spread
results in continued infection
2. After exposure (3-60 days), patient develops a single papule that turns into a shallow, painless,
nonexudative ulcer with indurated edges
3. Patients with strong evidence of primary syphilis, with negative serology results, should be
treated empirically with IM benzathine penicillin G
a. In these patients repeat nontreponemal serology should be done in 2-4 weeks to
establish baseline
b. 4-fold decrease at 6-12 months would confirm adequate treatment

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 GYNECOLOGY

SEXUAL ASSAULT

POSTEXPOSURE PROPHYLAXIS IN SEXUAL ASSAULT

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UTI

RECURRENT UTIS

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ABNORMAL UTERINE BLEEDING

1. Defined as menstrual bleeding that is:
a. Prolonged (>5 days)
b. Heavy (>1 pad every 2 hours)
c. Irregular

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INDICATIONS FOR SOME INVESTIGATIONS

1. Breast MRI Undiagnosed AUB as a
a. Patients with known cancer to evaluate for recurrence Contraindication:
b. High risk patients (eg, BRCA carrier, first degree relative of known  Undiagnosed AUB is a
BRCA carrier) contraindication to
2. Mammography endometrial ablation
a. Women age >30 because it can prevent
3. Core biopsy evaluation of the
a. Complex cyst (eg, echogenic debris, thick septa, solid components) endometrium in patients
b. If simple cyst mass recurs with possible
c. If mass does not disappear after aspiration endometrial
4. Endometrial biopsy hyperplasia/cancer
a. Postmenopausal bleeding  Undiagnosed AUB is a
b. Abnormal uterine bleeding in patients over age 45 contraindication to
c. Abnormal uterine bleeding in patients age <45: hysterosalpingogram
i. Who have failed medical management (ie, no change in because the procedure
abnormal uterine bleeding even after taking OCPs) could spread the
ii. >6 months of abnormal uterine bleeding cancerous endometrial
iii. Obesity cells into the abdomen
iv. Tamoxifen therapy
d. Thickened endometrial stripe with an ovarian mass (>4 mm on
ultrasound)
 Patients with abnormal
e. Endometrial cells on Pap test in a postmenopausal woman or a
genital tract
premenopausal woman with abnormal uterine bleeding or risk for
development should be
endometrial hyperplasia
evaluated for associated
5. Progesterone Withdrawal Test
renal abnormalities with
a. To evaluate secondary amenorrhea (no menses >6 months in
renal ultrasound
patients with previously irregular menses) to determine if the
amenorrhea is from the low estrogen levels (ie, no bleeding after
progesterone)

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CLOMIPHENE CITRATE
1. Used to induce ovulation
2. It is an estrogen modulator that primarily blocks estrogen receptors at the level of
hypothalamus → inhibits nega ve feedback mechanism → restora on of pulsa le GnRH
secretion by hypothalamus

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HCG
1. Produced by syncytiotrophoblast in early pregnancy for preserving corpus luteum in order to
maintain progesterone secretion until placenta starts making progesterone on its own
2. Production of hCG begins 8 days after fertilization and levels double every 48 hours until they
peak at 6-8 weeks gestation
3. Other functions
a. Male sexual differentiation
b. Maternal thyroid gland stimulation

ATYPICAL GLANDULAR CELLS ON PAP TESTING

1. If these cells are seen on pap testing, one should move forward with investigation of ectocervix,
endocervix and endometrium
2. Tests for these investigations are:
a. Ectocervix: colposcopy
b. Endocervix: endocervical curettage
c. Endometrium: endometrial biopsy

OVARIAN MASS IN POSTMENOPAUSAL PATIENT

1. Risk factors for ovarian cancer
a. Age
b. Fertility drugs
c. Nulligravidity
d. BRCA mutation
2. CA-125 is a biomarker for epithelial ovarian cancer
a. It may be increased in other gynecological conditions (eg, leiomyomata, endometriosis)
but these conditions occur in PREMENOPAUSAL women
b. Hence, specificity of CA-125 ↑ in postmenopausal women
c. Its levels are measured in conjunction with pelvic ultrasonography findings to
categorize an ovarian mass as likely malignant or benign
3. Management
a. Pelvic ultrasound and CA-125 levels
b. Periodic ultrasound
i. If mass has no malignant features on ultrasound (eg, small size, simple cyst) and
CA-125 is normal
c. Further imaging (MRI/CT)
i. If mass has suspicious features on ultrasound (eg, large mass, solid components,
septations) and/or CA-125 is ↑
d. Note: needle aspiration is contraindicated in postmenopausal women with adnexal mass
due to risk of spreading potentially malignant cells should the mass prove cancerous

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EPITHELIAL OVARIAN CARCINOMA

1. Epithelial ovarian carcinoma refers to a malignancy involving:
a. Ovary
b. Fallopian tube
c. Peritoneum
2. Diagnosis is by exploratory laparotomy
a. Image-guided biopsy is contraindicated as the mass may rupture and cause seeding of
cancerous cells in the abdominal cavity

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 GYNECOLOGY

OVARIAN TUMORS AND THEIR MARKERS

1. Dysgerminoma
a. ß-hCG
b. LDH
2. Granulosa cell tumor
a. Estradiol
b. Inhibin
3. Yolk sac tumors
a. AFP
4. Sertoli-Leydig Tumors
a. Androgens (testosterone, androstenedione)

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AROMATASE DEFICIENCY

1. Deficiency of enzyme aromatase which converts androstenedione and testosterone to estrone

and estradiol respectively
2. Features
a. Normal internal genitalia
b. External virilization
c. Undetectable serum estrogen levels
d. Transient masculinization of mother that resolves after delivery
3. Adolescence symptoms
a. Delayed puberty
b. Osteoporosis
c. Undetectable serum estrogen levels
d. No breast development
e. High concentrations of gonadotrophins that result in polycystic ovaries

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SERTOLI-LEYDIG CELL TUMOR

1. A type of sex cord-stromal tumor of the ovaries

a. Secretes high testosterone levels
2. Consider high suspicions of androgen-secreting tumor if there is:
a. Virilization
b. Rapid-onset (<1 year) hyperandrogenism
3. Symptoms
a. Due to testosterone excess
i. Hirsutism
ii. Virilization
1. Male-pattern baldness (eg, temporal hair loss)
2. ↑ muscle bulk
3. Clitoromegaly
4. Voice deepening
b. Due to estrogen deficiency (testosterone inhibits GnRH and pituitary FSH/LH release)
i. Breast atrophy
ii. Vulvovaginal atrophy
iii. Dyspareunia
iv. Oligomenorrhea
4. Diagnosis
a. Patients with virilization require evaluation of the tumor to be distinguished between
ovarian and adrenal sources of androgen production with:
i. Total testosterone
ii. 17-hydroxyprogesterone
iii. DHEAS

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b. Ovarian androgen-secreting tumors produce markedly elevated testosterone levels

(>150 ng/dL)
c. Adrenal tumors produce markedly elevated DHEAS levels (>700 mcg/dL)
d. Pelvic ultrasound
5. Differentials

Differentials Differentiating Points

Adrenocortical Carcinomas  ↑ DHEAS
Aromatase Deficiency  ↑ DHEAS
PCOS  Rarely causes virilization
 Mildly elevated testosterone

CAUSES OF HIRSUTISM

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HYPERANDROGENISM

Nodulocystic Acne

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MANAGEMENT OF SUSPECTED ECTOPIC PREGNANCY

1. An intrauterine pregnancy may be seen with TVUS at a ß-hCG level of 1500-2000 IU/L
2. An indeterminate pregnancy on TVUS should undergo ß-hCG level testing
a. If ß-hCG levels <1500 → repeat ß-hCG in 2 days
b. If ß-hCG levels >1500 → do TVUS again

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HPV

1. Vaccination
a. Routine vaccination in women start at age 11-12
b. Catch-up vaccination should be offered until age 26 for patients who are unvaccinated
or did not complete the series
2. Treatment of Condyloma accuminata
a. Cryotherapy
b. Topical imiquimod
c. Trichloroacetic acid

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CONDYLOMA ACCUMINATA

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PAP TEST
1. It begins every 3 years at age 21 in immunocompetent patients , regardless of the age of onset
of sexual activity or the number of sexual partners
2. Routine HPV testing in women age <30 is not done because infection mostly clears away and
does not progress to cervical dysplasia
a. Routine HPV testing otherwise can lead to unnecessary cervical procedures, leading to
pregnancy complications
b. At age ≥30, Pap tests with HPV co-testing may be done and repeated every 5 years if
negative or ONLY pap test is done every 3 years
3. Normal Pap tests exclude persistent HPV infection
4. Patients with adequate screening by age 65 can stop undergoing Pap test
a. If a patient has a history of CIN2 or higher on histology, screening should continue for
another 20 years
b. Don’t terminate Pap test at age 65 for patients with risk factors for cervical cancer:
i. Immunosuppression
ii. Tobacco use
iii. DES exposure

PAP SMEAR REQUIRING ENDOMETRIAL SAMPLING

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HELLP SYNDROME
1. Features
a. Hemolysis
b. ↑ liver enzymes
c. ↓ platelet count
2. Pathophysiology
a. Abnormal placentation → triggering systemic inflammation → ac va on of coagula on
system and complement cascade
b. Platelets are rapidly consumed → thrombocytopenia
i. Resulting thrombosis in portal system leads to hepatocellular necrosis → ↑
liver enzymes
3. Management
a. First of all, stabilize the patient with antihypertensive drugs and/or MgSO4
b. Afterwards, delivery is the only definite treatment
i. Indications for delivery are:
1. ≥34 weeks gestation
2. Any gestational age with abnormal fetal testing or severe worsening of
maternal status

LACTATIONAL AMENORRHEA
1. Amenorrhea due to ↑ prolac n in a lacta ng mother
a. ↑ prolac n inhibits GnRH production
2. It provides natural contraception for the first 6 months
a. After 6 months, >50% of women resume ovulation and require another form of
contraception

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HPO AXIS

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NORMAL PUBERTAL GROWTH IN GIRLS

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TANNER STAGES

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PRIMARY DYSMENORRHEA
1. At onset of menarche, adolescents have irregular hypothalamic-pituitary-ovarian axis
a. There is no ovulation in the beginning
2. As this axis matures, ovulation can cause excessive prostaglandin release during menses which
results in
a. Crampy, bilateral lower abdominal pain that may radiate to back and thighs
b. Nausea, vomiting, diarrhea
c. Fatigue and dizziness
3. Primary dysmenorrhea is common in up to 90% adolescents
4. Features
a. Starts 1-2 days before onset of menses
b. Resolves a few days after ONSET of menses
c. Patients also have associated malaise and dizziness
d. GIT symptoms
i. Due to prostaglandin-induced stimulation of GIT
ii. Includes nausea, vomiting and diarrhea
e. Normal pelvic examination
f. No pain after menses ends
g. Gets better as the patient ages
5. Risk factors
a. Age <30
b. BMI <20 kg/m2
c. Tobacco use
d. Menarche at age <12
e. Heavy/long menstrual periods
f. Sexual abuse
6. Treatment:
a. NSAIDs
i. In nonsexually active patients. NSAIDs inhibit prostaglandin synthesis
b. Combination OCPs
i. In sexually active patients who also want contraception
ii. Thins endometrial lining
iii. Reduces prostaglandin release
iv. ↓ uterine contrac ons
c. Do not use other contraceptions
i. IUD ↑ pain symptoms with its inflammatory reac on in the uterus
ii. Medroxyprogesterone ↑ body fat, ↓ lean muscle mass and ↑ risk of loss of
bone mineral density

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7. Differentials:

Adenomyosis  Age >40

 Symmetrically
enlarged”globular”
uterus
Endometriosis  Pain persists
THROUGHOUT menses
 Immobile uterus
Mittelschmerz  Pain occurs approx. 2
weeks prior to menses

Pelvic congestion  Dull, ill-defined pelvic

syndrome ache that worsens with
intercourse or during
long periods of
standing
 Pain prior to menses
that is then relieved by
menses

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SECONDARY DYSMENORRHEA
1. It is a pathological cause of painful menses
2. Patients with any of the following clinical features should be evaluated for secondary causes of
dysmenorrhea:
a. Symptom onset at age >25
b. Unilateral (non-midline) pelvic pain
c. No systemic symptoms
d. Abnormal uterine bleeding

PELVIC ORGAN PROLAPSE

UTERINE PROCIDENTIA
1. A form of pelvic organ prolapse
2. It occurs due to:
a. Weakened pelvic support
b. ↑ intraabdominal pressure
3. Symptoms
a. Vaginal pressure
b. Bulging mass that ↑ with Valsalva maneuver
4. Pelvic organ prolapse is often asymptomatic and does not require treatment. However, if
patients develop symptoms (a few are written below), then treatment is indicated, eg:
a. Pelvic pressure
b. Bowel-bladder dysfunction

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c. Sexual dysfunction
d. Tissue damage (eg, erosions)

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PREMENSTRUAL SYNDROME (PMS)

1. Recurrent physical and affective symptoms that generally occur 1-2 weeks before the onset of
menstruation and ends with the onset of menses or a few days thereafter
2. Evaluation should include a symptom diary over 2 menstrual cycles and it should show:
a. Recurrence of symptoms during the luteal phase (1-2 weeks before menses)
b. Resolution of symptoms during the follicular phase (onset of menses or a few days
thereafter)
3. To make the diagnosis, the symptoms should reach a point of socioeconomic impact
4. Treatment
a. SSRIs
b. OCPs
i. They are contraindicated in patients with migraines

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 GYNECOLOGY

GRANULOSA CELL TUMOR

1. Normally, granulosa cells have following functions:
a. Convert testosterone to estradiol (via aromatase)
b. Secrete inhibin
2. Tumor of these cells leads to overproduction of estradiol and inhibin
3. Chronic and unopposed estrogen exposure can lead to:
a. Endometrial hyperplasia
b. Cancer (eg, postmenopausal bleeding)
4. Evaluation
a. Endometrial biopsy
b. Surgical staging
c. After surgical management, inhibin levels can be monitored to evaluate for disease
progression or recurrence
5. Treatment
a. No associated endometrial cancer → unilateral salpingo-oophorectomy (preserves
fertility)
b. Associated endometrial cancer → bilateral salpingo-oophorectomy and hysterectomy
c. Note: endometrial ablation is contraindicated in endometrial cancer
6. Differentials

Differentials Differentiating Points

Brenner Tumors  Rare, benign subtype of epithelial ovarian
tumor
 Found incidentally
 No association with endometrial
hyperplasia
Embryonal carcinoma  Occurs in young women
 Secretes AFP and ß-hCG
 No association with endometrial
hyperplasia
Mature teratoma  Occur in young women (age 10-30)
Yolk sac tumor  Occurs in young women
 Secrete AFP
 No abnormal uterine bleeding

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 GYNECOLOGY

CHORIOCARCINOMA
1. It is a form of gestational trophoblastic neoplasia
2. It typically presents <6 months after a
pregnancy
3. Presentation
a. Irregular vaginal bleeding
b. Enlarged uterus
c. Pelvic pain
d. Pulmonary metastasis
i. Chest pain
ii. Hemoptysis
iii. Dyspnea
4. Diagnostic test: Quantitative ß-hCG
5. Staging: Chest X-ray
a. CT scan is insignificant in
choriocarcinoma’s staging

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 GYNECOLOGY

RECTOVAGINAL FISTULA
1. Most common cause is obstetric injury
a. Presents within the first 2 weeks postpartum
2. Most commonly occurs after:
a. Third- or fourth-degree laceration
b. Inadequate wound repair
c. Wound breakdown
d. Infection
3. In less industrialized countries, it occurs due to:
a. Poor intrapartum care
b. Prolonged 2nd stage of labor
i. Fetal head compression → ischemic pressure necrosis of rectovaginal septum
4. Presentation
a. Malodorous brown/tan discharge from vagina
5. Diagnosis
a. Dark red, velvety rectal mucosa on posterior vaginal wall on visual examination
b. Do anoscopy if fistula is not visualized but is highly suspected
6. Treatment
a. Surgical repair

VESICOVAGINAL FISTULA

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 GYNECOLOGY

CERVICAL CANCER

1. Most commonly asymptomatic

2. If symptomatic, presentation is following:
a. Vaginal discharge
b. Postcoital or intermenstrual bleeding
c. Cervical lesion
3. Diagnosis
a. Pap testing
b. Colposcopy
c. Endocervical curettage is done in cases of unsatisfactory colposcopy (eg,
squamocolumnar junction not completely visualized)

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GYNECOLOGY

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 GYNECOLOGY

MANAGEMENT OF CIN3

1. Management of noninvasive cancer is based on surgical margins:

a. Positive surgical margins:
i. Repeat conization (if fertility needs to be preserved)
ii. Hysterectomy (if no future fertility is desired)
b. Negative surgical margins:
i. Repeat Pap and HPV contesting at 1 and 2 years

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 GYNECOLOGY

CERVICAL CANCER IN HIV-POSITIVE PATIENTS

1. In HIV-positive patients, cervical cancer is an AIDS-defining illness because it indicates severe
immunocompromise
2. In immunocompromised patients, HPV can cause cervical dysplasia that rapidly progresses to
cancer
a. For this reason, HIV-positive patients require cervical cancer screening (eg, Pap testing)
at the time of HIV diagnosis, followed by close interval repeat testing (eg, in 6-12
months)

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 GYNECOLOGY

PRIMARY OVARIAN INSUFFICIENCY (POI)

1. Hypergonadotropic hypogonadism in women age <40 is known as POI

2. Diagnosis:
a. ↑ FSH
b. ↑ LH
3. Treatment:
a. HRT
i. Menopausal symptom relief
ii. Bone loss protection
b. Cryopreservation techniques
i. Fertility preservation
4. Differentials:
a. Hypothalamic amenorrhea
i. Patients with hypothalamic amenorrhea do not have vasomotor symptoms even
though they have low estrogen levels

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 GYNECOLOGY

HYPOTHALAMIC AMENORRHEA

48
 GYNECOLOGY

PRIMARY OVARIAN INSUFFICIENCY IN FRAGILE X SYNDROME

1. Common in patients who are FMR1 gene permutation carrier (ie, those with 50-200 CGG
repeats)
2. Associated features:
a. Neurobehavioral clinical features
i. Generalized anxiety disorder
ii. Autism
b. Family history of fragile X syndrome
3. Mechanism
a. This permutation causes FMR1 mRNA overexpression → cytotoxic effecr on ovarian
primordial follicles → accelerated follicle depletion
4. Women with ovarian failure at age <40 and no other obvious cause for POI are tested for FMR1
gene mutations

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 GYNECOLOGY

ENDOMETRIOSIS

1. It is a common cause of chronic pelvic pain

a. Look for pelvic pain for >6 months
2. Most common complaints are:
a. Dysmenorrhea
b. Noncyclic pain exacerbated by exercise
3. Physical examination
a. Fixed and immobile uterus
b. Rectovaginal nodularity
4. Diagnosis
a. Ultrasound
i. Adnexal mass
1. Homogeneous cystic ovarian mass with internal echoes (eg, “ground
glass”) is highly suggestive of an ovarian endometrioma
5. Treatment:
a. Asymptomatic patients: Reassurance and observation
b. Symptomatic patients: Medical or surgical (listed in table)

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 GYNECOLOGY

6. Indications for treatment of endometriosis:

a. Chronic pelvic pain
b. Dysmenorrhea, or increasingly worse lower abdominal cramping throughout menses,
that is unrelieved by NSAIDs
c. Dyspareunia
d. Infertility
7. Differentials

Differentials Differentiating Points

Epithelial Ovarian Tumor  Ultrasound shows septated mass with
solid components
Mature Teratoma  Ultrasound shows calcifications and
hyperechoic nodules
Chronic PID  It can cause chronic pelvic pain and
infertility (same as endometriosis)
 Its complication tubo-ovarian abscess
appears on ultrasound as thick-walled
multiloculated adnexal mass with air-fluid
levels and internal debris

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GYNECOLOGY

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 GYNECOLOGY

PCOS

53
 GYNECOLOGY

TUBO-OVARIAN ABSCESS
1. It is a complication of PID
2. Features
a. Fever
b. Abdominal pain
c. Abnormal discharge
d. Cervical motion tenderness
3. Diagnosis
a. Lab findings
i. ↑ CA-125
ii. ↑ C-reactive protein
iii. Leukocytosis
b. Pelvic ultrasound
i. Complex thick-walled multiloculated adnexal mass with air-fluid levels and
internal debris

PID TREATMENT
1. Inpatient treatment
a. IV cefoxitin or cefotetan + oral doxycycline
b. IV clindamycin + gentamicin
2. Outpatient treatment
a. IM ceftriaxone + oral doxycycline
3. Add Metronidazole if PID is complicated by tubo-ovarian abscess

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 GYNECOLOGY

OCPS PROFILE
OCPs Profile
 Pregnancy prevention
Benefits  Endometrial & ovarian cancer risk reduction
 Menstrual regulation (eg, anovulation, dysmenorrhea, anemia)
 Hyperandrogenism treatment
 Breakthrough bleeding
 Breast tenderness, nausea, bloating
 Hypertension
 Venous thromboembolism disease
Side Effects  ↑ risk of cervical cancer
 Liver disorders (eg, hepatic adenoma)
 ↑ triglycerides (due to estrogen component)
 Stroke, MI (very very rare)
 Migraine with aura
 ≥15 cigarettes/day PLUS age ≥35
 Hypertension >160/100 mm Hg
 Heart disease
 Diabetes mellitus with end-organ damage
 History of thromboembolic disease
Absolute  Antiphospholipid-antibody syndrome
Contraindications  Thrombophilia (eg, factor V Leiden)
 History of stroke
 Active breast cancer
 Cirrhosis & liver cancer
 Active hepatitis
 Major surgery with prolonged immobilization
 Use <3 weeks postpartum
 Mild or medication-controlled hypertension
Relative  Age ≥35 PLUS smoking <15 cigarettes/day
Contraindication  Certain medications (eg, lamotrigine, rifampin)
 Inherited thrombophilia carrier & family member with thrombophilia
plus thromboembolism
1. Hypertension
a. Due to ↑ angiotensinogen synthesis by estrogen during hepa c 1st pass metabolism
2. Venous thromboembolism
a. Due to hypercoagulable properties of estrogen

55
 GYNECOLOGY

MIGRAINE THERAPY

ABNORMAL UTERINE BLEEDING ON OCPS

56
 GYNECOLOGY

EMERGENCY CONTRACEPTION

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 GYNECOLOGY

VAGINAL CANCER
1. Clinical features
a. Vaginal bleeding
b. Malodorous discharge
c. Ulcerated vaginal lesion
i. Irregular plaque
ii. Located in upper third of posterior vagina
2. Features of metastatic disease
a. Pelvic pain
b. Urinary symptoms (eg, hematuria)
c. Bulk symptoms (eg, constipation)
3. Diagnosis
a. Biopsy
i. To evaluate depth of invasion
4. Management
a. Noninvasive cancer (VIN)
i. Topical therapy
ii. Wide local excision
b. Invasive
i. Surgery
1. Radical hysterectomy
2. Vaginectomy
3. Pelvic node dissection
ii. Chemoradiation
5. Differentials
a. Atrophic vaginitis
i. No ulcerative lesions are seen

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 GYNECOLOGY

DESQUAMATIVE INFLAMMATORY VAGINITIS

1. Presentation
a. Copious watery discharge
b. Inflamed erythematous vagina
2. Diagnosis
a. Wet mount
i. Predominant leukocytes
3. Treatment
a. Topical corticosteroids

TAMOXIFEN
1. Estrogen receptor antagonist in the breast and agonist in the uterus and bone
a. Antagonist in the breast = prevents breast cancer
b. Agonist in the uterus = excessive endometrial proliferation
i. Endometrial polyps in premenopausal women
ii. Endometrial hyperplasia and cancer in postmenopausal women
c. Agonist in the bone = ↑ bone density
2. Indication
a. Premenopausal women at low risk of breast cancer recurrence
b. Prevention of breast cancer in high risk patients
3. It is also 2nd line endocrine adjuvant agent for postmenopausal women who cannot use
aromatase inhibitor therapy
4. It also acts on CNS and have an antiestrogenic effect, leading to thermoregulatory dysfunction
→ hot flashes
5. It also increases blood lipid levels

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 GYNECOLOGY

SECONDARY AMENORRHEA
1. Defined as:
a. Cessation of previously established menses for ≥3 months OR
b. Cessation of irregular menses for ≥6 months

60
 GYNECOLOGY

PELVIC INFLAMMATORY DISEASE

1. Presentation
a. Fever
b. Lower abdominal pain
i. Worsens with menses
c. Mucopurulent cervical
discharge
d. Cervical motion tenderness
e. Uterine tenderness
f. Intermenstrual spotting
i. Due to cervicitis
2. Risk factors
a. Age <25
b. Sexual activity without barrier contraception
3. Complications
a. Ectopic pregnancy
b. Tubo-ovarian abscess
c. Infertility

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 GYNECOLOGY

d. Perihepatitis “Fitz-Hugh-Curtis Disease”

i. Vomiting
ii. ↑ transaminases
iii. RUQ pain which increases on inspiration

INTRAUTERINE ADHESIONS

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 GYNECOLOGY

URETHRAL PROLAPSE

ACUTE CERVICITIS
1. Most commonly because of Neisseria gonorrhoeae and Chlamydia trachomatis
2. Features
a. Mucopurulent cervical discharge
b. Friable cervix that bleeds with manipulation
3. Diagnosis
a. Gold standard is NAAT
b. On light microscopy, no organism is found because chlamydia is obligate intracellular
organism

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 GYNECOLOGY

LABIAL ADHESIONS

1. Causes
a. Low estrogen production (common in prepubertal girls age 2-3)
b. Chronic inflammation
i. Poor hygiene
ii. Infection (eg, vaginitis)
iii. Irritation (eg, diaper rash)
iv. Trauma (eg, saddle injury, sexual abuse)
2. Adhesions can be partial or complete
a. Partial adhesions are generally asymptomatic but some children may develop pain or
pruritus which can lead to secondary excoriations and exacerbate adhesion
development
3. Adhesions covering the urethral meatus can lead to following:
a. Abnormal urinary stream
b. ↑ risk of recurrent UTIs due to urine accumula on
4. Treatment
a. Asymptomatic: no treatment
b. Symptomatic: topical estrogen

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 GYNECOLOGY

VAGINITIS DIFFERENTIALS

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 GYNECOLOGY

VULVOVAGINAL CANDIDIASIS

1. Risk factors
a. Diabetes mellitus
b. Immunosuppression
c. Pregnancy (ie, states with ↑ estrogen)
d. OCPs
e. Antibiotic use
2. Presentation
a. White vaginal discharge
b. Vulvovaginal pruritis
c. Dysuria
d. Vaginal erythema and excoriation
3. Diagnosis
a. Normal pH
b. Budding yeast and pseudohyphae on microscopy
4. Women with recurrent vulvovaginal candidiasis infections (≥4 episodes in a year) and other
signs of diabetes (nocturia, urinary frequency) should be evaluated with hemoglobin A1c
5. Treatment
a. Fluconazole

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 GYNECOLOGY

BACTERIAL VAGINOSIS

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 GYNECOLOGY

AMSEL CRITERIA
1. It includes 4 points. If the patient has 3 out of 4, she is diagnosed with bacterial vaginosis
a. Homogenous vaginal discharge
b. pH >4.5
c. Clue cells on microscopy
d. Positive whiff test

OBESITY AND ANOVULATION

1. Mechanism by which obesity can lead to anovulation:

a. Obesity → ↑ insulin resistance and hyperglycemia → ↓ sex hormone-binding globulin
→ ↑ free androgen → ↑ aroma za on in the adipose ssue to estrone → ↑ estrone
2. High estrone levels affect GnRH pulses at the level of hypothalamus
a. It results in high frequency, short interval GnRH pulses
b. These pulses preferentially produce LH → imbalance in LH and FSH → lack of LH surge →
anovulation and abnormal uterine bleeding
3. Treatment
a. Weight loss
b. OCPs

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 GYNECOLOGY

HIDRADENITIS SUPPURATIVA

1. It is a chronic inflammatory condition which creates inflamed, purulent nodules in the

intertriginous areas (eg, axilla, inguinal region)
2. Causes spontaneously draining sinuses, scarring and multiple open comedones
3. Disease is multifocal and painful
4. It has a chronic progressive course with recurrences that affect follicles within the same region
5. Risk Factors
a. Obesity
b. Tobacco use
c. Family history
6. Treatment is doxycycline

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 GYNECOLOGY

5-Α-REDUCTASE DEFICIENCY

1. Normal male development

a. Male internal genitalia (eg, vas deferens, epididymis) are made by testosterone
b. Male external genitalia (eg, penis) and prostate are made by DHT
2. Hence, in patients with this disease, they have normal internal genitalia but phenotypically they
are females with undescended testes
3. At puberty, testosterone levels increase, leading to virilization:
a. Nodulocystic acne
b. Clitoromegaly
c. Voice deepening
d. Increased muscle mass
4. Differentials
a. Androgen insensitivity syndrome (AIS)
i. There is no acne or pubic and axillary hair in AIS but they do occur in 5-α-
reductase deficiency
ii. There is no breast development in 5-α-reductase deficiency as testosterone
binds to androgen receptor and inhibits breast tissue proliferation

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 GYNECOLOGY

ANDROGEN INSENSITIVITY SYNDROME

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 GYNECOLOGY

KLINEFELTER SYNDROME

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 GYNECOLOGY

INDICATIONS OF ENDOMETRIAL BIOPSY

PAP TESTS RESULTS REQUIRING ENDOMETRIAL BIOPSY

1. Women age <45 with endometrial cells on Pap tests and no risk factor for endometrial
hyperplasia do not require endometrial biopsy as this is fairly common, especially if pap test was
done during the first 10 days of menstrual cycle
2. Women age ≥35 with atypical endometrial cells on Pap tests need to undergo colposcopy,
endocervical curettage and endometrial biopsy
3. Patients diagnosed with endometrial cancer need to undergo hysterectomy with salpingo-
oophorectomy for cancer screening and treatment

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 GYNECOLOGY

BARTHOLIN DUCT CYST

1. Bartholin glands are found on the 4 and 8 o’clock positions at the posterior vaginal introitus
a. Their normal function is vulvovaginal lubrication
2. Bartholin ducts can get obstructed by:
a. Accumulation of mucus
b. Secondary to edema and trauma
3. Resultant obstruction leads to proximal duct distension and cyst formation
4. Features
a. Soft, mobile, nontender flesh-colored mass
b. Asymptomatic
c. Present at the base of labia majora
5. Treatment
a. Asymptomatic: observation and expectant management
b. Symptomatic:
i. Incision & drainage
ii. Placement of word catheter to reduce the risk of recurrence
iii. Marsupialization procedure
1. It creates another point of drainage for the gland
6. Differentials
a. Gartner Duct Cyst

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 GYNECOLOGY

i. Results from incomplete regression of the Wolffian duct during fetal

development
ii. Appear along the lateral aspect of the upper anterior vagina
iii. Do not involve vulva
b. Skene Gland Cysts
i. Located lateral to the urethral meatus in the anterior vaginal vestibule

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 GYNECOLOGY

STRESS URINARY INCONTINENCE

1. Intermittent leakage of urine associated with ↑ intraabdominal pressure

2. Causes
a. Weakened pelvic floor musculature due to:
i. Increasing parity (even in those who delivery by cesarean)
ii. Obesity
iii. Chronic high-impact exercise such as jogging
b. Urogenital mucosa atrophy
i. Due to ↓ estrogen
3. In postmenopausal women both these causes interplay and lead to unsupported bladder and
hypermobile urethra
4. Urinalysis and postvoid residual volume are normal
a. Postvoid residual volume:
i. Women = <150 mL
ii. Men = <50 mL
5. Management
a. Kegel exercises
b. Lifestyle modification (eg, weight loss)
c. Pessaries
d. Midurethral sling

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 GYNECOLOGY

MIXED URINARY INCONTINENCE MANAGEMENT

1. Voiding diary is included in initial evaluation in order to classify the predominant type of urinary
incontinence and determine optimal treatment:
a. Fluid intake
b. Urine output
c. Leaking episodes
2. Bladder training with lifestyle changes, which are:
a. Weight loss
b. Smoking cessation
c. ↓ alcohol consump on
d. ↓ caffeine intake
3. Kegel exercises
4. Pharmacotherapy and surgery in patients who have limited or incomplete symptom relief with
bladder training:
a. Urgency-predominant incontinence
i. Oral antimuscarinics
ii. Timed voiding
b. Stress-predominant incontinence
i. Midurethral sling
5. Notes: Urodynamic studies are reserved for patients who do not respond to any treatment or
those who are being considered for surgical intervention

URINARY INCONTINENCE SUMMARY

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 GYNECOLOGY

INTERSTITIAL CYSTITIS
1. It is also called Bladder Pain Syndrome
2. This is a chronic condition with unknown etiology
3. It is associated with following:
a. Other chronic pain conditions:
i. Fibromyalgia
ii. Endometriosis
iii. Irritable bowel syndrome
b. Sexual dysfunction
c. Psychiatric illnesses (eg, depression, anxiety)

CANDIDA VULVOVAGINITIS
1. Risk factors
a. ↑ Estrogen levels
i. Estrogen containing contraceptives
ii. Pregnancy
b. Sexual activity
c. Recent antibiotic use
d. Immunosuppression
e. Uncontrolled diabetes mellitus
2. Features
a. Vulvovaginal erythema
b. Vaginal discharge

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 GYNECOLOGY

c. Vulvar pruritis
d. Dyspareunia
e. Dysuria
3. Diagnosis
a. Normal vaginal pH (3.8-4.5)
b. Wet mount microscopy shows pseudohyphae, hyphae and budding yeast. However, it
can be negative too
i. Do a vaginal culture if wet mount is negative
4. Treatment
a. Oral
i. Fluconazole
b. Intravaginal
i. Clotrimazole

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 GYNECOLOGY

INTRADUCTAL PAPILLOMA

1. Features
a. Unilateral bloody nipple discharge (hallmark)
b. No associated mass or lymphadenopathy
2. Management
a. Mammography
b. Ultrasound
i. It would reveal normal breast tissue or single dilated breast duct
c. Biopsy or duct excision
i. For confirmation

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 GYNECOLOGY

BREAST PATHOLOGIES
1. DCIS
a. Microcalcifications on mammography
2. Fat necrosis
a. Firm, irregularly shaped mass with findings of oil cysts on mammography
3. Fibroadenoma
a. Solitary, painless, firm and mobile breast mass which is regular in shape
b. Estrogen-sensitive
4. Fibrocystic changes
a. Cyclic bilateral breast pain
b. Diffuse nodularity on breast examination
5. Lobular breast carcinoma
a. Fixed palpable breast mass with irregular borders
b. Can be bilateral

MAMMARY PAGET DISEASE

1. It is suspected in following presentation:
a. Eczematous and/or ulcerating rash localized to the nipple and spreads to the areola
b. Vesicles
c. Scaling
d. Nipple retraction
e. Bloody discharge
2. Most common cancer found in Mammary Paget Disease is adenocarcinoma
3. Management
a. Mammography
b. Biopsy

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 GYNECOLOGY

PHYSIOLOGIC GALACTORRHEA
1. Features
a. Bilateral
b. Guaiac negative (ie, no occult blood)
c. Appearance is milky or clear but can be yellow, brown, gray or green
2. Medications which cause galactorrhea:
a. Dopamine antagonists (antipsychotics, opiods, antidepressants)
b. Pituitary lactotrophs stimulants (eg, estrogen-containing contraceptives)
c. Chronic use of histamine receptor blockers (eg, cimetidine)
i. Inhibits estradiol metabolism → ↑ prolac n
3. Diagnosis
a. MRI
i. If prolactin is raised
ii. If symptoms of pituitary mass (eg, vision disturbances, headaches) are present

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 GYNECOLOGY

INFLAMMATORY BREAST CARCINOMA

1. It presents as a rapid onset edematous cutaneous thickening with following features:
a. “peau d’orange”
i. Superficial dimpling
ii. Fine pitting
b. Edematous breast
c. Erythematous breast
d. Painful breast
e. Itching, palpable breast mass
and nipple changes (eg,
flattening/retraction) may
also be present
2. Axillary lymphadenopathy is seen
(sign of metastasis)
3. Diagnosis
a. Mammography
b. Ultrasound
c. Tissue biopsy (diagnostic)
4. Differentials
a. Mastitis
i. Presents with fever
ii. Improves with
antibiotics
b. Ductal and Lobular
Carcinoma
i. No edematous or
erythematous
changes are seen
ii. Dimpling may be present

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 GYNECOLOGY

LACTATIONAL MASTITIS

1. Symptoms
a. Flulike symptoms (eg, fever, myalgias)
b. Focal unilateral breast pain with surrounding erythema and induration
c. Axillary lymphadenopathy
2. Most common causative agent is Staphylococcus aureus
3. Treatment
a. Against methicillin-sensitive Staph aureus
i. Dicloxacillin
ii. Cephalexin
b. Against MRSA (eg, history of recent antibiotic therapy, incarceration)
i. Clindamycin
ii. TMP-SMX
iii. Vancomycin
c. Analgesics
d. Continue breastfeeding every 2-3 hours
4. Differentials
a. Inflammatory breast cancer
i. Edematous breast
ii. Peau d’orange
b. Breast engorgement
i. Bilateral breast pain
ii. Generalized involvement
iii. Use NSAIDs and warm compresses for relief

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 GYNECOLOGY

SIMPLE BREAST CYST

1. It is a benign breast mass
a. A tender, mobile mass in a young patient is most likely benign
b. In a patient age <30 with a clinically benign mass, breast ultrasound is the 1st line
imaging study
i. Breast mammography in women age <30 is not recommended because:
1. They have relatively dense breast tissue
2. Radiation exposure is a potential risk factor for breast cancer in young
women
2. Features of simple breast cyst
a. Ultrasound shows posterior acoustic enhancement (indicative of fluid)
b. No echogenic debris or solid components
c. Symptoms range from asymptomatic to severe, localized pain
3. Management
a. Needle aspiration
i. Yields clear fluid
ii. Disappearance of mass
b. Reevaluate within 2-4 months
i. If there are no further symptoms or signs of recurrence, resume annual
screening

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 GYNECOLOGY

MASTALGIA

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 GYNECOLOGY

APPROACH TO POSTMENOPAUSAL BLEEDING

1. All patients with postmenopausal bleeding require further evaluation with:
a. Pap test for cervical cancer (regardless of when the last Pap test was performed)
b. Endometrial biopsy or TVUS for endometrial cancer
2. Treatment of endometrial hyperplasia/cancer
a. Hysterectomy with bilateral salpingo-oophorectomy

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 GYNECOLOGY

TOXIC SHOCK SYNDROME

1. Features
a. High fever
b. Hypotension
c. Diffuse red macular rash which involves palms and soles
2. Treatment:
a. Vancomycin + Clindamycin
i. Vancomycin: Bactericidal activity against gram-positive bacteria, including
MRSA
ii. Clindamycin: Inhibits TSS exotoxin production

DISSEMINATED GONOCOCCAL INFECTION

1. Caused by Neisseria gonorrhoeae
2. Presentation
a. Pustular dermatitis
b. Tenosynovitis
c. Migratory asymmetric polyarthralgia

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 GYNECOLOGY

ACUTE PELVIC/ABDOMINAL PAIN IN WOMEN DIFFERENTIALS

MANAGEMENT FOR ACUTE ABDOMINAL PAIN

1. Do pregnancy test first
a. If it is positive, do a pelvic ultrasound to check for intrauterine or ectopic pregnancy
b. If it is negative, do abdominal CT to evaluate for appendicitis or kidney stones
c. Abdominal X-ray may also be then considered to rule out intestinal obstruction or
perforation (free air under the diaphragm)

INVESTIGATIONS FOR PALPABLE ADNEXAL MASS

1. Pregnancy test and pelvic ultrasonography is the first-line test
2. A CT scan of abdomen and pelvis is indicated if mass has malignant features
3. CA-125 has low specificity for initial screening of ovarian cancer in premenopausal patients. It is
however helpful in postmenopausal women

PUDENDAL NEURALGIA
1. Presents as superficial pain located at pudendal nerve distribution, that is:
a. Vulva
b. Perineum
c. Rectum

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 GYNECOLOGY

MULLERIAN AGENESIS

1. Also called Mayer-Rokitansky-Kuster-Hauser Syndrome

2. Features
a. Absent uterus and cervix
b. Normal secondary sexual characteristics
c. Normal external genitalia
d. Normal lower 2/3rd of vagina
e. Normal FSH
3. Internal genitalia are derived from structures of intermediate mesoderm which develops into:
a. Paramesonephric (mullerian) ducts
i. Makes uterus, fallopian tubes, cervix and upper 1/3rd of vagina
b. Mesonephric (wolffian) ducts
i. Makes primitive kidney
4. Because of their common embryonic source and synchronous development in the 1st trimester
internal genital anomalies are often concurrent with renal abnormalities
a. Therefore, women with mullerian agenesis should undergo evaluation of the renal tract
with a renal ultrasound
i. Common abnormalities are:
1. Unilateral renal agenesis
2. Pelvic kidneys
3. Duplication of collecting system

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 GYNECOLOGY

VULVAR SQUAMOUS CELL CARCINOMA

1. Presentation
a. Bleeding
b. Vulvar pruritis
c. Unifocal erythematous, friable plaque/ulcer on labium majus
d. Dyspareunia

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 GYNECOLOGY

OVARIAN RESERVE
1. Women are born with their lifetime supply of oocytes, and a sharp decline in conception rates
occur after age 35 because of ↓ ovarian reserve
a. This is the reason why lack of conception after 6 months of unprotected intercourse in
women age >35 is considered infertility
2. Features
a. Normal regular menstrual cycles
b. Decreases oocyte number and quality

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CERVICAL INSUFFICIENCY
1. Vaginal spotting, pelvic pressure and ↑ vaginal discharge in the absence of labor (eg, no
contractions) are typical symptoms of cervical insufficiency
2. Treatment
a. Cervical cerclage

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ADENOMYOSIS
1. It is a disorder caused by an abnormal collection of endometrial glands and stroma within
uterine myometrium
2. Presentation
a. Multiparous women age >40
b. New-onset dysmenorrhea
c. Heavy menstrual bleeding
d. Chronic pelvic pain
3. Features
a. New-onset dysmenorrhea
b. Symmetrically enlarged (globular) uterus:
i. Boggy
ii. Tender
iii. Does not exceed 12 weeks in size
c. The enlarged uterus ↑ the endometrial cavity surface area, resul ng in concomitant
heavy menstrual bleeding (eg, anemia) typically seen in the patients
d. As repeated menstrual cycles keep shedding endometrial tissue within the myometrium,
patients often progress from dysmenorrhea to chronic, dull pain
4. Diagnosis
a. Initial: Pelvic ultrasonography and/or MRI
b. Definite: histology after hysterectomy
5. Treatment
a. Conservative
i. OCPs
ii. Progestin-releasing intrauterine device
b. Hysterectomy

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EROSIVE LICHEN PLANUS

1. Features
a. Glazed, brightly erythematous vulvar erosions with a border of serpentine-appearing
white striae (ie, Wickham striae), which cause:
i. Vulvar pain
ii. Vulvar pruritis
iii. Dyspareunia
b. Acute vaginal inflammation:
i. Friable mucosa
ii. Serosanguinous vaginal discharge
c. Chronic vaginal inflammation
i. Vaginal introitus stenosis
d. Lace-like reticular erosions on the gingiva and palate
i. Painful oral ulcers
ii. Plaque formation on the tongue
2. Diagnosis is made clinically but should be confirmed with vulvar punch biopsy
3. Treatment
a. High-potency topical corticosteroids
4. Differential
a. Behcet Disease
i. Oral lesions do not have associated plaques or a reticular appearance around
gingivae but ulcers with necrotic base
ii. Vulvar lesions do not have white striae along the margins

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SICCA SYNDROME
1. Impaired function of salivary and other exocrine glands can produce sicca syndrome, which is
characterized by:
a. Generalized dryness of mucous membranes
b. Dry mouth → ↑ risk of dental carries
c. Irritated/itchy eyes
d. Cough
e. Vaginal dryness → dyspareunia

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CONTRACEPTION
1. Copper IUD
a. Causes uterine inflammation which is toxic to sperms and ova
b. Can cause heavy menstrual bleeding
2. Levonorgestrel-containing IUD
a. Long-acting, reversible contraceptive
b. Mechanism
i. Thickens cervical mucus (blocks sperm entry)
ii. Impairs implantation
iii. Thins uterine lining (↓ menstrual bleeding)
c. A common side effect is amenorrhea
d. It is a good option in patients with heavy menstrual bleeding with contraindications for
OCPs
i. They are contraindicated in patients with unexplained vaginal bleeding
3. Medroxyprogesterone
a. Injections every 3 months
b. Weight gain is common side effect

CONTRAINDICATIONS OF IUD PLACEMENT

1. In patients with an IUD in situ at the time of infection, IUD removal is not required because its
removal increases risk of unintended pregnancy and does not affect treatment outcomes

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PRIMARY INFERTILITY
1. Failure to conceive after a year of unprotected, timed sexual intercourse in a nulliparous patient
age <35
2. Diagnosis
a. First-line imaging test is hysterosalpingogram

BREAST CANCER RISK FACTORS

 Most guidelines suggest routine screening mammography at age ≥50 due to increased risk of
cancer with increased age

BRCA CARRIER RISK

1. BRCA carrier status can be suspected if the patient has following:
a. Breast cancer diagnosis at age <50
b. Ovarian cancer at any age
2. Diagnosis
a. Testing for genetic mutations
3. Treatment
a. Bilateral mastectomy

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ENDOMETRIAL CANCER

 Tobacco use ↓ risk of endometrial cancer by s mula ng estrogen metabolism in the liver and
hence, decreasing estrogen levels
 For patients on progestin therapy, follow-up is with repeat endometrial biopsy (eg, every 3
months).

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CANDIDA INTERTRIGO

1. Presentation
a. Erythematous “beefy red” plaques within inguinal folds
b. Satellite lesions
2. Risk factors
a. Immunosuppression
i. Systemic corticosteroid use
ii. Diabetes mellitus
b. ↑ skin moisture or fric on
i. Obesity
ii. Tight-fitting clothing
3. Diagnosis
a. Clinical
b. Confirmation by visualization of hyphae or pseudohyphae on microscopic examination
of skin scrapings from affected areas
4. Treatment
a. Topical azoles
i. Clotrimazole
ii. Ketoconazole

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GENITO-PELVIC PAIN/PENETRATION DISORDER

OVARIAN TORSION

1. Any large mass (≥5 cm) can induce torsion

a. Mature cystic teratomas (dermoid cysts), common in premenopausal women, have an
elevated risk due to heterogeneous composition
i. Seen on ultrasound as partially calcified mass (teeth) with multiple thin,
echogenic bands (hair)
2. Torsion pain increases by physical activity

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MATURE CYSTIC TERATOMA

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OVARIAN HYPERSTIMULATION SYNDROME

1. It is an iatrogenic complication of ovulation-inducing medications
2. It is caused by overexpression of VEGF which results in bilaterally enlarged cystic ovaries with
increased vascular permeability (eg, increased Doppler flow), which causes third spacing (eg,
ascites, pulmonary edema)
3. Features
a. Abdominal pain
i. Due to ovarian enlargement by multiple follicles
b. Ascites
c. Respiratory difficulties

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HSV
1. Multiple, painful genital ulcers
2. Features
a. Tender inguinal lymphadenopathy
b. Open ulcers
i. Dysuria
ii. Sterile pyruia (WBCs present but bacteria absent)
iii. Acute urinary retention due to:
1. Reluctance to urinate
2. Lumbosacral neuropathy
3. Diagnosis
a. Viral culture
b. PCR

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URETHRAL DIVERTICULUM

1. Abnormal localized urethral mucosa (outpouching) due to recurrent periurethral gland infection
along the anterior vaginal wall
2. It can collect urine → postvoid dribbling and lower UTIs
3. Infection of diverticulum → tender anterior vaginal wall mass
a. Associated with expressed purulent or bloody urethral discharge
4. Presentation
a. Dysuria
b. Postvoid dribbling
5. It does not increase with Valsalva

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GESTATIONAL AGE ASSESSMENT

1. First trimester ultrasound with crown-rump length measurement is the most accurate method
of determining gestational age
2. In a women with reliable last menstrual period and normal menses, the estimated date of
delivery and gestational age are based on LMP
a. If the estimated gestational age (EGA) varies by >7 days in the first trimester and >10
days in the second trimester, then ultrasound EGA is used rather than LMP

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ANOGENITAL WARTS IN CHILDREN

1. Treatment
a. Asymptomatic: observation
b. Symptomatic or unresolved disease
i. Topical treatments (eg, podophyllotoxin)
ii. Surgical removal

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PHYSIOLOGIC LEUKORRHEA
1. It is a white, odorless cervical discharge composed of cervical mucus, normal vaginal flora and
vaginal squamous epithelium
2. Its discharge increases midcycle
3. It presents without manifestations of infection such as pruritis, erythema, pain, or a malodorous
discharge

OVARIAN HYPERTHECOSIS
1. A cause of virilization in postmenopausal women
2. Associated with:
a. Signs of insulin resistance
b. Low/normal LH and FSH levels
3. Diagnosis
a. Ultrasound= solid-appearing, enlarged ovaries

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IMPERFORATE HYMEN

RUPTURED OVARIAN CYST

1. Look for severe, sudden-onset abdominal pain following sexual intercourse or strenuous
exercise
2. Although hemoperitoneum does not typically occur with ovarian cyst rupture, however it can
occur in patients who are on anticoagulation
3. Physical examination
a. Lower quadrant tenderness
4. Diagnosis:
a. Abdominal ultrasound: Simple, thin-walled cyst with free fluid in pelvis
5. Management:
a. Hemodynamically stable patients: Observation
b. Hemodynamically unstable patients: Surgery

INTIMATE PARTNER VIOLENCE SCREENING

1. It should be done in all women of childbearing age at routine medical visits

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OSTEOPOROSIS RISK FACTORS

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IDIOPATHIC INTRACRANIAL HYPERTENSION

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