Chair’s Rounds: Obstetrics and Gynecology Clerkship
Daniel Clarke-Pearson, MD
University of North Carolina School of Medicine
Department of Obstetrics and Gynecology
Case 1: Postmenopausal Masses
APGO Educational Topic Area 55
A 55 year old White female G2P2 presents for annual physical examination. She has no major medical problems and
became menopausal 5 years ago. She is not taking any hormone replacement therapy. 3 maternal aunts have had
breast cancer and her sister, at age 40, developed advanced ovarian cancer. On physical examination, there is
suprapubic fullness and slight pain with deep palpation. Pelvic examination reveals an 8 cm mass in the right adnexa.
1. What are the potential causes of a pelvic mass? Are they different for premenopausal women?
2. If you suspected the patient might have ovarian cancer:
 What key points of history should be elicited?
 What findings might you discover on physical examination?
3. What additional test would you order to evaluate this mass?
4. The patient undergoes a pelvic ultrasound. What findings might suggest an ovarian malignancy?
5. What serum tumor markers might be obtained? How would the results be used in managing the patient?
6. What clinical characteristics would prompt you to recommend surgery versus medical management
(observation)?
7. What surgical options would you consider (minimally invasive surgery vs. laparotomy)? If this were ovarian
cancer, what are the goals of the surgical procedure?
8. What factors increase a patient’s risk for ovarian cancer?
9. How is advanced stage (III/IV) managed?
Case 2: Cervical Cancer
APGO Educational Topic52: Cervical Disease and Neoplasia (A,E)
A 35 year old Hispanic female G3P3 comes to the emergency room complaining of 40 days of vaginal spotting, pelvic
pain and a 10 pound weight loss. She has a negative health history, although she sees physicians only for urgent
care. She had a tubal ligation after her last vaginal delivery 8 years ago, and has not had a pap smear since.
1. What is the difference between menorrhagia, metrorrhagia and menometrorrhagia?
2. List the probably causes of bleeding in this patient.
On physical examination, her abdomen is normal and nontender. Pelvic exam reveals a 4 cm exophytic mass growing
from the cervix and involving 1 cm of the vaginal fornix
3. What is the most likely cause of this finding?
4. If you suspected cervical cancer, what other physical exam findings should you search for?
5. How would you establish a diagnosis?
A pap smear is reported to show HGSIL and a cervical biopsy reveals invasive squamous cell carcinoma.
6. Explain the disparity of the pap smear report and the cervix biopsy.
7. What causes cervical cancer? What are some risk factors for cervical cancer?
8. What would you do to determine the stage of this patient’s cancer? What are the typical sites of spread of
cervical cancer?
9. What treatment options would you consider?
Case 3: Perimenopausal Bleeding
APGO Educational Topic 54; Endometrial Hyperplasia/Carcinoma
A 52 year old White female G0P0 presents complaining of irregular periods and spotting. She has no other gynecologic
history, is mildly hypertensive and has diabetes mellitus (oral medications). On physical examination, she is 102 kg.
(BMI 31) The cervix and uterus are normal in size; blood is seen in the cervical os and vagina.
1. What are the likely causes of these symptoms?
2. What tests or studies would you perform or order?
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3. What is the thickness of a normal endometrial “stripe” in a menopausal woman?
4. Is a D&C necessary? What is a “fractional” D&C?
Endometrial biopsy is performed and is reported to show endometrial hyperplasia with atypia.
5. Is there more than one type of “hyperplasia”? Describe the association between hyperplasia with atypia and
endometrial cancer.
6. Describe surgical and medical management of endometrial hyperplasia with atypia.
7. What factors increase a woman’s risk of developing endometrial carcinoma?
8. What are the typical routes of spread of endometrial cancer?
9. How is endometrial cancer managed?
Case 4:
Abnormal Pap Smear
APGO Educational Topic 52: Cervical Disease and Neoplasia (B, C, D)
APGO Educational Topic 41: Gynecologic Procedures (E)
A 30 year old African American female G2P2 presents to UNC Dysplasia Clinic because of a recent pap smear that
showed HGSIL. She uses oral contraceptives and has no health problems. General physical and pelvic exam are
normal.
1. What is the likely cause of this abnormal pap smear?
2. What HPV types are most likely to cause:
a. HGSIL?
b. LGSIL?
c. Condylomata accuminata?
d. ASC-U?
3. How should this abnormal pap smear be evaluated?
4. Define:
a. Transformation Zone
b. Squamo-columnar junction
c. Satisfactory colposcopy
5. Colposcopic examination shows an area of white epithelium with mosaicism in the upper quadrants of the
cervix. A cervical biopsy shows severe dysplasia (CIN III) and the ECC is negative. What treatment options
would you present to this patient?
6. How effective are these various treatments?
7. Are there any cases of cervical dysplasia which you might observe rather than treat?
8. Is HPV associated with any other cancers?
9. Aside from HPV, are there other factors which increase a woman’s chances of developing cervical cancer?
10. Are there any treatments which might prevent abnormal pap smears and cervical cancer?
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Case 5:
Pre-operative Workup
APGO Educational Topic 41: Gynecologic Procedures ( A, B)
Ms. Harris is a 45 year old who comes to see you for a surgical consultation. You had advised her 2 years ago to have
a hysterectomy secondary to a large fibroid uterus (18 week size) which was causing menorrhagia and symptomatic
anemia. She hoped to avoid surgery by medical management and the onset of menopause. However, she was
unsuccessful and would like to revisit the idea of surgery.
1. What management options could you offer aside from a hysterectomy?
2. What important information do you need to obtain prior to scheduling her for surgery?
i) History
ii) Physical Exam
iii) Laboratory investigations
3. What are the key components of the informed consent for surgery?
You recall from your previous visit with her that she has a longstanding history of chronic hypertension which is fairly
well controlled on a diuretic and beta blocker. She mentions she has had a couple of episodes of chest pain and
shortness of breath in the past month.
4. What are the possible causes of these symptoms? What would you do to help resolve these issues prior to
proceeding with surgery? How do you reassure yourself she can undergo surgery safely?
These issues are resolved, and she is scheduled to undergo a total abdominal hysterectomy.
5. Would you advise her to have a bilateral salpingoophorectomy too?
6. What are some common intraoperative postoperative complications?
7. What are some common postoperative complications?
8. What steps do you take preoperatively or intraoperatively to decrease the risks of these complications?
Case 6:
Post-operative Complications
APGO Educational Topic 41: Gynecologic Procedures ( C, D)
At 0630 you are doing morning rounds on your patient, Ms. Jones, a 65 year old who underwent an abdominal
hysterectomy, BSO, pelvic and para-aortic lymphadenectomy 2 days ago for a Grade 2 endometrial cancer.
1. What are the key components of routine postoperative care?
You find she is in respiratory distress. She is sitting upright on the side of the bed, anxious and gasping for air.
RR=28, P=120, BP 130/90, Pulse oximetry=89. You review her operative note. Her estimated blood loss (EBL) was
250ml, and there were no intraoperative complications. Hct on Day #1 was 38% (42% preop).
2. What is your differential diagnosis?
3. What is your immediate medical management?
4. What do you do to evaluate the patient?
i. Data immediately available from the chart/nurses notes
ii. What tests would you order?
Labs: Hct 37%, WBC 10.0. Electrolytes normal. Chest x-ray: mild atelectasis, mild cardiomegally. EKG: Sinus
tachycardia
5. What is your differential diagnosis?
6. What are your next steps:
a. Treatment
b. Further evaluation
6. A spiral CT scan demonstrates multiple pulmonary emboli
a. What factors increase a patient’s risk of developing venous thromboemboli?
b. What prophylactic measures would you have ordered for this patient preoperatively?
c. How do you treat pulmonary emboli? What do you do to monitor therapy? How long should this
patient be anticoagulated?
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