Back to Basics:
Gynecology
Dr. John Lamensa
Assistant Professor
Department of Obstetrics and Gynecology
University of Ottawa
March, 2015
Overview
►
Normal Menstruation
 Sexual development
 Menstrual cycle
►
►
Amenorrhea
Abnormal uterine bleeding
PCOS
Menopause
Contraception
Infertility
Pelvic Pain
 Dysmenorrhea
 Endometriosis
Menstrual Abnormalities




►
►
►
►
►
►
Pelvic Mass
Ectopic pregnancy
Pap smears
Vaginal/pelvic infections
A mother is concerned that her 12 year old daughter has not had her
period yet (the other girls in her daughter’s class have already started
theirs). She also thinks her daughter does not show signs of puberty
yet. Knowing the first sign at the onset of puberty, you should ask
which of the following questions?
a)
Has her daughter had any acne?
b)
Has her daughter started to develop breasts?
c)
Does her daughter have any axillary or pubic hair?
d)
Has her daughter started her growth spurt?
e)
Has her daughter had any vaginal spotting?
The sequence of events in normal
pubertal development are:
a)
Peak growth, pubic hair, breast budding, menarche
b)
Breast budding, pubic hair, peak growth, menarche
c)
Breast budding, menarche, pubic hair, peak growth
d)
Pubic hair, breast budding, menarche, peak growth
Female Sexual Development
►
In infancy and pre-puberty, FSH and LH levels are
high or low ?
►
Prior to onset of puberty, FSH and LH levels
increase or decrease?
►
This stimulates ovaries to produce estrogen
A 9 year old girl presents for evaluation of regular
vaginal bleeding. History reveals thelarche at age 7
and adrenarche at age 8. Which of the following is
the most common cause of this condition in girls?
a)
Idiopathic
b)
Gonadal tumors
c)
McCune-Albright syndrome
d)
Hyperthyroidism
e)
CNS tumors
The most common cause of delayed puberty
is:
a)
b)
c)
d)
e)
Turner syndrome (45,X)
Craniopharyngioma
Constitutional delay
Anorexia nervosa
Primary hypothyroidism
Normal Menstrual Cycle
The initial work-up for a patient with 2° sexual
characteristics and 2° amenorrhea include all of
the following except:
a)
b)
c)
d)
e)
Pregnancy test
Pelvic ultrasound
Prolactin level
Thyrotropin level
Assessment of endogenous estrogen status
(progestational challenge)
Amenorrhea
Primary Amenorrhea
►
No menses by age 13 in the absence of development of
secondary sexual characteristics
or
►
No menses by age 15 regardless of presence of normal growth
and development
Secondary Amenorrhea
►
No menses for a length of time equivalent to a total of at least 3
of the previous cycle intervals
or
►
> 6 months of amenorrhea
Amenorrhea
A logical approach to the woman with either
primary or secondary amenorrhea is to consider
disorders based upon the level of control of the
menstrual cycle: hypothalamus and pituitary,
ovary, and uterus/vagina.
► all causes of secondary amenorrhea can also
present as primary amenorrhea.
► Primary is usually a genetic or anatomic
abnormality.
►
Amenorrhea - Etiology
PREGNANCY
ALWAYS NEED TO RULE OUT!
Hypothalamus
Extreme stress, Anorexia nervosa, Tumors,
Infection, Congenital (Kallman’s syndrome)
(20%/35%)
Pituitary
(5%/20%)
Ovary
(50%/40%)
Prolactin adenomas, 1o hypopituitarism,
Sheehan syndrome, (Thyroid)
Gonadal dysgenesis, Premature ovarian failure
(autoimmune, infection, irradiation, surgery, chemo)
Anovulation (PCOS, tumors)
Uterus/vagina
(20%/5%)
Congenital Absence, Imperforate hymen,
Transverse vaginal septum, Asherman’s syndrome
Others
Drugs (Metoclopramide, neuroleptics)
Premature ovarian failure may be due to
any of the following except:
a)
Turner’s syndrome
b)
Autoimmune dysfunction
c)
Hyperandrogenism
d)
Radiation exposure
A 15 year old female is brought to the ED because of
very heavy vaginal bleeding. Her Hb level is 90 g/L.
Each of the following diagnoses should be
considered except:
a)
b)
c)
d)
e)
Anovulatory, dysfunctional bleeding
Coagulopathy
Pregnancy
Endometrial polyps
Thyroid dysfunction
A 45 year old female is brought to the ED because of
very heavy vaginal bleeding. Her Hb level is 90 g/L.
What is the least likely diagnosis?
a)
b)
c)
d)
e)
Anovulatory, dysfunctional bleeding
Coagulopathy
Pregnancy
Endometrial polyps
Thyroid dysfunction
A 14 year old girl is brought to the ED by her mother because she has
been bleeding heavily for the past 2 weeks. She experienced menarche
6 months ago and has been very irregular. She denies any other medical
problems. She has never been sexually active. She has normal
secondary sexual development. Her BP is 100/60 and her pulse is 100.
She is 5 ft tall and weighs 95 lbs. Her abdomen is benign. She will not
let you perform a speculum or pelvic exam. Which of the following is
not indicated in the evaluation of this patient?
a)
b)
c)
d)
e)
HCG
Bleeding time
CBC
Type and Screen
Estradiol level
Approach to Abnormal Bleeding
Abnormal Bleeding
Investigations:
• HCG
• CBC, ferritin
• TSH, prolactin, coagulation profile
• Rule out organic diseases: H&P
• Endometrial biopsy (esp. if > 40 years old)
• + Ultrasound
* Menopausal bleeding is endometrial cancer
until proven otherwise – need tissue diagnosis
Acute DUB Treatment
Mild:
• OCP
• Cyclic Medroxy Progesterone Acetate (Provera)
Severe:
• Stabilize patient as required (ABC’s)
• Premarin IV 25 mg q4-6h or high dose OCP
• + Add OCP or Provera for maintenance
• D&C if severely ill or unresponsive to medical therapy
DUB Longterm Treatment
Hormonal Manipulation of Cycle
• Combined Contraceptives
• Progesterone only
• Progesterone IUD (Mirena)
• GnRH analogue
Control of Menorrhagia
• NSAIDs for menorrhagia
• Anti-fibrinolytic agents (Cyklokapron)
Surgical
• endometrial ablation
• hysterectomy
A 26 year old G0P0 complains of being too hairy. Her menses have
always been irregular occurring every 2 to 6 months. She also
complains of acne and is seeing a dermatologist for this. She denies
any other medical problems. She is 5’ 5’’ tall, weighs 200 lbs, and
her BP is 100/60. On exam, there is sparse hair around the nipples,
chin and upper lip. There is no galactorrhea, thyromegaly, or
temporal balding. Pelvic examination is normal. Which is the most
likely condition in this patient?
a)
b)
c)
d)
e)
Idiopathic hirsutism
Polycystic ovarian syndrome
Late onset congenital adrenal hyperplasia
Sertoli-leydig cell tumor of the ovary
Adrenal tumor
PCOS
►
Features:
 Menstrual irregularity (typically
oligomenorrhea/anovulation)
 Possible androgen excess (clinical: acne, hirsutism,
male-pattern hair loss)± biochemical.
 ± polycystic ovaries
 Metabolic issues/cardiovascular risks ( BMI; insulin
resistance; DM2; dyslipidemia)
 Rotterdam Criteria
In a woman with PCOS, a systemic manifestation
that is the direct effect of the hyperinsulinemic state
is:
a) hirsutism
b) obesity
c) acanthosis nigricans
d) hyperprolactinemia
PCOS - pathophysiology
insulin
↑estrogen
↓FSH + ↑LH
anovulation
↑peripheral
estrogen
↑androgens
from ovary
oligomenorrhea
obesity
HIRSUTISM
INFERTILITY
Treatment of PCOS
Cycle Control
►
►
►
Weight loss: diet, exercise & behavioural interventions are
key
Cyclic progesterone or OCP to prevent endometrial
hyperplasia/ cancer
Metformin to  insulin levels & ? reduce risk of
progression to type 2 diabetes
Infertility
►
►
►
Ovulation induction: Clomiphene, FSH, GnRH, etc.
Ovarian drilling
ART, Metformin to sensitize to ovulation induction
Treatment of PCOS/Hirsutism
- OCP (specifically Diane-35,
Yaz) antiandrogenic
- + spironolactone (inhibits
steroid receptor)
- Finasteride (5α reductase
inhibitor)
- Flutamide (androgen
receptor reuptake inhibitor)
- Mechanical removal of hair
The Ferriman-Gallwey score
The following statements are true except:
a)
Menopause occurs at ~51 years of age as a result
of a genetically determined depletion of ovarian
follicles responsive to gonadotropins.
b)
Menopause occurs earlier in smokers.
c)
Loss of ovarian function results in absolute
estrogen deficiency.
d)
Hormone replacement therapy should not be
used for prevention of cardiovascular disease or
dementia
Definitions

Menopause (Early and Late)
 after 12 consecutive months of amenorrhea, resulting
from the loss of ovarian follicular activity
 Menopause occurs with the final menstrual period
which is only known with certainty retrospectively one
year or more after the event.

Perimenopause (Menopausal Transition)
 the period immediately prior to menopause when
clinical, biological, and endocrinological features of
approaching menopause commence.
 The “climacteric” old. Early and Late too.
Clinical Conditions In Menopause

Vasomotor symptoms





75% of women
> 1 year in 80% of women
Primary indication for ERT/HRT
SSRI, clonidine, gabapentin, black cohosh
Urogenital atrophy
 Lubricants, moisturizers, local estrogen therapy

Osteoporosis
 Ca, Vit D, smoking cessation, exercise
 Bisphosphonates, ERT/HRT, SERMs (raloxifene)
HRT
► Good
 relief of vasomotor and GU symptoms
 Increases BMD, decreases fracture risk
 Decrease colorectal cancer
► Bad
 Increases VTE, CAD, stroke
►
►
? Increased risk of breast cancer, ovarian cancer,
and dementia
No increased risk of endometrial cancer
A 42 year old G4P4 woman states her cycles are regular and denies
any STIs. Currently she and her husband uses condoms, but they hate
the hassle of a coital dependent method. She is interested in a more
effective contraceptive method. They do not want any more children.
She reports occasional migraine headaches, has had a serious allergic
reaction to anesthesia as a child. She is a social drinker and smoker.
She weighs 70 kg, her BP is 142/88. Which is the most appropriate
method for this patient?
a)
b)
c)
d)
e)
Combination OCP
Diaphragm
Transdermal patch
Intrauterine device
Bilateral tubal ligation
Contraception
►
Combined Hormonal
OCP, Patch, Ring
• Cyclic, extended, continuous
•
►
Progestin Only
Progestin only pill (Micronor)
• DMPA (Depo-Provera)
•
►
Intrauterine Devices
•
•
►
Barrier Methods
•
►
Copper IUD (Nova-T)
Hormonal IUS (Mirena)
Male and female condom, diaphragm, cervical cap, sponge
Permanent Sterilization
•
•
Male
Female (laparoscopic and hysteroscopic)
Hormonal Contraception
Absolute contraindications
►
►
►
►
►
►
►
►
►
Pregnancy
Undiagnosed vaginal bleeding
Thromboembolic disease
Estrogen dependent tumors
Coronary/cerebrovascular disease
Impaired liver function
Uncontrolled hypertension
Migraines with neurological
symptoms
Smoker, age >35
Relative contraindication
►
►
►
►
►
►
Migraines (non-focal)
Controlled hypertension
Hyperlipidemia
Sickle cell anemia
Gallbladder disease
SLE
Method-related Pregnancy
Pill-Related Problems
bloating, nausea, and breast tenderness
► breakthrough bleeding
► amenorrhea
►
 goal of continuous or extended
 bothersome for cyclic regimens
►
post-pill amenorrhea
 median time for menses was 32 days and ≤90 days for
99%
 consider amenorrhea w/u.
Combined hormonal contraceptives:
a) Decrease the risk of stroke and VTE
b) Should only be started on the first day of a
menstrual period
c) Suppress ovulation mainly through an estrogen
dominant effect
d) Is contraindicated in women >35 years old
e) Decrease dysmenorrhea, menorrhagia and acne
In combined hormonal contraceptives, which of the
following is the primary contraceptive effect of the
estrogenic component?
a)
b)
c)
d)
e)
Conversion of ethinyl estradiol to mestranol
Atrophy of the endometrium
Suppression of cervical mucus secretion
Suppression of LH secretion
Suppression of FSH secretion
A 38 yo G3P3 would like to restart the birth control pill. Her PMHx is significant
for hypertension, well controlled with a diuretic, and a seizure disorder. Her last
seizure was 12 years ago and currently is on no anti-epileptic medications. She
complains of stress related headaches that are relieved with over the counter pain
medications. She is divorced, smokes 1 pack of cigarettes per day, drinks 3-4
alcoholic beverages per week. On exam, she weighs 90 kg, her BP is 126/80, and
pelvic exam is normal. She has some lower extremity non-tender varicosities. She
has taken birth control pills in the past and would like to restart them as they help
with her menstrual cramps. Which of the following would contradict the use of
combination oral contraceptives in this patient?
a)
b)
c)
d)
e)
Varicose veins
Tension headaches
Seizure disorder
Smoking in a woman over 35 years of age
Hypertension
True or False about OC
►
►
►
►
►
►
The combined OC reduces the risks
of ovarian and endometrial cancer.
Women on the combined OC should
have periodic pill breaks.
The combined OC affects future
fertility
The combined OC causes birth
defects if a woman becomes pregnant
while taking it
The combined OC must be stopped
in all women over 35
The combined OC causes acne.
►
True
►
False
►
False
►
False
►
False
►
False
27 yo nulligravid student was “celebrating” with her male partner
after passing her exams. Immediately after intercourse she
noticed that the condom was broken.
Her LMP was 12 days ago. She has regular 28 day cycles with
molimina. She normally takes Alesse but had stopped 6 months
ago.
She pages you, her medical student best-friend , at 2 am. She
does not want to get pregnant. What would be the appropriate
management(s) to offer this couple?
(You may chose up to three answers)
Contraception
a) Urgent pregnancy test (serum)
b) Suggest expectant management and wait to see if she
misses a period
c) If she still has her Alesse tablets, take 5 of these now, and
another 5 in 12 hours
d) Insertion of copper containing IUD
e) 0.75 mg Levonorgestrel po now and again in 12 hours
f) Suggest doing a handstand q hourly x 48 hours to
prevent implantation
Emergency Contraception
Yuzpe Method





within 72 hours of intercourse
2 Ovral tablets q12h x 2 doses (with Gravol!)
100 µg estradiol + 500 µg levonorgestrol (LNG) EACH dose.
6-8% chance of pregnancy decreases to 2% with Yuzpe
recent estimate of pregnancy 3.2%
‘Plan B’
 within 72 hours of intercourse
 0.75 mg (LNG) every 12h x 2 doses (less nausea) or 1 double dose of the
LNG EC regimen (1.5 mg) may be used, as they have similar efficacy with no
difference in side effects.
 increase in efficacy compared to Yuzpe with 1.1% pregnancy rate.
 beware BMI>30.
Copper IUD Insertion
 most effective
 within 5 days of intercourse (extended up to 7 days in Canada)
 1% failure rate
Ovral And Substitutions
Brand
Pills/Dose EE (μg)/Dose LNG (μg)/Dose
Ovral
2
100
500
Alesse
5
100
500
Triphasil
4 yellow
120
500
Triquilar
4 yellow
120
500
Minovral
4
120
600
Follow Yuzpe, therefore, repeat dose in 12h.
An 18 yo university student recently became sexually active
and is complaining of severe dysmenorrhea which is not
responsive to heating pads and mild analgesics. She does
not want to get pregnant. Which of the following is the
most appropriate treatment for this patient?
a)
b)
c)
d)
e)
NSAIDS
Narcotic analgesics
Short acting benzodiazepines
Combined hormonal contraceptive
Selective serotonin reuptake inhibitors (SSRIs)
A 27 yo woman complains of mood swings, depression,
irritability, and breast pain each month in the week prior to
her menstrual period. She often calls in sick at work
because she cannot function with these symptoms present.
Which is the best option for treating this patient?
a)
b)
c)
d)
e)
NSAIDS
Narcotic analgesics
Short acting benzodiazepines
Combined hormonal contraceptive
Selective serotonin reuptake inhibitors (SSRIs)
Continuous & Extended Hormonal
Contraception
Commonly used to various degrees worldwide
► Consider offering it to women for contraception,
medical reasons, and personal preferences
► As effective as cyclic regimens
► Fewer total days bleeding and similar BTB pattern
compared to cyclic. Both improving over time.
► Short-term safety data similar to cyclic
►
Continuous & Extended Hormonal
Contraception
►
Non-contraceptive benefits





Pain suppression (endometriosis)
Bleeding suppression (fibroids, bleeding diathesis)
Suppression of withdrawal symptoms (PMS)
Suppression of menstrual migraine
Management of perimenopausal symptoms
Pelvic Pain: Differential Diagnosis
ACUTE:
•
•
Adnexal:
•
•
Mittelschmerz
Ovarian cysts, rupture, torsion
•
Hemorrhage into ovarian cyst or
neoplasm
Uterine:
•
•
•
•
Degenerating fibroids
Torsion of pedunculated fibroid
Pyometra/hematometra
CHRONIC:
•
•
•
•
•
•
•
•
•
Endometriosis/adenomyosis
Dysmenorrhea (cyclic pain)
Ovarian cysts
Chronic PID
Adhesions
Uterine prolapse
Cancer invasive (late)
Fibroids
Pelvic congestion syndrome
Infectious
•
•
Acute PID
Endometritis
** RULE OUT PREGNANCY!**
A 39 yo G3P3 complains of severe, progressive, secondary
dysmenorrhea and menorrhagia. Pelvic examination
demonstrates a tender, diffusely enlarged uterus with no
adnexal tenderness. Endometrial biopsy was normal.
Which of the following is the most likely diagnosis?
►
►
►
►
Endometriosis
Endometritis
Adenomyosis
Leiomyoma
Endometriosis
• Abnormal growth of endometrial glands and stroma
outside the uterine cavity
• Pathogenesis is unknown
• Infertility
• Dysmenorrhea, dyspareunia, dyschezia
• On pelvic exam:
• Tender nodules especially over uterosacrals
• Uterine retroversion with decreased mobility
• Adnexal enlargement with tenderness
• May also be normal
Diagnostic Laparoscopy For Pelvic Pain
Should Be Performed To:
a) Evaluate women with cyclic pain who respond to
NSAIDs or OCP
b) Initially evaluate women with chronic non-cyclic
pelvic pain
c) Biopsy and treat endometriotic lesions
d) Lyse all adhesions
Which Of The Following Statement(s) Is/Are
True?
a) Women with endometriosis always have
dysmenorrhea or chronic pelvic pain.
b) Minimal or mild endometriosis should only be
treated medically and never surgically.
c) The degree of pelvic pain correlates with
laparoscopic findings.
d) Medical treatment of endometriosis includes OCP,
progestins, GnRH analogues (Lupron), Danazol.
e) Medical treatment of endometriosis results in long
term disease suppression and pain relief after
cessation of therapy.
Your 43 yo patient would like to get pregnant but is
concerned that she may be too old to get pregnant. You
recommend that she have her gonadotropin levels tested.
Which day of the menstrual cycle is best to test this?
Which day would be best to check her progesterone level
to confirm ovulation? (cycle interval 28 days)
a)
b)
c)
d)
e)
Day 3
Day 8
Day 14
Day 21
Day 26
Infertility - Etiology
 Tubal/Pelvic Pathology (35%)
 Sperm Problems (35%)
 Ovarian Problems (15%)
 Unexplained (10-15%)
Infertility Investigations
1. Ovaries
•
•
•
•
Day 3 FSH
LH kits, Day 21 progesterone. USS $$
TSH, Prolactin
Basal Body Temperature
2. Testes
•
Semen analysis x 2
3. Tubes
•
•
HSG/SIS (saline infusion sonohysterography)/ Tubal Patency
testing (ie. Echovist – starch solution with saline, shaken to form
millions bubbles)
Laparoscopy (with chromopertubation)
4. Sex
•
•
Timing
Frequency
Hysterosalpingogram (HSG)
HSG
Saline Sonohysterography
Images of sonohysterography. The uterine wall and saline in the uterine
cavity are seen as black or “empty” space. A fibroid is seen in the uterine
cavity in the image on the right.
Laparoscopy
31 y.o. woman complains of sudden onset of RLQ pain.
• pain is constant and worse with movements.
• no nausea/vomiting.
• bowel movements are normal.
Her LMP was 7 weeks ago, and she has been actively
trying to get pregnant. Past medical history is positive for
PID requiring hospitalization for IV antibiotics for 4
days.
Her vitals are stable, and she is afebrile. She is having
mild vaginal bleeding (<1 pad) that started today. The
abdomen is tender with guarding.
What is the most likely diagnosis?
a)
b)
c)
d)
e)
Ruptured ectopic pregnancy
Appendicitis
Incomplete abortion
Ovarian torsion
Hydatidiform mole
Location of Ectopic Pregnancy
What 3 initial investigations would be most
appropriate?
a) CBC
b) pelvic ultrasound (endovaginal and transabdominal)
c) flat plate (x-ray) of abdomen
d) quantitative HCG
e) sigmoidoscopy with possible colonoscopy
f) IVP with delayed films
In order to help distinguish an IUP from an ectopic
pregnancy, the change in hCG levels over 48 hours is
observed.
What percentage rise in hCG represents the lower limit of
normal values for viable IUP?
a) 33%
b) 50%
c) 66%
d) 100%
Investigations
• Hx & P/E
• HCG quantitative, CBC, blood T&S
• Pelvic Ultrasound and the Discriminatory Level
- an intrauterine pregnancy should be seen if
- HCG > 1 500 – 2 000 IU/L (transvaginal)
- HCG > 6 500 IU/L (transabdominal)
• Serial HCG
- normal doubling time is about 2 days
- inadequate doubling suggests abnormal pregnancy
• Laparoscopy: definitive diagnosis
Treatment
1. Medical (Methotrexate):
• 50 mg/m2 (1/10th chemo dose)
• serial HCG; weekly F/U
• 10-15% failure rate, 25% require 2nd dose
• Criteria:
• patient clinically stable
• no FHR
• hCG <5000
• <3.5cm unruptured ectopic pregnancy
• no hepatic/renal/hematologic disease
• compliance and F/U essential
2. Surgical
• Laparoscopy vs laparotomy
• Salpingectomy vs salpingostomy
Ectopic Pregnancy
A 60 year old woman presents with a pelvic mass. What
percentage of ovarian neoplasms in post-menopausal
women are malignant:
a) 5%
b) 10%
c) 30%
d) 50%
Ovarian Neoplasms
1.
21 yo G2P2 with increasing hair growth, more acne, with a 7cm left adnexal mass.
2.
A 23 yo woman undergoing laparoscopy for a 5 cm solid right ovarian mass. Pathology
shows hair, sebum and thyroid tissue.
3.
A 56 yo postmenopausal woman with enlarged uterus, vaginal bleeding, and a 6 cm
right adnexal mass.
4.
A 10 yo healthy young girl with LLQ pain and left ovarian mass.
5.
A 17 yo woman with primary amenorrhea with a pelvic mass. Karyotyping revealed a
mosaicism of sex chromosomes (45, X/46, XY)
►
►
►
►
►
Granulosa tumor
Germ cell tumor
Gonadoblastoma
Sertoli Leydig cell tumor
Mature teratoma (dermoid cyst)
Ovarian Cysts/Tumors
Benign vs. malignant
► Benign
►
 Physiological (follicular cysts, corpus luteal cysts,
hemorrhagic cysts)
 Endometrioma
 Benign adenomas
 Germ cell tumors (dermoid cysts)
Ultrasound:Ovarian Tumors
A 30 yo woman came to your office because her 70 yo grandmother
recently died from ovarian cancer. You discuss with her the risk
factors and prevention of ovarian cancer. Which of the following can
decrease a woman’s risk of ovarian cancer?
a)
b)
c)
d)
e)
Use of combination OC therapy
Menopause after age 55
NSAIDS
Nulliparity
Ovulation induction medications
Cervical Cancer Screening Guidelines
(2012)
Question
2005 Guidelines
Updated Cytology
Guidelines (2011)
Primary HPV guidelines (2011)
Initiation
Within 3 years of 1st vaginal sexual
activity (with cytology)
Age 21 years with cytology
in sexually active women
Age 30 years with primary HPV
screening
Interval (after a negative test)
Annual until 3 consecutive negative
cytology tests, then every 2-3 years
Every 3 years
Age ≥ 30: every 5 years
Cessation
Age 70 (if adequate negative
screening history in previous 10 years
(≥ 3 negative tests)
No change
Age 65 years if adequate negative
screening history and final negative
HPV test at age 65 years
Follow-up (after a positive
test)
• ASCUS (age ≥ 30): triage with HPV
• ASCUS (age < 30): repeat cytology
at 6 mos. intervals over 12 mos.
•ASC-H, HSIL, sq. ca., adenoca.
Refer to colposcopy
•AGC, atypical endocervical cells,
atypical endometrial cells. Refer to
colposcopy ± endometrial sampling
•LSIL: repeat cytology at 6 mos.
Intervals over 12 mos. Or refer to
colposcopy.
No change
Age ≥ 30:
• HPV +ve: triage with cytology
• HPV +ve/cytology +ve
(≥ASCUS): refer to colposcopy
• HPV +ve/cytology –ve: repeat
HPV test at 12 mos. Refer HPV
+ve results to colposcopy.
A 45 yo G4 P4 presents for her well-woman examination. She has
had 4 vaginal deliveries. Her LMP was 1 year ago and she still has
occasional vasomotor symptoms. Past health is notable for conization
of the cervix for adenocarcinoma in situ (AIS) performed 5 years ago.
All of her PAP smears have been normal since. How often should she
undergo PAP smear testing?
a)
b)
c)
d)
e)
Every 3 months
Every 6 months
Every year
Every 2 years
Every 3 years
Colposcopy
1° HPV Management Algorithm
HPV testing in women age 30-65 years
Positive
Negative
Cytology test
Repeat HPV testing
at 5 year intervals
until age 65
Negative
Repeat HPV
testing at 12
months
Negative
Positive (≥ ASCUS)
Colposcopy
Positive
1° HPV Screening
Disconnect between the Science and Reality:
• Clear evidence for primary HPV screening but
conventional PAP/cytology is sole modality so far
• HPV test not currently publicly-funded in Ontario
•
Currently more of a co-test
• Should implement primary HPV screening within
organized program
•
•
OCSP not fully organized – underway with patient
correspondence starting summer 2012
? implementation in 2015-2016.
A 21 yo woman is seen for a Pap smear showing HSIL, colposcopy
confirms a cervical lesion. Which of the following HPV types is often
associated with this type of lesion?
A 20 yo woman complains of bumps around her vaginal opening
which have been getting bigger. On physical exam, there are multiple
2-10 mm lesions around her introitus. Her cervix has no gross lesions.
A Pap test showed ASCUS. Reflex HPV testing showed no high risk
HPV. Which of the following HPV types is often associated with
this?
a)
b)
c)
d)
e)
HPV type 6
HPV type 11
HPV type 16
HPV type 42
HPV type 44
HPV Immunization
►
Prevents 2 high-risk (HR) Types that cause 80%
of cervical cancer
 16, 18 most likely assocaiated with cancer.
►
Immunized women continue to need screening
A 29 yo G0 complains of a vaginal discharge that is thin, grayish white
color. She noticed a slight fishy vaginal odor. She denies vaginal or
vulvar pruritis or burning. She is sexually active, but denies STIs in
the past. She is on OCP. Last month, she took a course of
amoxicillin for a sinus infection. What is the most likely diagnosis?
a)
b)
c)
d)
e)
Physiologic discharge
Candidiasis
Bacterial vaginosis
Trichomoniasis
Chlamydia
Parameter
Normal Findings
Vulvovaginal
candidiasis
Bacterial
vaginosis
Trichomoniasis
Symptoms
None or mild,
transient
Pruritus, soreness,
change in discharge,
dyspareunia
Malodorous
discharge, no
dyspareunia
Malodorous,
purulent discharge,
dyspareunia
Signs
Normal vaginal
discharge: white/
transparent, thick,
mostly odorless
Vulvar erythema,
edema, fissure .
Thick, white,
adherent, “cottagecheese”
Thin, homogeneous,
gray, malodourous
discharge
Purulent, greenishyellow discharge,
vulvovaginal
erythema
Vaginal pH
4.0 - 4.5
4.0 - 4.5
> 4.5
5.0 - 6.0
Amine Test
Negative
Negative
Positive (about 7080%)
Often positive
Saline
microscopy
PMN:EC ratio <1;
rods dominate;
squames +++
PMN:EC ratio <1; rods
dominate; squames
+++;pseudohyphae (about
40 percent); budding
yeast for nonalbicans
Candida
PMN:EC <1; loss of
rods; increased
coccobacilli;clue cells
(>90 percent)
PMN ++++; mixed
flora; motile
trichomonads (60
percent)
10% KOH
Negative
Pseudohyphae
(about 70 percent)
Negative
Negative
Culture if microscopy
negative
Culture of no value
If microscopy
negative perform
culture or rapid
antigen/nucleic acid
amplification tests
Other
Differential
Diagnosis
Physiologic
leukorrhea
Contact irritant or allergic
vulvar dermatitis,
chemical irritation, focal
vulvitis (vulvodynia)
Purulent vaginitis, DIV,
atrophic vaginitis, erosive
lichen planus
GENERAL DIAGNOSTIC
APPROACH
►
Office-based tests are under-utilized:
 Microscopy not performed in 37%
 pH not measured in >90%
 Whiff testing not performed in >90%
 Medication prescribed in 54% without clinical evaluation.
Vulvovaginitis Treatment

Candida
 Intravaginal OTC azole ovules and creams (clotrimazole, miconazole)
 Fluconazole 150 mg po single dose

Bacterial Vaginosis
Metronidazole 500 mg po BID for 7days
Metronidazole gel 0.75%, 5g pv OD for 5 days
• Clindamycin cream 2%, 5g pv OD for 7 days (oil-based)
•
•
 Alternatives
•
•

Metronidazole 2 g PO single dose (85% cure but higher relapse)
Clindamycin 300 mg PO for 7 days
Trichomonas
 Metronidazole 2 g po single dose
 Metronidazole 500 mg BID for 7 days
19 year old G0 woman presents to the ER with lower abdo/pelvic
pain for 2 days. She had developed a fever today and a vaginal
discharge. She has recently become sexually active and is not using
contraception. A pregnancy test is negative. What is the most likely
diagnosis?
a) early appendicitis
b) chlamydial cervicitis
c) disseminated herpes
d) PID
e) trichomonas vaginitis
PID
Clinical diagnosis
• ascending infection to endometrium, tubes, peritoneum
• spectrum of severity
• 2/3 asymptomatic, many subtle or mild symptoms.
Common:
•
•
•
•
fever > 38.3 C
lower abdominal/pelvic pain and tenderness (adnexal)
cervical motion tenderness on bimanual exam
abnormal discharge: vaginal or cervical.
Uncommon:
• nausea, vomiting
• dysuria
• irregular vaginal bleeding
• RUQ pain (Fitz-Hugh-Curtis)
Reasons for Hospitalization
• pregnancy
• failed outpatient management of oral antimicrobials
• unable to tolerate oral meds
• tubo-ovarian abscess
• severe illness, nausea/vomiting, high fever
• immunocompromised
• previous instrumentation
• unreliable for follow up or compliance
A 50 yo woman complains of leakage of urine. In addition
to genuine stress urinary incontinence (GSI), which of the
following is the most common cause of urinary leakage?
a)
b)
c)
d)
e)
Detrusor dyssynergia
Urethral diverticulum
Overflow incontinence
Mixed incontinence
Fistula
A 65 yo woman presents for evaluation of pelvic prolapse. She has a
history of well controlled chronic hypertension. She has had 3 SVD,
the last baby weighed 9 lbs and required forceps for delivery. She has
a Hx of chronic constipation and uses a laxative regularly. She has
smoked for 30 years and has a smoker’s cough. She is postmenopausal and has never been on HT. Which of the following is the
LEAST important in the subsequent development of genital prolapse
in this patient?
a)
b)
c)
d)
e)
chronic cough
chronic constipation
chronic hypertension
childbirth trauma
menopause
Pelvic relaxation
Predisposing Factors
• age
• pregnancy and vaginal childbirth
• menopause (↓ estrogen)
• changes in pelvic anatomy (surgery)
• obesity
• chronic cough
• chronic constipation
• connective tissue disorders
Treatment
1. Conservative
•
•
•
•
•
•
Pessary (not useful for rectocele)
Kegels
weight loss
stool softeners
HT
smoking cessation
2. Surgical
•
•
•
•
Vaginal Hysterectomy (for uterine prolapse)
Vaginal Repair (anterior, enterocele, and/or posterior repair)
Vault suspension
Anti-incontinence procedure
Good Luck!!
Any questions?