Disease
Disease
Primary
Dysmenorrh
ea
Description & H&P
H&P
Menstrual pain associated with
menstrual cycles in the absence
of pathological findings – usually
begins within 1-2 years after
menarche.
CC –
Lower abdominal cramps, may
radiate to back and groin and
upper thighs
HPI-
o
o
pain often starts several
hours before menses, and
lasts 24-72 hours
commonly associated
symptoms - nausea,
vomiting, diarrhea,
backache, headache,
fatigue, dizziness
Diagnosis and Diagnostic Study
Diagnosis and Diagnostic Study
No testing necessary in many cases, depending
on history and exam
o potentially useful tests
 pregnancy test
 Pap smear
 cervical cultures (or polymerase chain
reaction for gonococci and chlamydia)
 vaginal wet mount for bacterial
vaginosis, trichomoniasis, candidiasis
 CBC or ESR for infection or
inflammation
 urinalysis
 TSH
o tests to consider in difficult cases
 pelvic ultrasound
 hysteroscopy
 hysterosalpingogram
 laparoscopy may be last resort
Diagnosed By H&P
Secondary
Dysmenorrh
ea
o
o
o
secondary dysmenorrhea menstrual pain associated
with pelvic pathology
symptoms usually begin
after age 20-25 years in
cases of secondary
dysmenorrhea
symptoms which may
suggest secondary
dysmenorrhea:
 dyspareunia
 menorrhagia; heavy
menstrual flow
suggests adenomyosis,
myomas, polyps
 fever
 infertility suggests
endometriosis, chronic
inflammation
Cervical Cultures to R/O pelvic infections
Pelvic imaging to R/O presence of uterine
fibroids or other anomalies
Ultrasound or MRI
Clinical Intervention and Clinical Therapies
Clinical Intervention and Clinical Therapies
 Intervention
Oral contraceptives
 Depot-medroxyprogesterone acetate; surgical
laporatomy if marked disability
Pharmacologic therapy
 non-steroidal anti-inflammatory drugs
(NSAIDs) may reduce pain but increase
neurological adverse events in women with
primary dysmenorrhea (level 2 [mid-level]
evidence)
o insufficient evidence to guide selection of
specific NSAID
o dosing options include
 ibuprofen (Motrin, Advil) 800 mg orally
3 times daily, 600 mg orally every 6
hours, or 400 mg orally every 4 hours
 naproxen sodium (Anaprox) 550 mg
orally twice daily
 mefenamic acid (Ponstel) 250 mg orally
every 4-6 hours
 celecoxib (Celebrex) 400 mg initially
then 200 mg orally twice daily
o not recommended in advanced renal
disease, hepatic insufficiency, nursing
mothers
Exercise
Other
Other
Pain is produced by uterine
vasoconstriction, anoxia and
sustained contractions mediated
by prostaglandins
Disease
Dysfunctiona
l Uterine
Bleeding:
Heavy
Menstrual
Bleeding,
hypermenorr
hea;
menorrhagia
Description & H&P
excessive menstrual blood loss
which interferes with woman's
physical, emotional, social and
material quality of life(1)
normal menstrual flow is 2-8
days(1)
menstrual blood loss > 60-120
mL/period associated with
anemia and iron depletion
Causes:
o
potential causes in women
with ovulatory cycles
 uterine fibroid
(leiomyoma)
 increased fibrinolytic
activity in endometrium
 increased
prostaglandin levels
o specific cause often not
recognizable in heavy
menstrual bleeding related
to hormonal imbalance
Chief concern (CC):
o
excessive menstrual blood
loss which interferes with
woman's physical,
emotional, social and
material quality of life(1)
Past medical history (PMH):
o
features that may be more
common in women with
hemostatic disorder (such
as von Willebrand disease)
 excess menstrual
bleeding since
menarche
 bleeding after dental
extraction
 postoperative bleeding
 postpartum
hemorrhage
Social history (SH):
o
heavy menstrual bleeding
associated with absence
from work
Diagnosis and Diagnostic Study
Making the Diagnosis:
history of excessive menstrual blood loss which
interferes with woman's physical, emotional,
social and material quality of life
Differential diagnosis:
o
o
bleeding disorders
 von Willebrand disease
 thrombocytopenia
structural lesions
 uterine leiomyomata
 endometrial cancer
 cervical cancer
 cervical erosions
 cervical polyps
 vaginal lesions
Diagnostic Testing
CBC
Coagulopathy testing
hemostatic abnormalities may be
common in women with menorrhagia
at any age
white women with menorrhagia may
have increased prevalence of
inherited bleeding disorders
adolescents with menorrhagia may
have abnormalities of platelet count
or function
Imaging- ultrasound (First Line);
hysteroscopy (second line when
Ultrasound inconclusive);
sonohysterography
 Endometrial biopsy - used to rule out
endometrial cancer or atypical hyperplasia
o indications include
o persistent intermenstrual bleeding
o treatment failure in women > 45 years
old
-
Clinical Intervention and Clinical Therapies
o
improvement in quality of life measures should
be goal of any interventions
o clarifying values and patient preferences may
reduce hysterectomy rates for menorrhagia
medications
 levonorgestrel-releasing intrauterine
system (LNG-IUS) appears effective for
heavy menstrual bleeding and is treatment
of choice if
o hormonal treatments are acceptable
o at least 12 months use anticipated
 combined oral contraceptives is second-line
drug treatment option either nonsteroidal
antiinflammatory drugs
(NSAIDs) or tranexamic acid (Lysteda)
considered
o second-line treatment option if either
hormonal or non-hormonal treatments
are acceptable preferred treatment
option if hormonal treatments are not
acceptable
o tranexamic acid should not be used
before LNG-IUS if long-term use is
anticipated
 oral progestins (such as norethisterone 15 mg
once daily on menstrual cycle days 5-26)
or injected long-acting progestinsconsidered
third-line treatment options
 danazol may be effective for heavy menstrual
bleeding
surgery/procedures
 surgery reduces menstrual bleeding at 1 year
more than medical therapy, but
levonorgestrel-intrauterine system improves
quality of life as effectively as surgery
endometrial ablation
o preferable to hysterectomy in women
with heavy menstrual bleeding alone
and uterus ≤ 10 week pregnancy size
o is effective for reducing heavy uterine
bleeding in most women
o preprocedure endometrial thinning may
improve operative conditions and
amenorrhea at 12 months
referral for consideration of surgery or uterine artery
embolization (UAE) as first-line treatment
recommended for women with large fibroids and
heavy menstrual bleeding and other significant
Other
Complications:
o
o
anemia
iron deficiency anemia
Disease
Description & H&P
Diagnosis and Diagnostic Study
Skin:
o
look for signs of bleeding
disorders
Abdomen:
o
inspect and palpate for
abdominal and/or
suprapubic mass
Pelvic:
o
Vaginitis –
Atrophic
Vaginitis
visual inspection for vulvar,
vaginal or cervical lesions
bimanual exam for uterine
or adnexal mass, uterine
enlargement or tenderness
Description:
o
vaginal changes due to
post-menopausal estrogen
deficiency or other
conditions associated with
estrogen deficiency
Also called:
Diagnosis o usually a clinical diagnosis based on history
and physical exam
o diagnosis may be supplemented by vaginal
pH and/or cytology
Differential diagnosis:
o
o
o
urogenital atrophy
vaginal atrophy
Who is most affected:
o
post-menopausal women
without estrogen
replacement
Causes: Lack of estrogen
Risk Factors – anti estrogen
medication;
medroxyprogesterone,
tamoxifen, danazol, leuprolide,
nafarelin; cigarette smoking
Associated conditions:
o
urinary tract symptoms
(frequency, urge, dysuria)(1)
o lower urinary tract
infection(1)
o pelvic organ prolapse
History:
Chief concern (CC):
o
Other
symptoms such as dysmenorrhea or pressure
symptoms
 UAE, myomectomy or hysterectomy should all
be considered, discussed and documented
when surgery for fibroid-related heavy
menstrual bleeding is considered necessary
 vaginal hysterectomy preferred over
abdominal hysterectomy after incorporating
individual assessment
 dilation and curettage (D&C) should not be
used as therapeutic treatment
Physical:
o
Clinical Intervention and Clinical Therapies
lack of vaginal lubrication
o
o
superimposed microbially-induced vaginitis
 Candida vulvovaginitis
 bacterial vaginosis (BV)
 trichomoniasis
contact reaction to irritants
squamous cell carcinoma of cervix
Diagnostic Testing
o
o
o
estrogen therapy (vaginal preferred due to
limited systemic absorption) is primary treatment
 local estrogen therapy may be delivered by
vaginal cream, ring, or tablet
 local estrogen therapy by various
methods appear equally effective for
reducing symptoms of vaginal atrophy (level
2 [mid-level] evidence)
vaginal moisturizer or lubricant as supplement or
alternative
systemic (oral or transdermal) estrogen
replacement may be recommended if
osteoporosis or vasomotor symptoms
Pathogenesis:
o
thin vaginal epithelium, with
resultant glycogen and lactic
acid deficiency
Disease
Description & H&P
with coitus
pruritus
dyspareunia
discharge may occur
History of present illness
(HPI):
o
o
o
o
o
menopause
history of condition
requiring antiestrogenic
therapy
o breastfeeding
o use of certain personal
hygiene products (for
example, perfumes,
powders, soaps,
deodorants, panty liners,
spermicides, lubricants
containing irritants)
Physical:
Pelvic:
o
o
o
early stages
 vestibule thin and dry
 vagina mildly
erythematous
later stages
 loss of labial fat pad
resutis in pendulous
labia majora
 labia minora less
distinct
 clitoral prepuce
decreases, so clitoris
may appear larger
 vagina loses elasticity
and rugal folds
 vagina becomes
shortened, narrower
(introital stenosis)
 vagina easily
traumatized
possible associated findings
 urethral caruncle
 cystocele
 rectocele
 uterine prolapse
Diagnosis and Diagnostic Study
Clinical Intervention and Clinical Therapies
Other
Disease
vulvovaginal
Candidiasis
Description & H&P
Chief concern (CC):
Diagnosis and Diagnostic Study

o
most commonly presents as
acute vulvar pruritus or
vaginal discharge
o vaginal irritation and
soreness
o vulvar burning
o dyspareunia
o external dysuria
History of present illness


diagnosis suspected in woman with
symptoms (such as vaginal itching, vaginal
discharge, or external dysuria)
wet preparation (saline or 10% potassium
hydroxide) or Gram stain of vaginal
discharge showing yeasts, hyphae, or
pseudohyphae
culture or other test yielding positive results
for a yeast species
(HPI):
o
symptoms may be worse in
week before menses
Medication history:
o ask about
 oral contraceptives
 antibiotic use
 corticosteroid use
Past medical history (PMH):
o ask about
 pregnancy
 diabetes mellitus
 immunosuppression
Social history (SH):
o
ask about recent sexual
history and behavior
Physical:
Pelvic:
o
o
Bacterial
vaginosis
o
vaginal exam may reveal
 thick white "cottage
cheese-like" adherent
discharge
 labial and vulvar
erythema and swelling
 possible labial and
vulvar fissure and
pustulopapular
peripheral lesions
cervix normal on speculum
exam
polymicrobial infection of
vulva and vagina
 may be asymptomatic
 typically presents with
vaginal discharge
Making the diagnosis:
o
clinical diagnosis using (Amsel criteria)
requires 3 of the following
 homogeneous thin white or gray
Clinical Intervention and Clinical Therapies
o
o
do not treat if asymptomatic
uncomplicated vulvovaginal candidiasis
 effective options include
o numerous topical agents
(butoconazole, clotrimazole,
miconazole, nystatin, tioconazole,
terconazole)
o fluconazole (Diflucan) 150 mg orally in
single dose
 oral and intravaginal antifungals appear to
have similar effectiveness for uncomplicated
vaginal candidiasis
o addition of daily probiotics supplement to singledose fluconazole may further decrease
symptoms of vulvovaginal candidiasis
complicated vulvovaginal candidiasis (severe
disease, infection not caused by Candida albicans, or
infection in abnormal host)
 treat with topical agent for at least 7 days, or
with fluconazole 150 mg orally every 72
hours (every 3 days) for 3 doses
o topical boric acid or topical flucytosine may be
effective against Candida glabrata vaginal boric
acid and oral fluconazole may have similar
efficacy for symptomatic outcomes in patients
with diabetes
o recurrent vulvovaginal candidiasis
 defined as > 4 symptomatic episodes within
1 year
 treat with topical or oral azole for 10-14
days initially
o follow with suppressive therapy using
fluconazole 150 mg orally in single dose weekly
for 6 months
o in pregnancy
 antifungal treatments for vulvovaginal
candidiasis are FDA Pregnancy Category C
except for nystatin vaginal tablets (Category
A) and topical clotrimazole preparations
(Category B)
 treatment for 7 days may be needed and
topical imidazole may be more effective
than nystatin)
treat all symptomatic women
 first line therapy for nonpregnant women
includes 1 of 3 antimicrobial regimens
o metronidazole 500 mg orally twice daily for
7 days
Other
Prevention:
o
o
consider fluconazole 150
mg orally as prophylactic
treatment when giving
systemic antibiotics or as
maintenance therapy in
especially susceptible
patients(2)
for maintenance treatment
in recurrent vulvovaginal
candidiasis(3)
 fluconazole 100-200 mg
orally once weekly for 6
months considered firstline choice
 intermittent use of
topical treatments is
alternative
Whiff test:
o
positive whiff test is
presence of amine (fishy)
odor of vaginal discharge
Disease
Description & H&P
characterized by fishy
odor
o not a sexually transmitted
disease
o An overgrowth of
Gardnerella and other
aerobes
Chief concern (CC):
o
o
o
o
o
o
Trichomonia
sis
vulvovaginal itching or
burning
dyspareunia
foul-smelling (musty or
fishy) vaginal odor
thin, gray-white vaginal
discharge
may be asymptomatic
lack of perceived vaginal
odor associated with
unlikely diagnosis of BV
women who have sex with
women greatly affected
History:
Diagnosis and Diagnostic Study

o

o
o
in women
 motile T. vaginalis on wet mount of
vaginal secretions
 culture for T. vaginalis if trichomoniasis
suspected but not confirmed on wet
mount
 other diagnostic tests
o immuno-chromatographic assay
test
o nucleic acid probe test
o polymerase chain reaction (PCR)
test
o transcription-mediated amplification
test
in men
 culture for T. vaginalis from urethral
Other
o
discharge coating vaginal walls
> 20% clue cells present on wet mount
microscopy of vaginal discharge
 vaginal pH > 4.5
 positive whiff test - fishy or amine odor
of vaginal discharge alone or after
addition of 10% potassium hydroxide
(KOH)
vaginal pH > 4.5 is most sensitive and amine
odor most specific for BV

Chief concern (CC):
vulvar pruritus, burning,
profuse vaginal discharge,
rancid odor, postcoital
bleeding(1, 2)
o many women have little or
no symptoms(1)
o men may not have
symptoms or may have
symptoms of urethritis(1)
Physical:
Clinical Intervention and Clinical Therapies

metronidazole gel 0.75% one full applicator
(5 g) intravaginally once daily for 5 days
o clindamycin cream 2% one full applicator (5
g) intravaginally once daily at bedtime for 7
days
for pregnant women with symptoms - treat with 1
of 3 regimens
o metronidazole 500 mg orally twice daily for
7 days
o metronidazole 250 mg orally 3 times daily
for 7 days
o clindamycin 300 mg orally twice daily for 7
days
recommended treatment includes 1 of
o metronidazole 2 g orally in single dose
o tinidazole 2 g orally in single dose
alternative treatment - metronidazole 500 mg
orally twice daily for 7 days
o
before or after addition of
10% potassium hydroxide
(KOH)
whiff test can also be
positive with Trichomonas
wet mount(3)
 perform wet mount
preparation by 1 of 2
methods
o dilute vaginal discharge
with 1-2 drops of 0.9%
normal saline solution,
then place on slide with
coverslip, or
o place vaginal discharge
into 2 mL test tube
containing saline, then
place on slide
o examine slide
microscopically using
lower power (10X) and
high dry power (40X) look for clue cells
(vaginal epithelia
coated with
coccobacilli)
 consider microscopic exam
of 10% potassium hydroxide
(KOH) preparation to rule
out vulvovaginal
candidiasis(look for
evidence of hyphae)
Pathogenesis:
o
sexually transmitted
disease
o human host - lives only in
vagina, Skene's ducts, male
or female urethra (warm,
moist areas)
o attaches to walls of vagina,
causes inflammation and
discharge
Likely risk factors:
o
loss of normal acidity of
vagina
Disease
Description & H&P
Pelvic:
o
profusely frothy, thin, foulsmelling, greenish-yellowto-gray, purulent, creamy
vaginal discharge; vaginal
tenderness, may have
vulvar edema/erythema
Diagnosis and Diagnostic Study
o
o
o
o
o
Pelvic
Inflammato
ry Disease
(PID)
o
o
infection of female upper
genital tract
 many cases involve
sexually transmitted
organisms (for
example, Neisseria
gonorrhoeae, Chlamydi
a trachomatis)
 often polymicrobial
condition may include any
combination of
inflammatory disorders
 endometritis
 salpingitis
 pelvic peritonitis
 parametritis
 oophoritis
pathogens - many cases are
polymicrobial(1)
 Neisseria gonorrhoeae
 Chlamydia trachomatis
 endogenous pathogens
(that is, not sexually
transmitted) include
History:
Chief concern (CC):
o
o
may be asymptomatic(1)
symptoms, if present, may
include(1, 2)
 lower abdominal pain
Clinical Intervention and Clinical Therapies
Other
swab, urine, or semen
pH testing of vaginal secretions
whiff test
wet mount of vaginal secretions
culture for T. vaginalis
 of vaginal secretions in women if
trichomoniasis suspected but not
confirmed on wet mount
 of urethral swab, urine or semen in men

pH testing of vaginal secretions
 elevated pH (> 4.5) common in
trichomoniasis and bacterial vaginosis
whiff test
no historical, physical, or laboratory findings can
conclusively diagnose PID
 laboratory studies may be normal in patient
with PID
 abnormal laboratory studies may provide
supportive but not confirmatory evidence
 definitive diagnosis, if needed, may require
invasive testing, but treatment may be based
on clinical findings alone in most cases
 no single test has adequate sensitivity and
specificity to reliably diagnose or rule out
PID
 additional criteria which support diagnosis
include
o oral temperature > 38.3 degrees C (>
101 degrees F)
o abnormal cervical or vaginal
mucopurulent discharge
o presence of abundant white blood cells
(WBC) on saline microscopy of vaginal
fluid (wet mount)
o elevated erythrocyte sedimentation rate
o elevated C-reactive protein
o laboratory documentation of cervical
infection with Neisseria
gonorrhoeae or Chlamydia trachomatis
Diagnosing
perform pregnancy test to rule out ectopic
pregnancy
o test for Neisseria
gonorrhoeae and Chlamydia
trachomatis(recommend male partner be
tested)
IV regimens
 1 of following recommended regimens
o cefoxitin 2 g IV every 6 hours or cefotetan 2
g IV every 12 hours, PLUS doxycycline 100
mg orally or IV every 12 hours
 continue initial regimen until at least 24
hours after clinical improvement
 after discharge
 continue oral therapy
withdoxycycline 100 mg orally
every 12 hours to complete 14
days of therapy
 if tuboovarian abscess, consider
adding clindamycin ormetronidazol
e to doxycycline for more effective
anaerobic coverage
o clindamycin 900 mg IV every 8 hours,
PLUSgentamicin loading dose 2 mg/kg IV or
intramuscularly, then maintenance dose 1.5
mg/kg every 8 hours
 gentamicin once daily may be as
effective but not studied in PID
(see Single-daily dosing of
aminoglycosides)
 continue initial regimen until at least 24
hours after clinical improvement
 after discharge
 continue oral therapy
withclindamycin 450 mg orally 4
times daily or switch
to doxycycline 100 mg orally every
12 hours to complete 14 days of
therapy
 if tuboovarian
Pathogenesis:
nearly all cases are from
ascending infection of bacteria
from the endocervix
risk for PID correlates with risk
for acquiring new sexually
transmitted diseases
 aged < 25 years in 75%
cases and 10 times
increased risk
 single status, divorce,
separation
 earlier age at first
intercourse and increasing
number of male sex
partners
Differential to include
o ectopic pregnancy
o ovarian torsion
o appendicitis
Disease
Description & H&P
or pelvic pain
fever
abnormal vaginal
discharge or bleeding,
itching or odor
 dyspareunia
 back pain
 vomiting
History of present illness
(HPI):


o
ask about sexual history,
including risks for sexually
transmitted diseases
o ask about date of last
menstrual period to assess
for possibility of ectopic
pregnancy
o ask about quality of pain
(absence of migration of
pain may suggest PID over
appendicitis)
o ask about procedures
involving uterine
instrumentation that may
cause postsurgical PID,
such as
 pregnancy termination
 intrauterine device
insertion within
previous 6 weeks
 hysterosalpingography
 intrauterine
insemination
 in vitro fertilization
Physical:
General physical:
o
fever may occur
Abdomen:
o
lower abdominal
tenderness and rebound
tenderness may be present
bilateral abdominal
tenderness may suggest
PID over appendicitis
Pelvic:
o
assess for
Diagnosis and Diagnostic Study
o
o
o
o
inflammatory markers which may support
diagnosis of PID
 white blood cell count (WBC)
 erythrocyte sedimentation rate
 C-reactive protein
wet mount of vaginal fluid may show WBC
transvaginal ultrasound is imaging modality
of choice in initial evaluation of pelvic pain
for cases requiring more definitive evaluation
other diagnostic alternatives include
 computed tomography
 magnetic resonance imaging
 laparoscopy
Clinical Intervention and Clinical Therapies

abscess, clindamycinrecommende
d instead ofdoxycycline for more
effective anaerobic coverage
alternative regimen - ampicillin-sulbactam 3 g IV
every 6 hours PLUS doxycycline 100 mg orally
or IV every 12 hours (effective coverage
against Chlamydia trachomatis, Neisseria
gonorrhoeae and anaerobes and for patients
who have tuboovarian abscess)
Other
Disease
Description & H&P
Diagnosis and Diagnostic Study
Clinical Intervention and Clinical Therapies
Other

o
tenderness on
bimanual exam of
cervix, uterus or
adnexa (usually
described as cervical
motion tenderness or
adnexal tenderness)
 cervical discharge
 cervical friability
 pelvic mass
findings may be mild
with Chlamydia
o
Breast
Mass
o
most breast masses are
benign (most commonly
fibroadenoma), but breast
mass associated with
increased risk of breast
cancer in postmenopausal
women
History:
History of present illness
(HPI):
o
o
ask about
 duration of mass
 change in mass size
 changes related to
menstrual cycle
ask about related
symptoms
 breast tenderness or
swelling
 history of fever
 nipple discharge
o pathologic cause
more likely if
patient > 50 years
old, or discharge is
bloody, bloodcontaining, watery,
unilateral,
spontaneous, or
involves a single
duct
o physiologic cause
more likely with
initial evaluation imaging for palpable breast
mass
 for women ≥ 40 years old mammography is recommended study
but ultrasound may be appropriate initial
study if had mammography in previous
6
 for women 30-39 years old - either
mammography or ultrasound of breast
 for women < 30 years old - ultrasound
of breast followed by mammography if
o ultrasound suspicious for
malignancy
o ultrasound is negative or does not
correlate with palpable mass
o if the clinical examination or other
risk factors are concerning
Magnetic resonance imaging:
o
o
magnetic resonance imaging (MRI) may be
useful for detection of breast lesions in high
risk patients, including those with(1, 2, 3)
 silicone breast implants
 prior breast conserving surgery
 known carcinoma
 axillary metastasis and unknown
primary site
 extra dense breast tissue
magnetic resonance imaging plus clinical
exam and mammogram may be more
sensitive than ultrasound plus clinical
exam and mammogram to rule out
malignancy in women with suspected
invasive breast cancer
o
o
o
aspiration of painful cyst may be adequate if
simple cyst, no residual mass, and no bloody
aspirate
if initial ultrasound and/or mammogram
demonstrate specific benign findings such as
simple cyst or lymph node, further evaluation not
necessary
if suspicious for malignancy on clinical exam or
imaging
 core needle biopsy associated with higher
diagnostic accuracy for detection of breast
cancer than fine needle aspiration cytology
in patients with palpable breast masses
 consider triple test score
o clinical exam, imaging, and tissue
sampling each scored 1 for benign, 2
for suspicious, and 3 for malignant
o triple test score validated to be
accurate for diagnosing breast cancer if
score ≥ 6 and rule out breast cancer if
score 3-4
o excisional biopsy recommended if triple
test score 5
Benign causes of breast
mass:
o
infection and inflammation
 mastitis
 cellulitis
 abscess
 chronic infections from
mycobacteria or
parasites (such as
filariasis)
 mammillary duct fistula
 sarcoidosis
 foreign bodies
o solid, non-inflammatory
lump
 fibroadenoma of
breast (most common)
 benign cyst
Malignant and premalignant
causes of breast mass:
o
o
o
o
breast cancer in women
breast cancer in men
ductal carcinoma in
situ (DCIS)
lobular carcinoma in situ
Disease
Description & H&P
o
o
discharge that is
bilateral, multiduct, multicolored
or milky, sticky,
and occurs with
stimulation
ask about history of
breastfeeding and current
lactation status
ask about hormonal
medication use
 prior or current use of
oral contraceptives
 estrogen or hormone
replacement therapy )
Past medical history
(PMH):
o
o

findings that may be
associated with higher risk
for breast cancer include
 family history of breast
cancer
 postmenopausal
hormone replacement
therapy (HRT)
 contralateral breast
cancer
 cancer of uterus or
ovary
 atypical hyperplasia
 breast carcinoma in
situ
 radiation therapy to
chest

ask about
 prior breast mass or
biopsy
recent breast trauma or
surgery
Family history (FH):
o
ask about
 breast cancer in firstdegree relatives
 mother, sister, or
daughter with history of
Diagnosis and Diagnostic Study
Clinical Intervention and Clinical Therapies
Other
Disease
Description & H&P
Diagnosis and Diagnostic Study
Clinical Intervention and Clinical Therapies
Other
breast or ovarian
cancer before age 50
years or positive test
for mutated breast
cancer genes (if so,
considerBRCA
mutation testing)
Physical:
General physical:
o
Breast
Cancer
fever and chills may be
indicative of infection (such
as mastitis)
breast cancer classified as
 carcinoma in situ
(noninvasive carcinoma,
stage 0) if cancer cells
contained within duct
(ductal carcinoma in situ) or
lobule (lobular carcinoma in
situ)
 invasive breast cancer
(infiltrating breast cancer,
stages I-IV) if cancer cells
spread beyond basement
membrane of duct or lobule
to adjacent breast
parenchyma
o invasive breast cancer
classified as(6, 7)
 early breast cancer stages I, IIa, IIb
o no tumor
extension to chest
wall or skin
o can include
movable ipsilateral
axillary lymph
node metastases
o no distant
metastases
 locally advanced breast
cancer - stages IIIa,
IIIb, IIIc - any of the
following without
distant metastases
o metastases in
ipsilateral axillary
lymph nodes that
diagnosis of invasive breast cancer is based
ontriple assessment, which includes
 findings on clinical assessment include
o palpable breast mass
o palpable lymph nodes
o skin and/or nipple changes
 findings on mammography (with or
without ultrasound) include
o microcalcifications
o spiculated opacities
o nonpalpable lesions in ipsilateral or
contralateral breast
o solid masses that correlate with
physical exam findings
o adenopathy
o architectural distortion
 tissue sampling - core needle biopsy
and/or fine needle aspiration cytology
o excisional biopsy used for equivocal cases
o types of invasive breast cancer are
distinguished based on pathology
Differential diagnosis:
o
o
o
o
o
fibroadenoma
ductal carcinoma in situ
lobular carcinoma in situ
if pain
 fibrocystic changes
 dorsal radiculitis
 Tietze syndrome (inflammation in
costochondral junction)
 mastitis
if nipple discharge(1)
 intraductal papilloma
 duct ectasia
Early invasive breast cancer:
o
initial treatment options include
 breast-conserving surgery (lumpectomy)
followed by radiation therapy to breast
o breast-conserving surgery (plus
radiation therapy) for early breast
cancer appears as effective for survival
and rate of distant metastases as
mastectomy, but may be associated
with need for re-excision or future
mastectomy
o neoadjuvant (preoperative)
chemotherapy may be used for large
tumors to improve resectability
o adjuvant radiation therapy after breastconserving surgery may reduce 10-year
recurrence risk and 15-year breast
cancer-related mortality

o
o
mastectomy indicated for patient
preference, or if large or multicentric tumor
precludes breast conservation therapy
 for Paget's disease of breast, central
lumpectomy may result in similar 15-year
breast cancer-specific survival as
sentinel lymph node (SLN) biopsy is preferred
method of axillary lymph node assessment for
staging of early breast cancer with no clinical
evidence of lymph node involvement
adjuvant systemic therapy
 endocrine therapy for hormone receptorpositive tumors
o tamoxifen (Nolvadex) 20 mg/day for 5
years recommended for
premenopausal women and appears to
histopathologic types of breast
carcinomas
 in situ carcinomas
o ductal carcinoma in
situ (DCIS)
o lobular carcinoma
in situ (LCIS)
 incidental
finding of
microscopic
abnormal
tissue growth
in lobules of
breast
 does not progress to
cancer, but associated
with increased risk of
subsequent invasive
breast cancer in either
breast
 invasive carcinomas
o ductal
o inflammatory
 clinical
diagnosis
 associated
with diffuse
skin edema,
skin and
breast
erythema
(peau
d'orange),
firmness of
underlying
tissue without
Disease
Description & H&P

are clinically fixed
or matted
o metastases in
clinically detected
internal mammary
lymph nodes
o tumor > 5 cm and
metastases in
movable ipsilateral
axillary lymph
nodes
o tumor with direct
extension to chest
wall or skin
advanced breast
cancer - stage IV
(distant metastases)
Diagnosis and Diagnostic Study
o
Clinical Intervention and Clinical Therapies


partial duct obstruction
hyperprolactinemia
fat necrosis
History:
Chief concern (CC):
o
o
breast mass
can present as breast pain
History of present illness
(HPI):


ask about palpable
breast mass including
o duration of mass
o changes in size of
mass
o changes related to
menstrual cycle
nipple discharge
o pathologic cause
more likely if
patient > 50 years
old, or discharge is
bloody, bloodcontaining, watery,
unilateral,
spontaneous, or
involves a single
duct
o physiologic cause
more likely with
discharge that is
bilateral, multiduct,
multicolored or
milky, sticky, and
occurs with
o
o
reduce recurrence risk and all-cause
mortality over 15 years
o for postmenopausal women options
which may reduce recurrence risk
compared to tamoxifen alone include
 tamoxifen for 2-3 years followed by
aromatase inhibitors for 2-3 years
for total 5 years
 aromatase inhibitor monotherapy
for 5 years
 trastuzumab (Herceptin) for human
epidermal growth factor receptor type 2
(HER2)-positive tumors may increase
overall survival and disease-free survival
but may increase risk for heart failure
 chemotherapy
o decision to use chemotherapy should
be individualized, especially if favorable
prognosis where absolute benefit is
small
o combination chemotherapy for early
breast cancer may reduce 15-year allcause mortality, breast cancer
mortality, and recurrence risk
bisphosphonates
 bisphosphonates (as a drug class) may not
be associated with reduced rates of
recurrence or bone metastases in patients
with early breast cancer; clodronate and
zoledronic acid each have mixed results in
large randomized trials
 bisphosphonates may not decrease fracture
rate but may decrease bone loss so
recommended if osteoporosis along with
lifestyle interventions, calcium, and vitamin
D to reduce risk for bone loss
Locally advanced breast cancer:
for locally advanced breast cancer including
inflammatory breast cancer - treatment includes
 neoadjuvant chemotherapy
 surgery
o for noninflammatory disease mastectomy or breast-conserving
therapy
o for inflammatory disease - mastectomy
 radiation therapy
 endocrine therapy if hormone receptorpositive, including use in neoadjuvant
therapy
Other
o
o
o
o
o
palpable mass
involving ≥
one-third of
breast
 findings due to
tumor
embolization
to dermal
lymphatics and
engorgement
of superficial
capillaries
 classified as
T4d for
staging so
stage III or IV
on
presentation
 associated
with poor
prognosis
 does not apply
to locally
advanced
cancer
presenting late
in course of
disease and
with skin
involvement
medullary, not
otherwise specified
medullary with
lymphoid stroma
mucinous (colloid) if < 1 cm, has very
low incidence of
axillary lymph node
metastases, but
sentinel lymph
node biopsy may
be appropriate
papillary
(predominantly
micropapillary
pattern)
tubular - if < 1 cm,
has very low
incidence of
axillary lymph node
Disease
Description & H&P
stimulation
breast pain - ask about
location, severity, and
relationship to
menstrual cycle or
physical activity
 skin changes
 ask about hormonal
medication use
o prior or current use
of oral
contraceptives
o estrogen or
hormone
replacement
therapy
breast pain without other
symptoms not associated
with increased risk of breast
cancer
Diagnosis and Diagnostic Study
Clinical Intervention and Clinical Therapies
Other

addition of HER2 inhibitor (such as
trastuzumab) if HER2-positive, including
use in neoadjuvant therapy
Advanced breast cancer:

o
o
o
for advanced (metastatic) breast cancer
chemotherapy recommended for women with
triple-negative tumors (HER2, estrogen receptor,
and progesterone receptor), symptomatic or
rapidly progressive organ metastases, or
disease refractory to hormone therapy
 combination chemotherapy associated with
increased survival and time to progression
compared to single-agent chemotherapy,
but may increase adverse effects
 taxane-containing regimens may improve
overall survival, time to progression, and
overall response compared to some other
chemotherapy regimens
 chemotherapy agents which may improve
survival or progression-free survival in
women with advanced breast cancer which
progresses on first-line therapy include
eribulin (Halaven), everolimus (Afinitor), and
ixabepilone (Ixempra)
for HER2-positive advanced breast cancer
 trastuzumab (Herceptin) may improve
survival but associated with increased risk
of cardiac dysfunction
 addition of lapatinib (Tykerb) to paclitaxel
(or to letrozole) may increase progressionfree survival
 addition of pertuzumab (Perjeta) to
trastuzumab plus docetaxel increases
progression-free survival (level 1 [likely
reliable] evidence)
endocrine therapy for hormone receptor-positive
advanced breast cancer
 endocrine therapy associated with similar
survival rates compared to chemotherapy
for initial treatment of hormone receptorpositive metastatic breast cancer; endocrine
therapy may be preferred due to better
tolerability, except in rapidly progressive
disease
 aromatase inhibitors (anastrozole, letrozole,
exemestane) may have survival benefit over
other endocrine therapies in
postmenopausal women with advanced
breast cancer
o
o
o
metastases, but
sentinel lymph
node biopsy may
be appropriate
o lobular
o undifferentiated
o squamous cell
o adenoid cystic
o secretory
o cribiform
microinvasive carcinoma invasive carcinoma with no
focus of tumor cells > 1 mm
 typically occurs with
DCIS or LCIS with
small foci of tumor cells
beyond basement
membrane
 rarely occurs without
noninvasive disease
Paget's disease
 exudate or crust of
nipple and areola
caused by infiltration of
epidermis by
noninvasive breast
cancer epithelial cells
 can occur with
noninvasive disease
(usually DCIS, rarely
LCIS) or with invasive
disease (infiltrating)
breast sarcomas
 account for < 1% of all
primary breast
malignancies
 usually occur in women
ages 40-60 years
 most common types
include
o angiosarcoma
o malignant fibrous
histiocytoma
o stromal sarcoma
 other types can include
o phyllodes
tumor (includes
epithelial
component)
Disease
Description & H&P
Diagnosis and Diagnostic Study
Clinical Intervention and Clinical Therapies

o
o
o
o
o
o
o
o
o
preferred first-line therapy is anastrozole 1
mg orally once daily or letrozole 2.5 mg
orally once daily, alternative is tamoxifen
20-40 mg/day orally
 endocrine therapies used for disease
progression after first-line therapy include
exemestane 25 mg orally once daily or
fulvestrant (Faslodex) 250 mg
intramuscularly once monthly
bisphosphonates (oral or IV)
 may reduce risk of skeletal events in women
with advanced breast cancer and clinically
evident bone metastases
 may not reduce risk of skeletal events in
women with advanced breast cancer
without prior bone metastasis
 appear effective for pain relief in painful
bone metastases
denosumab (Xgeva) may reduce risk for
skeletal-related events more than
bisphosphonates in women with breast cancer
and bone metastases )
low-molecular-weight heparin (LMWH) reduces
symptomatic venous thromboembolism (VTE) )
and possibly 2-year mortality in patients with
advanced cancer
surgical resection of primary tumor associated
with increased survival in retrospective studies
of patients with advanced breast cancer
Recurrent breast cancer:
breast-conserving surgery for recurrent
ipsilateral breast cancer may be associated with
worse survival compared to mastectomy
limited evidence regarding adjuvant systemic
therapy for women with isolated locoregional
recurrence following primary treatment of
operable breast cancer
Surveillance after primary cancer treatment:
mammography surveillance might improve
overall survival and breast cancer-specific
survival
breast magnetic resonance imaging
(MRI)appears more accurate than clinical exam,
mammogram, and ultrasound for detection of
breast cancer recurrence
more intensive approaches to follow-up (addition
of chest x-ray and bone scan) may improve
disease-free survival but not overall survival
compared with regular physical exams and
Other
o
o
o
o
o
fibrosarcoma
liposarcoma
leiomyosarcoma
spindle-cell
sarcoma
rhabdomyosarcom
a
Disease
Description & H&P
Diagnosis and Diagnostic Study
Clinical Intervention and Clinical Therapies
Other
yearly mammography in women with early
breast cancer
Cystocele
descent of pelvic organs toward
or through the vaginal opening
due to loss of connective tissue
support in ≥ 1 of the following
anatomic locations
 anterior vaginal wall
o most common
o usually involves
bladder prolapse
(cystocele)
 posterior vaginal wall
o usually involves
rectal prolapse
(rectocele)
o may involve small
intestine
(enterocele)
 vaginal apex
o usually involves
prolapse of uterus,
cervix, or
posthysterectomy
prolapse of vaginal
cuff (vault
prolapse)
o may involve small
intestine
(enterocele), colon
(sigmoidocele), or
bladder (cystocele)
Also called:
o
o
o
o
o
o
o
pelvic relaxation
urogenital prolapse
uterovaginal prolapse
uterine prolapse
cystocele
rectocele
enterocele
Chief concern (CC):
o
most women are
asymptomatic
symptoms vary by position
of uterus and pressure on
surrounding pelvic
structures, and may not
correlate with stage or
o
Making the diagnosis:
o
o
o
o
o
diagnosis usually made clinically by pelvic
exam during routine well-woman evaluation
or in women with symptoms of pelvic organ
prolapse such as vaginal bulge and
incontinence
seeing or feeling vaginal bulge with tissue
prolapsing to or past vaginal opening
considered most specific symptom for pelvic
organ prolapse
grading systems used to standardize
findings on physical exam
 Baden-Walker grading system
commonly used in clinical practice to
evaluate anterior, apical, and posterior
pelvic floor support defects
Grade
Description
0
1
o
o
No prolapse
Normal position for each
pelvic site
o
Prolapse halfway to
hymen
o
Prolapse to hymen
o
Prolapse halfway past
hymen
o
Maximum descent
possible for each pelvic
site
2
3
4
Baden-Walker Grading System:

Pelvic Organ Prolapse Quantification
(POP-Q) staging system
o developed by the International
Continence Society (ICS), the
American Urogynecologic Society
(AUS), and the Society of
Gynecologic Surgeons (SGS)
o commonly used for clinical
research purposes
o
conservative management
 consider watchful waiting in asymptomatic
or mildly symptomatic women with early
stage prolapse without descent beyond
hymen
 pelvic floor muscle training (Kegel
exercises)
o characterized by systematic contraction
of pelvic floor muscles by conscious
contraction, electrical stimulation, or
biofeedback training
o often used adjunctively to symptomdirected therapy such as pessaries
o pelvic floor muscle training may
improve prolapse symptoms in women
with pelvic organ prolapse
 mechanical support (pessary)
o consider pessary use in all women with
symptomatic prolapse prior to surgical
intervention
o pessary selection usually determined
by severity of prolapse and patient's
cognitive status, manual dexterity, and
level of sexual activity
o pessary use reported to help resolve
most prolapse symptomsat 2 months in
women with symptomatic pelvic organ
prolapse
surgical management
 surgical correction usually delayed in
premenopausal women until all anticipated
childbearing has been completed
 women presenting with cervical lesions or
other evidence of cervical disease should
be evaluated and treated prior to prolapse
repair
 surgical approach to pelvic organ prolapse
is either reconstructive or obliterative
o reconstructive approach
 goal of reconstructive surgery is
correction of pelvic prolapse and
relief of associated symptoms
while maintaining sexual function
 procedures may be performed by
vaginal, abdominal, or
laparoscopic approach (vaginal
Differential diagnosis:
o
o
o
o
o
uterine leiomyoma prolapsed submucosal
myoma may present as
vaginal bulge or pressure
bladder diverticula
presenting as vaginal bulge
in 2 patients in case series
editorial can be found in ,
commentary can be found
in
primary invasive vaginal
carcinoma presenting as
irreducible third degree
uterovaginal prolapse in 60year-old woman in case
report
Skene gland abscess
presenting as painful
periurethral mass in case
report
urethral leiomyoma
presenting as exophytic
periurethral mass in 27year-old woman in case
report
Disease
Description & H&P
o
severity of prolapsed
may present with ≥ 1 of the
following
 vaginal symptoms
o sensation of or
visible bulge or
protrusion from
vagina (considered
only symptom
specific to pelvic
organ prolapse)
o pelvic pressure or
heaviness
o feeling of
something "falling
out" of vagina
 urinary dysfunction
o stress incontinenc
e
o frequency
o urgency
o obstructed voiding,
including
 weak or
prolonged
urinary stream
 urinary
hesitancy
 feeling of
incomplete
emptying
 bowel dysfunction
o incontinence of
flatus or liquid or
solid stool
o straining during
defecation
o urgency
o sense of blockage
or obstruction
during defecation
o feeling of
incomplete
emptying
o manual pressure
(splinting) on
perineum or
vagina to begin or
complete
defecation (more
Diagnosis and Diagnostic Study
Stage
Description

No prolapse (anterior and
posterior points all -3 cm, and
cervix [C] or posterior fornix
[D] is between TVL and TVL 2 cm)

Prolapse > 1 cm above
hymen (< -1 cm) and criteria
for stage 0 not met

Prolapse ≤ 1 cm above or
below hymen (at least 1 point
is -1, 0, or +1)

Prolapse > 1 cm below
hymen
Most distal prolapse ≤ 2 cm
less than TVL
0
I
II
III


IV
Clinical Intervention and Clinical Therapies

Complete eversion of lower
genital tract
Most distal prolapse TVL - 2
cm beyond hymen
Abbreviation: TVL, total vaginal length.
Pelvic Organ Prolapse Quantification
(POP-Q) Staging System:
o
approach accounts for 80%-90% of
procedures)
 reconstructive surgery may involve
hysterectomy or may preserve the
uterus
 mesh may be used as a surgical
adjuvant in reconstructive
procedures
obliterative approach
 goal of obliterative surgery is to
correct pelvic prolapse by partial or
total closure of vaginal canal
 colpocleisis usually reserved for
elderly women who
 are at high risk for
complications with
reconstructive procedures
 prefer to avoid hysterectomy
 do not desire to maintain
vaginal use for intercourse
Other
Disease
Description & H&P
o
common with
posterior vaginal
prolapse)
o digital evacuation
to complete
defecation
 dyspareunia
rarely painful but patients
may mistakenly attribute
other sources of pelvic
and/or low back pain to
prolapsed
History of present illness
(HPI):
o
o
sensation of or actual
vaginal bulging may vary
over time
 may be asymptomatic
or mildly symptomatic
in the morning with
protrusion worsening
throughout the day
 may be worse after
excessive standing,
heavy lifting, coughing,
or physical exertion
 may progress with
increasing body mass
index but not reversed
by weight loss
symptoms of urinary
dysfunction may change
with disease severity
 stress urinary
incontinence may
occur with mild
prolapse and improve
or resolve as prolapse
progresses beyond
hymen
 women with prolapse
beyond hymen more
likely to report
symptoms of
obstructed voiding,
including position
change and/or manual
Diagnosis and Diagnostic Study
Clinical Intervention and Clinical Therapies
Other
Disease
Description & H&P
Diagnosis and Diagnostic Study
Clinical Intervention and Clinical Therapies
Other
pressure on prolapsed
area (splinting) to begin
or complete urination
Menopause
Description:
o
o
normal physiological event
cessation of menstrual
periods, but menopausal
symptoms often occur
before menopause
Definitions:
o
menopause - cessation of
menses
o reproductive stage - from
menarche (first menstrual
period) to beginning of
perimenopause (when
cycles become variable)
o perimenopausal - time
around menopause during
which menstrual cycle and
endocrine changes are
occurring, including first 12
months without periods
o postmenopausal - begins
at time of final menstrual
period, overlapping with
perimenopause by 12
months
o menopausal transition climacteric - time from late
reproductive stage into
postmenopause
Who is most affected:
o
o
o
average age 51 (2 years
earlier in smokers)
median onset of
perimenopause 45.5-47.5
median age of natural
menopause 51.4
 based on crosssectional study of
14,620 women aged
40-55 years
 risk factors for earlier
age of menopause
were current smoking,
lower educational
o
history of no menstrual period for 1 year in
women > 45 years old generally accurate for
diagnosis
o some physicians order follicle-stimulating
hormone (FSH) to confirm diagnosis earlier
o perimenopause should be diagnosed based
on menstrual history and age, laboratory
testing unnecessary;
best predictors that menopause will occur within
4 years, based on prospective cohort studies
 age > 50 years
 amenorrhea for 3-11 months
 menstrual cycle irregularity within 12 months
follicle-stimulating hormone (FSH)
 normal range
o child < 4 milli-units/mL
o reproductive period 6-10 milli-units/mL
o perimenopause 14-24 milli-units/mL
o menopausal > 30-40 milli-units/mL

single FSH value unreliable in
perimenopausal years; serial FSH
levels needed
o
o
use of estrogen (hormone replacement therapy
[HRT])
 primary reasons for considering estrogen
are
o symptom relief - described here
o prevention of osteoporosis
 risks may outweigh benefits for long-term
use of HRT
 estrogen should NOT be used for
cardiovascular disease prevention
treatments for alleviation of menopausal
symptoms
 vasomotor symptoms
o estrogen proven to reduce vasomotor
symptoms
o phytoestrogens may reduce hot flash
severity or frequency in women with
vasomotor menopausal symptoms,
insufficient data to define effective
phytoestrogen supplements but
extracts containing genistein ≥ 30
mg/day have most supportive evidence
o other treatments shown in randomized
trials to reduce vasomotor symptoms
include
 progestogens in high doses (but
rarely given without estrogens)
 tibolone (Livial), not available in
United States
 clonidine
 venlafaxine (Effexor)
 paroxetine (Paxil)
 gabapentin
 St. John's wort
 urogenital symptoms
o vaginal lubricants
o estrogen reduces symptoms of
urogenital atrophy
o tibolone improves libido and vaginal
lubrication
o testosterone improves sexual
enjoyment and libido
 estrogen shown to improve quality of life in
short-term trials
 estrogen reduces depressive symptoms in
Causes:
o
physiologic process of
ovarian failure, oocyte
depletion
Pathogenesis:
o
decreased estradiol-17beta secretion by ovarian
follicles
o decreased sex hormone
binding globulin (SHBG)
leads to increased free
testosterone
o hot flushes may be due to
acute lowering of
hypothalamic setpoint from
estrogen withdrawal
o hypothalamic-pituitary
insensitivity to estrogen
may occur in
perimenopausal women
diethylstilbestrol (DES)
exposure in utero associated
with increased lifetime risk of
early menopause
Complications:
o
most menopausal
symptoms (for example, hot
flushes) usually resolve with
time
o genital atrophy may be
chronic
o perimenopausal transition
may be associated with
increased risk for new
depressive symptoms
Differential diagnosis:
o
o
o
pregnancy
hypothyroidism, hyperprolac
tinemia
primary ovarian insufficiency
(POI), Savage syndrome
(no receptors on ovary),
autoimmune oophoritis
Disease
Description & H&P
o
o
o
o
o
o
o
o
attainment, being
separated/widowed/div
orced, nonemployment
and history of heart
disease; risk factors for
later age of
menopause were
parity, prior use of oral
contraceptives, and
Japanese race
Chief concern (CC):
hot flush (vasomotor
instability) then cold
sweat (night sweats)
urogenital symptoms vaginal dryness, vaginal
irritation, dyspareunia,
decreased sexual pleasure,
dysuria, frequency,
urgency, suprapubic pain
psychologic symptoms mood swings (emotional
lability), difficulty
concentrating, apathy
urinary incontinence NOT
associated with
menopausal transition
History of present illness
(HPI):
secondary amenorrhea, by
definition
up to 90% women have
altered menstrual pattern
during perimenopause (510 years)
self-limited appearance of
increased scalp hair loss
(perhaps related to
synchronous hair shedding
and asynchronous
replacement)
anovulation associated
with irregular cycle
intervals and bleeding
duration but not with
heavy bleeding
o

novulation associated
with
Diagnosis and Diagnostic Study
Clinical Intervention and Clinical Therapies
postmenopausal women
health recommendations upon reaching
menopause
 health recommendations regarding
cardiovascular disease prevention
 health recommendations regarding
osteoporosis prevention
o increased dose recommendations for
calcium and vitamin D - calcium 1,2001,500 mg/day and vitamin D 400-800
units/day
o weight-bearing exercise
o only medications proven definitively to
prevent fractures are bisphosphonates
(alendronate, risedronate)
o other medications which may prevent
fractures include estrogen, calcitonin
and sodium fluoride
o for details,
see Osteoporosis andCalcium and
vitamin D for treatment and prevention
of osteoporosis
o cognitive behavior therapy (delivered by group
or self-help approach) may reduce overall
problem rating of hot flushes and night sweats in
menopausal women
o alternative therapies may be effective
Diet:
o calcium 1,200-1,500 mg/day and vitamin D
400-800 units/day recommended
 calcium citrate has best absorption, and
may be preferred if
o achlorhydria
o constipation or gas with calcium
carbonate
o history of renal stones
 calcium carbonate (CaCO3) is cheaper, and
absorption can be improved by taking with
fruit (acid)
 role of calcium in peri- and postmenopausal
women based on consensus opinion of The
North American Menopause Society can be
found in Menopause 2001 Mar/Apr;8(2);84
o flaxseed 40 g/day reduced total and highdensity lipoprotein (HDL) cholesterol
compared with wheat germ placebo
 based on 1-year randomized trial of 199
menopausal women
 differences were not clinically significant
o
Other
Disease
Description & H&P
o
short cycles (< 21
days)
o long cycles (> 36
days)
o short duration of
menstrual bleeding
(1-3 days)
o long duration of
menstrual bleeding
(> 8 days)
 heavy bleeding
associated with
o baseline
leiomyomata
o overweight
o obesity
o hysterectomy accelerates
menopause by 3-5 years
 postsurgical
menopause more
severe
o smoking
 accelerates
menopause by 3-5
years and also
increases severity of
symptoms
 estradiol converted to
antiestrogen 2hydroxy-estradiol
Physical:
General physical:
o
if seen during hot flush,
may observe flushed face
and anterior chest wall for
about 90 seconds
Skin:
o
thin elastic skin, increased
facial hair, thin brittle nails
Pelvic:
o
o
pelvic relaxation
vagina - decreased
secretions, pale thin
epithelium, loss of rugae,
vulvar/vaginal atrophy
cervix - decreased
secretions
o
Diagnosis and Diagnostic Study
Clinical Intervention and Clinical Therapies
and no significant differences in
menopausal symptoms
 Reference - J Clin Endocrinol Metab 2005
Mar;90(3):1390 in BMJ 2005 May
7;330(7499):1094
o omega-3 fatty acids may not alleviate
symptoms of depression in middle-aged
women (level 2 [mid-level] evidence)
 based on randomized trial without intentionto-treat analysis
 120 patients with moderate-to-severe
depression randomized to ethyleicosapentaenoic acid 0.15 g plus ethyldocosahexaenoic acid 0.15 g daily vs.
placebo for 8 weeks
 depression improved in both groups but no
significant difference between treatments
 omega-3 fatty acids beneficial in patients
with moderate depression based on
subgroup analysis
o Prempro FDA approved in lower dose with
ethinyl estradiol 0.45 mg and
medroxyprogesterone 1.5 mg
o Premarin 0.45 mg dose FDA approved for
vasomotor symptoms associated with
menopause and symptoms of vulvar and vaginal
atrophy
transdermal estradiol 0.03% gel may reduce
frequency and severity of hot flushes in
postmenopausal women
o
one frequently used progestin is
medroxyprogesterone acetate (Provera, generic)
but not specifically indicated for reduction in
vasomotor symptoms
o micronized progesterone 300 mg orally once
daily associated with reduction in hot flashes
and/or night sweats in 12-week randomized
placebo-controlled trial in 133 healthy
postmenopausal women, allocation concealment
not stated
megestrol acetate (Megace) 20 mg twice daily can
reduce hot flashes up to 80% but may cause weight
gain
testosterone may improve sexual motivation
 addition of testosterone to hormone therapy
may improve sexual desire and satisfying
sexual activity in peri- and postmenopausal
women
Other
Disease
Description & H&P
Diagnosis and Diagnostic Study
Clinical Intervention and Clinical Therapies
Non-hormonal therapies:
o
systematic reviews of nonhormonal therapies for
hot flashes
 treatments with evidence for efficacy
o selective serotonin reuptake inhibitors
(SSRI) or serotonin norepinephrine
reuptake inhibitors (SNRI)
antidepressants
o SSRIs reduce frequency and severity
of hot flashes in menopausal and
postmenopausal women
o venlafaxine extended-release 75
mg/day may reduce effect of hot
flashes
o desvenlafaxine 100-200 mg/day may
modestly reduce number of hot
flushes in postmenopausal women
clonidine
Clonidine (Catapres):
o clonidine 0.1-0.2 mg twice daily
 2 randomized trials with 96 women found
clonidine more effective than placebo for
reducing hot flushes
 side effects - orthostatic hypotension,
dizziness, blurred vision, constipation, dry
mouth
 contraindications - hypotension, coronary
insufficiency, cerebrovascular disease,
chronic renal failure

gabapentin
Gabapentin (Neurontin):
o gabapentin may modestly reduces hot
flashes with adverse effects
o gabapentin may be as effective as estrogen
but with more side effects
o gabapentin associated with increased rate of
headache, dizziness and disorientation

o
treatments with limited or inconsistent
evidence for efficacy
o isoflavones
o black cohosh
o vitamin E
Eszopiclone (Lunesta):
eszopiclone (Lunesta) may reduce insomnia
and possibly menopausal symptoms in
Other
Disease
Description & H&P
Diagnosis and Diagnostic Study
Clinical Intervention and Clinical Therapies
Other
women with perimenopausal-onset insomnia
Phenobarbital/belladonna/ergotamine
o
(Bellergal):
Bellergal-S (phenobarbital 40 mg, ergotamine
0.6 mg, belladonna 0.2 mg) 1 tablet orally twice
daily
 may be addictive
 not highly effective
 sedating
 contraindications - alcohol or drug
dependence, asthma, urinary retention

Intrauterine
Pregnancy
o
most common signs and
symptoms are due to
hormonal changes of
pregnancy - estrogen,
progesterone, human
chorionic gonadotropin
(hCG), human placental
lactogen (hPL), relaxin,
prolactin, increased renin
and angiotensin
o
serum human chorionic gonadotropin (hCG)
is positive even before missed period,
see Pregnancy testing for details
Comment
Test
Value
s
Decreas
Albumin
e
General symptoms:
o
amenorrhea
 commonly the initial
symptom
 see Pregnancy testing
o weight gain
 ideally 25-35 lbs (11.516 kg)
 see Weight gain in
pregnancy
o fatigue
 worse in first trimester,
improves in second
trimester
 sleep alterations
HEENT symptoms:
o
tender, bleeding gums
 may appear in second
month of pregnancy
and worsen until 1
month before delivery
 will regress following
Bicarbonate
Decreas
e
Dilutional
effect
Compensat
ory to
respiratory
alkalosis
pO2
General Physical:
o
o
o
use acetaminophen (Pregnancy Category B)
avoid NSAIDs
 NSAIDs (including COX-2 inhibitors) affect
fetal kidneys and ductus arteriosus
 aspirin is Pregnancy Category C in doses <
150 mg/day and Pregnancy Category D in
standard doses
 NSAIDs are Pregnancy Category B in first
and second trimesters, but Pregnancy
Category D in third trimester
Headache:
o
Unchang
ed
may be due to increased blood flow and swelling
of sinus drainage tracts, fatigue, tension or eye
strain
o relaxation and warm compresses may help with
symptom relief
o acetaminophen may be needed
o if dizziness, blurred vision, or scotomata,
consider pregnancy-induced hypertension
Breast pain:
Increase
support bra
acetaminophen
Heartburn (reflux):
Blood gases
(arterial)
pH
Analgesia:
o
o
o
o
pCO2
reduced blood pressure
(mean 105/60 mm Hg)
 result of reduced
systemic vascular
resistance and smooth
muscle relaxation
caused by
progesterone
 gradual return to normal
blood pressure in third
trimester
Skin:
Decreas
e
Mild
respiratory
alkalosis
Decreas
Increased
BUN
o
o
o
progesterone leads to relaxation of lower
esophageal sphincter and reduced bowel motility
especially in first trimester, while expanding
uterus displaces stomach in third trimester
frequent small meals
avoid lying recumbent after eating, sleep with
head elevated
avoid overeating, spicy foods, fried foods, gasproducing foods (cabbage, Brussels sprouts,
o
darkening of linea alba
(linea nigra), areola, axillae,
perineum and inner thighs
 all attributed to
melanocytic stimulation
by estrogen and
progesterone

extensive abdominal
hyperpigmentation in
woman of dark skin
color in case report
chloasma - "mask of
pregnancy"
 occurs in up to 75% of
pregnant women
 reddish brown color
may develop over
bridge of nose and
under eyes
 usually resolves in 1
year, but sometimes not
Disease
Description & H&P
delivery
nasal congestion and
nosebleeds - from estrogen
and progesterone-mediated
perivascular edema
o headaches common related to sinus congestion,
tension, fatigue
Breast symptoms:
Diagnosis and Diagnostic Study
e
GFR
Calcium
Decreas
e
Due to
decreased
albumin
Cholesterol
Increase
Creatinine
Decreas
e
Increased
GFR
Creatinine
clearance
Increase
Increased
GFR
Increase
Lower
renal
threshold
Decreas
e
Dilutional
and
increased
use by
growing
fetus
Transferrin
Increase
Greater
iron
absorption
due to
increased
requiremen
t
Magnesium
Decreas
e
o
o
breast tenderness, swelling,
tenderness, tingling,
heaviness
o common in first 8 weeks
post-conception
o due to increasing amount of
beta-hCG, estrogen,
progesterone
Circulatory symptoms:
o
o
lower extremity edema,
varicose veins
 mostly in third trimester
 due to increased
plasma volume and
compression of venous
return from gravid
uterus
 expansion of plasma
volume
o begins at fourth
week of pregnancy
o increases by 15%
in first trimester
o peaks at 28-34
weeks, then
plateaus until
delivery
o average gain at
term 1,100-1,600
mL
dizziness and syncope
 may be positional, may
occur when supine
 more often in warmer
climates - lower
vascular resistance
due to dilation of
peripheral vessels to
dissipate heat
Glycosuria
Iron
Clinical Intervention and Clinical Therapies
onions)
limited evidence regarding treatment of heartburn in
pregnancy
 ranitidine is the best-studied medication shown
to be effective for heartburn in pregnancy,
evidence based on small short-term trials
 aluminum phosphate has efficacy as an antacid
antacids effective, but may bind iron
o calcium carbonate (Tums) may provide antacid
and source of calcium
 generally considered safe and first-line
therapy
 excessive carbonate can lead to milk-alkali
syndrome (hypercalcemia, renal
impairment, metabolic alkalosis)
 H2 blockers
o all 4 drugs are FDA Pregnancy Category B
o ranitidine (Zantac) and cimetidine(Tagamet;
Nu-Cimet in Canada) preferred
over famotidine (Pepcid)
and nizatidine (Axid) due to more fetal
safety data
o cimetidine no recommended by some
researchers due to possibility of
feminization
exposure to proton pump inhibitors in early
pregnancy might not be associated with
significantly increased risk of adverse outcomes
 proton pump inhibitors
o omeprazole (Prilosec; Losec in Canada) is
Pregnancy Category C
 despite C rating, some
recommend omeprazole as proton
pump inhibitor of choice due to more
fetal safety data
 embryonic and fetal toxicity reported,
but low risk
o other proton pump inhibitors are Pregnancy
Category B
 esomeprazole (Nexium)
 lansoprazole (Prevacid) -recommended by some as proton
pump inhibitor of choice
 pantoprazole (Protonix)
 rabeprazole (AcipHex)
Abdominal pain:
o
sharp pain often due to spasm of round
ligaments
 often associated with movement
Other
completely
vascular spiders
 appear in 66% of white
patients and 11% of
black patients during 25 months of pregnancy
 90% regress by 3
months postpartum
 most common around
eyes
o striae (stretch marks) over
abdomen, breast, hips
 develop in 65% of
pregnant women
 permanent but may
fade over time
o hirsutism and acne - due to
placental androgens
HEENT:
o
o
brownish-red opacities on
posterior cornea
(Krukenberg spindles)
o swollen nasal turbinates
o gingivitis, gum hypertrophy,
bleeding gums
Breast:
o
breast enlargement due to
vascular engorgement,
ductal growth (estrogen
effect) and alveolar
hypertrophy (progesterone
effect)
o breast veins become more
visible
o nipples may become more
erect and darker
o areolae darken
o expression of colostrum
from nipples may occur in
third trimester
Cardiac:
o
o
o
o
heart rate increases slightly
systolic ejection murmur
(II/VI) heard in 96% of
women
diastolic murmur in
pregnancy is abnormal
wide splitting of S1 and
Disease
Description & H&P
Diagnosis and Diagnostic Study

due to enlarged uterus
compressing inferior
vena cava, causing
venous pooling and
decreased cardiac
output
Respiratory symptoms:
o
dyspnea of pregnancy,
decreased exercise
tolerance
o 60%-70% of women will
experience in first or
second trimester
o may cause sleep
disturbance
o causes
 progesterone-induced
hyperventilation in
early pregnancy
 decreased functional
residual capacity due
to limited movement of
diaphragm secondary
to gravid uterus in late
pregnancy
Gastrointestinal symptoms:
o
o
increased appetite and
dietary cravings
 persists throughout
pregnancy
 driven by increased
estrogen
nausea and vomiting
 occurs in 70% of
pregnancies
 usually between 6-16
weeks gestation
 more common in
younger women,
primigravidas and
overweight women
 rarely severe enough
to compromise nutrition
 mostly due to high
levels of serum
estrogen and hCG, but
can be due to
hyperthyroidism,
Osmolality
Uric acid

Decreas
e
Dilutional
Decreas
e
During 1st
and 2nd
trimesters,
dilutional
Serum
Enzymatic
Activities
o
Alkaline
phosphatase
Increase
Drug metabolism
Increase
o
Serum
Hormones
Cortisol
Increase
Growth hormone
Increase
Insulin
Increase
Parathyroid
hormone
Progesterone
Clinical Intervention and Clinical Therapies
Increase
Due to
decreased
total
calcium
Increase
9-47 ng/mL
(1st
trimester);
55-255
ng/mL (3rd
trimester)
more common on right side due to normal
dextrorotation of uterus
 improved physical fitness and abdominal
wall muscle tone can help prevent round
ligament strain
 advice for patients
o regular exercise
o avoid sudden movement
o rise and sit gradually
o rest and local heat is best treatment,
consider lying down on side of pain
o analgesia occasionally necessary with
acetaminophen
abdominal pain in second or third trimester
should be evaluated to rule out uterine irritability
or premature contractions
also consider non-pregnancy-related abdominal
problems
 appendicitis - occurs in 0.13% pregnancies
in any trimester, 35% fetal mortality with
perforation, may be felt in right upper
quadrant instead of right lower quadrant,
laparoscopic appendectomy has been
safely performed in pregnancy (Surg
Endosc 1990;4:100)
 nephrolithiasis (renal colic) - 1/1,000
pregnancies, may have increased incidence
of preterm labor (Am Fam Physician
1989;40:185), usually diagnosed by
ultrasound but may be difficult to
differentiate obstructive vs. physiologic
hydronephrosis
 cholelithiasis and cholecystitis (biliary colic)
- increased risk of cholelithiasis in
pregnancy, but no increased incidence in
symptomatic biliary disease; 1-6 in 10,000
pregnant patients get cholecystectomy,
safest period is second trimester
 gastroenteritis - oral hydration preferable,
monitor hydration status closely
 hepatic disorders
o intrahepatic cholestasis of pregnancy
o acute fatty liver of pregnancy - rare but
fatal, more common in young
primiparas and multiple gestation,
usually late in third trimester; onset with
anorexia, nausea, vomiting, malaise,
headache; later epigastric and RUQ
abdominal pain, jaundice, coma with
Other
splitting of S2 heart sounds
in third trimester
o point of maximal impulse
shifted cephalad to fourth
intercostal space and
laterally to midclavicular line
(due to enlarging uterus)
o cardiac output increased by
30%-50% above baseline,
higher in left lateral
decubitus position
o jugular venous distension
(JVD) common
Lung:
o
physiological
hyperventilation
 elevation of diaphragm
decreased functional
residual capacity
 tidal volume increases
40% at rest, minute
ventilation increases by
30%
Abdomen:
o
o
o
striae gravidarum
linea nigra - line of
increased pigmentation
develops from xiphoid to
symphysis pubis
uterine enlargement
 palpable at 12-14
weeks
 manual measurement
of fundal height as
accurate as ultrasound
from 18-32 weeks
gestation
 insufficient data to
assess utility of routine
use of symphysisfundal height
measurements in
routine antenatal care,
no evidence of
improved pregnancy
outcome in single
identified trial
 expected fundal height
Disease
Description & H&P
multiple gestation, or
molar pregnancies
 vomiting in early
pregnancy reported in
56% of 9,098 firsttrimester registrants;
more common in
primigravidas, younger
women, women with
limited education,
nonsmokers and
women weighing > 170
lbs: vomiting
associated with lower
incidence of stillbirth,
miscarriage or
premature delivery
o gastroesophageal reflux
 occurs in 50% of
women in third
trimester
 due to relaxation of
lower esophageal
sphincter (by
progesterone) and
expanding uterus
o constipation
 from decreased gastric
motility and increased
water absorption
(progesterone-related)
Neurologic symptoms:
o

headache prevalence in
pregnancy
migraine during pregnancy
diagnosis significantly
associated with
o stroke
o myocardial
infarction/heart disease
o pulmonary
embolus/venous
thromboembolism
o hypertension
o preeclampsia/gestational
hypertension
o smoking
o diabetes
Diagnosis and Diagnostic Study
Prolactin
Increase
Testosterone
Increase
Thyroxine-binding
globulin
Increase
Free T4
Unchang
ed
Free T3
Unchang
ed
Total T4
Increase
Due to
increased
thyroxine
binding
globulin
TSH
Decreas
e
In first
trimester
Hematologic
values
Bleeding time
Unchang
ed
Blood volume
Increase
by 50%
ESR
Increase
Fibrinogen
Increase
Decreas
Hemoglobin/hema es by
Average
Clinical Intervention and Clinical Therapies
hepatic encephalopathy, bleeding
diathesis, metabolic acidosis, mild
hypertension, proteinuria, edema; high
maternal mortality if diagnosis and
delivery delayed
o PIH-associated hepatic changes
include nausea, vomiting, epigastric
and RUQ abdominal pain; HELLP
syndrome includes microangiopathic
hemolytic anemia, elevated
transaminases and thrombocytopenia
o fulminant hepatitis - usually viral,
delivery of fetus may be necessary for
survival
 ruptured ovarian cyst
 adnexal torsion
 red degeneration (necrobiosis) of uterine
fibroid - most common in early second
trimester
Back pain:
o
compensatory lumbar lordosis, ligament laxity,
poor abdominal muscle tone and poor posture
contribute to back pain
o prevention includes avoiding excessive weight
gain, improving posture, proper bending with
straight back, wearing flat or low-heeled shoes
o firm bed mattress, local heat, massage may help
o acetaminophen if analgesia needed
o consider lumbar disk disease if associated leg
weakness
o exercise may reduce low back pain during
pregnancy
Constipation
o progesterone decreases bowel motility
especially in first trimester, expanding uterus
displaces and compresses intestine in third
trimester
o iron replacement may also worsen constipation
o increase fluids (at least 2 quarts/day = 8
glasses/day = 64 oz/day)
o increase bulk (fresh fruit, vegetables, whole
grains, fiber supplementation)
o fiber supplementation (as bran or wheat fiber)
daily effective in treating constipation in
pregnancy based on 1 trial; if ineffective,
stimulant laxatives are more effective than bulkforming laxatives but may cause more side
effects, based on 1 trial (Reference - Cochrane
Database Syst Rev 2001;(2):CD001142 [review
Other
= 37.1 cm + 0.119 x
(gestational age in days
- 280) + 0.074 × (initial
weight in kg - 66.5) +
1.01 (if parous, 0 if
nulliparous) + 0.91 (if
female fetus, 0 if male
fetus), based on series
of 325 women with
uncomplicated
singleton pregnancies
who had ultrasound
dating < 20 weeks
gestation
o Leopold maneuvers for fetal
size and position
o fetal heart tones for viability
Back:
o
lumbar lordosis to maintain
center of gravity
Neuro:
o
unsteady gait in third
trimester due to relaxation of
pelvic joints, lumbar
lordosis, and gravid uterus
Extremities:
o
lower extremity edema
 usually bilateral,
consider deep vein
thrombosis (DVT) if
unilateral
 due to compression of
inferior vena cava by
gravid uterus
Pelvic:
o
o
o
o
o
congestion and bluish hue
of vagina (Chadwick's sign)
in early first trimester due to
increased blood flow
softening of cervix (Hegar's
sign)
mucous plug
softening and enlargement
of uterus after 6 weeks
uterine size larger than
dates with full bladder,
trophoblastic disease,
uterine fibroids, multiple
Disease
Description & H&P
Diagnosis and Diagnostic Study

migraine diagnosis not
associated with several
non-vascular diagnoses
(pneumonia, transfusions,
postpartum infection or
hemorrhage)
Genitourinary symptoms:
tocrit
10-15%
Plasminogen
Increase
o
Platelets
Decreas
e
urinary frequency, nocturia,
stress incontinence
 due to enlarging uterus
and increased
progesterone
 urinary stasis may lead
to increased urinary
tract infections
in pregnancy, age > 35 years,
high body mass index (BMI),
and family history of
incontinence associated with
risk for urinary incontinence
Musculoskeletal symptoms:
Normal >
100,000
Red cell volume s
Increased
erythropoie
tin 2-4 fold
due to
increased
human
placental
lactogen
and red
cell mass
WBC
Average
12,000
cells/mm 3
Increase
o
o
low back pain
carpal tunnel syndrome
 most common in
second and third
trimesters
 results from edema of
hands and wrists
 should resolve after
delivery
o leg cramps
 usually during second
half of pregnancy
 mainly gastrocnemius
muscle
 tend to occur during
sleep, often cause
awakening
 may be due to calcium
or magnesium
deficiency
hip pain - hormone relaxin
contributes to laxity of sacroiliac
joint and symphysis pubis,
beginning at 10-12 weeks of
pregnancy
o unsteady gain after 20
weeks gestation due to
12.5 g/dL
Increase
Abbreviations: BUN, blood urea nitrogen;
ESR, erythrocyte sedimentation rate;
GFR, glomerular filtration rate; THS,
thyroid-stimulating hormone; WBC, white
blood cell count.
Serum Chemistries:
o
tumor markers including serum
carbohydrate antigen 15-3, squamous
cell carcinoma antigen, and CA-125 may
be elevated during normal pregnancy
Clinical Intervention and Clinical Therapies
updated 2010 Jan 18])
exercise
mild laxatives (milk of magnesia), stool
softeners, bulk producers (cellulose powders)
are also safe and effective
o cathartic laxatives and enemas rarely needed
o review of constipation treatments in pregnancy
 increase fluid intake
 increase fiber in diet
 bulking agents (for example, psyllium)
considered first-line therapy
 osmotic/saline laxatives
o lactulose and magnesium citrate are
Pregnancy Category B
o PEG, sodium phosphate (Visicol) and
magnesium hydroxide (Milk of
Magnesia) do not have pregnancy
category designation
o PEG considered first choice if bulking
agents ineffective
o long-term use of magnesium citrate or
sodium phosphate may lead to
hypermagnesemia, hyperphosphatemia
and dehydration
 stimulant laxatives
o bisacodyl (Correctol)
and senna(Senokot)
o Pregnancy Category C
o low risk in short-term use
o long-term use not recommended
 stool softener
o docusate (DSS)
o Pregnancy Category C
o no toxicity reports
o contained in some prenatal vitamins
 lubricants - avoid use in pregnancy
o castor oil is Pregnancy Category X
o mineral oil is Pregnancy Category C
 lubiprostone (Amitiza) is Pregnancy
Category
Diarrhea
o fluid replacement
o attapulgite (Kaopectate in Canada) is Pregnancy
Category C
 attapulgite considered antidiarrheal of
choice in pregnancy
 formulation of Kaopectate contains bismuth
subsalicylate and NOT recommended
o loperamide (Imodium) in Pregnancy Category B
o
o
Other
gestations, macrosomia,
polyhydramnios
o uterine size less than dates
with intrauterine growth
retardation (IUGR),
oligohydramnios,
malpresentation
Rectal:
o
hemorrhoids due to increase
in portal system venous
pressure
Disease
Description & H&P
o
o
o
lordosis of pregnancy and
changes in center of gravity
pelvic pain
uterine sensations
 quickening (sensation
of fetal movement)
occurs at 16-20 weeks
gestation
o 16-18 weeks in
multigravidas
o 19-20 weeks in
primigravidas
 Braxton-Hicks
contractions
o common in third
trimester
o irregular
contractions less
frequent than
every 8 minutes
other symptoms - pruritus,
paresthesias (from nerve
compression), snoring,
swelling of vulva/vagina,
palpitations
Diagnosis and Diagnostic Study
Clinical Intervention and Clinical Therapies

limited human data, animal data suggests
low risk
 avoid during first trimester, possible
increase in fetal cardiac malformation
o antidiarrheals NOT recommended
 alosetron (Lotronex) is Pregnancy Category
B,
 bismuth subsalicylate (Pepto Bismol,
Kaopectate) is Pregnancy Category C;
salicylate absorption can increase perinatal
mortality, premature closure of ductus
arteriosus, neonatal hemorrhage,
decreased birth weight, prolonged gestation
or labor, and possible teratogenicity
 diphenoxylate/atropine (Lomotil) is
Pregnancy Category C, teratogenic in
animals
Nasal congestion:
o
may be related to increased circulation and
edema mediated by estrogen
o increasing humidity with vaporizer may be
helpful
o saline nose drops or sprays are safe and
effective
 Nasal and Ocean are some common brand
names
 can be made at home by adding 1/2
teaspoon table salt to 1 cup warm water,
make fresh daily, use dropper for
application
 FDA Pregnancy Category A
o decongestants
 avoid oral decongestants, which have been
associated with small increase in minor birth
defects
 oral decongestants should be avoided
during first trimester of pregnancy due to
association with gastroschisis
 use pseudoephedrine if oral drug
necessary, best safety record during
pregnancy of oral decongestants
 topical nasal decongestants
o can cause rhinitis medicamentosa if
used > 3 days
Allergic symptoms:
o
topical nasal steroids effective in allergic rhinitis,
but must be used continuously and have 3-7 day
Other
Disease
Description & H&P
Diagnosis and Diagnostic Study
Clinical Intervention and Clinical Therapies
lag period; FDA Pregnancy Category C
(antihistamines
 chlorpheniramine (Chlor-Trimeton; ChlorTripolon in Canada) considered first-line if
oral antihistamine needed, FDA Pregnancy
Category B
 doxylamine is Pregnancy Category A, but
cough/cold products with doxylamine
usually contain other products
 other antihistamines that are Pregnancy
Category B
o clemastine (Tavist)
o diphenhydramine (Benadryl)
o cetirizine (Zyrtec; Reactine in Canada),
but not recommended during first
trimester
o loratadine (Claritin), but not
recommended during first trimester
 antihistamines that are Pregnancy Category
C
o brompheniramine (Dimetapp)
o desloratadine (Clarinex)
o fexofenadine (Allegra)
o promethazine (Phenergan;
o triprolidine (Actifed)
ough medications that are Pregnancy Category C
 benzonatate (Tessalon Pearls)
 codeine (Pregnancy Category D for prolonged
use or high doses at term) - avoid use in first
trimester
 dextromethorphan (Robitussin DM)
 guaifenesin (Robitussin, Fenesin, Humibid,
Mucinex) - avoid use in first trimester
 hydrocodone (Pregnancy Category D for
prolonged use or high doses at term) - avoid use
in first trimester
Hemorrhoids:
o
o
o
o
o
o
treat constipation
prevention by avoiding constipation and
prolonged sitting
Kegel exercises improve rectal muscle tone
often regress after delivery
if symptomatic, especially after delivery from
prolonged pushing
 sitz baths (immersing hips and buttocks)
with warm water for 20 minutes
 then application of witch hazel (Tucks pads)
preparation H, Anusol, Tucks, ProctoFoam safe
Other
Disease
Description & H&P
Diagnosis and Diagnostic Study
Clinical Intervention and Clinical Therapies
o
Contracepti
on
Other
and effective
thrombosed (hard and tender) external
hemorrhoids may require incision and
evacuation under local anesthesia
progestogen-only contraceptives
 Pearl index about 0.3% with perfect use and
about 9% with typical use (includes inconsistent
or incorrect use)
 usual dosing regimen with progestogen-only
pills is 1 active pill orally once daily (no or
placebo or pill-free interval)
 progestogen-only pills are considered best
option for women who prefer oral contraceptive
but have contraindications to combined oral
contraceptives including nonbreastfeeding
women immediately postpartum (not associated
with increased risk of thrombosis)
IUDs
 most women are good candidates for hormonal
and nonhormonal IUDs, including, both parous
women and nulliparous women, adolescents,
and women with history of ectopic pregnancy
 significant complications are rare.
 both hormonal and nonhormonal IUDs may be
inserted any time during cycle when pregnancy
can be excluded
 options include copper IUD, levonorgestrelreleasing intrauterine system
barrier methods
 barrier methods include male condom or
female condom, diaphragm, cervical cap,
andsponge
 these methods are often used with
spermicide
 barrier methods are less effective than
hormonal methods or IUDs
tubal sterilization
 indicated for well-informed women who have
completed childbearing considered ideal
candidates for sterilization, but age and parity
should not limit use
 there are no absolute contraindications to tubal
sterilization
 interval procedure may be performed anytime,
but ideally between days 6-13 of menstrual cycle
 postpartum and postabortion procedures may
also be performed
o
o
o
o
o
emergency contraception is
defined as contraceptive
methods used after
unprotected intercourse or
potential contraceptive
failure and before
implantation
emergency contraception
may be indicated for any
reproductive-aged woman
who does not want to be
pregnant following
unprotected or inadequately
protected sexual intercourse
no clinical exam or testing is
required prior to
administering emergency
contraception although
consider pregnancy testing
and testing for sexually
transmitted infections
initiate emergency
contraception as soon as
possible after unprotected
intercourse as efficacy
declines with increasing
delay between intercourse
and treatment (not effective
once implantation has
occurred)
emergency contraception
options
 copper intrauterine
device (IUD)
o considered most
effective method of
emergency
contraception with
about 0.09%
pregnancy rate if
inserted within 5
days of intercourse
o well-tolerated in
most women
o efficacy not
Disease
Description & H&P
Diagnosis and Diagnostic Study
Clinical Intervention and Clinical Therapies

o
o
efficacy varies by sterilization technique and
patient age (women aged < 30 years at
sterilization may have increased risk for method
failure compared to older women)
o Essure (hysteroscopic procedure) reported
to be most effective sterilization method
overall
fertility awareness-based methods
 fertility awareness-based methods are an
alternative to hormonal methods and
devices, but effectiveness depends on
appropriate guidelines being followed
consistently.
 methods include
o calendar or rhythm method (estimates
timing of ovulation by documenting
longest and shortest cycle durations
over 6-12 month period)
o temperature or basal body temperature
(BBT) method (estimates times of
ovulation by measuring BBT daily until
elevated readings for ≥ 3 days indicate
ovulation has occurred)
o ovulation or Billings ovulation method
(estimates timing of ovulation by
assessing cervical mucus secretions
throughout cycle) o symptothermal
methods (combination of preceding 3
methods)
o at-home use of technological
instruments (such as ovulation
prediction kits) to identify fertile phase
via samples of urine, saliva, or cervical
mucus (may be combined with other
methods)
emergency contraception
 emergency contraception is used to avoid
pregnancy after unprotected intercourse or
potential contraceptive failure and before
implantation
 emergency contraception should be initiated
as soon as possible after unprotected
intercourse as efficacy declines with
increasing delay between intercourse and
treatment
 options include copper IUD, levonorgestrel
(Plan B), ulipristal acetate (UPA), and
combined oral contraceptives
Combined oral contraceptives (COCs):
Other
o
affected by body
weight (may be
used in obese
women)
o requires insertion
by trained medical
professional
o associated with
same
contraindications
as routine IUD use
o if IUD fails to
prevent pregnancy,
immediately
remove device and
rule-out ectopic
pregnancy (may
have increased risk
if pregnancy occurs
during use)
levonorgestrel (Plan B)
 progestogen-only oral
contraceptive available
in single-dose (1.5 mg)
or double-dose
regimens (2 pills
containing
levonorgestrel 0.75 mg
each taken 12 hours
apart)
 considered most
effective when
administered within 72
hours (3 days) of
intercourse and
associated with about
1.1%-2.4% failure rate
 levonorgestrel may be
used ≥ 1 time/cycle,
even if earlier episode
of unprotected
intercourse occurred
outside 120 hour
treatment window (will
not disrupt implanted
pregnancy)
 levonorgestrel may be
used in women with
contraindications to
daily hormonal
Disease
Description & H&P
Diagnosis and Diagnostic Study
Clinical Intervention and Clinical Therapies
o
o
o
o
o
COCs contraindicated women with certain
medical conditions including but not limited to
 breast cancer
 venous thromboembolism
 migraine with aura
dosing regimens
 usual dosing regimen is 1 active pill orally
once daily for 21 consecutive days followed
by 7-day pill-free
adverse effects
 estrogenic effects (such as altered bleeding
patterns, mood changes, breast
enlargement/tenderness, and nausea)
 androgenic effects (such as acne, hirsutism,
and lipid changes)
 COCs reported to double the risk for venous
thromboembolism compared to nonusers,
but overall risk is still low
 current use of oral contraceptives may be
associated with increased risk for ischemic
stroke but not hemorrhagic stroke or
myocardial infarction
noncontraceptive benefits may include
improvement in
 acne
 premenstrual symptoms and dysmenorrhea
 menorrhagia
 polycystic ovary syndrome
oral contraceptives and cancer
 combined oral contraceptives may be
associated with decreased mortality from
cancer and various other causes
 COCs may reduce risk for some cancers,
like endometrial and ovarian cancer
Progestogen-only injectable contraceptives:
o
depot medroxyprogesterone acetate (DMPA)
(Depo-Provera)
 formulations include
o depot medroxyprogesteroneacetate
(Depo-Provera) 150 mg/1 mL
administered by healthcare provider via
intramuscular injection every 3 months
o Depo-subQ Provera 104 mg/1 mL
administered by patient or healthcare
provider via subcutaneous injection
every 3 months
Other
o
o
contraceptives
ulipristal acetate (CDB2914)
 progesterone receptor
modulator developed
for use as emergency
oral contraceptive in
single 30 mg dose
 considered most
effective when taken up
to 120 hours (5 days)
after unprotected
intercourse with about
2% pregnancy rate and
no apparent decline in
efficacy during that time
 repeat dosing with
ulipristal acetate (UPA)
not recommended
combination oral
contraceptives (Yuzpe
regimen)
 may be formulated from
variety of standard oral
contraceptives
o standard dose is 2
tablets of Ovral in 2
dose regimen (2
tablets/dose) with
first dose within 72
hours of
unprotected
intercourse and
second dose 12
hours later
o other brands may
be substituted for
Ovral with similar
efficacy
o associated with
about 3.2% failure
rate
o Yuzpe regimen
associated with
significantly more
nausea and
vomiting than
levonorgestrel-only
regimen
o anti-emetic taken 1
Disease
Description & H&P
Diagnosis and Diagnostic Study
Clinical Intervention and Clinical Therapies


Other

DMPA may be used by women of all ages,
testing not typically indicated in healthy women
prior to starting DMPA
administration
o first DMPA injection may be given any time
in menstrual cycle if reasonably certain
woman is not pregnant
 if administered within 5-7 days of start
of menstrual cycle, backup
contraception not required
 if administered > 5-7 days since start of
menstrual cycle, advise patient to
abstain from intercourse or use back-up
contraception for 7 days
o repeat DMPA injections every 3 months (1213 weeks)
o

hormone-related adverse effects
o bleeding irregularities most common adverse
effect associated with DMPA use (in about 20%40% patients)
o DMPA may be associated with 2-3 kg (4.4-6.6
lbs) weight gain over 1 year,
 complications
o DMPA associated with decreased bone
mineral density (level 3 [lacking direct]
evidence)
o loss of bone mineral density with use of
depot medroxyprogesterone may reverse
after method discontinuation (level 3
[lacking direct] evidence)
o recent DMPA use (within last 5 years) for ≥
12 months may be associated with
increased risk for breast cancer
o implantable contraceptives are a type of longacting reversible contraceptive (LARC) method
(along with intrauterine devices)(1)
 primary mechanism of action is prevention
of ovulation by suppression of
hypothalamic-pituitary-ovarian axis
 progestin-only implants may also reduce
pelvic pain associated with dysmenorrhea,
endometriosis, and pelvic congestion
syndrome
o etonogestrel-releasing implant
 Implanon is a progestin-only subdermal
contraceptive implant for use up to 3 years
 Nexplanon is a radiopaque, bioequivalent
modification of Implanon with redesigned
o
hour before Yuzpe
emergency
contraception may
help reduce
incidence and
severity of nausea
and vomiting
mifepristone (RU486)
(Mifegyne)
 availability limited to
China and Vietnam (not
licensed for use in
United States, Canada,
or United Kingdom)
 associated with about
1.5% failure rate (varies
by dose and time of
treatment during
menstrual cycle)
 progesterone receptor
modulator
(antiprogestin)
containing mifepristone
additional considerations
 risk of pregnancy
reported to be 3 times
greater in women with
body mass index (BMI)
≥ 30 kg/m2 compared to
women with BMI < 25
kg/m2 with any
hormonal emergency
contraception
 concomitant use (and
up to 28-days after last
use) of liver enzymeinducing drugs may
decrease efficacy of
hormonal emergency
contraception by
reducing concentrations
of levonorgestrel (LNG),
ulipristal acetate, and
combination oral
contraceptives
Disease
Description & H&P
Diagnosis and Diagnostic Study
Clinical Intervention and Clinical Therapies
inserter
healthcare providers in the United States
should complete FDA-mandated training
from manufacturer prior to insertion or
removal of implants
o transdermal patch or vaginal ring are methods of
delivering continuous combined hormonal
contraception
o contraceptive patch (Ortho Evra/Evra)
transdermal combined hormonal contraceptive
containing estrogenic ethinyl estradiol (EE) and
progestogenic norelgestromin
contraceptive patch may increase risk of venous
thrombosis in women without previous thrombotic
disease
NuvaRing contains estrogenic ethinyl estradiol 2.7
mg and progestogenic etonogestre
Barrier methods:

Condom:
o
male condom
 male barrier contraceptive characterized by
thin sheath designed to cover entire length
of penile shaft during intercourse
Female condom
 female barrier contraceptive characterized by
soft, loose-fitting sheath or pouch (polyurethane,
nitrile, or latex) about 17 cm long with flexible
ring on each end
 accounts for about 0.2% of all condom use
worldwide
Cervical cap:
o
o
o
cervical cap is a small, metal, rubber, or plastic
cap designed to prevent sperm from entering
cervix
reported first-year pregnancy rates 4.8%-19.3%
(may be more common in nulliparous women)
use contraindicated in women with
 notably distorted cervical anatomy
 cervical intraepithelial neoplasia (CIN)
 cervical cancer
 history of toxic shock syndrome (USMEC
Category 3; UKMEC Category 3)
 high risk of HIV infection (USMEC Category
4; UKMEC Category 4 due to concomitant
use of spermicide)
 HIV infection with or without use of
antiretroviral therapy (USMEC Category
Other
Disease
Description & H&P
Diagnosis and Diagnostic Study
Clinical Intervention and Clinical Therapies
o
o
o
o
3;UKMEC Category 3 due to concomitant
use of spermicide)
 AIDS (USMEC Category 3; UKMEC
Category 3 due to concomitant use of
spermicide)
see Barrier contraceptive methods for details
Other barrier methods:
sponge
 disposable female barrier contraceptive
designed to absorb ejaculate, carry
spermicide, and block ostium of uterus
(external cervical os)
 not recommended for use in women with
history of toxic shock syndrome (USMEC
Category 3; UKMEC Category 3)
 types include
o Today sponge
o Pharmatex sponge (vaginal tampon)
o Protectaid sponge
spermicide
 chemical barrier contraceptive characterized
by mechanical interference with sperm
movement and biochemical immobilization
and destruction of sperm
 due to relatively low efficacy, spermicide
alone not recommended for contraception in
some regions, including Western Europe
o reported pregnancy rate in first year of
use
 6%-18% with perfect use
 26%-28% with typical use
(includes method- and user-failure)
o insufficient evidence to establish
efficacy of spermicides for pregnancy
prevention
 FDA requires manufacturer warning stating
nonoxynol-9 does not prevent HIV or other
sexually transmitted disease transmission
and may increase risk of contracting
HIV/AIDS
 nonoxynol-9 may increase susceptibility to
human papillomavirus infection, especially
in women with HIV
indications and contraindications
 well-informed women who have completed
childbearing considered ideal candidates for
sterilization, but age and parity should not
limit use
Other
Disease
Description & H&P
Diagnosis and Diagnostic Study
Clinical Intervention and Clinical Therapies
Other

o
o
o
Cervical
Cancer
o
o
invasive carcinoma
originating in transformation
zone of cervix, most
commonly in squamous
cells
second most common
cancer in women
there are no absolute contraindications to
tubal sterilization
timing
 interval procedure may be performed
anytime, but ideally between days 6 and13
of menstrual cycle
 postpartum procedure may be performed
o at time of cesarean delivery
o within 2 days postpartum (if not
performed within 2 days postpartum,
wait ≥ 6 weeks postpartum to perform
interval procedure)
 postabortion procedure may be performed
immediately or within 1 week after abortion
if no suspicion of pelvic infection
efficacy
 efficacy varies by sterilization technique and
patient age (women aged < 30 years at
sterilization may have increased risk for
method failure compared to older women)
 Essure (hysteroscopic procedure) reported
to be most effective sterilization method
overall (10-year cumulative pregnancy rate
0.01%-0.02%)
 10-year cumulative failure rate about 1.9%
for abdominal tubal sterilization procedures
tubal sterilization may be performed via
 transcervical route (hysteroscopy) with
mechanical implants including
o Essure
o Adiana
o Ovabloc
 abdominal route
o with laparoscopic techniques, including
 electrocoagulation
 mechanical devices
 tubal excision (complete or partial
salpingectomy)
o with minilaparotomy, including
 Pomeroy technique (most
common)
Making the diagnosis:
Treatment overview:
o
o
most women diagnosed as part of evaluation
of abnormal Pap smear, with or without
symptoms (such as vaginal bleeding or other
discharge), using colposcopically directed
cervical biopsy
o
treatment plan is based on clinical staging (FIGO
staging and radiologic staging) and risk
assessment including nodal status
and histological biopsy results
treatment for early invasive cancer (small tumors
histologic types
 squamous cell carcinoma is
most frequent type
accounting for two-thirds of
cervical cancers(1, 2, 3, 4)
 adenocarcinoma accounts
for about 10%-20% cervical
Disease
Description & H&P
worldwide, third most
common cause of female
cancer mortality
Chief concern (CC):
o
o
o
o
o
early stage disease
 usually asymptomatic
and detected by
cervical smear
 symptoms at
presentation reported
in about 16%-32% of
women
vaginal bleeding or bloodstained vaginal discharge
 may be postcoital,
intermenstrual,
postmenopausal, or
spontaneous
lymphedema in lower
extremities (from lymphatic
compression of locally
invaded pelvic lymph
nodes)
pelvic pain if lymph nodes
involved
may have backach
Diagnosis and Diagnostic Study
o
other methods of diagnosis include
 cervical biopsy of grossly visible or
palpable lesion
 cone biopsy (via laser or cold knife
cone) if microinvasion or early stage
cervical carcinoma suspected
Differential diagnosis:
o
o

Chlamydia trachomatis or other sexually
transmitted infection in women presenting
with
 complaint of vaginal bleeding,
serosanguineous vaginal discharge,
pelvic pain
 inflamed or friable cervix
endometrial adenocarcinoma
MRI preferred to CT scan and should
include pelvic and abdominal imaging
o better than CT for tumor extension
assessment
o equal to CT for nodal involvement
assessment
Clinical Intervention and Clinical Therapies
≤ 4 cm confined to cervix) based on European
Society for Medical Oncology (ESMO) and
Scottish Intercollegiate Guidelines Network
(SIGN) guidelines
 initial treatment is surgery or radiation
o surgery and radiation therapyappear to
have similar efficacy for early stage (IB
or IIA) cervical cancer
o for patients who have
surgery,chemoradiation used if any of
following risk factors
 positive margins
 parametrial involvement
 pelvic node involvement
o consider adjuvant radiation therapyfor
patients who have negative nodes, and
any 2 of the following
 greater than a third stromal
invasion
 lymphovascular space invasion
 tumor diameter > 4 cm
o adjuvant radiation therapy after radical
hysterectomy may decrease risk of
disease recurrence compared with no
further treatment
 FIGO stage IA1
o treat with either of
 conization with free margins
 simple hysterectomydepending on
patient age, desire for childbearing,
and hormonal status
o pelvic lymphadenectomy
 pelvic lymphadenectomy
recommended by ESMO if
lymphovascular space involved
 SIGN recommends not removing
pelvic lymph nodes during
treatment for International
Federation of Gynecology and
Obstetrics (FIGO) IA1 disease
 FIGO stage IA2
o treat with surgery
o pelvic lymph nodes should be removed
o surgical options include simple or
radical hysterectomy or conization ortra
chelectomy (fertility-sparing alternative
to hysterectomy) in young patients
 FIGO stage IB1 - no standard treatment,
options include
Other
cancers(1)
o small cell carcinoma
rare compared to
squamous cell
carcinoma or cervical
adenocarcinoma
Who is most affected:
o
women aged 30-45 years
Causes:
o
persistent infection with
oncogenic types of human
papillomavirus (HPV)(1, 3)
o most prevalent oncogenic
types are HPV-16, HPV-18
Pathogenesis:
o
progression of epithelial
change associated with
human papillomavirus
(HPV) infection(6, 7)
 viral particles enter
basal layer through
small tears in mucosa,
infect metaplastic
epithelium in ring of
mucosa known as
cervical transformation
zone
 molecular virology of
HPV persistence,
progression, and
invasion poorly
understood
o not known how
often precancer
develops from mild
lesion vs. an
equivocal lesion or
cytologically
normal HPVinfected tissue
o persistent HPV
infection of
epithelium in
cervical
transformation
zone causes most
cases of cervical
cancer
Disease
Description & H&P
Diagnosis and Diagnostic Study
Clinical Intervention and Clinical Therapies
o
o
surgery
 options
includehysterectomy and radical
trachelectomy
 SIGN recommends radical surgery
for stage IB1 disease if there are
no contraindications , not
recommended if tumor > 4 cm
o external irradiation plus
brachytherapy (short-waved radiation
therapy delivered by applicators
inserted in uterus via vagina)
o combined radiation therapy and surgery
- preoperative brachytherapy followed
by surgery 6-8 weeks later
treatment for locally advanced cancers (FIGO
stage IB2 tumors and higher) based on ESMO
and SIGN guidelines
 stage IB2-IVA
o chemoradiation associated with
increased survival compared to
radiation therapy alone in women with
locally advanced cervical cancer, but
may increase acute toxicity
o chemotherapy as adjuvant to radiation
therapy may reduce risk of death and
disease progression
o chemotherapy
 SIGN recommends any patient
considered suitable for radiation
therapy should
 have concurrent
chemotherapy with a platinumbased chemotherapy if well
enough to tolerate
 have their hemoglobin level
monitored and corrected if it
falls below 12 g/dL
 insufficient evidence of usefulness
of adjuvant chemotherapy after
chemoradiation
o external irradiation plus brachytherapy
o SIGN recommends monitoring
hemoglobin in patients receiving
radiation or chemoradiation and correct
if hemoglobin level falls below 12 g/dL
(120g/L
o adjuvant extrafascial hysterectomy after
radiation therapy may be considered for
patients with persistent disease
Other

progression from small
cervical intraepithelial
neoplasia (CIN) lesion
to cancer can take > 10
years
o regression of CIN may occur
o cancer spreads locally to
parametria, vagina, and
pelvic sidewall
o nodal spread common,
usually occurs in stepwise
manner to pelvic lymph
nodes, then to para-aortic
nodes
smoking associated with
increased risk of squamous
cell carcinoma of the cervix
but not
adenocarcinoma diethylstilbe
strol (DES) exposure in utero
may increase risk for cervical
cancer
Disease complications:
o
o
o
lymphedema (may also be
treatment related) in 1 or
both lower limbs(5)
complications due to
advanced disease
progression(5)
 renal failure, ureteric
obstruction (from
lymphadenopathy or
tumor invasion)
 thrombosis and
hemorrhage
 rectovaginal or
vesicovaginal fistulas
(rare)
sexual dysfunction
 many women with
cervical cancer
experience sexual
problems (disease or
treatment related) due
to vaginal changes
and/or hormonal
changes including(5)
o loss of libido
Disease
Description & H&P
Diagnosis and Diagnostic Study
Clinical Intervention and Clinical Therapies

stage IVB - platinum-based combination
chemotherapy may be beneficial, such as
o cisplatin with paclitaxel
o cisplatin with topotecan
o treatment for locoregional and metastatic
recurrence
 palliative chemotherapy standard treatment
for most patients
 SIGN recommends cisplatin with either
topotecan or paclitaxel for palliative
chemotherapy for stage IVB or recurrent
cervical cancer
 pelvic exenteration an option for central
pelvic recurrence without extrapelvic
metastases
 consider salvage radiation therapy in
patients with pelvic recurrence who were
not previously irradiated
o SIGN recommendations for pregnant
women with cervical cancer
 choice of therapeutic modality should be
decided for nonpregnant patients
 immediate treatment recommended for
women diagnosed before 16 weeks
gestation
 for women with early stage disease (FIGO
IA1, IA2, IB) diagnosed after 16 weeks of
gestation, treatment may be delayed to
allow fetal maturity to occur
 for women with advanced disease (FIGO
1B2 or greater) diagnosed after 16 weeks
gestation, decision to delay must be based
on gestational age at time of diagnosis
Medications:
o
Chemoradiation:
chemoradiation associated with increased
survival compared to radiation therapy alone
in women with locally advanced cervical
cancer
Surgery and procedures:
Indications:
o
surgery for early stage disease
 conserves ovarian function
 results in less vaginal shortening and
fibrosis compared to radiation therapy,
Other
o
change in sexual
activity
o decreased orgasm
 women who have been
treated for cervical
cancer more likely than
controls without cancer
to have persistent
vaginal changes that
compromise sexual
activity (N Engl J Med
1999 May
6;340(18):1383 full-text)
 review of sexual
morbidity after radical
hysterectomy for
cervical cancer can be
found in Expert Rev
Anticancer Ther 2010
Jul;10(7):1037
Complications of radiation
therapy:
o
o
o
acute radiation toxicity may
include(2)
 fatigue
 diarrhea
 irritative bladder
symptoms
acute toxicity is increased
when concomitant
chemotherapy is given,
especially(1, 2, 5)
 hematologic effects
(anemia, leukopenia,
thrombocytopenia)
 gastrointestinal effects
late radiation side effects
(occur ≥ 3 months after
completion of radiation
therapy)(2, 5)
 small bowel obstruction
 fistula
 rectal bleeding
 rectosigmoid stenosis
 ureteric stricture
 bladder
o urinary frequency,
urgency
Disease
Description & H&P
Diagnosis and Diagnostic Study
Clinical Intervention and Clinical Therapies

beneficial for residual sexual function
allows accurate assessment of lymph node
status
Prevention of human papillomavirus (HPV)
infection:
HPV vaccination:
o



quadrivalent human papillomavirus (HPV)
recombinant vaccine against HPV types (6, 11,
16, and 18) (Gardasil)
 Gardasil 0.5 mL intramuscular injections
into deltoid or anterolateral thigh given at 0,
2, and 6 months; costs about $155 per dose
or $465 for full course
quadrivalent HPV vaccine induces
immunogenicity in children aged 9-15 years
quadrivalent HPV vaccine is effective in
preventing cervical and external genital disease
in women aged 24-45 years but may not be
cost-effective
quadrivalent HPV vaccine associated with
decreased genital lesions related to HPV-6/11 in
men aged 16-26 years
bivalent HPV recombinant vaccine against HPV16/18 vaccine (Cervarix)
Other
o
o
o
o
dysuria
detrusor instability
hematuria
ulceration
Screening
do not start cervical cancer
screening before age 21 years
Do not perform cervical cancer
screening at age 21-65 years
stop screening after age 65
years if consecutive normal
testing for prior 10 years
 for women aged 21-29
years
o cervical cytology
(Pap smear or
liquid-based)
recommended
every 3 years )
o human
papillomavirus
(HPV) DNA testing
not recommended
 for women aged 30-65
years
o combination of
cytology screening
plus HPV testing
every 5 years
recommended, but
cytology screening
alone every 3
years is an
alternative
o HPV testing alone
not recommended
 cervical cancer
screening appears
to reduce incidence of
invasive cervical
cancer
 cervical cancer
screening appears to
reduce incidence of
cervical cancer
in women > 30 years
old, but efficacy of
Disease
Description & H&P
Diagnosis and Diagnostic Study
Clinical Intervention and Clinical Therapies
Other

screening uncertain in
women < 30 years
optimal screening
interval for cervical
cancer screening is
uncertain
management of abnormal
screening results varies by
abnormality, age, and prior
history
 colposcopy generally
recommended for highgrade cytologic
abnormalities, or lowgrade cytologic
abnormalities which
persist or are
associated with positive
HPV test
 repeat testing at shorter
intervals (such as 12
months) generally
recommended for lowgrade cytologic
abnormalities or
following negative
colposcopy
o
Spontaneo
us Abortion
– First
Trimester
Abortion
Description:
o
o
spontaneous pregnancy
loss occurring before 13
weeks gestation, with most
losses occurring before 12
weeks gestation
miscarriage - refers to
spontaneous abortion
before 20 weeks gestation,
types include
 threatened
spontaneous abortion bleeding before 20
weeks gestation with
closed cervix, woman
may or may not
miscarry
 complete spontaneous
abortion - all products
o
clinical presentation by type of spontaneous
abortion
 threatened abortion
o vaginal spotting or light bleeding
o closed cervix
o no size-date discrepancy on
bimanual exam
 complete abortion
o on exam
 history of heavy vaginal
bleeding that has since abated
 closed cervix
 small, contracted uterus
o on ultrasound
 empty uterus
 thickened endometrial lining
 missed abortion
o on exam
 absence of vaginal bleeding
Treatment
 expectant management
o expectant management is effective
method in selected cases of confirmed
first trimester pregnancy loss
o women with an intact gestational sac
should be informed that resolution may
take several weeks and efficacy may
be lower
o in absence of hemorrhage or infection,
it is safe to wait indefinitely for
miscarriage to complete without further
intervention
o patients can switch at any time to
medical or surgical uterine evacuation
 medical uterine evacuation
o most effective for incomplete
miscarriage
o may be preferred over expectant
management for anembryonic gestation
Who is most affected:
o
women with pregnancy < 12
weeks gestation
o women > 35 years old
Causes:
o
chromosomal abnormalities
maternal infections(1)
 Listeria
 syphilis
 toxoplasmosis
 bacterial vaginosis, usually
caused
byMycoplasma or Ureaplas
ma
o bacterial vaginosis in
early pregnancy may
increase risk of
miscarriage
Disease
Description & H&P
o
o
o
o
o
of conception have
passed
 incomplete
spontaneous abortion some but not all
products of conception
have passed
 inevitable spontaneous
abortion - cervix has
dilated but passage of
products has not
occurred, miscarriage
is unavoidable, usually
with vaginal bleeding
 septic spontaneous
abortion - incomplete
miscarriage associated
with ascending
infection of the
endometrium,
parametrium, adnexa
uteri, or peritoneum
recurrent
miscarriage/spontaneous
abortion - defined as ≥ 2
consecutive or 3 total
clinical pregnancy losses
anembryonic gestation
(empty sac or blighted
ovum) - gestational sac
without embryonic
structures
embryonic or fetal demise
(missed abortion) nonviable pregnancy
(absence of embryo within
intact gestational sac or
absence of fetal heart
activity in visible embryo)
that has been retained in
the uterus
stillbirth - fetal death after
20-24 weeks gestation
pregnancy of unknown
location - positive urine or
serum pregnancy test and
transvaginal ultrasound
findings of no intrauterine
fluid collection with normal
or near normal adnexa
Diagnosis and Diagnostic Study
Clinical Intervention and Clinical Therapies

closed cervix
on ultrasound
 embryonic pole ≥ 5 mm without
fetal cardiac activity
 embryonic pole < 5 mm and no
interval growth in 1 week
 incomplete abortion
o on exam
 heavy vaginal bleeding
 open cervix
 visible products of conception
in cervical opening
o on ultrasound, heterogeneous
and/or echogenic material along
endometrial stripe or in cervical
canal
 septic abortion
o pelvic exam and ultrasound
findings similar to incomplete
abortion
o clinical signs of sepsis
 inevitable abortion may present with
o on exam
 moderate vaginal bleeding
 open cervix
 no visible products of
conception in cervical opening
o on ultrasound
 visible products of conception
in uterus
 fetal cardiac activity may be
present or absent
anembryonic gestation may present on
ultrasound with(1)
 gestational sac > 13 mm without yolk
sac or > 18 mm without embryonic pole
 empty gestational sac > 38 days of
gestation and no interval growth > 1
week
 absent fetal heart tones on Doppler fetal
monitor
o
Making the diagnosis:
o
diagnosis made with combination of clinical
and ultrasound findings
 speculum exam with products of
conception visible in cervical opening or
vaginal vault can be diagnostic
or missed abortion/miscarriage
performed with misoprostol, which can
be administered on outpatient basis as
single or divided dose vaginally or
orally with or without priming
with mifepristone
 nonsteroidal anti-inflammatory
drug (NSAID) before misoprostol
may reduce side effects of fever,
chills, and severe cramping
(narcotic/acetaminophen may also
be prescribed)
 vaginal misoprostol
 reported dose range 400-800
mcg
 vaginal misoprostol effective
for completing miscarriage
within 24 hours and avoiding
need for uterine curettage with
anembryonic gestation or
missed abortion/miscarriage
before 24 weeks
 misoprostol 400 mcg vaginally
increases resolution rate of
early miscarriages but
increases pain
 oral misoprostol
 oral misoprostol appears no
more effective than expectant
management
 for priming with mifepristone, give
600 mg orally followed by
misoprostol 400 mcg orally 48
hours later
surgical uterine evacuation
o surgical evacuation reduces rate of
unplanned hospital admission but no
differences in infection rates compared
to expectant management in women
with fetal demise or incomplete
abortion/miscarriage before 13 weeks
gestation
o surgical uterine evacuation should be
offered to women who prefer to
complete their miscarriage in a shorter
amount of time than that of expectant
management or medical management
o insufficient evidence to recommend
routine antibiotic prophylaxis prior to
surgical uterine evacuation, so
o
o

Other
reproductive tract abnormalities
 shortened cervix
 congenital uterine
abnormalities
o congenital uterine
anomalies,
particularly
subseptate or septate,
unicornuate, and
bicornuate uteri, may
be more common in
women experiencing
miscarriage than in
unselected population
Complications:
o
o
hemorrhage or heavy
bleeding
 defined as soaking
through 2 sanitary pads
per hour for two hours
in a row
 if women experience
heavy bleeding, screen
for anemia and treat as
indicated
 heavy bleeding may
lead to symptoms
ofhypovolemic shock,
including
o tachycardia and/or
arrhythmia
o tachypnea or
dyspnea
o fever or low body
temperature
o hypotension and/or
syncope
reproductive tract infection
 may be due to retained
products of conception
 women with bacterial
vaginosis at time of
surgical uterine
evacuation may be at
increased risk for
subsequent pelvic
inflammatory disease
(PID)
 bacterial sacroiliitis and
Disease
Description & H&P
Diagnosis and Diagnostic Study

Chief concern (CC):
o
o
o
most patients present with
vaginal bleeding or recent
vaginal bleeding that has
subsided
patients may also present
with
 pelvic pain similar to
period pain or cramps
 recent pelvic pain that
has subsided
 size-dates discrepancy
on bimanual exam
 loss of pregnancy
symptoms
typical presentation by type
of miscarriage
 threatened
spontaneous abortion may or may not have
cramping
 inevitable spontaneous
abortion - heavy
bleeding with possible
visualization of
products of conception
 completed
spontaneous abortion history of pain and
bleeding and passage
of products of
conception, but
subsided at
presentation
 missed spontaneous
abortion - may have
spotting or brownish
discharge and
symptoms of early
pregnancy
o
o
o
o
in absence of visible tissue, consider
ultrasound, beta-human chorionic
gonadotropin (beta-hCG), progesterone
or combination of tests to differentiate
miscarriage from viable intrauterine
pregnancy or ectopic pregnancy
transvaginal ultrasound, serial serum hCG
levels, and progesterone may all be required
to establish definite diagnosis
if serum hCG levels positive for pregnancy,
but transvaginal ultrasound fails to confirm,
diagnosis of pregnancy of unknown location
warranted and should be made(6)
 if single hCG measurement < 3,000
milliunits/mL and patient stable
o treatment for suspected ectopic
pregnancy not indicated as may
interrupt viable intrauterine
pregnancy
o confirm diagnosis of ectopic
pregnancy vs. viable or nonviable
intrauterine pregnancy with followup testing
 if single hCG measurement ≥ 3,000
milliunits/mL
likely diagnosis is nonviable intrauterine
pregnancy
follow-up hCG and ultrasound indicated to
confirm diagnosis prior to initiating treatment
Clinical Intervention and Clinical Therapies
antibiotic prophylaxis should be given
based on individual clinical indications
o screening for infection,
including Chlamydia trachomatis,
should be considered prior to surgical
uterine evacuation
o consideration should be given to
offering local anesthesia or sedation for
women who prefer it
o vacuum aspiration preferable to sharp
curettage
o Rho(D) immune globulin (anti-D immune
globulin, RhoGAM)
 often recommended for any bleeding before
20 weeks gestation if Rh-negative mother
 typical dosing in United States is 50 mcg
(250 units) in women with bleeding before
12 completed gestational weeks and 300
mcg (1,500 units) after 12 weeks
 Royal College of Obstetricians and
Gynaecologists (RCOG) recommendations
for Rho(D) immune globulin in Rh(D)
negative, nonsensitized women with
miscarriage
o indicated for spontaneous
abortion/miscarriage at ≥ 12 weeks
gestation
o indicated for surgical evacuation of the
uterus regardless of gestation
o consider giving Rho(D) immune
globulin for medical evacuation of the
uterus regardless of gestation
o not required for spontaneous
abortion/miscarriage at < 12 weeks
gestation as long as there is no
instrumentation of the uterus
o regardless of management method, followup indicated to assure completion of miscarriage
o acknowledge psychological sequela with
pregnancy loss and provide support, follow-up,
and access to formal counseling when needed
Medications:
Misoprostol:
History of present illness
(HPI):
o
patient may present with
history of
o
misoprostol can be administered on outpatient
basis as single or divided dose orally,
sublingually, or vaginally
 bleeding and cramping usually begin 2-6
hours after administration and most severe
symptoms peak within 3-5 hours
Other
o
gluteal abscess after
dilation and curettage
for incomplete
miscarriage in case
report
psychological sequelae
 feelings of loss and
grief common


miscarriage associated
with increased risk of
depression especially in
women without
previous children
Disease
Description & H&P
o
o
o


spotting or bleeding
pelvic pain or cramping
ask about
 severity of bleeding
and attempt to quantify
by number of pads or
tampons
 passage of products of
conception
 pelvic pain - if present,
quality, location,
duration
o slight pain is
suggestive of
threatened
miscarriage
o moderate pain is
suggestive of
inevitable,
incomplete, or
septic miscarriage
o severe pain that
has since abated
is suggestive of
complete
miscarriage
 gestational age
o date of last
menstrual period
o estimated length of
gestation
o previous
ultrasound results
General physical:
patients with incomplete or
septic spontaneous
abortion may present with
symptoms ofhypovolemic
shock, including(5)
 tachycardia and/or
arrhythmia
 tachypnea or dyspnea
 fever or low body
temperature
 hypotension and/or
syncope
check for orthostatic vital
signs
Diagnosis and Diagnostic Study
Clinical Intervention and Clinical Therapies
o
o
o
o
o
o
o
o
o

bleeding may continue for up to 3 weeks
side effects include
 nausea in 22%-35%
 fever in 15%
 diarrhea in 6%-21%
 vomiting in 7%
Vaginal misoprostol:
vaginal misoprostol
 doses used in clinical trials ranged from
400-800 mcg
 range of reported success rate after single
dose of misoprostol 33%-60% at 24 hours
 success rates improve to 80%-88% with
repeat doses
 higher success rate with incomplete
spontaneous abortion than with other types
of miscarriage
side effects
 include nausea, fever, vomiting, and
diarrhea
 increase with repeated doses
 increase with oral or sublingual route
compared to vaginal route
vaginal misoprostol effective for completing
miscarriage within 24 hours and avoiding
need for uterine curettage with anembryonic
gestation or missed spontaneous abortion
before 24 weeks
Mifepristone:
mifepristone destabilizes implantation site before
treatment with misoprostol(4)
success rate with combination of mifepristone
plus misoprostol > 90% in early pregnancy
loss(4)
FDA-approved regimen for medical abortion is
mifepristone 600 mg orally followed by
misoprostol 400 mcg orally 48 hours later, but
other regimens may be effective
 see dosage and administration
in mifepristone for additional information
mifepristone 48 hours before misoprostol
appears no more effective than two doses of
oral misoprostol 48 hours apart
regardless of management method, follow-up
indicated to assure completion of miscarriage
and to process experience
 findings suggestive of completion of
Other
Disease
Description & H&P
Diagnosis and Diagnostic Study
Clinical Intervention and Clinical Therapies
Cardiac:
o
patients with incomplete or
septic spontaneous
abortion may present with
maternal tachycardia and/or
arrhythmia
Pelvic:

o
vaginal bleeding and
attempt to quantify
amount and duration
pelvic exam signs
suggestive of first trimester
pregnancy loss include
 open or closed cervix
 size-date discrepancy
on bimanual exam
 small, contracted
uterus
 products of conception
in cervical opening
o
o
miscarriage(1)
o repeat ultrasound showing absence of
previously documented pregnancy
o 80% drop in beta-hCG level one week
following passage of tissue
 if ectopic pregnancy has been
excluded, no need to follow betahCG levels to zero
 for cases where no intrauterine
pregnancy has been documented,
consider following beta-hCG levels
to resolution
o in absence of hemorrhage or infection,
safe to wait indefinitely for miscarriage
to complete without further intervention
o patients can switch at any time to
medical or surgical uterine evacuation
for any management method, counsel patient on
signs that require immediate medical attention
such as
 heavy bleeding - soaking through 2 sanitary
pads per hour for 2 hours
 high fever (alert patients receiving medical
management that misoprostol may cause
fever within 24 hours of treatment and this
should not be interpreted as infection)
 pelvic pain
 feeling ill several days after miscarriage
regardless of management method, counsel
patients that
 normal menstrual periods usually return
between 1 and 2 months after miscarriage
 no medical necessity to withhold any
contraceptive method once beta-hCG has
returned to zero and products of conception
have passed
 no evidence of medical necessity for delay
of next attempt at conception
Other