Back to Basics:
Gynecology
Dr. Jessica Dy
Assistant Professor
Department of Obstetrics and Gynecology
University of Ottawa
March 29, 2010
Overview
►
►
Normal Menstruation
►
 Sexual development
 Menstrual cycle
►
►
 Dysmenorrhea
 Endometriosis
Menstrual Abnormalities




Amenorrhea
Abnormal uterine bleeding
PCO
Menopause
Contraception
Infertility
Pelvic Pain
►
►
►
►
Pelvic Mass
Ectopic pregnancy
Pap smears
Vaginal/pelvic infections
Female Sexual Development
A mother is concerned that her 12 yo daughter has not had
her period yet (the other girls in her daughter’s class have
already started their period). She thinks her daughter hasn’t
shown signs of puberty yet. Knowing the usual first sign of
the onset of puberty, you should ask which of the following
questions?
a)
Has her daughter had any acne?
b)
Has her daughter started to develop breasts?
c)
Does her daughter have any axillary or pubic hair?
d)
Has her daughter started her growth spurt?
e)
Has her daughter had any vaginal spotting?
The usual events in normal pubertal
development from first to last are:
a)
Peak growth, pubic hair, breast budding, menarche
b)
Breast budding, pubic hair, peak growth, menarche
c)
Breast budding, menarche, pubic hair, peak growth
d)
Pubic hair, breast budding, menarche, peak growth
Secondary Sexual Characteristics
“Baby Has Gone Mad!”
Breast Development (Thelarche)
10.5 yo
Hair Development (Pubarche)
11.0 yo
Growth (peak height velocity)
11.4 yo
Menstruation (Menarche)
12.8 yo
Hypothalamic-Pituitary-Ovarian Axis
Hypothalamus
GnRH
Pituitary
FSH, LH
Ovary
Estradiol
Breast/Uterus/Vagina
Female Sexual Development
►
►
►
In infancy and pre-puberty, FSH and LH
levels are high or low ?
Prior to onset of puberty, FSH and LH levels
increase or decrease?
This stimulates ovaries to produce
Tanner Staging
Abnormal Sexual Maturation
►
Accelerated Maturation
 Precocious puberty
 Dev’t of 2o sexual characteristics < 8 years
►
Delayed Maturation
 Absence of thelarche by 13 years
 Absence of menarche by 15 years
A 9 year old girl presents for evaluation of regular
vaginal bleeding. History reveals thelarche at age 7
and adrenarche at age 8. Which of the following is
the most common cause of this condition in girls?
a)
Idiopathic
b)
Gonadal tumors
c)
McCune-Albright syndrome
d)
Hypothyroidism
e)
CNS tumors
Precocious Puberty
True (or Central) (GnRH dependent)
• Idiopathic (74%)
• CNS lesions (e.g., infections, tumors)
Pseudo (or Peripheral) (GnRH Independent)
• Ovarian (e.g., granulosa cell tumor)
• McCune-Albright syndrome
• Adrenal
•
Hypothyroidism
Precocious Puberty: Investigations
• Initial:
• Height and weight
• Estradiol levels
• Androgens: DHEAS, testosterone
• FSH, LH, TSH levels
• Bone age
• Secondary:
• Imaging of pituitary/sella
• Ultrasound ovaries, uterus, adrenals
• Bone scan (McCune-Albright)
Precocious Puberty: Treatment
• Aimed at underlying process:
• Tumor: resection, radiation, chemo
• Idiopathic:
− GnRH agonist therapy suppresses GnRH
− when therapy stopped, appropriate
chronologic changes resume
• McCune-Albright syndrome:
− Medroxyprogesterone acetate
− Aromatase inhibitors
Abnormal Sexual Maturation
►
Accelerated Maturation
 Precocious puberty
 Dev’t of 2o sexual characteristics < 8 years
►
Delayed Maturation
 Absence of thelarche by 13 years
 Absence of menarche by 15 years
The most common cause of
delayed puberty is:
a)
b)
c)
d)
e)
Turner’s syndrome
Craniopharyngioma
Constitutional delay
Anorexia nervosa
Primary hypothyroidism
Delayed Puberty
Delayed Menarche + 2o Sexual Dev’t
► Anatomic genital abnormalities
► Androgen insensitivity syndromes (complete forms)
Delayed Puberty + Inadequate/Absent 2o Sexual Dev’t
► Hypothalamic-pituitary dysfunction (low FSH)
 Reversible: Constitutional delay, weight loss due to extreme dieting,
protein deficiency, fat loss without muscle loss, drug abuse
 Irreversible: Kallmann's syndrome, pituitary destruction
►
Gonadal failure (high FSH)
 Abnormal chromosomal complement (eg, Turner's syndrome)
 Normal chromosomal complement: chemotherapy, irradiation,
infection, infiltrative or autoimmune disease, resistant ovary
syndrome
Delayed Puberty
1.
2.
3.
4.
Anatomic genital abnormalities
Androgen Insensitivity Syndrome
Central Cause (low FSH)
Gonadal Disorders (high FSH)
The Menstrual Cycle
…and other menstrual
abnormalities
Normal Menstrual Cycle
Normal Menstrual Cycle
►
Follicular Phase
►
Luteal Phase
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Proliferative Phase
►
Secretory Phase
►
Corpus Luteum
►
Progesterone
►
►
Granulosa Cells
(dominant follicle)
Estrogen
Amenorrhea
Primary Amenorrhea
►
No menses by age 13 in the absence of development
of secondary sexual characteristics
or
►
No menses by age 15 regardless of presence of normal
growth and development
Secondary Amenorrhea
►
No menses for a length of time equivalent to a total of
at least 3 of the previous cycle intervals
or
►
> 6 months of amenorrhea
Hypothalamic-Pituitary-Ovarian Axis
Hypothalamus
Pituitary
Ovary
Uterus/vagina
Amenorrhea - Etiology
PREGNANCY
ALWAYS NEED TO RULE OUT!!
Hypothalamus
Extreme Stress, Anorexia nervosa, Tumors,
Infection, Congenital (Kallman’s syndrome)
(35%)
Pituitary
(20%)
Prolactin adenomas, 1o hypopituitarism,
Sheehan syndrome, (Thyroid)
(20%)
Congenital, Premature Ovarian Failure,
Anovulation (PCO, tumors)
Uterus/vagina
(5%)
Congenital Absence, Imperforate hymen,
Vaginal septum, Asherman’s syndrome
Others
Drugs (Metoclopramide, neuroleptics)
Ovary
Amenorrhea - Hypothalamic
Extreme stress/systemic illness/nutritional
deprivation
Anorexia Nervosa
►
►



Calorie restriction +/- exercise induced
Loss of pulsatile GnRH secretion
Critical body fat threshold
Hypothalamic tumor, infiltrative disorder
Congenital GnRH deficiency
►
►

Kallmann’s syndrome
Amenorrhea - Pituitary
Pituitary Adenomas:
►
►
►
►
Non-functioning – most common (30-40% of all pituitary
lesions)
Prolactinoma
Growth Hormone secreting - Acromegaly
ACTH secreting - Cushing’s Disease
Primary Hypopituitarism
Sheehan syndrome
►
►
Postpartum hemorrhage & ischemic necrosis of anterior
pituitary (portal system)
Failure of lactation
Amenorrhea – Pituitary Lesions
Any mass lesion may cause stalk compression
↓ dopamine suppression
↑ prolactin levels
↓ GnRH secretion
↓ FSH/LH levels
amenorrhea
Amenorrhea - Ovary
►
Anovulatory: PCOS
►
Ovarian failure
 Premature exhaustion of follicles
 “menopause” occurs < 40 years
 Genetic, idiopathic, surgical, radiation,
chemotherapy, immunological
Premature ovarian failure may
be due to any of the following
except:
a)
Turner’s syndrome
b)
Autoimmune dysfunction
c)
Hyperandrogenism
d)
Radiation exposure
Ovarian Abnormal Development
►Gonadal



Pure gonadal dysgenesis : 46 XX
Turner’s Syndrome: 45 XO, +/- mosiacisms
Swyer’s syndrome: 46 XY
►Androgen


insensitivity I (testicular feminization)
Absent receptor for testosterone
46 XY, development of female habitus, breast development,
diminished pubic/axillary hair, absent uterus, blind vagina, gonads
are testes
►Androgen


Dysgenesis
insensitivity II
5a-reductase enzyme deficiency (T → DHT)
46 XY, born with female external genitalia, but male pubertal
development
Amenorrhea – Uterus/Vagina
►Blockage





(Mullerian abnormalities)
transverse vaginal septum
imperforate hymen
non-communicating cavities
Cervical stenosis
Congenital mullerian agenesis (MRKH syndrome)
►Endometrial
Failure (Asherman’s syndrome)
 2o vigorous D&C, usually postpartum
 ++ adhesions in uterine cavity
The initial work-up for a patient with
2o sexual characteristics and amenorrhea
include all of the following except:
a)
b)
c)
d)
e)
Pregnancy test
Pelvic ultrasound
Prolactin level
Thyrotropin level
Assessment of estrogen status
Approach to
Amenorrhea
yes
Stop investigating
no
E+P challenge
no bleed
*Need to do Karyotype
Polycystic Ovarian
Syndrome (PCOS)
PCOS
Syndrome resulting from chronic
anovulation and/or chronic ovarian
androgenism
► Can be associated with  insulin levels
► Diagnosis is made clinically +/- biochemical
support
► Wide spectrum seen in clinical practice
►
PCOS - pathophysiology
insulin
↑estrogen
↓FSH + ↑LH
anovulation
↑peripheral
estrogen
↑androgens
from ovary
oligomenorrhea
obesity
HIRSUTISM
INFERTILITY
PCOS
►
Clinical features:
 Average age 15-35 years
 Hirsutism, anovulation/amenorrhea, infertility, insulin resistance,
obesity, acanthosis nigricans (HAIR-AN)
►
Biochemistry:
  testosterone and DHEAS, LH:FSH ratio > 2:1
 Fasting glucose:insulin ratio < 4.5 => insulin resistance
►
Ultrasound:
 multiple follicles peripherally arranged (“string of pearls”)
►
Diagnosis (need 2 out of 3 to make Dx):
 Oligomenorrhea/irregular menses
 Clinical or lab evidence of hyperandrogenism
 Polycystic ovaries on US
Clinical Significance of PCOS
Infertility
► Menstrual bleeding problems
►
 Oligo/amenorrhea & DUB
►
Androgen effects:
 hirsutism, acne and alopecia
 risk of endometrial cancer
►  risk of CAD
►  risk of type 2 diabetes if insulin
resistant
►
Treatment of PCOS
Cycle Control
►
►
►
Weight loss: diet and exercise
Cyclic progesterone or OCP to prevent
endometrial hyperplasia/ cancer
Metformin to  insulin levels & ? reduce risk of
progression to type 2 diabetes
Infertility
►
►
►
Ovulation induction: Clomiphene, FSH, LHRH,
etc.
Metformin to sensitize to ovulation induction
Ovarian drilling
Treatment of PCOS
Hirsutism
► OCP or specifically Diane 35: antiandrogenic
► Mechanical removal of hair
► + spironolactone (inhibits steroid receptor)
► Finasteride (5alpha reductase inhibitor)
► Flutamide (androgen reuptake inhibitor)
Abnormal Uterine
Bleeding
Abnormal Uterine Bleeding
Abnormal bleeding at unexpected time (premenarche or post-menopausal)
► Change in pattern of menstrual flow
►
 Frequency (interval < 24 days)
 Duration (> 7 days)
 Amount (> 80 cc per cycle/clots)
►
Need to rule out organic causes
Abnormal Uterine Bleeding
Menorrhagia:
• Cyclic menstrual bleeding occurring at regular intervals
but excessive in amount (>80 cc/cycle)
and/or duration (>7 days)
Metrorrhagia (intermenstrual bleeding):
• Uterine bleeding occurring at irregular intervals
Polymenorrhea
• Cycles occurring too frequently, < 24 days
Menometrorrhagia:
• Excessive amount of bleeding at irregular intervals
Causes of Abnormal Uterine Bleeding
►
Ovarian


►
anovulatory cycles
Ovarian cancer
►



Uterine






polyps, fibroids
PID, endometritis
IUD
exogenous hormones
endometrial hyperplasia
endometrial cancer
Cervical
►
External Genitalia



►
Polyps
Infection
cervical cancer
Vulvovaginitis
trauma
Vaginal or vulvar cancer
Others


Coagulation disorders
Thyroid disease
A 15 yo female is brought to the ED because
of very heavy vaginal bleeding. Her Hb level is
90 g/L. Each of the following diagnoses
should be considered except:
a)
b)
c)
d)
e)
Anovulatory, dysfunctional bleeding
Coagulopathy
Pregnancy
Endometrial polyps
Thyroid dysfunction
A 45 yo female is brought to the ED because
of very heavy vaginal bleeding. Her Hb level is
90 g/L. What is the least likely diagnosis?
a)
b)
c)
d)
e)
Anovulatory, dysfunctional bleeding
Coagulopathy
Pregnancy
Endometrial polyps
Thyroid dysfunction
Approach to AUB
Abnormal Bleeding
Investigations:
Dysfunctional Uterine Bleeding
(DUB)
Uterine bleeding without any evidence of organic disease
► i.e., no polyps, malignancy, pregnancy, etc.
►
Diagnosis of exclusion
Anovulatory DUB (90%)
► no ovulation = no progesterone secretion
► Prolonged, high, unopposed estrogen exposure
► Fragile endometrium, areas of shedding and re-growth
Ovulatory DUB (10%)
► Luteal phase progesterone unable to maintain
endometrium
Acute DUB Treatment
Mild:
• OCP
• Cyclic Medroxy Progesterone Acetate (Provera)
Severe:
• Stabilize patient as required (ABC’s)
• Premarin IV 25 mg q4-6h or high dose OCP
• + Add OCP or Provera for maintenance
• D&C if severely ill or unresponsive to medical therapy
DUB Longterm Treatment
Hormonal Manipulation of Cycle
• Combined Contraceptives
• Progesterone only
• Progesterone IUD (Mirena)
• GnRH analogue
Control of Menorrhagia
• NSAIDS for menorrhagia
• Anti-fibrinolytic agents (Cyklokapron)
Surgical
• endometrial ablation
• hysterectomy
Coffee Break !!!
MENOPAUSE
The following statements are true except:
a)
b)
c)
d)
Menopause occurs at ~51 years of age as
a result of a genetically determined
depletion of ovarian follicles responsive to
gonadotropins.
Menopause occurs earlier in smokers.
Loss of ovarian function results in absolute
estrogen deficiency.
Hormone replacement therapy should not
be used for prevention of cardiovascular
disease or dementia
Menopause
►
Physiologic
 average age 50-51 in North America
 1-2M oocytes at birth, 500,000 in puberty, only 400-500
ovulate, the rest vanish by atresia
 Few remaining oocytes not responsive to gonadotropins
►
Artificial
 Surgery
 radiation
Menopause
►
Perimenopause
 2-8 years preceding and 1 year after last menses
 Elevated FSH in follicular phase
 Irregular menses
►
Menopause
 Final menstruation
►
Postmenopause
 6-12 months of amenorrhea
Menopause
before oophorectomy
Estradiol
Testosterone
after oophorectomy
Androstenedione
FSH
Clinical Conditions In Menopause
►
Vasomotor symptoms




►
75% of women
> 1 year in 80% of women
Major indication for ERT/HRT
SSRI, clonidine, gabapentin, black cohosh
Urogenital atrophy
 Lubricants, local estrogen therapy
►
Osteoporosis
 Ca, Vit D, smoking cessation, exercise
 Bisphosphonates, ERT/HRT, SERMs (raloxifene)
HRT
► Good
 relief of vasomotor and GU symptoms
 Increases BMD, decreases fracture risk
► Bad
 Increases VTE, CAD, stroke
►
►
? Increased risk of breast cancer, dementia
No increased risk of endometrial cancer
CONTRACEPTION
Contraception
►
Permanent
 Vasectomy, tubal ligation
►
Reversible
 Barrier methods
 Hormonal Contraceptives
•
(pill, patch, ring), progesterone only
 Intrauterine devices
 Post-coital
 Abstinence, rhythm, withdrawal, lactation
Barrier Contraception
►
Male condom
 Protects against STIs
 Failure rate 10-30% in typical use
►
Female barriers
 Female condom, diaphragm, cervical cap
 Need to fit properly, more inconvenient
 Failure rate higher than male condom
►
Spermicidal preparations
 30% failure rate when used alone (typical use)
Combined hormonal contraceptives:
a) Decrease the risk of stroke and VTE
b) Should only be started on the first day of a
menstrual period
c) Suppress ovulation mainly through an estrogen
dominant effect
d) Is contraindicated in women >35 years old
e) Decrease dysmenorrhea, menorrhagia and acne
Hormonal Contraception
►
Combined Contraceptives
 Pill, patch, ring
 Most contain low dose (20-35 mg) ethinyl
estradiol +
progestin
 Mechanism of action (mainly from progestin):
•
Ovulatory suppression by FSH/LH inhibition
•
Decidualization of endometrium
•
Thickening of cervical mucous
 Non-contraceptive benefits
 Multiple, but mild side effects
 Does not protect against STI’s
Hormonal Contraception
Absolute
contraindications
►
►
►
►
►
►
►
►
►
Pregnancy
Undiagnosed vaginal bleeding
Thromboembolic disease
Estrogen dependent tumors
Coronary/cerebrovascular
disease
Impaired liver function
Uncontrolled hypertension
Migraines with neurological
symptoms
Smoker, age >35
Relative
contraindication
►
►
►
►
►
►
Migraines (non-focal)
Controlled hypertension
Hyperlipidemia
Sickle cell anemia
Gallbladder disease
SLE
Hormonal Contraception
►
Progestin Only Methods
 Suitable for lactating women or women with
contraindications to combined OCP
 “Minipill” (Micronor)
•
•
Higher failure rate
Taken daily, no pill free interval
 Depot-medroxyprogesterone acetate
•
•
•
•
•
Injectable, q 3 mos
Common irregular bleeding to complete amenorrhea
Highly effective
Return to fertility may take up to 1-2 yrs
Risk of osteoporosis
Intrauterine Device (IUD)
Device that sits in the uterine cavity
► Nova-T (copper containing)
►
 foreign body reaction in endometrium
►
Mirena (levonorgestrel releasing)
 decidualization of endometrium +
thickening of cervical mucous
One time insertion, lasts up to 5 years
► Very effective, failure rate 1%
► Reversible
►
IUD
Absolute
contraindications
► Pregnancy
► Undiagnosed vaginal
bleeding
► Acute or chronic PID
► Lifestyle risk for PID
► Allergy to copper
► Wilson’s disease (for
copper)
► Immunosuppressed
individuals
Relative contraindication
► Valvular heart disease
► Past Hx of PID
► Past Hx of ectopic
pregnancy
► Abnormalities of the
uterine cavity, fibroids
► Severe dysmenorrhea or
menorrhagia (for copper)
► Cervical stenosis
Contraception Case
27 yo nulligravid student was “celebrating” with her male
partner after successfully passing her exams. Immediately
after intercourse she noticed that the condom is broken.
Her LMP was 12 days ago and she has regular 28 day cycles
with molimina. She normally takes Alesse but has stopped
taking this about 6 months ago.
She paged you at 2 am. She does not want to get pregnant.
What would be the appropriate management(s) to offer this
couple?
(You may chose up to three answers)
Contraception
a) Urgent pregnancy test (serum)
b) Suggest expectant management and wait to see if she
misses a period
c) If she still has her Alesse tablets, take 5 of these now, and
another 5 in 12 hours
d) Insertion of copper containing IUD
e) 0.75 mg Levonorgestrel po now and again in 12 hours
f) Suggest doing a handstand q hourly x 48 hours to
prevent implantation
Emergency Contraception
Yuzpe Method
 within 72 hours of intercourse
 2 Ovral tablets q12h x 2 doses (often with Gravol)
 6% chance of pregnancy decreases to 2% with
Yuzpe
‘Plan B’
 within 72 hours of intercourse
 0.75 mg levonorgestrel every 12h x 2 doses (less
nausea)
 similar efficacy to Yuzpe
Copper IUD Insertion
 within 5 days of intercourse
 1% failure rate
INFERTILITY
Infertility
Definition:
• one year of ‘frequent’ unprotected intercourse without
conception
Primary: no prior pregnancies
• Secondary: previous conception
•
• 10-15% of couples in the reproductive age group
• must investigate both partners
Infertility - Epidemiology
Time Required for Conception in Couples
Who Will Attain Pregnancy
Duration of Exposure
% Pregnant
3 months
57%
6 months
72%
12 months
85%
24 months
93%
Guttmacher 1956
Infertility - Etiology
15%
35%
15%
►
Ovarian Problems (15%)
►
Tubal/Pelvic Pathology (35%)
►
Sperm Problems (35%)
►
Unexplained (10-15%)
35%
Etiology
Ovulatory dysfunction (15-20%)
1.
•
•
•
Hypothalamic (functional amenorrhea)
Pituitary: prolactinoma, hypopituitarism
Ovarian
•
•
•
•
•
PCOS
POF
Luteal phase defect (poor follicle production,
premature corpus luteum failure, failed uterine lining
response to progesterone)
Systemic diseases (thyroid, Cushing, renal/hepatic failure)
Congenital (Turner, gonadal dysgenesis, gonadotropin
deficiency)
Infertility: Ovulatory
Dysfunction
Overall Primary Investigations:
• Day 3 FSH
• Day ‘21’ progesterone
• TSH
• Prolactin
• Basal Body Temperature
Etiology
2.
•
Outflow tract abnormality
Tubal obstruction (~35%)
•
•
•
•
PID
Adhesions (previous surgery, peritonitis,
endometriosis)
Ligation/occlusion (e.g., previous ectopic)
Uterine factors (<5%)
•
•
•
•
•
•
Congenital anomalies (DES exposure), bicornuate uterus, uterine
septum
Intrauterine adhesions (e.g. Asherman’s)
Infection (endometritis, pelvic TB)
Fibroids/polyps
Endometrial ablation
Cervical factors (5%)
•
•
Hostile, or acidic cervical mucous
Anti-sperm antibodies
Infertility: Tubal Factor
Overall Primary Investigations:
• Hysterosalpingogram or
• Sonohysterogram/saline infusion scan or
• Laparoscopy
• In early proliferative phase of cycle after cessation
of menses for evaluation of structural defects
• diagnostic and therapeutic (may open tubes)
Hysterosalpingogram
(HSG)
Hysterosalpingogram (HSG)
Laparoscopy
Laparoscopy
Etiology
3.
Male factor (~40%)
•
Pre testicular
•
•
Testicular
•
•
•
•
Hypothalamic, pituitary (low LH, FSH, T)
Testicular failure (sometimes high FSH, low
T)
Genetic
Acquired Insult (infectious, varicocele)
Post testicular (normal FSH,LH,T)
•
Obstruction
Infertility: Sperm/Male
Factor
Semen analysis
• WHO Criteria:
• volume
• concentration
• motility
• morphology
> 2.0 ml
> 20 million sperm/ml
> 50%
> 30% normal forms
Infertility: Sperm/Male
Factor
Overall Primary Investigations:
• semen analysis x 2
Other investigations:
• karyotype
• TSH, Testosterone, PRL, FSH
• postcoital (sperm/cervical mucus interaction)
Infertility Investigations
1. Ovarian Function
•
•
•
•
Day 3 FSH
Day 21 progesterone
TSH, Prolactin
Basal Body Temperature
2. Female Genital Tract
•
•
HSG/SHG/SIS
Laparoscopy
3. Male Factor
•
Semen analysis x 2
Infertility - Treatments
• Approach based on fertility requirements:
1) Oocytes
2) Abnormal Female Genital Tract
3) Sperm
• use these categories to organize treatment
options for each particular couple
Treatment Options
1. Ovarian problems:
-
Treat any hypothyroidism/hyperprolactinemia
If PCOS, weight loss, metformin, ovarian drilling
Induce ovulation (clomiphene, letrozole, etc) +
IUI/IVF
donor oocytes/embryos, adoption
2. Tubal factors:
-
Tuboplasty
In-Vitro Fertilization (IVF)
3. Male factors:
-
Artificial Insemination (washed or donor sperm)
IVF + ICSI
Varicocele repair, surgical repair of obstruction
ICSI
Intracytoplasmic Sperm Injection:
• requires very few moving sperm
• can combine with testicular sperm retrieval
• requires IVF (female risks & discomfort)
Pelvic Pain
Pelvic Pain
26 yo G0P0 woman presents to the office with 8 years of
constant pelvic pain. She has had 3 previous diagnostic
laparoscopies (2 months, 2 years, and 6 years ago). All
demonstrated a normal pelvis. She has recently been seen by
specialists in General Surgery, GI, Urology, Orthopedics,
and Gynecology. All investigations have been normal and no
cause for the pain has been found.
Differential Diagnosis
Gynecologic - ACUTE: Gynecologic - CHRONIC:
1.
Adnexal:
• Mittelschmerz
• ovarian cysts, rupture,
•
2.
Uterine:
•
•
•
3.
torsion
Hemorrhage into ovarian cyst
or neoplasm
Degenerating fibroids
Torsion of pedunculated fibroid
Pyometra/hematometra
•
•
•
•
Endometriosis/adenomyosis
dysmenorrhea (cyclic pain)
Ovarian cysts
Chronic PID
•
•
•
•
•
adhesions
Uterine prolapse
Cancer invasive (late)
Fibroids
Pelvic congestion syndrome
Infectious
•
•
Acute PID
Endometritis
** RULE OUT PREGNANCY!!!
Differential Diagnosis
Non-Gynecologic:
1. Urinary tract:
•
•
infection, stones, retention
interstitial cystitis
2. GI:
•
•
appendicitis, diverticulitis, obstruction, infarct
constipation, hernia, IBD, IBS
3. MSK:
•
nerve entrapment, referred pain, abdominal wall, MS
4. Psychological trauma:
•
•
Depression, anxiety, somatization
~20% of chronic pelvic pain patients have a history of sexual
abuse/assault
Diagnostic laparoscopy for pelvic
pain should be performed to:
a) Evaluate women with cyclic pain who respond to NSAIDs
or OCP
b) Initially evaluate women with chronic noncyclic pelvic
pain
c) Biopsy and treat endometriotic lesions
d) Lyse all adhesions
Pelvic Pain - Investigations
►
Gynecology
related:




►
CBC, bhCG
vaginal/cervical
cultures
pelvic U/S or MRI
Laparoscopy
GI related:



stool cultures
abdominal U/S,
CT/MRI
endoscopy
►
Urologic:
 urine cultures,
urinalysis
 IVP, U/S, CT
►
Musculoskeletal:
 xray, CT, MRI
Endometriosis
Abnormal growth of endometrial tissue
outside the uterine cavity
► Pathogenesis is unknown
► Infertility
► dysmenorrhea, dyspareunia, dyschezia
► On pelvic exam:
►
 Tender nodules, fixed uterus
 May also be normal
Which of the following statements are
true?
a) Women with endometriosis always have dysmenorrhea or
chronic pelvic pain.
b) Minimal or mild endometriosis should never be treated
surgically, only medically.
c) The degree of pelvic pain correlates with laparoscopic
findings.
d) Medical treatment of endometriosis includes OCP,
progestins, GnRH analogues, Danazol.
e) Medical treatment of endometriosis results in long term
disease suppression and pain relief after cessation of
therapy.
Case
31 y.o. woman complains of sudden onset of RLQ pain.
The pain is constant and worse with movements. There is
no nausea/vomitting. Bowel movements are normal.
Her LMP is 7 weeks ago, and she has been actively trying
to get pregnant. Past medical history is positive for PID
requiring hospitalization for IV antibiotics for 4 days.
Her vitals are stable, and she is afebrile. She is having
mild vaginal bleeding (<1pad) that started today.
What is your differential diagnosis???
Case
What 3 initial investigations would be most appropriate?
A) CBC
B) pelvic ultrasound (endovaginal and transabdominal)
C) flat plate (x-ray) of abdomen
D) Quantitative bhCG
E) sigmoidoscopy with possible colonoscopy
F) IVP with delayed films
Ectopic Pregnancy
Ectopic Pregnancy
Definition
• embryo implants outside of the endometrial cavity
Epidemiology
• 1-2% of all pregnancies
• ~14% if previous ectopic pregnancy
• ~1/30,000 pregnancies is heterotopic (1 IUP + 1 ectopic)
• 4th leading cause of maternal mortality
Location of Ectopic
Pregnancy
Ectopic Pregnancy
Ectopic Pregnancy
Ectopic Pregnancy
Risk Factors
Tubal surgery
Previous ectopic
Previous salpingitis
Assisted Reproduction
Age < 25
Previous pelvic infection
Infertility
Cigarettes
Relative Risk
20
10
4
4
3
3
2.5
2.5
* ~50% of patients have no risk factors
* IUD use does not increase the risk of ectopic pregnancy
Ectopic Pregnancy
Clinical Presentation
• amenorrhea
• abdominal pain (90%) + rebound (45%)
• vaginal bleeding
• bimanual exam:
- CMT and adnexal tenderness (usually unilateral)
- palpable adnexal mass (50%)
• ruptured ectopic pregnancy:
- acute abdomen with  pain
- hypovolemic shock
Investigations
• Hx & Px
• bHCG quantitative, CBC, blood T&S
• Pelvic ultrasound
- an intrauterine pregnancy should be seen if
bhCG > 1200-1500, definitely by 2,000
• Serial bhCG:
- normal doubling time is about 2 days
- inadequate doubling suggests abnormal pregnancy
• Laparoscopy: definitive diagnosis
In order to distinguish an IUP from an ectopic
pregnancy, the change in bHCG levels over 48
hours is observed. What percentage rise in bHCG
represents the lower limit of normal values for
viable IUP?
a) 33%
b) 50%
c) 66%
d) 100%
Treatment
1. Medical (Methotrexate):
• 50 mg/m2 (1/5 chemo dose)
• serial bhCG weekly f/u
• 10-15% failure rate, 25% require 2nd dose
• criteria: - patient clinically stable
- <3.5cm unruptured ectopic pregnancy
- no FHR
- bhCG <5000
- no hepatic/renal/heme disease
- compliance and f/u essential
2. Surgical
• Laparoscopy vs laparotomy
• Salphingectomy vs salphingotomy
Tea Break!!!
Pelvic Mass
Differential Diagnosis
Adnexal
►
►
►
►
Ovarian cysts/tumors
Ectopic pregnancy
Tubo-ovarian abscess
hydrosalpinx
Uterine
►
►
►
►
►
Pregnancy
Fibroids
Adenomyosis
Endometrial cancer
hematometra
*And non-gynecologic causes:
Pelvic kidney, GI masses, abscess, lymph nodes
A 60 year old woman presents with a pelvic mass.
What percentage of ovarian neoplasms in postmenopausal women is malignant
a) 5%
b) 10%
c) 30%
d) 80%
Ovarian Cysts/Tumors
Benign vs. malignant
► Benign
►
 Physiological (follicular cysts, corpus luteal
cysts, hemorrhagic cysts)
 Endometrioma
 Benign adenomas
 Germ cell tumors (dermoid cysts)
Ovarian Tumors
Ovarian Tumors
Pelvic Mass
1) History:
- weight loss/gain
- increase in abdominal girth
- fatigue
- fevers/chills
- abnormal vaginal discharge or bleeding
- menstrual history
- pregnancy symptoms (amenorrhea, molimina)
- pain
- bowel/bladder dysfunction
- family history of gynecological/bowel cancers
Pelvic Mass
2) Physical Exam:
- complete general survey (including nodes)
- abdominal exam
- pelvic: speculum, bimanual, pelvi-rectal
3) Investigations:
- U/S: abdominal and endovaginal
- + CT or MRI
- pre-op investigations
- + pregnancy test
Pelvic
relaxation/prolapse
Definitions
• Cystocele: downward displacement of bladder
• Uterine Prolapse: descent of the uterus and cervix into
vaginal canal towards the vaginal introitus
• Rectocele: protrusion of rectum into posterior vagina
• Enterocele: herniation of small bowel into vagina
• Vaginal Vault Prolapse: descent of vaginal apex into
vaginal canal towards introitus after a hysterectomy
Pelvic relaxation
Predisposing Factors
• age
• pregnancy and vaginal childbirth
• menopause (↓ estrogen)
• changes in pelvic anatomy (surgery)
• obesity
• chronic cough
• chronic constipation
• connective tissue disorders
Symptoms
• Pelvic pressure, bulge, heaviness
• Low back ache
• Possibly relief with lying down
• worse symptoms at the end of the day
• Voiding difficulty, incomplete emptying, UTIs, stress
incontinence
• Constipation (need to reduce the rectocele to have BM)
• dyspareunia
Treatment
1. Conservative
•
•
•
•
•
•
Pessary (not useful for rectocele)
Kegels
weight loss
stool softeners
HRT
smoking cessation
2. Surgical
•
•
•
•
Vaginal Hysterectomy (for uterine prolapse)
Vaginal Repair (anterior, enterocele, and/or posterior repair)
Vault suspension
Anti-incontinence procedure
Pap Smear
Management
Screening Test
• Sampling of transformation zone
(endo/exocervix)
• Detection of early pre-malignant
lesions
• Multiple classification systems
Bethesda vs CIN System
PAP Smear Management
Possible Results (Squamous)
•Within Normal Limits
• Atypical Squamous Cells of Undetermined Significance
(ASCUS):
• may favour reactive or premalignant/malignant process
• Low Grade Squamous Intraepithelial Lesion (LSIL)
• High Grade Squamous Intraepithelial Lesion (HSIL)
• Squamous Cell Carcinoma
PAP Smear Management
Possible Results (Glandular cells)
• Within Normal Limits
• Atypical Glandular Cells of Undetermined Significance
(AGUS):
• may favour reactive or premalignant/malignant process
• Adenocarcinoma
• endocervical, endometrial, extra-uterine, NOS
Gynecologic
Infections
Case
19 year old G0 woman presents to the ER with
lower abdo/pelvic pain for 2 days. She had
developed a fever today and a vaginal
discharge. She has recently become sexually
active, and is not using contraception. A
pregnancy test is negative.
Case
What is the most likely diagnosis?
A) early appendicitis
B) chlamydial cervicitis
C) disseminated herpes
D) PID
E) trichomonas vaginitis
Acute Pelvic Inflammatory
Disease (PID)
• Clinical diagnosis implying patient has upper genital tract
infection and inflammation
• Ascending infection to endometrium, tubes, peritoneum
• Most often an STD: chlamydia, gonorrhea
• Rarely endogenous vaginal bacteria, TB
PID – Risk factors
►
►
►
►
►
►
►
►
Age < 30, sexually active
Vaginal douching
IUD (esp. 1st 10 days post insertion)
Invasive gyne procedures: D&C, endometrial
biopsy
History of previous STI
Multiple sexual partners
No barrier contraception
Contact with infected person
Presentation
• Spectrum of severity
•Up to 2/3 asymptomatic, many subtle or mild symptoms
• Common:
• Fever > 38.3
• lower adbo pain and tenderness (adnexal)
- Cervical motion tenderness on bimanual exam
• abnormal discharge: vaginal, cervical
• Uncommon:
• Nausea, vomiting
• Dysuria
• irregular vaginal bleeding
• RUQ pain (Fitz-Hugh-Curtis)
Investigations
►
Bloodwork
 BhCG (r/o ectopic), CBC, blood cultures if septic
►
Speculum exam
 Vaginal swab
 Cervical cultures for GC and chlamydia
►
Ultrasound
 May be normal
 Fluid in cul-de-sac
 Hydrosalpinx, tubo-ovarian abscess, pelvic
abscess
►
Laparoscopy
 For definitive diagnosis
What are the criteria that would require
inpatient treatment of PID?
Treatment - Outpatient
ORAL Regimen A:
►
►
►
Ofloxacin 400 mg twice daily for 14 days
OR
Levofloxacin 500 mg once daily for 14 days
WITH OR WITHOUT
Metronidazole 500 mg twice daily for 14 days
Treatment - Outpatient
ORAL Regimen B:
►
►
►
►
Ceftriaxone 250 mg IM in a single dose
OR
Cefoxitin 2 g IM x 1 and Probenecid 1g PO
PLUS
Doxycycline 100 mg twice daily for 14 days
WITH or WITHOUT
Metronidazole 500 mg twice daily for 14 days
Treatment - Inpatient
PARENTERAL Regimen A:
• Cefoxitin 2g OR Cefotetan 2g IV q6h (at least 48 h)
PLUS
• Doxycycline 100mg IV/PO BID x 14 days
PARENTERAL Regimen B:
• Clindamycin 900mg IV q8h (at least 48 h)
PLUS
• Gentamicin 2mg/kg loading dose then 1.5mg/kg maintenance
dose q8h (at least 48 h)
Treatment - Inpatient
Alternative PARENTERAL Regimens:
►
►
►
►
►
Ofloxacin 400 mg IV q 12 hours
OR
Levofloxacin 500 mg IV once daily
WITH OR WITHOUT
Metronidazole 500 mg IV q 8 hours
OR
Ampicillin/Sulbactam 3 g IV q 6 hrs
PLUS
Doxycycline 100 mg orally/IV q 12 hrs
Chlamydial Cervicitis
• Etiology: Chlamydia trachomatis
• Intracelluar parasite
• Most common bacterial STI in Canada
• Often associated with N. Gonorrhea
• Reportable disease
• Risk Factors:
• sexually active < 25 y.o.
• history of previous STI
• new partner in last 3 months
• multiple partners
• no barrier contraception
• contact with infected person
Presentation
►
►
►
►
►
Asymptomatic (70%)
mucopurulent endocervical discharge
pelvic pain/discomfort to PID
Urethral syndrome: dysuria, frequency, pyuria with
no bacteria
post coital spotting or intermenstrual bleed
Investigations:
►
►
Cervical cultures
Rescreen women 3-4 months after treatment due
to high prevalence of repeat infection
Treatment - Chlamydia
• Doxycycline 100mg PO BID x 7 days
OR
• Azithromycin 1g PO x 1
Alternative treatments:
• Erythromycin base 500 mg qid for 7 days OR
• Erythromycin ethylsuccinate 800 mg qid for 7 days OR
• Ofloxacin 300 mg twice daily for 7 days OR
• Levofloxacin 500 mg for 7 days
* if pregnant Erythromycin, Amoxicillin, Azithromycin
**Screen and treat partners
Neisseria Gonorrhea
Cervix, urethra, rectum:
• gram negative intracellular diplococci
• reportable disease
Presentation and Risk Factors:
• same as chlamydia
Investigations:
• cervical, rectal and throat culture
Treatment
►
►
►
►
►
Ceftriaxone 125mg IM x 1 OR
Cefixime 400mg PO x 1 OR
Ciprofloxacin 500mg PO x 1 OR
Ofloxacin 400 mg/Levofloxacin 250 mg
AND
Treatment for Chlamydia
* If pregnant: cephalosporin regimen or 2g
spectinomycin IM
Vulvovaginitis
Organism
Discharge
Symptoms
Wet Mount
Candida(Yeast)
White thick
-itching
KOH
-satellite lesions -hyphae
-edematous
-red
Ph
<5
Bacterial Vaginosis Grey, thin,
(anaerobes,
diffuse
Gardnerella, etc.)
- fishy odour
- worse after
intercourse
- no irritation/
inflammation
Trichomonasis
(Trichomonas
Vaginalis)
Yellow/green
-strawberry
spots
-fagellated
protozoa
5-6.5
Clear/white
- no irritation/
inflammation
-normal
epithelial cells
<4.5
Physiologic
(high E2 states)
- clue cells
5-5.5
KOH (+whiff test)
Vulvovaginitis
Treatment
Candida(Yeast)
-clotrimazole, miconazole, terconazole
-Diflucan 150 mg PO x 1(resistant cases)
-lactobacillus acidophilus
Bacterial Vaginosis
Metronidazole 500mg PO BID x 7 days
(or 2g PO x1)
OR Clindamycin 300mg PO BID x 7 days
OR topical above creams QHS x 7 days
Trichomonas
Metronidazole 500mg PO bid x 7days
or 2g PO x 1
Questions?