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USMLE Step 2 (Subject) / Gynecology (Lesson)

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• Polycystic ovarian syndrom (PCOS) Epidemiology:- Frequency: 6-10% of women in their reproductive years Clinical features:- Menstrual irregularities (primary or secondary amenorrhea, oligomenorrhea)- Difficulties conceiving or infertility- Obesity and possibly other signs of metabolic syndrome- Hirsutism, acne vulgaris, oily skin- Androgenic alopecia- Acanthosis nigricans: hyperpigmented, velvety plaques (axilla, neck) Diagnosis requires two of the following three criteria:1. Polycystic ovaries2. Oligo-/anovulation3. Hyperandrogenism Diagnosis:- Blood hormone levels: ↑ testosterone; DHEA-S; LH:FSH ratio > 2:1- Evaluate for metabolic disease: Hypertension, diabetes mellitus, BMI, hyperlipidemia- Ultrasound: Enlarged ovaries with numerous anechoic cysts; "String of pearls” appearance Treatment: - If the patient is overweight (BMI ≥ 25 kg/m2): weight loss via lifestyle changes - Combined oral contraceptive therapy- If seeking treatment for infertility: Ovulation induction with clomiphene citrat or letrozole
• Trichomoniasis Epidemiology:- Incidence 5-50% Etiology:- Pathogen: Trichomonas vaginalis (anaerobic, motile protozoan with flagella)- Risk factor: Unprotected sex with multiple partners Clinical features:- Foul-smelling, frothy, yellow-green, purulent discharge- Vulvovaginal pruritus, burning sensation, dyspareunia, dysuria, strawberry cervix Diagnosis:- Saline wet mount of vaginal smear: protozoa with multiple flagella- If wet mount is inconclusive → culture- pH of vaginal discharge > 4.5 Treatment: Single-dose PO metronidazole or tinidazole. Treat partners; test for other STDs. Complications: Chorioamnionitis/endometritis, infection, preterm delivery, miscarriage, PID
• Pelvic inflammatory disease (PID) A polymicrobial infection of the upper genital tract that is associated with Neisseria gonorrhoeae, Chlamydia trachomatis, and endogenous aerobes/anaerobies. Risk factors: non-Caucasian ethnicity, smoking, multiple sex partners, prior STDs and/or PID. Clinical features:- Lower abdominal pain, fever, chills, menstrual disturbances, and a purulent cervical discharge- Cervical motion tenderness (chandelier sign) and adnexal tenderness Diagnosis:- Presence of lower abdominal or pelvic pain plus one of the following:→ Uterine tenderness→ Adnexal tenderness→ Cervical motion tenderness- A WBC count >10,000 has poor positive and negative predictive value for PID- Order a β-hCG and ultrasound to rule out pregnancy and to evaluate for the possibility of tubo-ovarian abscess- Ultrasound: Look for→ Thickening or dilation of the fallopian tubes→ Fluid in the cul-de-sac→ Multicystic ovary→ Tubo-ovarian abscess Treatment:- Outpatient regimens→ One single dose of IM ceftriaxone + doxycycline OR→ Cefoxitin + probenecid + doxycycline→ If signs of vaginitis or recent gynecological instrumentation → add oral metronidazole.- Inpatient regimens (IV):→ Cefoxitin + doxycycline OR→ Clindamycin + gentamicin→ Switch to oral therapy with doxycycline after clinical improvement. Complications: - Repeated episodes of infection, chronic pelvic pain, dyspareunia, ectopic pregnancy, infertility- RUQ pain (Fitz-Hugh-Curtis syndrome) may indicate an associated perihepatitis (abnormal liver function, shoulder pain)- Risk of infertility ↑ with repeated episodes of salpingitis (10% after 1st episode, 25% after second, 50% after third)
• Uterine leiomyoma (fibroids) Predisposing factors:- Nulliparity- Early menarche (< 10 years old)- Age: 25-45 years- Race: Black women are at increased risk.- Obesity- Family history Clinical features:- Hypermenorrhea, menorrhagia, metrorrhagia (possibly associated anemia)- Dysmenorrhea- Enlarged, firm and irregular uterus during bimanual pelvic examination- Back or pelvic pain/discomfort- Urinary tract or bowel symptoms (e.g., urinary frequency/retention, constipation, features of hydronephrosis) - Infertility  Diagnosis:- Ultrasound (best initial test)- MRI: to evaluate the uterus and ovaries for potentially complicated surgical cases and visually differentiate between leiomyomas, adenomyomas, and adenomyosis Treatment:- Asymptomatic fibroids: Do not require treatment- Hormone therapy→ Gonadotropin-releasing hormone (GnRH) agonists: e.g., leuprolide, goserelin→ Estrogen-progestin contraceptive pills are controversial.→ Levonorgestrel-releasing intrauterine devices aid (to control heavy bleeding)- NSAIDs: to control pain- Antifibrinolytics (e.g., tranexamic acid): reduce bleeding- Androgenic agonists (e.g., danazol): suppress growth of fibroids but has many side effects (e.g., acne, edema, hairloss, etc.)- Surgical therapy→ Myomectomy: excision of subserosal or intramural fibroids → Hysterectomy: definitive treatment 
• Breast cancer Risk factors:- Female gender, older age- White race- Genetic mutation or breast cancer in first-degree relatives- Alcohol consumption- High-fat and low-fiber diet- History of fibrocystic change with cellular atypia- ↑ exposure to estrogen (nulliparity, early menarche, late menopause, first full-term pregnancy after age 35) History/PE:- Single, nontender, firm-to-hard mass with ill-defined margins- Skin or nipple retraction, axillary lymphadenopathy, breast enlargement, redness, edema, pain, fixation of the mass to the skin or chest wall- Ulceration; supraclavicular lymphadenopathy; edema of the arm; metastases to the bone, lung, and liver- Prolonged unilateral scaling erosion of the nipple with or without discharge (Paget's disease of the nipple) Diagnosis:- Postmenopausal: Mammography. Look for ↑ density with microcalcifications and irregular borders. - Premenopausal: Ultrasound- Tumor markers for recurrent breast cancer include CEA and CA 15-3 or CA 27-29- Receptor status of tumor: ER, PR, HER2/neu- Metastatic disease: ↑ ESR, ↑ alkaline phosphatase (liver and bone metastases), ↑ calcium- Imaging: CXR; CT of the chest, abdomen, pelvis, and brain; bone scan Treatment:- Hormone (+) patients should receive tamoxifen- ER (-) patients should receive chemotherapy- Trastuzumab highly effective in HER2/neu-expressive cancers- Partial mastectomy (lumpectomy) plus axillary dissection followed by radiation therapy- Modified radical mastectomy (total mastectomy + axillary dissection) Prognosis:- Axillary lymph node status (most important prognostic factor)- Tumor size- Patient's age- Receptor status (ER/PR-negative and triple-negative disease are associated with a worse prognosis) Complications: Pleural effusion in 50% of patients with metastatic beast cancer; edema of the arm is common
• Cyst and abscess of bartholin duct The Bartholin glands are located in both sides of the inner labia and serve primarily to produce the mucous that moisturizes the vaginal mucosa. The mucous is secreted into two ducts that appear in the posterior vaginal introitus. A Bartholin gland cyst is usually caused by blockage of the duct as a result of inflammation or trauma; a Bartholin gland abscess occurs when the obstructed duct becomes infected. Cysts: - 1-3 cm in size, unilateral, often asymptomatic. If larger, lead to periodic painful, swelling and dyspareunia. - Pelvic exam: unilateral, palpable mass in the posterior vaginal introitus- Treatment: Asymptomatic → No therapy ± warm soaks. - Consider drainage and biopsy if > 40 years old to exclude carcinoma. Abscess:- Acute unilateral pain and tender swelling- Dyspareunia- Pain especially while walking and sitting- Fever (∼ 20% of cases)- Prompt pain relief with discharge (indicates spontaneous rupture of abscess)- Treatment: Incision and drainage - Test for gonorrhea and Chlamydia and other pathogens.- If reoccuring: Marsupialization
• Endometrial cancer Type I endometrioid adenocarcinomas derive from atypical endometrial hyperplasia and are the most common female reproductive cancer in the US. Type II endometrial cancer is mostly estrogen-independent and is strongly associated with a genetic predisposition. Although type II cancers tend to be more aggressive, diagnosis and management are similar for both types. Risk factors for estrogen-dependent tumors:- Nulliparity- Early menarche and late menopause- PCOS (polycystic ovary syndrome)- Unopposed estrogen replacement therapy (e.g., for menopausal symptoms)- Breast cancer: history of breast cancer, tamoxifen treatment- Metabolic syndrome (esp. obesity and diabetes mellitus type 2 )- Lynch syndrome (hereditary nonpolyposis colorectal cancer) History/PE:- Abnormal uterine bleeding is the main symptom.→ Postmenopausal: any amount of vaginal bleeding, including spotting or staining → Perimenopausal/premenopausal: metrorrhagia, menometrorrhagia→ Vaginal bleeding usually does not occur in type II cancer.- Later stages may present with pelvic pain, palpable abdominal mass, and/or weight loss. Diagnosis:- Physical exam and pregnancy test if premenopausal- Ultrasonography: If postmenopausal, can do transvaginal and evaluate endometrial stripe (< 4 mm unlikely to be endometrial cancer). Shows thickened endometrium with hypertrophy and neoplastic change.- Endometrial/endocervical biopsy: If postmenopausal and any bleeding, must perform a biopsy regardless of ultrasonography results. Therapy:- High-dose progestins for women of childbearing age.- TAH/BSO (Total abdominal hysterectomy/Bilateral salpingo-oophorectomy) ± radiation for postmenopausal women.- TAH/BSO with adjuvant chemotherapy (e.g., carboplatin, paxitaxel) for advanced-stage cancer.
• Cervical cancer Etiology:- Infection with high-risk HPV types: 16, 18 Risk factors:- Early onset of sexual activity; multiple sexual partners (strongest risk factors)- High parity- Immunosuppression (e.g., HIV infection) - History of sexually transmitted infections (e.g., herpes simplex, chlamydia)- Cigarette smoking- Low socioeconomic status- In-utero exposure to diethylstilbestrol (DES)  Clinical features:- Abnormal vaginal bleeding: menometrorrhagia, postcoital spotting, irregular vaginal bleeding- Abnormal vaginal discharge: blood-stained or purulent malodorous discharge- Cervical ulceration- Late symptoms: Hydronephrosis, compression of veins or lymphatic vessels in the pelvic area, leading to swelling of the lower extremities Screening:< 21 years: No screening21-29 years: Every 3 years perform Pap smear30-65 years: Every 3 years perform Pap smear or every 5 years perform co-testing (Pap smear + HPV test)65 years: Stop screening if prior tests were negative and no immunocompromised status Treatment:Low-grade → follow-up/colposcopyHigh-grade: - Ablation: Cryotherapy or laser ablation- Excision: LEEP, laser and cold-knife conization- Hysterectomy ± radiation/chemotherapy- If pregnant: Reevaluation with cytology and colposcopy 6 weeks after birth
• Vaginal cancer Accounts for 1-2% of all gynecologic malignancies.  Localization: The upper third of the posterior vaginal wall is the most common site. Etiology:- Postmenopausal women: Usually squamous cell carcinoma- Younger women: Usually other histologic types (eg, adenocarcinoma) Risk factors:- Age > 60- Infection with HPV 16, 18, 31, and 33- Tobacco use- Immunosuppression- Chronic irritation (eg, long-term pessary use or prolapse)- Low socioeconomic status- Radiation for cervical cancer- In utero DES exposure (clear cell adenocarcinoma only) Clinical features:- Vaginal bleeding- Leukoplakia, vaginal ulceration with contact bleeding- Malodorous discharge- Possibly urinary frequency Diagnostics:- Pelvic exam- Colposcopy: if abnormal cytology results without a clearly visible lesion during pelvic exam- Biopsy of mass to determine histopathology: spindle-shaped cells, desmin positive Treatment:- Local excision when few and small - Extensive involvement of the vaginal mucosa may require partial or complete vaginectomy- Invasive disease requires radiation therapy or radical surgery
• Ovarian cancer Risk factors: - Age, low parity, ↓ fertility, delayed childbearing, positive family history- BRCA1 carries a 45% lifetime risk; BRCA2 25% lifetime risk- Lynch syndrome (HNPCC) is associated with an ↑ risk of colon, ovarian, endometrial, and breast cancer- Peutz-Jeghers syndromeProtective factors: OCPs taken for >5 years Clinical features:- Generally asymptomatic- Abdominal pain and ascites- Cancer cachexia- Possible disruption of menstrual cycle- Dyspnea due to malignant pleural effusion- Abdominal or pelvic mass- Late: Renal failure, small bowel obstruction, ascites Diagnosis:- Transvaginal ultrasonography: Solid mass, thick septations, ascites- Tumor markers: → Epithelial ovarian tumor: CA-125→ Yolk sack tumor: alpha-fetoprotein→ Non-gestational choriocarcinoma: β-hCG→ Granulosa cell tumor: inhibin B Treatment:- Frozen section and histology positive for carcinoma: radical surgical staging → Removal of the greater omentum→ Lymphadenectomy→ Hysterectomy with bilateral salpingo-oophorectomy- Chemotherapy: First-line therapy: carboplatin polychemotherapy and antimitotics (e.g., paclitaxel) Prevention: BRCA1 ⊕- Annual transvaginal US and CA-125 - Prophylactic oophorectomy is recommended by age 40 or whenever childbearing is completed
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• Ovarian tumor markers Epithelial: CA-125 Endodermal sinus (yolk sac tumor): AFP Embryonal carcinoma: AFP, β-hCG Choriocarcinoma: β-hCG Dysgerminoma: LDH Granulosa cell: Inhibin
• Fibroadenoma Proliferative breast lesion without atypia. A benign, slow-growing breat tumor with epithelial and stromal components. The most common breast lesion in women <30 years of age. History/PE:- Round, rubbery, discrete, relatively mobile mass 1-3 cm in diameter. Generally nontender.- Masses are usually solitary, although up to 20% of patients develop multiple fibroadenomas.- Masses do not change during the menstrual cycle. Note hormonal relationship: can ↑ in size during pregnancy or hormonal therapy and ↓ in size in menopause. Diagnosis:- Breat ultrasound to differentiate cystic from solid masses.- Needle biopsy or FNA.- Excision with pathologic exam if the diagnosis remains uncertain.
• Endometrial hyperplasia Etiology: increased estrogen stimulation- Follicle persistence- PCOS- Estrogen-producing ovarian tumors (e.g., granulosa cell tumors, theca cell tumors)- Hormone replacement therapy without progestin administration Clinical features: - Constant bleeding, intermenstrual bleeding, postmenopausal bleeding Diagnosis:- Ultrasonography: endometrial thickening (> 1 cm in premenopausal women and > 5 mm in postmenopausal women)- Hysteroscopy with fractional curettage- Clinical chemistry: FSH, estradiol, testosterone Treatment:- Endometrial hyperplasia without atypia →  Cyclic progestin administration- Endometrial hyperplasia with atypia → Total abdominal hysterectomy with/without bilateral salpingo-oophorectomy
• Germ cell tumors - 15-25% of all ovarian tumors 1. Teratoma- Most common of all germ cell tumors (90% of cases)- Malignant transformation in 2% of cases- Ultrasound: Enourmous, complex cyst- Struma ovarii: teratoma with endodermal differentiation into thyroid tissue- Treatment: Cystectomy without oophorectomy; Salpingo-oophorectomy if past child-bearing age 2. Dysgerminoma: - Most common malignant ovarian tumor in young women (20-30 years)- Female histological equivalent to the male seminoma 3. Yolk sac tumor of the ovary: - Often malignant- Occurs mainly in childhood and adolescence 4. Non-gestational choriocarcinoma: - Rare and extremely malignant- Normally accompanied by beta hCG production
• BRCA patients Screening: Every 6 months- Breast cancer screening with MRI and mammography - Endometrial/Ovarian cancer screening with transvaginal ultrasound with Ca-125  Prophylaxis:- TAH + BSO at age 35.- Mastectomy with reconstruction indicated at any age.- Tamoxifen chemoprevention for women unwilling to undergo mastectomy.
• Hydatidiform mole Risk factors:- Prior molar pregnancy- History of miscarriage- Patients ≤ 15 and ≥ 35 years Complete mole:- Does not contain any fetal or embryonic parts- Caused by fertilization of an empty egg - Fetal karyotypes→ 46XX: more common (∼ 90% of cases)→ 46XY: less common (∼ 10% of cases) Partial mole:- Contains fetal or embryonic parts in addition to trophoblastic tissue- Caused by fertilization of an egg with two sperms- Fetal karyotypes: 69XXX, 69XXY, 69XYY Clinical features:- Complete mole→ Vaginal bleeding during the first trimester→ Uterus enlargement > gestational age→ Passage of vesicles that may resemble a bunch of grapes through the vagina→ Preeclampsia with severe features (before the 20th week of gestation)→ Hyperemesis gravidarum→ Theca lutein cysts→ Hyperthyroidism- Partial mole→ Less severe symptoms due to β-HCG levels that are lower than in complete moles→ Vaginal bleeding→ Pelvic tenderness Diagnostics:- β-HCG level measurement (initial test of choice): higher than expected for the gestational age- Transvaginal ultrasound- Uterine evacuation (for definite diagnosis and treatment)- Chest x-ray: in case of dyspnea or chest pain Treatment:- Uterine evacuation by dilation and suction curettage- Monitor β-HCG levels until in reference range (usually 8-12 weeks)→ Contraception is prescribed as pregnancy would make it hard to determine the significance of a rising β-hCG- Chemotherapy (usually methotrexate) if unresolved
• Choriocarcinoma Highly aggressive, malignant tumor consisting of trophoblastic tissue. Exhibits histological signs of malignancy and a tendency to metastasize early. Etiology:- Choriocarcinoma only develops after fertilization and implantation of the egg. - Most cases of choriocarcinoma are preceded by a hydatidiform mole:→ 50% hydatidiform mole→ 25% miscarriages or ectopic pregnancy→ 25% normal pregnancy Clinical features:- Postpartum vaginal bleeding and inadequate uterine regression after delivery- Theca lutein cysts- Additional symptoms depend on the site of metastasis (e.g., seizures from metastases in the brain; dyspnea or hemoptysis from metastases in the lungs) Diagnostics:- Very high β-HCG (initial test of choice)- Pelvic ultrasound- Uterine dilation and curettage (D&C): Both diagnostic and therapeutic Treatment:- Localized disease: Methotrexate followed by actinomycin D (fertility sparing)- Cyclophosphamide used in refractory disease- Surgical treatment (e.g., hysterectomy): may be indicated to stop bleeding from cancerous lesions or to excise distant metastases- Monitor β-HCG levels for at least 12 months.
• Vulvar cancer Risk factors:- Infection with HPV 16, 18, 31, and 33 - Immunosuppression- Vulvar dystrophy and vulvar or cervical intraepithelial neoplasia (VIN/CIN)- Smoking Classification:- Squamous cell carcinoma (> 80% of cases)- Melanoma- Adenocarcinoma (Paget's disease of the vulva) Clinical features:- May initially be asymptomatic- Local pruritus, possibly with burning sensation and pain- Reddish, blackish, and/or whitish patches of discoloration- Lumps or growths of various shapes, often wart-like lesions or ulcers- Vulvar bleeding or discharge- Dysuria, dyspareunia- Lymphadenopathy in the groin area Diagnostics: - Pelvic exam and colposcopy- Biopsy Treatment: - Paget's disease: Local resection - Melanoma: Vulvectomy and lymph node dissection- Squamous cell carcinoma: Vulvectomy and lymph node dissection- Radiotherapy and/or palliative chemotherapy: when disease metastasizes to peripheral lymph nodes or other organs
• Condylomata acuminata HPV types 6 and 11: responsible for ∼ 90% of genital warts Location:- ♀: vulvar, cervix, urethra (rare), anal region- ♂: glans penis, foreskin, urethra, anal region Diagnosis:- Visual inspection- Application of 5% acetic acid turns lesions white (not a specific finding) Clinical findings:- Exophytic, cauliflower-like lesions- Often asymptomatic; may cause pruritus, tenderness, or bleeding in rare cases Treatment:- Pharmacotherapy: local cytostatic treatment or immune response modifiers (e.g., imiquimod)- Cryotherapy: freezing external warts with CO2, N2O, or N2 - In case of numerous warts: curettage, laser surgery, or electrocoagulation
• Lichen sclerosis Lichen sclerosus is a chronic inflammatory disease with characteristic white, atrophic plaques. Epidemiology: Prepubertal girls & perimenopausal or postmenopausal women Clinical features:- Thin, white, wrinkled skin over the labia majora/minora; atrophic changes that may extend over the perineum & around the anus- Excoriations, erosions, fissures from severe pruritus- Dysuria, dyspareunia, painful defecation Diagnosis:- Punch biopsy: confirms diagnosis and rules out squamous cell carcinoma Treatment:- High potency topical steroids (clobetasol, sometimes betamethasone) or calcineurin inhibitors (tacrolimus)- If necessary, surgical excision
• Endometriosis Common, benign, and chronic disease in women of reproductive age that is characterized by the occurrence of endometrial tissue outside the uterus. Epidemiology:- Age of onset: 20-40 years- Incidence: 2-10% of all women Clinical features:- Up to one-third of patients are asymptomatic.- Chronic pelvic pain that worsens before the onset of menses- Dysmenorrhea- Pre- or postmenstrual bleeding- Dyspareunia- Infertility- Dyschezia (difficult or painful defecation) Diagnostics:- Physical examination: Rectovaginal tenderness, adnexal masses- Transvaginal ultrasound (best initial test)→ The uterus is generally not enlarged. → Evidence of ovarian cysts (chocolate cysts)→ Nodules in bladder or rectovaginal septum- Laparoscopy (confirmatory test) - MRI, coloscopy, cystoscopy, or other interventions are potentially indicated if endometrial cells are suspected. Treatment:- Mild to moderate pelvic pain without complications: Empirical medical therapy with NSAIDs and continuous hormonal contraceptives- Severe symptoms: GnRH agonists (e.g., buserelin, goserelin) and estrogen-progestin OCPs- Surgical therapy: Laparoscopic excision and ablation of endometrial implants
• Ovarian cyst Fluid-filled sacs within the ovary that result from a disruption in the development of follicles or corpus luteum Types:- Follicular cyst: cysts lined with follicular epithelium; the most common form of ovarian cysts- Chocolate cysts related to endometriosis- Corpus luteum cyst: Corpus luteum cysts develop physiologically during the menstrual cycle or during pregnancy (corpus luteum graviditatis).  Clinical features: most often asymptomatic unless complications occur Diagnosis: - Pelvic ultrasound: → Smooth lining on all sides→ Single or multiple→ Hypoechoic to anechoic→ Fluid-level Follow up:- < 3 cm: Does not warrent re-evaluation- 3-10 cm: Reimaging within 12 weeks- > 10 cm: Needs evaluationCysts should never be aspirated! Complications:1. Ovarian torsion- Sudden onset unilateral lower abdominal pain- Nausea, vomiting- Pelvic ultrasound with Doppler velocimetry shows enlarged, edematous ovaries with decreased blood flow.- Treatment: Detorsion via laparoscopic surgery is recommended for viable ovaries.2. Ruptured ovarian cyst - Sudden onset unilateral lower abdominal pain- In case of a very large cyst: Fluid and blood loss may cause acute abdomen and shock.- Pelvic ultrasound shows free fluid, most commonly in the pouch of Douglas (rectouterine pouch).- Treatment: Hemodynamically stable patients can be observed and given analgesics.- Hemodynamically unstable patients require laparoscopy to control hemorrhaging.
• Incontinence - Overview Stress incontinence:- Urethral hypermobility, intrinsic sphincter deficiency- Poor pelvic support caused by pelvic postmenopausal estrogen loss, connective tissue disorders, or childbirth- Urinary leakage on activities that increase intra-abdominal pressure- Positive Q-tip test (rotates more than 30°)- Treatment: Duloxetine, surgery  Urge incontinence:- Sphincter dysfunction, detrusor overactivity or overactive bladder → autonomous contractions of the detrusor muscle and premature initiation of a normal micturition reflex- Strong, sudden sense of urgency, followed by involuntary leakage- Treatment: Anticholinergic medication (e.g. oxybutynin, solifenacin, propantheline), surgery Mixed incontinence: Combination of mechanisms of stress and urge incontinence Overflow incontinence:- Impaired detrusor contractility and/or bladder outlet obstruction → chronically distended bladder with ↑ bladder pressure → dribbling of urine - Frequent, involuntary intermittent/continuous dribbling of urine in the absence of an urge to urinate- Occurs only when the bladder is full- Often occurs with changes in position- Treatment:→ Parasympathomimetic, cholinergic medication (e.g. bethanechol)→ Acute settings: intermittent catheterization→ Timed voiding for day to day management
• Incontinence - Diagnostics & Therapy Diagnostics:- Detailed medical history (including medication)- Voiding diary to assess frequency and volume of micturition- Neurological, vaginal, and rectal examination- Urine dipsticks and urine culture to exclude urinary tract infections- Creatinine and blood urea nitrogen (BUN) - Sonography→ Quantification of residual urine after micturition→ Renal ultrasound- Quantification of leaked urine: pad test (Patients wear a preweighed sanitary pad and drink a specified volume of liquid. Thereafter, the pad is weighed again to measure urinary leakage. Small volume leaks are characteristic of urge incontinence.)- Micturating cysto-urethrogram (MCU) to detect morphological abnormalities- Urodynamic examination to measure bladder pressure and urethral closure pressure- Cystoscopy to rule out tumors and vesicorectal or vesicovaginal fistulae- MRI to identify pelvic floor defects Treatment:- Modify contributing factors (e.g., drugs) and treat reversible causes.- Physical measures to prevent leakage: → Absorbent products→ Catheterization→ Urethral occlusion→ Pessaries and penile compression devices- Lifestyle modifications:→ Weight loss→ Dietary changes (e.g., decrease consumption of alcohol, caffeine, carbonated drinks)→ Smoking cessation- Behavioral therapies and exercises:→ Bladder training→ Kegel exercises→ Vaginal weighted cones→ Biofeedback- Topical vaginal estrogen in postmenopausal patients with vaginal atrophy
• Pelvic organ prolapse Risk factors:- Multiple vaginal deliveries and/or traumatic births- Low estrogen levels (e.g., during menopause)- Congenital connective tissue disorders- Previous pelvic surgery (e.g., hysterectomy)- Increase intraabdominal pressure (e.g., cough related to chronic lung disease and/or smoking, ascites, obesity, pelvic tumors, or constipation.)- Diabetes mellitus Clinical features:- Feeling of pressure on or discomfort around the perineum (“sensation of vaginal fullness”)- Lower back and pelvic pain - Rectal fullness, constipation, incomplete rectal emptying- Prolapse of the anterior (in cystocele/urethrocele) or the posterior (in enterocele/rectocele) vaginal wall, possibly with excessive vaginal discharge on inspection, bimanual examination, and speculum examination of the patient in lithotomy position; occurs at rest and with increased abdominal pressure- Weakened pelvic floor muscle and anal sphincter tone (ask the patient to contract the pelvic floor muscles during digital examination) Diagnostics:Stage 0: no prolapseStage 1: The most distal portion of prolapse is more than 1 cm above the level of the hymen.Stage 2: The most distal portion of prolapse is 1 cm or less proximal or distal to the hymenal plane.Stage 3: The most distal portion of prolapse is more than 1 cm from the hymenal plane but no more than 2 cm less than the vaginal length.Stage 4: The vagina is completely everted or uterine procidentia has occurred. Treatment:- Insertion of a vaginal pessary (to support the pelvic organs) - Kegel exercises: pelvic floor muscle training (also as a preventive measure)- Obliterative surgery: The vagina is closed off or narrowed to provide more support for pelvic organs.- Reconstructive surgery→ Sacrocolpopexy: fixation of the vaginal apex to the sacrum→ Suspension techniques→ Colporrhaphy: reinforcement of the vaginal wall for the repair of cystocele or rectocele→ Sacrohysteropexy: fixation of the cervix to the sacrum for the repair of uterine prolapse
• Ectopic pregnancy Localization:- Ampulla >> isthmus > fimbriae > interstitial pregnancy  Risk factors- History of PID- Previous ectopic pregnancy- Past surgeries involving the fallopian tubes- Endometriosis- Bicornuate uterus (risk factor for interstitial pregnancy) Clinical features:- Patients usually present with signs and symptoms 4-6 weeks after their last menstrual period- Lower abdominal pain and guarding- Vaginal bleeding- Signs of pregnancy: amenorrhea, nausea, breast tenderness, frequent urination- Tenderness in the area of the ectopic pregnancy- Cervical motion tenderness, closed cervix- Enlarged uterus Diagnostics:- Transvaginal ultrasound (TVUS)→ Empty uterine cavity in combination with a thickened endometrial lining- Quantative β-hCG test→ > 2000 → should definitely be seen→ < 1500 → too soon → watch and wait for 48 hours and then repeat. An intrauterine pregnancy will double in size in 48 hours while an ectopic pregnancy will not Treatment:- Methotrexate→ Uncomplicated ectopic pregnancies→ β-hCG ≤ 5000 mlU/mL→ No fetal heartbeat and ectopic mass size < 4 cm- Salpingostomy (tube‑conserving operation)→ Patients with unruptured tubal pregnancy who do not meet the criteria for conservative treatment- Salpingectomy (not function-preserving)→ Ruptured tube, heavy bleeding, large ectopic mass
• Bacterial vaginitis Most common vaginal infection in women (40-45% of all cases) Pathogen: Gardnerella vaginalis (a gram-variable rod) Risk factor:- Sexual intercourse- Intrauterine devices (IUDs)- Douching- Pregnancy Clinical features:- Commonly asymptomatic- Increased vaginal discharge, usually gray or milky with fishy odor - Pruritus and pain are uncommon Diagnostics: vaginal discharge sample- Amsel's criteria: 3 of 4 must apply to confirm diagnosis→ Whiff test: add 1-2 drops of 10% KOH to vaginal fluid → intensification of the fishy odor→ Vaginal pH > 4.5→ No leukocytes visible on microscopy→ Clue cells: vaginal epithelial cells covered with bacteria identified on wet mount preparation Treatment:- First-line: oral metronidazole- Alternative: topical metronidazole or clindamycin Complications: Chorioamnionitis/endometritis, infection, preterm delivery, miscarriage, PID
• Vulvovaginal candidiasis Epidemiology: Second most common cause of vulvovaginitis (20-25% of all cases) Risk factors:- Pregnancy - Immunosuppression- Diabetes mellitus- Antimicrobial treatment (e.g., after systemic antibiotic treatment)- Oral contraceptive pills Clinical features:- White, crumbly, and sticky vaginal discharge that may appear like cottage cheese and is typically odorless- Erythematous vulva and vagina- Vaginal burning sensation, strong pruritus, dysuria, dyspareunia Diagnostics:- Pseudohyphae on wet mount with potassium hydroxide (KOH)- Vaginal pH within normal range (4-4.5) Treatment:- Topical azole (e.g., fluconazole, miconazole, clotrimazole)- Alternatively: topical nystatin (as vaginal tablet or cream) or single-dose oral fluconazole
• Miscarriage Spontaneous abortion/miscarriage = loss of pregnancy before 20 weeks' gestation(after 20 weeks = stillbirth) Etiology:- Abnormalities of the reproductive organs→ Septate uterus→ Uterine leiomyomas→ Uterine adhesions→ Cervical incompetence- Systemic diseases: Diabetes mellitus, hyper-/hypothyroidism, genetic disorders, infections, hypercoagulability (e.g., antiphospholipid syndrome)- Chromosomal abnormalities account for up to half of all spontaneous abortions.- Iatrogenic (e.g., amniocentesis or chorionic villus sampling)- Environmental (exposure to toxins such as drugs or maternal smoking during pregnancy) Threatened abortion- Vaginal bleeding- Fetal activity- Cervical os: closed- Reversible- Treatment: Expectant management, weekly pelvic ultrasound, RhD antibodies Inevitable abortion- Vaginal bleeding, and visible/palpable products of conception- Fetal activity may be present.- Cervical os: dilated- Irreversible Missed abortion- No bleeding- No expulsion of the products of conception- No fetal activity- Cervical os: closed- Irreversible Incomplete abortion- Vaginal bleeding; products of conception within the cervical canal or uterus- Usually occurs > 12 weeks' gestation- Cervical os: dilated- Irreversible Complete abortion- Vaginal bleeding; products of conception completely outside of the uterus- Usually occurs < 12 weeks' gestation- Cervical os: closed- Irreversible; No treatment required Diagnostics:- Doppler ultrasound: Detect fetal heart beats - Pelvic examination - Transvaginal ultrasound:→ Absence of fetal cardiac motion→ Abnormalities of the yolk sac or gestational sac- Downtrending β-hCG  Treatment for inevitable, incomplete, or missed abortions:- Expectant management (option for women < 14 weeks gestation): Surgical evacuation is usually recommended if evacuation does not occur after 4 weeks.- Medical evacuation: Misoprostol is used to induce cervical ripening and expulsion of the products of conception.- Surgical evacuation (dilation and curettage): preferred method in septic abortion or if there is heavy bleeding or significant maternal disease - Rh(D)-negative women should receive Rh(D)-immune globulin in all cases of vaginal bleeding during pregnancy.
• Menopause Menopause is the time at which a woman permanently stops menstruating, and is diagnosed after 12 months of amenorrhea.- Average age at menopause: ∼ 49-52 years Clinical features:- Irregular menses (which gradually decrease in frequency) → complete amenorrhea- Increased sweating, hot flashes, and heat intolerance- Impaired sleep (insomnia and/or night sweats)- Depressed mood or mood swings- Anxiety/irritability- Loss of libido- Cognitive decline- Breast tenderness and reduced breast size- Vulvovaginal atrophy Diagnosis: Clinical, but following tests might help- ↓ Estrogen and ↓ progesterone- FSH levels can fluctuate widely in perimenopause.- Lipid profile: ↑ total cholesterol, ↓ HDLHyperthyroidism and menopause present similarly. For this reason, serum TSH should be checked in all suspected perimenopausal cases with heat intolerance and disturbed sleep to determine the cause! Treatment:- For hot flashes: avoidance of triggers; environmental temperature regulation (e.g., using fans)- For atrophic vaginal symptoms: vaginal estrogen creams, rings, or tablets- For impaired sleep and/or hot flashes: exercise, acupuncture, and relaxation techniques- Prevention of osteoporosis: Smoking cessation, adequate vitamin D + calcium intake and regular weight-bearing exerciseIf diagnosed with osteoporosis, bisphosphonates are used. If vitamin D deficiency is diagnosed, use Vit D2 50,000 units weekly.- Hormone-replacement therapy: For short-term treatment of vasomotor symptoms in women < 60- Selective estrogen receptor modulators: tamoxifen, ospemifene, and raloxifene- Paroxetine: for vasomotor symptoms (i.e., hot flashes)- Clonidine and/or gabapentin
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• Infertility Inability of a couple to conceive despite 1 year of unprotected sex. Epidemiology:- Infertility affects approx. 10-15% of couples of reproductive age. Etiology (female)- Ovarian insufficiency (30%)- Impaired ovum transport in fallopian tubes (30%): fallopian tube adhesions and/or obstruction- Sexual dysfunctions (10%): sexual arousal disorder, genito-pelvic pain disorder - Diminished ovarian reserve (10%)- Decline in functioning oocytes (either reduced number or impaired development)- Uterine causes (5%): Anatomical anomalies, uterine leiomyoma, Asherman's syndrome- Cervical anomalies (5%): Insufficient mucous production, antisperm antibodies- Hypogonadotropic hypogonadism- Functional hypothalamic amenorrhea- PCOS- Hyperprolactinemia (e.g., pituitary adenoma) Etiology (male):- Sperm disorders (e.g., reduced sperm count, impaired motility, reduced ejaculate volume)- Scrotal hyperthermia (varicocele)- Testicular damage (e.g., congenital anomalies, injuries, infections such as mumps)- Psychiatric and psychosomatic disorders (e.g., impaired libido, anejaculation)- Kallmann syndrome Work-up #1: Blame the man first1. Erectile dysfunction2. Semen analysis2. Mixed antiglobulin reaction test for antisperm antibodies Work-up #2: 1. History2. Inhospital mucous: - < 6 cm on a smush test → inhospital → treat with estrogen or bypass with ICSI- Fern sign → hospital3. Assess for anovulation→ Body temperature rise→ Hormone tests: Progesterone should be elevated during the luteal phase → treat with clomiphene or pergonal4. Assess patency of fallopian tubes and uterus: hysterosalpingography or sonohysterosalpingography5. Examine cervix and assess for endometriosis
• Congenital adrenal hyperplasia Autosomal recessive defects in enzymes that are responsible for the production of cortisol. The most common defects are:- 21β-hydroxylase (> 95% of CAH)- 11β-hydroxylase (∼ 5% of CAH)- 17α-hydroxylase (rare)Low levels of cortisol → lack of negative feedback to the pituitary → ↑ ACTH → adrenal hyperplasia and increased synthesis of adrenal precursor steroids Clinical features:- Hypoglycemia- Adrenal crisis → vomiting and diarrhea → dehydration- Failure to thrive- Hyperpigmentation in areas that are not exposed to sunlight (e.g., palm creases, mucous membranes of the oral cavity, and/or genitalia) is a common feature in all forms of CAH. Diagnostics:- ↑ Specific steroid precursors in blood and/or urine samples - Screening is conducted by measuring 17-hydroxyprogesterone (also for newborns)- If steroid precursors are not elevated at baseline but CAH is still suspected → Administer exogenous ACTH (cosyntropin) and measure again- Hypocortisolism is seen in all forms of CAH and cortisol levels remain low even after administration of cosyntropin. Treatment:- For all forms: lifelong glucocorticoid replacement therapy→ Hydrocortisone in neonates and children→ Prednisolone or dexamethasone in adolescents and adults- 21β-hydroxylase deficiency: lifelong fludrocortisone therapy (aldosterone substitution)- 11β-hydroxylase deficiency: Spironolactone to block mineralocorticoid receptors- 17α-hydroxylase deficiency: Spironolactone to block mineralocorticoid receptors; Estrogen replacement therapy for female genotype
• Mastitis Inflammation of the breast parenchyma that is frequently seen in nursing mothers two to four weeks postpartum Incidence: up to 10% of nursing mothers (particularly 2-4 weeks postpartum) Etiology:- Staphylococcus aureus (most common)- Other pathogens (Streptococcus, Escherichia coli) are rare Clinical features:- Tender, firm, swollen, erythematous breast (generally unilateral)- Pain during breastfeeding- Reduced milk secretion- Flu-like symptoms, malaise, fever, and chills- Possible reactive lymphadenopathy Diagnosis: Clinical diagnosis- Breast milk cultures or imaging may be required if there is no response to initial treatment. Treatment:- In nursing mothers: frequent emptying of the breast; breastfeeding with both breasts is recommended every 2-3 hours. - Analgesics (e.g., ibuprofen)- Cold compresses- Oral penicillinase-resistant penicillin or cephalosporin (e.g., dicloxacillin or cephalexin)- In the case of methicillin-resistant Staphylococcus aureus (MRSA): clindamycin or trimethoprim-sulfamethoxazole (TMP-SMX)
• Intraductal papilloma Solitary or multiple benign lesions that arise from the epithelium of breast ducts Peak incidence:  40-50 years- Solitary lesions: ∼ 48 years- Multiple lesions: ∼ 41 years Clinical features:- Most common cause of unilateral bloody nipple discharge- Large, central lesion- Palpable breast tumor close to or behind the nipple- Multiple lesions: Usually asymptomatic but may rarely cause nipple discharge- Peripheral lesions; smaller than solitary papilloma Diagnosis:- If lesion is palpable: Core needle biopsy is confirmatory and rules out malignancy - Otherwise: Ductogram Treatment: surgical excision of the affected duct
• Imperforate hymen Pathogenesis: Incomplete degeneration of hymen Clinical features:- Cyclic lower abdominal pain- Bulk symptoms (defecatory & urinary dysfunction)- Primary amenorrhea- Suprapubic mass (uterus)- Blue-tinged vaginal mass Management: Hymenal incision & drainage
• McCune-Albright syndrome 1. Polyostotic fibrous dysplasia 2. Café-au-lait spots 3. Precocious puberty
• Primary ovarian insufficiency Definition: Amenorrhea before the age of 40 Major causes:- Turner syndrome - Fragile X syndrome (FMR1 premutation)- Autoimmune oophoritis- Anticancer drugs- Pelvic radiation- Galactosemia Clinical features:- Hypoestrogenic symptoms (eg, hot flashes) Diagnostics:- ↑ FSH after > 3 months of amenorrhea in a women under age 40- ↓ Estrogen Treatment:- Estrogen therapy (with progestin if intact uterus)
• Genito-pelvic pain/penetration disorder Risk factors:- Sexual trauma- Lack of sexual knowledge- History of abuse Clinical features:- Pain with vaginal penetration- Distress/anxiety over symptoms- No other medical cause Treatment:- Desensitizaiton therapy- Kegel exercises
• Inflammatory breast carcinoma A rare form of advanced, invasive carcinoma, characterized by dermal lymphatic invasion of tumor cells. Most commonly a ductal carcinoma. Clinical features:- Erythematous and edematous ("peau d'orange") skin plaques over a rapidly growing breast mass- Tenderness, burning sensation, blood-tinged nipple discharge- Axillary lymphadenopathy- Nipple changes (eg, flattening/retraction) Treatment: Chemotherapy + radiotherapy + radical mastectomy
• Indications for hospitalization for pelvic inflammatory disease - Pregnancy - Failed outpatient treatment - Inability to tolerate oral medications - Noncompliant with therapy - Severe presentation (eg, high fever, vomiting) - Complications (eg, tubo-ovarian abscess, perihepatitis)
• Vaginal foreign boies Clinical features:- Prepubertal girls- Vaginal spotting- Malodorous vaginal discharge- No signs of trauma (eg, lacerations)- Toilet paper most common object Diagnostics: External pelvic examination in knee-chest or frog-leg position Management:- Small: Attempt at removal (after application of a topical anesthetic in the vaginal introitus) can be made using vaginal irrigation with warm fluid or a swab- Vaginoscopy under sedation/anesthesia
• US Preventive Services Task Force recommendations for breast cancer screening Definitely beneficial: Recommended- Mammogram every 2 years for women age 50-74- Genetic counseling & possible testing for women with evidence of high-risk family history* Possibly beneficial: Individualize- Mammogram in women before age 50 Definitely not beneficial: Not recommended- Breast self-examination at any age- Genetic testing for women without high-risk family history *High-risk family history includes:- Two 1st-degree relatives with breast cancer, including 1 relative age < 50- Three or more 1st- or 2nd-degree relatives with breast cancer- 1st- or 2nd-degree relative with breast & ovarian cancer- 1st-degree relative with bilateral breast cancer- Breast cancer in a male relative
• Estrogen-progestin contraceptives: Benefits & risks Benefits:- Endometrial & ovarian cancer risk reduction- Menstrual regulation- Hyperandrogenism treatment Risks:- VTE- Hypertension- Hepatic adenoma- Stroke, myocardial infarction- Cervical cancer
• When to stop Pap testing - Age 65 or hysterectomy PLUS - No history of CIN 2 or higher AND - 3 consecutive negative Pap testsOR- 2 consecutive negative co-testing results
• Premenstrual syndrome/Premenstrual dysphoric disorder Premenstural syndrome: Onset of severe discomfort or functional impairment prior to menstruation.Premenstrual dysphoric disorder: Severe form of affective symptoms that interferes with daily life, including having abnormal disagreements with family, friends, and colleagues Clinical features (occuring during luteal phase):- Physical: Bloating, fatigue, headaches, hot flashes, breast tenderness- Behavioral: Anxiety, irritability, mood swings, decreased interest Evaluation: Symptom/menstrual diary Treatment: SSRI
• Endometrial biopsy indications Age ≥ 45:- Abnormal uterine bleeding- Postmenopausal bleeding Age < 45:- Abnormal uterine bleeding PLUS→ Unopposed estrogen (obesity, anovulation)→ Failed medical management→ Lynch syndrome (hereditary nonpolyposis colorectal cancer) Age ≥ 35: - Atypical glandular cells on Pap test
• Aromatase deficiency Karyotype: 46 XX or 46 XY (normal sex development) Pathophysiology: Mutations in the CYP19A1 gene which encodes for the enzyme aromatase → ↓ serum estrogen and ↑ serum testosterone Clinical features:- Birth: ambiguous genitalia despite normal internal genital organs- Impaired maturation of secondary sexual characteristics- Primary amenorrhea- Virilization (e.g., hirsutism, severe acne)- Tall stature- Osteoporosis- Mothers of affected children may experience virilization during pregnancy (may start at 12 weeks' gestation and typically disappear after delivery) Treatment:- Estrogen and progesterone replacement therapy- Calcium and vitamin D supplemenation- Surgical correction of ambiguous genitalia
• Pap tests requiring endometrial evaluation Result: Benign appearing endometrial cellsGroup requiring endometrial sampling:- Premenopausal women with→ Abnormal uterine bleeding OR Risk for endometrial hyperplasia- Postmenopausal women Result: Atypical glandular cellsGroup requiring endometrial sampling: Women age ≥ 35 OR at risk for endometrial hyperplasia Result: Atypical glandular cells, favor neoplasticGroup requiring endometrial sampling: All women
• Vulvovaginal atrophy Etiology:- Low estrogen levels- Atrophy of the epithelium in vagina and vulva Clinical features:- Decreasing labial fat pad- Vaginal soreness, dryness- Narrowing of the vaginal introitus- Dyspareunia, burning sensation after sex- Discharge, occasional spotting- Commonly associated with receding pubic hairDoes not commonly involve the perianal region (vs. lichen sclerosus). Treatment: Estrogen cream
• Vulvar lichen planus Epidemiology:- Women age 50-60 Clinical features:- Vulvar pain or pruritus- Dyspareunia- Erosive variant (most common):→ Erosive, glazed lesions with white border→ Vaginal involvement ± stenosis→ Associated oral ulcers- Papulosquamous variant:→ Small pruritic papules with purple hue Diagnosis:- Vulvar biopsy Treatment: High-potency topical corticosteroids

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