Gynecology

Diagnostic Methods
Diagnostic Test
Measures
Pap Smear
Method of cervical
screening used to
detect potentially
pre-cancerous and
cancerous processes in
the endocervical canal
Colposcopy
Method of looking at the

cervix under
magnification
Indications
Current USPSTF Guidelines
< 21 years old
No pap smear
21 - 30 years old
No HPV
If HPV (-), pap smear
every 3 - 5 years
30 - 65 years old
Most recent every 5
years
Demonstration of Pap Technique
Appropriate selection of speculum
Adequate sample collection
Factors affecting results
Preparing the Patient
Refer her to colposcopist
She cannot be menstruating.
Premedicate with Motrin 400 - 800 mg to reduce
cramps
Colposcopist will use vinegar and possibly iodine
Expect mild cramping afterwards
Will have discahrge afterwards
Possibly get odor later due to mild infection
Endometrial cancer
Test Interpretation
Parameters
Yeast
Organisms
Bacterial vaginosis
Trichomonas
Atypical squamous cells
ASCUS
of undetermined
significance
Low grade squamous
LSIL
interepithelial lesion
High grade squamous
HSIL
interepithelial lesion
AGC
Atypical glandular cells
Result
Endometrial
Biopsy
Histological analysis of
the endometrium
No anesthesia
Uterine perforation
Pelvic infection
Hysterosalpingogram
Ultrasound that involves

placing the probe inside
the vagina
X-ray that images the inside of the
uterus and fallopian tubes
Benign
Risks
Vasovagal reaction
Transvaginal
Ultrasound
Done with minimal to no

cervical dilation
Low cost compared to
hospital D&C
Excessive uterine
bleeding
Bacteremia
Postmenopausal
Infertility evaluation
Uterine septum
Endometrial polyps
Uterine fibroids
Methods
Liquid-based pap smears
Slide (spray) pap smears
USPSTF recommends at least every
3 years beginning at age 21 - 70
Atrophy (absence of
hormonal effect)
Endometrial hyperplasia
Advantages
Performed in office
Other
98 - 100% specificity
Works best if the pathology is
present in at least of the
Proliferative
endometrium
endometrium (estrogen)
Contraindications
Pregnancy
Secretory endometrium
Pelvic infection (treat first)
(progestin)
Bleeding diathesis (referral)
Dyssynchronous
Cervical stenosis (referral)
endometrium
Cervical cancer (referral)
(unopposed estrogen)
Endometritis
Simple or Complex
Endometrial
Hyperplasia
Without atypia
Thin Strip
< 4 - 5 mm
Low risk of endometrial

cancer
With atypia
Uses contrast dye
Asherman's syndrome
Compiled by Drew Murphy, Duke Physician Assistant Class of 2015
Diagnostic Methods
Diagnostic Test
Measures
Hysteroscopy
Procedure to visually
evaluate the uterine cavity
GonadotropinReleasing
Hormones (GnRH)
Follicle
Stimulating
Hormone (FSH)
LHRH that induces

release of RSH and LH
Indications
Result
Abnormal bleeding
LOW
Hypogonadism
Menopause
Menstrual irregularities
LOW
Gonadal failure
Predicting ovulation
Evaluation of infertility
Pituitary disorders
HIGH
Evaluate infertility
Luteinizing
Hormone (LH)
Anterior pituitary
glycoprotein that
stimulates follicular
production of estrogen,
ovulation, and corpus
luteum formation
Other
Can be either diagnostic or operative
HIGH
Glycoprotein secreted in
pulsatile manner by the
anterior pituitary that
stimulates the
development of follicles
in granulosa cells
Test Interpretation
Parameters
Endocrine problems with

precocious puberty
LOW
Ovulation preduction
HIGH
Testicular dysfunction
Disorders of sexual
differentiation
Hypothalamic
hypogonadism
Dopamine
Opiates
1 Hypopituitary
hypogonadism
Epinephrine
2 Gonadal failure
Stress
Malnutrtion / anorexia
Severe illness
Hyperprolactemia
Pregnancy
PCOS
1 Gonadal failure
Ovarian agenesis
Alcoholism
Gondatropin-secreting
pituitary tumors
Pituitary failure
Hypothalamic failure
Severe stress
Anorexia
Malnutrition
Severe illness
Pregnancy
Hemochromoatosis
Hyperprolactemia
Gonadal failure
Precocious puberty
Pituitary adenoma
Menopause
PCOS
Serum or plasma
No steroids, ACTH, gonadotropin, or
estrogen medications for 48 hours.
Plasma or 24-hour urine

Levels fluctuate widely during
the day
FSH increase begins 2 days before
Plasma or 24-hour urine

Best time to obtain sample is 11 am 3 pm.
Plasma LH surge proceeds ovulation
by 24 - 36 hours
Ovulation tests typically use urine LH
to determine ovulation status.
Diagnostic Methods
Diagnostic Test
Progesterone
Measures
Indications
Monitor ovulation
induction
Ectopic pregnancy
LOW
Infertility
Risk pregnancy
HIGH
Evaluate sexual maturity
Menopausal status
Menstrual and
fertility problems
Fetal-placental health
Steriod sex hormones

produced by the corpus
luteum after ovulation
Tumor marker
Estrogen
Result
Hormone that causes

proliferation of
endometrial glands
Estradiol
LOW
with gynecomastia or
feminization syndromes
Menstrual and
fertility problems
Menopausal status
Sexual maturity
HIGH
Interfering Factors
Maternal illnesses
Glycosuria
UTI
Drugs
Testosterone
Estrogen precursor that

exerts anabolic effects
and influences behavior
Ambiguous sex
characteristics
Precocious puberty
Virilizaiton syndromes
Tumor markers
LOW
HIGH
Hirsutism
Monitoring antiandrogen
treatment
Test Interpretation
Parameters
Preeclampsia
Threatened abortion
Placental failure
Fetal demise
Ovarian neoplasm
Amenorrhea
Ovarian hypofunction
PCOS
Ovulation
Pregnancy
Hyperadrenocorticalism
Adrenocortical
hyperplasia
Luteal cysts
Molar pregnancy
Choriocarcinoma
Failing pregnancy
Turner's syndrome
Hypopituitarism
Hypogonadism
PCOS
Menopause
Anorexia
Precocious puberty
Ovarian tumor
Adrenal tumor
Gonadal tumor
Normal pregnancy
Cirrhosis
Liver necrosis
Hyperthyroidism
1 / 2 Ovarian failure
Drugs
Ovarian tumor
Adrenal tumor
Congenital
adrenocortical
hyperplasia
Trophoblastic tumor
PCOS
Idiopathic hirsutism
Drugs
Other
Serum sample
Levels rise rapidly after ovulation
Interfering Factors
Hemolysis of sample
Drugs
Production begins after ovulation and
rises rapidly for 3 - 4 days.
Serum, urine, or salivary

Estrone (E1)
Major circulating estrogen after
menopause
Less potent than estradiol
Estradiol (E2)
Physiologically most important
Feedback mechanism for FSH/LH
Peaks during ovulatory phase
Begins to rise by 4th day of cycle
Estriol (E3)
Major estrogen in pregnancy
Levels increase throughout
pregnancy
Serum sample
Level vary by state of sexual maturity
Interfering Factors
Drugs
Alcohol
Diagnostic Methods
Diagnostic Test
Measures
Progesterone
Withdrawal Test
Stimulation test done to

evaluate the hypothalamicpituitary-gonadal axis
Indications
Result
2 Amenorrhea
Inadequate estrogen
production
Hypothalamic
dysfunction
Abnormal uterus
Bleeding
No Bleeding
(Lack of Estrogen)
LOW
Pituitary adenoma
Prolactin
Human
Chorionic
Gonadotropin
(hCG)
Amenorrhea
Anterior pituitary
hormone that promotes
lactation
Placental glycoprotein
hormone
HIGH
Galactorrhea
Hypothalamic pituitary
disorders
Pregnancy
Monitor risk
pregnancy
Post-ectopic aborotion
Post-molar pregnancy
hCG-producing tumors
Cirrhosis
Interfering Factors
Too early in pregnancy
Hemolysis of blood
Diluted urine
Hematuria / proteinuria
Drugs
Test Interpretation
Parameters
LOW
HIGH
Other
Amenorrhea Differential
Pregnancy
Pituitary hypofunction Excessive athletic activity
Hypothalamic
Menopause
dysfunction
Systemic disease
Ovarian failure
Sheehan syndome
Serum sample
Pituitary destruction by Surge with breast stimulation,
tumor
pregnancy, nursing, stress, exercise,
Pituitary adenomas and during sleep
Interfering Factors
2 Amenorrhea
Galactorrhea
Stress
Hypothyroidism
Trauma
PCOS
Surgery
Anorexia
Fear of blood tests
Paraneoplastic
Drugs
syndrome
Peak levels with initiation of lactation
Hypothalamus and
Surge each time infant suckles
pituitary stalk disease
Renal failure
Hypoglycemia
Hypothyroidism
Drugs
Prolactin-producing
pituitary adenoma
Dopamine-interfering
diseases
Levels of estrogen
Threatened or
Serum or urine
incomplete abortion Production begins after implantation
Fetal demise
(around day 21 - 23)
Normal pregnancy
For first few weeks, serum levels are
Ectopic pregnancy
higherly than urine levels
Molar pregnancy
Serum concentration rises quickly
Choriocarcinoma
and doubles about every 2 days
Germ cell tumors
(for the first few weeks)
Hepatomas
t = 3 - 7 days
Lymphoma
Feedback loop is intact
Diagnostic Methods
Diagnostic Test
Interferring
Factors in
STI Testing
Measures
Stuff that messes with

STI testing
Indications
Vaginal Wet
Prep
Cervical
Testing
Cervical culture for STIs
Gram Stain
Method of differentiating
bacterial species into two
large groups based on
cell wall characteristics
Nucleic Acid
Amplification
Testing (NAAT)
Very sensitive test for

STI pathogens
Test Interpretation
Parameters
Some organisms are

Menses may alter
sensitive to lubricants
vaginal / cervical
and disinfectants
test results
Douching 24 hours of Voiding 2 hours before
collection may alter pH
urethral or urinary
and organisms
sampling
Fecal material
contimination
Recent antibiotics
Gynecologic test where a

sample of vaginal discharge
is observed by wet mount
microscopy by placing the
specimen on a glass slide and
mixing with a salt solution
Result
Other
Lable all specimens with patient
indentifier, date, time, and specimen
source
Specific temperature,
transport time, and
culture medium required
for certain organisms
Gently rotate swab over vaginal wall or area of

inflammation while avoiding cervical
mucus and blood
Obtain pH by dipping narrow range pH paper
(3 - 6 range) in vaginal secreations from swab or
vaginal wall
Insert discharge-moistened swab into tube
containing 1 mL saline
Send to lab or examine microscopically
20 minutes
Place patient in lithotomy position
Insert un-lubricated speculum to expose cervix
Remove cervical mucos with cotton swab and
discard swab
Insert streile swab into endocervical canal and wait
15 - 30 seconds
Inoculate plate directly or place in transport media
Urethra (Calcium Alginate-Tipped Swab)
Collect discharge
with Visible Discharge
without insertion
Insert tip 1 - 2 cm into
without Visible
urethral meatus
Discharge
Rotate 3 - 5 seconds
Same as but more
shallowly
Cervix (Cotton Swab)
Generally not done
BV infection
Gonorrhea
Chlamydia
HSV
Mycoplasma
Ureaplasma
Trichomonas
Vaginal Specimen Procedure
Insert swab with collection tube into vagina
Self-obtained low vaginal swab (SOLVS) sensitivity
is even better than urine NAAT
Refrain from douching or tub

bathing > 24 hours prior to culture
Avoid vaginal secretions
Clue Cells
Gold-standard for
bacterial vaginosis
diagnosis
Can be done using a urine sample
Diagnostic Methods
Diagnostic Test
Gonorrhea
Culture
Measures
Special culture is
required for gonorrhea
HSV Viral
Culture
Gold-standard for
diagnosing HSV
Herpes Serology
Study of serum for Herpes

viral components and
antibodies
Direct
Methods for
Syphilis
Direct identification of
spirochetes
Indications
Have chocolate agar, Thayer-Martin, or Jembec
plates at room temperature
Roll swab in a "Z" pattern and cross streak
Incubate plates at 36C 1 hour of collection
Anal / Rectal Culture
Done in those with rectal exposure
Insert sterile cotton swab 2 - 3 cm into anal canal
(beyond rectal sphincter)
Press laterally to sample anal crypts and
avoid feces
Oropharyngeal Culture
Obtained in those who have engaged in oral sex
Swab posterior pharynx and tonsillar crypts
Include areas of inflammation or exudate
Must identify that specimen is to evaluate
for gonorrhea
Urethral Culture
Collect > 1 hour post-urination
Swab is inserted gently into anterior urethra
Perform supine exam if patient is prone to
vasovagal syncope
Urethral / prostatic massage may increase
culture yield
Vesicle
Open vesicle with 18-guage needle
Abrade base of lesion with cotton swab to obtain
epithelial cells
Crusted Lesion
Remove crust with moist gauze
Scrape base of lesion with cotton swab
Advantages
Disadvantages
Helpful if IgM positive
Less sensitive
Only 85% of (+) patients
IgG titer > 1:160
have (+) serology
Rapid results
Darkfield Microscopy
Requires fresh specimen
Direct Fluorescent
Antibody Testing
(DFA-TP)
Requires fluorescence
microscope
Can be used with
air-dried specimens
Better sensitivity with
fresh specimen
Result
Test Interpretation
Parameters
Other
Jembec plates have a small reservoir
for a CO2 tablet
Do not refrigerate
If stool contaminates swab in rectal
sampling, repeat swab is required.
90% sensitivity
Place swabs (in both methods) in
viral transport medium immediately
and refrigerate if there is a test delay
POSITIVE for
Acute Infection
4-fold rise in titer
NEGATIVE
Does not exclude

diagnosis
Recurrent infections are less likely to

show a dramatic increase in titer
Diagnostic Methods
Diagnostic Test
Syphilis
Serology
Gonorrhea
Testing
Measures
Components in the
serum present during a
syphilis infection
Testing for the presence

of Neissera gonorrhea
Indications
Detects antibodies
against specific
treponemal antigens
Treponemal
Used for confirmatory
testing
Positive 4 - 6 weeks
post-inoculation
Nontreponemal
Detects antibodies
Nonspecific
to reagin
Many false positives
False Positive Etiologies
Malaria
Typhus
Leptospirosis
Cat-Scratch fever
Leprosy
Hepatitis
Mononucleosis
Periarteritis nodosa
Lupus
Acute infections
Lymphogranuloma
Hypersensitivity
venereum
reactions
Mycoplasma pneumonia Recent immunizations
Use in
Gram Stain
(urethral only)
Culture yield is 85% 95%
Culture
Benefit of susceptibilities
DNA by PCR Amplication
(NAAT or NAT)
Chancroid
Testing
Haemophilus ducreyi
DNA Amplication / PCR /

NAAT for Chlamydia
Gold-standard for
detecting Chlamydia
Result
Gram Stain
Fast and sensitive

Cervical, urethral, or
urine specimens
No serological
methodologies
DNA PCR Amplication
Culture
Culture takes too long

(5 - 7 days)
Most common form
of testing
Serological studies are

outdated
Rapid and accurate
results
Test Interpretation
Parameters
Other
Types of Treponemal Tests
FTA-ABS
MHA-TP
TP-PA
TP-EIA
Types of Nontreonemal Tests
VDRL
RPR
TRUST
Treponemal test results are reported
as "reactive" or "nonreactive."
Nontreponemal test results are
reported as a titer.
Co-infection with Chlamydia is high.

You can send a specimen for both
tests.
Gram Stain
Gram negative
intracellular diplococci
Gram negative diplococci

Gram Stain
Make sure that the lab knows to

look for H. ducreyi
"School of fish"
Diagnostic Methods
Diagnostic Test
Measures
Indications
Result
Test Interpretation
Parameters
Methods for Diagnosis
HIV Testing
Detect antibodies to the

virus (EIA)
Detect viral antigen

(Western blot)
Detect viral nucleic acid

(NAT)
Culture HIV virus
Initial Screen
EIA or ELISA
If repeatedly reactive,
perform confirmatory
test
Determining HIV status
EIA Reactive but

IFA / WB
Non-Reactive
Repeat test in
3 - 6 months
Western blot
Confirmatory Test
IFA
Trichomonas
Testing
Wet prep
Urinalysis microscopic
(incidental finding)
Culture (less common)
Pap smear
Other
ELISA or EIA
99% sensitive
99% specific
Western Blot
Based on using electrophoresis
technique to separate HIV antigen
derived from virus grown in culture
Antigen Test (p24) ELISA-Type
Method
Detects free antigen or bound
antigen / antibody complexes
Detectable 2 - 6 weeks post-infection
HIV Viral Load (HIV RNA)
Accurate marker for prognosis,
disease progression, response to
antiviral treatment, and indication for
antiretroviral prophylactic treatment
Trichomonas vaginals
Wright's Stain
Donovan bodies
C. granolomatis
Testing
Determines
C. granolomatis infection
status
Granuloma inguinale
Complement
Fixation Test for C.
trachomatis
Detects serotype L1, L2,

or L3 of Chlamydia
trachomatis
Lymphogranuloma venereum
HPV Testing
Helps differentiate the

numerous strains of HPV
Giemsa's Stain
Gram Stain
Pap smear
HPV High-Risk
DNA typing
(usually associated with
Pap test)
Bipolar rod-shaped
bacteria encapsulated in
mononuclear
lymphocytes
Offer HPV vaccine for 9 - 26 year olds
Diagnostic Methods
Diagnostic Test
Measures
Indications
Hepatitis A
Screening for
Hepatitis
Reportable
STIs
When to screen for the

various forms of hepatitis
STIs that need to be

reported to local / state
departments of
public health
Heptatis B
Result
MSM
Injection drug users
MSM
Injection drug users
Multiple sex partners
STI clinic patients
Pregnant
HIV-infected
Hepatitis C
HIV-infected
Chlamydia
Chancroid
Gonorrhea
Acute hepatitis A
HIV
Acute hepatitis B
Syphilis
Acute hepatitis C
Test Interpretation
Parameters
Other
Offer vaccine during screen if not
immune to hepatitis A or B (do not
give B vaccine to pregnant patients)
Clinical Medicine
Condition / Disease
Adrenarche
Menarche
Cause
Maturational increase in adrenal

androgen production which
beings at about 6 years of age in
both and
Initiation of
menstruation
Signs and Symptoms
Test
Hair growth
Body odor
Skin oiliness
Acne
Average 2.5 years after

onset of puberty
Not necessarily
ovulatory initially
Menses (Day 1)
Bleeding starts
Laboratory
Result
Treatment
Medications
Other
Seems to be unrelated to the
pubertal maturation of the
neuroendocrine-gonadotropingonadal axis
Thelarche
Beginning of breast development
Average age US is 12 years 8 months
(and dropping)
Produces one fully mature oocyte

which is ovulated mid-cycle
Follicular / Proliferative Phase

Ovarian follicules
develop leading to
mature graafian follicle
Menstrual
Cycle
Cyclical changes in
hormones from
hypothalamus, anterior
pituitary, and ovaries
Follicle Stimulating
Hormone (FSH)
Hormone released by the

anterior pituitary
Lutenizing
Hormone (LH)
Hormone secreted by the

anterior pituitary
"Surge" induces
ovulation of the
dominant follicle
Induces androgen
synthesis by the
follicular theca cells
Ovulation
Release of the egg from

the dominant follicle
Usually around day 14
Proteolysis of dominant
(Graffian) follicle with
layers of granulosa and
theca cells
Estrogen
Steroid hormone produced

by ovarian granulosa cells
Granulosa cells covert androgens to estrogen
Progesterone
Steroid hormone produced

by the corpus luteum
Slowed endometrial proliferation induces

secretion of endometrial glands
Inner lining of the uterus
Proliferation
Straight glands
No glycogen
Glycogen
Secrete mucus
Luteal / Secretory Phase
Tortuous glands
Length constant at
14 days
Spiral arteries rupture
Functional endometrium
is shed
Mentsrual
2 - 8 days (average)
25 - 60 cc blood loss
Luteal / Secretory Phase

Mature follicle
transforms into corpus
After ovulation
luteum secreting
progrestone and
estrogen
Proliferation of granulosa cells in the follicle
(that secrete estrogen)
Induces granulosa cells to become sensitive to LH
leading to ovulation
Essential for early ovarian follicle

growth
Negative feedback on GnRH
secretion
Theca cells help by producing

androgens
Negative feedback to pituitary for
FSH secretion
Proliferation of the endometrial glands
Follicular / Proliferative
Phase
Endometrium
Estrogen levels rise
Progesterone
> 4 at Day 21
Ovulation has
occurred
Cervical Mucous
Thinner in proliferative phase
Thicker in luteal phase
Clinical Medicine
Condition / Disease
Premenstrual
Syndrome
Cause
Recurrent psychological or
physical symptoms occurring
specifically during the luteal phase
of the menstrual cycle
Signs and Symptoms
Perimenopause
Menopause
Sadness / despair /
suicidal
Severe form of PMS
Menstrual changes that occur

around 4 years prior
to menopause
Absence of menses for

> 1 year
Vulvar Disease
Any of a group of disease

that affect the vulva
Lichen
Chronicus
Progressive vulvar pruritus

and burning due to an
unknown trigger
Lichen Sclerosus
Chronic, intense
vulvar pruritus
Lichen Planus
Disease of the skin and/or

mucous membranes possibly
due to an
autoimmune process
Laboratory
Result
Treatment
Medications
Acne
Breast swelling
Fatigue
GI disturbance
Insomnia
Bloating
Headache
Food cravings
Depression / anxiety / irritability
5 symptoms
Premenstrual
Dysphoric
Disorder
Test
Exercise
Regular sleeping habits
Stress management
Proper diet
Avoid caffeine, sugars, and salt
Medical therapy
Counseling
Hysterectomy with bilateral
oophorectomy
Panic attacks
Tension / anxiety
Mood swings / crying
Irritability that
affects others
Disinterest in
daily activities
Binge eating / craving
Physical symptoms
Heavy bleeding and clots
Anovulatory cycles
Other
Often resolves by the end of
menstruation
85% of have 1 symptoms
Laparoscopic bilateral oophorectomy
Spironolactone
Contraceptives
Pyridoxine
Alprazolam
Buspirone
Gonadorelin
Analogues
Metolazone
Calcium
Supplements
NSAIDs
Variable cycle length

State of estrogen
deficiency
Menstual irregularities
(first symptom)
Vasomotor instability
Vaginal dryness
Depression
Lipid changes
Bone loss
Depletion of ovarian
follicles
Hot flashes
Cardiovascular changes
Burning
Irritation
Abnormal growth
Infectious Etiologies
Ulcerative infections
Pediculosis pubis
Scabies
Candidiasis vulvitis
Condyloma
Folliculitis / carbuncle
Non-Infectious Etiologies
Contact dermatitis
Atrophic changes
Other dermatitis
Neoplasia
Unilateral / localized
Thin, white
"onion skin"
"Cigarette paper"
skin
Stenosis of
vaginal introitus
Violaceous, flat topped

papules (erosive type)
Possible oral or vaginal
lesions
Vulvar Biopsy
Avoid irritants
Pat dry (do not over dry)
Lukewarm water
Baking soda
Soaks
Burrow's solution
compresses
Use when sure of
vulvar lesion
Petrolatum
etiology
Olive oil
Lubrication
Vitamin A and D
ointment
Possibly estrogen, antimicrobials, or
corticosteroids
Antihistamines
Vulvar burning
Thickened and white skin
Disfigurement
Hormone replacement therapy

(controversial)
GU symptoms
Mood changes
Sleep disturbance
Pruritis
Vulvar pruritus
Average age is 51.4 years old

Premature if age < 40 years old
Topical medium-potency steroids

Biopsy
Diagnostic
Biopsy
Diagnostic
White patches
Ulcerations
Chronic burning and
itching
Common in all ages

Maintain a high index of suspicion in
peri- and postmenopausal due to
higher risk of malignancy.
Biopsy
Diagnostic
Hydroxyzine
SSRIs
Gynecological referral
Testosterone
Potent topical steriods

Topical hormones (possibly)
Topical steroids
Douches
Suppositories
Vaginal estrogen cream
(if atrophic)
Porgesterone
(not EBM)
Risk of squamous cell cancer is 4 - 6%
Beware of adhesions and introital

stenosis
Clinical Medicine
Condition / Disease
Cause
Ulcerative
Vulvar Lesions
Ulcerative lesions,
generally due to
infectious agents,
on the vulva
Parasitic Vulvar
Infections
Parastic infections of the

vulva and surrounding
tissue
Signs and Symptoms
Herpes Simplex
Syphilis
Pediculosis Pubis
Test
Laboratory
Result
Treatment
Medications
Look carefully for crabs

Excoriations prominent
Scabies
Look for typical pattern

on the rest of the body
Vaginal discharge
(usually not chief
complaint)
Erythematous
Symmetrical
Confluent
Excoriations
Fissures
Perfumed Products
Sprays
Pads
Soaps
Detergents
Bubble bath
Toilet tissue
Look for yeast vaginitis
Vulvitis
Yeast Vulvitis
Vulvar infection by yeast
Contact
Dermatitis
Inflammatory reaction
due to an outside trigger
Atrophic Changes
Assoicated with reduced estrogen

levels, postmenopausal, or
lactation
1% Hydrocortisone cream
Remove offending agent
Products added to barrier contraceptives and latex
Erythematous
Thin, smooth, and shiny

mucosa
Topical estrogen
Biopsy
Diagnostic
Moderate-strength topical steroids
Bichloroacetic acid
Condyloma
Acuminate
Other
Multiple, recurrent
vesicles
Pruritic
Painful
Single chancre
"Heaped up" or
"rolled" edge
Painless
"Cauliflower-like"
lesions
Verrucous
Dry
Bulky
Genital warts usually

caused by HPV 6 or
11 infection
Trichloroacetic
acid
Podophyllin
10 - 25%
Sinecatechins
15%
Podofilox 0.5% solution or gel
Imiquimod (Aldara) 5% cream
Intradermal
Interferon
Medications
5-FU
Cryosurgery
Electrosurgery
Surgery
Excision
Topical
Medications
Can be dysplastic and cancerous

Condyloma Lata (Secondary Syphilis)
Smooth, moist, and flat lesions
Use only TCA or BCA on vaginal
lesions
Laser vaporization
Paget Disease
Very rare malignancy originating

in vulvar apocrine-gland-bearing
skin cells or as a manifestation of
adjacent primary anal, rectal or
bladder adenocarcinoma
Fiery red lesions with white hyperkeratotic areas
> 65 years old
Local excision
Higher incidence of underlying

carcinoma (especially colon and
breast)
Vulvectomy
Clinical Medicine
Condition / Disease
Cause
Signs and Symptoms
Test
Laboratory
Result
Bleeding
Vulvar pruritis
Discharge
Dysuria
Chronic irritation
Raised, often white or

gray lesions
Red / white ulcerative

or exophytic lesions
Treatment
Medications
Local cauterization (early VIN)

Biopsy
Diagnostic
Local excision laser cauterization
(with higher grade VIN)
CXR
Vulvar Cancer
Fourth most common

gynecological cancer
Simple vulvectomy
IVP
Workup
Inguinal lymphadenopathy (if spread)

Risk Factors
HPV
Immunocompromised
Smoking
Lichen sclerosis
History of cervical
Northern European
cancer
ancestry
Vulvar
Melanoma
5% of all vulvar
malignancies
Raised, irritated,
pigmented lesion
Pruritis
Severe vulvar pain
Severe vulvar edema
Uncomforable walking /
sitting
Bilateral (associated
with gonorrhea)
Vaginal discharge
Dyspareunia
Adjunctive postoperative radiation
Cystoscopy
5 Year Survival
Proctoscopy
Excisional
Biopsy
Diagnostic and
required
70 - 93% if
negative nodes
25 - 41% if
positive nodes
Wide local excision

Avoid tanning beds
Additional Etiologies
Strep
E. coli
Anaerobes
May be adenocarcinoma in > 40
years old
Incision and drainage
Bartholin's
Gland Abscess
Vaginitis
Abscess typically caused

by N. gonorrhea
and Chlamydia
Biopsy
Dysuria
Urinary frequency
Pruritis
Spotting
Infection of the vagina
Erythema
Bacterial
Vaginosis
Vaginal infection by
polymicrobal, anaerobic
overgrowth of normal
vaginal flora
Asymptomatic
(50 - 75%)
Fishy odor
Heavy discharge
Pruritus
Odor after intercourse
Thin, adherent,
homogeneous discharge
Malodorous
White or gray mucosa
Bubbles
Requires 3 of 4 Criteria
Typical discharge
pH > 4.5
(+) "Whiff" amine test
Clue cells
Other
Most frequent on posterior vulva and
perineum
90% squamous cell, 5 - 10%
melanoma
Typically in postmenopausal but
can occur in 30 to 40 years olds
Preceded by vulvar intraepithelial
neoplasm (VIN)
Recurs in of
Staging
I - Vulva only
II - Vulva and lower urehtra, vagina,
or anus
III - Extension to adjacent perineal
structures
IV - Further extension or any distant
LNs
Word catheter
R/O
(leave for 1 - 2 weeks)
Adenocarcinoma
Consider antibiotic treatment
Marsupialization (if recurrent)
Vaginal Discharge pH Values

Normal
Bacterial
Vaginosis
Trichomonas
Vaginitis
Yeast
Vaginitis
Atrophic
Vaginitis
4 - 4.5
> 4.5
5-6
4 - 4.5
> 4.7
500 mg orally BID
for 7 days
0.75% gel daily for
5 days
2% cream at
bedtime for 7 days
300 mg orally BID
Clindamycin
for 7 days
100 mg ovules at
bedtime for 3 days
Tinidazole 1 gram daily for 5 days
(expensive)
Metronidazole
"Whiff"
Amine Test
POSITIVE
Saline Wet
Mount
Clue cells
Relative absence of lactobacilli

Increases preterm labor risk in
pregnant
30% 3-month and 50% 1-year relapse
rates
Clinical Medicine
Condition / Disease
Trichomonas
Vaginitis
Cause
Vaginal infection by an
anaerobic, flagellated
protozoan
Signs and Symptoms
Test
Severe pruritus
Malodorous (musty)
discharge
Dysuria
Dyspareunia
Possibly asymptomatic
Greenish-yellow, frothy
discharge
Petechiae or "strawberry markings" on cervix
Yeast Vaginitis
Vaginal infection by
yeast
Pruritus
Burning
"Cottage cheese"
discharge
Dyspareunia
Vaginal erythema
No odor
Laboratory
Result
Atrophic
Vaginitis
Vaginal Cancer
Acute
Cervicitis
Chronic
Cervicitis
Infectious
Cervicitis
Noninfectious
Cervicitis
Nabothian Cyst
Extremely rare cancer
Sudden onset of
inflammation or infection
of the cervix
Recurrent or multiple
episodes of cervicitis
Infection of the cervix
Cervicitis due to
non-pathological substances
Seen in amenorrheic
Dyspareunia
No odor
(unless concomitant
infection)
Other
Saline Wet
Mount
Pap Test
May not be seen

15% of the time Single-dose oral tindazole 2 grams
Warming slide
makes them
Treat partners
easier to see
Can make
diagnosis on thin Follow-up and look for other STIs
prep
OTC imidazoles
Pseudohyphae (resistance being seen)
Topical imidazole (prescription)
KOH
Wet Prep
Budding yeast
Oral fluconazole 150 mg

Gentian violet
Butoconazole 2%
May not be seen
Prescription
Nystatin
15% of the time
Medications
Terconazole
May Be Precipitated By
Hormone changes
Oral corticosteroid treatment
Oral antibiotics
Tight / hot clothing
Obesity
If recurrent or multiple episodes,
consider hyperglycemia, diabetes,
and immunocompromised state (HIV)
Pruritus
Burning
Spotting (possibly)
Pale, thin vaginal
mucosa
No discharge
Loss of vaginal rugation
Abnormal bleeding
Pain
Mass
Dyspareunia
Risk Factors
HPV
DES
Mucopurulent
endocervical discharge
Edematous cervical
appearance
Inflammed / reddened
appearance
Cervical friability
(bleeding on contact)
Leukorrhea
Vulvar irritation
KOH Wet Prep
NEGATIVE
Colposcopy
Estrogen replacement
Excision
Diagnostic
Excisional
Biopsy
Treatment dependent on cell type,

location, and involvement
Granular redness
Patchy erythema
Cervical stenosis
Chalmydia
Gonorrhea
Herpes simplex
HPV
Trichomoniasis
Mycoplasma genitalium
Cytomegalovirus
Chemical irritation /
Mechanical irritation
allergic response
Trauma
Systemic inflammatory
Radiation
disease
Large yellowish lumps
Epithelial inclusion cyst
Medications
Motile flagellated Single-dose oral metronidazole 2

protozoans
grams
Inflammation of the
vagina due to the
thinning and shrinking of
the tissues
Treatment
Seen in menopausal
Appear to be filled with with thinned epithelium
fluid
Vaginal Intraepithelial Neoplasm

(VAIN)
Starts with dysplasia
Usually HPV related
Adenocarcinoma, melanoma, and
sarcoma are less common
May also be caused by bacterial

vaginosis
No treatment necessary
Cryotherapy
Electrocautery
Normal physical finding

Occurs when new tissue regrows on
the cervix (typically after childbirth)
Clinical Medicine
Condition / Disease
Endocervical
Polyp
Cause
Common benign polyp or

tumor on the surface of
the cervical canal
Signs and Symptoms

Asymptomatic
Red, flame-shaped,
and fragile
Thin or broad-based
attachment
Small, pedunculated,
sessile lesions
Test
Laboratory
Result
Biopsy
Always send to
pathology
Postcoital spotting
Asymptomatic
(early disease)
Abnormal vaginal
bleeding
Postcoital bleeding
Vaginal discharge
Foul odor
Pelvic pain
Treatment
Medications
Remove by hemostat and gentle

twisting motion
Broad-based lesions need to
evaluated
Silver nitrate simple cautery
(if needed)
Screening
Start at age 21
Flank pain
Weakness
Cervical
Cancer
Cervical Squamous
Cell Carcinoma
Cervical
Adenocarcinoma
Third most common

gynecologial cancer
Anemia
Cervical lesion
Ulceration
Friable tissue
Nodularity or firm
consistency
Persistent HPV infection
HPV 16
HPV 18
Vesicovaginal /
rectovaginal fistula
Weight loss
Mobility of the cervix
Pap Smear
Nodularity of the
uterosacral ligament
Risk Factors
Young age (< 18 years
Multiple sex partners
old) at first sexual
Smoking
History of STIs
High-risk sexual partner
Lack of screening
SES status
Nonwhite
Long-term use of oral
HIV / AIDS /
contraceptive pills
immunocompromised
Multiparity
Uncircumcised partner
( 3 live births)
Younger age at first fullGenetic (possibly)
term pregnancy
Common Causes of Death
Uremia
Pulmonary embolism
Hemorrhage
Sepsis
Large bowel obstruction
Typically 1 cm of
90% develop from
squamocolumnar
intraepithelial layers
junction
Majority are large cell,
Verrucous (associated
nonkeratinizing type
with HPV 6)
Derived from glandular
< 35 years old
elements
Develop in the
Not visible until more
endocervical canal
advanced
Cell Types
Mucinous
Endometrioid
Clear cell
Serous
Limited value in Annual if < 30 years old

detecting grossly
Every 5 years after 3 consecutive
visible invasive
(-) if > 30 years old
disease
HPV testing if cytology ASC-US
Colposcopic
Guided Biopsy
Diagnostic
CT / MRI /
PET
Evaluate for
metastasis
Other
Often a result of hyperestrogen state
Removal is curative 90%.
Stop screening if > 70 years old, with 3

consecutive (-), and no abnormal test
in previous 10 years
Stop if post-total hysterectomy for
benign disease and no history of CIN
2/3
Immunocompromised or history of
cervical dysplasia needs continued
annual screening
LEEP
Preinvasive /
CKC
Microinvasive
Simple
hysterectomy
Radical
hysterectomy and
pelvic
Early Stage
lymphadenectomy
(IA2 - IIA)
1 radiation with
concurrent chemo
Locally Advanced 1 radiation with
(IIB - IVA)
concurrent chemo
Metastic /
Chemo
Persistent /
Palliative radiation
Recurrent
Total pelvic exenteration
(if central pelvic recurrence)
CIN I - II is most common in 20's

CIS is most common between 25 - 35
years old
CIN 1
Low-grade dysplasia
10% progress to CIN 2 or 3
CIN 2
High-grade dysplasia
5% progress to cancer if untreated
CIN 3
High-grade dysplasia
12 - 40% progress to cancer if
untreated
Types of Cervical Cancer
Squamous cell carcinoma (70 - 75%)
Adenocarcinoma (20 - 25%)
Adenosquamous carcinoma (3 - 5%)
See PowerPoint Undifferentiated carcinoma
slides for
Neuroendocrine carcinoma
information about Staging
the HPV vaccine I - Carcinom confined to cervix
II - Invades beyond uterus, but not to
pubic wall or lower of vagina
III - Tumor extends to the pelvic wall
involves lower of the vagina
causes hydronephrosis
IV - Carinoma extended beyond true
pelvis or involves the mucosa of the
bladder or rectum
Factors Affecting Prognosis
Stage
LN metastasis
Tumor volume
Depth of cervical stromal invasion
Lymphovascular space invasion
Histologic type / grade
Location of recurrence
Can also be large cell, keratinizing or
small cell types
Incidence has increased over the last

several decades.
Cytology
Less effective in
detecting
preinvasive lesions
Clinical Medicine
Condition / Disease
Cause
Signs and Symptoms
Failure to menstruate by
16 in presence of
secondary sexual
characteristics
Laboratory
Test
Result
-hCG
TSH
FSH
Evaluation
LH
Prolactin
Karyotype
Pituitary MRI
Failure to menstruate
Cessation of menstrual
flow for a period of time
= 3 cycles
Lack of conception
Abnormal
Uterine
Bleeding
Adhesions and/or fibrosis

of the endometrium
Bleeding that differs in

quantity or timing than
normal
Visual field defects
By age 14 in the absence

of secondary sexual
characteristics
Secondary
Asherman's
Syndrome
Outflow Tract
Amenorrhea
Galactorrhea
Primary
Amenorrhea
Treatment
Etiologies
Post-surgical scarring
D&C
Myomectomy
Cesarean delivery
IUD adhesions
Uterine anamolies
Endometritis
Pregnancy and Pregnancy-Related
Ectopic pregnancy
Spontaneous /
Abruptio placentae
threatened abortion
Trophoblastic disease
Benign Growths
Cervical / endometrial
Leiomyomata uteri
polyps
Adenomyosis
Infections
Endometritis
Cervicitis
Genital warts
Vaginitis
Hypoestrogenized atrophy
Malignancies
Endometrial
Ovary
Cervix
Vagina
Drugs
Antipsychotics /
Hormones
anticonvulsants
Anticoagulants
Nonsteroidals
Corticosteroids
Herbal / nutritional
SSRI
supplements
Non-Genital Tract Diseases
Urethritis
Bladder cancer
UTI
IBD
Hemorrhoids
Medroxyprogesterone
acetate 10 mg for
10 days
Progestin
Challenge
Ovary
Amenorrhea
Pituitary
Amenorrhea
Bleed in
2 - 14 days
Evaluates estradiol
and outflow tract
status
Ultrasound
Evidence of
adhesions
HSG
Evaluate uterine
cavity
Hypothalmus
Amenorrhea
Medications
Surgery
Create functional
vagina
Allow menstrual
efflux
Potentiate fertility
Hormone
replacement
therapy
Chronic
anovulation
Dostinex
Bromocriptine
Surgery
Hormone
replacement
Surgery
Hormone
replacement
therapy
Modify behavior
Dissection of adhesions
Balloon catheter
Antibiotics
NSAIDs
Pregnancy
Test
Always first
Hormones
Combined oral
contraceptive pills
Menstrual
Calendar
Basal Body
Temperature
Progesterone
Progestins
Estrogens
Danazol
Assess ovulatory
Antifibrinolytic agents
status
Levonorgestrel intrauterine system
Urine LH
Serial
Ultrasound
Endometrial
Biopsy
Transvaginal
US Saline
Saline-Infused
Sonohysterography
Hysteroscopy
DDAVP
GNRH agonists
Diagnostic
Surgery
Hysteroscopic
endometrial
ablation
Nonhysteroscopic
EA
Other
All causes of secondary amenorrhea
can also present as primary
amenorrhea
Etiology Sites of Amenorrhea
I - Outflow tract
II - Ovaries
III - Pituitary
IV - CNS / hypothalamus
Risk Factors
# of surgical instrumentations
# of endometrial / myometrial
infections
Time from fetal demise to surigcal
instrumentation
Prognosis for Asherman's treatment
is directly related to the extent of
adhesive disease.
Menorrhagia
Blood flow > 80 mL or lasts > 7 days
Polymenorrhea
Bleeding cycles < 21 days apart
Oligomenorrhea
Bleeding cycles > 35 days apart
Differential Diagnosisof AUB
Complications of pregnancy
Trauma
Cancer
Benign pelvic pathology
Systemic disease
Iatrogenic
When AUB is related to changes in
hormones that directly affect the
menstruation cycles, the condition is
called dysfunctional uterine bleeding.
Risk Factors
Overweight
Exercise excessively
Excessive stress
Polycystic ovarian syndrome
Hysterectomy
Clinical Medicine
Condition / Disease
Cause
Ovulatory
(Structural)
Bleeding
Bleeding during
ovulation
Anovulatory
Bleeding
Failure of ovulation to
produce a luteal phase
Leimyoma
Endometrial
Polyps
Uterine fibroid that arises

from the myometrium
Hyperplastic growths of
endometrial glands and
stroma
Signs and Symptoms
Test
Laboratory
Result
ITP
Coagulation Defects
Factor VIII
STD
Infections
Fungal
Fibroids
Adenomyosis
Foreign bodies (IUD)
Vascular anomalies
Malignancy
Menorrhagia
Bleeding diathesis
Distorted lining
Estrogen-producing
AVM
tumor
Intermenstrual Bleeding
Polyp
Tumor
Cancer
Infection
Contraceptive use
Hypothyroidism
PCOS
Adenomas
Hyperprolactinemia
Medication
Hypothalamic
Adrenal hyperplasia
dysfunction
Age > 35
Obesity
Endometrial Hyperplasia Anovulation > 6 months
/ Cancer
Breast CA history
Tamoxifen history
Gynecological history
Puberty
Perimenopause
Blood dyscrasia
Coagulopathies
Hepatic disease
Cushing's disease
Emotional or
Renal disease
physical stress
Smoking
Anorexia nervosa /
Foreign bodies (IUD)
sudden weight loss
Trauma
Sexual intercourse
Sexual abuse
MVA
"Straddle" injury
Heavy, prolonged
Dysmenorrhea
Ultrasound
bleeding
Dyspaurenia
Pelvic pain / pressure / fullness
X-Ray
Urinary frequency
Lower back pain
Infertility
Reproductive
Irregular, enlarged
dysfunction
Hysteroscopy
uterus
Most Common Risk Factors
African-American
Obesity
Laparoscopy
Age > 40
Nulliparity
Early menarche (age < 10)
Ultrasound
Abnormal bleeding
Infertility (possible)
Saline Infusion
Sonogram
Treatment
Diagnostic
Surveillance
Myomectomy
If calcified
Hysterectomy (if symptomatic)
Helpful for
submucous
Ocassionally
necessary
Diagnostic
Medications
Levonorgestrel intrauterine system

Menopause mimicking treatments
(GnRH)
Uterine artery embolization
MRI-guided focused ultrasound
Power morcellation
Polypectomy
Other
Most common pelvic tumor

Protective Factors
Multigravia (> 5 pregnancies)
Postmenopausal
Smoking
Prolonged use of OCPs
Long acting progestin-only
contraception
Usually benign (95%)

Increased risk if on Tamoxifen or are
obese
Clinical Medicine
Condition / Disease
Endometriosis
Adenomyosis
Endometrial
Hyperplasia
Cause
Endometrial tissue
(glands or stroma) any
place outside of
the uterus
Endometeriosis within
the muscle of the uterus
Proliferation of the
endometrial glands
usually due to chronic
unopposed estrogen
Signs and Symptoms

Symptoms range in
severity
Dysmenorrhea
Dyspareunia
Pain with defecation
Infertility
Dysuria
Sacral backache
Pelvic pain
Bowel changes
Tenesmus
Ovarian mass / tumor
Urinary symptoms
Chronic fatigue
Lateral displacement of
the cervix (28%)
Stenosis of the
cervical os
Test
Laboratory
Result
Typically ages 25 - 35
Laparoscopy
Gold-standard
Ultrasound
Diagnostic
MRI
Depending on
circumstances
Other
Laboratory
Tests
Not indicated
Appearances
Black
Blue
Papular
Stellate
Flame-like
Powder burn
Clear
Vesicular
Puckered
Peritoneal defects
Severe dysmenorrhea
Severe menorrhagia
Chronic pelvic pain
Large uterus
(12 week size)
Treatment
Medications
Depends on symptoms, age, fertility

status, and comorbidities.
Medical Therapy (first line)
NSAIDs
Estrogen-progestin contraceptive pills
(continuous)
Acupuncture
Excision (if reproducible focal
tenderness on pelvic examination)
Progestins
Second-Line
Androgens
Medical Agents
GnRH Agonists
Surgical Therapy
(if medical therapy fails)
Laser treatment
Electrosurgery
Thermal therapy
MRI
Diagnostic
Hysterectomy
At
Tender, globular uterus Hysterectomy
Postmenopausal
bleeding
Risk Factors
Unopposed estrogen
Ages 50 - 70
PCOS
Diabetes mellitus
Obesity
Nulliparity
Late menopause
Tamoxifen
(age > 55)
Lynch syndrome
Abnormal bleeding
Ultrasound
Thickened
endometrial
stripe
Progestins (if no atypia)
Biopsy
Diagnostic
Hysterectomy (if atypia)
Diagnostic
Endometrial
Done regardless of
Biopsy
Type I Endometrial Carcinoma
stripe
Estrogen-dependent Endometrial hyperplasia
Curettage
Diagnostic
History of unopposed
D&C +
estrogen
Hysteroscopy
Atypia
Younger perimenopausal
Not reliable
Pay attention to
Carcinoma
Pap Smear
Type II Endometrial Carcinoma
atypical glandular
Possibly estrogencells
Occurs spontaneously
independent
Thin, older,
Transvaginal
Endometrial stripe
postmenopausal
Ultrasound
Atrophic endometrium
without unopposed
Less well-differentiated
Doppler Flow Postmenopausal
estrogen
Poorer prognosis
Functional Ovarian Cysts
< 10 cm
Ultrasound
Not really neoplasms but
Minimal
Folicular cysts
Findings for
exaggeration of normal
septations
Corpus luteum cysts
Benign
process
Very common
Unilateral
Follicular Cyst
> 10 cm
May rupture and cause
Failure of ovulation
Solid
acute pelvic pain
leading to continued
Ultrasound
Multiple
follicular growth
Findings for septations > 3 mm
Surgery not indicated
Persistent Corpus Luteum Cyst
Malignant
Bilateral
Missed onset of menses Secretes progesterone
Ascites
Adnexal enlargement
One-sided pain
Doppler flow
Can exist as simple or complex

hyperplasia atypia
Atypia increases the risk of
endometrial cancer.
Abnormal bleeding
Endometrial
Cancer
Ovarian Cyst
Most common
gynecologic cancer in
developed countries
Closed sac, having a

distinct membrane and
division compared to the
rest of the ovary
Other
Common, chronic, benign, and
associated with estrogen
Distribution (in descreasing order)
Ovary
Culdesac
Uterosacral ligaments
Round and posterior broad ligaments
Fallopian tubes, uterus, bladder, or
rectum
Most commonly accepted etiological
theory is retrograde menstruation.
Endometeriosis is associated with
epithelial ovarian cancer but not
endometrial cancer.
Hysterectomy with bilateral

salpingoophorectomy with pelvic and
paraaortic lymph node dissection
Adjunctive postoperative radiation

chemotherapy
Medroxyprogesterone
(for recurrence)
Symptomatic treatment
(pain medications)
Oral conraceptives
(prevents new ones)
Surveillance for torsion
(if large or pedunculated)
Adenocarcinoma is the most

common form.
Can be estrogen-dependent or
independent
68% are in early stage at the time of
diagnosis.
Staging
I - Confined to uterus
II - Spread to connective tissue of
cervix but not beyond uterus
III - Confined to pelvis
IV - Distant metastasis
Unopposed estrogen leads to
endometrial cancer
Probably-Benign Physical Exam
Mobile
Cystic
Unilateral
Smooth
Probably-Malignant Physical Exam
Fixed
Solid
Bilateral
Nodular
Clinical Medicine
Condition / Disease
Dermoid
Polycystic
Ovary
Syndrome
Ovarian Cancer
Menopause
Cause
Asymptomatic, unilateral
cystic adnexal mass
Signs and Symptoms

Asymptomatic
Located high in pelvis
Mobile, nontender mass
Dermoid Derivatives in
Cyst
Cartilage
Bone
Teeth
Infertility
Hirsutism
Acanthosis nigricans
Acne
Test
Laboratory
Result
Pelvic
Ultrasound
Not necessary
Second most common

gynecologic malignancy
Cessation of montly cycle

of mentstration
hCG
Insulin resistance
-patterned hair loss
Hypertension
Hyperlipidemia
Medications
Other
Surgical removal
Obesity (but not always)
One of the most common

endocrine disorders due
an unknown, but likely
genetic, etiology
Treatment
TSH
CV disease
Obstructive sleep apnea
Nonalcoholic
steatohepatitis
Recurrent SAB
Depression
FSH
Dysfunctional uterine
and carcinoma
bleeding
Vague symptoms
Pelvic pain
Bloating
Urinary tract symptoms
Ultrasound
"Clothing too tight"
"Abdomen enlarging"
with Doppler
Palpable adnexal mass
Blood Flow
Risk Factors
Nulliparity / infertility
Early menarche
PCOS
Late menopause
Genetic
Endometriosis
CA 125
Obesity
Breast cancer history
Probably Benign
Possibly Malignant
Mobile
Fixed
Cystic
Solid
CT / MRI
Unilateral
Bilateral
Smooth
Nodular
7 Dwarves of Menopause
Itchy
Bitchy
Sweaty
Sleepy
Bloated
Forgetful
Psycho
Hot flashes
Hot flushes
Dry hair
Hair loss
Facial hirsuitism
Dry mouth
Osteoporosis
Fractures
Back pain
Lower voice
Breast size
Softer breasts
Loss of breast
Coronary artery disease
ligamentous supports
Dyspareunia
Vaginitis
Uterovaginal prolapse
Cystoureteritis
Ectropion
Urinary frequency
Urinary urgency
Stress incontinence
Vulva atrophy
Vulva dystrophy
Pururitus vulvae
As indicated to
R/O other
disorders
Weight loss
Treat insulin resistance
OCPs with minimal
androgenic
activity
Consider
Androgen Excess
spironolactone
Hair removal
Skin / acne
treatments
Amenorrhea treatment
Infertility treatments
OCPs
Endometrial
Intermittent oral
Protection
progestin only
See Ovarian Cyst

Total abdominal hysterectomy with
section of benign
bilateral salpingoophorectomy
vs. malignant
parameters
Surgical staging may be required

Diagnostic
Chemotherapy
Need to Screen for

Mood disorders
Eating disorders
Metabolic abnormalities
Most common cause of death due to

gynecological cancer
Protective Factors
Oral contraceptives
Multiparity
Tubal ligation
Breastfeeding
Staging
I - Confined to ovary or fallopian tube
II - Extension into uterus or tube
III - Retroperitoneal LNs or peritoneal
involvement
IV - Distant metastasis
> living have been through
menopause
Symptoms often start years before
actual cessation of menses
Average age of onset in US is 51.4
years old
Clinical Medicine
Condition / Disease
Cause
Natural
Menopause
Permanent cessation of
mentsruation resulting from the loss
of ovarian follicular activity and
estrogen secretion
Climacteric
Phase marking transition from the

reproductive phase to the
non-reproductive state
Premenopause
Part of the climacteric before

menopause occurs
Perimenopause
Time period before the final

menstrual cycle when the cycle is
irregular and climacteric symptoms
increase through the first year
of menopause
Signs and Symptoms
Test
Laboratory
Result
Occurs after 12 months of consecutive

amenorrhea without pathological /
physiological cause
Diagnosis cannot necessarily be made by
laboratory testing
Extends for longer
Process rather than a
variable period
specific point in time
before / after the
perimenopause
Treatment
Medications
Other
There are no biological markers for
this event.
Irregular menstrual cycles

May experience climacteric symptoms
Abrupt cease to
menstruation (10%)
Postmenopause
Phase of life that comes after
menopause
Contraception is needed throughout
perimenopause until menopause
May be fertile during

this time
Menopausal Transition
Ovarian
Functions /
Hormones
Leading to
Menopause
Remaining oocytes do
Oocytes disappear from
not respond to
ovary
gonadotropins
Ovarian
Estrogen
Endocrine changes during

menopause
Fewer ovarian follicles
Gonadotropins
Factors
Influencing the
Timing of
Menopause
Hormone
Levels
Things to consider when

diagnosing menopause
Ovaries produce less

hormones
Sensitivity in target
organs
Ovarian
Androgen
Do not
correspond with
symptomatology
Greatest in
estradiol
Estrone
Higher levels if
obese
Postmenopausal ovary secretes

relatively more androgen than
estrogen.
by 33%
No cyclical pattern
Ovarian
Small amount
Progesterone
comes from
adrenal
FSH
FSH > LH
LH
LOW with
Prolactin
cessation of
menses
Early Menopause
Genetics
Smoking
Alcohol
Nulliparity
Medically-treated
Shorter menstrual cycles
depression
during adolescence
Type 1 DM
Treatment of childhood
Toxic chemical exposure
cancer
Delayed
Multiparity
BMI
History of OCP use
Clinical Medicine
Condition / Disease
Cause
Signs and Symptoms

Ammenorrhea
Menorrhagia
Altered
Menstrual
Function
Different types of
menstruation
Infrequent menstruation
Metrorrhagia
Intermenstrual bleeding
Metromenorrhagia
Laboratory
Result
Mood Changes
in Menopause
Sudden onset of warmth

seen in 80% of US
Mood changes seen in

menopause
Medications
Other
Bleeding occurring
after intercourse
Prolonged / excessive
bleeding that occurs
irregularity
Polymenorrhea
Cycle < 21 days
Post-Menopausal
Bleeding
Bleeding occur after the

onset of menopause
Sweating over head,

neck, upper chest,
and back
Headache-like pressure
Lasts moments to
until flush
10 minutes
1 - 2 flashes / hour
1 - 2 episodes / week
Palpitations
Night sweats
Insomnia
Waking episodes
Uncommon Symptoms
Weakness
Fatigue
Faintness
Vertigo
Aggravants
Caffeine
Alcohol
Hot drinks
Eating
Spicy foods
Food additives
Stressful environment
Fatigue
Drugs
Warm / humid climate
Fatigue
Anxiety
Difficulty concentrating
Memory loss
Depression
Worsened by sleep
No risk of major
disturbance
depressive disorder
Irritabilty and mood swings are common
during climacteric
Insomnia
Impacted by vasomotor
Worse with estrogen
symptoms
deficiency
No in sleep apnea
Effects mood
May need short course
May turn to alcohol
of treatment
Heat / burning in the
face, neck, and chest
Hot Flash
Treatment
Absence of
menstrual cycle
Abnormally heavy
and prolonged
Oligomenorrhea
Postcoital Bleeding
Test
Dress in layers
Mean Body
Temperature
Drink a glass of cold water / juice at

onset
Keep thermos of ice water / ice pack
by the bed at night
Use cotton sheets, lingerie, and
clothing
+ 2.5C
Avoid triggers
Regular exercise
Relaxation techniques
Hot Flush
Visible redness that lasts 2 - 3
minutes
feel warm even though central
temperature decreases
Most severe during the first 1 - 2
years
Usually stop within 5 years of onset
Risk Factors
Obesity
Smoking
Sedentary lifestyle
SES
African American
See PowerPoint slides for the massive

list of medications for vasomotor
symptoms
Sleep hygiene
Medical therapy
Clinical Medicine
Condition / Disease
Menopausal
Genitourinary
Changes
Decreases in Sexual
Function in Menopause
Cause
Genitourinary changes
seen in menopausal
Possible loss of mojo seen

in menopause
Signs and Symptoms

Present in 75%
Rugation
Burning
Itching
Vaginismus
Bleeding
Uterine prolapse
Cystocele
Rectocele
UTIs
Urgency
Symptomatic in 40%
Dryness
Discharge
Dyspareunia
pH
Susceptible to
trichomoniasis and
candidiasis
Cystitis
Dysuria
Incontinence
Suction
Currettage IAB
Method of IAB
Treatment
Medications
Estrogen
Testosterone propionate cream
Topical hydrocortisone cream
Topical progesterone cream
SERMs
Vaginal lubricants / moisturizers
Tibolone (not available in US)
Testosterone
Evaluation of Patient Requesting IAB

hCG
Pregnancy Status
Document LMP
Previous pregnancy
history
Medical History
Medical history
Surgical history
Ultrasound
Estimated gestation age
(if indicated)
Patient Examination
Vaginal / speculum
External genitalia
Cervix / lesions / pap /
exam
cultures
Lower segment
softening
Uterine size
Adnexal masses
Adnexal tenderness
Cervical motion tenderness
Progressive metal
Dilation
dilators
Osmotic dilation
Insertion of suction cannula and
negative pressure
Sometimes followed with light instrument
currettage
No improvement with estrogen
Tibolone (not available in US)
Libido
Continue pregnancy
Adoption
Induced abortion
Other
Long-Term Effects of Estrogen
Deficiency
Dementia
Cardiovascular disease
Osteoporosis
Less collagen
Impaired balance
Biopsy any suspicious lesions
Vaginal dryness
Permission is required in minors from a parent /

grandparent that the minor has lived with
for 6 months
Deliberate termination
of pregnancy
Laboratory
Result
Dyspareunia
Paths With Unintened

Pregnancy
Induced
Abortion
Test
Wet Prep
GC /
Chlamydia
Testing
Other STD
Testing
Evaluation
Regular sexual activity

Bacterial vaginosis
STDs
Treat All
Prophylactic
Infections
antibiotics
possibly before
procedure
Comply with state
laws and
Referral
regulations
Refer to reputable
providers
RhIg (if patient
is RH (-))
Pap Smear
Hematocrit
Contraception
Post-Abortion
Pre-conception
counseling
Counsel regarding
symptoms of
complications
Rh(D) Status
Follow-up
Pain
Management
Environment
important
Operator
technique
Paracervical block
Anxiolytics
Conscious
sedation in
selected cases
Missed Abortion
Embryo / fetus dies in utero but
products of conception are
retained
NC law states that abortion can take
place up to 20 weeks
will experience abortion by age
45
Gestational Size
Firm, walnut - nulliparous, not
pregnant
Small lime - 6 weeks
Small lemon - 8 weeks
Orange - 10 weeks
Grapefruit - 12 weeks
Earlier IAB is safer (best < 8 weeks)
Long-Term Sequelae
Relief
Sadness
Sense of loss
Guilt
Muliple procedure risks
Incompetent cervix
Suction vs. Sharp Currettage
More rapid uterus evacuation
Blood loss
Risk of uterine perforation
Risk of synechiae or Asherman's
syndrome
Clinical Medicine
Condition / Disease
Cause
Signs and Symptoms
Laboratory
Result
Treatment
Medications
Osmotic dilation
Method of IAB
See Suction Cutterage IAB

Slower evacuation of the uterus
Most often used when suction equipment not
available
Manual Vacuum
Aspiration IAB
Medical
Abortion
Type of IAB seen

especially in developing
countries
Use of medications to
terminate established
pregnancy
Manual vacuum
aspirator with
locking valve
Generates vacuum
equivalent to
electric pump
Semi-flexible plastic
cannula
Used for both IAB and

missed abortion
Mifepristone +
misoprostol
See Suction Cutterage IAB
600 mg mifepristone initially then 400

mg 2 days later up to 49 days
gestation
Misoprostol vaginal insertion up to 63
days gestation
75 mg IM methotrexate before 49
days gestation
Folic acid antagonist (damages rapid
growth of chorionic villi)
Methotrexate +
misoprostol
Misoprostol alone
Emergency
Contraception
Urinary
Incontinence
Prevention of pregnancy
5 days of unplanned
sexual activity
Loss of urinary control
Unanticipated sexual
activity
Contraception failure
Sexual assault
Within 120 hours
Side Effects
Nausea / vomiting
Breast tenderness
Fatigue
Irregular bleeding
Headache / dizziness
Types
Genuine stress
Urge
Cough Stress
Mixed
Overflow
Test
Extraurethral
Functional
Obesity
Increased
Chronic respiratory
Intra-Abdominal
conditions
UA
Pressure
Chronic heavy lifting
Aging
Connective Tissue
Urine Cultures
ERT associated with
Damage
amount of skin collagen
Pelvic Floor Trauma
Urodynamic
Muscular disruption Peripheral nerve damage
Testing
Connective tissue damage
(including laceration of perineal body)
Other
Not the standard of care for IAB or
missed abortion
Complications (all procedures)
Vasovagal reaction
Retained products of conception
Uterine perforation
Cervical injury
Pelvic infection
Hemorrhage
Hematometra
DIC (extremely rare)
Can be done as early as 4 weeks LMP
Progressive metal
dilators
Dilation
Surgical
Currettage IAB
Test
Mifepristone
Blocks progesterone and promotes
lack of implantation
Misoprostol
Uterine contraction and evacuation
Methotrexate
Antimetabolite
In cases where medical abortions fail,

surgical intervention is required.
Assess for pelvic

organ support /
prolapse
Voiding Diary
Behavioral
Therapy
Diagnostic
Pharmacotherapy
Assess the
bladder, urethra,
and pelvic support
and pinpoints the
problem site
Total input
Total output
Leakage
Pelvic muscle
exercises
Biofeedback
Electrical stim.
Behavior mod.
Urethral tone
Ineffectiveness
Antiocholinergic
Botox A
Pessary
Burch urethropexy
Pubovaginal sling
Mid-urethral sling
Injectable bulking agents
75 - 99% effectiveness rate

Names
Plan B
Levonorgestrel
Ella
EC will not induce abortion in
established pregnancy or interfere
with pre-embryo or embryo
devlopment.
45 - 70% will have UI at some point
Polytetrain their lifetime
fluoroethylene About 11% will undergo surgery for
UI or prolapse in their lifetime
Complications of UI Surgery
GAX bovine
Bladder perforations
collagen
Urinary retention
UTI
Silicone Polymers Urgency
Behavioral therapy has shown to be
the most effect treatment in RCTs.
Carbon Particles
Autologous Ear
Cartilage
Clinical Medicine
Condition / Disease
Cause
Signs and Symptoms

Increased abdominal
pressure
Coughing or straining
Not assoicated
with urge
Walking or standing
(if severe)
Stress
Incontinence
Urinary incontinence due

to internal physical
pressure
Urge
Incontinence
Overflow
Incontinence
Uncontrolled urine loss

associated with a strong
desire to void
Often very sudden and May be precipitated by

without warning
the sound of running
Often with large volume water, cold, or "key in
urine loss
the door"
Urinary incontinence due

urethral blockage
Bladder unable to empty properly
Functional
Incontinence
Urinary incontinence in
which there is a need to
urinate but physical or
mental reasons prevent
them from getting to a
bathroom
Pelvic Support
Disorders
Prolapse
Chronic Pelvic
Pain
Acute Pelvic
Pain
Generally noncyclical
pain lasting 6 months
Pelvic pain lasting

3 months
Hormonal deprivation
Age / lack of dexterity
Immobility
Dementia
Irritative conditions
Environmental factors
of LUT
Diseases
Diuretics
Medications
Autonomic agents
Urine volume
"Bulge"
"Bladder drop"
"Relaxation"
"Dropped uterus"
Cystocele
Rectocele
Enterocele
Uterine prolapse
Localized to pelvis, abdominal wall below the
umbilicus, buttocks area
Etiologies (top 4 in each category)
Gastrointestinal
Celiac disease
Coilitis
Colon cancer
IBS
Gynceological
Adhesions
Adenomyosis
Adnexal cyst
Endometritis
Musculoskeletal
Degenerative disc
Fibromyalgia
Levator ani syndrome
Myofascial pain
Psychiatric / Neurologic
Abdominal epilepsy
Abdominal migraines
Depression
Neurologic dysfunction
Urologic
Bladder cancer
Chronic UTI
Intersitial cystitis
Radiation cystitis
Reproductive Age (top 2 in each category)
Appendicitis
Bowel obstruction
Ectopic pregnancy
Ovarian torsion
Cystitis
Pyelonephritis
Dissecting AA
Poisoning
Pregnancy
Corpus leuteum
Ectopic pregnancy
hematoma
Endometritis
Ovarian torsion
Ovarian vein thrombosis
Placental abruption
Test
Laboratory
Result
Treatment
Medications
Other
Etiologies
Childbirth-related anatomy changes
Weakness of the pelvic floor muscles
Collagen synthesis
Previous pelvic surgery
Smoking / chronic constipation
Aging / estrogen deficiency
Etiologies
Bladder oversensitivity from
infection
Neurologic disorders
Patient Factors
Sacrocolpopexy
Causes functional disability
Diary of symptoms related to sexual
activity, physical activity, medicaiton
regimen, and psychosocial stressors
What Patients Expect:

TV
Ultrasound
Evaluation
Personalized care plan / evaluation
Explanation for their symptoms

Reassurance regarding findings /
prognosis
Adolescents
Similar to reproductive age
Imperforate hymen / dysmenorrhea
Sexual assault / abuse
Transverse vaginal septum
Postmenopause
Similar to reproductive age
Atrophic vaginitis
Fissures
Cuff injuries
Clinical Medicine
Condition / Disease
Cause
Signs and Symptoms
Test
Laboratory
Result
Treatment
Medications
Congitive behavor therapy /

desensitization
Vaginal dilators
Imperative to identify underlying pathology
Other
Often etiology is a combination of
physiologic, emotional, and relational
factors
Treat underlying physical pathology
Dyspaurenia
Sexual education and counseling

patient / partner
Pelvic floor physical therapy
Local estrogen
therapy
Pharmacology
Antidepressants
Neurontin
Painful sexual activity

Physical exam and history
component evaluation
Vulvar Pain
Syndrome
Vaginismus
Intersitial
Cystitis
Chronic discomfort in the

vulvar region with no
identified infection or
dermatologic cause
Painful, involuntry reflex

spasm of the pubococcygeal
muscles in anticipation of
vaginal penetration
Painful bladder
syndrome
Pain when gentle

pressure is applied
during exam at the
introitus
Pain with attempt at

intercourse or any
sexual activity
Vulvar burning
Painful urination
Painful menses in with

normal anatomy
Secondary
Dysmenorrhea
Painful menstruation in
the presence of a disease
or pathology
Sexual Desire
Dysfunction
Decreased libido
Biofeedback
Factors
Pelvic floor muscle
Inflammatory response /
response
cycle of response
Previous sexual assault /
Connective tissue
abuse history
disorders
SSRI and tricyclic antidepressant

therapy
Vaginal dilators
Biofeedback
Sexual counseling alone or with
partner
Vaginal lubrications
Estrogen therapy
Physical therapy
Rape / incest / sexual assault / trauma

Bechet's syndrome
Lubrication
Sexual phobias
Previous negative
experience
Painful intercourse
Urinary frequency
Nocturia
Prior or immediately
following menses
Generally occurs in adolescents
Recurrent, cyclic pain symptoms

Endometriosis
Uterine fibroids
Adenomyosis
STIs
Endometrial polyps
Emotional component
Relationship component
Physical fatigue
Intimacy component
Vestibulitis
Form of vulvodynia and is specific to
the region affected
Usually unable to perform speculum
exams or engage in sexual activity
Often debilitating to physical function
/ relationships
Perineoplasty
Factors
Cramping pelvic pain
Primary
Dysmenorrhea
Lifestyle modification
(regarding clothing and exercise)
UA
Normal
Bladder
Instillation
Potassium
Challenge
Evaluation
Bladder diary
Diagnosis of exclusion
Oxalate diet
Elmiron (expensive)
NSAID therapy
OCPs
Progesterone therapy
(include Depo)
Mirena IUD
Acupuncture
Thiamine supplementation
Fat / vegetarian diet
Leading cause of school absences
Medical therapy
Surgery
Clinical Medicine
Condition / Disease
Cause
Sexual Arousal
Dysfunction
Lack of genital response
Orgasmic
Response
Dysfunction
Unable to achieve
an orgasm
Sexual Pain
Disorders
Consistent pain with

intercourse
Normal Breast
Exam Findings
Typical characteristics of
a breast with no
pathology
Signs and Symptoms
Mammogram
Using sound waves to

image breast tissue
Breast MRI
A very expensive way to

image breasts
Breast Fine Needle

Aspiration (FNA)
Obtaining a biopsy using

a needle
Treatment
Medications
Other
Inframammary ridge
Consistency
Homogeneous
Cystic
Ropey
Diagnostic
Abnormalities
Breast
Ultrasound
Laboratory
Result
Vaginismus
Pain / vestibulitis
Recent labor / delivery / birthing experience
Surgical trauma
Lack of lubrication
Medications
Stress
Physical / emotional
Previous sexual trauma
stress
Previous childhood
Partner component
experience
Environment /
Sexual aversion
circumstances of
emotional intimacy
Chronic vaginitis
Vaginismus
Vulvodynia
Vestibulitis
Interstitial cystitis
Firm
Density
Soft
Flaccid
Screening
Low-energy X-rays to
examine the human
breast
Test
F/U Abnormal area on

mammogram
Helpful in young with
denser breast tissue
Smooth
Lumpy
Nodular
Asymptomatic
2 Views (CC and MLO)
Symptomatic
S/P Lumpectomy
F/U Abnormal
screening images
Additional views taken
Microcalcification
Masses
Densities
Differentiates between
solid mass and
fluid-filled cyst
Supplements
mammography
Evaluate implants for

rupture
Risk with breast
Breast cancer staging
density
Advantages
Fast
Outpatient
Quick results
Immediate recovery
Disadvantages
Small amount of
May not be enough for
material collected
pathologic diagnosis
BI-RADS
BI-RADS 0 - Needs additional imaging
BI-RADS 1 - Negative
BI-RADS 2 - Benign finding
BI-RADS 3 - Probably benign, shortinterval F/U recommended
BI-RADS 4 - Suspicious abnormality,
consider biopsy
BI-RADS 5 - Highly suggestive of
malignancy
Can guide FNA or core needle
biopsy
Not used for screening
More sensitive than mammogram,

but there are more false positives.
May be ultrasound-guided
Core Needle Biopsy
Used to sample solid mass or
suspicious calcifications
Surgical / Excisional Biopsy
Inadequate results on core biopsy
Location of lesion limits ability to
perform needle biopsy
Clinical Medicine
Condition / Disease
Mastalgia
Nipple
Discharge
Cause
Rarely presenting
symptom of breast
cancer
Abnormal fluid leaking

out of the nipple
Intraductal
Papilloma
Benign growth
within duct
Ductal Ectasia
Widening and harding of

duct
Breast Mass
Tissue of different
consistency found on a
breast exam
Signs and Symptoms
Test
Laboratory
Result
Worse just before

Evaluate for mass
menses
Breast Exam
Bilateral, poorly
Possibly cysts or
Cyclic Pain
localized
fibroademonas
Resolves spontaneously
Usually lasts 1 - 4 days
> 35 years if not
Non-Cyclic Pain
Mammogram
imaged in past
Unilateral, sharp,
year
and localized
Not related to menses
Resolves spontaneously Usually < 4 days / month
Pathologic
Confined to 1 duct
Spontaneous, unilateral,
Associated with mass
bloody
Age > 40
Physiologic
Discharge only with
Multiple duct
compression
involvement
Often bilateral
Etiologies
Intraductal pailloma
Ductal ectasia
Fibrocystic changes
Medications
Infection (purulent)
Malignancy
Hyperprolactinemia
Blood discharge
Thick, sticky discharge

Red, itchy, or
irritated nipple
Fibrocystic
changes / cyst
Fat necrosis
Malignancy
Palpable mass
Ductogram
Localized infection of
breast tissue
Fibrocystic
Changes
Most common benign

condition of the breast
Fibroadenoma
Common benign
neoplasm in young due
to hormonally influenced
growth of fibrous and
ductal tissue
Reduce or eliminate caffeine

Avoid sodium premenstrually
NSAIDs
Evening primose oil
Danazol (for severe, persistent pain)
Physiologic Discharge
Most often due to a benign process
Exclude coexisting abnormalities

Check prolactin level
Offer reassurance if workup (-)
Counsel to avoid stimulating nipple
Spontaneous resolution
Pathologic Discharge
Diagnostic mammogram ultrasound
Surgical referral for excision of duct
Antibiotic therapy
Evaluation may differ depending
upon age of the patient
Intraductal papilloma
Abscess
Not usually seen in

postmenopausal
(except those on HRT)
Often recurs
Consider biopsy of tissue to R/O
inflammatory carcinoma
Antibiotic therapy
Incision and drainage
Red, tender, indurated,

and warm
Rapid appearance /
disappearance
Enlarging cysts
Masses
Firm
Mobile
Often tender
Bilateral (possible)
Single or multiple
Often UOQ
Mass
Round
Firm
Nontender
Relatively mobile
1 - 5 cm
Often UOQ
Can grow rapidly in

pregnancy
Supportive bra
Fibroadenoma
Uncommon in
postmenopausal
Cyclical pain
Teens - 30s year old
Other
Warm compresses
Clear, brown, or
green discharge
S. aureus
Non-Lactating Breast
Medications
Can be helpful but

Surgical excision
not required
Often associated with lactation (mastitis)
Breast Abscess
Treatment
Biopsy if redness and induration does

not resolve with antibiotics
Mammogram
Ultrasound
Evaluate dominant
mass
Can distinguish
fluid-filled cyst
from solid mass
Usually ages 30 - 50
Biopsy to exlude cancer if no fluid or
bloody fluid on aspiration or mass
persists after aspiration
Supportive bra
Avoid trauma
Avoid caffeine
NSAIDs
FNA
For cytology
Danazol (for severe, persistent pain)
Ultrasound
Diagnostic
Close observation after confirmation

by cytology
Core Needle
Biopsy
Confirm diagnosis
Surgical excision (if uncertain

diagnosis or larger mass)
Clinical Medicine
Condition / Disease
Cause
Signs and Symptoms

Skin retraction /
dimpling
Fat Necrosis
Breast
Implants
Uncommon benign
inflammatory process
Prosthesis used to change

the size, form, and texture of
a womans breast
Trauma
Silicone, saline, or
combination
Capsule Contraction /
Scarring (15 - 25%)
Ecchymosis
Tenderness
Injurgy
Surgical resection
Reconstruction /
reduction / implant
removal
Radiation
Subpectoralis or
subcutaneous
Firmness
Distortion
Discomfort
Most commonly
diagnosed cancer
Laboratory
Result
Mammogram
Treatment
Medications
Other
Can be indistinguishable from
malignancy on physical exam
Spontaneous resolution
Diagnostic
Ultrasound
MRI
Biopsy (if any doubt)

No association with increase in
breast cancer
Evaluate for
rupture
Ultrasound
Reduce known risk factors

Prophylactic mastectomy
(in risk )
Single mass
Tamoxifen
Mammographic
Ultrasound
Raloxifene
Chemoprevention
Nontender, firm
abnormality with no
Mammogram
Aromatase
palpable mass
inhibitors
Screening
Endocrine therapies
Ill-defined margins
Clincial Breast
(if ER/PR positive)
Exam
2 1st degree
Later Findings
relatives with
breast cancer (or
Skin / nipple retraction
Axillary adenopathy
Breast Self
one age < 50)
Exam
3+ relatives of any
Breast enlargement
Erythema
age
Combo breast /
Peau d'orange
Edema or pain
Genetic Testing
Dedicated Screeing for risk
ovarian cancer in
Indications
Breast MRI
population
relatives
Fixation of mass to chest wall
2+ relatives with
ovarian cancer
Late Findings
FNA
1st relative with
Supraclavicular
bilateral breast CA
Ulceration
adenopathy
Breast cancer in
Mets to bone, liver, lung,
Core Needle
relative
Arm edema
Surgery
or brain
Biopsy
Modifiable Risk Factors
Lumpectomy
Mastectomy
Overweight / obesity
Physcial inactivity
LN sampling
No children / 1st birth
Stereotactic
Use of HRT
Reconstruction
> 1 alcoholic
after age 30
Biopsy
Chemotherapy
drink / day
Not breastfeeding
Non-Modifiable Risk Factors
Adjuvant therapy to eliminate
Diagnostic
Needle
micrometastases
Race
Palliative
Localized
Age
History of chest XRT
History of atypical
Biopsy
Adjuvant
Long menstrual history
Radiation Therapy
hyperplasia
Palliative
Endocrine Therapy
Personal / family history
Inherited genetic
Adjuvant / palliative systemic therapy
of breast cancer
mutations
Open /
Gail Model
Excisional
Hormonal treatment for ER/PR (+)
Biopsy
cancers
Current age
Age at menarche
Number of breast
Trastuzamab
Age at 1st live birth
biopsies
(adjuvant)
Race
Targeted Therapy
History of atypical
1st degree relatives with Skin Biopsy
Laptinib
hyperplasia
breast cancer
(palliative)
Early Findings
Breast Cancer
Test
Mammogram
Tamoxifen
Raloxifene
Aromatase
inhibitors
Exemestane
White have a incidence than

African American beginning at age
45. Before age 45, AA have a
mortality rate.
USPSTF Screening Guidelines
C - Mammogram not recommended
ages 40 - 49 except for BRCA
mutations or history of chest
radiation
B - Mammogram recommended age
50 - 74 every 2 years
I - Mammogram over age 75
D - Teaching self-examinations
I - Digital mammogram or MRI over
film mammogram
Factors Influencing Survival
Age at diagnosis
Stage
Race / ethnicity
Socioeconomic status
HER-2 / neu
Human epidermal receptor growth
factor-2
Mutation lead to overproduction of
HER-2
Earlier-staged cancer has a much
higher survival rate than later
diagnosed cancers.
Trastuzumab
Lapatinib
Clinical Medicine
Condition / Disease
In situ Breast
Cancer
Invasive Breast
Cancer
Cause
Non-invasive maligancy
Malignancy has spread to

surrounding tissue
Inflammatory
Breast Cancer
Uncommon (< 5%) form

of breast cancer
Paget's Disease
Rare (< 1%) form of

breast cancer
Sexually
Transmitted
Disease
Illnesses that have a

significant probability of
transmission between
humans by means of
sexual behavior
Signs and Symptoms

Has not invaded
surrouding tissue
Likely to progress if
untreated
Ductal or lobular
Minimal difference in
prognosis
Subtypes of Invasive
Ductal Carcinoma
Medullary
Colloid
Tubular
Papillary
Often mistaken for

infection
Erythema
Edema
Itching / burning of
nipple or areola
Mass
Rare ulcer caused by

Hemophilus ducrevi
Endocrine therapy
Other
Can be ductal (80%) or lobular (20%)
Possibly associated with occult
invasive cancers (1 - 3%)
Good prognosis
Radiation
Chemotherapy
Endocrine therapy
Chemotherapy
Diagnostic
Mastectomy
Eczema-like changes or Skin Biopsy of

erosions
Erosive Area
Diagnostic
Surgery
Same day
Next day or longer
NAAT
MHA-TP
Erythema and edema are a result of

dermal lymphatic blockage by cancer
cells
Usually corresponds to either
invasive ductal or DCIS
Good prognosis if there are no
infected LNs
High Risk Populations
Ages 15 - 24
Southeast or urban
African-American use
Commercial sex workers
Substance abusers
Sexual abuse victims
Incarcerated
Meeting partners on internet
Most Common New Infections
(in decreasing order)
HPV
Chlamydia
Trichomoniasis
Gonorrhea
HSV-2
Syphilis
HIV
Hepatitis B
Usually presumptive clinical diagnosis
Multiple ulcerations
Often with a
co-infection
Commonly Reported Populations
SES
Prostitutes
Hetereosexual
Enlarged lymph nodes
Medications
Surgery
Aggressive
Cervical cancer
Herpes simplex virus
Genital Ulcers in US
Primary syphilis
Chancroid
Ulcer Exam Characteristics
Location and number
Pain, friability
Induration
Depth / diameter / base
Irregular or smooth
borders
Adenopathy
Highly contagious
Chancroid
Radiation
Skin Biopsy
Enhanced transmission
and acquisition of HIV
Treatment
Mammogram Microcalcifications
Usually no masses
Infertility
Not a nice place to have

an ulcer
Laboratory
Result
Inguinal adenopathy
Genital lesions
Gram Stain
Vaginal discharge
Cervical mucous /
Adnexal mass
Wet Mount
friability / pain
/tenderness
Risk Factors
New sex partner in last
Rapid Plasma
Multiple sexual partners
60 days
Reagin
Unmarried
SES
Past history of STI
Substance abuse
Darkfield
Early onset of sexual
Lack of barrier
Microscopy
activity
contraception use
STI Risk Factors in Who Have Sex with
Cultures
STI risk varies widely
Number of partners
Bisexuality
Specific sexual practices
PCR
Complications of STIs
Upper genital tract
infections
Genital Ulcer
Test
Antibiotic therapy
Clinical Medicine
Condition / Disease
Lymphogranuloma
Venereum
Granuloma
Inguinale
Condyloma
Cause
Signs and Symptoms
Genital ulcers due to

Chlamydia trachomatis
infection
Rectal ulceration /
stricture
Genital infection by
Klebsiella granulomatosis
Chronic or recurrent
ulcerative vulvitis
Inguinal
lymphadenopathy
Malodorous discharge
Inguinal swelling
Warts
Cervical dysplasia
Cancer
Papillomatous, white,
cauliflower-like
(condylomata)
Genital disease due to

human papilloma virus
Laboratory
Test
Result
Complement
Fixation Test
for C.
Positive
Trachomatis
Serotypes L1,
L2, and L3
Stained Direct
Smear
Donovan bodies
Biopsy of
Ulcer
Pap
Colposcopy
Biopsy
Risk HPV
DNA Typing
Vesicles on an erythmatous base
Herpes
Simplex Virus
Syphilis
Genital infection due

to, primarily, HSV-2
STI caused by the

spirochete bacterium
Treponema pallidum
Transmission
Direct contact
Autoinoculation
Herpetic whitlow
Asymptomatic carrier
Perinatal (vertical transmission)
2 - 7 day course
System symptoms
Primary Infection
possible
Local, painful symptoms
Milder, shorter
Recurrent Infection
Prodromal phase
Non-systemic
Preciptiants
Sun, wind, or trauma
Fever
Menses
Stress
Primary Infection
Contagious
21-day incubation period
Chancre
Painless
Rubbery regional LAD
Generalized LAD in 3 - 6 weeks
Secondary Infection
Contagious
6 weeks - 6 months
Symptoms last only a
after infection
few weeks
Fever
Malaise
Headache
Arthralgias
Condyloma
Bilaterally symmetrical
Alopecia
papulosquamous rash
Denuded tongue
Firm, rubbery, non-tender lymphadenopathy
Latent Infection
No clinical
After secondary stage
manifestations
Can occur first year after 2 infection (early) or
> 1 year with risk of transmission (late)
Diagnostic
Viral Culture
PCR
Serology
Tzank Prep
Direct
Fluorescence
Antibody
Darkfield
Microscopy
Direct
Fluorescence
Antibody
Treatment
Medications
Anitbiotic therapy
Stricture dilation
Surgery
Antibiotic therapy
High-Risk HPV
Types
Low-Risk HPV
Types
Colposcopy
Biopsy
Surgical excision
Cryotherapy
Chemotherapy
Immunotherapy
Surgical excision
HPV vaccinations
93% for vesicles
72% for ulcers
92% for primary
infection
43% for recurrent
infection
27% for crusted
lesions
> 95% sensitive
and specific in
any stage
Not usually
performed but
can be
Other
Caused by the L serotypes of C.
trachomatis
>
Abstinence when lesions are present

Educate about recurrence,
asymptomatic shedding, and sexual
transmission
Condoms for all sexual exposures
Educate about neonatal risk
Gardasil
Ceravix
Risk of Cervical Cancer with HPV

High-risk (oncogenic) - 16, 18, 31, 33,
35, 39, 45, 51, 52, 56, 58, 68, 69, 82
Low-risk (non-oncogenic) - 6, 11, 40,
42, 43, 44, 54, 61, 72, 81
Be on the lookout for cervical
adenocarcinoma and squamous cell
cancer.
Primary Infection
Infection in a patient without
antibodies to HSV-1 or HSV-2
Nonprimary Infection
Acquisition of 1 type of HSV in a
patient with antibodies to the other
type of HSV
Recurrent Infection
Reactivation of the same type of HSV
as those antibodies already present
in serum
Partner education
Antivirals may reduce transmission
Follow-up labs at 1, 3, 6, 12 months or

until non-reactive
VDRL Serology
Diagnostic
Tertiary Infection
Rarely infectious
CSF (+)
Multi-organ involvement
Disease over 4 years duration
Cardiovascular, late benign, and
neurosyphilis
RPR Serology
TRUST
Serology
HIV testing recommended
Treponemal
Serology Tests
CSF
Recommended in
symptomatic, late- Investigate partners from the last year
latent, and HIV
co-infection
Clinical Medicine
Condition / Disease
Chalmydia
Cause
Infection by the
intracellular obligate
bacteria Chlamydia
trachomatis
Signs and Symptoms

Cervical mucopus
Cervical ectopy
Vaginal discharge
Cervical friability
Symptoms may be
delayed up to 30 days
Dysuria
Acute urethral syndrome
Lower abdominal pain
Pelvic pain
High-Risk Populations
< 26 years
New sex partner in past
> 2 sex partners in
60 days
past year
Vaginal discharge
Gonorrhea
Infection by the Gram

negative intracellular
diplococcus Neisseria
gonorrhea
Pelvic
Inflammatory
Disease
Infection of the uterus, fallopian

tubes, and / or ovaries as it
progresses to scar formation with
adhesions to nearby tissues and
organs
HIV
Human immunodeficiency
virus in
More common in and

African Americans
Disseminated infection
Septic arthritis
Vertical transmission
Opthalmia neonatorum
Salpingitis
Endometritis
Uterine, adnexal, or cervical

motion tenderness
Risk Factors
Sexually active
Multiple partners
Douching
Smoking
Fever
Mono-like illness
Diarrhea
Herpes simplex
Transmittable
STDs Between
s
Proven Transmission
STDs to watch out for

who have sex with
None (Chance)
Intentional prevention of
conception and
pregnancy
Contraception
Intentional control of
fertility
Genital warts (HPV)

Trichomoniasis
Theoretical
Transmission
Treatment
Medications
75% sensitive
EIA
Cheap
PCR
95% sensitive
Urine Testing
May increase
detection
Culture
85% sensitive
PCR
Gold-standard
Re-test for chlamydia 3 months posttreatment
Chlamydia
Gonorrhea
Syphilis
Hepatitis B
HIV
85% (25 - 90%) failure
rate / year
Abstinence
0% failure rate / year
Withdrawal
(Coitus Interruptus)
4 - 27% failure
rate / year
Douche
"Outercourse"
Fertility Awareness-Based Methods

Based on consistent
Inexpensive
symptoms of ovulation
Control of fertility
Must be committed,
20 - 25% failure
motivated, and vigilant
rate / year
No chemicals,
Effective if regular cycles
hormones, or foreign
Accepted by religious organizations
Most commonly caused by a

polymicrobial upper genital infection
consisting of gonorrhea, chlamydia,
and endogenous organisms.
Infertility risk increases with every
episode of PID
Multiple antibiotics
Treat while awaiting cultures

Rapid Testing
EIA
HIV RNA
Diagnostic
Other
Not related to SES
7 - 10 day incubation
Complications
PID
Infertility
Ectopic pregnancy
Perihepatitis
Perinatal transmission
Most common in who have sex
with
Complications
PID
Infertility
Ectopic pregnancy
Tubo-ovarian abscess
Perihepatits
HIV ( risk by 3 - 5x)
Abdominal pain
Asymptomatic ( 50%)
Acute Symptoms
Laboratory
Result
60% sensitive
Culture
Difficult
Rarely used
Test
Confirm positives with supplemental

testing
Offer HIV testing to all patients
evaluated for STIs
Avoid contact with partner's
menstrual blood or visible gential
lesions
Cover sex toys with condom
Latex sheet
Barriers During
Dental dam
Oral Sex
Cut-open condom
Use gloves and lubricant for manual
sex that may cause bleeding
Pearl Index
Number of unintended pregnancies
per hundred per year
Fertility Awareness-Based Methods
Periodic abstinence
Symptothermal
Rhythm method
Ovulation method
Fertility awareness
Natural family planning
Clinical Medicine
Condition / Disease
Periodic
Abstinence
Cause
Abstinence on the days of a

woman's menstrual cycle when
she could become pregnant
Cyclebeads
Method of keeping track of

when ovulation is occurring
Barrier Methods
Mechanical barrier to
prevent sperm from entering
the uterus
Nonoxynol-9
Spermicide
Other
Spermicides
Spermicides that are not

available in the US
Signs and Symptoms

Fertility awareness
Calendar rhythm
Temperature change
Cervical mucus changes
Based on 26 - 32
day cycle
White beads day 8 - 19
are "unsafe"
Spermicide
Red bead marks the

onset of menses
Available online or on
smartphone
Cervical cap
Diaphragm
Condom
Sponge
Does not protect against HIV, chlamydia, or
gonorrhea
Only readily available
Causes irritation and
spermicide in US
allergic reactions
10 - 29% failure rate / years
Octoxynol-9
Menfegol
"Naturally green"
Benzalkonium chloride
spermicide
Lemon juice
Neem oil
Must be fit
Cervical Cap
Silicone rubber cap that

is placed on top of
the cervix
Diaphragm
Rubber barrier to
contraception
Condom
Synthetic nitrile form of

barrier contraception
Condom
Usually latex barrier that

goes around the penis
Requires prescription
Requires manual
Insert up to 24 hours
dexterity
before intercourse
Can wear for up to
Needs spermicide
48 hours
No protection against Risk of nonmenstrual
STI / HIV
toxic shock
7.6 - 14% failure rate / year
Requires manual
Requires prescription
dexterity
Needs to be refit after
Needs spermicide
weight changes or
No protection against
pregnancy
STI / HIV
Risk of UTIs, vaginitis,
10 - 20% failure
and nonmenstrual toxic
rate / year
shocck
Stronger than latex (less
5 - 20% failure
breakable)
rate / year
Test
Laboratory
Result
Treatment
Medications
Other
Average fertile period is 6 days per
cycle. Sperm can survive in the
female up to 5 days.
$3 - 27
$0.50 - 1.50 each application
$60 - 89 plus exam / fitting

The FemCap
Sized 22, 26, or 30 mm
Groove to hold spermicide
Removal strap
$15 - 75 plus cost of fitting and

spermicide
$4 each
Never use and condoms at the same time

Often lubricated with
spermicide
"Natural" condoms
available
May cause UTIs in s
Do not protect from STI

"Spray on" versions
available
3 - 15% failure rate /
year
$0.25 - 2 each
Polyurethane condoms break more
than latex
It is better to use nonlubricated
condom with vaginal spermicide
$9 - 15 for a box of 3
Today
Contraceptive Sponge
Polyurethane foam with

nonoxynol-9
Does not prevent STIs
Clinical Medicine
Condition / Disease
Oral
Contraceptive
Pills
Injectable
Contraception
Cause
Signs and Symptoms
Estrogen Effects
Progestin Effects
Inhibit ovulation
Inhibit ovulation
(usually)
Thickened cervical mucus
Alters endometrium
Effective sperm
Luteolysis
Hampers implantation
Biological Activities of OCPs
Hormonal method of
Estrogenic
Progestational
Androgenic
Endometrial
controlling fertility
Effect on serum lipoproteins
Never give estrogencontaining
3 - 9% failure rate / year contraception or OCPS
to a smoker
35 years old
Does not protect against
Method of hormonal
Invisible to partner
STIs or HIV
contraception that does not have
Must see provider for
1 - 2% failure rate / year
pill or device to remember daily
regular injections
Given IM Q 3 months
Inhibits ovulation
0.3% failure rate / year (highly effective)
Depo-Provera
Medroxyprogesterone
acetate
Amenorrhea after a year

Weight gain can be
significant
Cannot immediately
discontinue
Can use in smoker or
nursing
Test
Laboratory
Result
Treatment
Medications
Other
$15 - 50+ / month

Absolute Contraindications
Cardiovascular disease
Coagulation disorders
See
Dyslipidemia
Pharmacology Diabetes
section for more Neurologic disease
information about Known / suspected pregnancy
oral contraception Undiagnosed vaginal bleeding
Known / suspected estrogenpills
dependent neoplasm
Active liver disease or adenoma
Estrogen / progesterone injections

are available outside of the US
$35 - 100 / injection plus exam

Adverse Effects
Lipid changes
Depression
Acne
Headache
Risk of endometrial cancer and PID
Large risk of osteoporosis
Contraceptive
Implants
Method of hormonal
contraception where a
hormone-delivering
device is inserted into
patient
Nexplanon
1 rod implant used for

contraception
Ortho Evra
Patch
Transdermal release of 6
mg norelgestromin and
0.75 mg ethinyl estradiol
NuvaRing
Intravaginal daily release of

0.120 mg etonogesrel and
0.015 mg ethinyl estradiol
Norplant
Norplant II
(Jadelle)
Sino-Implant II
6 rods
Levonorgestrel
5 years
No longer available
2 rods
Levonorgestrel
5 years (Europe)
2 rods
Levonorgestrel
4 years
Etonorgestrel or
3 years
progesterone
Must be trained by company-approved provider to
insert and remove
Same indications and
Wear 1 patch / week for
contraindications as
3 weeks then 1 week off
other estrogen and
progesterone containing
Risk of thrombotic
events
Insert day 5 of menstrual Wear for 3 weeks and
cycle
take 1 week off
Insert new ring every 4th
1-2% failure rate / year
week
Side Effects
Amenorrhea
Weight gain
Acne
Depression
Less effective if obese patient
$400 - 800 insertion

$75 - 150 removal
$15 - 80 / month
Norelgestromin
Progestin-active metabolite of
norgestimate
Do not use in smokers 35 years old
$15 - 80 / month
Risk of thrombotic events
Clinical Medicine
Condition / Disease
Cause
Emergency
(Post-Coital)
Contraception
Method of contraception
taken after unprotective
intercourse
Morning After
Pill
Emergency contraception that

suppresses ovulation and changes
cervical mucus and endometrium
Plan B One-Step
(Next Choice One Dose)
Form of emergency
contraception that delivers
1.5 mg levonorgestrel
Ella
Ulipristal acetate
(selective progesterone
receptor modulator)
Mifepristone
(RU 486)
Paragard-T IUD
Intrauterine
Device /
System
ParaGard Copper T
380A
Mirena IUS
Skyla
Signs and Symptoms

Pregnancy risk by
75 - 80%
Can be taken up to 5
days after unprotected
Test
Best if initiated 72
hours of unprotected
intercourse
Must obtain informed
consent
Laboratory
Result
Treatment
Medications
Other
Counsel about family planning
methods
Advise patients to seek prompt
medical care if no period 21 days of
treatement
No evidence of teratogenic effects
Other methods of
emergency contraception
Not an abortifacient
Not effective if already

pregnant
Consider prophylactic
antiemetics before
OTC
No estrogen
One table
$10 - 70 each
$10 - 70 each
Effectiveness if overweight / obese

Available by prescription Works 5 days after
only
unprotected intercourse
Effectiveness if
overweight / obese
Inhibits ovulation
Changes endometrium
72 hours of
unprotected intercourse
Effective after
implantation occurs
Toxic effect on sperm
Changes endometrium
One 30 mg oral tablet
Insert 5 days of unprotected intercourse
Small contraceptive device,

often 'T'-shaped, often
containing either copper or
levonorgestrel, which is
inserted into the uterus
Excellent for who

cannot take estrogen
Often used in later
reproductive years
before menopause
0.5 - 1.5% failure rate /
year
Use in those unsure

about sterilization
Must be inserted and
removed by health care
provider
Discrete
Not an abortifacient
No need to remove if PID occurs
Expensive up-front cost Do not use if risk of STIs

Cervical and
Copper changes cervical mucus

endometrial cancer
and creates a hostile environment
0.7% failure rate / year
for sperm
IUD that delivers

levonorgestrel
20 g / day
Levonorgestrel-releasing
system
Lasts up to 12 years
$500 - 1000
Can cause heavy

bleeding and cramping
Progestin changes
cervical mucus
Lasts for 5 years
No lipids or breast
cancer
Improves anemia
Incidence of ovarian
cysts
Use up to 3 years
Recent approved by FDA
$500 - 1000
Non-Contraceptive Benefits
Menorrhagia
Anemia
Part of HRT
Hysterectomy alternative
Risk of endometrial cancer
Helps with tamoxifen-induced
endometrial effects
Clinical Medicine
Condition / Disease
Cause
Signs and Symptoms
Lactation
Contraceptive
Method
Use of prolonged
lactation to remain
infertile
+ 10% failure rate / year
Tubal Ligation
Vasectomy
sterlization
sterlization
Test
Laboratory
Result
Most effective if infant not taking any

supplemental formula / food and nursing at least
every 4 hours
General / local
Done in outpatient
anesthesia
surgery
1 week recovery
Can be done
immediately postpartum
May be reversible
(but no guarantee)
Local anesthesia
Done in clinic or office
2 - 3 day recovery
Treatment
Medications
Other
$1500 - 6000
750,000 / year
Risk of ectopic pregnancy if
pregnancy occurs (rare)
$350 - 1000
500,000 / year
Safest form of sterlization
Essure
Non-incisional
permanent birth control
Adiana
Transcervical sterilzation
system using electrothermal
energy
Inner polyethylene
terephthalate fibers
Takes 3 months for
barrier to develop
$1300 - 3500
Inserted into fallpian
tubes through
hysteroscopy
Hysterosalpingogram
Confirm tubal
blockage
Discontinued in 2012
Pharmacology
Drug
Generic Examples /
Brand Name
Mechanism of Action
conjugated equine
estrogen
synthetic non-equine
estrogen
sex hormone
esterifried estrogen
Indications
Menopause
Hot flashes
Vaginal dryness
Dysparunia
(vaginal estrogen)
Overactive bladder
GSUI
Moderate-severe
vasomotor symptoms
Moderate-severe
symptoms of vulvar and
vaginal atrophy
Osteoporosis prevention
Hysterectomy
(as monotherapy)
Pharmacokinetics
Contraindications
Adverse Effects
Monitoring / Other
A: Oral, vaginal,
transdermal, cream, gel,
or ring
Breast cancer
Estrogen-dependent neoplasia
Undiagnosed abnormal genital
bleeding
Thromoboembolic disease
Known or suspected pregnancy
Porphyria
Acute liver disease
Endometeriosis
Fibroids
PMS
Migraines
Gallbladder disease
Hypertriglyceridemia
Seizure disorder
Endometrial cancer
Breast cancer (small risk)

Breast tenderness
Headache
Irregular bleeding (15%)
0.625 mg CEE
1 mg micronized estradiol
1.25 mg pip. estrone SO4
50 g / day estradiol patch
Vaginal estrogen provides
greater relief than PO or
transdermal
Should not be used for the CV
disease prevention
Use the lowest effective
estrogen dose ( progestin) for
the shortest duration of time
Monitoring (within several
weeks)
Resolution of symptoms
Adverse effects
Blood pressure
Weight
Compliance
Reevaluate monitoring every 3 6 months for possible taper or
discontinuation
Sites need to be rotated.
Caution needs to be taken to
prevent unintentional exposure
of children and pets to Evamist
Estrogen
piperazine estrone
sulfate
micronized estradiol
Maintain bone
mineral density
estradiol acetate
Delivers estradiol to venous circulation at a

continuous rate
Sites of Application
Alora
Climara
Elestrin
Estraderm
Transdermal
Estradiol
EstroGel
Vivelle-Dot
Minivelle
EstroGel
Elestrin
Estradiol
replacement
Divigel
Estrasorb
Divigel
Estrasorb
Evamist
Evamist
Progestins
medroxyprogesterone
acetate
norethindrone acetate
norethindrone
micronized
progesterone
progesterone gel
levonorgestrel
Prevents
endometrial
hyperplasia
Premphase
Hormone
Therapy
Regimens
Prefest
Prempro
Femhrt
Activella
Angeliq
Combipatch
Climara Pro
Duavee
Hormone replacement
therapy
D: Weekly or biweekly
(patches) or Q day
(others)
Application-site reaction (5 - 10%)
Upper arm and shoulder

One full arm from wrist
to shoulder
Upper thigh area
About 2 palm prints
No need to rub
Both legs from thigh
to ankle
Rub for 3 minutes
Inside forearm
Multiple sprays should
be adjacent to nonoverlapping areas
Uterus present
Continuous estrogen
10 - 14 days of progestin
every month
Continuous estrogen
Continuous Combined
Continuous progestin
Continuous estrogen
Intermittent Combined Frequent (3 - 4) cycles of
progestin every month
Continuous estrogen
Continuous with 14 Days
14 days of progestin
Every Month
every other month
Hypersensitivity
Active thrombophlebitis
Thromboembolic disorders
Cerebral hemorrhage
Liver disease
Breast / genital carcinoma
Undiagnosed vaginal bleeding
Has no effect on hot flashes

Should not be used for CV
disease prevention
Total use is declining.
Continuous-Cyclic
Methods of
delivering hormone
replacement
Pharmacology
Drug
Drugs Used If HRT Is

Contraindcated
Generic Examples /
Brand Name
venlafaxine
paroxetine
megestrol acetate
gabapentin
Mechanism of Action
Alternative to hormone
replacement therapy
Selective estrogen
receptor modulator
Ospemifine
Osphena
Raloxefene
Evista
Selective estrogen
receptor modulator
Ospemifene
Osphena
Selective estrogen
receptor modulator
Conjugated equine
estrogen
Bazedoxifine
Duavee
Venlafaxine
Effexor
Serotoninnorepinephrine
reuptake inhibitor
Paxil
Selective serotonin
reuptake inhibitor
Catapres
Sympatholytic
Neurotin
GABA analog
Paroxetine
Clonidine
Gabapentin
Soy
Isoflavones
Chlamydia
Treatment
Uncomplicated Gonococcal
Infection Treatments of Cervix,
Urethra, and Rectum
Pharyngeal Gonococcal
Infection
Vasomotor urogenital
symptoms
bugbane
rattleweed
azithromycin
doxycycline
erythromycin base
erythromycin ethyl
succinate
levofloxacin
oflaxacin
ceftriaxone
azithromycin
doxycycline
cefixime
ceftriazone
azithromycin
doxycycline
Pharmacokinetics
Contraindications
Adverse Effects
Monitoring / Other
Contraindicated
hormone replacement
therapy
Urogenital symptoms
Dysparunia
Treatment / prevention
of osteoporosis
Estrogen
contraindication
Can stimulate endometrium
Monitoring is needed for
hyperplasia and VB
Dysparunia
Estrogen contraindication
Vasomotor symptoms
Selective estrogen
receptor modulator
black snakeroot
Black Cohosh
Indications
Can stimulate the

endoemetrium, but are rarely
associated for VB and
hyperplasia
Progestin
contraindication
D: Daily
Hot flashes
Cannot tolerate
estrogen
D: Daily
A: Oral or transdermal
D: Daily
D: TID
Dry mouth
Appetite
Nausea
Constipation
Headache
Nausea
Insomnia
Dry mouth
Sedation
Somnolence
Dizziness
No consistent evidence in RCTs
Nonsteroidal compounds
with estrogenic activity
derived from plants
Hot flashes (not FDA-approved)
Most studied herb

for menopausal
symptoms
Menopausal symptoms
Azithromycin or doxycycline
Alternative Treatments
GI upset
Headache
Dizziness
Hepatotoxicity (?)
A: Oral
Abstinence from intercourse

for 7 days from when therapy
was initiated
Azithromycin is recommended
for pregnancy and chlamydial
infection
A: Oral or IM
(ceftriaxone)
CDC no longer recommends

cefixime at any dose as firstline treatment
Erythromycin base
Erythromycin ethyl
succinate
Levofloxacin
Ofloxacin
Ceftriaxone + azithromycin OR doxycycline

Cefixime + azithromycin OR doxycycline
Azithromycin
Ceftriaxone + 1 of
Doxycycline
A: Oral or IM
(ceftriaxone)
D: Daily or BID
(doxycycline)
Pharmacology
Drug
Generic Examples /
Brand Name
Mechanism of Action
Gonoccal Conjunctivitis
ceftriaxone
Additional
Gonococcal
Infections
cefixime
Disseminated
Gonococcal Infection
cefotaxime
Meningitis
ceftizoxime
Inpatient
Treatment for
PID
Outpatient
Treatment for PID
Endocarditis
cefotetan
cefoxitin
Regimen A
Trichomoniasis
Treatment
Metronidazole
Counseling
Regimen B
Adverse Effects
Monitoring / Other
Ceftriaxone daily for 2

days then switch to
cefixime for 7 days
Cefotaxime or
ceftizoxime
Ceftriaxone IV for
10 - 14 days
Ceftriaxone IV for 4
weeks
A: Oral (doxycycline)
Doxycycline + cefotetan
or IV
or cefoxitin
May discontinue parenteral

therapy 24 hours after clinical
improvement, but oral therapy
with doxycycline should
continue to complete 14 days
of therapy!
Clindamycin +
gentamicin
Cefoxitin + probenecid + doxycycline

metronidazole
PO Metronidazole OR
Metronidazole 0.75% gel OR
Clindamycin 2% cream
Tindazole OR
Clindamycin OR
Clindamycin ovules
metronidazole gel
clindamycin
metronidazole
Metronidazole OR Tinidazole (once)
tinidazole
Metronidazole (BID for 7 days)
Disulfiram-like reaction
may occur if taken with
alcohol
Avoid alcohol 1 - 3 days

after discontinuing
1-Day Therapy
tioconazole
butoconazole
3-Day Therapy
clotrimazole
miconazole
terconazole
boric acid
7 - 14 Day Therapy
nystatin
terconazole
Reaction to penicillin which

occurs secondary to
spirochete lysis and
pro-inflammatory cytokine
cascade
Can occur as early as

2 hours after PCN
A: Oral or intravaginal
A: Oral
Flushing
Palpitation
Tachycardia
Nausea / vomiting
Alcohol should be
avoided during use
Butoconazole 2%
sustained-release cream
fluconazole
JarischHerxheimer
Reaction
Ceftriaxone
Contraindications
Ceftriaxone + doxycycline metronidazole
butoconazole
Vulvovaginal
Candidiasis
Treatment
Pharmacokinetics
A: Oral, IM, or IV
doxycycline
clindamycin
gentamicin
ceftriaxone
doxycycline
metronidazole
cefoxitin
probenecid
metronidazole
Bacterial Vaginitis
Treatment
Indications
A: Oral or intravaginal
PO Fluconazole
Tioconazole 6.5%
ointment
Butoconazole 2% cream
Clotrimazole
Miconazole
Terconazole 0.8% cream
Terconazole
Boric acid
Clotrimazole 1% cream
Clotrimazole
Miconazole 2% cream
Miconazole
Nystatin
Terconazole
Supportive treatment
Fever
Chills
Tachycardia
Tachypnea
Pharmacology
Drug
Generic Examples /
Brand Name
Mechanism of Action
Primary, Secondary, or
Early Latent Stage
benzathine PCN
Syphilis
Treatment
Indications
Late Latent or Tertiary

Stage
aqueous PCN
Neurosyphilis
First Episode Therapy
(for 7 - 10 days)
acyclovir
Genital Herpes
Treatment
Episodic Therapy
valacyclovir
Suppressive Therapy
(up to a year)
Pharmacokinetics
Contraindications
Adverse Effects
Monitoring / Other
Benzathine PCN 2.4 mil

units IM once
Benzathine PCN 2.4 mil
units IM weekly for 3
weeks
Aqueous PCN G
3 - 4 mil units IV Q4H for
10 - 14 days
Acyclovir
A: Oral
Valacyclovir
Famciclovir
Acyclovir
Valacyclovir
Famciclovir
Acyclovir
Valacyclovir
Famciclovir
Foscarent
Headache / confusion
Nausea / vomiting
Thrombocytopenia
Renal insufficiency
Rash / pruritis
Fever
Arthralgias
Myalgia
TTP
Cidofovir
famciclovir
Trifluridine
Implants
IUD
Vasectomy
Sterilazation
Injection
Pills
2nd Most Effective
Patch
Ring
Condoms
2nd Less Effective
Diaphragm
Fertility awareness
Spermicides
Less Effective
Withdrawal
Estrogen Family
Ethinyl estradiol
Mestranol
Estradiol valerate
Progestin Family
MPA
Norethindrone
Ethynodiol
Norethynodrel
Norgestrel
Levonorgestrel
Norgestimate
Desogestrel
Drosperinome
Estrogen Dose Varies Among OCs
Consider if overweight or
heavy menses
High-Dose
Necon
(50 g)
Ovcon
Ovral
Bevicon
Intermediate-Dose
Lelen
(30 - 35 g)
Ortho-Novum
Long-acting reversible
contraceptives and DMPA are
significantly more effective
than pill, patch, or ring.
Most Effective
Contraceptive
Efficacy
How well
contraceptive
methods work
Inhibit ovulation by
suppressing FSH and
LH surge
Hormonal
Contraceptives
Decrease
implantation by
altering endometrial
lining
Decrease sperm
transport by
thickening the
cervical mucus and
decreasing fallopian
cilia activity
Low-Dose
(20 g)
Consider if underweight,
< 35 years old, or
perimenopausal
Alesse
Cyclessa
Loestrin
Thrombophlebitis
Thromboembolic disorders
Cerebrovascular disease
Coronary occlusion
Severe liver dysfunction
Known / suspected breast cancer
Undiagnosed, abnormal vaginal
bleeding
Known / suspected pregnancy
Smokers > 35 years old
Migraines
Hypertension
Uterine leiomyoma
Gestational diabetes
Elective surgery
Epilepsy
Obstructive jaundice in
pregnancy
Sickle cell disease
Diabetes mellitus
Gallbladder disease
Thromboembolism
Stroke
MI
Hepatocellular adenoma
Gallbladder disease
Hypertension
Breast cancer (controversal)
Progestin Androgenic Activity
Appetite
Noncyclic weight gain
Hirsutism
Acne
Oily skin
Libido
Pruritis
Monophasic OCs
Consistent estrogen and
progestin for 21 days
Multiphasic OCs
Estrogen and progestin vary
weekly for 21 days
The risk of DVT is highest when
the patient takes an OC
postpartum (12 weeks after)
Noncontraceptive Benefits
Dysmenorrhea
Days / amount of menstrual
flow
Iron stores with menorrhagia
Restore regular menses in
anovulatory
Ovarian cancer
Endometrial cancer
PID
Possibly prevent ovarian cyst
Benign breast disease
Ectopic pregnancy
Side effects need to be
evaluated closely
Pharmacology
Drug
DrosperinoneContaining OCPs
Generic Examples /
Brand Name
Yasmin
Mechanism of Action
Counter-acts estrogen-induced
stimulation of RAAS
Contraception
Blocks testosterone form

binding to androgen receptors
Acne
Yaz
Safyral
Natazia
estradiol valerate /
dienogest
Extended-Cycle
Oral
Contraceptives
Seasonale
Seasonique
LoSeasonique
Lybrel
First OCP containing

estradiol varlerate
and dienogest
Altering the artifical
21/7 regimen of
typical OCs
Indications that
warrant cessation of
oral contraceptions
Missed Oral
Contraception
Pills
What to do when a
patient forgets to
take a OC pill
NuvaRing
EE / norelgestromin
EE / etognorgestrel
Pharmacokinetics
Contraindications
Adverse Effects
Renal insufficiency (use caution)

Hyperkalemia (use caution)
VTE
Monitoring / Other
PMDD
When to Stop
Oral
Contraception
Ortho Evra
Indications
Transdermally
delivers hormonal
contraception
Vaginal ring delivery

system of hormonal
contraception
Previosu attempts with

estradiol resulted in poor cycle
control
Dienogest provides good
endometrial stabilty
First 4-phasic OCP
Heavy menstrual bleeding in who use an OC
Severe PMS
Cyclic depression
Cyclic headache
Endometriosis
Wish to avoid menses at Wish to avoid menses as

a specific time
much as possible
"ACHES"
Visual disturbances
Unilateral numbness,
Abdominal pain
Chest pain, SOB, or
weakness, or tingling
hemoptysis
Severe chest, left arm, or
neck pain
Headache
Slurred speech
Eye problems
Hepatic mass / pain
Severe leg pain
Time of Missed Pill
Recommendation
Usual Time for
Take pill as soon as
Taking OCP
remembered
Take first pill when
remembered
1 Day
Take the second at the
usual time
Take 2 pills the first day
Take 2 pills the next day
2 Days
Then resume pack
Use condoms for 7 days
Same indications as other estrogen and progestin
containing products
> 90 kg (when it is most effective)
If Patch Falls Off
Reapply to same place or
immediately replace
< 1 Day
No back-up
contraception
Stop current
contraception cycle
Start new cycle with new
patch
> 1 Day (or unsure)
Restart replacement
schedule at day 1
Back-up contraception
for 1 week
Same indications as other estrogen and progestin
containing products
Reasons for Discontiue
Foreign body sensation

Coital problems
Device expulsion
Lybrel gives patients 0 periods /

year. The others average
around 4 periods / year.
Same as other estrogen and

progestin containing products
Application site reactions (20%)

VTE (high risk than oral)
Wear weekly for 3 weeks then

take 1 week off
Patch changes can occur at any
time on change day
Discourage the use of oils,
creams, or cosmetics around
the patch.
Can bathe, swim, and exercise
with patch on
Same as other estrogen and

progestin containing products
Vaginitis (14%)
Headache (12%)
Leukorrhea (6%)
Left in place 3 weeks and then

removed for 1 week
Withdrawal bleeding occurs
2 - 3 days after removal
May be removed for up to 3
hours during intercourse
without requiring back-up
Pharmacology
Drug
Generic Examples /
Brand Name
Mechanism of Action
Hormonal
contraception
without using
estrogen
Progestin-Only
Contraceptives
Indications
When estrogen is not
recommended
Pharmacokinetics
Hypertension
Thromboembolic disease
Depo-Provera
depo-subQ provera 104
Impantable hormonal
contraception
Nexplanon
Emergency
Contraception
Alesse
Levlen
Trilevlen
Lo-Ovral
Ovral
Plan B One-Step
Next Choice
ella
Prevent pregnancy
after unprotected
interocurse
Plan B One-Step
and Next Choice
levonorgestrel
OTC emergency
contraception
ella
ulipristal
Direct inhibitory effect on

follicular rupture and may
prevent implantation
Adverse Effects
Monitoring / Other
Irregular menses
BTB / spotting
Immediately reversible
Norethindrone serum levels
fall to undetectable levels at
24 hours.
If > 3 hours late, use back-up
method for 48 hours
Return to fertility can be
delayed at least 6 months after
last injection to ovulation
Smokers > 35 years old

Breastfeeding
Intolerant to estrogen
with poor compliance
Breastfeeding
Intolerant to estrogen
Taking antiepileptics
Smokers
Patients with weight

gain, acne, or nausea
Minimal drug
interactions
A: Within 5 days of
beginning of menses or
(-) pregnancy test
D: Q 12 weeks
Short-term protection following rubella

immunization or on isotretinoin
etonorgestrel implant
Contraindications
Cerebrovascular disease
MPA
Injectable hormonal
contraception
D: Daily at the same time
Private
Convenience
Inhibit / delay ovulation

Does not interrupt /
disrupt an established
pregnancy
A: 72 hours
(levonorgestrel) or 120
hours (ulipristal)
Weight gain
Appetite
Headache
Bloating
Breast tenderness
Depression
HDL
Osteoporosis
Similar to other progestrin-only
contraceptives
Strange bleeding patterns
Ovulation resumes 3 weeks

of removal in 90%
Antiemetic should be given

before the first dose of
combined estrogen / progestin
to reduce estrogen-related
nausea and vomiting.
Not abortifacient
A: 72 hours
17 years old
A: 120 hours
Prescription only
May reduce by CYP3A4 inducer
Need for less side effects
Oral Contraceptive Agents

Brand Name
Monophasic Pills
Estrogen
Progestin
Brand Name
Triphasic Pills
Estrogen
Progestin
Loestrin 24 Fe
ethinyl estradiol
norethindrone acetate
Ortho Tri-Cyclen
ethinyl estradiol
norgestimate
Ocella
Yaz
Yasmin
ethinyl estradiol
drospirenone
Brand Name
Natazia
Four-Phasic Pills
Estrogen
estradiol valerate
Progestin
dienogest
Brand Name
NuvaRing
(vaginal ring)
Other
Estrogen
Progestin
ethinyl estradiol
etonogestrel
Nexplanon (implant)
etonogestrel
Hormone Replacement Therapy

Class
Estrogen
Progestin
Estrogen + Progestin
Estrogen Receptor
Modulator
Estrogen + Selective
Estrogen Receptor
Modulator
SSRI
Generic Name
conjugated equine
estrogen
medroxyprogesterone
cyclic estrogen +
medroxyprogesterone
Brand Name
ospemifine
Osphena
conjugated estrogen +
bazedoxifine
Duavee
paroxetine
Brisdelle
Premarin
Provera
Prempro
Emergency
Brand Name
Plan B One-Step
Next Choice
Ella
Generic Name
levonorgestrel
ulipristal

Gynecology

Enviado por

Dados do documento

Direitos autorais

Formatos disponíveis

Compartilhar este documento

Compartilhar ou incorporar documento

Opções de compartilhamento

Você considera este documento útil?

Este conteúdo é inapropriado?

Direitos autorais:

Formatos disponíveis

Gynecology

Enviado por

Direitos autorais:

Formatos disponíveis

Diagnostic Methods

Method of looking at the

Ultrasound that involves

Done with minimal to no

Low risk of endometrial

Uses contrast dye

LHRH that induces

Endocrine problems with

Plasma or 24-hour urine

Plasma or 24-hour urine

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Evaluate sexual maturity

Steriod sex hormones

Hormone that causes

Estrogen precursor that

Serum, urine, or salivary

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Stimulation test done to

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Stuff that messes with

Cervical culture for STIs

Very sensitive test for

Some organisms are

Gynecologic test where a

Gently rotate swab over vaginal wall or area of

Refrain from douching or tub

Can be done using a urine sample

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Study of serum for Herpes

Requires fresh specimen

4-fold rise in titer

Does not exclude

Recurrent infections are less likely to

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Testing for the presence

DNA Amplication / PCR /

Fast and sensitive

DNA PCR Amplication

Culture takes too long

Serological studies are

Co-infection with Chlamydia is high.

Gram negative diplococci

Make sure that the lab knows to

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Methods for Diagnosis

Detect antibodies to the

Detect viral antigen

Detect viral nucleic acid

Culture HIV virus

Determining HIV status

EIA Reactive but

Culture (less common)

Detects serotype L1, L2,

Helps differentiate the

Offer HPV vaccine for 9 - 26 year olds

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

When to screen for the

STIs that need to be

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Maturational increase in adrenal

Signs and Symptoms

Average 2.5 years after

Produces one fully mature oocyte

Follicular / Proliferative Phase