PROLOG: Gynecology and Surgery

ISBN 978-1-948258-16-6

Copyright 2019 by the American College of Obstetricians and Gynecologists. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission of the publisher.

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Contributors

PROLOG Editorial and Advisory Committee

CHAIR

Ronald T. Burkman Jr, MD

Professor of Obstetrics and Gynecology

University of Massachusetts Medical School–Baystate

Division of General Obstetrics and Gynecology

Baystate Medical Center

Springfield, Massachusetts

MEMBERS

Bernard Gonik, MD

Professor and Fann Srere Endowed Chair of Perinatal Medicine

Division of Maternal–Fetal Medicine

Department of Obstetrics and Gynecology

Wayne State University School of Medicine

Detroit, Michigan

John F. Greene Jr, MD

Vice President of Medical Affairs, Hartford Region

Hartford HealthCare

Professor of Obstetrics and Gynecology

University of Connecticut School of Medicine

Farmington, Connecticut

Roger P. Smith, MD

Assistant Dean for Graduate Medical Education, Faculty and Academic Affairs

Professor, Integrated Medical Science, Division of Obstetrics and Gynecology

Charles E. Schmidt College of Medicine

Florida Atlantic University

Boca Raton, Florida

PROLOG Task Force for Gynecology and Surgery, Eighth Edition

CO-CHAIRS

Amy M. Johnson, MD

Residency Program Director

Associate Professor

Department of Obstetrics and Gynecology

University of Connecticut School of Medicine

Hartford Hospital

Farmington, Connecticut

James M. Shwayder, MD, JD

Professor

Department of Obstetrics and Gynecology

University of Mississippi Medical Center

Jackson, Mississippi

MEMBERS

Carrie L. Bell, MD

Assistant Professor

University of Michigan Health System

Department of Obstetrics and Gynecology

Ann Arbor, Michigan

Betty Chou, MD

Assistant Professor

Residency Program Director

Department of Gynecology and Obstetrics

Johns Hopkins University School of Medicine

Baltimore, Maryland

Sean L. Francis, MD

Donald E. Baxter Endowed Chairman

Department of Obstetrics and Gynecology and Women’s Health

Associate Professor and Fellowship Director

Female Pelvic Medicine and Reconstructive Surgery

University of Louisville School of Medicine

Louisville, Kentucky

Scott Graziano MD, MS

Associate Professor

Department of Obstetrics and Gynecology

Assistant Dean for Clinical Development

Loyola University Chicago Stritch School of Medicine

Maywood, Illinois

Nicole W. Karjane, MD

Professor

Residency Program Director

Department of Obstetrics and Gynecology

Medical Director, Mother–Infant Unit

Virginia Commonwealth University Health System

Richmond, Virginia

Cara R. King, DO, MS

Assistant Professor

Minimally Invasive Gynecologic Surgery

Department of Obstetrics and Gynecology

University of Wisconsin School of Medicine and Public Health

Madison, Wisconsin

Elizabeth Lutz, MD, MPH

Assistant Professor

Residency Program Director

Department of Obstetrics and Gynecology

University of Mississippi Medical Center

Jackson, Mississippi

Melissa I. March, MD

Assistant Professor

Department of Obstetrics and Gynecology

Division of Maternal–Fetal Medicine

University Hospitals Cleveland Medical Center

Case Western Reserve University School of Medicine

Cleveland, Ohio

Lisa Pompeo, MD

Associate Professor

Residency Program Director

Department of Obstetrics, Gynecology, and Women’s Health

Rutgers New Jersey Medical School

Newark, New Jersey

ACOG STAFF

Sandra A. Carson, MD

Vice President for Education, Emeritus

Erica Flynn, MBA, MS

Senior Director, Educational Development and Testing

Division of Education

Elizabeth Moran, MA

Editor

Division of Education

DISCLOSURE STATEMENT

The Accreditation Council for Continuing Medical Education (ACCME) requires that all faculty and planning committee members disclose any financial interests relative to topics within this edition of PROLOG. This information will be obtained in advance by staff via the American College of Obstetricians and Gynecologists’ (ACOG) online disclosure system. There must be ample time for resolution of all potential conflicts of interest. This information (with resolution of any conflicts of interest) should be on file before honoraria are paid.

DISCLOSURE OF FACULTY AND INDUSTRY RELATIONSHIPS

In accordance with ACOG’s policy, all faculty and planning committee members have signed a conflict of interest statement in which they have disclosed any financial interests or other relationships with industry relative to topics in this edition of PROLOG. Such disclosure allows for better evaluation of the objectivity of the information presented.

CONFLICT OF INTEREST DISCLOSURE

This PROLOG unit was developed under the direction of the PROLOG Advisory Committee and Task Force for Gynecology and Surgery, Eighth Edition. PROLOG is planned and produced in accordance with the Standards for Commercial Support of the ACCME. Any discussion of unapproved use of products is clearly cited in the appropriate critique.

Current guidelines state that continuing medical education (CME) health care providers must ensure that CME activities are free from the control of any commercial interest. The task force and advisory committee members declare that neither they nor any business associate nor any member of their immediate families has material interest, financial interest, or other relationships with any company manufacturing commercial products relative to the topics included in this publication or with any provider of commercial services discussed in the unit. All potential conflicts have been resolved through ACOG’s mechanism for resolving potential and real conflicts of interest.

Preface

Purpose

PROLOG (Personal Review of Learning in Obstetrics and Gynecology) is a voluntary, strictly confidential self-evaluation program. PROLOG was developed specifically as a personal study resource for the practicing obstetrician–gynecologist. It is presented as a self-assessment mechanism that, with its accompanying performance information, should assist the physician in designing a personal, self-directed, lifelong learning program. It may be used as a valuable study tool, a reference guide, and a means of attaining up-to-date information in the specialty. The content is carefully selected and presented in multiple-choice questions that are clinically oriented. The questions are designed to stimulate and challenge physicians in areas of medical care that they confront in their practices or when they work as consultant obstetrician–gynecologists.

PROLOG also provides the American College of Obstetricians and Gynecologists (ACOG) with one mechanism to identify the educational needs of the Fellows. Individual scores are reported only to the participant; however, cumulative performance data and evaluation comments obtained for each PROLOG unit help determine the direction for future educational programs offered by ACOG.

Process

The PROLOG series offers the most current information available in five areas of the specialty: 1) obstetrics; 2) gynecology and surgery; 3) reproductive endocrinology and infertility; 4) gynecologic oncology and critical care; and 5) patient management in the office. The series now includes a sixth volume for the subspecialty of female pelvic medicine and reconstructive surgery. A new PROLOG edition is produced annually, addressing one of those subject areas. Gynecology and Surgery, Eighth Edition, is the second unit in the eighth 5-year PROLOG series.

Each unit of PROLOG represents the efforts of a task force of subject experts under the supervision of an advisory committee. PROLOG sets forth current information as viewed by recognized authorities in the field of women’s health. This educational resource does not define a standard of care, nor is it intended to dictate an exclusive course of management. It presents recognized methods and techniques of clinical practice for consideration by obstetrician–gynecologists to incorporate in their practices. Variations of practice that take into account the needs of the individual patient, resources, and the limitations that are special to the institution or type of practice may be appropriate.

Each unit of PROLOG is presented as a two-part set, with performance information and cognate credit available to those who choose to submit their assessment for confidential scoring. The first part of the PROLOG set is the Assessment Book, which contains educational objectives for the unit and multiple-choice questions. The questions can be completed by taking an online assessment. Participants can work through the unit at their own pace, choosing to use PROLOG as a closed- or open-book assessment. Submitting the online assessment is encouraged but voluntary.

The second part of PROLOG is the Critique Book, which reviews the educational objectives and questions set forth in the Assessment Book and contains a discussion or critique of each question. The critique provides the rationale for correct and incorrect options. Current, accessible references are listed for each question.

Continuing Medical Education Credit

ACCME Accreditation

The American College of Obstetricians and Gynecologists (ACOG) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

AMA PRA Category 1 Credit(s)™

The American College of Obstetricians and Gynecologists designates this enduring material for a maximum of 25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ACOG Cognate Credit(s)

The American College of Obstetricians and Gynecologists designates this enduring material for a maximum of 25 Category 1 ACOG Cognate Credits. The American College of Obstetricians and Gynecologists has a reciprocity agreement with the American Medical Association that allows AMA PRA Category 1 Credits™ to be equivalent to ACOG Cognate Credits.

Participants who submit their assessment for scoring and receive a passing of 80% will be credited with 25 continuing medical education (CME) credits for this unit. Those who complete the assessment for CME credit will receive a performance report that provides a comparison of their scores with the scores of a sample group of physicians who have taken the unit as an examination. An individual may request credit only once for each edition. Participants receive CME verification immediately after they pass the online assessment. Paper answer sheets are NOT available for this edition.

Credit for PROLOG Gynecology and Surgery, Eighth Edition, is initially available through December 2021. During that year, the unit will be reevaluated. If the content remains current, credit is extended for an additional 3 years, with credit for the unit automatically withdrawn after December 2024.

Conclusion

PROLOG was developed specifically as a personal study resource for the practicing obstetrician–gynecologist. It is presented as a self-assessment mechanism that, with its accompanying performance information, should assist the physician in designing a personal, self-directed learning program. The many quality resources developed by ACOG, as detailed each year in ACOG’s Publications and Educational Materials Catalog, are available to help fulfill the educational interests and needs that have been identified. PROLOG is not intended as a substitute for the certification or recertification programs of the American Board of Obstetrics and Gynecology.

Electronic Assessment for CME Credit

To receive the CME credits for this edition, participants must complete an online assessment. Assessment results must be 80% or higher to achieve a passing score and attain CME credit. To access the online assessment, please visit https://prolog.acog.org. Test results and the CME certificate will be available upon completion of the examination.

If you purchased a print book, use the key code located on the inside front cover of the Critique Book and follow the directions provided. If you purchased an eBook, please follow the instructions online, through https://prolog.acog.org, to purchase and access the assessment. Paper answer sheets are NOT available for this edition.

PROLOG Objectives

PROLOG is a voluntary, strictly confidential, personal continuing education resource that is designed to be stimulating and enjoyable. By participating in PROLOG, obstetrician–gynecologists will be able to do the following:

• Review and update clinical knowledge.

• Recognize areas of knowledge and practice in which they excel, be stimulated to explore other areas of the specialty, and identify areas requiring further study.

• Plan continuing education activities in light of identified strengths and deficiencies.

• Compare and relate present knowledge and skills with those of other participants.

• Obtain continuing medical education credit, if desired.

• Have complete personal control of the setting and of the pace of the experience.

The obstetrician–gynecologist who completes Gynecology and Surgery, Eighth Edition, will be able to

• establish a differential diagnosis and screen patients with appropriate diagnostic tests for specific gynecologic conditions.

• determine the appropriate medical management for specific gynecologic conditions in adolescents and adult women.

• identify appropriate surgical interventions for various gynecologic conditions and strategies to prevent and treat surgical complications.

• apply concepts of anatomy, genetics, pathophysiology, and epidemiology to the understanding of diseases that affect women.

• counsel women regarding treatment options and adjustment to crises that may alter their lifestyles.

• apply professional medical ethics and the understanding of medical–legal issues relative to the practice of gynecology.

Gynecology and Surgery, Eighth Edition, includes the following topics (item numbers appear in parentheses):

COUNSELING

Adverse effects of the etonogestrel subdermal implant (23)

Atypical endometrial hyperplasia and endometrial cancer (111)

Complications of embolization (36)

Eating disorders and irregular menstruation (103)

Emergency contraception in an obese patient (47)

End-of-life care (83)

Extended-cycle combined oral contraceptives (109)

Heavy menstrual bleeding with intrauterine device (89)

Human papillomavirus vaccination (129–133)

Leiomyosarcoma complications (10)

Lynch syndrome (38)

Mature cystic teratoma with recurrence (81)

Obesity (60)

Patient who has a sexual partner with genital herpes (110)

Pregnancy despite use of emergency contraception (123)

Recommendations to prevent osteoporosis (87)

Recurrent urinary tract infection (128)

Risk of acquiring human immunodeficiency virus after sexual assault (125)

Role of hormone therapy in heart disease (41)

Smoking cessation (170–173)

EPIDEMIOLOGY AND BIOSTATISTICS

Endometrial ablation (77)

Familial cancer syndromes (177–179)

Oliguria in an elderly patient (26)

Ovarian torsion (8)

Ovary preservation or removal at the time of hysterectomy (79)

Perioperative pulmonary complications (6)

Postoperative management of nerve injuries (164–166)

Postoperative pelvic abscess (51)

Risk of hepatitis C after exposure (25)

Risk of hepatitis C in a healthy patient (117)

Use of prophylactic antibiotics in surgery for a patient allergic to penicillin (118)

Wound dehiscence (28)

ETHICAL AND LEGAL ISSUES

Discussion of medical errors (122)

Electronic communication and office practice (53)

Ethical management of unexpected surgical findings (67)

Experience with new technology (105)

Peer review of operative complications (31)

Recognition of physician burnout (88)

MEDICAL MANAGEMENT

A patient with ductal carcinoma in situ (98)

Adenocarcinoma in situ (108)

Adnexal mass in a postmenopausal woman (73)

Adverse effects of pharmacologic therapy for overactive bladder (40)

Appropriate treatment of sexually transmitted diseases (39)

Asymptomatic leiomyomas (22)

Bacterial vaginosis (2)

Beta-blocker therapy in perioperative care (92)

Clinical depression (49)

Complex endometrial hyperplasia (3)

Complications of hysteroscopic sterilization (74)

Contraception in a patient with gastric bypass (71)

Contraception in the morbidly obese patient (84)

Contraceptive options for a woman with diabetes mellitus and a seizure disorder (66)

Depot medroxyprogesterone acetate and bone loss (75)

Dysmenorrhea (15)

Dysmenorrhea in an adolescent patient (57)

Ectopic pregnancy (69)

Endometrial neoplasia classification (94)

Endometriosis (56)

Evaluation of urinary incontinence (59)

Fibrocystic breast disease (12)

First-trimester pregnancy loss (37)

Follow-up after loop electrosurgical procedure (7)

Genitourinary syndrome of menopause (68)

Gynecologic care in patient with human immunodeficiency virus (100)

Heavy menstrual bleeding in a patient with a low platelet count (24)

Hormone therapy after hysterectomy for endometriosis (1)

Hormone therapy for vasomotor symptoms (116)

Human immunodeficiency virus exposure and prophylaxis (70)

Hysteroscopic complications (97)

Immunizations (17)

Intrauterine device malposition (46)

Leiomyoma classification (144–148)

Management of gynecologic issues in women with breast cancer (27)

Management of urinary tract injuries (137–140)

Medical therapy for a patient who has genital herpes (90)

Medical therapy for chronic pelvic pain (121)

Metformin hydrochloride for polycystic ovary syndrome (18)

Molar pregnancy (104)

Nonhormonal therapy for menopausal symptoms (154–156)

Office hysteroscopy (20)

Outpatient management of pelvic inflammatory disease (78)

Ovarian cancer in BRCA1 and BRCA2 mutation carriers (54)

Ovarian mass in a premenopausal woman (32)

Pelvic organ prolapse (33)

Perioperative anticoagulants (184–187)

Perioperative care of a patient with diabetes mellitus (35)

Pessary use (86)

Postoperative ileus (11)

Premalignant and in situ breast disease (157–159)

Risk of endometrial cancer in a postmenopausal woman (93)

Thickened endometrium without postmenopausal bleeding (91)

Trocar injuries (114)

Urinary frequency (4)

Vulvar skin disorders (134–136)

Weight loss in an obese patient (101)

OFFICE PROCEDURES

Coding for office-based procedures (119)

Patient safety in the office (167–169)

PHYSIOLOGY

Vascular supply of the pelvis (174–176)

SCREENING AND DIAGNOSIS

Abnormal cervical cytology results (149–153)

Abnormal uterine bleeding in an adolescent patient (62)

Anterior abdominal wall anatomy and surgical complications (107)

Atypical glandular cells revealed on cytology (50)

Cervical cancer screening in a patient with human immunodeficiency virus (44)

Cervical cytology showing endometrial cells (95)

Cervical intraepithelial neoplasia (180–183)

Chronic pelvic pain (9)

Complications of uterine artery embolization (13)

Eating disorders and irregular menstruation (72)

Etiology of abnormal uterine bleeding in an adolescent patient (21)

Evaluation of persistent vulvar pain (52)

Heavy menstrual bleeding in an adolescent patient (120)

Heavy menstrual bleeding in an older reproductive-aged woman (126)

Intraoperative hypotension (5)

Intrauterine device with missing strings (63)

Migration of etonogestrel subdermal implant (115)

Ovarian mass in an adolescent (34)

Ovarian remnant syndrome (64)

Pediatric vulvar disease and vaginitis (160–163)

Perioperative cardiac evaluation (61)

Postmenopausal bleeding (65)

Pregnancy in a patient with a cesarean scar (127)

Pregnancy of unknown location (19)

Recurrent yeast infection (99)

Severe dyspareunia (80)

Sexual dysfunction in menopausal women (29)

Tumor markers (141–143)

Vaginal intraepithelial neoplasia (85)

Vulvar intraepithelial neoplasia classification (58)

SURGICAL MANAGEMENT

Age-based preoperative evaluation (43)

Cost-effectiveness for vaginal hysterectomy (124)

Electrosurgical injury to the bowel (30)

Effect of prior surgery on laparoscopic entry techniques (45)

Hemorrhage during surgery (55)

Pelvic floor anatomy (48)

Postoperative delirium in an older patient (112)

Postoperative oliguria (76)

Prophylactic antibiotics for abdominal surgery (106)

Risk reduction for a BRCA mutation carrier (82)

Risk-reducing salpingectomy (16)

Route of hysterectomy (42)

Surgery for uterovaginal prolapse (14)

Surgical considerations of obesity (113)

Urinary incontinence with intrinsic sphincter deficiency (96)

Uterosacral ligament suspension for vaginal prolapse (102)

A complete subject matter index appears at the end of the Critique Book.

1

Hormone therapy after hysterectomy for endometriosis

A 34-year-old woman, gravida 2, para 2, presents with worsening hot flushes, sleep disruption, and vaginal dryness after undergoing a laparoscopic-assisted vaginal hysterectomy with bilateral salpingo-oophorectomy (BSO) 2 months ago to treat severe dysmenorrhea resulting from endometriosis. The operative report describes complete excision of the visible implants of endometriosis without complications. She is otherwise healthy. On examination, her blood pressure is 138/82 mm Hg. Pelvic examination shows mild atrophy and an intact vaginal apex with no lesions or tenderness. The best next step in management of this patient’s symptoms is to initiate systemic therapy with

(A) clonidine

*  (B) estrogen

(C) gabapentin

(D) paroxetine

(E) micronized progesterone

Hysterectomy with BSO is considered the most definitive therapy for endometriosis and its associated pain. It generally is considered when patients have failed more conservative therapy such as hormonal management and surgical ablation or excision. Hysterectomy with ovarian conservation has been associated with up to a 61% chance of symptom recurrence and a 31% likelihood of requiring further surgical intervention within 5 years of surgery. In addition, women who undergo ovarian conservation have been shown to be six times more likely to have a recurrence of symptoms and eight times more likely to require additional surgery compared with those who have their ovaries removed. Although removal of the ovaries reduces the risk of recurrent symptoms, it comes with the risks associated with hypoestrogenemia because of surgical menopause, which tends to be particularly concerning in young women.

Women younger than 40 years who are hypoestrogenic—whether because of surgical menopause or primary ovarian insufficiency—appear to be at one-and-one-half-fold to threefold higher risk of bone loss and approximately 50% higher risk of death as a result of ischemic cardiovascular events compared with women who experience menopause at ages 49 years and 50 years. These younger women also are likely to experience vasomotor symptoms, sleep disorders, psychosexual dysfunction, and vaginal dryness, as reported in the described patient, and are at increased risk of all-cause mortality. Estrogen therapy is recommended in these younger, hypoestrogenic women to mitigate the effects of premature loss of their endogenous hormone function.

Although recurrence of endometriosis after definitive surgery may be slightly more common in women treated with estrogen therapy compared with those who are not, the overall rate of recurrence appears to be less than 1% per year. In addition, this risk appears to be lower in women with complete excision of all endometriotic implants, as in this patient, and thus is not high enough to deprive symptomatic women of this treatment. In a young woman who presents with severe vasomotor symptoms because of surgical menopause, the most appropriate management option is to initiate systemic estrogen therapy, because it is the most effective treatment for menopause-related vasomotor symptoms and is well tolerated. In addition, although previous expert opinion suggested delaying initiation of estrogen therapy for 6–12 months after surgery, this delay leads to significant menopausal symptoms with no reduction in recurrence risk; therefore, initiating estrogen therapy in the postoperative period is recommended.

Clonidine is a centrally acting alpha-1 agonist that has been shown to be more effective than placebo in treating vasomotor symptoms, with just less than 40% reduction in hot flushes, compared with 20% for placebo. However, it is not approved by the U.S. Food and Drug Administration (FDA) for this indication and will not decrease the patient’s risks of osteoporosis and cardiovascular disease. In addition, patients taking clonidine frequently report significant adverse effects of dry mouth, insomnia, and drowsiness. For these reasons, estrogen therapy would be a better option for this patient.

Gabapentin is an analog of gamma aminobutyric acid generally used as an anticonvulsant. It also has been shown to reduce vasomotor symptoms by 45–71%; however, it is not FDA approved for this indication and appears to be less effective than estrogen therapy. Dizziness, peripheral edema, and somnolence are common adverse effects reported in users of gabapentin. Although gabapentin is a reasonable option for treating vasomotor symptoms, it again will not address this patient’s other symptoms and risks, which are caused by her hypoestrogenic state.

Paroxetine is a selective serotonin reuptake inhibitor (SSRI) that is FDA approved to treat vasomotor symptoms related to menopause at a dose of 7.5 mg daily. Although SSRIs are superior to placebo at treating vasomotor symptoms, with reduction in hot flushes of approximately 40% (33–67%), compared with 13–38% for placebo, they are less effective than estrogen therapy, which has shown reduction in hot flushes of approximately 75%. In addition, paroxetine will not decrease the patient’s risks of osteoporosis, cardiovascular disease, and all-cause mortality, and the use of SSRIs such as paroxetine can be limited by adverse effects including nausea, dizziness, constipation, and sexual dysfunction. For these reasons, paroxetine is not the best answer and should be reserved for those in whom estrogen therapy would be contraindicated.

Therapy with micronized progesterone may reduce vasomotor symptoms; however, estrogen therapy has been shown to be significantly more effective. In addition, progestin therapy has not been shown to reduce the additional risks associated with a hypoestrogenic state in young women and may be associated with adverse effects such as bloating and breast tenderness. Progestin therapy generally is used in addition to systemic estrogen to prevent endometrial hyperplasia in women with an intact uterus. Although progestin therapy is not needed to protect the endometrium in women taking systemic estrogen therapy after hysterectomy, there is theoretic concern that unopposed estrogen may increase the risk of malignant transformation in residual endometriotic implants. This theoretical risk is very low and must be weighed with the known risks of progestin therapy because such outcomes-based evidence is lacking. Although it may be reasonable to add a progestin to estrogen therapy in these women, treatment with a progestin alone is not the best option.

* Indicates correct answer.

Note: See Appendix A for a table of normal values for laboratory tests.

Al Kadri H, Hassan S, Al-Fozan HM, Hajeer A. Hormone therapy for endometriosis and surgical menopause. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD005997.

Hayes LP, Carroll DG, Kelley KW. Use of gabapentin for the management of natural or surgical menopausal hot flashes. Ann Pharmacother 2011;45:388–94.

Hoffman BL, Schorge JO, Bradshaw KD, Halvorson LM, Schaffer JI, Corton MM. Endometriosis. In: Williams gynecology. 3rd ed. New York (NY): McGraw Hill Education; 2016. p. 230–48.

Hoffman BL, Schorge JO, Bradshaw KD, Halvorson LM, Schaffer JI, Corton MM. The mature woman. In: Williams gynecology. 3rd ed. New York (NY): McGraw Hill Education; 2016. p. 492–511.

Hormone therapy in primary ovarian insufficiency. Committee Opinion No. 698. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;129:e134–41.

Management of endometriosis. Practice Bulletin No. 114. American College of Obstetricians and Gynecologists. Obstet Gynecol 2010;116:223–36.

Management of menopausal symptoms. Practice Bulletin No. 141. American College of Obstetricians and Gynecologists [published erratum appears in Obstet Gynecol 2016 127:166]. Obstet Gynecol 2014;123:202–16.

2

Bacterial vaginosis

A 33-year-old woman, gravida 3, para 3, presents to the office with a symptomatic vaginal discharge. Upon completion of the evaluation, she received a diagnosis of bacterial vaginosis. During the subsequent discussion, the patient indicates she has been treated for the same problem twice in the past 3 years. With the first episode, she was treated with an oral medication that she often forgot to take and that also caused nausea. She was treated with a vaginal cream the second time but disliked it because it was so messy. The best management choice for this patient is

*  (A) secnidazole, 2 g orally

(B) metronidazole, 2 g orally

(C) clindamycin, 300 mg orally twice daily for 7 days

(D) vaginal metronidazole-boric acid suppression for 6 months

Bacterial vaginosis accounts for 40–50% of cases of vaginal discharge among reproductive-aged women in the United States. It is commonly diagnosed using the Amsel criteria, which requires the presence of at least three of the following: 1) a homogenous, thin, grayish-white discharge; 2) a vaginal pH of 4.5; 3) a positive whiff test on a wet prep treated with 10% potassium hydroxide; and 4) clue cells representing 20% or greater of epithelial cells on wet prep. Up to 75% of women with this infection are asymptomatic. When symptomatic, women are treated to reduce discharge and odor. Patients with recurrent bacterial vaginosis should be reevaluated for other sexually transmitted infections, such as human immunodeficiency virus (HIV), gonorrhea, chlamydial infections, and herpes simplex virus type 2. Patients with such diseases are candidates for treatment of asymptomatic bacterial vaginosis.

There are a number of treatment regimens that are effective in treating bacterial vaginosis. However, until recently, all regimens included treatment with oral or vaginal preparations for several days. Recently, the U.S. Food and Drug Administration approved secnidazole, a second-generation 5-nitroimidazole, which has a 17-hour half-life compared with metronidazole (which has a half-life of 8 hours). The drug is administered as a single dose of 2 g of oral granules. These granules can be mixed with applesauce to help hide their bitter taste. In blinded randomized clinical trials, secnidazole was superior to placebo in treating bacterial vaginosis. Subsequent adverse effects, such as yeast infections, nausea, and headache, occurred at rates of 2% or less. When a single dose of secnidazole was compared with metronidazole given twice daily for 7 days in a blinded randomized clinical trial, the clinical cure rates (normalization of the Amsel criteria) at 28 days were 77.0% and 79.3%, respectively, and the combined clinical and bacteriological cure rates in the same time frame were 59.5% and 60.1%, respectively. Thus, for this patient who forgets pills, dislikes vaginal preparations, and experiences nausea with metronidazole, a single-dose treatment with secnidazole is the best treatment choice for her bacterial vaginosis.

There are no data to support that treatment with a single oral dose of metronidazole is effective for the treatment of bacterial vaginosis. Because this patient is forgetful when taking prolonged courses of oral medications, a 7-day course of clindamycin is not the best choice. Finally, the occurrence bacterial vaginosis of three episodes of bacterial vaginosis in the past 3 years does not justify placing her on a suppressive regimen that combines vaginal and prolonged oral therapy. Any patient with more than three documented episodes of bacterial vaginosis within 12 months may benefit from suppressive therapy.

Bohbot JM, Vicaut E, Fagnen D, Brauman M. Treatment of bacterial vaginosis: a multicenter, double-blind, double-dummy, randomized phase III study comparing secnidazole and metronidazole. Infect Dis Obstet Gynecol 2010;2010:10.1155/2010/705692. Epub 2010 Sep 15.

Hillier SL, Nyirjesy P, Waldbaum AS, Schwebke JR, Morgan FG, Adetoro NA, et al. Secnidazole treatment of bacterial vaginosis: a randomized controlled trial. Obstet Gynecol 2017;130:379–86.

Schwebke JR, Morgan FG Jr, Koltun W, Nyirjesy P. A phase-3, double-blind, placebo-controlled study of the effectiveness and safety of single oral doses of secnidazole 2 g for the treatment of women with bacterial vaginosis. Am J Obstet Gynecol 2017;217:678.e1–9.

3

Complex endometrial hyperplasia

A 39-year-old nulligravid woman reports irregular, heavy menses. She is hoping to get pregnant after she gets married in 1 year. Her body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) is 37. Her physical and pelvic examinations are unremarkable. Pelvic ultrasonography shows an endometrial lining thickness of 1 cm and a 3-cm intramural leiomyoma. Endometrial sampling shows complex atypical hyperplasia. The best next step in the patient’s management is

(A) combination oral contraceptives

*  (B) levonorgestrel intrauterine device (IUD)

(C) laparoscopic supracervical hysterectomy

(D) laparoscopic total hysterectomy

Endometrial carcinoma is the most common gynecologic cancer in the United States. Endometrial hyperplasia is often a precursor to endometrial carcinoma; however, endometrial hyperplasia encompasses a heterogenous group of histologic findings that are associated with varied malignant potential. Endometrial hyperplasia is caused by estrogenic stimulation of the endometrium not adequately opposed by progestins, which results in proliferative glandular changes of the endometrium. In contrast to the diffuse field effect of prolonged unopposed estrogen that causes endometrial proliferation and benign hyperplasia, true premalignant lesions (which are also estrogen sensitive) originate from localized proliferation of a sporadically mutated endometrial gland. Distinguishing between benign hyperplasia and true precancerous lesions is important to avoid the undertreatment or overtreatment of patients.

There are two systems of endometrial premalignant nomenclature commonly used: the 1994 World Health Organization schema (WHO94) and the endometrial intraepithelial neoplasia (EIN) diagnostic schema. The WHO94 schema has four categories of histologic classification: 1) simple hyperplasia, 2) complex hyperplasia, 3) simple hyperplasia with atypia, and 4) complex hyperplasia with atypia (also called complex atypical hyperplasia). Each of these categories has an increasing risk of malignant potential (ie, less than 1%, 3%, 8%, and 29%, respectively). Atypical hyperplasia is equated with precancerous potential. These classifications are based on glandular complexity and nuclear atypia, which are subjective and not highly reproducible. Additionally, the WHO94 schema does not suggest management algorithms for each of these categories, leaving some health care providers unsure of how aggressively to treat the endometrial process.

Pathologists are most likely to reference the WHO94 schema; however, the EIN schema more clearly designates the malignant potential of the endometrial histology and has clear recommendations for management. The EIN schema has three categories: 1) benign endometrial hyperplasia (ie, benign diffuse changes caused by prolonged estrogen effect that should be treated with hormonal therapy if symptomatic); 2) endometrial intraepithelial neoplasia (ie, a precancerous lesion that should be treated with hormonal therapy or surgery); and 3) endometrial adenocarcinoma (ie, endometrioid type, well-differentiated cancer that should be treated with surgery). Because the EIN nomenclature system better distinguishes the malignant potential and offers treatment recommendations, many gynecologic providers prefer this system of reporting.

The described patient’s complex atypical hyperplasia has a high malignant potential, which is considered a precancerous lesion. This diagnosis should be managed as an EIN. Therefore, surgery (ie, hysterectomy) or hormonal treatment is recommended. In addition to having poor pathological reproducibility, atypical hyperplasia can have diagnostic discrepancies between endometrial sampling and hysterectomy specimen. Approximately 40% of patients who received a diagnosis of complex atypical hyperplasia were found to have concomitant carcinoma diagnosed on hysterectomy. If a patient with this diagnosis does not desire future fertility and is not a poor surgical candidate, total hysterectomy is recommended. However, for this patient who wants to become pregnant soon, hormonal treatment is the best next step in managing her condition.

Oral and local progestin therapies are commonly used but are unproven alternatives to hysterectomy. Although many studies describe the effectiveness of progestin therapy, there has been no standardization of medication, dose, or schedule for the various progestin therapies that have been used to treat hyperplasia. There is no consensus on the preferred hormonal treatment for endometrial hyperplasia. Options include oral medroxyprogesterone, intramuscular depot medroxyprogesterone, micronized vaginal progesterone, oral megestrol acetate, and levonorgestrel IUD (Table 3-1). Oral progestins and the levonorgestrel IUD are the most commonly used hormonal treatments for endometrial hyperplasia and are reasonable first nonsurgical options. Studies have shown atypical endometrial hyperplasia regression rates of approximately 70% with oral progestins and 90% with the use of a levonorgestrel IUD. For this patient with who wishes to retain her fertility, the levonorgestrel IUD should be offered to manage her complex atypical hyperplasia. Although the ideal frequency and duration is not yet determined, it is reasonable to advise serial endometrial sampling every 3–6 months for hormonal treatment surveillance. Endometrial sampling can be performed with the IUD in situ.

Combination oral contraceptive pills are not an appropriate treatment for complex atypical hyperplasia. Endometrial hyperplasia is mediated by excess estrogen, specifically estrogen that is unopposed by progestin. Hormonal treatment should be progestin-only to counter-balance the unopposed estrogen.

If this patient did not desire pregnancy or failed progestin therapy, surgical treatment with total hysterectomy would be an appropriate and reasonable management option. The surgical approach can be abdominal, vaginal, or minimally invasive (laparoscopic or robot-assisted) and can be performed with or without bilateral salpingo-oophorectomy. These surgical decisions are individualized for the patient. Supracervical hysterectomy is not an acceptable surgical treatment option because of concerns for a concomitant carcinoma. Leaving the cervix in situ at the time of hysterectomy puts the patient at risk of leaving behind residual disease if an underlying cancer is present.

Endometrial intraepithelial neoplasia. Committee Opinion No. 631. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;125:1272–8.

Kurman RJ, Kaminski PF, Norris HJ. The behavior of endometrial hyperplasia. A long-term study of untreated hyperplasia in 170 patients. Cancer 1985;56:403–12.

Trimble CL, Method M, Leitao M, Lu K, Ioffe O, Hampton M, et al. Management of endometrial precancers. Obstet Gynecol 2012;120:1160–75.

4

Urinary frequency

A 68-year-old woman presents to your office with new-onset urinary frequency and loss of urine for the past month. Her primary care physician started her on an antimuscarinic agent 2 weeks ago, and she has shown no improvement. She is a tobacco user and completed radiation therapy for cervical cancer 20 years ago. Pelvic examination is unremarkable and urinalysis is negative for leukocytes, nitrites, and white blood cells. Microscopic hematuria is noted. The best next step in the evaluation of this patient is

*  (A) cystoscopy

(B) renal ultrasonography

(C) intravenous pyelography

(D) voiding cystography

Overactive bladder is defined as a symptom syndrome suggestive of lower urinary tract dysfunction. The syndrome is characterized by urinary urgency with or without urge incontinence, usually with frequency and nocturia, in the absence of pathologic or metabolic factors. Overactive bladder affects one in six people in the United States, resulting in more than 37 million affected individuals. The estimated cost of incontinence is more than $16 billion and numerous quality-of-life studies demonstrate a significant effect on the population. Although overactive bladder symptoms are very common, the diagnosis is made when pathologic and metabolic factors have been ruled out. Initial evaluation includes a complete history and physical examination. There are certain red flags that should prompt the health care provider to proceed with further evaluation. Descriptors such as sudden onset or extremely severe can imply underlying pathology. Presence of a mass in the abdomen or pelvis or bony tenderness can result from cervical, uterine, or ovarian malignancies as well as metastatic disease. Given this patient’s history of radiation therapy, late-onset radiation cystitis should be included in the differential diagnosis.

Bladder cancer is a common malignancy affecting the urinary tract. Hematuria is the most frequent presentation, but bladder cancer also can present with urinary frequency, dysuria, and other symptoms consistent with a urinary tract infection. Tobacco use is the greatest risk factor for bladder malignancy. Other risk factors include radiation therapy to the pelvis as well as various occupational exposures such as chemicals handled by hairdressers.

For a patient presenting with urinary frequency, the gynecologic care provider should include a urinalysis in the initial evaluation. Hematuria in the absence of a urinary tract infection or evidence of urinary stones is an indication for further evaluation. The described patient has a sudden onset of urinary frequency and urine loss with microscopic hematuria and significant risk factors for bladder cancer. The most appropriate next step is to evaluate the lower urinary tract. Cystoscopy is the most effective way to rule out bladder malignancy and, therefore, is indicated for this patient.

Renal ultrasonography has several functions when evaluating the upper urinary tract. For example, with chronic kidney disease resulting from long-term vascular pathology caused by diabetes or hypertension, the kidney is typically smaller than normal size. With acute disease, such as obstruction of the ureter secondary to stones or iatrogenic injury, the kidney is enlarged. Ultrasonography can identify kidney stones as well as a large renal mass. The preferred imaging technique to evaluate the upper urinary tract in patients with hematuria is urography using computed tomography. The absence of contrast allows stones to be visualized. Intravenous contrast allows the anatomy of the upper urinary tract to be evaluated for small masses or evidence of malignancy and can delineate the path of the ureter evaluating for obstruction, fistula, or a duplicated system. Because this patient’s symptoms are not suggestive of upper tract disease, such as severe onesided back, groin, or pelvic pain, this test is not indicated.

An intravenous pyelography is used to evaluate the patency of the ureters. This patient’s presentation is not initially concerning for ureteral obstruction. Patients with ureteral obstruction typically present with upper tract disease symptoms. They can experience fever, nausea, or emesis. If the obstruction is acute in onset, such as in an iatrogenic obstruction, serum creatinine can transiently rise 0.3 mg/dL from its baseline before the other kidney compensates.

A voiding cystography is typically utilized to evaluate the bladder for defects, including checking the integrity of a cystotomy repair. With this process, a fluoroscopic study of the bladder is performed while the patient is voiding. If a cystotomy repair or a urethral anastomosis continues to leak, contrast would be visualized escaping the cavity. See Video 4-1 at https://prolog.acog.org/gyn/8 to view a cystoscopy.

Chong EC, Khan AA, Anger JT. The financial burden of stress urinary incontinence among women in the United States. Curr Urol Rep 2011;12:358–62. Available at: https://link.springer.com/article/10.1007%2Fs11934-011-0209-x. Retrieved January 30, 2018.

Metts MC, Metts JC, Milito SJ, Thomas CR Jr. Bladder cancer: a review of diagnosis and management. J Natl Med Assoc 2000;92:28–94.

Urinary incontinence in women. Practice Bulletin No. 155. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;126:e66–81.

Wilson L, Brown JS, Shin GP, Luc KO, Subak LL. Annual direct cost of urinary incontinence. Obstet Gynecol 2001;98:398–406.

Wrenn K. Dysuria, frequency, and urgency. In: Walker HK, Hall WD, Hurst JW, editors. Clinical methods: the history, physical, and laboratory examinations. 3rd ed. Boston (MA): Butterworths; 1990. p. 842–4.

5

Intraoperative hypotension

A 30-year-old woman is undergoing an exploratory laparotomy for large complex adnexal masses. She is allergic to penicillin, otherwise healthy, and not obese. Sequential compression devices are placed before induction of anesthesia. Prophylactic cephalexin is given. Upon entering the abdomen, the anesthesia team alerts you that the patient has a blood pressure of 60/30 mm Hg, a pulse of 130 beats per minute, and oxygen saturation of 80%. They are having difficulty ventilating her with evidence of laryngeal edema. The rhythm strip notes sinus tachycardia, and the patient has diffuse flushing. In addition to a bolus of intravenous fluids, the best next step is to administer

(A) broad-spectrum antibiotics

(B) blood products

*  (C) epinephrine

(D) heparin

(E) hydrocortisone

Anaphylactic shock is an immediate sensitivity reaction that occurs within minutes or hours after exposure to a trigger. More than 90% of immediate sensitivity reactions begin within 5–10 minutes, with fatal anaphylactic reactions occurring soon after contact with the trigger. Because early symptoms often include itching, flushing, and hives, the diagnosis can be delayed if the patient is intubated and draped. In those patients who develop anaphylaxis, estimates of perioperative anaphylaxis-related mortality are 1.4–9%.

The hallmark of perioperative anaphylaxis is cardiovascular and respiratory collapse. A cutaneous reaction may not be present. Combining the timing of the trigger with the onset of symptoms confirms the diagnosis (Appendix B). When the reaction occurs within the first 30 minutes of the trigger, the most likely causes are antibiotics (usually penicillin and cephalosporins), neuromuscular blocking agents, and hypnotic induction medications. Approximately 50% of the perioperative anaphylactic reactions in the United States are a result of antibiotics. When the reaction occurs after 30 minutes, the triggers are more likely latex, blood products, colloid volume expanders, protamine, and dyes. Treatment for perioperative anaphylaxis begins with early recognition, fluid therapy to compensate for the vasodilation, and epinephrine. Table 5-1 lists the grades of severity of immediate reactions to anesthesia along with symptoms and treatments. After initial resuscitation, patients may receive hydrocortisone but epinephrine is the initial drug of choice. Given the clinical picture and intraoperative exposures, the described patient is most likely suffering from an anaphylactic reaction and should receive epinephrine in addition to an intravenous fluid bolus.

Septic shock occurs secondary to an infectious etiology in which the patient develops peripheral vasodilation and intravascular hypovolemia. Presenting signs and symptoms include, but are not limited to, evidence of infection, hypotension, fever, tachycardia, tissue hypoperfusion, and low urine output. Sepsis presents as a serious sequela of pneumonia, bacteremia, or urinary and intraabdominal infections. Risk factors include extremes of age, immune deficiencies, burns, wounds, and hospitalization. The initial treatment includes blood pressure support with norepinephrine, broad-spectrum antibiotics, and intravenous fluid resuscitation. Because this patient presented for an elective procedure and has no risk factors or signs of a preexisting infection, septic shock is highly unlikely in this acute scenario and broad-spectrum antibiotics are not the best treatment option.

Acute and massive blood loss can present as hypotension and tachycardia. Treatment includes identification and control of the bleeding vessel as well as transfusion of blood products. The described patient was undergoing a laparotomy without any visualized bleeding, which makes acute, massive blood loss highly unlikely. In addition, a rash combined with acute pulmonary symptoms would not be evident with hypotension secondary to acute