GYNECOLOGY NOTES

Legal Issues and Ethics

Informed consent
Required for all procedures when patient is alert and hasnt received any narcotics or med that affect decision-making. Not
required in true emergency situations that would risk the patients life.
Elective cesarean section
Can be done just because the patient is afraid of pain. Do it at 39 weeks.
Patient privacy
Patient privacy is the responsibilty of physicians - can be fined or assessed criminal penalties for violating the privacy of
patients protected health information
Justice - requires physicians to educate patients about all treatment options in a nonjudgmental way regardless of the
nature of treatment and the patients socioeconomic status

Conflicts of interest
Drug companies can support conferences at which physicians receive CME credit
Investigators can do research for companies in which they own stock, if they declare the COI and it is addressed
Development

Puberty
Typically thelarche adrenarche growth spurt menarche
Delayed puberty
No secondary sex characteristics by age 14 delayed puberty.
Primary amenorrhea = no period by 16
No sex characteristics at all
Could be brain problem (no GnRH or no FSH) or ovarian problem (no estrogen)
Most common cause gonadal dysgenesis, most often because of chromosomal abnormalities - Turners is most
common, can also see 46XY and 46XX. If XY, remove gonads due to risk of cancer.
Brain: Kallman syndrome is failure of GnRH neurons to migrate to hypothalamus. Also impaired sense of smell. Boys
often born with micropenis. Treat with hormone replacement.
Noonan syndrome: Autosomal dominant. Short, webbed neck, triangular shaped face, delayed puberty, learning
problems
No period, normal breasts, normal pubic/axillary hair
Get a pregnancy test! Could be pregnant.
Most likely Mullerian agenesis - uterus just doesnt form. But have normal ovaries b/c they arent Mullerian structures.
1/3 will have renal anomalies - missing kidney, etc.
No period, normal breasts, minimal pubic/axillary hair: Most likely androgen insensitivity. 46XY
In androgen insensitivity, get breast development due to estrogen - mostly from peripheral conversion. The gonads and
adrenals also make a little bit.
Recall XY genotype can also have gonadal dysgenesis rather than androgen insensitivity - difference is that will not have
any secondary sexual characterisitics
Remove gonads after puberty
Workup:
Start with TSH, prolactin, bone scan. Only then add FSH to distinguish between brain and ovarian causes of delayed
puberty. Also free T4, adrenal and gonadal steroid levels
Physical exam - visual field defect, goiter
Skull imaging
Treatment:

Goals are to promote development, prevent osteoporosis, and promote full height potential - can use OCPs + growth
hormone
If phenotypic female is 46 X,Y remove gonads because they are predisposed to cancer. Can leave Turner
streak ovaries in place.

Precocious puberty
Onset of secondary sex characteristics more than 2 standard deviations below the mean - 7 in white girls, 6 in African
American girls
Causes
Most often idiopathic - GnRH pulse generator just gets turned on.
But other central causes include tumor, hydrocephalus, head trauma, hypothyroidism.
Hypothyroidism is unique because it causes delayed bone age while most other causes of precocious puberty cause
accelerated bone age.
Peripheral causes include granulosa cell tumors or adrenal tumors
Treat with GnRH agonist disrupts pulsatile GnRH!
If not treated, girl will at first grow fast, but then long bone epiphysis will close early eventual shorter
height
Variations
Period before hair or breasts: McCune Albright
Hair with high levels of DHEA and DHEA-S: Congenital adrenal hyperplasia/21 hydroxylase deficiency

Hypogonadotropic hypogonadism (Low FSH, Low estrogen)

Poor nutrition or eating disorders
Extremes in exercise
Chronic illness, stress
Primary hypothyroidism
Cushing syndrom
Pituitary adenoma
Craniopharyngioma

Annual exam
Test all sexually active < 25 yrs for gonorrhea and chlamydia

Infections
KOH prep lyses RBCs and lymphocytes, making diagnosis easier. Very positive whiff test with BV, postive whiff test with
trichomonas (but less so than BV), and psuedohyphae with candida.
Bacterial vaginosis
Diagnosis based on 3 of 4 Modified Amsel criteria: Thin gray homogenous discharge, pH > 4.5, positive whiff test, clue
cells
Assoced with preterm delivery, postpartum endometritis, and pelvic inflammatory disease
Treat with metronidazole. Warn about disulfiram reaction with alcohol (flushing, HA, hypotension, tachycardia, dizziness,
nausea, vomiting)
Trichomonas
Yellow-green frothy discharge, no fever or pain. Strawberry cervicitis because its highly inflammatory (BV is not).
Trichomonads are unicellular protozoans - can see them moving across the slide with flagella
Drop of KOH fishy odor = positive whiff test
Treat with metronidazole - partner needs treatment, too!
Candida vaginitis
Thick white clumpy discharge, erythema, swelling, intense itching
KOH hyphae
Herpes
Painful genital ulcerations, fever, dysuria. Resolution of the acute episode must happen before speculum can be inserted
for endocervical gonorrhea and chlamydia testing. If she was high risk, could offer prophy for G & C
Multinucleate giant cells and inflammation. Culture is the gold standard for diagnosis, but it has a 10-20% false negative
rate! Serum antibody testing would only indicate lifetime exposure, not identify the cause of a particular lesion.
Syphilis

Painless ulcer with rolled edges in primary, then 9 weeks later copper penny lesion rash on palms and/or soles. May also
have condylomata lata - flat moist lesions on vulva. will progress to tertiary syphillis (CNS, CV involvement)
If high suspicion,do treponemal specific tests - not the nontreponemal tests (VDRL or RPR), which are non-specific (e.g.
false positive RPR with lupus). But the treponemal tests remain positive for life! Also early serology may be negative if
antibodies havent developed yet.
If pregnant, treat all stages with penicillin G (IV or IM). If not pregnant, can consider doxycycline or tetracycline except for
CNS involvement. Can give one dose for early syphillis, but late disease requires 3 weeks. Monitor titers after.
Chancroid
Tender ulcer with ragged edges on a necrotic base. Tender LAD.
Haemophilus ducreyi is a small, gram negative rod
Hepatitis B
If a patient has not been vaccinated and has unprotected sex with a person who has Hep B, treatment depends on HBsAg
status of the partner. Always vaccinate the patient, but if partner is HBsAG+, then also give Hepatitis B immunoglobulin.
Acute salpingitis = pelvic inflammatory disease:
Lower abdominal pain (mild to severe), adnexal tenderness, fever, cervical motion tenderness, new foul-smelling
discharge, +/- dysuria and painful defecation. Can have RUQ if have perihepatic adhesions = Fitz Hugh and Curtis
Syndrome.
Risk factors: nulliparity, IUD around time of placement (disrupts endocervix)
Can be caused by ascending vaginal flora (especially if after menses) or by STIs. Usually polymicrobial!
Gonorrhea:
Mucopurulent cervicitis with exacerbation during and after period.
May have septic arthritis (migratory arthritis of large joints), pharyngitis, or disseminated gonorrhea (eruptions of painful
pustules on erythematous base - do gram stain and culture).
Can cause blindness in baby - presents by day 5, vs. chlamydia which presents > 5 days later. Erythromycin ointment only
protects against gonorrhea, not chlamydia - that requires 14 days of oral erythromycin.
Chlamydia:
Often associated with gonorrhea.
Most common cause of mucopurulent discharge (though gonorrhea also causes). Doesnt cause pharyngitis (lacks
pili).
In pregnancy, treat with amoxicillin, azithromycin (single dose), or erythromicin. Outside of pregnancy, do one dose of
azithromycin or 7 days of doxycycline
Can also cause lymphogranuloma venereum, large and very painful lymphadenopathy with small, painless (or even
absent) ulcers
Note that G/C dont typically cause vaginitis - more cervicitis and upper tract infections.
Generally treat for both, even with a negative gram stain (chlamydia is intracellular, gonorrhea can have false negatives),
but negative results on nucleic acid amplification are reliable - only treat for whatever is positive.
Management
Inpatient; If significant fever, admit and give inpatient IV abx to prevent scarring of fallopian tubes and possible infertility
(IV cefotetan or cefoxitin and IV or oral doxycycline, or clindamycin + gentamicin). Treat before cultures return. Continue
IV abx for 24 hours after clinical improvement, then doxy for 14 days as an outpatient.
Outpatient: If fever is low grade, can tolerate oral meds, no peritoneal signs, can follow up, and not at the extremes of
age. Ceftriaxone, cefoxitin or other 3rd gen cephalosporin (single injection IM) AND doxycycline for 2 weeks, with or
without metronidazole for 2 weeks. Follow up in 48 hrs!
If G/C - recent partners should be informed with or without consent and treated.
Consider ultrasound to look for TOA.
If persistent hydrosalpinx and pelvic pain, do laparoscopy to investigate and then consider salpingectomy
Big risk of tubal infertility - 12% after one episode, 25% after two episodes, 50% after three. Also risk of chronic pelvic pain
and ectopic pregnancy. Counsel on avoiding future episodes.
Tuboovarian abscess
Can be bilateral! Symptoms = severe abdominal pain (diffuse abdominal and bilateral adnexal tenderness), diarrhea,
nausea, fever. Can see 3-4 cm complex masses on pelvic ultrasound
Cause: Most often STIs like gonorrhea and chlamydia, but can be ascending infection from the GI or GU tract.
Aerobic and anaerobic polymicrobial infection. E Coli, Klebsiella, Garderella vaginalis, prevotella, GBS, enterococcus.
Treatment
Need anaerobic coverage! Clinda or metronidazole. Can often be treated without surgical drainage, but rupture is a
surgical emergency.

Urinary tract infections

Most often caused by E coli
Low pelvic pain, urinary frequency, urinary urgency, hematuria, or new issues with incontinence
If urinary symptoms with negative urinalysis/culture, then suspect urethritis - chlamydia, gonorrhea, or trichomonas. Do a
swab.
PAP smears
Schedule:
Start at age 21, regardless of age of sexual activity, unless patient is immune compromised (lupus, HIV,
steroids, etc.) then do at onset of sexual activity (twice first year and then annually)
Age 21 to 65, do cytology alone every 3 years
Age 30 to 65, can do cytology and HPV (cotesting) every 5 years.
Discontinue between 65 and 70 if 3 consecutive negative smears or 2 negative consecutive cotesting in 10 years
and no history of high grade intraepithelial neoplasia or cancer. Still need yearly bimanual and rectovaginal exams!
Not necessary after hysterectomy, unless it was done for cervical cancer or high grade dysplasia
Exceptions: Doesnt apply to women who have had cervical cancer, who are infected with HPV, have a weak immune
system, or were exposed to DES in utero (risk of clear cell vaginal cancer - usually in teens or 20s! Also risk for genital
tract anomalies in both women and men)
Abnormal PAP
If atypical squamous cells of undetermined significance (ASGUS) send HPV type. If high risk HPV
colposcopy with biopsy, or as an alternative, can repeat PAP in 12 months and if normal, return to routine
screening.
Only initiate further therapy with biopsy-confirmed dx of cervical dysplasia
Mammograms
American cancer society and ACOG: yearly at age 40. USPSTF: every two years at age 50.
BRCA screening: may be appropriate if 1st and 2nd degree relatives on the same side of the family have breast and
ovarian cancer (once cancer type per person)
Colon cancer
Colonoscopy at 50 and repeat every 10 years, or signmodioscopy at 50 and repeat every 5 years
Bone density
DEXA scan beginning at age 65.
Consider early screening if: early menopause, steroids, sedentary, alcohol, smoking, hyperthyroid, anticonvulsants, Vit
D deficiency, family history, chronic liver or kidney disease, dowager hump, etc.
Osteopenia = -1 to -2.5 - should be interpreted with risk factors for fracture. If no risk factors, do counseling on calcium
and Vit D intake and reduce risk factors in order to delay need for meds.
Risk factors for fracture: previous fractures, FH of osteoporosis, race, dementia, falls, poor nutrition, smoking, low BMI,
estrogen deficiency, alcoholism, insufficient physical activity
Compression fractures of thoracic spine is most common.
Treatment:
Lifestyle: Balanced diet with calcium and Vit D, 1200 mg calcium per day, exercise, avoid lots of alcohol, quit smoking
If risk factors for osteoporosis and an osteoporotic fracture, treat with bisphosphates. Before starting, do a DEXA scan
and then repeat every two years
HRT not recommended for long term disease prevention - especially in patients with CV disease

Labs
Start CV related labs at age 45: Lipid panel every 5 yrs through age 75, fasting blood glucose every 3 years. Thyroid
screening every 5 years starting at age 50
Urinalysis if 65+ because the risk of urosepsis

Vaccinations
Pregnancy or the possibility of pregnancy w/in 4 weeks is a contraindication to MMR and varicella vaccines!
Tetanus, Hep B, and pneumococcal vaccines are okay in pregnancy
Varicella vaccine at age 60. Its a live attenuated vaccine - give even if the patient has already had shingles!

Dont give HPV vaccine if pregnant! Usually give to girls 9-26 and boys 9-21 (or up to 26 in men who have sex with
men)
Nutrition
Folate lowers homocysteine levels reduces nonfatal MIs and fatal coronary events in women. Dietary
intake is not enough! Women of reproductive age should take a daily 400 microgram supplement.
Menopause

Average age of menopause is 51 yrs. Technically means the last period, but used to describe the chapter in life after that
point. Perimenopause/climacteric is the transitional period.
Symptoms: Hot flashes, night sweats, vaginal dryness. Some women are asymptomatic due to peripheral conversion of
androgens to estrogen. Hot flashes usually increase in frequency up to menopause and then continue for several years
after.
Diagnosis: Clinical, but AMH decline is the earliest marker, followed by inhibin B, then estradiol.
Treatment:
Estrogen (+/- progesterone) is most effective treatment. HRT = estrogen plus progesterone, indicated if she has a
uterus. Do smallest effective dose for shortest possible time.
Dont use to prevent CV disease because of slight increase in risk for breast cancer and cardiovascular disease (MI,
stroke). No increased risk from 6 months of treatment, no increased CV risk in women in their 50s.
Reduced risk of osteoporosis and colon cancer.
Added benefit on lipid profile: Increase HDL and reduce LDL - but not recommended for primary prevention of heart
disease
Other less effective options: Clonidine, soy products, SSRIs, anti-seizure meds
Contraceptive counseling
Endometrium grows with estrogen and progresterone. Progesterone maintains it, estrogen stabilizes it

OCPs
Reduce risk of PID, endometriosis, ovarian cancer, endometrial cancer benign breast disease, and ectopic pregnancy.
Maybe also slight decrease in breast cancer risk.
Patch
Twice the rate of DVTs as compared to OCPs

Combined: Pill, patch, ring

Have similar rates of efficacy - 10% failure on average, but < 1% failure with perfect use
Estrogens are all the same, progesterones are different - more or less androgenic (can cause or improve acne). Can look
up this scale.
Levonorgesterol: more androgenic
Can use perpetuously, but likely to have breakthrough bleeding because lining is thin. Can then decide to take a break
after spotting happens if she wants.
Average age of menopause is 51.5 yrs - can discontinue around then. Menopause - no period for 1 year.

LARCs: Long acting reversible contraception

Equally effective as tubal ligation

Estrogen
Anything under 50 micrograms is low dose - that's true of all OCPs now.
Slight gradation of VTE risk - still only 1 in 1000 per year. Pregnancy is like 30 per 10,000, post partum is 300 per 10,000

Emergency contraception

Multiple OCPs: do ASAP, esp within 72 hours and no later than 120 hours. Then just begin OCPs as contraception
immediately after, dont wait until next period. Biggest side effect is nausea and vomiting.
Plan B = levonorgestrel: - take it twice. Most common side effect is nausea - give zofran - but less nausea than with OCP
method. 75% effective for up to 3 days, just like taking OCPs
Ella = ulipristal: Selective progesterone agonist/antagonist. 75% effective for up to 5 days
Paraguard: Can do for up to 7 days! 99% effective - the best emergency contraception.
Usual rules of thumb about contraindications for OCPs dont apply! Benefits outweigh the risks even if CV disease, etc.
Progesterone
Good for women with migraines, women who are breastfeeding, can start right away after delivery - does not increase
stroke risk?
Good for smokers, people with hypertension, other CV risk markers - obesity, diabetes
Still ovulate with progesterone! Someone who has ovulatory pain might want to avoid progesterone only.
Depo-provera:
Given every 3 months
Fertility can take 6 months to 1.5 years to come back - unlike pill, which is instant.
Might not be good for women who want to get pregnant right away
Black box warning - can lose bone mineral density after two years, might not regain it. Also have bone density loss
with pregnancy and breast feeding - but this is reaccumulated afterwards
Good for women with sickle cell or epilepsy - get fewer episodes with depo!
Nexplanon
Matchstick implant for 3 years
Progesterone only
Some of the highest rates of unscheduled bleeding
Mirena
5 years, but data on it for cycle control up to 7 - contraceptive efficacy up to 5.
Creates a thin endometrium by having a foreign body, also creates thicker cervical mucous and impairs fallopian cilia
movement
80-90% reduction in bleeding. 20% have no periods. Also have less pain because of reduced progestins. But bleeding is
unscheduled - especially for 3-6 months
Paraguard
Copper IUD for 10 years
Main impact on sperm swimming
Heavier bleeding - might be a good choice for women who have light periods at baseline, not good for women who have
heavy periods

Skyla
Basically mirena, good for three years

IUDs in general
Small infection risk at the time of placement - maybe 1%? No long term risk
Contraindicated if current STI, PID currently or within the past three months.

Guideline for the discussion:

1) Failure rates
2) Ask what things are easy or hard for her
3) Taking the pill
Take it the same time every day
What to expect:
Periods will be regular, women will start to bleed anywhere from 0-4 days after last hormonal pill.
Shorter placebo stretch: Good for women who have migraines, or can have seasonal - have a period every few months
Lighter periods --> less pain (reduced prostaglandins):
Progesterone makes the endometrium decidualize (thinner), estrogen stabilizes the lining.
Better skin: more sex hormone binding globulin from the liver

Weight gain: Studies show it's not associated with the pill, except for Depo-Provera because it's a huge dose of
intramuscular progesterone. Stimulates appetite.
Biggest weight gain is in adolescent women who are already overweight - be careful giving Depo to this group
Nausea: usually gets better over time
Mood disorder: usually if prone to mood disorders
Breast tenderness, transient hot flashes
Contraindications
Migraines: STOP THE PILL IF MIGRAINES WITH AURAS - increased stroke risk. But they can take progesterone only
forms of contraception - progesterone doesn't increase clot risk.
Poorly controlled HTN
Smoking over age 35
Previous history of clots or strong family history
History of hormone positive cancer - OCPs don't cause breast cancer
Missed pills:
Miss one pill: take both the next day. Miss two pills, take two for two days - use back up method
Miss three pills - have a period and start a new pill pack. Maybe not a good method for them
4) The patch
Change it weekly, new area of skin, one week don't wear it
Same risks/benefits/CIs as the pill
Less effective in women over 200 lbs - same is actually true for the pill
5) Ring
Wear it three weeks, take it out for one week
May have increased vaginal discharge. If it falls out, rinse it off and put it back in within three hours. Can take it out for
sex, but have to put it back in within 3 weeks
Put it in with circle vertical, not horizontal
Store it in the fridge
PERMANENT CONTRACEPTION

Essure
Placed in the FT with a hysteroscope? Made of fibers that cause local inflammation and tube grows into it.
Takes three months to become effective. Then have to have a hysterosalpingogram to ensure that it worked. Is actually a
fairly painful procedure. Basically no failures when tubal occlusion is confirmed
Do it immediately after a period - during it's hard to see, and with thin lining easier to see the openings. Can also take
OCPs before to suppress the lining. Give toradol before hand.
Not candidate:
people who might want to be pregnant in the future.
Nickel allergies! Can't wear cheap jewelry or get a rash at the belt buckle. If questionable, go to derm for skin patch testing
Previous surgery on tubes -need to get the op report to know whether one or both FTs is still there
Laproscopic or post partum tubal ligation
CREST Study: 2% failure rate over 10 years
Certain types of ligations are more likely to fistulize and recanulate
Increased risk of ectopic pregnancy if they do get pregnant - also true with IUDs
Slightly reduces risk of ovarian cancer. Does not reduce risk of breast, cervical, or endometrial cancer. No decrease in
menstrual flow.
Abortion

Medical abortion
Start with mifepristone (anti-prostaglandin), follow with misoprostol (induces uterine contractions).Oxytocin has a high
failure rate.
More bleeding than surgical procedures. If bleeding is very heavy, then do a D&C - e.g., soaking more than a pad per
hour for several hours. Do D&C even if she is asymptomatic.
Surgical abortion

Manual vacuum aspiration: okay up to 8 weeks.

Dilation and curettage: less than 16 weeks
Dilation and evacuation: Can be done after 16 weeks
PMS/PMDD
Risk factors: Family history of PMS, vitamin B6, calcium deficiency, or Mg deficiency. More common with older age,
symptoms tend to get worse with time.

Treatment:
OCPs
Correct deficiencies in Vitamin A, E, and B6
Irregular Vaginal Bleeding
If heavy periods consider fibroids.
If intermenstrual bleeding, also consider endometrial hyperplasia, endometrial polyp, uterine cancer
If irregular periods suggests anovulatory process

Menorrhagia
Fibroids = leiomyomata
Usually asymptomatic, but most common symptom is very heavy periods w/out spotting in between periods - maybe
b/c increased surface area, ulceration of fibroids, or disrupted hemostatic mechanisms during menses
Other symptoms/signs:
May have enlarged uterus and symptoms from compression of adjacent organs - urinary frequency from bladder
compression or constipation from compression of sigmoid colon.
Note: enlarged uterus, urinary frequency, and constipation are not seen with adenomyosis or endometriosis.
Pressure, pain if fibroid on pedicle twists, submucosal fibroid can prolapse through cervix labor like
contractions.
Irregular midline mass that moves w/ cervix. If subserosal, may feel bumpy uterus on exam
Submucosal fibroids recurrent abortions
On biopsy - well circumscribed non-encapsulated myometrium. If > 10 mitotic figures PHF, then leiomyosarcoma.
Red degeneration/carneous degeneration = center of fibroid becomes red, painful due to rapid growth
Differential: ovarian mass, tubo-ovarian mass, pelvic kidney, endometrioma (dysmenorrhea, dyspareunia)
Diagnosis: Symptoms + exam, do ultrasound to confirm. Lateral, fixed, or fluctuant are not typical for fibroids!
Still have to rule out endometrial cancer in women over 40! Do endometrial biopsy
Treatment:
If asymptomatic, observe.
Intervene if anemic.
Meds:
Start with NSAIDs
Progestin if small. Cant use an IUD if uterine cavity is irregular
GnRH agonist to shrink fibroids temporarily, correct anemia, or make surgery easier. Will regrow, so not typically used
except as prep for surgery.
Surgery
If no pregnancy desired:
Hysterectomy if symptoms despite medical treatment and no desire for pregnancy. Most common indication for the
procedure!
Uterine artery embolization - 5 year 75% effective. Increased risk of placental abnormalities.
If pregnancy desired
Myomectomy if symptomatic but want to become pregnant - 25% will need hysterectomy in 20 years. Does increase risk
of uterine rupture - do c-section if endometrial cavity entered during the procedure.
Risk: Small risk of progressing to cancer.
Suspect if rapid growth (> 6 week size in one year). Especially if post-menopausal, because fibroids grow in response to
estrogen
Radiation is a risk factor.

Adenomyosis
Endometrial glands and stroma penetrates the myometrium tries to slough off during menstruation but
gets trapped regular but heavy periods, prolonged periods painful cramps or pain all the time, bloating.
Risk Factors: women 35-50 who have had prior things mess with the uterus - pregnancy, C-section, d&c, other surgery,
etc.
Diagnosis: Enlarged, soft, boggy uterus on physical exam. Diagnose with transvaginal ultrasound
Treatment: GnRH agonist is first line, but will recur. Hysterectomy is the next best option, but if dont want that, can do
progesterone IUD or endometrial ablation
Clotting disorder - Von Willebrand Disease
Heavy periods right from the start, not helped by OCPs
Secondary Amenorrhea
Amenorrhea can result from any one of four main causes: Hypothalamic, pituitary, ovarian, or uterine/outflow tract

Hypothalamic:
Excessive exercise, wt loss, stress, hypothyroid, hyperprolactinemia
Hyperprolactinemia [see below for causes of hyperprolactinemia]
Prolactin inhibits pulsatile GnRH low FSH low estradiol thin, dormant endometrium and risk of
osteoporosis
Hypothyroid
Increased TRH stimulates prolactin secretion amenorrhea and can also have galactorrhea

Pituitary:
Sheehan, irradiation or surgery on pituitary
Sheehan syndrome:
Hypotension after delivery hemorrhagic pituitary necrosis.
The pituitary gland is particularly vulnerable b/c of hypertrophy and hyperplasia of the lactotrophs during pregnancy
without any increase in vascular supply. Does not affect posterior pituitary, because that gland has its own arterial blood
supply
Low TSH, FSH, LH (monophasic body temp), ACTH, prolactin. Will bleed in response to estrogen and progestin.

Ovarian:
PCOS, premature ovarian failure

Uterine/outflow tract:
Cervical stenosis
Risk after cervical conization. If untreated severe endometriosis
Adhesions
Diagnose adhesions with hysterosalpingogram = radiologic study with radio-opaque dye, used to evaluate the cavity or
the fallopian tubes, or saline infusion sonohysterography = vaginal u/s with saline to enable enhanced visualization of
the cavity
Treat with operative hysteroscopy. Maybe insert UID or pediatric foley catheter to prevent adhesions from reforming.
Consider combined estrogen/prgoesterone and reevaluate cavity before trying to conceive.
Galactorrhea
Can be caused by: pituitary adenoma, pregnancy, breast stim, meds, chest wall trauma, or hypothyroidism!

Hyperprolactinemia causes
Drugs: tranquilizers, TCAs, antihypertensives, narcotics, OCPs, anti-psychotic meds
Hypothyroidism - TRH stimulates prolactin secretion!

Hypothalamic causes (decreased dopamine): craniopharyngioma, sarcoidosis, histiocytosis, leukemia

Pituitary causes: adenoma, empty sella, acromegaly
Hyperplasia of the lactotrophs
Renal disease - acute or chronic
Chest surgery or trauma - herpes, breast implants!

Work up
Prolactin can be elevated from stimulation of the breast during physical exam! Most accurate if patient is fasting - get
fasting prolactin before proceeding with further work up.
If prolactin is mildly elevated (20-60) measure TRH
If prolactin is seriously elevated, normal, or patient has neuro symptoms MRI
Pituitary adenoma is especially likely if estrogen is very low (< 40)

Management
Just watch
If galactorrhea but normal menses and normal serum prolactin
If microadenoma and do not want to conceive, have no estrogen deficiency
Bromocriptine or cabergoline (dopamine agonists) if want to have kids. Bromocriptine can be used during pregnancy!
Can treat with estrogen
If estrogen levels are adequate, can treat with periodic progestin withdrawal

Infertility

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10-15% of couples are affected by infertility. For a normal couple, 20-25% chance of getting pregnant in a given month.
Do simple tests before more complicated ones - e.g., if woman and man both seem okay but are experiencing trouble
conceiving, do semen analysis before hysterosalpingogram.
Basically six possible etiologies of infertility:
Ovulatory dysfunction - 30-40% of infertility
Caused by hypothalamic disturbances (hypothyroid, hyperprolactinemia), PCOS, and premature ovarian failure.
Exercise induced hypothalamic cause: normal FSH with low estrogen.
Premature ovarian failure: can be caused by chemo, radiation, autoimmune, fragile X, turner syndrome. Usually FSH > LH
because LH is cleared faster.
Test with basal body temp (0.5 degree rise w/ progesterone), LH surge, or progesterone level.
Treat with clomid.
Evaluation
OTC ovulation kits are good, they look for LH in urine - ovulation happens 36 hours after LH surge.
Cant use body temp, because it retroactively registers ovulation and the egg is only good for 24 hours.
Can conceive if have sex < 3 days before ovulation (sperm can live up to 5 days), can be fertilized for up to 12 hours after
ovulation.
Endometrial bx for secretory tissue
Over age 30: Day 3 FSH, AMH testing
Uterine dysfunction
Fibroids, do hystosalpingogram to dx, treat with hysteroscopic procedure
Tubal dysfunction
Suspect if hx of chlamydia or gonorrhea, dx with hystosalpingogram (laparoscopy is gold standard), could try tx with
laparoscopy but generally bad - IVF is better
But most women have no hx of gonorrhea or chlamydia - these infections are often asymptomatic.
Cervical dysfunction (rare)
Suspect if thick viscid cervical mucus before ovulation. Inject washed sperm through a catheter to bypass cervix.
Male factor - DO A SPERM ANALYSIS IF THE WOMAN SEEMS NORMAL!!!
Varicocele, hernia, mumps, klinefelter (xxy). Might need IVF (cant swim)
Cant dx based on one test - repeat in 2-3 months because spermatogonia sperm takes 74 days
Test even if the man has fathered other children
Peritoneal factor (endometriosis) - 0.5-5% of fertile women and 25-40% of infertile
3 Ds of Endometriosis: dysmenorrhea, dyspareunia, dyschezia. But can be asymptomatic!
Dx with laparoscopy (lesions can be clear to red to the classic powder burn color),
Treatment in general:

10

First try OCPs and NSAIDs. Can also do GnRH agonists for the short term - will downregulate release of FSH and LH.
Laparoscopy with ablation/excision of endometriosis in patients who are planning pregnancy
If no pregnancy desired, remove ovaries with or without a hysterectomy.
Treatment of infertility
Hysterosalpingram to check the tubes
If tubes are patent, give clomid and consider IUI
Endometrioma: Complex ovarian cysts made up of endometrial tissue

ART
1-2% of pregnancies in the US! Do for severe tubal factor, male factor, endometriosis, or other unexplained infertility not
responsive to medical therapy
Androgenism

PCOS
Ratio of LH to FSH is often a supporting diagnostic factor, but inconsistent and unreliable
Signs of hyperandrogenism - acne, hirsutism, alopecia. Caused by perpetual anovulation?
Consider other causes of hyperandrogenism
congenital adrenal hyperplasia, hyperprolactinemia, adrenal/ovarian tumors, Cushing, thyroid
DHEA-S is made by adrenal gland, testosterone is from ovaries
Hyperthecosis: Like PCOS, but more severe androgenism - difficult to induce ovulation

Cushings syndrome
Can cause hirsutism! Order dexamethasone suppression test or 24 hour urine cortisol
Other causes:
Congenital adrenal hyperplasia:
Congenital aromatase deficiency: Prevents conversion of androgens to estrogens - in utero can even lead to
masculinization of the mother that resolves after delivery. Will be XX with ambiguous external genitalia and normal internal
genitalia. Have delayed puberty, osteoporosis, undetectable circulating estrogens, high gonadotropins, and polycystic
ovaries.
Breast mass

Breast cancer generally:

Age is the most important risk factor - 1 in 30 at 60 yrs. Infiltrating intraductal cancer is most common.
Do clinical breast exam every 3 years for women 20-39 yrs. Mammogram annually over 40 yrs.
BRCA1 and BRCA2 screening - autosomal dominant!
Do if 2 first degree relatives with breast cancer.
BRCA1 - 50-70% chance of breast cancer, 30% chance of ovarian. BRCA2 is slightly lower.
Work up of dominant breast mass = mass felt to be separate from the rest of the tissue.
Triple assessment: Physical exam + imaging + core needle biopsy. If all three agree 99% chance that it is
not cancer. If any one is suspicious, remove the mass
Imaging:
Ultrasound or MRI is best in young patient, not hampered by dense breast tissue. Consider MRI if at high risk for breast
cancer
Mammograms
Have 10% false negative and false positive rates - still need to do histology of any palpable mass even if normal
mammogram!
No increased risk of cancer from radiation - dose is too low
Suspicious findings:
Small clusters of calcifications - especially if linear and wispy, spiculated and invasive borders, architectural distortion,
asymmetric increased tissue density when compared with prior studies, or corresponding area in the opposite breast

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Fat necrosis can look identical to breast cancer, with ill defined mass with cluster of calcifications. FN is more likely dx
than breast cancer if patient recalls trauma, but still have to do a biopsy.
Biopsy: greater risk of breast cancer need more tissue. Do core needle or excisional if red flags - older
patient, family history, fixed, bloody nipple discharge, nipple retraction.
FNA is acceptable if low risk. Can distinguish fibroadenoma from cyst, sometimes r/o cancer. But cant distinguish
in situ from invasive cancers
If fluid from a cyst is straw colored and mass disappears dont need to send for cytology.
If fluid is not straw colored (e.g, bloody) or if mass doesnt disappear send for cytology or just do
excisional biopsy.
Core needle: removes more tissue than FNA, but bruising and pain. If not palpable, can do stereotactic or needle
localization for bx
Stereotactic localization uses 3d view of the breast. Can still miss 2-4%.
Needle localization - excises more tissue, good for borderline histologic conditions like DCIS. Can still miss 3-5%.
Excisional: Removes the entire mass, more bruising and pain.
Fibrocystic change:
Cyclic, painful, engorged breast, lumpy bumpy, more pronounced just before menstruation, occasionally associated with
serous or green discharge.
Decrease caffeine - it can increase the pain associated with fibrocystic change, take NSAIDs, OCPs or progestin
Random benign masses
Fibroadenoma: Firm, nontender, rubbery, mobile. Does not change with menses (= dominant mass). Can just monitor,
but many women will want it removed.
Galactocele: cystic mammary gland tumor, occur when obstruction of milk flow in lactating breast
Bloody nipple discharge
If no mass and only one duct - most often intraductal papilloma. Small, benign tumor. But must do ductal exploration to r/o
cancer.
Cancer is second most common cause!
Mastitis
Can accompany pregnancy or nursing. Most often 2nd-4th week after delivery.
Treat with oral or IV abx, depending on severity. May use ibuprofen in addition to acetaminophen for pain. Keep
breastfeeding or expressing milk.
No ultrasound needed unless worried about breast abscess
GynOnc

HPV
16, 18, 31, 45 are high risk. 6, and 11 are low risk.
Gardasil vaccine covers 6, 11, 16, 18 - 16 and 18 cause 50% of cervical cancer and dysplasia
20% of population has HPV, usually transient.
HPV and cervical cancer
Transformation zone: area of columnar squamous metaplasia. Moves up endocervical canal, beginning at
os.
Screen with PAP - use biopsies to look at actual lesions
Start at age 21 regardless of age of onset of sexual intercourse.
If hysterectomy for benign reasons no more PAP. But if hysterectomy w/ a history of cervical
dysplasia, still need annual PAP smears!
Findings on PAP
ASCUS (atypical squamous cells of undetermined significance) - can triage management based on HPV typing. Not true
for LSIL or HSIL.
LSIL (low grade) or HSIL (high grade) follow with colposcopy

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Atypical glandular cells colposcopy, endocervical curettage, endometrial biopsy because it could be
endometrial, cervical, or vaginal cancer.
Colposocopy
Treat with ascetic acid squamous epithelium is pink and smooth, columnar is red and irregular.
Transformation is ghost white.
Acetowhite change = intraepithelial lesions turn white with acetic acid. They also have vascular changes
Punctations = new vessels on their endpoints,
mosaicism = new blood vessels on their sides.
Atypical vessels = biggest red flag. Corkscrew, hairpin, etc = more serious angiogenesis.
Biopsy suspicious lesions seen on colposcopy
CIN1 = lower is atypical, 60% regress. 1% chance of cancer without treatment
Expectant management. Follow with Pap smears at 6 months and 1 year, or do HPV DNA testing at 1 year. Dont do
excisional or ablative procedures.
CIN2 lower atypical, 40% regress, 5% would progress to cancer without treatment
Expectant management if patient is younger than 25, just like CIN1. If older, have to remove it - LEEP (office) or cold knife
cone (OR)
CIN3 = Carcinoma in Situ = full thickness, regresses. > 12% would progress to cancer without treatment
Microinvasive cancer: Invasion of < 3 mm beyond the basement membrane
Treatment:
ASCUS: Do HPV testing or repeat Pap in 12 months. If HPV is negative, then just resume routine screening and do Pap
in 3 years. If HPV is positive or repeat Pap at 1 year is still ASCUS or higher, then do colposcopy with ECC and directed
biopsies. If patient is 21-24 yrs, then follow the protocol but only do colposcopy if Pap shows HSIL, cant rule out high
grade lesion, or is AGC (atypical glandular cells).
CIN1 or CIN 2 in younger than 25 yrs: expectant management. Follow with Pap smears at 6 months and 1 year, or do
HPV DNA testing at 1 year. Dont do excisional or ablative procedures.
CIN2 & CIN3: immediate treatment
Ablation with cryotherapy or laser, but then no dx info
Excise with LEEP (office or OR, uses a loop) or cold knife cone (remove entire transformation zone with scalpel in OR)
In general, do cold knife cone if
Unsatisfactory colposcopy - including inability to visualize the entire transformation zone
Positive endocervical curettage,
Pap smear showing adenocarcinoma in situ
Cervical biopsies that cant rule out invasive cancer
Discrepancy between Pap smear and biopsy results! E.g., if Pap shows HSIL but biopsies are benign, then do cold
knife cone!
Cervical cancer
Usually squamous, can be adenocarcinoma
Symptoms: post coital bleeding! Most common cause of death is bilateral ureteral obstruction uremia.
Also suspect advanced disease if flank tenderness or leg swelling.
Risk factors: early age of coitus, STDs (indicates higher likelihood of exposure to high risk HPV), early childbearing, low
socioeconomic status, HPV, HIV, cigarette smoking, multiple sexual partners, exposure to DES
Treatment:
Early cervical cancer (within cervix) - can do radical hysterectomy or radiation. In women who want to become
pregnant, can do radical trachelectomy!
Advanced cervical cancer: radiation (brachy and tele) with chemo (usually platinum based to sensitize to radiation).
Lose sexual function and ovarian function - thats why surgery can be a better treatment for women who are eligible.
Endometrial hyperplasia
Increased gland to stroma ratio due to chronic exposure to estrogen. Can progress to endometrial cancer.
Four classifications based on two categories
Architecture: simple (with space between glands) or complex (crowded glands)
Presence or absence of atypia - increased nuclear to cytoplasm ratio
Simple no atypia = 1% progression to cancer
Complex without atypia = 3% risk
Simple with atypia = 8% risk
Complex with atypia = 29% chance of progression
Risk factors

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Age 50-70
Obesity - increased estrogen because of aromatase (testosterone estrodiol, androstenedione estrone)
Nulliparity - more exposure to estrogen in life, late menopause, early menarche
Diabetes - independent risk factor for endometrial hyperplasia and cancer
Tamoxifen - SERM, estrogen agonist on uterus
Estrogen replacement therapy if taken without progresterone
Hereditary nonpolyposis colorectal cancer = Lynch syndrome. 40-60% risk of endometrial cancer
Granulosa cell tumor - makes estrogen
Diagnosis
Abnormal vaginal bleeding or post menopausal bleeding endometrial biopsy, D&C in OR, or ultrasound
(post menopause < 5mm endo stripe = low risk)
Treatment
Progesterone: stroma decidualization and thinning of endometrium, oral or IUD. Repeat endometrial biopsy in 3-6
months
If atypia are present: Progesterone if desire to maintain fertility, otherwise hysterectomy is first line
Endometrial cancer
Most common female genital tract cancer. Usually detected early because associated with early symptom of abnormal
uterine bleeding - that is the most common symptom, too.
Can also have abnormal vaginal discharge and lower abdominal discomfort. Can increase uterine size, but usually not the
most common finding given the early diagnosis of the cancer
Risk factors: Unopposed estrogen (not HRT!), early menarche, late menopause, diabetes, estrogen-secreting ovarian
tumors, hypertension, family history (HNPCC or Lynch Syndrome)
OCPs decrease risk due to progesterone
Types
Type 1 Endometrial cancer
Typical endometrioid cell type, estrogen-dependent. Happens during menopause or soon after in patients with classic risk
factors of unopposed estrogen. Usually low grade and not as aggressive
Type 2 Endometrial cancer
Late menopause, thin patients, or those with regular periods - i.e., the atypical patient. Usually papillary serous or clear
cell, estrogen independent (ER neg) and aggressive.
Diagnosis:
Must work up any woman over 35 with abnormal uterine bleeding, and women younger than 35 if risk factors
Do an endometrial biopsy, and then maybe a D&C for diagnostics.
Once diagnosis is known, turn to staging
If early stage, do a chest x-ray. If suspcious for later stage, do a CT, MRI, PET, etc. CA-125 may be helpful in predicting
which patients may have extrauterine spread, but is not absolutely necessary
Treatment
Surgery is most important, even if stage 1! Usually total abdominal hysterectomy, BSO, bilateral pelvic and para aortic
lymphadenectomy for staging. Can do TVH with or without BSO if medically unstable or contraindications to major
surgery. Ideally, only do that with well-differentiated endometroid adenocarcinomas, avoid in aggressive types like clear
cell carcinoma, papillary serous carcinomas.
Do radiation if high suspicion for spread, and chemotherapy if surgery shows metasis.
If Grade 1 and want to get pregnant, can do high dose progestin with endometrial sampling in 2-3 months with
hysterectomy after childbirth
Vulvar cancer
Can have no signs or symptoms! Or can present with itching/ Biopsy any suspicious lesion on post menopausal women.
Average age is 65. Lichen sclerosus or any state of chronic vaginal itching is a risk factor. But can get in 30s - HPV,
cigarette smoking, immune suppression.
Precursors include VIN1, VIN2, VIN3
HPV related VIN 3: Presents as dark spots on the vulva, occasionally itchy, may be there for a few years before person
seeks treatment.
Treatment:
VIN2: Best treatment for diffuse lesions is a skinning vulvectomy, but that is disfiguring and involves removal of the
clitoris. Can also do CO2 laser ablation of the lesions to maintain sexual function.
VIN3: Wide local excision. High rate of recurrence, need close surveillance.
If cancer is diagnosed:

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Radical vulvectomy, including wurgical staging with removal of primary tumor and the ispilateral inguinal lymph nodes.
Only microinvasive squamous cell cancer can be treated by wide local excision - applies to small lesions that are well
differentiated with invasion of less than 1 mm.
Usually squamous, but can have melanoma and basal cell
Pagets disease of the vulva: white plaque like lesions and poorly demarcated erythema, no discrete mass. Its an in situ
carcinoma of the vulva, associated with breast cancer.
Verrucous carcinoma: Cauliflower like lesions
Melanoma: Can first appear as an in situ lesion - just a pigmented spot. 5% of melanomas are vaginal, which is suprising
given the lack of surface area and the lack of sun.
Bartholins gland
Can get adenocarcinoma! Fixed firm mass, fast onset
Differential includes Bartholin gland cyst - but any new BG cyst in a post menopausal woman has to be investigated.
Can also get BG abscesses - common sign of gonorrhea infection
Post Menopausal Bleeding

Differential dx of post menopausal bleeding:

Endometrial cancer: see above
Endometrial polyp:
Endometrial glands and stroma on a stalk; can cause postmenopausal bleeding. Can see with hysteroscopy or saline
infusion sonohysterography
Could be malignant! Still need to have surgery to remove them if > 1.5 cm!
Atrophic endometrium:
The most common cause of postmenopausal bleeding! Friable endometrium or vaginal tissue due to low estrogen

Workup of post menopausal bleeding:

1.) Endometrial biopsy - 90-95% sensitive.
2.) If endometrial biopsy is benign, but the patient has a lot of risk factors for cancer, then do direct visualization of the uterine
cavity with hysteroscopy
Adnexal Masses

Adnexal mass:
Defined: something off of the uterus
DDx: Gynecologic and nongynecologic (urologic, GI). Benign or malignant.
Uterine fibroid - typically midline and irregular
TOA - typically adnexal tenderness
Sertoli-Leydig - usually androgen
Endometrioma - usually less than 8 cm, associated with dysmenorrhea and dyspareunia
Ovarian: functional cyst, ectopic pregnancy,
Evaluation
Age:
Helps predict risk and type of malignancy
Premenopausal mass: unlikely to be cancer, if it is, most likely germ cell (dermoid cyst is the most common). Post
menopause: 29-35% risk of cancer.
Family history:
5-10% hereditary.
Increased risk of BRCA (Frank criteria) in families with
Breast cancer in 2 or more relatives < 50 OR one or more < 50 AND ovarian cancer
Ovarian cancer: 2 or more cases
Male breast cancer and any other breast or ovarian cancer
Ashkenazi Jewish and any breast or ovarian cancer
HNPCC Amersterdam
Colon cancer < 50 yrs in any family member
Colon cancer in 3 or more family members

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No history of FAP
Physical exam:
Size, location, consistency, tenderness, mobility
Metastatic disease - ascites, lymphadenopathy
Rectovaginal exam
Imaging
Transvaginal ultrasound is first! Great sensitivity and specificity. Nodularity and solid components are concerning
Reserve CT and MRI for specific situations
Blood tests
Premenopausal: Rule out pregnancy with serum beta HCG or urine test, also AFP, LDH. CA-125 only if concerned about
cancer
Post menopause: CA 125
Other: CEA, CA 19-9

Management of adnexal mass: Depends on age and ovarian size

If prepubertal and > 2 cm likely neoplasm, operate.
If menopausal and > 5 cm likely neoplasm, operate
If reproductive age and > 10 cm likely neoplasm, operate.
Observe if small (< 5 cm). Most likely to be a follicular cyst or corpus luteum
If 5-10 cm, operate if septations, solid, or excrescenses (= abnormal outgrowth), otherwise observe for a month.

Functional cysts: Can cause unpleasant symptoms but unlikely to stick around for very long. Usually a unilocular simple
cyst without evidence of blood, soft tissue, or excrescenses.
Follicular
Corpus luteum
Hemorrhagic: Consider if the patient is 3 weeks into her cycle. Can form a complex cyst.

Ovarian torsion
Sudden onset of colicky abdominal pain (unilateral, abdominal or pelvic!), nausea +/- vomiting, and presence of cyst
(maybe free fluid) on ultrasound. Maybe hypoactive bowel sounds. Tender abdomen with involuntary guarding
Risk: 14 weeks pregnancy when the uterus rises above the pelvic brim, or immediately postpartum when the uterus
involutes
Treatment: Needs immediate surgical exploration. If untwisting adnexa results in reperfusion, then can just do ovarian
cystectomy. But if perfusion cant be restored, then do oophorectomy.
Ovarian cancer
Germ cell, stromal cell, or epithelial
Germ most common in young women (especially dermoid cysts), epithelial most common later (most common kind of
tumor overall). True for both benign and malignant. Stromal are rare
Highest mortality among gynecologic cancers
Risk factors: Nulliparity, low parity, delayed childbearing, PCOS, hereditary cancer syndromes (HNPCC, BRCA)
Protective: pregnancy, birth control pills, tubal ligation, hysterectomy,
Symptoms: mostly GI symptoms, less common gynecologic. Usually 3 months before seeking care.
Diagnosis: Do CT of abdomen and pelvis.
Management
Surgical debulking and staging, with chemo for advanced disease - carboplatin and paclitaxel. Remove both sides
and uterus if done with child bearing, lymph node removal
If pleural effusion, thoracentesis to rule out malignant pleural effusion.
60-80% remission, but 80% relapse
Serum markers
CA-125: best marker, but not great. Also less sensitive and less specific in young women.
False positives: peritoneal inflammation (endometriosis, PID)
LDH: dysgerminoma
Beta HCG: choriocarcinoma, embryonal carcinoma
AFP: endodermal sinus
Inhibins, estradiol: granulosa
Testosterone: sertoli-leydig

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Ovarian Tumors
Germ cell - most common ovarian cancer in young women.
Symptoms: Often presents with pelvic mass and pain due to rapid growth. Usually found early.
Benign teratomas are the most common kind, and the most common tumor in women of all ages.
All 3 cell layers, can have solid and cystic components, can produce TRH!
Prone to torsion! Often present with severe acute abdominal pain, especially during pregnancy, puerperium, and in
children or younger patients.
Can rupture! Uncommon, presents with shock and hemorrhage.
Treatment: Surgical cystecomy or unilateral oophorectomy, inspect contralateral ovary (15-20% are bilateral).
Malignant teratomas - only 1% of teratomas.
Usually early in life. Often have immature neural tissue - that quality determines grade.
If grade 1, just do surgery. If grade 2 or 3 and implants or reoccurrences chemo
Struma ovarii = germ cell tumor made all or partly of thyroid tissue. 10% malignant.
Malignant ovarian tumors include:
Dysgerminoma
Endodermal sinus tumor (yolk sac)
Immature teratoma
Rare (embryonal, choriocarcinoma)
Epithelial - of ovarian tumors, most common in patients > 30 years, most common cause of ovarian cancer deaths.
Often caught very late! Tend to spread to peritoneum and bowel. Can have early GI symptoms -bloating, early satiety,
increased girth, pain - but frequently noted only in retrospect.
Often CA-125 positive, more specific in older women
Serous - most common tumor (usually benign), usually bilateral
Mucinous - can be large in size (30 cm!), loculated, can rupture and cause mucous in peritoneum (psuedomyxoma
peritonei) repeat bouts of bowel obstruction
Endometrioid: can coexist with primary endometrial cancer in the uterus
Clear cell:
Treatment of epithelial cancer: Maximum debulking, chemotherapy with platinum agent
Stromal
Stromal tumors are solid! Makes sense because they are stromal tissue.
Fibroma (fibroadenoma)
Solid firm benign tumor
Sometimes associated with ascites and pleural effusions (Miggs syndrome)
Granulosa-theca cell tumor:
Solid, usually yellow tumor.
The granulosa cells make estrogen, inhibin. Cause endometrial hyperplasia and post menopausal bleeding.
Sertoli Leydig tumors
Secrete androgens masculinization and hirsutism
Dermatologic

Lichen simplex chronicus

Chronic itching thick, purplish leathery skin
Treat with high dose topical corticosteroids and antihistamines to control the itching
Lichen sclerosis
Chronic inflammatory derm condition w/ itching and pain.
Affects vulva and anus, spares vagina painful intercourse, defecation.
Happens in women > men, usually prepubertal or post menopausal. Thin epidermis, hyperkeratosis,
elongation of the rete pegs fragile, thin, crinkled skin. White skin.
DDx: lichen planus (usually involves the vagina, LS doesnt), psoriasis, VIN, vitiligo
No definitive cure, treat with corticosteroids, avoid irritants, wear cotton undies
Cancer of vulva often presents with itching and can be assoced with LS - worry if a bump appears! 5% risk of cancer.
Lichen Planus
Inflammatory mucocutaneous eruptions with remissions and flaires. Lacy reticulated pattern of the labia
and perineum, can cause scarring and erosions, adhesions obliteration of the vagina!

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Treatment is challenging since no single agent is universally effective

Psoriasis
Can get psoriasis in the vulva! Suspect if silvery white lesions elsewhere.

Vulvar candidiasis
Diabetes is a risk factor!
Can cause fissures in the labial folds tears on the labia and burning on the skin with urination

Bartholins gland abscess

usually polymicrobial and not sexually transmitted
Bx in women over 40 - can be assoced with cancer
Miscellaneous

Vulvar vastibulitis
Syndrome with symptoms and findings limited to the vulvar vestibule, including severe pain on vestibular touch or
attempted vaginal entry, tenderness to pressure and erythema.
Treat with TCAs, topical anesthetics
Hysterectomy and oopherectomy have a risk of ureteral injury - whether ligation, thermal injury, etc. Can present post-op
like pyelonephritis. Ligation will present fast, thermal injury or ischemia (e.g., from over dissection and destruction of blood
supply) can take a week.

Post op fever:
Wind: pneumonia, atelectasis on Day 1
Water: UTI on Day 3
Walking: DVT or PE on Day 5
Wound infection: Day 7
Wonder Drugs: > 7 days

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Sexual violence
Offer prophy abx to all rape victims
Dont do an exam on a kid unless seriously have to
Kids can get yeast infections after abx

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