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Jennifer H. Horan, DO- Gynecologic Disorders Board Review 2014 - ARMC Emergency Medicine
This document provides an overview of common gynecologic disorders organized by anatomy. It discusses conditions affecting the cervix like cervicitis and tumors. For the vagina, it covers issues like Bartholin's abscess, vaginitis, and vulvovaginitis. The uterus section details dysfunctional bleeding, endometriosis, prolapse, and tumors. It also reviews ovarian cysts, torsion, and cancer. Other topics include pelvic inflammatory disease, Fitz-Hugh-Curtis syndrome, gestational trophoblastic disease, and cervical cancer. Clinical presentations, risk factors, diagnoses, and treatments are summarized for each condition.
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Jennifer H. Horan, DO- Gynecologic Disorders Board Review 2014 - ARMC Emergency Medicine
- 1. Gynecologic Disorders for BoardReview Jennifer H. Horan, DO PGY-4 Emergency Medicine Arrowhead Regional Medical Center
- 2. Gynecology Cervix ◦ Cervicitis ◦ Tumors ◦ ◦ ◦ ◦ Vagina ◦ ◦ ◦ ◦ Bartholin’sAbscess Foreign Body Vaginitis Vulvovaginitis Dysfunctional Bleeding Endometriosis Prolapse Tumors GTD Leiomyoma Infections ◦ PID ◦ Fitz-Hugh-Curtis ◦ Tubo-ovarian Abscess Ovary ◦ Torsion ◦ Tumors Uterus Lesions ◦ HSV ◦ HPV
- 3. Ovary Ovarian Cysts ◦ Mostfrequently seen in reproductive years ◦ Follicular Cyst - MC 1st 2 weeks of cycle Thin-walled, fluid filled ◦ Corpus Luteal Cyst Last 2 weeks of cycle More likely to hemorrhage ◦ Clinical Presentation: Pelvic Pain (generalized, dull)
- 4. Ovarian Cysts Exclude pregnancy CheckHemoglobin (in case hemorrhagic cyst) Dx: ultrasound Tx: symptomatic treatment & out-patient follow-up D/C: torsion precautions Cyst is considered large if >3 cm (increased risk for torsion)
- 5. Ovary Ovarian Torsion ◦ Ovarytwists in its vascular pedicle ◦ 50-80% cases associated with ovarian tumor or large cysts; previous pelvic surgery/adhesions ◦ The twist causes venous/lymph obstruction leading to congestion and edema, then ischemia & necrosis ◦ Ovary has DUAL blood supply so arterial obstruction is rare, thus Doppler US may show flow
- 6. Ovarian Torsion Sxs: unilateralsevere pain, nausea, NO fever Risk factors ◦ Hx cyst, assisted reproductive therapy Presentation atypical Exam: unilateral tenderness Labs NOT helpful Dx: Doppler ultrasound; laparoscopy (gold standard)
- 7. Ovary Ovarian Cancer ◦ Peakage 55-65 ◦ Affects 1 in 70 women ◦ Disease is often advanced at time of diagnosis 50% mortality ◦ Risk Factors: FMH ovarian, breast or colon ca Infertility, low parity, high-fat diet, lactose intolerance ◦ Sxs: subacute abdominal pain, bloating, weight loss/gain, ascites, pleural effusion ◦ Dx: US and CT Scan, CA-125 ◦ Tx: surgery, chemotherapy, and/or radiation
- 8. Cervix Cervical Cancer ◦ RiskFactor: HPV HPV Vaccine – Girls 9-26 ◦ ◦ ◦ ◦ In patients with HIV AIDS Mostly squamous cell cancers Post-coital bleeding Dx: Pelvic exam, biopsy
- 9. Cervix Cervicitis ◦ Inflammation ofthe cervix ◦ Also from trauma, irritants ◦ Can have mucopurulent cervicitis Tx for STDs (GC, Chlamydia)
- 10. Vaginal Bleeding inNONPregnant Differential diagnosis:
- 11. Vaginal Bleeding inNONPregnant DUB mcc abnormal vaginal bleeding in reproductive women ◦ MC adolescence or perimenopausal Anovulatory bleeding – failure of corpus luteal cyst formation ◦ Tx: OCPs, D&C, NSAIDs for pain Ovulatory Bleeding – 10%, less understood ◦ Bleeding disorder, medications Sever bleeding – CBC, transfusion/resuscitation, and consider (IV) Premarin
- 12. Uterus Endometriosis ◦ Endometrial tissueoutside of the uterus ◦ 6-8% of women ◦ Ovaries (MC) (aka chocolate cyst), fallopian tubes, abdomen, bladder, lung (catamenial pneumothorax) ◦ Menses-related abdominal pain ◦ Infertility, chronic pelvic pain ◦ Tx: pain management, hormonal therapy, surgical management
- 13. Uterus Uterine Prolapse andCystocele ◦ Vaginal wall weakness caused by age, multiparity, decreasing estrogen levels, pelvic trauma ◦ Dx: Can see bladder, uterine prolapse on pelvic exam Valsalva maneuver helpful ◦ Tx: digital reduction, Pessary, surgery
- 14. Uterus Uterine Fibroids (Leiomyoma) ◦ Benigntumors of uterine muscle ◦ Higher incidence in AA women ◦ Heavy bleeding, pelvic pain ◦ Can be submuscosal, suberosal, intramural ◦ Dx: Ultrasound ◦ Tx: hormone regulation, surgery, NSAIDs
- 15. Uterus Uterine Cancer ◦ MCGYN malignancy, specifically endometrial ◦ Risk Factors: Early menses, late menopause, nulliparity Unopposed estrogen use DM, HTN, obesity ◦ Sxs: post-menopausal bleeding ◦ Dx: biopsy, D&C, Hysteroscopy ◦ Tx: surgery, chemotherapy, and/or radiation ◦ *Vaginal bleeding in a postmenopausal woman is (endometrial) cancer until proven otherwise*
- 16. While we arein the pelvis… Pelvic Inflammatory Disease (PID) ◦ ◦ ◦ ◦ Polymicrobial Complications: infertility, ectopic pregnancy Clinical Dx – CMT (Chandelier Sign) Admit: pregnant, oral intolerance, TOA Fitz-Hugh-Curtis Syndrome ◦ Infection from fallopian tubes contaminates abdomen Bacterial infection of perihepatic space ◦ RUQ and shoulder pain ◦ “Violin-string” adhesions
- 17. Vagina Vulvovagintis ◦ Vaginal discharge,itching ◦ Causes: Infection, allergic reaction, foreign body, irritant/chemical Atrophic Vaginitis Post-menopausal secondary to estrogen deficiency Tx: topical or oral estrogen replacement therapy ◦ MC problem in children ◦ Normal vaginal pH 4.0-4.5 ◦ Any condition changing the vaginal pH
- 18. Vagina Bacterial Vaginosis ◦ MCCof abnormal vaginal discharge ◦ Gardnerella/anerobes take over normal flora ◦ Dx: Amsel Criteria (3 of 4) Copious think white discharge pH >4.5 Clue cells on wet mount; cx not helpful May have fishy odor with KOH whiff test ◦ Tx: Metronidazole (PO or gel) 500 mg PO bid for 7 days (2 g PO x1not recommended)
- 19. Vagina Candidal Vaginitis ◦ CandidaAlbicans is part of normal flora ◦ ◦ ◦ ◦ Overgrows Associated with DM, abx, pregnancy Sxs: vulvar pruritis (MC) Exam: vulvar erythema Dx: wet mount (psuedohyphae, budding yeast); culture is gold standard ◦ Cottage cheese discharge ◦ Tx: Fluconazole (one dose 150mg PO), or OTC vaginal creams Avoid PO in pregnancy
- 20. Vagina Vaginitis ◦ Trichimoniasis Protozoa Sxs: yellow-green, frothy, malodorous discharge Exam: strawberry cervix Dx: wet mount Tx: Metronidazole PO
- 21. Vagina Bartholin’s Cyst ◦ Bartholin’sglands are normal Located inferiorly at vaginal introitus ◦ Cyst (painless), abscess (painful) ◦ Abscess: polymicrobial Staph, Strep, E.Coli, or STD ◦ Tx: I&D, Word Catheter, Abx ◦ Definitive Tx: Marsupialization
- 22. Uterus Gestational Trophoblastic Disease ◦Tumors formed form abnormal placental cells that implant and proliferate within the uterus ◦ Choriocarcinoma ◦ Hydatidaform Mole – molar pregnancies Complete MC Develops from 1 (duplicates) or 2 sperm fertilizing an empty egg 46XX or 46XY karyotype Lacks a fetus Uterus LARGER than dates „grapelike vesicles‟ „snowstorm‟ on US with empty egg 20% malignant Partial 2 sperm fertilize a normal egg 69XXX or 69XXY Fetus present Uterus SMALLER than dates Non-viable fetus AND normal &vesicular chorionic villi 5% to malignancy
- 23. GTDs Hydatidaform Mole ◦ Sxs: Painless,abnormal vaginal bleeding Uterine size greater than normal Hyperemesis gravidarum (hCG levels >100k) Symptoms of hyperthyroid Early preeclampsia ◦ Tx: depends on type/pathology More benign (80%)or slow growing – D&C, chemotherapy Malignant (2% choriocarcinoma), metastatic tumors – chemo/XRT/surgery ◦ Often fertility can be maintained Monitor hCG levels after evacuation
- 24. A Few Questions… A17 year old seually active girl present complaining of dysuria for 3 days. She denies fever, abdominal pain, vomiting, and diarrhea. Abdominal examis normal. Pelvic examination reveals a homogenous white discharge that coats the vaginal walls. Pregnancy tests is negative, and wet mount shows clue cells. The best treatment is: ◦ ◦ ◦ ◦ ◦ A. B. C. D. E. Azithromycin Ceftriaxone Fluconazole Levofloxacin Metronidazole
- 25. A Few Questions… A17 year old seually active girl present complaining of dysuria for 3 days. She denies fever, abdominal pain, vomiting, and diarrhea. Abdominal examis normal. Pelvic examination reveals a homogenous white discharge that coats the vaginal walls. Pregnancy tests is negative, and wet mount shows clue cells. The best treatment is: ◦ ◦ ◦ ◦ ◦ A. B. C. D. E. Azithromycin Ceftriaxone Fluconazole Levofloxacin Metronidazole
- 26. A 23 yearold woman presents complaining of lower abdominal pain. Pelvic examination reveals yellow vaginal discharge, as well as moderate cervical motion tenderness. Adnexa are tender, but no masses are present. Outpatient management may be considered if the patient has: ◦ ◦ ◦ ◦ ◦ A. B. C. D. E. A physician who can provide follow-up Pelvic Abscess Positive pregnancy test result Taken antibiotics already for similar complaints Temperature >38.8C (>102F)
- 27. A 23 yearold woman presents complaining of lower abdominal pain. Pelvic examination reveals yellow vaginal discharge, as well as moderate cervical motion tenderness. Adnexa are tender, but no masses are present. Outpatient management may be considered if the patient has: ◦ ◦ ◦ ◦ ◦ A. B. C. D. E. A physician who can provide follow-up Pelvic Abscess Positive pregnancy test result Taken antibiotics already for similar complaints Temperature >38.8C (>102F)
- 28. A 25 yearold female presents to the ER with left lower quadrant pain, nausea and vomiting for 6 hours. Her last menstrual period ended 10 days ago, She is afebrile, and CBC and chemistry are grossly normal. Her pregnancy test is negative. Ultrasound reveals multiple small cysts throughout both ovaries consistent with PCOS, the largest of which is on the left ovary and measures 2.5 cm. What is the most likely diagnosis? ◦ ◦ ◦ ◦ A. B. C. D. Arterial blood supply obstruction Ectopic pregnancy Follicular rupture Venous blood supply obstruction
- 29. A 25 yearold female presents to the ER with left lower quadrant pain, nausea and vomiting for 6 hours. Her last menstrual period ended 10 days ago, She is afebrile, and CBC and chemistry are grossly normal. Her pregnancy test is negative. Ultrasound reveals multiple small cysts throughout both ovaries consistent with PCOS, the largest of which is on the left ovary and measures 2.5 cm. What is the most likely diagnosis? ◦ ◦ ◦ ◦ A. B. C. D. Arterial blood supply obstruction Ectopic pregnancy Follicular rupture Venous blood supply obstruction
- 30. A 65 yearold female presents to the ER with a chief complaint of vaginal bleeding for 5 days. She is using about 2 pads per day. Prior to this episode, she has not had a menstrual period for 9 years. She has no PMH, and her only medications include hormone replacement therapy. Vital signs are normal and Hgb is 12.5. Pelvic exam reveals a small amount of blood in the vaginal vault, but no lesions, CMT, or adnexal tenderness. What is the most likely cause of this patient’s vaginal bleeding? ◦ ◦ ◦ ◦ A. B. C. D. Atrophic vaginitis Estrogen deficiency Endometrial neoplasm Hormonal supplementation
- 31. A 65 yearold female presents to the ER with a chief complaint of vaginal bleeding for 5 days. She is using about 2 pads per day. Prior to this episode, she has not had a menstrual period for 9 years. She has no PMH, and her only medications include hormone replacement therapy. Vital signs are normal and Hgb is 12.5. Pelvic exam reveals a small amount of blood in the vaginal vault, but no lesions, CMT, or adnexal tenderness. What is the most likely cause of this patient’s vaginal bleeding? ◦ ◦ ◦ ◦ A. B. C. D. Atrophic vaginitis Estrogen deficiency Endometrial neoplasm Hormonal supplementation
- 32. A 23 yearold G1P0 woman 7 weeks pregnant by dates, was discharged form another ED 3 weeks ago with a diagnosis of ‘threatened abortion’ and was given instructions for pelvic rest. She presents today for persistent vaginal bleeding and sever nausea and vomiting. She has not passed any tissue. Urine pregnancy test is positive. The top of the uterus is felt halfway between the umbilicus and pubic bone. You repeated the transvaginal ultrasound today, with the finding below. What is the clinical suspicion at this time? ◦ ◦ ◦ ◦ A. B. C. D. Choriocarcinoma Hydatdiform mole, complete Hydatidiform mole, incomplete Incomplete abortion
- 33. A 23 yearold G1P0 woman 7 weeks pregnant by dates, was discharged form another ED 3 weeks ago with a diagnosis of ‘threatened abortion’ and was given instructions for pelvic rest. She presents today for persistent vaginal bleeding and sever nausea and vomiting. She has not passed any tissue. Urine pregnancy test is positive. The top of the uterus is felt halfway between the umbilicus and pubic bone. You repeated the transvaginal ultrasound today, with the finding below. What is the clinical suspicion at this time? ◦ ◦ ◦ ◦ A. B. C. D. Choriocarcinoma Hydatdiform mole, complete Hydatidiform mole, incomplete Incomplete abortion
- 34. References HippoEM.com Naderi, Sassan. IntensiveReview for Emergency Medicine Qualifying Examination. McGraw-Hill Companies. New York. 2010 Tintinalli MD, Judith E. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th Edition. McGraw-Hill Companies. New York. 2011. Wagner MD, Mary Jo. Peer VII. ACEP. Dallas, Texas. 2006.
Editor's Notes
- #6 Ovarian tumor – usu benign, OHSS (ovarian hyperstimulation syndrome) someone receiving infertility treatment, PCO –hxirreg periods
- #7 No labs: anatomic issues, not infectiousDoppler for mass or other suspicious pathology, blood flow but CAN HAVE FALSE -BUT If you clinically suspect torsion in a person with ovarian cysts or mass, there is no foolproof way to rule it out. CALL GYN.
- #8 Bloating “pants don’t fit”Ascites is women without other liver hx – gynca until proven otherwise
- #9 Refer for bx
- #10 Inflammation – “think urethritis in men”Latex allergy, diaphragm
- #11 Differential dxOCPirreg use, thyroid dis, coagulopaties, DUB
- #12 Premarin = IV EstrogenAlso ovulatory bleeding (10%) – less well understood – bleeding d/o (VWB), rx (NSAIDs, Coumadin, ASA)
- #13 Chocolate cyst
- #14 CC – ‘ball’ or ‘something coming out of my vagina’Sxs: pressure, pain, constipation, back painPessary – retaining wall
- #15 US does not have to be ordered in ED, but US is where you will see them/dx.
- #17 …while we are in the abd…Polymicrobial – mostly GC, Chlam, other organismsCMT US to r/o abscess/TOACx: scarringF-H-C: BOARD FAVORITE; think outside the box with RUQ pain cc in age approp female
- #18 Irritant – douches, soaps
- #19 pH closer to six, if using nitrazine paperMay see clue cell slide – ‘potato chip sprinkled with pepper’ epithelial cell + bactCx NOT helpful, gardnerellavaginalis colonized >50% women
- #20 Cottage cheese dc – cc or examPO and topical equally effectiveComplicated infections - >4/yr, require longer tx
- #21 Strawberry cervix – punctate hemorrhagesDon’t forget to treat sexual partners
- #22 Located 4 & 7 o’clock at vaginal opening
- #24 TSH and hCG have similar structuresMore sever sxs seen with COMPLETE Mole
- #26 Clindamycin vaginal cream or pills can also be used
- #28 Remember ADMIT pregnant, oral intolerance, TOA
- #32 VB in previously menopausal pts is endometrialca until proven otherwise. Refer to gyn for further eval