1. Gynecologic Disorders
for Board Review
Jennifer H. Horan, DO PGY-4
Emergency Medicine
Arrowhead Regional Medical Center

2. Gynecology

Cervix

◦ Cervicitis
◦ Tumors


◦
◦
◦
◦
Vagina
◦
◦
◦
◦
Bartholin’s Abscess
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
◦ Most frequently 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
Check Hemoglobin (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
◦ Ovary twists 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: unilateral severe 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
◦ Peak age 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
◦ Risk Factor: 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 of the cervix
◦ Also from trauma, irritants
◦ Can have mucopurulent cervicitis
 Tx for STDs (GC, Chlamydia)

10. Vaginal Bleeding in NONPregnant

Differential diagnosis:

11. Vaginal Bleeding in NONPregnant

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 tissue outside 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 and Cystocele
◦ 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)
◦ Benign tumors 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
◦ MC GYN 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 are in 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
◦ MCC of 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
◦ Candida Albicans 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’s glands 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…

A 17 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…

A 17 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 year old 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 year old 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 year old 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 year old 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 year old 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 year old 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 year old 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 year old 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. Intensive Review 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.