tag:blogger.com,1999:blog-68870872770119291302011-11-27T16:59:40.619-08:00Gynecology Lecture Notes, Books, MCQ and Good ArticlesMedCosmosnoreply@blogger.comBlogger11100tag:blogger.com,1999:blog-6887087277011929130.post-75625530897230437652008-09-06T03:03:00.000-07:002008-09-06T03:12:28.756-07:00HISTORY<br /><br /><br /><br />includes ID, CC, HPI, PMH, Meds, Allergies, etc...<br /><br />Obstetrical History<br />Gravida__ Para__ SAB__ TAB__ L__<br />year, hospital, outcome, mode of delivery, sex, gestational age,<br />weight, complications<br /><br />Menstrual History<br />LNMP, LMP<br />age menarche, menopause<br />cycle length, duration, regularity<br />flow<br />associated symptoms<br />• pain, PMS<br />abnormal menstrual bleeding<br />• intermenstrual, post-coital<br /><br /><br />Sexual History<br />age when first sexually active<br />number and sex of partners<br />history of sexual assault or abuse<br /><br />Contraceptive History<br />present and past contraception modalities<br />reasons for discontinuing<br />compliance<br />complications/failure/side-effects<br /><br />Gynecological Infections<br />STDs, PID (herpes, chlamydia, gonorrhea, etc...)<br />vaginitis, vulvitis<br />lesions<br />include treatments, complications, etc...<br /><br />Gynecological Procedures<br />last Pap smear<br />• history of abnormal Pap<br />• follow-up and treatments<br /><br />gynecological or abdominal surgery<br />previous ectopic pregnancies<br /><br /><strong><br />PHYSICAL EXAMINATION</strong><br /><br /><br />height, weight, BP<br />breast exam<br />abdominal exam<br />pelvic exam including<br />• observation of external genitalia<br />• speculum exam +/– smears and swabs<br />• bimanual exam<br />• cervix size, consistency, os, and tenderness<br />• uterus size, consistency, contour, position, shape,<br />mobility, and other masses<br />• adnexal mass, tenderness<br />• rectovaginal exam<br />• rectal exam<br /><br /><br />INVESTIGATIONS<br />Bloodwork<br />CBC<br />• evaluation of abnormal uterine bleeding, preoperative investigation<br />ßhCG<br />• investigation of possible pregnancy or ectopic pregnancy,<br />work-up for GTN<br />• monitored after the medical management of ectopic and in<br />GTN to assess for cure and recurrences<br />LH, FSH, TSH, PRL<br />• amenorrhea, menstrual irregularities, menopause, infertility, etc...<br />Notes APPROACH TO THE PATIENT . . . CONT.<br /><br /><br /><br />Imaging<br /><br />ultrasound<br />• transvaginal ultrasound provides enhanced details of structures located<br />near the apex of the vagina; i.e. intrauterine and adnexal structures<br />• may be used for<br />• acute or chronic pelvic pain<br />• rule in or out ectopic pregnancy, intrauterine pregnancy<br />• assess uterine, adnexal, ovarian masses (i.e. solid or cystic)<br />• uterine thickness<br />• follicle monitoring during assisted reproduction<br /><br />hysterosalpingography<br />• an x-ray is taken after contrast is introduced through the<br />cervix into the uterus<br />• contrast flows through the tubes and into the peritoneal<br />cavity if the tubes are patent<br />• used for evaluation of size, shape, configuration of uterus,<br />tubal patency or obstruction<br /><br />sonohystography<br />• saline infusion into endometrial cavity under ultrasound<br />visualization expands endometrium, allowing visualization<br />of uterus and fallopian tubes<br />• useful for investigation of abnormal uterine bleeding,<br />uncertain endometrial findings on vaginal U/S, infertility,<br />congenital/acquired uterine abnormalities (i.e. uterus<br />didelphys, uni/bicornate, arcuate uterus)<br />• easily done, minimal cost, extremely well-tolerated,<br />sensitive and specific<br />• more accurate than hysterosalpingography and frequently<br />avoids need for hysteroscopy<br />Genital Tract Biopsy<br /><br /><br />vulvar biopsy<br />• under local anesthetic<br />• Keye’s biopsy or punch biopsy<br />• hemostasis achieved with local pressure, Monsel solution or<br />silver nitrate<br /><br />vaginal and cervical biopsy<br />• punch biopsy or biopsy forceps<br />• generally no anesthetic used<br />• hemostasis with Monsel solution<br /><br />endometrial biopsy<br />• in the office using an endometrial suction curette (Pipelle)<br />• hollow tube guided through the cervix used to<br />aspirate fragments of endometrium (well-tolerated)<br />• a more invasive procedure using cervical dilatation and curettage<br />may be done in the office<br /><br />Colposcopy<br />diagnostic use<br />• provides a magnified view of the surface structures of the<br />vulva, vagina and cervix<br />• special green filters allow better visualization of vessels<br />• application of 1% acetic acid wash dehydrates cells and<br />reveals white areas of increased nuclear density (abnormal)<br />or areas with epithelial changes<br />• biopsy of visible lesions or those revealed with the acetic acid<br />wash allows early identification of dysplasia and neoplasia<br /><br />therapeutic use<br />• cryotherapy<br />• tissue destruction by freezing<br />• for dysplastic changes, genital warts<br />• laser<br />• cervical conization<br />• encompasses the cervical transformation zone and<br />into the endocervical canal<br />• methods include cold knife, laser excision, or electrocautery<br /><br /><br /><br /><strong>DIFFERENTIAL DIAGNOSIS OF COMMON GYNECOLOGICAL COMPLAINTS</strong><br /><br /><br /><em>VAGINAL DISCHARGE</em><br /><br />Physiological<br />normal vaginal discharge (midcycle)<br />increased estrogen states, e.g. pregnancy, BCP<br />Infectious<br />candida vulvovaginitis (Candida albicans)<br />trichomonas vaginitis (Trichomonas vaginalis)<br />bacterial vaginosis (Gardnerella vaginalis)<br />chlamydia<br />gonorrhea<br />bartholinitis or Bartholin abscess<br />PID<br />Neoplastic<br />VAIN<br />vaginal squamous cell ca<br />invasive cervical ca<br />fallopian tube ca<br />Other<br />allergic/irritative vaginitis<br />foreign body<br />atrophic vaginitis<br />enterovaginal fistulae<br /><br /><br /><em>VAGINAL/VULVAR PRURITUS</em><br />Infectious<br />Candida vulvovaginitis<br />Trichomonas vaginitis<br />Herpes genitalis (HSV)<br />Other<br />postmenopausal vaginitis or atrophic vaginitis<br />chemical vaginitis<br />hyperplastic dystrophy<br />lichen sclerosis<br />vulvar ca<br /><br /><br /><em>GENITAL ULCERATION</em><br />Infectious<br />painful<br />• herpes genitalis (HSV)<br />• chancroid (Hemophilis ducreyi)<br />painless<br />• syphilis (Treponema pallidum)<br />• granuloma inguinale<br />(Calymmatobacterium granulomatis)<br />• lymphogranuloma venereum<br />(C. trachomatis - serotypes L1-L3)<br />Malignant<br />vulvar ca<br /><br />Other<br />trauma<br />foreign body<br />Bechet disease (autoimmune disease resulting in oral and genital<br />ulcerations with associated superficial ocular lesions)<br /><br /><br /><br /><em>INGUINAL LYMPHADENOPATHY</em><br />Infectious<br />HSV<br />syphilis<br />chancroid<br />granuloma inguinale (D. granulomatis)<br />Malignant<br />vulvar ca<br />vaginal ca<br />anal ca<br />lymphoma<br /><br /><br /><em>PELVIC MASS</em><br />Uterus, Asymmetrical<br />leiomyomata<br />leiomyosarcoma<br />Uterus, Symmetrical<br />pregnancy<br />adenomyosis<br />endometrial ca<br />Adnexal, Ovarian<br />corpus luteum cyst<br />follicular cyst<br />theca lutein cyst<br />endometrioma<br />inflammatory cyst (tubo-ovarian abscess)<br />luteoma of pregnancy<br />polycystic ovary<br />benign neoplasms<br />• dermoid cyst (most common)<br />malignant neoplasms<br />• granulosa cell tumour (most common)<br />Adnexal, Non-ovarian<br /><br />gynecological<br />• ectopic pregnancy<br />• pelvic adhesions<br />• paratubal cysts<br />• pyosalpinx/hydrosalpinx<br />• leiomyomata or fibroids<br />• primary fallopian tube neoplasms<br /><br />gastrointestinal<br />• appendiceal abscess<br />• diverticular abscess<br />• diverticulosis, diverticulitis<br />• carcinoma of rectum/colon<br /><br />genitourinary<br />• distended bladder<br />• pelvic kidney<br />• carcinoma of the bladder<br /><br /><br /><em>DYSPAREUNIA</em><br /><br />atrophic vaginitis<br />chemical vaginitis<br />lichen sclerosis<br />Candida vulvovaginitis<br />Trichomonas vaginitis<br />acute or chronic PID<br />endometriosis<br />fibroids<br />adenomyosis<br />congenital abnormalities of vagina<br />• e.g. septate vagina<br />retroverted, retroflexed uterus may cause dyspareunia<br />ovarian cysts/tumours<br />symptomatic retroverted uterus<br />psychological trauma<br />vaginismus<br />vulvodynia<br /><br /><em><br />PELVIC PAIN</em><br />Acute Pelvic Pain<br />gynecological causes<br />• ectopic pregnancy<br />• abortion - missed, septic, etc...<br />• ruptured ovarian cyst<br />• torsion of ovary or tube<br />• hemorrhage into ovarian cyst, neoplasm<br />• degeneration of fibroid<br />• torsion of pedunculated fibroid<br />• acute PID<br />• mittelschmertz (ovulation pain as follicle ruptures into<br />peritoneal space)<br /><br /><br />non-gynecological causes<br />• appendicitis<br />• UTI - cystitis, pyelonephritis<br />• renal colic<br />• mesenteric adenitis<br />• diverticulitis<br />• inflammatory bowel disease<br /><br /><br /><em>Chronic Pelvic Pain</em><br />refers to pain of greater than 6 months duration<br /><br />gynecological causes of CPP<br />• chronic PID<br />• endometriosis<br />• adenomyosis<br />• invasive cervical ca (late)<br />• leiomyomata<br />• uterine prolapse<br />• adhesions<br />• cyclic pelvic pain<br />• primary dysmenorrhea<br />• secondary dysmenorrhea<br />• ovarian remnant syndrome<br />• pelvic congestion syndrome<br />• ovarian cyst<br /><br />non-gynecological causes<br />• referred pain<br />• urinary retention<br />• urethral syndrome<br />• penetrating neoplasms of GI tract<br />• irritable bowel syndrome<br />• partial bowel obstruction<br />• inflammatory bowel disease<br />• diverticulitis<br />• hernia formation<br />• nerve entrapment<br />• constipation<br />• psychological trauma<br />• 20% of CPP is due to history of previous sexual<br />abuse/assault<br /><br /><br /><em>ABNORMAL UTERINE BLEEDING</em><br />abnormal vaginal bleeding<br />pregnant not pregnant<br />first trimester 2nd and 3rd<br />• see obstetric section<br />normal pregnancy abnormal pregnancy<br />• implantation bleed<br />• abortion intrauterine extrauterine<br />• trophoblastic • ectopic<br /><br /><br /><em><strong><br />Approach to Abnormal Vaginal Bleeding<br />Gynecological Causes</strong></em><br /><br />increased bleeding with menses<br />• polyps<br />• adenomyosis<br />• leiomyomata<br />• endometriosis<br />• IUD<br /><br /><br />bleeding following a missed period<br />• ectopic pregnancy<br />• abortion - missed, threatened, inevitable, incomplete, or complete<br />• implantation bleed<br />• trophoblastic disease<br />• placental polyp<br /><br />irregular bleeding<br />• dysfunctional uterine bleeding<br />• polycystic ovarian disease<br />• vulvovaginitis<br />• PID<br />• benign or malignant tumours of vulva, vagina, cervix, or uterus<br />• ovarian malignancy<br />• anovulation (e.g. stress amenorrhea)<br />• oral contraceptive use<br />• polyps<br /><br /><br />postmenopausal bleeding<br />• endometrial ca until proven otherwise<br />• atrophic vaginitis (most common cause)<br />• ovarian malignancy<br />• benign or malignant tumours of vulva, vagina or cervix<br />• withdrawal from exogenous estrogens<br />• atrophic endometrium<br />• endometrial/endocervical polyps<br />• endometrial hyperplasia<br />• trauma<br />• polyps<br />• lichen sclerosis<br />common causes vary according to age group<br />adolescent<br />• anovulatory<br />• exogenous hormone use<br />• coagulopathy<br />reproductive<br />• anovulatory<br />• exogenous hormone use<br />• fibroids<br />• cervical and endometrial polyp<br />• thyroid dysfunction<br />premenopause<br />• anovulatory<br />• fibroid<br />• cervical and endometrial polyp<br />• thyroid dysfunction<br />post menopausal<br />• endometrial cancer until proven<br />otherwise<br />• other endometrial lesion<br />• exogenous hormone use<br />• atrophic vaginitis<br />• other tumour (vulvar, vaginal,<br />cervix)<div class="blogger-post-footer"><img width='1' height='1' src='https://blogger.googleusercontent.com/tracker/6887087277011929130-7562553089723043765?l=medcosmosgynecology.blogspot.com' alt='' /></div>MedCosmosnoreply@blogger.com42