Genitourinary - Exam 2 (Gynecological conditions)

How often should a female get a pap smear exam done

every 3 years (after baseline at 21)

The menstrual cycle is a vital sign of

overall endocrine health

HPO (hypothalamic-pituitary-ovarian) axis function

uterine and endometrial health

Normal menstrual cycle

24-38 days

flow up to ~7 days

Endometrial cycle (uterus) three phases

menstrual phase

proliferative phase (estrogen driven)

secretory phase (progesterone driven)

Endometrial cycle (uterus) - Menstrual phase

shedding of functional layer of endometrium

bleeding and cramping (prostaglandins)

Endometrial cycle (uterus) - Proliferative phase

estrogen driven

endometrium thickens

glands and blood vessels regenerate

Endometrial cycle (uterus) - Secretory phase

progesterone driven

endometrium prepares for implantation

if no pregnancy → menses

Three parts of the pelvic exam

observation and speculum exam

bimanual exam

recto-vaginal exam

What is the goal of a pap smear (assess transitional zone of cervix for…)

screen for cervical cancer

Urinary tract infection (UTI)

suprapubic tenderness on palpation

red/swollen urethral meatus

absence of systemic signs (fever)

Types of UTIs (Upper to lower)

Pyelonephritis - infection of kidneys

Cystitis - infection of bladder

Urethritis - infection of urethra

Why are UTIs more common in women

shorter urethra

What is the best way to prevent risk of UTI after intercourse

urinate afterwards

Bacterial vaginosis

thin, homogenous gray-white discharge

“fishy” odor

Candida vaginitis

thick, white, “cottage-cheese” discharge

vulvar erythema

itching and burning

Trichomonas

frothy, yellow-green discharge

“strawberry cervix”

strong odor

Uterine prolapse

uterus descends into or beyond vaginal canal due to weakened pelvic floor muscles and ligaments

MC in postmenopausal women who had multiple vaginal deliveries

What is the best standard for diagnosis of uterine prolapse

physical exam

Uterine prolapse treatments

pelvic floor exercises (kegels)

pessary devices (donut, ring, gellhorn)

hormonal therapy

surgical repair

What are the two types of cervical cancer

squamous cell carcinoma (MC)

adenocarcinoma

Cervical cancer pt presentation

persistent HPV infections

dyspareunia

pelvic pain/discomfort

abnormal vaginal bleeding

unusual vaginal discharge

unexplained weight loss and fatigue

Cervical cancer exam findings

friable/ulcerative cervix

abnormal bleeding from cervix

enlarged and tender cervix

Cervical cancer risk factors

persistent HPV infections

multiple sex partners

early sexual activity

smoking

immunosuppression

long-term use of oral contraceptives

What is the gold standard for diagnosing cervical cancer

cervical biopsy

Cervical cancer treatment

watchful waiting

loop electrosurgical excision procedures (LEEP)

conization

radiation, chemo, hysterectomy

pelvic exenteration

Vulvar cancer types

squamous cell carcinoma (MC)

melanoma

Vulvar cancer pt presentation

persistent itching, burning, pain

skin changes (color or thickening)

hx of HPV

immunosuppression

pain/tenderness

visible lump/ulcer/wart-like growth

bleeding unrelated to menses

Vulvar cancer exam findings

visible lump/ulcer/lesion

color changes or thickening skin

tenderness/induration/fixed masses

enlarged inguinal lymph nodes

Vulvar cancer risk factors

HPV infection

>50

chronic vulvar conditions (lichen sclerosis)

smoking

immunosuppression

hx of cervical cancer

What is the gold standard for diagnosing vulvar cancer

biopsy

Vulvar cancer treatment

topical treatments

surgical excision

radiation/chemo

radical vulvectomy

Types of vaginal cancer

squamous cell carcinoma (MC)

adenocarcinoma

Vaginal cancer pt presentation

abnormal vaginal bleeding (postcoital)

watery/bloody vaginal discharge

pelvic pain or pressure

dyspareunia

mass in vagina

Vaginal cancer exam findings

mass/ulcer/lesion in vaginal wall

abnormal discharge

palpable mass or thickening of vaginal wall

Vaginal cancer risk factors

HPV infection

>60

hx of cervical cancer

smoking

What is the gold standard for diagnosing vaginal cancer

biopsy

Vaginal cancer treatment

topical treatments

surgical excision

radiation/chemo

vaginectomy

pelvic exenteration

During the bimanual exam, if you find a tender and enlarged ovary what could the possible causes be

cyst, torsion, acute infection

During the bimanual exam, if you find a fixed, nodular adnexal mass what could the possible causes be

endometriosis or malignancy

During the bimanual exam, if you have fullness with marked tenderness and FEVER what could the possible causes be

abscess

What is the MC tumor of the gynecoid pelvic and MC reason for a hysterectomy

Myomas (Uterine Fibroids)

Myomas (Uterine Fibroids) types

Subserosal - grow on outer surface of uterus

Intramural - grow within the uterine wall

Submucosal - protrude into uterine cavity

Myomas (Uterine Fibroids) pt presentation

MC asymptomatic

hx of frequent urination/constipation, infertility or recurrent miscarriages

family hx of fibroids

menorrhagia

pelvic pressure/pain

dyspareunia

abdominal distortion

Myomas (Uterine Fibroids) risk factors

MC closer to menopause

African American

family hx

estrogen + progesterone promote growth

obesity

nulliparity

What is the best way to diagnose Myomas (Uterine Fibroids)

transvaginal ultrasound

What is the x-ray finding for Myomas (Uterine Fibroids)

cauliflower-like radioopaque mass

Myomas (Uterine Fibroids) treatments

watch and wait

hormonal therapy = GnRH

UAE

myomectomy

hysterectomy

Ovarian cysts types

functional cysts (follicular and corpus luteum cysts) (MC)

dermoid cysts

endometriomas

cystadenomas

polycystic ovaries

Ovarian cysts pt presentation

MC asymptomatic

sudden onset of dull or sharp pelvic pain (one side)

menstrual irregularities or pain during menses

feeling bloated/fullness or abdominal distension

dyspareunia

nausea/vomiting (esp. if cyst ruptures)

Ovarian cyst exam findings

palpable mass or tenderness on affected side

Ovarian cyst risk factors

reproductive age

hormonal imbalance

pregnancy

endometriosis

severe pelvic infections

What is the primary diagnostic tool used to dx ovarian cysts

transabdominal or transvaginal ultrasound

Ovarian cysts treatments

watchful waiting and pain management

hormonal therapy - birth control

laparoscopic cystectomy

oophorectomy

Salpingitis types

acute - sudden onset, severe symptoms

chronic - long-standing, recurrent, less severe symptoms

Salpingitis pt presentation

previous dx of STI (chlamydia or gonorrhea)

fever and chils

abnormal vaginal discharge

dyspareunia

dysuria

irregular menstrual bleeding or spotting

Salpingitis exam findings

purulent/mucopurulent cervical discharge

friable cervix

adnexal tenderness

chandelier sign

tenderness along posterior aspect of pelvis (inflamed fallopian tubes)

Salpingitis risk factors

hx of PID or STIs

sexually active <25

IUDs

hx of pelvic surgery

What is the gold standard for dx salpingitis

laparoscopy

Salpingitis treatments

antiobiotics and pain management

drainage of abscess

salpingectomy

What is the MC bacterial cause of Pelvic inflammatory disease (PID)

chlamydia

Pelvic inflammatory disease (PID) is a leading cause of ______ in women due to damage to the fallopian tubes

infertility

Pelvic inflammatory disease (PID) pt presentation

persistent/severe lower abdominal pain

fever and chills

dyspareunia

dysuria

abnormal uterine bleeding

Pelvic inflammatory disease (PID) exam findings

abnormal vaginal/cervical discharge

friable cervix

chandelier sign

Pelvic inflammatory disease (PID) risk factors

increase of exposure to STIs

hx of PID or STIs

sexually active <25

What is the gold standard to dx Pelvic inflammatory disease (PID)

laparoscopy

Pelvic inflammatory disease (PID) treatment

antibiotic therapy and pain management

drainage of existing abscesses

hysterectomy

salpingo-oophorectomy

Endometriosis common sites

ovaries, fallopian tubes, outer surface of uterus, pelvic lining

When does endometriosis begin

onset of menses

symptoms confused with “typical” dysmenorrhea or UTIs

Dr not taking symptoms seriously

Endometriosis pt presentation

pelvic pain correlating with menstrual cycle

pain during bowel movements/urination/menstruation

fatigue, bloating, nausea

severe menstrual cramps unresponsive to pain relief

menorrhagia

dyspareunia

infertility

chronic pelvic pain

Endometriosis risk factors

family hx

early menarche (1st period)

short menses but heavy flow

nulliparity

autoimmune

Asian and Caucasian

Endometriosis exam findings

fixed and tender uterus

palpable nodules

chandelier sign

Endometriosis gold standard for dx

laparoscopy

Endometriosis treatments

hormonal therapy - birth control, GnRH

pregnancy

laparoscopy

hysterectomy

What is one of the MC causes of infertility

Polycystic ovary syndrome (PCOS)

Polycystic ovary syndrome (PCOS) pt presentation

irregular menstrual cycles or amenorrhea

excessive hair growth on face, chest, back (hirsutism)

acne or oily skin

thinning hair or male-pattern baldness

acanthosis nigricans

Polycystic ovary syndrome (PCOS) risk factors

genetic predisposition (PCOS or diabetes)

obesity

insulin resistance

sedentary lifestyle

What is the primary diagnostic tool to dx Polycystic ovary syndrome (PCOS)

transvaginal ultrasound

What blood tests could be used to dx Polycystic ovary syndrome (PCOS)

elevated androgens (testosterone)

LH

low or normal FSH

insulin levels

thyroid function

Rotterdam criteria for PCOS (dx requires 2/3!!)

irregular ovulation or anovulation

hyperandrogenism (clinical/hormonal)

polysystic ovaries on US

Polycystic ovary syndrome (PCOS) treatments

lifestyle modifications

oral contraceptives

anti-androgen meds

metformin

IVF

Ovarian cancer types

epithelial (MC) - originating from cells on outer surface of ovaries

germ cell - arise from cells that produce eggs

stromal - develop from CT cells that hold ovary together

Ovarian cancer is the __ MC cause of cancer-related deaths in women

5th

Ovarian cancer pt presentation

persistent bloating or abdominal distension

pelvic or abdominal pain (vague or persistent)

changes in bowel habits

unexplained weight loss or gain

Ovarian cancer exam findings

palpable adnexal mass or ovarian enlargement

tenderness or irregularity in adnexa

eval for metastasis

Ovarian cancer risk factors

>50 (postmenopausal)

family hx (BRCA1 and 2)

nulliparity

early menarche or late menopause

long term HRT

obesity

fertility treatments

Ovarian cancer dx primary imaging tool + definitive dx

pelvic ultrasound

biopsy

Ovarian cancer treatments

surgical excision

chemo/radiation

hysterectomy

bilateral salpingo-oophorectomy

What is the MC gynecological cancer in the US

uterine cancer

Uterine cancer types

endometrial carcinoma (MC)

uterine sarcoma

Uterine cancer pt presentation

abnormal vaginal bleeding (postmenopausal!)

pelvic pain or pressure

dyspareunia

unexplained weight loss

Uterine cancer exam findings

abnormal vaginal discharge or blood

enlarged or irregularly shaped uterus

tenderness or masses in uterus

Uterine cancer risk factors

>50 (postmenopausal)

estrogen hormone therapy long term

obesity

family hx

endometrial hyperplasia

diabetes and hypertension

Uterine cancer dx primary imaging tool and gold standard

transvaginal ultrasound

endometrial biopsy

Uterine cancer treatment

hormonal therapy (progestins)

surveillance

radiation/chemo

total hysterectomy

bilateral salpingo-oophorectomy

Cancer prevention screening recommendations

cervical cancer - pap smear

breast cancer - mammography

ovarian cancer - routine screening

endometrial/uterine cancer - awareness

vulvar/vaginal cancer - self-exams and gynecological exams

Perimenopause pt presentation

irregular menstrual cycles

hot flashes and night sweats

mood swings

sleep disturbances

vaginal dryness or discomfort during intercourse

Menopause pt presentation

hot flashes, night sweats, sleep disturbances

vaginal dryness and thinning of vaginal walls

decreased bone density

weight gain

hair thinning

What supplements can women take to help with hot flashes

black cohosh

vitamin E and K

What is the primary medical treatment for menopause

estrogen hormone therapy

Menopausal physcial changes

vaginal rugae flatten

cervix, uterus, ovaries decrease in size