Female Reproductive System

• Patients with a personal (or family) history of breast, ovarian, prostate, or pancreatic cancer may benefit from hereditary cancer risk evaluation (genetic counseling) to determine risk for these cancers.

• BRCA1 and BRCA2 are inherited in an autosomal dominant pattern.

• Up to 6\% of breast cancer and 20\% of ovarian cancer cases are caused by BRCA1/BRCA2 mutations.

• Some ethnic groups are at higher risk for BRCA mutations.

• Men with BRCA mutations are at higher risk of breast cancer and prostate cancer.

• Women with a high lifetime risk (risk ≥20\%) should undergo:

  • annual screening mammogram

  • annual breast MRI

  • clinical breast exam every 6\text{ to }12\text{ months} starting 10\text{ years} before the age at diagnosis of the youngest affected family member.

• Practical screening rule: ask, “At what age were family member(s) diagnosed with breast cancer?” and screen 10\text{ years earlier}. Example: if a sister was diagnosed at age 35, begin MRI screening at age 25.

Dominant Breast Mass/Breast Cancer

• Adult to older female with a dominant mass on one breast that feels hard and irregular; may be attached to skin/tissue or immobile.

• Common location: upper outer quadrant (tail of Spence).

• Skin changes: peau d’orange (orange-peel), dimpling, retraction.

• Nipple changes: may have painless or serous/bloody discharge; nipple may be displaced or fixed.

• Diagnostic approach:

  • order diagnostic mammogram with ultrasound

  • refer to breast surgeon if needed

  • note up to 15\% of women with breast cancer will have a negative mammogram; ultrasound can detect the mass

  • refer for diagnostic biopsy if indicated

• Metastatic sites (common):

  • bone (e.g., back pain)

  • liver (jaundice, abdominal pain, anorexia, nausea)

  • lungs (dyspnea, cough)

  • brain (headache)

Ectopic Pregnancy

• Reproductive-age, sexually active female with pelvic pain (diffuse or unilateral) ± vaginal bleeding.

• Pain onset usually early in the first trimester; can be dull or sharp (not typically crampy).

• If intraperitoneal bleeding, pain may radiate to the shoulder; patient may shuffle to reduce pelvic jarring.

• Reports amenorrhea to light menses in the prior 6-7\text{ weeks}.

• Risk factors: prior ectopic, current IUD use, tubal ligation, IVF.

• Majority occur in the fallopian tube.

• Definite diagnosis: serum quantitative hCG and transvaginal ultrasonography.

Inflammatory Breast Cancer (IBC)

• Recent/acute onset of a red, swollen, warm area in the breast of a middle-aged woman (median age 59) with rapid growth.

• Symptoms develop quickly; may have breast tenderness or itching; may mimic mastitis; often no discrete lump.

• Skin may be pitted (peau d’orange).

• Suspect in breast inflammation that does not respond to antibiotics.

• Prognosis: most IBC has lymph node metastases; ~1/3 have distant metastases at diagnosis.

• Demographics: more common in African Americans, who tend to be diagnosed younger.

• IBC is rare but very aggressive (approx. 1\%\text{ to }5\% of breast cancers).

Ovarian Cancer

• Typical patient: middle-aged or older woman with vague abdominal bloating/discomfort, early satiety, GI reflux-type symptoms, low-back/pelvic pain, dyspareunia, changes in bowel habits, fatigue.

• Most patients (≈ 75\%) are diagnosed after spread beyond the ovary, contributing to poor overall survival.

• Five-year survival with distant metastases is 25\%; if diagnosed at stage I, survival >90\%.

• Current screens (e.g., CA-125) lack sufficient specificity for average-risk; transvaginal ultrasound alone performs poorly for early-stage disease.

• Family history look-for: two or more first- or second-degree relatives with ovarian, endometrial, or colon cancer, or a combination of ovarian and breast cancer.

• Women with high-risk family histories should be referred for genetic counseling and testing (e.g., BRCA1/BRCA2, Lynch syndrome).

• Screening can start 10\text{ years} before the earliest age of first diagnosis in the family.

Paget’s Disease of the Breast (PDB)

• Older female with a history of a red, scaly rash starting on the nipple and spreading to the areola of one breast.

• Symptoms may include itching, pain, burning; skin lesion may enlarge and crust/ulcerate/bleed.

• Up to half of women have an associated breast mass.

• Rarely occurs in men.

Normal Findings: Anatomy – Breasts

• Puberty starts with breast buds (Tanner stage II) and ends at stage V.

• During puberty, tender and asymmetrical breast buds are common; one breast can be larger (gynecomastia in some boys).

• Tail of Spence is the most common cancer site.

• Simple breast cysts are benign, round to oval; highest prevalence ages 35\text{-}50.

• Fibroadenomas are the most common solid breast tumors; consist of fibrous tissue; ultrasound preferred; biopsy sometimes needed.

• High estrogen levels promote growth of fibroadenomas; low estrogen (menopause) may shrink them.

• BRCA1/BRCA2 mutations can raise lifetime breast-cancer risk to as high as 72\%.

• Risk factors for male breast cancer include cryptorchidism, positive family history, and BRCA mutations.

• Diagnostic test for breast cancer or any solid tumor: tissue biopsy.

Cervix and Transformation Zone

• Cervical ectropion: bright-red, bumpy tissue with irregular surface around the os; benign; more friable than surrounding squamous epithelium.

• Ectropions may enlarge with high estrogen states (adolescents, combined hormonal contraception, pregnancy).

• If ectropion is present, sample the transformation zone (TZ) during Pap testing; TZ is where ectropion meets squamous epithelium and is a common site for metaplasia and abnormal cells.

Cervical and Vaginal Mucus

• Mucus varies: scant to thick white, runny white, or clear stringy mucus.

• After menses, discharge is scant; midcycle, large amount of clear mucus (the mucus plug) is normal unless on hormonal contraception (which thickens mucus).

• Mucus can be mixed with blood and appear red to dark-brown during menses.

Uterus

• Uterus includes the corpus and cervix; endometrium consists of glandular epithelium and stroma.

• Fibroids (uterine leiomyoma) can enlarge the uterus; may be asymptomatic or cause menorrhagia, pelvic pain, intermenstrual bleeding.

• Fibroids are usually benign; rare malignant transformation to leiomyosarcoma.

Ovaries

• Ovaries produce estrogen, progesterone, and small amounts of testosterone.

• Polycystic ovary syndrome (PCOS): multiple ovarian cysts with higher estrogen and higher androgens; symptoms include acne, hirsutism, oligomenorrhea, insulin resistance.

• During menopause, ovaries atrophy; a palpable ovary in a postmenopausal woman is abnormal – rule out ovarian cancer; order pelvic/intravaginal ultrasound and refer to a gynecologist.

Benign Variants

• Supernumerary nipples form a V-shaped line on both sides of the chest down the abdomen and are symmetrically distributed.

Menstrual Cycle – Normal Findings

• Based on a 28-day cycle.

• Follicular (proliferative) phase: Days 1–14.

  • FSH from the anterior pituitary stimulates ovarian follicle maturation.

  • Estrogen produced by developing follicles; estrogen is predominant in the first two weeks and stimulates endometrial growth.

• Ovulatory phase: Day 14 (midcycle).

  • LH surge from the anterior pituitary induces ovulation and maturation of the dominant follicle.

  • The follicle migrates to the fimbriae of the fallopian tube; conception may occur.

• Luteal phase: Days 14–28.

  • Progesterone from the corpus luteum predominates and stabilizes the endometrium.

Menstruation

• If not pregnant, estrogen and progesterone fall drastically, triggering menses.

• The drop in hormones stimulates the hypothalamus and the pituitary to initiate a new cycle via FSH.

Menopause

• Menopause: cessation of menses for 12 consecutive months; average age ≈ 51\text{ years}.

• Perimenopause: ~10 years around the final menstrual period with hormonal fluctuations.

• Premature menopause (primary ovarian insufficiency): cessation of menses before age 40\text{ years}; vasomotor symptoms common; vaginal dryness, decreased lubrication, libido changes; urinary symptoms may occur if estrogen is not used.

Women’s Health Initiative (WHI) and Hormone Therapy

• Average US menopause age ≈ 51\text{ years}.

• WHI findings: combined estrogen–progestin therapy increases risks of stroke, heart disease, venous thromboembolism (VTE), breast cancer, and pulmonary embolism.

• USPSTF guidance (general): does not recommend combined estrogen–progestin or unopposed estrogen for chronic disease prevention; applicability to relief of menopausal symptoms may differ.

• Practical guidance: duration of hormone therapy typically <5\text{ years}; many experts consider it acceptable for healthy women within <60\text{ years} and within 10 years of menopause, with no contraindications.

• Estrogen-alone therapy can alleviate dyspareunia and vaginal/urethral atrophy; estrogen can worsen or exacerbate systemic lupus erythematosus (SLE) risk.

• For women with a uterus, use both estrogen and progesterone (or progestin) to reduce endometrial cancer risk; unopposed estrogen is used only after hysterectomy.

Fertile Time Period and Ovulation Testing

• Highest pregnancy chance occurs 1–2 days before ovulation; characterized by copious, clear, thin, elastic cervical mucus.

• Cervical mucus method for fertility awareness; ovulation kits (urine LH) can detect LH rise within ~12\text{ hours} after it appears in serum.

• False positives can occur with PCOS, ovarian failure, or menopause.

Conception and Early Pregnancy

• Conception occurs when sperm fertilizes the egg; the zygote travels down the fallopian tube to the uterus and divides to form a blastocyst.

• Implantation occurs in the endometrium; typically takes 3\text{ to }4\text{ days} for implantation.

• Placenta fully formed by 18\text{ to }20\text{ weeks}.

• Hormones: estrogen and progesterone rise; human chorionic gonadotropin (hCG) produced by placenta.

• Pregnancy duration: 280\text{ days} or 40\text{ weeks}.

Laboratory Procedures: Cervical Cytology (Pap Test)

• Liquid-based cytology (e.g., ThinPrep) is used to screen for cervical cancer and is read by computer; higher false-negative rates (historically 20\%\text{ to }45\%).

• If the cervix bleeds easily during sampling, consider cervicitis.

• Some individuals may have slight spotting after Pap testing.

• Do not perform a Pap test or liquid-based cytology during heavy menses.

• Best time to perform Pap: at least 5\text{ days} after menses stops.

• Avoid douching, vaginal products, tampons, or intercourse for 2$–$3\text{ days} before Pap.

2018 Screening Guidelines (Summary)

• USPSTF: no cervical cytology before age 21\text{ years}; age 21–29 cytology alone; age 30–65 Pap with co-testing (HPV) or Pap every 3 years; up to every 5\text{ years} with co-testing if normal.

• ACOG: higher-frequency screening for HIV-positive or DES-exposed individuals, or others with special risk.

Liquid-Based Cervical Cytology (ThinPrep)

• Use a broom-shaped plastic brush inserted into the cervical os; ensure sampling of transformation zone if present.

• Place brush in liquid medium and swish; cover; read by computer; abnormal results reviewed by cytologist/pathologist.

Conventional Pap Test

• Use a wooden spatula to sample ectocervix (ectocervix surface) and brush for endocervix; smear both on a slide; fix with spray.

• Sampling ectocervix first minimizes bleeding.

Screening Women Without a Cervix

• Stop screening if a patient has had a hysterectomy for a benign condition and is not at high risk for cervical cancer.

Bethesda System (Cervical Cytology Reporting)

• A standardized reporting system for cervical cytology.

• Specimen satisfactory if both squamous epithelial cells and endocervical cells are present; absence of endocervical cells occurs in ~10\%\text{ to }20\% of specimens and is common in adolescents and postmenopausal women.

• Considerations when sampling: pelvic radiation or pregnancy should be noted; lubricants or excessive blood can interfere with results.

• ASC-US (Atypical Squamous Cells of Undetermined Significance): mildly abnormal cells with unidentified cause (infection, irritation, or precancer).

• Age-specific guidelines for ASC-US and HPV testing:

  • Age 20\text{-}\text{years} or younger: do not perform Pap if younger than 21.

  • Age 21\text{-}\text{24}: repeat Pap in 12 months preferred; reflex HPV acceptable.

  • Age 25\text{-}\text{29}: reflex HPV preferred; repeat Pap in 12 months acceptable.

  • Age 30\text{ or older}$: cotesting with high-risk HPV; if HPV positive, colposcopy.

• ASC-H (Atypical Squamous Cells Cannot Exclude HSIL): presence suggests possible precancer; requires colposcopy (age 21\text{ or older}).

• AGC (Atypical Glandular Cells): associated with premalignancy or malignancy in 30% of cases; follow-up depends on AGC subcategory; follow-up often includes colposcopy, endocervical sampling, and endometrial sampling.

• LSIL (Low-Grade Squamous Intraepithelial Lesions): mildly abnormal cells, usually HPV-related; age-guided management (see above).

• HSIL (High-Grade Squamous Intraepithelial Lesions): more likely associated with precancer/cancer; management depends on age; colposcopy or immediate excisional treatment (e.g., LEEP) is common.

Human Papillomavirus (HPV) Testing and Vaccination

• HPV types 16 and 18 account for nearly all cervical cancer cases.

• Gardasil vaccine (for males and females) typically given at age 11\text{ or }12; can be given from age 9 to 26.

• If first dose before age 15, a two-dose series is required (0, 6–12 months).

• If first dose at age 15 or older, a three-dose schedule (0, 1–2, 6 months).

• Schedule interruptions do not require dose repetition; vaccine now recommended for ages 9\text{ to }45.

Colposcopy and Related Procedures

• Colposcopy: specialized microscope to visualize the cervix, obtain biopsies, and access treatment (cryotherapy or laser) as needed.

• A vaginal speculum is used to expose the cervix.

• After visualization, acetowhitening is performed with 3–5% acetic acid to highlight abnormal areas (leukoplakia-like appearance).

• Biopsy samples are taken from acetowhitened areas, the cervical os (glandular cells), and the squamocolumnar junction (transformation zone).

• Post-procedure: mild cramping and spotting are normal; NSAIDs or analgesics can be used for pain.

Ablative and Excisional Treatments

• Ablative treatments: cryotherapy or laser therapy for abnormal superficial cervical cells.

• Loop Electrosurgical Excision Procedure (LEEP): electrosurgical instrument used to excise the cervix; biopsy interpretation determines deeper management (size/depth/severity) and subsequent treatment (cryo/laser/conization).

Additional Laboratory Procedures

• KOH (Potassium Hydroxide) slide: useful for fungal infections (hair, nails, skin); KOH lyses squamous cells to visualize hyphae/spores.

• Vaginal swabs do not require KOH to visualize Candida.

• Whiff test: BV diagnosis; positive if strong fishy odor after adding KOH.

• Tzanck smear: adjunct for evaluating herpes infections; not commonly used; positive shows large nuclei in squamous cells.

Practical Tips and Guidelines

• Pap/cytology and HPV testing are not recommended before age 21—even with STI exposure or multiple partners; pelvic exam may be used to check for PID and STI testing.

• Do not confuse endometrial biopsy with colposcopy.

Contraception Overview

• Infertility: defined as failure to conceive after 12\text{ months} of unprotected sex; roughly 50\% of pregnancies in the US are unplanned.

• A table of method effectiveness (simplified):

  • Least effective: fertility awareness, spermicide, male/female condom, withdrawal, sponge.

  • Moderate effectiveness: injectable, pill, patch, ring, diaphragm.

  • Most effective: implant, IUD, vasectomy, tubal/hysterectomy.

• Minors: many states allow consent to contraceptive services without parental consent; some require age thresholds.

• Rule out pregnancy before initiating contraception; check blood pressure as part of health eval.

• OC (combined hormonal contraception) basics:

  • Several types: monophasic, biphasic, triphasic pills; ethinyl estradiol (EE) with various progestins.

  • Drospirenone-containing pills (Yaz, Yasmin, Slynd) have higher DVT and hyperkalemia risk; monitor potassium in patients on ACE inhibitors, ARBs, or potassium-sparing diuretics.

  • Extended-cycle options (Seasonale, Yaz/Desogen variants) reduce frequency of menses; may cause breakthrough bleeding early on.

  • Non-oral forms include the cervical ring (NuvaRing) and transdermal patch (Ortho Evra); higher estrogen exposure with patch can increase VTE risk.

  • BP monitoring: estrogen-containing methods can raise blood pressure; reassess within 4$-$8 weeks of initiation.

  • Breastfeeding considerations: progestin-only pill (POP) or other progestin-only methods are preferred during lactation.

Combined Hormonal Contraception – Practical Aspects

• Absolute contraindications include conditions increasing clot risk (thrombophlebitis, thromboembolic disorders, coagulation defects like factor V Leiden), major surgery with immobilization, heavy smoking (>15 cigarettes/day) in women >35, high stroke risk (e.g., CVA, TIA, certain migraines), active liver disease, pregnancy, and certain cancers (estrogen-dependent).

• Relative contraindications include migraines with aura (especially >35), smoking younger than 35, uncontrolled hypertension, and other cardiovascular risk factors.

• Special mnemonics: My CUPLETS (Migraine with aura, CAD/CVA, Undiagnosed bleeding, Pregnant, Liver tumors, Estrogen-dependent tumor, Thrombus/embolus, Smoker) as a quick reference for absolute contraindications.

• Drospirenone-containing pills: avoid in hyperkalemia, kidney disease, or adrenal insufficiency.

• Common adverse effect management:

  • Unscheduled (spotting) bleeding is common in the first weeks; usually improves by the 3rd month.

  • Lower-estrogen-dose pills may have higher breakthrough bleeding; switching to ~30\mu g EE formulations may help.

  • If a dose is missed, follow standard guidance for doubling up and using backup contraception as needed; if a dose is missed in the last week, finish current pack and start a new pack immediately.

Contraception: Special Methods

• Combined Oral Contraceptives (COCs): various regimens; typical-use failure ~9\%; include iron-containing last week pills in some brands.

• Rapid-start strategies: quick-start, day-one start, Sunday start; ensure pregnancy ruled out; backup contraception typically required for the first 7\text{ days}.

• Ring (NuvaRing): 3 weeks in, 1 week out; continuous use possible; do not use in women who smoke and are ≥35.

• Patch (Ortho Evra): 3 weeks wear, then 1 week off; higher estrogen exposure; higher VTE risk; adherence considerations.

• Progestin-only methods (POP, DMPA, etonogestrel implant, LNG IUD) vary in duration and side effects; POPs require strict timing; DMPA (Depo-Provera) lasts ~3\text{ months} per dose and can cause amenorrhea with long-term use; boxed warning for bone density effects with long-term use (> 2\text{ years} ).

• Intrauterine devices (IUDs): LNG-releasing (e.g., Mirena) for up to 5\text{ years}; copper IUD (Paragard) up to 10\text{ years}; LNG IUD reduces bleeding; copper IUD may cause heavier menses initially; insert only by trained clinician; contraindications include active PID, pregnancy, known STI, uterine/cervical abnormalities, prior ectopic pregnancy, Wilson’s disease (copper IUD).

• Barrier methods: male/female condoms; diaphragms with spermicide; cervical caps; spermicides increase infection risk with HIV; avoid silicone oil lubricants with silicone-based devices.

• Emergency contraception: effective if used within 72\text{ hours} (ulipristal: up to 120\text{ hours}); LNG pills include Plan B One-Step, My Way, Next Choice; some regimens require taking two doses 12 hours apart; check for pregnancy if period delayed.

• Cervical hygiene and partner treatment considerations: BV and trichomonas require partner treatment rarely (BV generally not STI-driven); all patients should be counseled on safer sex practices and STI screening where indicated.

Pelvic Organ Prolapse

• Prolapse can involve cystocele (bladder), rectocele (rectum), uterine prolapse, enterocele (small bowel), and vaginal vault prolapse.

• Causes: weakening of pelvic floor muscles and ligaments; may be asymptomatic early.

• Evaluation: bimanual exam with bearing down to reveal prolapse.

• Plan: pessary placement or surgical repair (urogynecologist referrals).

• Management by compartment: cystocele (anterior wall bulging; urinary symptoms); rectocele (posterior bulging; constipation/rectal fullness); uterine prolapse (cervix descends; may require surgery or pessary); enterocele (small bowel herniation).

Polycystic Ovary Syndrome (PCOS)

• Hormonal disorder with anovulation/oligo-ovulation, infertility, hyperestrogenism, hyperandrogenism, and insulin resistance.

• Associated risks: type 2 diabetes, dyslipidemia, metabolic syndrome, endometrial hyperplasia, obesity, depression, sleep apnea.

• Classic presentation: overweight adolescent/young woman with hirsutism (≈70%), acne, amenorrhea/oligomenorrhea, and male-pattern hair growth.

• Diagnostic clues on transvaginal ultrasound: enlarged ovaries with multiple small follicles ("ring of pearls").

• Lab findings: elevated serum testosterone, DHEA, androstenedione; FSH-normal or low; impaired glucose tolerance/diabetes on OGTT.

• Treatment: first-line is OCs to suppress ovaries; spironolactone for hirsutism; alternative progestin therapy if OCs not desired; metformin to induce ovulation if fertility desired; weight loss reduces androgen/insulin levels.

• Complications and risks: CHD, type 2 diabetes, endometrial cancer risk, obesity, infertility, NAFLD, endometrial hyperplasia.

Vulvovaginal Infections

• Bacterial Vaginosis (BV)

  • Overgrowth of anaerobic bacteria; risk factors include sexual activity and douching; not an STI; treatment often still important in pregnancy.

  • Classic signs: fishy odor; thin, milky discharge; minimal inflammation.

  • Tests: clue cells on wet mount; positive Whiff test; vaginal pH > 4.5.

  • Treatment: metronidazole (oral BID × 7 days) or metronidazole vaginal gel; avoid alcohol to prevent disulfiram-like reaction; clindamycin cream for external infection; partners usually not treated.

• Candidiasis (Vulvovaginal Candidiasis)

  • Overgrowth of Candida albicans; common risk factors include diabetes, antibiotic use, HIV infection.

  • Classic signs: thick, white curd-like discharge; intense pruritus; vulvar swelling.

  • Diagnostic labs: wet mount showing pseudohyphae and budding yeasts with many WBCs.

  • Treatment: topical azoles (miconazole, clotrimazole) for 7 days; prescription fluconazole 150 mg as a single dose; fluconazole contraindicated in pregnancy; probiotic lactobacillus support not proven for post-antibiotic prevention.

• Trichomoniasis

  • Caused by Trichomonas vaginalis; inflammatory vaginitis with pruritus, burning, and discharge; strawberry cervix (punctate bleeding) may be seen.

  • Labs: motile protozoa with flagella on microscopy; NAAT (more sensitive) for detection from vaginal samples.

  • Treatment: metronidazole 2 g PO single dose or 500 mg BID for 7 days; tinidazole as alternative; treat sexual partners and avoid sex until completion of therapy.

• Atrophic Vaginitis (Vulvovaginal Atrophy)

  • Due to chronic estrogen deficiency; genital tissues show thinning and decreased lubrication.

  • Symptoms: dryness, itching, dyspareunia; vaginal bleeding with intercourse possible; relapse common.

  • Management: nonhormonal moisturizers/lubricants initially; for moderate-to-severe symptoms, topical estrogen therapy (cream/tablet/capsule/vaginal ring) with progesterone if uterus is intact; re-evaluate Pap if atrophic cytology is suspected; use estrogen with caution in estrogen-sensitive conditions.

Classic Cases and Clinical Pearls

• Classic breast cancer case includes a dominant, nonmobile mass with skin changes and possible axillary involvement; imaging and biopsy are essential.

• Classic cervical cancer workup relies on Pap/HPV testing with follow-up Colposcopy for abnormal cytology.

• Endometriosis: retrograde menstruation theory; estrogen stimulates ectopic endometrial tissue; can cause infertility (25–35% among infertile patients); treatment includes hormonal therapy (OC, GnRH analogues like leuprolide, aromatase inhibitors) and NSAIDs for pain.

• Fibrotic breast changes: common in 30–50-year-olds; cyclic breast pain; avoid caffeine; bras with support; refer if dominant mass.

• Lichen sclerosus: chronic inflammatory skin condition of the vulva; can be asymptomatic or painful; management involves topical therapies and monitoring.

• Ovarian cancer risk reduction: risk-reducing bilateral salpingo-oophorectomy (BSO) between 35\text{ and }40\text{ years} for BRCA1/BRCA2 carriers after childbearing; reduces ovarian cancer risk significantly.

• Pelvic organ prolapse and related conditions require pelvic floor rehabilitation and possible surgical repair depending on severity.

Quick Reference: Key Numerical Values, Formulas, and Concepts

• Lifetime risk thresholds and surveillance:

  • BRCA-associated cancer risk contributions: 6\%\ (breast), 20\%\ (ovarian).

  • Screening initiation: start ten years before youngest affected relative's diagnosis age.

• Menstrual cycle timing:

  • Follicular phase: Days 1-14; Ovulation around day 14; Luteal phase: Days 14-28.

• Pregnancy timing:

  • Implantation: 3$-$4\text{ days} after fertilization.

  • Placenta formation complete by 18$-$20\text{ weeks}.

  • Gestation duration: 280\text{ days} or 40\text{ weeks}.

• Pap/HPV guidelines (2018 recap):

  • Age < 21\text{ years}: no screening.

  • Age 21–29: Pap alone; no routine HPV co-testing.

  • Age 30–65: Pap with HPV co-testing every 3-5\text{ years} depending on co-testing.

• Condensed vaccine schedules:

  • Gardasil: two doses if started before age 15 (0, 6–12 months); three doses if started at 15 or older (0, 1–2, 6).

  • Vaccination window: from 9 to 45$$ years old.

Connections and Clinical Implications

• Genetic risk assessment (BRCA1/BRCA2) informs risk-reducing strategies (surveillance, chemoprophylaxis, and risk-reducing surgeries).

• Early detection and high-risk screening (MRI for breast cancer) can improve outcomes, especially in BRCA mutation carriers.

• Colposcopy and the Bethesda System standardize interpretation of cervical cytology and direct further testing.

• Hormone therapy decisions require balancing menopausal symptom relief with cancer and cardiovascular risks; individualized risk assessment is essential.

• PCOS and endometriosis have overlapping symptoms but require distinct management strategies, including fertility planning and metabolic risk mitigation.

• BV, candidiasis, and trichomoniasis are common vaginal infections with distinct etiologies, diagnostic tests, and treatment regimens; partner treatment is not routinely required for BV, but is for trichomoniasis.