Benign Gynecological Disorders

1. Tory Davis, PA-C Mercy Hospital Benign Gynecological Disorders

2. POP Pelvic Organ Prolapse Defects in pelvic support structures result in pelvic relaxation abnormalities Classified by anatomical location Severity by Stage 0-IV

3. Anatomic location Anterior vaginal wall Cystocele Bladder prolapses Posterior wall Rectocele Apical wall defect Uterine prolapse Vaginal vault prolapse (post-hyst)‏ Enterocele

5. Causes Age Parity Vag parity 3xRR >2 deliveries4.5RR Obesity Hx pelvic surgery Diseases/conditions Chronic cough Constipation Heavy lifting Menopause Inherent quality of connective tissue

6. Symptoms Vaginal fullness Pressure Heaviness Discomfort Dysparunia Reducible mass in introitus Low back pain Incomplete void Stress incontinence Frequency Urinary hesitancy Splinting Coital laxity

7. POP PE Lithotomy position first, standing prn Vulvar ulcerations Relaxed genital hiatus Thin walled, smooth bulging mass Varying severity Observed valsalva Check anterior and posterior walls Rectovaginal

8. Prevention Antepatrum, intrapartum, postpartum pelvic floor exercises Avoid other reversible/controllable risk factors Estrogen therapy p menopause to maintain pelvic tissue tone

9. Tx Attention to psychosocial aspects Pessary Kegels Estrogen (local)‏ Surgical

10. Urinary Incontinence 13 million women 30-40% of US women in lifetime Up to 70% do not seek treatment Involuntary loss of urine Can be sign, symptom or diagnosed condition 3x more common in women (shorter urethra and greater likelihood of connective tissue, muscle and nerve injuries)‏

11. Etiology of UI Gender Age In elderly, 30% increase prevalence with each 5-year age increase Hormonal status Birthing trauma Damage to pelvic floor neuromusculature POP

12. Types Stress UI: urinary leakage on effort or exertion Urge UI: leakage immediately preceded by sense of urgency “Gotta go!” Mixed UI: Likely most common

13. UI History Duration Frequency Severity Social implications What do I mean? Use of protective items (pads, diapers, etc)‏ Mental function

14. Workup Pelvic exam Q tip test for bladder neck hypermobility Cough stress test Neuro exam Urodynamic studies

15. Treatment- Stress UI Reduce caffeine and alcohol Fluid restriction Timed voiding Kegels Biofeedback Electric stimulation Pessaries Surgery

16. Kegel Exercises Focused repetitive voluntary contractions of pelvic floor musculature Have pt contract muscles as if to prevent a fart or to stop urine Hold 3-5 seconds, then relax 50-100 reps daily Cure or significant improvement in up to 75%

17. Urge UI Involuntary contractions of bladder “Overactive Bladder” Cause unknown Prevalence 10-50%

18. Treatment As for SUI plus Drugs! Anticholinergics Oxybutinin (Ditropan)‏ Tolterodine (Detrol)‏ Available in IR, long-acting or patch Increase bladder capacity, decrease bladder contractions, improve urgency symptoms in 70%

19. Benign vulvar/vaginal disorders Infectious causes: already covered, right? But still need to be considered Atrophic vaginitis Lichen sclerosis Bartholin glands Vulvodynia

20. Atrophic vaginitis Hypoestrogenic vagina High pH Thinned vaginal epithelium SX: dryness, spotting, serosanguinous discharge, dyspareunia Tx: intravaginal estrogen (cream, ring, pv tablet) Not in women with hx of breast or endometrial cancer, though, right?

21. Lichen sclerosis Benign chronic inflammatory process Most common vulvar derm d/o Acute phase- red/purple lesions on non-hair-bearing areas of vulva, perineum, perianal area in hourglass pattern Erythema and edema Intense pruritis

22. Lichen sclerosis Chronic- skin is thin, white, shiny Loss of genital landmarks Labia minora fusion Introital stenosis Pain/dyspareunia from loss of elasticity Increased risk of squamous cell carcinoma

23. Lichen sclerosis Tx Steroids Topical high potency for 3 months, taper to less potent for maintenance

25. Bartholin’s gland What are the Bartholin glands for? What can go wrong with them?

26. Bartholin’s gland cyst Obstruction of the duct of the Bartholin’s gland retention of secretionscystic dilation Infection can occur Sx: pain, tenderness, erythema, dyspareunia with fluctuant mass Drain with Word catheter or marsupialization Excision if recurrent

29. Vulvodynia Vulvar pain in absence of relevant physical findings Sx: burning, raw, irritation, hyperalgesia, allodynia Prevalence 1.5% 2 types: Localized provoked 20-30 yrs Vestibular erythema, tenderness, introital pain Generalized unprovoked 40 yrs Larger area of pain (?neuropathic, pudendal nerve injury, referred pain?)‏

30. Benign Cervical Disorders Stenosis Nabothian cysts Polyps Already covered: HPV and other STIs, cervical dysplasia

31. Cervical stenosis Narrowing of the endocervical canal, usually at level of internal os Partial to full occlusion of the os Obstruction of menstrual flow (can lead to amenorrhea)‏ Infertility Pelvic pain

32. Cervical stenosis etiology Congenital Inflammatory Neoplastic Surgical Think of this when treating cervical dysplasia: LEEP causes less stenosis than cold-knife cone biopsy

33. Nabothian cysts Don’t freak out. Benign Yellowish translucent raised pearl-like lesions on ectocervix 1 mm to 3 cm Few or multiple

34. Cervical Polyps Small, pedunculated neoplasms Originate from endocervix Common Esp multigravidas over age 20 Mostly benign, but remove and send to pathology due to malignant change potential

35. Cervical polyps Asymptomatic or c/o intermenstrual or postcoital bleeding Sometimes assoc with infertility Why? PE: red fragile growth protruding from os 2 mm to 3 cm Not palpable Remove by grab-n-twist Larger ones to OR

36. Adnexal masses Common, usually benign Management dictated by presentation Malignancy must be excluded US usually 1st imaging for adnexa Septations, solid parts and Doppler flow within lesion are suspicious If likely benign and <6 cm, observe Why 6 cm?

37. Benign ovarian growths Follicular cyst- most common. From growth of follicle, often doesn’t release the egg Usually not sx, usually resolve Corpus luteum cyst Hemorrhagic cyst Dermoid cyst- the cyst with teeth

38. Cyst management If fluid-filled, monitor with periodic U/S If not, remove it Laparoscopic approach most common Also remove if >6 cm to reduce risk of torsion Prevention with OCPs Tx pain with NSAIDs

39. PCOS Polycystic Ovarian Syndrome Common (5-10%) female endocrinopathy Oligo or amenorrhea and anovulation Hyperandrogenism What’s that look like? Ultrasonographic evidence of polycystic ovaries Frequently, infertility Insulin resistance

40. PCOS Does this topic really belong here? Please read the Richardson article “Current Perspectives in Polycystic Ovary Syndrome” posted on myUNE Write 1-2 paragraphs on what “system” PCOS belongs in (Endo vs Women's Health)‏ Defend with supporting evidence from the article (etiology, clinical features, lab features, treatment, prognosis, etc)‏ Due Thursday April 15 to me at my next lecture.

41. Premature Ovarian Failure Ovaries don’t produce enough estrogen in women < 40 Despite high levels of circulating gonadotropins Suspect in female <40 with s/s of estrogen deficiency

42. S/sx of estrogen deficiency Atrophic vaginitis Osteopenia/osteoporosis Decreased libido Infertility Menstrual changes

43. POF Dx High FSH, low estradiol Find cause Enzyme defects Genetic defects Autoimmune causes (thyroiditis, Addison’s, hypoparathyroid, myasthenia gravis)‏ Environmental factors (chemo, smoking, viruses, surgery)‏

44. POF Tx Desiring pregnancy: IVF plus exogenous hormones to support endometrium Not desiring pregnancy: HRT until age 50s Either: psychosocial support

45. Uterine Disorders Will be covered in Menstrual Abnormalities lecture Questions?