Back to Basics: Gynecology

1. Back to Basics:Gynecology Dr. John Lamensa Assistant Professor Department of Obstetrics and Gynecology University of Ottawa

3. Normal Menstruation Sexual development Menstrual cycle Menstrual Abnormalities Amenorrhea Abnormal uterine bleeding PCOS Menopause Contraception Infertility Pelvic Pain Dysmenorrhea Endometriosis Pelvic Mass Ectopic pregnancy Pap smears Vaginal/pelvic infections Overview

4. A mother is concerned that her 12 year old daughter has not had her period yet (the other girls in her daughter’s class have already started theirs). She also thinks her daughter does not show signs of puberty yet. Knowing the first sign at the onset of puberty, you should ask which of the following questions? • Has her daughter had any acne? • Has her daughter started to develop breasts? • Does her daughter have any axillary or pubic hair? • Has her daughter started her growth spurt? • Has her daughter had any vaginal spotting?

5. The sequence of events in normal pubertal development are: • Peak growth, pubic hair, breast budding, menarche • Breast budding, pubic hair, peak growth, menarche • Breast budding, menarche, pubic hair, peak growth • Pubic hair, breast budding, menarche, peak growth

6. Female Sexual Development • In infancy and pre-puberty, FSH and LH levels are high or low ? • Prior to onset of puberty, FSH and LH levels increase or decrease? • This stimulates ovaries to produce estrogen

7. A 9 year old girl presents for evaluation of regular vaginal bleeding. History reveals thelarche at age 7 and adrenarche at age 8. Which of the following is the most common cause of this condition in girls? • Idiopathic • Gonadal tumors • McCune-Albright syndrome • Hypothyroidism • CNS tumors

8. The most common cause of delayed puberty is: • Turner’s syndrome • Craniopharyngioma • Constitutional delay • Anorexia nervosa • Primary hypothyroidism

9. Normal Menstrual Cycle

10. The initial work-up for a patient with 2° sexual characteristics and 2° amenorrhea include all of the following except: • Pregnancy test • Pelvic ultrasound • Prolactin level • Thyrotropin level • Assessment of endogenous estrogen status (progestational challenge)

11. Amenorrhea Primary Amenorrhea • No menses by age 13 in theabsence of development of secondary sexual characteristics or • No menses by age 15 regardless of presence of normal growth and development Secondary Amenorrhea • No menses for a length of time equivalent to a total of at least 3 of the previous cycle intervals or • > 6 months of amenorrhea

12. Amenorrhea - Etiology ALWAYS NEED TO RULE OUT! PREGNANCY Extreme Stress, Anorexia nervosa, Tumors, Infection, Congenital (Kallman’s syndrome) Hypothalamus (35%) Prolactin adenomas, 1o hypopituitarism, Sheehan syndrome, (Thyroid) Pituitary (20%) Congenital, Premature Ovarian Failure (autoimmune, infection, irradiation, surgery, chemo) Anovulation (PCOS, tumors) Ovary (20%) Congenital Absence, Imperforate hymen, Vaginal septum, Asherman’s syndrome Uterus/vagina (5%) Drugs (Metoclopramide, neuroleptics) Others

13. Premature ovarian failure may be due to any of the following except: • Turner’s syndrome • Autoimmune dysfunction • Hyperandrogenism • Radiation exposure

14. A 15 year old female is brought to the ED because of very heavy vaginal bleeding. Her Hb level is 90 g/L. Each of the following diagnoses should be considered except: • Anovulatory, dysfunctional bleeding • Coagulopathy • Pregnancy • Endometrial polyps • Thyroid dysfunction

15. A 45 year old female is brought to the ED because of very heavy vaginal bleeding. Her Hb level is 90 g/L. What is the least likely diagnosis? • Anovulatory, dysfunctional bleeding • Coagulopathy • Pregnancy • Endometrial polyps • Thyroid dysfunction

16. A 14 year old girl is brought to the ED by her mother because she has been bleeding heavily for the past 2 weeks. She experienced menarche 6 months ago and has been very irregular. She denies any other medical problems. She has never been sexually active. She has normal secondary sexual development. Her BP is 100/60 and her pulse is 100. She is 5 ft tall and weighs 95 lbs. Her abdomen is benign. She will not let you perform a speculum or pelvic exam. Which of the following is not indicated in the evaluation of this patient? • hCG • Bleeding time • CBC • Type and Screen • Estradiol level

17. Approach to Abnormal Bleeding

18. Abnormal Bleeding • Investigations: • hCG • CBC, ferritin • TSH, prolactin, coagulation profile • Rule out organic diseases: H&P • Endometrial biopsy (esp. if > 40 years old) • + Ultrasound • * Menopausal bleeding is endometrial cancer • until proven otherwise – need tissue diagnosis

19. Acute DUB Treatment • Mild: • OCP • Cyclic Medroxy Progesterone Acetate (Provera) • Severe: • Stabilize patient as required (ABC’s) • Premarin IV 25 mg q4-6h or high dose OCP • + Add OCP or Provera for maintenance • D&C if severely ill or unresponsive to medical therapy

20. DUB Longterm Treatment • Hormonal Manipulation of Cycle • Combined Contraceptives • Progesterone only • Progesterone IUD (Mirena) • GnRH analogue • Control of Menorrhagia • NSAIDs for menorrhagia • Anti-fibrinolytic agents (Cyklokapron) • Surgical • endometrial ablation • hysterectomy

21. A 26 year old G0P0 complains of being too hairy. Her menses have always been irregular occurring every 2 to 6 months. She also complains of acne and is seeing a dermatologist for this. She denies any other medical problems. She is 5’ 5’’ tall, weighs 200 lbs, and her BP is 100/60. On exam, there is sparse hair around the nipples, chin and upper lip. There is no galactorrhea, thyromegaly, or temporal balding. Pelvic examination is normal. Which is the most likely condition in this patient? • Idiopathic hirsutism • Polycystic ovarian syndrome • Late onset congenital adrenal hyperplasia • Sertoli-leydig cell tumor of the ovary • Adrenal tumor

22. In a woman with PCOS, a systemic manifestation that is the direct effect of the hyperinsulinemic state is: a) hirsutism b) obesity c) acanthosisnigricans d) hyperprolactinemia

23. PCOS - pathophysiology insulin ↑estrogen ↓FSH + ↑LH anovulation ↑peripheral estrogen ↑androgens from ovary oligomenorrhea obesity HIRSUTISM INFERTILITY

24. Treatment of PCOS Cycle Control • Weight loss: diet and exercise • Cyclic progesteroneor OCP to prevent endometrial hyperplasia/ cancer • Metformin to  insulin levels & ? reduce risk of progression to type 2 diabetes Infertility • Ovulation induction: Clomiphene, FSH, LHRH, etc. • Metformin to sensitize to ovulation induction • Ovarian drilling

25. Treatment of PCOS/Hirsutism The Ferriman-Gallwey score - OCP (specifically Diane-35) antiandrogenic - + spironolactone (inhibits steroid receptor) - Finasteride (5αreductase inhibitor) - Flutamide (androgen reuptake inhibitor) - Mechanical removal of hair

26. The following statements are true except: • Menopause occurs at ~51 years of age as a result of a genetically determined depletion of ovarian follicles responsive to gonadotropins. • Menopause occurs earlier in smokers. • Loss of ovarian function results in absolute estrogen deficiency. • Hormone replacement therapy should not be used for prevention of cardiovascular disease or dementia

27. Definitions • Menopause • after 12 consecutive months of amenorrhea, resulting from the loss of ovarian follicular activity • Menopause occurs with the final menstrual period which is only known with certainty retrospectively one year or more after the event. • Perimenopause • the period immediately prior to menopause when clinical, biological, and endocrinological features of approaching menopause commence. • The “climacteric” should be abandoned to avoid confusion.

28. Clinical Conditions In Menopause • Vasomotor symptoms • 75% of women • > 1 year in 80% of women • Primary indication for ERT/HRT • SSRI, clonidine, gabapentin, black cohosh • Urogenital atrophy • Lubricants, moisturizers, local estrogen therapy • Osteoporosis • Ca, Vit D, smoking cessation, exercise • Bisphosphonates, ERT/HRT, SERMs (raloxifene)

29. HRT • Good • relief of vasomotor and GU symptoms • Increases BMD, decreases fracture risk • Decrease colorectal cancer • Bad • Increases VTE, CAD, stroke • ? Increased risk of breast cancer, ovarian cancer, and dementia • No increased risk of endometrial cancer

30. A 42 year old G4P4 woman states her cycles are regular and denies any STIs. Currently she and her husband uses condoms, but they hate the hassle of a coital dependent method. She is interested in a more effective contraceptive method. They do not want any more children. She reports occasional migraine headaches, has had a serious allergic reaction to anesthesia as a child. She is a social drinker and smoker. She weighs 70 kg, her BP is 142/88. Which is the most appropriate method for this patient? • Combination OCP • Diaphragm • Transdermal patch • Intrauterine device • Bilateral tubal ligation

31. Contraception • Combined Hormonal • OCP • Patch • Ring • Progestin Only • Progestin only pill (Micronor) • DMPA (Depo-Provera) • Intrauterine Devices • Copper IUD (Nova-T) • Hormonal IUS (Mirena) • Barrier Methods • Male and female condom, diaphragm, cervical cap, sponge • Permanent Sterilization • Male • Female (laparoscopic and hysteroscopic)

32. Absolute contraindications Pregnancy Undiagnosed vaginal bleeding Thromboembolic disease Estrogen dependent tumors Coronary/cerebrovascular disease Impaired liver function Uncontrolled hypertension Migraines with neurological symptoms Smoker, age >35 Relative contraindication Migraines (non-focal) Controlled hypertension Hyperlipidemia Sickle cell anemia Gallbladder disease SLE Hormonal Contraception

33. Methods of Birth Control Currently UsedBy Women Who Have Had Intercourse

34. Combined hormonal contraceptives: • Decrease the risk of stroke and VTE • Should only be started on the first day of a menstrual period • Suppress ovulation mainly through an estrogen dominant effect • Is contraindicated in women >35 years old • Decrease dysmenorrhea, menorrhagia and acne

35. In combined hormonal contraceptives, which of the following is the primary contraceptive effect of the estrogenic component? • Conversion of ethinyl estradiol to mestranol • Atrophy of the endometrium • Suppression of cervical mucus secretion • Suppression of LH secretion • Suppression of FSH secretion

36. A 38 yo G3P3 would like to restart the birth control pill. Her PMHx is significant for hypertension, well controlled with a diuretic, and a seizure disorder. Her last seizure was 12 years ago and currently is on no anti-epileptic medications. She complains of stress related headaches that are relieved with over the counter pain medications. She is divorced, smokes 1 pack of cigarettes per day, drinks 3-4 alcoholic beverages per week. On exam, she weighs 90 kg, her BP is 126/80, and pelvic exam is normal. She has some lower extremity non-tender varicosities. She has taken birth control pills in the past and would like to restart them as they help with her menstrual cramps. Which of the following would contradict the use of combination oral contraceptives in this patient? • Varicose veins • Tension headaches • Seizure disorder • Smoking in a woman over 35 years of age • Hypertension

37. True or False about OC • The combined OC reduces the risks of ovarian and endometrial cancer. • Women on the combined OC should have periodic pill breaks. • The combined OC affects future fertility • The combined OC causes birth defects if a woman becomes pregnant while taking it • The combined OC must be stopped in all women over 35 • The combined OC causes acne. • True • False • False • False • False • False

38. 27 yo nulligravid student was “celebrating” with her male partner after passing her exams. Immediately after intercourse she noticed that the condom was broken. Her LMP was 12 days ago. She has regular 28 day cycles with molimina. She normally takes Alesse but had stopped 6 months ago. She pages you at 2 am. She does not want to get pregnant. What would be the appropriate management(s) to offer this couple? (You may chose up to three answers)

39. Contraception • Urgent pregnancy test (serum) • Suggest expectant management and wait to see if she misses a period • If she still has her Alesse tablets, take 5 of these now, and another 5 in 12 hours • Insertion of copper containing IUD • 0.75 mg Levonorgestrel po now and again in 12 hours • Suggest doing a handstand q hourly x 48 hours to • prevent implantation

40. Emergency Contraception Yuzpe Method • within 72 hours of intercourse • 2 Ovral tablets q12h x 2 doses (with Gravol!) • 100 µg estradiol + 500 µg levonorgestrol (LNG) EACH dose. • 6% chance of pregnancy decreases to 2% with Yuzpe • recent estimate of pregnancy 3.2% ‘Plan B’ • within 72 hours of intercourse • 0.75 mg (LNG) every 12h x 2 doses (less nausea) or 1 double dose of the LNG EC regimen (1.5 mg) may be used, as they have similar efficacy with no difference in side effects. • increase in efficacy compared to Yuzpe with 1.1% pregnancy rate. Copper IUD Insertion • within 5 days of intercourse (extended up to 7 days in Canada) • 1% failure rate

41. OVRAL AND SUBSTITUTIONS

42. An 18 yo university student recently became sexually active and is complaining of severe dysmenorrhea which is not responsive to heating pads and mild analgesics. She does not want to get pregnant. Which of the following is the most appropriate treatment for this patient? • NSAIDS • Narcotic analgesics • Short acting benzodiazepines • Combined hormonal contraceptive • Selective serotonin reuptake inhibitors (SSRIs)

43. A 27 yo woman complains of mood swings, depression, irritability, and breast pain each month in the week prior to her menstrual period. She often calls in sick at work because she cannot function with these symptoms present. Which is the best option for treating this patient? • NSAIDS • Narcotic analgesics • Short acting benzodiazepines • Combined hormonal contraceptive • Selective serotonin reuptake inhibitors (SSRIs)

44. Endometriosis Endometritis Adenomyosis Leiomyoma A 39 yo G3P3 complains of severe, progressive secondary dysmenorrhea and menorrhagia. Pelvic examination demonstrates a tender, diffusely enlarged uterus with no adnexal tenderness. Endometrial biopsy was normal. Which of the following is the most likely diagnosis?

45. Pelvic Pain: Differential Diagnosis • CHRONIC: • Endometriosis/adenomyosis • Dysmenorrhea (cyclic pain) • Ovarian cysts • Chronic PID • Adhesions • Uterine prolapse • Cancer invasive (late) • Fibroids • Pelvic congestion syndrome • ** RULE OUT PREGNANCY!** ACUTE: • Adnexal: • Mittelschmerz • Ovarian cysts, rupture, torsion • Hemorrhage into ovarian cyst or neoplasm • Uterine: • Degenerating fibroids • Torsion of pedunculated fibroid • Pyometra/hematometra • Infectious • Acute PID • Endometritis

46. Diagnostic laparoscopy for pelvic pain should be performed to: • Evaluate women with cyclic pain who respond to NSAIDs or OCP • Initially evaluate women with chronic non-cyclic pelvic pain • Biopsy and treat endometriotic lesions • Lyse all adhesions

47. Which of the following statements are true? • Women with endometriosis always have dysmenorrhea or chronic pelvic pain. • Minimal or mild endometriosis should never be treated surgically, only medically. • The degree of pelvic pain correlates with laparoscopic findings. • Medical treatment of endometriosis includes OCP, progestins, GnRH analogues, Danazol. • Medical treatment of endometriosis results in long term disease suppression and pain relief after cessation of therapy.

48. Endometriosis • Abnormal growth of endometrial glands and stroma outside the uterine cavity • Pathogenesis is unknown • Infertility • Dysmenorrhea, dyspareunia, dyschezia • On pelvic exam: • Tender nodules especially over uterosacrals • Uterine retroversion with decreased mobility • Adnexal enlargement with tenderness • May also be normal

49. Your 43 yo patient would like to get pregnant but is concerned that she may be too old to get pregnant. You recommend that she have her gonadotropin levels be tested. Which day of the menstrual cycle is best to test this? Which day would be best to check her progesterone level to confirm ovulation? (cycle interval 28 days) • Day 3 • Day 8 • Day 14 • Day 21 • Day 26

50. Infertility - Etiology • Tubal/Pelvic Pathology (35%) • Sperm Problems (35%) • Unexplained (10-15%) • Ovarian Problems (15%)