GYNECOLOGY TiKi TaKa

___________________________
. THE BREAST:
________________
* BENIGN BREAST DISEASES:
______________________________
1 . Fibroadenoma.
2 . Fibrocystic disease.
3 . Intraductal papilloma.
4 . Fat necrosis (H/O of breast trauma).
5 . Mastitis (Inflamed, painful breast in women who are breast-feeding).
* MALIGNANT BREAST DISEASE (BREAST CANCER):
_____________________________________________________
1 . Ductal carcinoma insitu (DCIS).
2 . Lobular carcinoma insitu (LCIS).
3 . Invasive ductal carcinoma.
4 . Invasive lobular carcinoma.
5 . Inflammatory breast cancer.
6 . Paget's disease of the breast & nipple.
* NIPPLE DISCHARGE:
________________________
. H/O of bilateral nipple discharge -> Prolactinoma.
. Order prolactin levels & TSH levels (Hypothyroidism & Hyperprocatinemia).
. Surgical duct excision is NEVER the answer for bilateral, milky nipple discha
rge.
. These pts sh'd undergo workup for prolactinoma (PRL & TSH levels).
.
NIPPLE DISCHARGE
_
_____________________
|
_____________________________________
________________________
|
|
. UNI-lateral
. BI-lateral
|
|
_________________________
. PROLACTINOMA
|

|
-> Order TSH & PRL
. BLOODY
. NON-BLOODY
-> Exclude hypothyroidism & hyperprolactinemia
|
|
. MALIGNANCY
. INTRADUCTAL PAPILLOMA
. The most common cause of unilateral NON-bloody discharge is INTRA-DUCTAL PAPI
LLOMA.
. Symptoms: watery, serous or seosanguinous fluid disharge.

. Think cancer if associated e' palpable mass, involvement of more than 1 duct
or bloody discharge.
. Dx -> MAMMOGRAM -> Look for underlying mass or calcification.
. Dx -> SURGICAL DUCT EXCISION -> Definitive diagnosis.
. N.B.
. Cytology is NOT helpful & is NEVER the answer for nipple discharge.
* BREAST MASS:
_________________
{1} FIBROCYSTIC DISEASE:
____________________________
. Age -> 20 - 50 ys.
. Cyclical, bilateral, painful breast lump(s).
. Pain will vary with the menstrual cycle.
. Dx -> U/$ -> Simple cyst -> Sharp margins & posterior acoustic enhancement.
. Dx -> Fine needle aspiration (FNA) -> Cyst will collapse.
. Tx -> OCPs (Oral contraceptive pills) - Danazol may be used for severe pain.
{2} FIBROADENOMA:
_____________________
. Discrete, firm, NON tender & highly MOBILE breast nodule.
. HIGLY MOBILE MASS on clinical examination.
. Dx -> (1) -> CBE -> Clinical breast examination.
. Dx -> (2) -> U/$ & Mammography (If pt < 40 ys).
. Dx -> (3) -> FNA -> Epithelial & stromal elements.
. Tx -> Surgery (Diagnostic & therapeutic) -> Not necessary.
. N.B.
. Never diagnose a simple cyst on clinical exam alone !
. The Dx must be confirmed with either U/$ or FNA.
. N.B.
. Clinical breast examination in 6 weeks is appropriate follow up for a cystic
mass that disappears after FNA.
. If the mass recurs on the 6 week follow up, FNA may be repeated & a core biop
sy can be performed.
. N.B.
. A young pt who presents with a breast lump with NO signs of malignancy,
. can be asked to return after her menstrual period for reexamination, which ma
y reveal regression of the mass.
. Mammography is NOT useful in young pts due to density of the breast tissue.
. WHEN DO YOU ANSWER THE FOLLOWING ??
______________________________________________
(1) ULTRASOUND:
__________________
. 1st step in workup of a palpable mass that feels cystic on exam.
. Imaging test for younger women with dense breast.
(2) MAMMOGRAPHY (>50 ys old) & BIOPSY (or biopsy alone if < 40 ys old):
_______________________________________________________________________
. Cyst recurs > twice within 4-6 weeks.
. There is bloody fluid on aspiration.
. Mass doesn't disappear completely upon FNA.
. There is bloody nipple discharge (Excisional biopsy).

. There are skin edema & erythema suggestive of inflammatory breast carcinoma (
Excisional biopsy).
. N.B.
. Mammogram sh'd be done before biopsy as biopsy distorts radiography.
(3) FINE NEEDLE ASPIRATION or CORE BIOPSY:
_________________________________________________
. Needed for a palpable mass.
. May be done after U/$ or instead of U/$.
. N.B.
. Core biopsy is superior to FNA.
(4) CYTOLOGY:
_______________
. Any aspirate that is grossly bloody must be sent for cytology.
(5) OBSERVATION WITH REPEAT EXAM IN 6-8 WEEKS:
_______________________________________________________
. Cyst disappears on aspiration & the fluid is clear.
. Needle biopsy & imaging studies are negative.
. N.B.
. A cluster of microcalcifications on mammaogram are mostly benign, however;
. approximately 15-20 % represent early cancer.
. The next step in workup is core needle biopsy under mammographic guidance.
________________________________________________________________________________
______________________________
. BREAST CANCER:
____________________
{1} PRE-INVASIVE DISEASES:
______________________________
______________________________
. Both ductal carcinoma in situ (DCIS) & lobular carcinoma in situ (LCIS) ++ th
e risk of invasive disease.
. If biopsy reveals DCIS :
-> Schedule surgical resection with clear margins (Lumpectomy; breast conserv
ing surgical resection).
-> Radiation therapy (RT).
-> Tamoxifen for 5 ys to prevent the development of invasive disease.
. It is NOT necessary to perform surgery.
. LCIS is classically seen in premenopausal women.
. N.B. Risks associated with Tamoxifen use:
-> Endometrial carcinoma.
-> Thromboembolism.
. Contraindications to Tamoxifen:
-> Patient is active smoker.
-> Previous thromboembolism.
-> High risk for thromboembolism.
{2} INVASIVE BREAST DISEASES:
__________________________________
__________________________________
(1) INVASIVE DUCTAL CARCINOMA:

_____________________________________
. is the most common form of breast cancer (85% of all cases).
. Unilateral.
. Metastatizes to bone, liver & brain.
(2) INVASIVE LOBULAR CARCINOMA:
______________________________________
. 10 % of breast carcinomas.
. Multifocal (within the same breast) & bilateral in 20 %.
(3) INFLAMMATORY BREAST CANCER:
_______________________________________
. Uncommon, grows rapidly & metastatizes early.
. Red, swollen, warm breast & pitted, edematous skin (Classic peau d'orange app
earance).
(4) PAGET's DISEASE OF THE BREAST & NIPPLE:
__________________________________________________
. Pruritic, erythematous, scaly nipple lesion.
. Often confused e' dermatosis-like eczema or psoriasis.
. Look for inverted nipple or discharge.
* ESTABLISHED RISK FACTORS FOR BREAST CANCER:
________________________________________________________
. Age > 50 ys.
. Familial BRCA1/BRCA2 mutation carrier.
. Benign breast disease, especially cystic disease, proliferative & atypical ty
pes of hyperplasia.
. Exposure to ionizing radiation.
. 1st childbirth after age 30 or nulliparity.
. Higher socioeconomic status.
. H/O of breast cancer.
. H/O of breast cancer in a 1st degree relative.
. Hormone therapy.
. Obesity (BMI > 30 Kg/m2).
* BREAST CANCER SCREENING GUIDELINES (USPSTF):
_________________________________________________________
. Mammogram every 1-2 ys recommended for ages 50-74 ys.
. Screening before age 50 is NO longer recommended.
. Women < 50 sh'd only consider mammographic screening based on high individual
risk for early onset breast cancer.
. Teaching breast-self examination is NO longer encouraged.
. Clinical breast exams are NO longer routinely advised.
* When are BRCA1 & BRCA2 gene testing indicated?
__________________________________________________
. Family H/O of early-onset (<50ys of age) breast cancer or ovarian cancer.
. Breast &/or ovarian cancer in the same pt.
. Family H/O of MALE breast cancer.
. Ashkenazi Jewish heritage.
. N.B.
. Primary ttt of invasive carcinoma when tumor size < 5cm is:
-> LUMPECTOMY + RADIOTHERAPY + ADJUVANT THERAPY + CHEMOTHERAPY.
. N.B.
. Sentinel node biopsy is preferred over axillary node dissection.
. ALWAYS test for E & P receptors & HER2/neu receptor protein.

. N.B.
. Primary ttt of inflammatory, tumor size > 5 cm & metastatic disease is SYSTEM
IC THERAPY.
. N.B.
. Breast conserving surgical therapy (Lumpectomy) + Radiotherapy is the standar
d of care for invasive disease.
. There is NO survival benefit with modified radical mastectomy.
* When is breast conserving therapy NOT the answer ?
___________________________________________________
. Pregnancy.
. Prior irradiation to the breast.
. Diffuse malignancy or > 2 sites in separate quadrants.
. Positive tumor margins.
. Tumor > 5 cm.
* When is adjuvant hormonal therapy included in management ?
_____________________________________________________________
. In any hormone receptor +ve (HR+) tumors regardless of age, menopausal status
, stage & type of tumor.
.
.
.
.

N.B.
There is greatest benefit when both ER+ & PR+ receprors are present.
Therapy is nearly as good when there are only ER+ estrogen receptors.
Adjuvant therapy has the least benefit when only PR+ receprors are present.

.
.
.
.

N.B.
Tamoxifen competitively binds estrogen receptors.
5 ys ttt -> 50 % -- in recurrence & 25 % -- in mortality.
May be used in pre or postmenopausal pts.

. N.B.
. Aromatase inhibitors (Astronazole - Exemestane - Letrozole) block peripheral
production of Estrogen.
. This is the standard of care in HR+ postmenopausal women (More effective than
Tamoxifen).
. Doesn't cause menopausal symptoms but doesn't ++ the risk of osteoporosis.
.
.
al
.

N.B.
LHRH analogs (Goserelin) or Ovarian ablation (Surgical oophorectomy or Extern
beam RT)
is an alternative or an addition to Tamoxifen in premenopausal women.

* TAMOXIFEN BENEFITS & ADVERSE EFFECTS:

_________________________________________________
TAMOXIFEN
|
______________________________________________________
______________________
|
|
BENEFITS
ADVERSE EFFECTS
____________
_____________________

. -- incidence of contralateral breast cancer.

. Exacerbates menopausal symptoms.
. -- fractures (As Raloxifen).
. ++ risk of endometrial cancer .
. -- serum cholesterol.
(1% in postmenopausal women after 5 ys ttt)
. -- cardiovascular mortality risk.
. ++ risk of thromboembolism (As Raloxifen).
. ++ bone density in postmenopausal women.
. TAMOXIFEN -> E ANTAGONIST on BREAST -> -- Breast cancer.
. TAMOXIFEN -> E AGONIST on ENDOMETRIUM -> ++ Endometrial cancer.
. TAMOXIFEN -> No effect on ovary !
. RALOXIFEN -> E ANTAGONIST on BREAST (As Tamoxifen) -> -- Breast cancer.
. RALOXIFEN -> E AGONIST on BONE (As Tamoxifen) -> -- Osteoporosis (1st line of
ttt).
. RALOXIFEN -> ++ Thromboembolism (H/O of DVT is a contraindication).
. N.B.
. All women e' a H/O of Tamoxifen use & vaginal bleeding need evaluation & ENDO
METRIAL BIOPSY.
.
.
m.
.
.

N.B.
The only difference between Tamoxifen & Raloxifen is the effect on endometriu
Tamoxifen -> ++ cancer.
Raloxifen -> - - cancer.

* When is chemotherapy included in management ?

________________________________________________
. Tumor size > 1 cm.
. Lymph node +ve disease.
* When is TRASTUZUMAB included in management ?
___________________________________________________
. Indicated for metastatic breast cancer overexpressing HER2/neu.
. It is a monoclonal Ab directed against the extracellular domain of the HER2/n
eu receptor.
. It is used to treat & control visceral metastatic sites.
* N.B.
. INVASIVE BREAST CANCER in an HR -ve , pre or postmenopausal woman -> Chemothe
rapy + RT alone.
. INVASIVE BREAST CANCER in an HR +ve, premenopausal woman -> Chemotherapy + RT
+ Tamoxifen.
. INVASIVE BREAST CANCER in an HR +ve, postmenopausal woman -> Chemotherapy + R
T + Aromatase inhibitor.
________________________________________________________________________________
______________________________
* UTERUS:
___________
* ENLARGED UTERUS:
_______________________
. An enlarged uterus may be caused by the following -> PREGNANCY - LEIOMYOMA ADENOMYOSIS.
. Always make sure that pregnancy (B-HCG/urine pregnancy test) is NEGATIVE befo
re considering other causes.

{1} LEIOMYOMA:
_________________
. It is a smooth muscle growth of the myometrium.
. It is the most common benign uterine tumor.
. H/O of African American woman of childbearing age with an enlarged, firm, asy
mmetric, non tender uterus.
. B-HCG is NEGATIVE.
. ++ tumor growth & symptoms during pregnancy & tumor shrinkage in menopause.
. Growth corresponds to Estrogen stimulation.
. Leiomyoma is most commonly ASMPTOMATIC (INTRAMURAL location).
. Intermenstrual bleeding & menorrhagia (SUBMUCOSAL location) e' distortion of
the uterine cavity seen on U/$.
. Bladder, rectum or ureter compression symptoms (SUBSEROSAL location).
. Subserosal type is parasitic (Break away from uterus & obtain blood supply fr
om omentum or intestinal mesentery).
. Acute onset pain in pregnant woman as tumor outgrows blood supply & degenerat
es.
{2} ADENOMYOSIS:
___________________
. Abnormal location of endometrial glands & stroma within the myometrium of the
uterine wall.
. When symptomatic, it causes dysmenorrhea & menorrhagia.
. The uterus feels soft, globular, symmetrical & tender.
. Unlike leiomyoma, there is NO change with high ++ or -- Estrogen states.
. N.B.
. Asymmetric & NON-tender uterus -> Leiomyoma.
. Symmetric & tender uterus -> Adenomyosis.
DIAGNOSIS OF LEIOMYOMA Vs AD
ENOMYOSIS
_____________________________
___________________
|
____________________________________
____________________
|
|
LEIOMYOMA
ADENOMYOSIS
_______________
_________________
. Symptoms:
. 2ry dysmenorrhea & menorrhagia.
enorrhea & menorrhagia.
. Syms of bladder & rectal compression.
. Pelvic exam:
. Asymmetrically enlarged & firm.
etrically enlarged & Soft.
. NON tender uterus.
. May be tender immediately before & during menses.
. U/$:
. Large intramural or subserosal myomas;
fusely enlarged uterus.
. Saline infusion can show submucosal myomas.
ic areas within the myometrial wall.

. 2ry dysm

. Symm

. Dif
. Cyst

. Hysteroscopy: . Direct visualize tumors.

/A.

. N

. HISTOLOGY: . Is the defnitive diagnosis.

he defnitive diagnosis.

. Is t

MANAGEMENT OF LEIOMYOMA Vs ADENOM

YSOSIS
__________________________________
___________________
|
________________________________
____________________
|
|
LEIOMYOMA
ADENOMYOSIS
_______________
_________________
. Observation: . Serial pelvic exams for most pts.
. LEVONORGESTEROL (IUS) -- heavy menses.
. Pre-surgucal shrinkage: GnRH analog 3-6 months

. N/A.

. It -- size by 70% -> Regrowth after stoppage.

. Myomectomy: . Preserves fertility.
. N/A.
. Laparotomy - Laparoscopy.
. Pts with Leiomyoma must deliver next pregnancies by CESAREAN SECTION because
of ++ risk of scar rupture.
. Embolization of vessels: Preserves uterus - Invasive radiology.

. N/A.

. Hysterectomy: . Best choice when fertility is completed.

. Defnitive ttt: Transabdominal or transvaginal hyst
erectomy.
. N.B.
. Dysmenorrhea + Heavy menses + Enlarged uterus + No sex pain -> Uterine fibroi
d.
. Submucosal fibroid interfere with implantation -> Infertility.
. They are Estrogen dependent tumor -> ++ with OCPs or pregnancy & regress afte
r menopause.
________________________________________________________________________________
______________________________
. POSTMENOPAUSAL BLEEDING:
__________________________________
. The most common cause is VAGINAL or ENDOMETRIAL ATROPHY.
. The most important Dx to rule out is ENDOMETRIAL CARCINOMA (The most common g
ynecological malignancy).
. ENDOMETRIAL BIOPSY is the 1st step in management of any pt with postmenopausa
l bleeding.
. Never give Estrogen alone to a woman with a uterus !

. Always combine e' Progesterone to prevent unopposed endometrial stimulation.

. The most important risk factors for endometrial carcinoma are UN-OPPOSED ESTR
OGEN STATES:
. (Obesity - Nulliparity - Late menopause - Early menarche - Chronic anovulatio
n - H/O of Tamoxifen use).
. All POSTMENOPAUSAL BLEEDING is suspected ENDOMETRIAL CARCINOMA until proven o
therwise.
. All reproductive age women with chronic anovulation (eg. PCOs) are at high ri
sk of endometrial carcinoma.
. Give progestins to prevent endometrial hyperplasia & cancer.
. Pelvic exam. -> If the endometrial biopsy reveals ATROPHY & NO cancer -> No f
urther work up is needed.
. Give HRT (Estrogen + Progesterone).
. Pelvic exam -> If the endometrial biopsy reveals ADENOCARCINOMA ->
. Perform SURGERY STAGING (TAH & BSO + Pelvic & paraaortic lymphadenectomy + Pe
ritoneal washing).
+ Radiation therapy if LN metastasis, > 50% myometrial invasion, +ve sugical ma
rgins or poorly differentiated
+ Chemotherapy if metastasis.
. Hysteroscopy -> Identifies endometrial or cervical polyps as source of bleedi
ng.
. U/$ -> Measures thickness of endometrial lining.
. In postmenopausal pts the endometrial lining stripe should < 5 mm thick.
________________________________________________________________________________
______________________________
* OVARIES:
____________
* OVARIAN ENLARGEMENT:
_____________________________
{1} SIMPLE CYST = PHYSIOLOGIC CYSTS (LUTEAL or FOLLICULAR CYSTS):
____________________________________________________________________________
. The most common cysts during the reproductive years.
. Asymptomatic unless torsion occurs (Only with large cysts).
. Dx -> B-hCG -> -ve.
. Dx -> U/$ -> fluid filled simple cystic mass.
. Tx -> Follow up exam in 6-8 wks (Resolves spontaneously).
. Tx -> Steroid contraception prevents new cysts.
. Tx -> Laparoscopic removal if: cysts > 7 cm in diameter or previous steroid c
ontraception without cyst resolution.
{2} COMPLEX CYST = BENIGN CYSTIC TERATOMA (DERMOID CYST):
_____________________________________________________________________
. Benign tumors.
. Contain cellular tissue from all 3 germ layers.
. Rarely, squamous cell carcinoma can develop.
. Dx -> B-hCG -> -ve.
. Dx -> U/$ -> Complex mass.
. Tx -> Laparoscopic/laparotomy removal: Cystectomy (retain ovarian function) Oophrectomy (if no fertility desire).
. N.B. Fine needle aspiration of a complex ovarian cyst is NEVER the correct an

swer on the test.

{3} BILATERAL OVARIAN ENLARGEMENT:
___________________________________________
. Polycystic ovarian $yndrome (PCO$).
. PCO $ is associated with Valproic acid.
{4} OVARIAN HYPERTHECOSIS:
________________________________
. Nests of lutinized theca cells in the ovarian stroma that produce high levels
of androgens.
. H/O of postmenopausal woman (She may be premenopausal) with SEVERE HIRSUTIS &
ACNE.
. Tx -> OCPs (Both E & P) to suppress androgen production (By -- LH stimulation
of theca cells).
. Tx -> OCPs (Both E & P) to decrease free androgens (By ++ sex hormona binding
globulin).
{5} LUTEOMA OF PREGNANCY:
________________________________
. Non-neoplastic, tumor-like mass of the ovary: emerges during pregnancy & regr
esses spontaneously after delivery.
. Found incidentally during a C.S. or postpartum tubal ligation.
. It can be hormonally active & produce androgen -> Maternal & fetal hirsutism
& verilization.
. No ttt is needed.
{6} THECA LUTEIN CYSTS:
___________________________
. Benign neoplasms caused by HIGH LEVELS of FSH & B-hCG.
. Associated e' twins & molar pregnancies.
. Spontaneously regress after pregnancy.
{7} PRE-PUBERTAL or POST-MENOPAUSAL OVARIAN MASS:
____________________________________________________________
. Risk factors: BRCA1 gene - +ve family H/O - High no of lifetime ovulations Infertility - Use of perineal talc powder.
. Protective factors: OCPs - Chronic anovulation - Breastfeeding - Short reprod
uctive life.
. N.B.
. Sudden onset of severe lower abdominal pain in the presence of abdominal mass
= OVARIAN TORSION.
. Laparoscopy & de-torsioning of the ovaries is needed urgently.
. If blood supply is not affected -> Cystectomy can be done.
. If there is necrosis -> Oophorectomy is needed.
. Pt sh'd receive a 4 week follow up & yearly evaluation to ensure there is com
plete resolution.
. N.B.
. The initial workup of an ovarian mass -> B-hCG - U/$ - Laparoscopy/Laparotomy
if complex or > 7cm.
.
REGNANCY

. SUDDEN ONSET HIRSUTISM or VEILIZATION DURING P

________________________________________________

______________________
PHYSICAL EXAMINATION & PELVIC ULTRASONO
GRAPHY

________________________________________
____________________
|
_______________________________________________________
_______________________
|

|
|

No ovarian mass
Bilateral solid

Bilateral cystic
Unilateral solid
|

|
|

Abdominal CT
Theca lutein cysts
Pregnancy luteoma
Laparotomy/Laparoscopy
to rule out adrenal mass
Rule out ++ B-hCG states
to rule out malignancy
. N.B.
. Postmenopausal woman with abdominal distension & ovarian mass -> Suspect Ovar
ian neoplasm.
. Dx -> CT Abdomen -> Ascites ? (No -> Laparoscopy) (Yes -> Laparotomy -> Ooph
rectomy & surgical staging).
. OVARIAN MASSES QUIZ:
__________________________
.Q. 9 yrs old girl - Rt adnexal pain - Complex cystic mass on U/$ -> GERM CELL
TUMOR
-> It is the most common in young women.
-> The most common malignant epithelial cell type -> DYSGERMINOMA.
-> Tumor markers (LDH - B-hCG - a-FP).
.Q. 67 ys old - Progressive weight loss - Distended abdomen - Left adnexal mass
-> EPITHELIAL TUMOR.
-> The most common ovarian cancer in postmenopausal women.
-> The most common malignant subtype is SEROUS.
-> Tumor markers (CA-125 - CEA).
.Q. 58 ys old - Postmenopausal bleeding - Endometrial hyperplasia - Rt ovarian
mass on U/$ -> GRANULOSA THECA
-> Granulosa theca is a stromal tumor.
-> It secretes ESTROGEN & can cause endometrial hyperplasia.
-> It may be present in children with precocious puberty.
-> Tumor marker (ESTROGEN).
.Q. 48 ys old - ++ facial hair - Deepening of voice - Adnexal mass on exam -> S
ERTOLI-LEYDIG
-> Sertoli-Leydig is a stromal tumor.
-> It secretes TESTOSTERONE.
-> Pt presents with masculinization syndromes.
-> Tumor marker (TESTOSTERONE).
.Q. 64 ys - H/O of gastric ulcer - Dyspepsia - Weight loss & abdominal pain - A
dnexal mass-> KRUKENBURG TUMOR
-> Krukenburg tumor is a matastatic gastric cancer.
-> It is a mucin producing adenocarcinoma from the stomach that has meta
statized to one or both ovaries.
-> Tumor marker (CEA).

. GENERAL MANAGEMENT OF OVARIAN MASSES:

__________________________________________________
. U/$ ( & CT for postmenopausal women).
. Biopsy via laparoscopy for simple cysts suggestive of malignancy (No septatio
ns or solid components).
. Biopsy via laparoscopy for postmenopausal without ascites.
. Tumor markers (LDH, B-hCG, a-FP, CA 125, CEA, E & P).
. PRE-menstrual women -> Salpingo-oophrectomy.
. POST-menopausal women -> TAH & BSO (Total abdominal hysterectomy & Bilateral
Salpingo-oophrectomy).
________________________________________________________________________________
______________________________
* CERVIX:
___________
___________
. CERVICAL NEOPLASIA:
__________________________
. The most common HPV types associated with cervical cancer are HPV 16, 18, 31,
33 & 35.
. HPV 6 & 11 are benign condyloma accuminata.
. PAP SMEAR CLASSIFICATION:
_________________________________
. INDETERMINATE SMEARs -> Atypical squamous cells of undetermined significance
(ASCUS).
. ABNORMAL SMEARs ->
-> Low grade squamous intraepithelial lesion (LSIL) -> HPV, mild dysplasia or
CIN 1.
-> High grade squamous intraepithelial lesion (HSIL) -> Moderate dysplasia, se
vere dysplasia, CIS, CIN 2 or 3.
-> Cancer -> Invasive cancer.
. Risk factors associated e' cervical neoplasia:
__________________________________________
. Early age of intercourse - Multiple sexual partners - Cigarette smoking - Imm
unosuppression.
. SCREENING:
______________
. Started at age 21, regardless of onset of sexual activity.
. Conventional method -> 50 % sensitivity.
. Liquid based prep. -> 75-80 % sensitivity.
. HPV DNA TEST -> Useful in management of ASCUS.
. Pt < 30 ys old -> Annually for conventional Pap or Every 2 ys for liquid base
d.
. Pt > 30 ys old -> Screen every 2-3 ys if > 3 consecutive -ve PAP smears.
. CERVICAL CANCER SCREENING GUIDELINES (USPSTF):
___________________________________________________________
. Pap screening NOT recommended for women > 65 ys with recent normal Pap smear.
. Pap smear NOT recommended for women with total hysterectomy for benign diseas
e.
. HPV testing alone is NOT suffecient for screening.
. N.B.

. ASCUS is most commonly found in women e' inflammation due to early HPV infect
ion.
. 10-15 % of pts with ASCUS have premalignant or malignant disease.
. 2 Pap smears revealing ASCUS must be followed up with colposcopy & biopsy.
. PAP at age 21 ys ==================> ASCUS: FOLLOW UP
|
_______________________________
______________________
|
|
CERTAIN
UN CERTAIN
___________
_______________
|
|
. PAP 3-6 months.
. Colposcopy & biopsy.
. HPV DNA testing.
|
____________________
|
- ve
|
Follow up

|
+ ve
(PAP -> ASCUS)
(HPV -> 16 & 18)
|
Colposcopy & biopsy

* WORKUP FOR AN ABNORMAL PAP SMEAR:

_____________________________________________
. First ASCUS -> Repeat Pap & HPV DNA testing.
. Abnormal Pap smear or 2 ASCUS Pap smears -> Colposcopy & ECTO-cervical biop
sy.
. NON-pregnant pts e' abnormal Pap smear -> ENDO-cevical curettage.
. CONE BIOPY -> Performed after colposcopy or ECC if Pap smear & biopsy findi
ngs are not consistent.
-> Abnormal ENDO-cervical curettage histology.
-> An ENDO-cervical lesion.
-> A biopsy showing microinvasive carcinoma of the
cervix.
* MANAGEMENT OF ABNORMAL HISTOLOGY:
______________________________________________
. CIN 1 or CIN 2 & 3 after ablation or excision -> Follow up (Repeat Pap smears
& colposcopy / 4-6 months for 2 ys).
. CIN 2 or 3 -> Ablative methods (Cryotherapy - Laser vaporization - Electofulg
iration).
. CIN 2 or 3 -> Excisional procedures (LEEP Loop Electrosurgical Excision Proce
dure - Cold knife conization).
. Biopsy confirmed recurrent CIN 2 or 3 -> HYSTERECTOMY.
* INVASIVE CERVICAL CANCER:
__________________________________

.
.
.
.
.
cm

Average age : 45 ys.

Dx -> Cervical biopsy -> Squamous cell carcinoma.
Dx -> Metastatic work up (Pelvic exam - CT - Cystoscopy - Proctoscopy).
Tx -> HYSTERECTOMY.
Tx -> Adjuvant therapy (Radio/Chemo) -> if Metastasis to LNs - Tumor size > 4
- Poorly differentiated.

* CERVICAL NEOPLASIA IN PREGNANCY:

___________________________________________
. CIN / DYSPLASIA -> Pap smear & colposcopy / 3 months during pregnancy.
-> Repeat Pap & colposcopy 6-8 weeks post-par
tum.
-> Any persistent lesions are then defnitivel
y treated postpartum.
. Micro-invasive cervical cancer -> Cone biopsy to ensure no frank invasion.
-> Deliver vaginally, re-e
valuate & treat 2 months post-partum.
. Invasive cancer -> Before 24 weeks -> Definitive ttt (Radical hysterectomy or
Radiotherapy).
-> After 24 weeks ---> Conservative management up
to 32-33 weeks.
---> C.S. delivery &
begin definitive ttt.
. N.B. During pregnancy. the 1ry goal of colposcopy is the exclusion of invasiv
e cancer.
. Any woman with cytologic specimen suggesting HSIL, sh'd undergo colpo
scopy & direct biopsy.
. If the biopsy is -ve -> A 2nd biopsy is recommended 6-8 weeks after d
elivery.
* PREVENTION OF CERVICAL DYSPLAIA BY VACCINATION:
_____________________________________________________________
. Give QUADRIVALENT HPV recombinant vaccine (Gardasil) to all females 8 - 26 ys
of age.
. It protects against the HPV types (6 - 11 - 16 - 18).
. Testing for HPV before vaccination is not needed.
. Sexually active women can receive the vaccine.
. Women e' previous abnormal cervical cytology or genital warts can receive the
vaccine but less effective.
. Can be given for pts e' previous CIN, but less effective.
. It is NOT recommended for PREGNANT, LACTATING or IMMUNO-SUPPRESSED women.
. Vaccinated females must still follow Pap smear recommendations.
* PELVIC PAIN:
________________
. INITIAL WORK UP -> 1 - Pelvic exam.
-> 2 - Cervical cultures (Gonorrhea & Chlam
ydia).
-> 3 - ESR - WBCs - Blood culture.
-> 4 - U/S.
{1} CERVICITIS:
________________
. C/O -> Cervical discharge without other syms.
. Dx -> Cervical cultures for Gonorrhea & Chlamydia.
. Tx -> Single dose of oral cefexime & Azithromycin.

. N.B. Always treat cervicitis to cover both Gonorrhea & Chlamydia.

. Anti - Gonorrhea -> Ceftriaxone IM - Cefexime PO.
. Anti- Chlamydia -> Azithromycin PO - Doxycycline PO.
{2} ACUTE SALPINGO-OOPHRITIS:
__________________________________
. C/O -> Lower pelvic pain after menstruation.
. Ex -> Cervical motion tendrness.
. Dx -> +ve cervical cultures - ++ WBCS & ESR.
. Dx -> Rule out pelvic abscess e' U/S.
. Tx -> OUT-patient -> TWO ORAL antibiotics -> Ofloxacin & Metronidazole.
. Tx -> IN-patient -> THREE IV antibiotics -> IV Cefoxitin or Cefotetan & Doxyc
ycline or Clindamycin &Gentamycin.
. N.B. Admit if (Nulligravida - IUD insertion - Outpt ttt failure - Pelvic absc
ess).
{3} CHRONIC PELVIC INFLAMMATORY DISEASE:
_________________________________________________
. C/O -> Infertility - Dyspareunia.
. H/O of ectopic pregnancy or abnormal vaginal bleeding.
. Dx -> NEGATIVE cervical cultures & lab tests.
. Dx -> U/S -> Bilateral cystic pelvic masses (Hydrosalpinges).
. Tx -> Lysis of tubal adhesions (Helpful for infertility).
. Tx -> Severe unremitting pelvic pain may require a pelvic clean out (TAH - BS
O).
{4} TUBO-OVARIAN ABSCESS:
______________________________
. C/O -> Ill-appearing woman - Severe lower addominal, pelvic, back or rectal p
ain.
. Systemic signs & symptoms -> Nausea, vomiting, fever & tachycardia.
. Dx -> ++ WBCs & ++ RBCs.
. Dx -> Pus on culdocentesis.
. Dx -> U/S -> Unilateral pelvic mass (Multilocular cystic complex adnexal mass
).
. Dx -> Blood cultures -> Anaerobic organisms.
. Tx -> Admission + IV Clindamycin & IV Gentamycin.
. Tx -> If no reponse within 72 hs or abscess rupture -> Exploratory laparotomy
+ TAH BSO or percutaneous drainage.
. N.B. All cases of cervicitis & Cases of Acute Salpingo-oophritis (If no syste
mic syms or pelvic abscess) require OUTPATIENT ANTIBIOTICs.
. N.B. All cases of Tubo-ovarian abscess & Cases of Acute Sapingo-oophritis (If
nulligravida or adolescent pt - Previous
outpatient ttt failure - IUD
inserted - Fever - Pelvic abscess) require ADMISSION + IN-PATIENT ANTIBIOTICs.
. N.B. All pts withacute salpingo-oophritis require admission + Antibiotics if t
he pt is NULLIGRAVIDA, VOMITING
(Can't take oral ttt) or feverish > 39
c.
________________________________________________________________________________
______________________________
* DYSMENORRHEA:
____________________
{1} PRIMARY DYSMENORRHEA:
________________________________

.
.
.
.
.
.

H/O -> Recurrent crampy lower abdominal pain.

H/O -> Nausea, vomiting & diarrhea during menstruation.
Syms begin 2-5 ys after onset of menstruation (Ovulatory cycles).
NO pelvic abnormality.
Syms are due to EXCESSIVE ENDOMETRIAL PROSTAGLANDIN F2.
PGF2 causes uterine contractions & acts on GIT smooth muscles.

{2} SECONDARY DYSMENORRHEA = (ENDOMETRIOSIS - ADENOMYOSIS - LEIOMYOSIS):

________________________________________________________________________________
________
< ENDOMETRIOSIS >
______________________
. It involves endometrial glands outside the uterus.
. Age -> > 30 ys.
. C/O -> DYSMENORRHEA - DYSPAREUNIA - DYSCHEZIA & INFERTILITY.
. The most common site is -> OVARY -> Adnexal enlargement due to endometrioma "
CHOCOLATE CYST".
. The 2nd most common site is -> CUL-DE-SAC -> Uterosacral ligament nodularity
& tendrness on rectovaginal exam.
. This location is associated with bowel adhesions & a fixed retroverted uterus
.
. Dx -> U/S -> Endometriomas (Best initial).
. Dx -> LAPAROSCOPY ( Most accurate).
. Dx -> ++ CA-125.
. Tx -> 1st line ttt -> CONTINOUS ORAL PROGESTERONE (COP) or ORAL CONTRACEPTIVE
PILL (OCP).
. Tx -> 2nd line ttt -> Testosterone derivatives (Danazol) or GnRH analogs (Leu
prolide).
. Tx -> Laparoscopic lysis adhesions -> may improve fertility.
. Tx -> TAH & BSO can be done if fertility isn't desired.
. N.B. CA-125 can be elevated in: Ovarian cancer - Cirrhosis - Endometriosis Peritonitis - Pancreatitis.
________________________________________________________________________________
______________________________
* VAGINAL BLEEDING & IT'S ABSENCE:
_________________________________________
{1} PREMENARCHAL VAGINAL BLEEDING:
___________________________________________
. Bleeding before menarche .. Before average age of menarche 12 ys.
. The most common cause -> FOREIGN BODY.
. You must exclude SARCOMA BOTRYOIDES
(Cancer of vagina or cervix suggested by a grape like mass arising from the v
aginal lining & cervix).
. Other causes: Tumor of the pituitary adrenal gland or ovary & sexual abuse.
. Dx -> PEVIX EXAM UNDER SEDATION.
. Dx -> CT or MRI of pituitary, abdomen & pelvis to look for estrogen procedure
tumor.
. If the work up is NEGATIVE -> Dx is IDIOPATHIC PRECOCIOUS PUBERTY.
{2} ABNORMAL VAGINAL BLEEDING:
_____________________________________
. Irregular bleeding in reproductive age sh'd always be evaluated 1st for pregn
ancy.
. If pregnancy is ruled out-> Work up for anatomical causes of bleeding or anov
ulation can be started.

. In any woman in childbearing age with 2ry amenorrhea, 1st rule out pregnancy.
. N.B. Ingested DI-ETHYL-STILLBESTEROL during pregnancy causes VAGINAL ADENOCAR
CINOMA.
. N.B. Radiation therapy is higly effective for squamous cell carcinoma of vagi
na.
. Excellent alternative for pts who are poor surgical candidates.
________________________________________________________________________________
______________________________
* PRIMARY AMENORRHEA:
____________________________
. Absence of menses at age 14 ys WITH-OUT 2ry sexual characters.
or
. Absence of menses at age 16 ys WITH PRESENCE of 2ry sex characters.
. Dx -> 1. Physical exam & U/S -> Are BREASTS present or absent ? Breasts indic
ate adequate Estrogen production.
-> Is a UTERUS present or absen
t on U/S ?
-> 2. KARYOTYPING - TESTOSTERONE - FSH.
* WORK UP FOR PRIMARY AMENORRHEA:
___________________________________________
. IF BOTH UTERUS & BREASTS ARE PRESENT:
_______________________________________________
. Work up as 2ry amenorrhea: -> Imperforate hymen.
->
->
->
->

Vaginal septum.
Anorexia nervosa.
Excessive exercise.
Pregnancy before the 1st m

enses !
. IF THE BREATS ARE PRESENT & THE UTERUS IS ABSENT:
_____________________________________________________________
. Order Testrosterone levels & Karyotyping:
. {MULLERIAN AGENESIS} XX karyotype, Normal testosterone for FEMALE.
. {ANDROGEN ISNENSITIVITY = TESTICULAR FEMINIZATION} XY karyotype, Normal testo
sterone for MALE.
. IF THE BREASTS ARE ABSENT & THE UTERUS IS PRESENT:
______________________________________________________________
. Order FSH & Karyotype.
. {GONADAL DYSGENESIS = TURNER'S $} XO karyotype, FSH ELEVATED.
. {HYPOTHALAMIC - PITUITARY FAILURE = KALLMAN'S $} XX karyotype, FSH LOW.
. ABSENT BREASTS & UTERUS -> Not cilinically relevent !!
. N.B. In pts e' Mullerian agenesis, with absent uterus, cervix & upper vagina,
intact ovaries with normal estrogen
levels, VAGINAL RECONSTRUCTION
sh'd be performed to elongate the vagina for satisfactory intercourse.
. N.B. In cases with ABSENT BREASTS WITH UTERUS PRESENT, FSH levels are ordered
1st:

. FSH ++ -> Do KARYOTYPING to detect TURNER'S $ (XO).

. FSH -- -> Do CRANIAL MRI to detect HYPOTHALAMIC-PITUITARY FAILURE.
* MULLERIAN AGENESIS:
___________________________
. Normal female 2ry sex characters.
. Normal testosterone levels (Intact ovaries).
. Absence of all Mullerian duct derivatives (Fallopian tubes, uterus, cervix &
upper vagina).
. Tx -> Surgical elongation of the vagina for satisfactory intercourse & counse
ling about infertility.
* ANDROGEN INSENSITIVITY $ = TESTICLAR FEMINIZATION = PSEUDOHERMAPHRODITE MALE:
________________________________________________________________________________
___________________
. No public or axillary hair.
. Karyotyping -> Male genotype XY.
. Ulrasound -> TESTES.
. The testes produce BOTH NORMAL levels of ESTROGEN for a FEMALE & TESTOSTERONE
for a MALE.
. Tx -> Removal of testes before age 20 due to ++ risk of testicular cancer.
. Estrogen replacement will then be needed.
. N.B. Androgen insensitivity $ (46 XY) is a MALE with 1ry amenorrhea, bilatera
l inguinal masses, breast
development, no pubic or axillar
y hair.
. The peripheral tissues are unresponsive to androgens, with normal and
rogen concentrations.
. No mullerian structures (No uterus - No fallopian tubes).
. The vagina ends with a blind pouch.
. Tx -> Gonadectomy AFTER puberty to avoid testicular carcinoma AFTER c
ompletion of breast development
& end of height spurt.
. N.B. Andogen insensitivity $ -> PRESENCE of Mullerian inhibiting factor.
* GONADAL DYSGENESIS = TURNER'S $:
_________________________________________
. Karyotyping -> 45 XO .. Absence of one X chromosome (45,XO).
. Absence of 2ry sex characters.
. ++ FSH.
. Because the second X chromosome is essential to the development of normal ova
rian follicles, streak gonads develop.
. Tx -> Estrogen & Progesterone replacement for development of 2ry sex characte
rs.
. N.B. Other manifestations of Turner's $ -> Aortic coarctation & upper BP > lo
wer BP.
* HYPOTHALAMIC PITUITARY FAILURE = KALLMAN'S $:
__________________________________________________________
. Karyotyping 46 XX.
. U/$ -> Normal uterus.
. LOW FSH.
. It may be due to stress, excessive exercise or anorexia nervosa.
. ANOSMIA (Hypothalamus doesn't produce GnRH).
. CT head will rule out any brain tumor.
. Tx -> Estrogen & Progesterone replacement for development of 2ry sex characte
rs.
________________________________________________________________________________

______________________________
* SECONDARY AMENORRHEA:
_______________________________
. Regular menses are replaced by an absence of menses for 3 months.
or
. Irregular menses are replaced by an absence of menses for 6 months.
* WORK UP FOR SECONDARY AMENORRHEA:
______________________________________________
{1} PREGNANCY TEST (B-hCG) !!
{2} THYROTROPIN (TSH) (RULE OUT HYPOTHYROIDISM):
_________________________________________________________
. An elevated TRH in primary hypothyroidism -> ++ prolactin.
. -- TSH -> ++ TRH -> ++ PRL.
. Treart hypothyroidism with thyroid replacement for rapid restoration of menst
ruation.
{3} PROLACTIN (RULE OUT HYPERPROLACTINEMIA):
______________________________________________________
. If elevaed:
. 1. Review medications ( Antipsychotics & Antidepressants have ANTI-DOPAMINE s
ide effect -> ++ PRL).
. 2. CT or MRI HEAD (To rule out pituitary tumor).
.. Tumor < 1 cm -> Give bromocrptine (Dopamine agonist).
.. Tumor > 1 cm -> Surgical ttt.
. 3. If the cause of ++ PRL is idiopathic -> Tx -> Bromocriptine.
{4} PROGESTERONE CHALLENGE TEST (PCT):
______________________________________________
. +ve PCT -> Any withdrawal bleeding is diagnostic of ANOVULATION !
. Tx -> CYCLIC PROGESTERONE to prevent endometrial hyperplasia.
. CLOMIPHENE ovulation induction is done if pregnancy is desired.
. -ve PCT -> Inadequate Estrogen or Outflow tract obstruction.
{5} ESTROGEN-PROGESTERONE CHALLENGE TEST (EPCT):
____________________________________________________________
. 3 weeks of oral estrogen followed by 1 week of progesterone.
. +ve EPCT -> Any withdrawal bleeding is diagnostic of INADEQUATE ESTROGEN !!
----------------. Next step is -> Get FSH level:
.. ++ = OVARIAN FAILURE. Y chromosome mosaicism may be
the cause if pt < 25 ys. Order karyotyping
.. ---- = HYPOTHALAMIC PITUITARY INSUFFECIENCY. Order B
RAIN CT or MRIto rule out a tumor.
.. Give Est replacement therapy to prevent osteoporosis
& cyclic progestins to prevent end. hyperplasia.
. -ve EPCT -> Diagnostic of outflow tract obstruction or endometrial scarring (
Asherman $).
---------------. Next step is -> Order a HYSTEROSALPINOGRAM to identify the
lesion.
. Tx -> Adhesion lysis follwed by Estrogen stimulation of th
e endometrium.

. N.B. TRH -> ++ PRL.

. Hypothyroidism -> Hyperprolactinemia.
. N.B. Pregnancy & thyroid states:
. ++ TBG - T3 - T4
. NORMAL TSH - Free T3 & T4.
. N.B. Vigrous atheletes have -- LH & -- GnRH -> Estrogen defeciency -> 2ry ame
norrhea -> Infertility.
. These atheletes have -- BMI with thin well defined musculature.
. N.B. Acquired hypogonadotrophic hypogonadism is a cause of amenorrhea seen mo
st commonly in association with
significant stressors, eating diso
rders & excessive exercise.
. Tx -> PULSATILE GnRH therapy can induce ovulation.
. N.B. The cause of amenorrhea in lactating mothers is INHIBITION of GnRH by +
+ circulating PROLACTIN
. NOT human placental lactogen xxx (Common mistake).
. N.B. The main cause of irregular menstrual cycles in women shortly after mena
rche is:
. IMMATURE HYPOTHALAMIC PITUITARY GONADAL AXIS & ANOVULATION
. This leads to insuffecient gonadotropins secretions.
. Dx -> Give progesterone -> Withdrawal bleeding.
________________________________________________________________________________
______________________________
* PRE-MENSTRUAL $YNDROME:
_________________________________
{1} PRE-MENSTRUAL TENSION:
________________________________
. Distressing physical, psychological & behavioral syms recurring at the same p
hase of the menstrual cycle.
. Disappear during the remainder of the cycle.
{2} PRE-MENSTRUAL DYSPHORIC DISORDER (PMDD):
______________________________________________________
. More severe, involving major disruptions to daily functioning & relationships
.
. Dx -> Menstrual diary.
. Tx -> SSRI (Fluoxetine) & Vit. B 6.
________________________________________________________________________________
______________________________
. ENDOCRINE DISORDERS:
___________________________
. Hirsutism -> Excessive male pattern hair growth in a woman.
. Verilization -> Hirsutism + Masculinizing signs
(Clitoromegaly - Baldness - Low voice - ++ muscle ma
ss - loss of female body contour).
. Almost all cases of hirutism are either PCOS or IDIOPATHIC.
. More serious causes of hirsutism (ANDROGEN SECRETING TUMORS) need to be exclu
ded in work up.
. WORK UP -> TESTOSTERONE - DHEAS - LH/FSH - 17 HYDROXYPROGESTERONE.

{1} POLYCYSTIC OVARIAN $YNDROME (PCOS):

_______________________________________________
. It is considered as OVARIAN cause of infertility.
. Gradual onset of hirsutism, obesity, acne, irregular bleeding & infertility.
. Chronic anovulatory cycles -> Infertility.
. Dx -> LH / FSH -> +++++++++ !
. Dx -> U/S -> Bilaterally enlarged ovaries.
. Anovulation -> No corpus
->
->
->

luteum production of progesterone

Unopposed estrogen
Hyperplastic endometrium & irrgular bleeding
Predisposition to ENDOMETRIAL CANCER.

. ++ TESTOSTERONE -> ++ LH levels

-> ++ Theca cell production of androgens
-> Hepatic production of SHBG is suppres
sed
-> ++ total Testosterone & ++ free Testo
sterone.
. Ovarian enlargement -> U/S -> Necklace like pattern of multiple peripheral cy
sts 20-100 cystic follicles in each ovary
-> ++ Androgens -> Multiple follicles in
various stages of development -> Stromal hyperplasia
-> Thickened ovarian capsule -> Bilatera
lly enlarged ovaries.
. Dx -> LH : FSH ratio -> 3:1 (Normal is 1.5:1).
-> Testosterone levels -> Milly elevated.
-> Pelvic U/S -> Bilaterally enlarged ovaries with multiple subcapsular
small follicles & ++ stromal echogenecity.
. Tx -> Oral contraceptive pills -> for irregular bleeding & hirsutism.
-> The progesterone compone
nt prevents endometrial hyperplasia.
. Tx -> Spironolactone -> for suppression of hair follicles.
. Tx -> Clomiphene citrate or Human menopausal gonadotropin (HMG) -> for infert
ility.
. Tx -> Metformin -> enhances ovulation & manages insulin resistance.
{2} ADRENAL or OVARIAN TUMOR:
___________________________________
. RAPID onset hirsutism & verilization (without a family H/O).
. DHEAS is MARKEDLY ELEVATED in an ADRENAL tumor -> Do CT to detect ADREAL MASS
.
. TESTOSTERONE is MARKEDLY ELEVATED in an OVARIAN tumor -> Do U/S to detect ANE
XAL MASS.
. Tx -> Surgical removal of the tumor.
{3} CONGENITAL ADRENAL HYPERPLASIA (21 HYDROXYLASE DEFICIENCY):
______________________________________________________________________________
. GRADUAL onset hirsutism WITHOUT verilization.
. 2nd or 3rd decade of life.
. Ass. e' menstrual irregularities & anovulation.
. Serum 17 HYDROXY PROGESTERONE level is markedly ELEVATED.
. Precocious puberty with short stature is common.
. Family H/O may be +ve !
. Tx -> CORTICOSTEROID REPLACEMENT -> Arrest of all signs of androgenicity & re

store ovulatory cycles.

{4} IDIOPATHIC HIRSUTISM:
_____________________________
. Most common cause of hirsutism.
. No verilization.
. Normal lab tests.
. Tx -> SPIRONOLACTONE (Topical to remove unwanted facial & chin hair).
. N.B. Anovulation classically presents with a H/O of AMENORRHEA followed by UN
PREDICTABLE BLEEDING.
. because prolonged unopposed estrogen stimulates the endometrium.
. D.D. PCO - Hypothyroidism - Pituitary adenoma - Hyperprolactinemia Medications (Antipsychotics).
. N.B. PCO pts are at risk of developing DYSLIPIDEMIA, INSULIN RESISTANCE & TYP
E 2 DM.
. A standard 2 hour glucose tolerance test is imp. to early diagnosis.
. N.B. TESTOSTERONE is produced by the OVARY & ADRENAL GLANDS.
. N.B. DHEAS___________________________ ADRENAL GLANDS.
. N.B. LH/FSH___________________________ ANTERIOR PITUITARY GLAND.
. N.B. 17-OHP is a precursor in cortisol synthesis & converted peripherally to
androgens.
. TO SUM UP:
_____________
. PCO -> + TESTOSTERONE & + DHEAS & + LH & -- FSH & N 17-OHP.
. CAH -> + TESTOSTERONE & + DHEAS & N LH & N FSH & +++ 17-OHP.
. OVARIAN TUMOR -> ++ TESTOSTERONE & NORMAL VALUES OF OTHER HORMONES.
. ADRENAL TUMOR -> + TESTOSTERONE & ++ DHEAS & NORMAL VALUES OF OTHER HORMONES.
________________________________________________________________________________
______________________________
* MENOPAUSE DISORDERS:
____________________________
. 12 months of amenorrhea with ++ FSH & LH.
. MENOPAUSE Mean age is 51 ys.
. Smokers experience menopause 2 ys earlier.
. Dx -> Serial levels of ++ GONADOTROPINS (FSH > 50).
. EARLY menopause is between age 40 & 50.
. Early menopause mostly idiopathic but can be after radiation or surgical ooph
rectomy.
. PREMATURE OVARIAN FAILURE if menopause occured before age 30 ys.
. It may be due to autoimmune disease or Y chromosome mosaicism.
. Menoopausal symptoms are related to LACK OF ESTROGEN:
-> Amenorrhea -> Menses become anovulatory.
-> Hot flashes -> Unpredictable profuse sweating & heat in 75 % of women.
Obese women are less likely to develop hot flashes due to peripheral conver
sion of androgens to estrone.
-> Reproductive tract -> -- vaginal lubrication, ++ vaginal pH & ++ vaginal inf
ections.
-> Urinary tract -> ++ urgency, frequency, nocturia & urge incontinence.
-> Psychic -> Depressed mood, emotional lability & sleep disorders.
-> CVS dis -> THIS IS THE MOST COMMON CAUSE OF MORTALITY (50%).
-> Osteoporosis.
. N.B. Menopause & Hyperthyroidism may have similar manifestations, next step i

s:
. TSH & FSH
|
__________________________________
_________________
|
|
MENOPAUSE
HYPERTHYROIDISM
|
|
. NORMAL TSH & T4.
. -- TSH & ++ T4
. ++ FSH & ++ LH.
. NORMAL FSH & LH.
. N.B. In
.
.
.

pts with pre-mature ovarian failure:

Amenorrhea, hypo-estrogenism, ++ FSH & ++ LH,-- E in women < 40 ys.
Mostly idiopathic, they lack viable oocytes.
Tx of infertility is IVF using donor oocytes !!

. N.B. PREMATURE OVARIAN FAILURE -> Hypogonadism in a pt < 40 ys.

. Causes -> Chemotherapy, radiation, autoimmune, Turner's $ & Fragile X
$.
. Dx -> -- E, ++ FSH & LH (FSH : LH > 1) i.e. FSH less or slower in cle
arance.
. Dx -> ++ FSH with amoenorrhea > 3 months in a woman < 40 ys is diagno
stic.
. N.B. SECONDARY AMENORRHEA ALGORITHM -> B-hCG
|
_________________________
|

|
NEGATIVE
POSITIVE -> PREGNANCY

|
|
_______________________________________________________________
________________________
|
|
|
|
|
++ PROLACTIN
++ FSH
++ TESTOSTERONE
++ TSH & -- T4
H/O of uterine procedures
|
|
|
|
|
Normal TSH
Ovarian failure
PCO
Hypothyroidism
Normal FSH
No PRL ++ medications
Normal TSH
Normal creatinine
Normal PR

L
|
|
MRI brain with pituitary focus
E/P stimulation
No withd
rawal bleeding
|
Hysteroscopy or HSG
to rule out
ASHERMAN $
________________________________________________________________________________
______________________________
* OSTEOPOROSIS:
__________________
. The most common affected site is VERTEBRAL BODIES -> Crush #s, kyphosis & -height.
. Hip & wrist #s are the next most common sites.
. The most common risk factor is +VE FAMILY H/O in a THIN WHITE FEMALE.
. Other risk factors: Steroid use, low Ca intake, SMOKING & ALCOHOL.
. PREVENTION with Ca & Vit. D, weight bearing exercise & elinination of cigaret
tes & alcohol.
. Dx -> DEXA SCAN (Dual energy x-ray absorptiometry) to assess BONE DENSITY.
-> Results in the form of T-score -> >- 2.5 = Osteoporosis.
. Ca loss is assessed with a 24 hour urine hydroxyproline or NTX (N-telo-peptid
e, a bone breakdown ptn product).
. Tx -> BIPHOSPHONATES & SERMs are the 1st line of therapy.
-> Biphosphonates (Alendronate - Risedronate) INHIBIT OSTOCLASTIC ACTIVI
TY.
-> SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMs) INCREASE BONE DENSITY.
. SERMs are protective against the heart & bone AGONIST effects but br
east ANTAGONIST effects.
. RALOXIFENE has bone AGONIST effects but endometrial ANTAGONIST effec
ts.
prevents endometrial cancer.
. N.B. Estrogen is NEVER the 1ry ttt of osteoporosis bec. of ass. risks of clot
s & endometrial cancers.
. N.B. DEXA SCAN -> T-score -> 1.5 - 2.5 -> OsteoPENIA.
-> > 2.5

-> OsteoPOROSIS
.
________________________________________________________________________________
______________________________
* HORMONE REPLACEMENT THERAPY (HRT):
______________________________________________
. HRT is used to ttt the following:
. HRT is NOT used in the following:
_________________________________

___

______________________________
. Menopausal vasomotor symptoms (Hot flashes).
osis.
. Genitourinary atrophy.
. Estrogen sensitice cancer (Breast or endometrial).
. Dyspareunia.
. Liver disease.

. Osteopor

. Active thrombosis.
. Unexplained vaginal bleeding.
. BENEFITS of HRT:
. RISKS of HRT:
____________________
________________
. -- rate of osteoporotic #s.
. ++ risk of DVT.
. -- rate of colorectal cancer.
. ++ risk of heart attacks & breast cancer.
(Risk of breast cancer is only ass. e' therapy > 4ys).
. N.B.
. Women withOUT a uterus can be given CONTINOUS ESTROGEN.
. All women WITH a uterus must also receive PROGESTIN therapy to prevent endome
trial hyperplasia.
. GUIDELINES for HRT:
_______________________
. Only start HRT for vasomotor symptoms.
. Never give HRT for the prevention of CVS disease.
. Use the lower dose of HRT to ttt syms.
. Use the shortest duration of HRT to ttt syms; reevaluate annually.
. Don't exceed 4 ys of ttt (++ risk of breast cancer after 4 ys of ttt).
. N.B. On HRT, the requirement of L-thyroxine is ++ in ttt of menopausal women.
________________________________________________________________________________
______________________________
* CONTRACEPTION:
_____________________
{1} BARRIER METHODS:
________________________
. Condoms, vaginal diaphragm & spermicides.
. Protective agaisnt STDs.
{2} STEROID CONTRACEPTION:
________________________________
. Combination of E + P.
. Progestin only pill called "mini-pill".
. ABSOLUTELY CONTRAINDICATED in:
-> Pregnancy.
-> Acute liver disease.
-> Vascular disease (thromboembolism, DVT, CVA & SLE).
-> Hormone dependent cancer (Breast carcinoma).
-> Smoker > 35 ys.

-> Uncontrolled HTN.

-> Migraines with aura.
-> DM with vascular disease.
. RELATIVELY CONTRAINDICATED in:
-> Migraines.
-> Depression.
-> DM.
-> Chronic HTN.
-> Hyperlipidemia.
. BENEFITS:
-> -- Ovarian & endometrial cancer.
-> -- Dysmenorrhea.
-> -- DUB.
-> -- Ectopic pregnancyy.
{3} INTRA-UTERINE DEVICE (IUD):
____________________________________
. Levonorgestrel impregnated.
. Copper banded.
. ABSOLUTELY CONTRAINDICATED in:
-> Pregnancy.
-> Pelvic malignancy.
-> Salpingitis.
. RELATIVELY CONTRAINDICATED in:
-> Abnormal uterine size or shape.
-> Immunosuppression.
-> Nulligravity.
-> Abnormal Pap smear.
-> H/O of ectopic pregnancy.
. BENEFITS:
-> Effective & avoids side effects of hormonal therapy.
. N.B.
. Low dose OCPs don't ++ the risk of cancer, heart disease or thromboembolic ev
ents in women with no ass. risk factors
as HTN, DM or smoking.
.
RACEPTIVE PILLs

ORAL CONT
|
_______________________________________

________________________
|
|
SERIOUS SIDE EFFECTS
PROTECT AGAINST
__________________________
_____________________
1 . Venous thromboembolism.
1 . Ovarian cysts & cancer.
2 . Cardiovascular events & stroke.
2 . Endometrial cancer.
3 . ++ Triglycerides.
3 . Benign breast disease.

4 . Cholestasis or cholecystitis.
4 . Dysmenorrhea -> Anemia.
5 . DM.
6 . HTN.
. N.B. OCPs does NOT cause weight gain (Common mistake).
. N.B. Emergency contraception -> LEVONORGESTREL !
________________________________________________________________________________
______________________________
* INFERTILITY:
_________________
. Inability to achieve pregnancy after 12 months of unprotected & frequent inte
rcourse.
. INFERTILITY WORK UP STEPS:
1
2
3
up

->
->
->
is

The 1st step is SEMEN ANALYSIS.

If normal -> ANOVULATION work up.
If semen analysis is normal & ovulation is confirmed, FALLOPIAN TUBE work
done.

{1} SEMEN ANALYSIS:

_______________________
. Normal volume > 2 ml.
. Normal pH 7.2 - 7.8.
. Normal sperm density > 20 million / ml.
. Normal sperm motility > 50 %.
. Normal sperm morphology > 50 % normal.
. If abnormal values -> REPEAT THE SEMEN ANALYSIS in 4-6 weeks.
. If AGAIN ABNORMAL -> IUI, ICSI or IVF.
. If NO VIABLE SPERM -> Artificial insemination by donor may be used !
{2} ANOVULATION:
___________________
. Dx -> Basal body temperature (BBT) chart -> NO midcycle temperature elevation
.
. Dx -> Progesterone -> LOW.
. Dx -> Endometrial biopsy -> Proliferative histology.
. Treatable causes of anovulation -> Hypothyroidism & hyperprolactinemia.
. Tx -> INDUCTION OF OVULATION -> CLOMIPHENE CITRATE is the agent of choice.
-> If Clomiphen
e failed -> Human menopausal gonadotrophin (hMG).
. Most common side effect -> OVARIAN HYPERSTIMULATION (Ovarian size must be mon
itored during induction).
{3} TUBE ABNORMALITIES:
____________________________
. Dx -> Chlamydia Ab -> A -ve IgG Ab test for Chlamydia rules out infection-ind
uced tubal adhesions.
. Tx ->
. Tx ->
attempt
. Tx ->
. N.B.

HYSTEROSALPINGOGRAM (HSG) -> If normal -> No further tests needed.

LAPAROSCOPY -> Performed after ABNORMAL HSG to visualize the oviducts &
reconstruction.
If tubal damage is severe -> IVF.

. Unexplained infertility -> Normal semen analysis, confirmed ovulation & paten
t oviducts.
. No ttt is indicated & 60 % of pts with unexplained infertility will achieve a
spontaneous pregnancy within next 3 ys.
. N.B.
. IN VITRO FERTILIZATION = IVF.
. Eggs are aspirated from the ovarian follicles suing an U/$ guided transvagina
l approach.
. They are fertilized with sperm in lab -> resulting in formation of embryo.
. Multiple embryos are tansferred into the uterine cavity with a cumulative pre
gnancy rate of 55 % after 4 IVF cycles.
. IVF with the use of oocyte donor can be the only clue & ttt of premature ovar
ian failure.
________________________________________________________________________________
______________________________
. GESTATIONAL TROPHOBLASTIC DISEASE (GTN) = HYDATIFORM MOLE = VESICULAR MOLE:
________________________________________________________________________________
_______________
. Abnormal proliferation of placental tissue involving both the cytotrophoblast
& / or syncitiotrophoblast.
. It can be either benign or malignant.
. GTN is most common in Taiwan or Phillippines.
. Risk factors are maternal age extremes (< 20 ys & > 25 ys) & folate defecienc
y.
. The most common syms -> Bleeding < 16 wks gestation & passage of vesicles fro
m the vagina.
. Other syms -> Hypertension, hyperthyroidism, hyperemesis gravidarum & no feta
l heart tones appreciated.
. The most common signs are fundus larger than dates, absence of fetal heart to
nes.
. U/$ -> Bilateral cystic enlargement of the ovary (Theca-Lutein cysts).
. The most common site of distant metastasis is the LUNGS.
. N.B. ++ BP before 20 wks is either chronic hypertension or Hydatiform mole (G
TN).
. U/$ -> SNOW STORM APPEARANCE.
. N.B. Hyperemesis gravidarum -> Severe form of nausea & vomiting during pregna
ncy.
. Starts at 4th - 10th week, not resolving till 20th week.
. NORMAL BCG levels.
. Mild ++ in ALT & AST.
. Mild ++ in amylase & lipase (Salivary gland / vomiting).
. Ketonuria.
.
NT HYDATIFORM MOLE

* BENIGN HYDATIFORM MOLE

* MALIGNA
|

|
_______________________
______________________________________
|
|
|
|
COMPLETE
i"N"complete
tic
Good P. Mets
Bad P. Mets
|

__
|
NON metasta
|

|
Empty egg
Pevis or lungs

nly

"N"ormal egg
Brain or liver

46 XX
00 % cure

69 XXY
65 % cure
Triploidy

> 95 % cure
Dizygotic ploidy

Fetus Absent
ENT CHEMOTHERAPY
MULTIPLE agents

Uterus o

fetus "N"on viable

SINGLE AG

UNTIL AFTER B-hCG is NEGATIVE for 3 WEEKS

20 % malignancy
1 YEAR on OCP
F/UP for 5 ys

10 % malignancy

FOLLOW UP FOR

NO chemotherapy, serial B-hCG titers until

negative, follow up for 1 year on OCP
. Dx -> U/$ -> HOMOGENOUS INTRAUTERINE ECHOES WITHOUT GEATATIONAL SAC OR FETAL
PARTS
-> SNOW STORM APPEARANCE.
. MANAGEMENT -> Baseline quantitative B-hCG titer.
-> CXR -> Rule out metastasis.
-> Suction dilatation & curettage (D&C) to evacu
ate the uterine contents.
-> Place the pt on effective contraceptve pills
to ensure no cofusion bet. rising B-hCG titers from
recurrent disease & normal pregnancy.
SORRY FOR
BEING SO LATE
THANK
YOU SO MUCH
Dr. WAEL TAW
FIC MOHAMED
_____________
__________________